The diagnosis and management of lower abdominal pain is difficult, particularly for the inexperienced accident and emergency (A&E) or surgical trainee. In women, potential gynaecological causes may further confuse the picture. We analysed the incidence, spectrum of presentation and immediate management of 322 women presenting consecutively to an inner city A&E department over a 6-month period with lower abdominal pain. A standard questionnaire relating to history, examination, immediate investigations and preliminary diagnosis was completed by the attending A&E doctor. The cause of abdominal pain, according to the A&E doctor's diagnosis, was gynaecological in 61%, gastroenterological in 23%, urological in 7% and non-specific in 9% of cases. Of the women, 39% (124/322) were referred to a duty specialist, of whom 86% (107/124) required admission for investigation and/or treatment. Women initially diagnosed as having pain of gynaecological origin formed the largest group of patients to be referred. In 69% (67/97) of these cases, the A&E doctor's initial diagnosis was confirmed by the gynaecologist. This study shows that pain of gynaecological origin was the largest single cause of lower abdominal pain in women presenting to our A&E department and that, in the majority of cases, these women needed to be referred to the duty gynaecologist for immediate treatment. Although overall diagnostic accuracy rate was relatively high, the management of potentially life-threatening gynaecological conditions such as ectopic pregnancy was poor. These results emphasise the need to improve in-service gynaecological training in A&E departments.