Clinical cases
Pelvic pain: a case-based approach
This is an illustrative educational case — not a real patient. Pelvic pain is common and has many causes, from period-related pain to serious emergencies. The skill lies in structuring the assessment around the dangerous causes first, particularly in women who could be pregnant. We follow a fictional case to show that reasoning.
Education and reference only. This article explains how treatments work in plain language — it contains no doses and is not a substitute for advice from your doctor or pharmacist. Always discuss your own treatment with a qualified clinician.
The presentation
A 26-year-old woman has lower abdominal pain that has worsened over a day, now sharper on the right side, with some light vaginal bleeding and shoulder-tip discomfort. Her last period was later than usual. Straight away, several features raise concern: the one-sided pain, the abnormal bleeding, the shoulder-tip pain (which can signal blood irritating the diaphragm) and the possibility of pregnancy. This combination makes excluding an ectopic pregnancy the immediate priority.
The must-not-miss causes
The assessment is built around excluding the serious causes of acute pelvic pain: ectopic pregnancy (a pregnancy outside the womb, which can bleed catastrophically), appendicitis, ovarian torsion (a twisted ovary cutting off its blood supply) and pelvic infection. In any woman of reproductive age with abdominal or pelvic pain, a pregnancy test is one of the very first investigations, because a positive result completely changes the urgency and the pathway.
How the assessment is structured
A focused history covers the pain's site, timing and character, the menstrual and sexual history, and associated symptoms such as fever, bleeding, or urinary and bowel changes. Examination looks for tenderness, guarding and signs of shock. Investigations include a pregnancy test, urine tests, blood tests and, where needed, an ultrasound scan. In this case a positive pregnancy test with one-sided pain and bleeding points urgently towards a possible ectopic pregnancy and prompts immediate specialist assessment.
The common, less urgent causes
Not all pelvic pain is an emergency. Common causes include period pain (dysmenorrhoea), ovulation pain, ovarian cysts, endometriosis, pelvic inflammatory disease, urine infections and irritable bowel syndrome. These are worked through once the dangerous causes are excluded. Persistent or recurrent pelvic pain deserves proper assessment too, as conditions like endometriosis are often diagnosed late.
What the case teaches
The lesson is the discipline of the approach: in any woman who could be pregnant, exclude ectopic pregnancy early with a pregnancy test, and structure the rest of the assessment around the other serious causes before settling on a benign explanation. Severe pain, heavy bleeding, fainting or a positive pregnancy test with pain all warrant urgent care.
In short
Key takeaways
- Pelvic pain has many causes, from period pain to life-threatening emergencies.
- In any woman who could be pregnant, a pregnancy test is one of the first steps — ectopic pregnancy can be fatal.
- Serious causes to exclude include ectopic pregnancy, appendicitis, ovarian torsion and pelvic infection.
- One-sided pain with abnormal bleeding, shoulder-tip pain or fainting needs urgent assessment.
- Educational illustration only — severe pelvic pain, heavy bleeding or collapse is an emergency; call 999.
Answers
Frequently asked questions
Is this based on a real person?
No — it is a fictional teaching case for education, not advice for any individual.
When is pelvic pain an emergency?
Severe pain, heavy bleeding, feeling faint or collapsing, or pain with a positive or possible pregnancy all need urgent care — call 999 or go to A&E. Shoulder-tip pain with pelvic pain in early pregnancy is a red flag for ectopic pregnancy.
What if my pelvic pain is ongoing rather than sudden?
Persistent or recurrent pelvic pain should be assessed by a GP. Conditions such as endometriosis are common and often diagnosed late, so it is worth seeking help rather than putting up with it.
Go deeper
Related guides
Sources
Where this is drawn from
- NICE CKS — Pelvic pain; NICE NG73 — Ectopic pregnancy and miscarriage
- Royal College of Obstetricians and Gynaecologists — pelvic pain
- NHS — Pelvic pain
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