Musculoskeletal strain or injury: Given the commonality of musculoskeletal issues and the fact that groin pain can often be related to physical activity, strain, or overuse, this diagnosis is highly plausible. Activities such as running, cycling, or sudden stops and starts in sports can lead to groin strain.

Hernia (inguinal or femoral): Hernias are more common in women as they age and can cause groin pain, especially if the hernia becomes incarcerated or strangulated.
Ovarian cysts or torsion: Ovarian cysts are common in women of reproductive age and can cause pain if they rupture or torsion occurs, leading to severe, acute groin pain.
Urinary tract infections (UTIs) or kidney stones: While not exclusively causing groin pain, UTIs and kidney stones can radiate pain to the groin area and are common in women.
Endometriosis: This condition, where tissue similar to the lining inside the uterus grows outside of it, can cause chronic pelvic pain that may be perceived as groin pain.

Ectopic pregnancy: Although less likely in a 46-year-old female, ectopic pregnancy can occur and is a medical emergency. It presents with severe, sudden abdominal or pelvic pain and can be life-threatening if not promptly diagnosed and treated.
Appendicitis: While the pain of appendicitis typically starts near the navel and then moves to the lower right abdomen, atypical presentations can occur, and missing this diagnosis can have serious consequences.
Pulmonary embolism: In rare cases, a pulmonary embolism can cause referred pain to the groin due to the involvement of the diaphragm or adjacent structures, though this would typically be accompanied by respiratory symptoms.

Avulsion fractures or osteitis pubis: These are less common conditions that can cause groin pain, often related to specific activities or trauma.
Nerve entrapment syndromes (e.g., ilioinguinal or genitofemoral neuralgia): These conditions involve compression or irritation of nerves and can cause chronic pain in the groin area.
Tumors (e.g., sarcomas, lymphomas): Although rare, tumors in the groin area or pelvis can cause pain and should be considered in the differential diagnosis, especially if other symptoms like weight loss or night sweats are present.