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Clinical Practice Guidelines

Adolescent gynaecology - lower abdominal pain

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  • See also

    Adolescent gynaecology - heavy menstrual bleeding
    Abdominal pain - acute 

    Dysmenorrhea 

    Sexual health history taking in the adolescent
    Engaging with and assessing the adolescent patient
    Urinary tract infection

    Key points

    1. This guideline focuses on gynaecological causes of abdominal and pelvic pain. Other causes for acute abdominal pain must also be considered
    2. Obstetric emergencies (eg ectopic pregnancy, miscarriage, placental abruption and uterine rupture) and gynaecological emergencies (eg ovarian or adnexal torsion) require urgent gynaecological or surgical referral
    3. Ovarian or adnexal torsion are clinical diagnoses, and gynaecological referral should not be delayed by investigations (eg ultrasound)

    Background

    • Gynaecological causes for abdominal pain increase in prevalence after puberty
    • Pain characteristics and associated symptoms may help differentiate between the various gynaecologic causes of lower abdominal pain

    Assessment

    History

    • Menstrual history: menarche, last menstrual period, frequency, duration, flow, pain, flooding, large clots (>2 cm in diameter), frequency of pad/tampon changes
    • Vaginal discharge
    • Pain characteristics: location, time course eg sudden onset, quality, severity, triggers and associated symptoms eg bowel, bladder, fever, nausea, vomiting
    • Sexual history and contraception. If sexually active discuss safe sex and contraception
    • Systemic features: fever, weight loss, vomiting, headache
    • Adolescent assessment (HEADSS screen)
    • For non-specific, episodic abdominal pain, consider chronic conditions such as constipation, abdominal migraine and functional abdominal pain

    Examination

    • Pallor, hypotension, tachycardia
    • Abdominal mass (uterine or ovarian)
    • Vaginal examination is rarely indicated. It should be discussed with a senior clinician, and if needed should only be performed once

    Gynaecological causes of acute abdominal pain

    Cause Clinical features
    Critical
    Ovarian or adnexal torsion Pelvic pain: acute/sudden onset, sharp, unilateral (usually right lower quadrant) or generalised, may be intermittent 
    Adnexal mass
    Nausea and vomiting
    Ectopic pregnancy Abdominal/pelvic pain
    Missed period with subsequent vaginal bleeding
    Can have shoulder tip pain
    Acute placental abruption Vaginal bleeding
    Abdominal and/or back pain
    Uterine contractions in severe cases
    Disseminated intravascular coagulation (DIC)
    Any gestation (peak between 24–26 weeks)
    Uterine rupture Uterine tenderness
    Peritoneal irritation
    Vaginal bleeding
    Abnormal fetal heart rate
    Molar pregnancy Vaginal bleeding
    Pelvic pain
    Enlarged uterus
    Severe vomiting
    Infection
    Pelvic inflammatory disease (PID) Risk factors (eg unprotected sex)
    Post coital bleeding
    Mucopurulent discharge
    Lower abdominal or pelvic pain
    Fever
    Other
    Pregnancy Breast tenderness
    Vomiting
    Bleeding
    Pelvic discomfort
    Dysmenorrhoea Crampy and intermittent lower abdominal pain
    Suprapubic or back pain
    May have associated symptoms such as nausea, vomiting, headache, dizziness or fainting
    Mittelschmerz Mild unilateral recurrent midcycle pain caused by normal follicular enlargement
    Ruptured ovarian cyst Sudden, severe, unilateral pelvic pain, can be precipitated by strenuous physical activity
    Spontaneous miscarriage Early pregnancy crampy pelvic pain
    Vaginal bleeding
    Passage of some or all of the products of conception
    Endometriosis Crampy pelvic pain associated with menses. Depending on its location can be associated with pain on passing stool or urine, or during sexual intercourse
    Imperforate hymen Amenorrhoea
    Cyclical pain
    Marked distension of the vagina may cause back pain or pain with defaecation or urination
    Retained foreign body Vaginal discharge
    Intermittent bleeding or spotting
    Functional abdominal pain Periumbilical or diffuse pain, variable location, exacerbated by stress
    Functional impairment out of proportion to pain, chronic duration

    Management

    Investigations

    • Many non-gynaecological causes of acute abdominal pain do not require investigation
    • Perform (with consent) a ßhCG (urine and/or blood if need a quantitative result)
    • If significant bleeding, see Adolescent gynaecology - heavy menstrual bleeding
    • If features to suggest a critical cause
      • Ovarian/adnexal torsion is a clinical diagnosis and requires urgent gynaecological referral that should not be delayed by investigations eg ultrasound
      • Pelvic ultrasound: transabdominal (with full bladder) or transvaginal (in sexually active adolescents with consent)
    • If features of infection
      • Urine MCS to exclude UTI
      • First pass urine (nucleic acid amplification tests) for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalisor self-collected vaginal swab or clinician-collected endocervical swab for gonorrhoea, chlamydia and MCS
      • FBE, CRP +/- blood culture if high degree of concern for pelvic inflammatory disease or sepsis

    Assessment of lower abdominal pain in adolescent females

    Adolescent gynaecology - lower abdominal pain diagram


    Treatment

    Treatment is dependent on the underlying cause

    Consider consultation with local paediatric team when

    • Child with haemodynamic instability, marked pain or unclear cause

    Consultation with gynaecological (or surgical) team when

    • Suspected ovarian or adnexal torsion or ectopic pregnancy/threatened miscarriage/non-viable pregnancy (urgent)
    • Causes requiring surgical intervention
    • Pelvic inflammatory disease

    Consider transfer when

    Needing advice regarding escalation of care, if beyond the local centre capabilities

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    Stable and a review is scheduled with a GP

    Last updated August 2025

    Reference List

    1. Brown J et al, 2014, Endometriosis: An overview of Cochrane Reviews, Cochrane Database Systematic Reviews, Issue 3
    2. Brown K et al 2024, Evaluation of acute pelvic pain in female children and adolescents. Retrieved from: https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-female-children-and-adolescents (viewed April 2025)
    3. Brown R et al, 2015, Pelvic pain, British Medical Journal, 5637, p1–2
    4. Burnett M et al 2017, Primary Dysmenorrhea Consensus Guideline, Journal of Obstetrics and Gynaecology Canada, 39(7), p585–95
    5. Fishman MB et al, 2025, Chronic abdominal pain in children and adolescents: Approach to the evaluation. Retrieved from: https://www.uptodate.com/contents/chronic-abdominal-pain-in-children-and-adolescents-approach-to-the-evaluation (viewed April 2025)
    6. Hertweck P, 2010, Common problems in pediatric and adolescent gynaecology, Expert Review of Obstetrics and Gynecology 5, p311–28
    7. Irani S 2005, Paediatric and Adolescent Gynaecology - A Multidisciplinary Approach, Obstetrics and Gynaecology, 7(3), p218–218
    8. Jarrell JF, et al 2018, Consensus Guidelines for the Management of Chronic Pelvic Pain, Journal of Obstetrics and Gynaecology Canada, 40(11), p747–87
    9. Kives S, et al 2017, Diagnosis and Management of Adnexal Torsion in Children, Adolescents, and Adults, Journal of Obstetrics and Gynaecology Canada, 39(2), p82–905
    10. Neuman M 2024, Causes of acute abdominal pain in children and adolescents. Retrieved from: https://www.uptodate.com/contents/causes-of-acute-abdominal-pain-in-children-and-adolescents (viewed April 2025)
    11. Peacock A et al, 2012, Period problems: Disorders of menstruation in adolescents, Archives of Disease in Childhood 97, p554–60
    12. Robert CB et al, 2015, Pelvic Inflammatory Disease, New England Journal of Medicine, 372, p2039–48
    13. Smorgick N et al, 2018, Pelvic Pain in Adolescents, Seminars in Reproductive Medicine, 36, p116–22
    14. Solnik MJ, 2006, Chronic pelvic pain and endometriosis in adolescents, Current Opinions in Obstetrics and Gynecology, 18(5), p511–8
    15. Stuparich MA et al, 2017, Endometriosis in the Adolescent Patient, Seminars in Reproductive Medicine, 35(1), p102–9

  • Reference List

    1. Brown J et al, 2014, Endometriosis: An overview of Cochrane Reviews, Cochrane Database Systematic Reviews, Issue 3
    2. Brown, K et al 2019, Evaluation of acute pelvic pain in adolescent female. Retrieved from UpToDate,  https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-the-adolescent-female (viewed June 2020)
    3. Brown R et al, 2015, Pelvic pain, British Medical Journal, vol. 5637 pp. 1–2
    4. Burnett M et al 2017, Primary Dysmenorrhea Consensus Guideline, Journal of Obstetrics and Gynaecology Canada, vol. 39(7) pp. 585–95.
    5. Fishman, MB et al, 2019, Chronic abdominal pain in children and adolescents: Approach to the evaluation. Retrieved from UpToDate, https://www.uptodate.com/contents/chronic-abdominal-pain-in-children-and-adolescents-approach-to-the-evaluation (viewed June 2020)
    6. Hertweck P, 2010, Common problems in pediatric and adolescent gynecology, Expert Review of Obstetrics and Gynecology vol. 5 pp. 311–28
    7. Irani S 2005, Paediatric and Adolescent Gynaecology - A Multidisciplinary Approac, Obstetrics and Gynaecology, vol. 7(3) pp. 218–218
    8. Jarrell JF, et al 2018, Consensus Guidelines for the Management of Chronic Pelvic Pain, Journal of Obstetrics and Gynaecology Canada vol. 40(11) pp.747–87
    9. Kives S, et al 2017, Diagnosis and Management of Adnexal Torsion in Children, Adolescents, and Adults, Journal of Obstetrics and Gynaecology Canada, vol. 39(2) pp. 82–905.
    10. Neuman, M 2019, Causes of acute abdominal pain in children and adolescents. Retrieved from UpToDate, https://www.uptodate.com/contents/causes-of-acute-abdominal-pain-in-children-and-adolescents (viewed June 2020)
    11. Peacock A et al, 2012, Period problems: Disorders of menstruation in adolescents, Archives of Disease in Childhood vol. 97 pp. 554–60.
    12. Robert CB et al, 2015, Pelvic Inflammatory Disease, New England Journal of Medicine, vol. 372 pp. 2039–48
    13. Smorgick N et al, 2018, Pelvic Pain in Adolescents, Seminars in Reproductive Medicine, vol. 36 pp. 116–22
    14. Solnik MJ, 2006, Chronic pelvic pain and endometriosis in adolescents, Current Opinions in Obstetrics and Gynecology, vol. 18(5) pp. 511–8
    15. Stuparich MA et al, 2017, Endometriosis in the Adolescent Patient, Seminars in  Reproductive Medicine, vol. 35(1) pp. 102–9