Mittleschmerz (Mid-Cycle Pain)



Mittleschmerz is a German word literally meaning "middle pain" or mid cycle pain. It is used medically to refer to pain occurring during ovulation (ovulation is the release of egg from one of the ovaries in a woman). This usually occurs at the middle of a woman's menstrual cycle... that is, in between two menstrual period.

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Mittleschmerz is also called ovulatory pain or ovulation pain and rightly so.

Mid cycle pain usually start suddenly, coinciding with the moment of release of eggs from the ovary. It is normally a dull pain, occurring on the right or left lower abdomen, depending on which ovary just released the egg. The pain could last from a few minutes to 3 to 8 hours and then disappears.

In some cases, the pain of mittleschmerz may be sharp, severe, cramp-like like menstrual pain it self, lasting a few hours or up to 3 to 6 days.

Mittleschmerz could occur every month or sometimes once in three to four months.

This pain could be severe in some young ladies, causing them to bend over, mimicking serious causes of lower abdominal pain like appendicitis, twisted or ruptured ovarian cyst, and even appendicitis.

What differentiate this pain from the appendicitis, ectopic pregnancy or ovarian twist or rupture is the fact that this pain is recurrent, over months, and all investigations or scans done will come back to be normal.

Mittleschmerz is thought to be due to an accompanying slight bleed into the linings of the wall of the pelvis called the peritoneum at the moment of the release of eggs during ovulation. Ultrasound scan at mid-cycle has been reported to detect a more than usual amount of fluid in the pelvic pouch in as much as 40 percent of women.

Free blood in contact with the peritoneum causes irritation, transmitted as mid-cycle pain.

The bleeding may even track out as vaginal very small vaginal spotting.

The pain is usually in the lower abdomen, right or left side depending on which side an egg is released from.

The pain could be so specific that a woman may be able to tell from which ovary she has released an egg for that month. It may be severe enough to cause disruptions of normal day to day activities.

Not every woman who ovulates feels or experiences mid-cycle pain. It occurs in 1 in 5 women.

Typically, mid cycle pain is common in young women (in the adolescent age group) within a few months to years of starting her period or menstruation, commonly seen in the 11 to 30 year olds, though this pain can occur at any time up to 45years of age.

Mid-cycle pain or Mittleschmerz could be confused for, and needs to be differentiated from appendicitis if it is occurring on the right or in the right ovary, and can also be confused for ectopic pregnancy if there is associated vaginal bleed or spotting.


DIAGNOSIS OF MID CYCLE PAIN


By carefully keeping a "PAIN CALENDER", a woman may be able to pin this pain to occurring in the mid point between two menstrual period, especially if her menstrual cycle comes on regularly around every 28 days. This will no doubt help give even more weight to the diagnosis of mid cycle pain or mittleschmerz.

The careful physician would want to carry out some basic base line investigations like a full blood count (or Complete Blood Count CBC - if you are American), crp (cryo-reactive-protein) to exclude infective causes like appendicitis.

A quick pelvic ultrasound scan will help to exclude a twisted or ruptured ovarian cyst.

A urine and blood pregnancy test and an ultrasound scan will also help exclude ectopic pregnancy.


CASE EXAMPLE

Bumi is 14 years old. She started her menses at the age of 11. In the last 13 months, she has been having this lower abdominal pain that comes on and off. Each time it presents, it is sudden in onset, moderate to severe in intensity, does not radiate or spread any where, there is usually no loss of appetite, no change in bowel habit ( no diarrhoea or new onset constipation), pain lasts a few hours to a day or two, and often disappears by the time she gets to see her G.P.

All investigations done come back as normal.

She has been seen and referred to the surgical team and discharged without the cause of her abdominal pain found. Careful history taking revealed the pain occurs between her cycle and a diagnosis of mid cycle pain was clinched, after successive pain was documented on a pain calender kept by Bumi as would be expected of mittleschmerz.


TREATMENT OF MID CYCLE PAIN

Once the cause of a recurrent lower abdominal pain in a young woman is identified to be most likely due to mid cycle pain or mittleschmerz, the most important part of the treatment is to carefully explain to the young lady and her parents or partner (if present), that this pain is "normal" in some women, and that they will not come to any harm from it.

Once this is understood, most women find this pain more manageable. Because the level of irritation caused by the release of fluid onto the peritoneum may vary from one woman to the other, the corresponding pain experienced will also vary. Lots of empathy is therefore required when dealing with these ladies.

Simple pain killers like paracetamol taking with an anti-inflammatory agent like ibuprofen (if you are not allergic to any of these, or if ibuprofen does not worsens your asthma if you are asthmatic), will help take the pain away.

You can get simple pain killers from your nearest chemist, or shop online from the Women Sexual Health section of reputable online pharmacies like Express Chemist or Pharmacy2U.

For pain lasting a few hours to days, take these pain killers regularly, up to three or four times a day, as advised by your doctor.

The use of a heat pad or warm water bottle placed on the side of the abdomen where the pain is experienced has brought comfort to some.

For severe mid cycle pain not responding to simple pain killers, the use of oral contraceptive pills to stop ovulation all together may be necessary. This is a weighty decision that must be taking together with your doctor.

If you decide to take oral contraceptive pills, it is therefore wise you first discuss with your doctor to know which is good for you and the risk you may face taking that.

See a list of other causes of Mittleschmerz - like pain or pain that can be confused with mid-cycle pain.


REFERENCE:

Pediatric and Adolescent Gynecology by S. Jean Herriot Emans

S. Jean Emans, Marc R. Laufer, Donald Peter Goldstein. Page 430.




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