Mittelschmerz - When ovulation hurts

by Tina Coleman

Mid-cycle pain, called mittelschmerz, affects about twenty percent of women. It ranges from mild to severe, and relief is usually available. But first, it is crucial to see your gynecologist to rule out other possible causes.

No doubt you're all too familiar with the PMS, cramping, headaches, bloating, and constipation or diarrhea that accompany your period every month. But some women also experience mid-cycle (ovulation) pain, usually beginning in their middle to late teens (although it can begin later). Painful ovulation, when severe, is referred to as mittelschmerz, a German word that means "middle pain." Most women who experience painful ovulation usually report a nagging pain that begins as a sharp twinge and diminishes into a dull ache for the next day or so. But for other women, the pain can be severe enough to be disabling and can even be confused with appendicitis.

While the discomfort can occur on either side of the abdomen, it is more commonly experienced on the right. Mittelschmerz can occur during intercourse or it can be aggravated by intercourse, working out or other physical activity. In addition to pain, some women also experience gastrointestinal symptoms and increased frequency of urination. It is not associated with endometriosis, in which the pain occurs at the onset of the menstrual period rather than in mid-cycle. It may occur every month, but more typically occurs every third to fourth cycle.

Ovulation occurs at the mid-point in the menstrual cycle. It refers to the release of an egg from a woman's ovary into her fallopian tube. Over the following three days, the egg travels down the tube to the uterus. If fertilization doesn't occur during this time, the egg dies and then disintegrates. With the disintegration of the egg, the lining of the uterus also begins to degenerate, producing the bleeding that is characteristic of each menstrual cycle.

Joseph K. Hurd, Jr., MD, Chairman of the Department of Gynecology at the Lahey-Hitchcock Clinic in Burlington, Massachusetts, says that mittelschmerz is believed to be caused by a small leakage of blood from the ovary that occurs at the time of ovulation. This blood, which is later resorbed, is thought to cause an irritation of the abdominal wall.

The degree of pain you feel depends on your individual pain threshold and the volume of blood that is released, among other factors. Hurd says the amount of space that exists between a woman's ovary and her abdominal wall can also affect the severity of the irritation. In fact, he had a patient who found she could halt her mittelschmerz by doing a somersault. This, he believed, created enough of a shift in the space between her ovary and abdominal wall to alleviate the pain. (Don't try this at home unless you are limber enough not to injure yourself!) Mittelschmerz does not lead to other gynecologic problems, he adds.

The best way to diagnose your discomfort is to keep a chart or diary showing when the pain occurs in relation to the start of your menstrual periods. Your health care provider will use this diary in conjunction with your medical history, a physical exam, and perhaps some other medical tests to rule out other possible causes of your pain before making a diagnosis of mittelschmerz.

The occasional patient, says Hurd, will require laparoscopy, in which a laparoscope--a narrow tube with a fiber-optic light on the end--is introduced through a small incision below the navel and into the abdominal wall. This procedure allows for a direct view of the pelvic organs.

Because the pain of mittelschmerz can be anxiety-provoking and, if severe enough, can be confused with appendicitis, Hurd warns that women should be careful not to "get railroaded into undergoing unnecessary gynecologic surgery."

Rest until you feel better, drink plenty of fluids, and take your temperature every four hours. Over-the-counter pain relievers, such as acetaminophen or aspirin, and a heating pad will usually provide relief from the pain of mittelschmerz. If the pain is disabling and you do not wish to become pregnant, you may want to ask your gynecologist to prescribe oral contraceptives. They will inhibit ovulation, thereby solving the problem.

If however, the pain does not go away within two or three days, or if you have vaginal bleeding or discharge, call your health care provider immediately. Seek care immediately if the pain increases, you begin to vomit blood, you feel dizzy or faint, you have a high temperature, or if your abdomen becomes swollen and hot to touch. This may indicate a medical crisis unrelated to your menstrual cycle.