Objective: To assess the extent of diagnosed and undiagnosed pelvic inflammatory disease (PID) in Aboriginal women in remote central Australia. Design, setting and subjects: Retrospective cross-sectional study in five remote central Australian primary health care centres. Medical records of all resident Aboriginal women aged 14–34 years were examined. Data were from presentations with documented lower abdominal pain, excluding other causes, for 2007–2008. Main outcome measures: PID investigations undertaken, PID diagnoses made, recommended treatment, and presentations meeting the guideline criteria for diagnosing PID based on pelvic examination, symptom profile or history. Results: Of 655 medical records reviewed, 119 women (18%) presented 224 times with lower abdominal pain. Recommended investigations to diagnose PID were infrequently undertaken: bimanual examination (15 cases [7%]); testing for gonorrhoea and chlamydia (78 [35%]); and history taking for vaginal discharge (59 [26%]), intermenstrual bleeding (27 [12%]) and dyspareunia (17 [8%]). There were 95 presentations (42%) consistent with guidelines to diagnose PID, most (87 [39%]) based on symptom profile and history. Of these, practitioners made 15 diagnoses of PID, and none had the recommended treatment documented. Conclusion: Pelvic inflammatory disease occurred frequently among Aboriginal women in central Australia during the study period but was vastly underdiagnosed and poorly treated. Undiagnosed or inadequately treated PID leads to poorer reproductive health outcomes in the long term. Increased awareness of PID symptoms, diagnosis and treatment and a revision of the guidelines is needed to improve detection and management of PID in this high-risk setting.