Suspected condition	Clinical presentation	Diagnostic evaluation
Primary dysmenorrhea	Recurrent, crampy, suprapubic pain occurring just before or during menses and lasting two to three days; pain may radiate into the lower back and thighs, and may be associated with nausea, fatigue, bloating, and general malaise; normal pelvic examination findings1	Diagnosis is clinical; urine tests should be ordered to rule out pregnancy or infection9
Endometriosis	Cyclic (can be noncyclic) pelvic pain with menstruation; may be associated with deep dyspareunia, dysuria, dyschezia, and subfertility; rectovaginal examination findings include fixed or retroverted uterus or reduced uterine mobility, adnexal masses, and uterosacral nodularity10,11	Transvaginal and pelvic ultrasonography are highly accurate for detecting ovarian and bowel endometriomas; magnetic resonance imaging may be indicated for deeply infiltrating endometriosis11,12; laparoscopy with biopsy and histology is the preferred diagnostic test11,13–16
Pelvic inflammatory disease	History of lower abdominal pain in sexually active patients; abnormal pelvic examination findings consisting of cervical motion tenderness, uterine tenderness, and/or adnexal tenderness; other associated clinical features include oral temperature > 101°F (38.3°C) and abnormal cervical or vaginal mucopurulent discharge17	Saline microscopy of vaginal fluid may show organism; elevated erythrocyte sedimentation rate or C-reactive protein level suggests infection; laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis is confirmatory; transvaginal ultrasonography is not usually indicated but may show thickened tubes with fluid collection, free pelvic fluid, or tubo-ovarian complex17
Adenomyosis	Usually associated with menorrhagia; may include intermenstrual bleeding; physical examination findings include enlarged, tender, boggy uterus	Transvaginal ultrasonography and, if necessary, magnetic resonance imaging will usually detect endometrial tissue within the myometrium18
Leiomyomata	Cyclic pelvic pain with menorrhagia and occasionally dyspareunia, particularly with anterior and fundal fibroids	Transvaginal ultrasonography can identify fibroids
Ectopic pregnancy	History of amenorrhea, abnormal uterine bleeding, severe sharp lower abdominal pain, and/or cramping on the affected side of the pelvis; may present with complications (e.g., hypotension, shock)	Positive urinary human chorionic gonadotropin pregnancy test; pelvic or transvaginal ultrasonography demonstrating extrauterine gestational sac
Interstitial cystitis	History of suprapubic pain (usually noncyclic) associated with urinary symptoms (e.g., frequency, nocturia); pain may radiate into the groin and rectum and is usually relieved by voiding; negative pelvic examination findings	Urinalysis; cystoscopy with hydrodistension and biopsy, which may show irritation of the bladder wall mucosa10
Chronic pelvic pain	History of noncyclic pelvic pain for at least six months; pain may radiate anteriorly toward the vagina or posteriorly toward the rectum and is worsened by anxiety; may be associated with dyspareunia and difficulty with defecation; pelvic examination findings may be normal, but burning pain exacerbated by unilateral rectal palpation suggests pudendal nerve entrapment of the affected side10	Pelvic magnetic resonance imaging along the pudendal nerve to assess the nerve and surrounding structures; if findings on workup are negative, the diagnosis is based on clinical history10