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Mittelschmerz - ovulatory pain. Some women have midcycle pain due to either distension of the ovarian
capsule or spillage of the ovarian contents at the time of ovulation. This pain usually coincides with the
12th-16th day of the menstrual cycle (count the first day of bleeding as day #1). Women will sometimes have a
small amount of vaginal bleeding during this time.
Symptoms: Gradual or rapid onset of pelvic pain that will usually peak in 24 hours and then remit.
Occasionally the pain will be acute in onset and more painful then usual. This may be a ruptured ovarian cyst.
The most significant piece of history is the timing of the pain- Mittelschmerz will usually be on the 12th-16th
day. In women with irregular and/or infrequent periods the diagnosis will be more difficult.
Pelvic Examination: Often the exam is only significant for generalized lower pelvic discomfort that is mild to
moderate in nature. The ovary will sometimes be enlarged (a woman ovulates from only one side each month
so the pain is often lateralizing and changes sides month-to-month).
Diagnosis: A menstrual diary and pain scale are very helpful. The patient can mark the first day of her cycle
and then each day that she has pain. If the pain occurs only during midcycle it is Mittleschmerz. Pain that
occurs frequently throughout the month will fall into another category.
Treatment: NSAIDs such as ibuprofen 800 mg po tid will help to alleviate discomfort. Primary treatment is
ovulatory suppression with birth control pills.
Irritable Bowel Syndrome (IBS) - may be the source of 50% of cases of chronic pelvic pain or may occur
in conjunction with diseases such as endometriosis. IBS is a disease of abnormal bowel motility triggered
by situational stress and certain substances (lactose). Studies show that patients with IBS have increased
colonic contractions particularly in response to meals. IBS is often worse the week prior to and during menses
and may cause dyspareunia. The discomfort that occurs is often left lower quadrant and lower abdominal -
causing many women to interpret their symptoms as related to the uterus and/or ovaries.
Symptoms: Colicky abdominal pain with a sensation of rectal fullness and bloating. Pain is often relieved
with bowel movement and exacerbated by meals. The symptoms wax and wane in a cyclic fashion,
sometimes lasting for months. The cycles often parallel physical or emotional stress. Abdominal pain is
usually accompanied by diarrhea and/or constipation but occasionally may be the only complaint.
Physical Examination: In patients with IBS the uterus and ovaries should be WNL unless a coexisting
gynecological problem exists. It is best not to examine these patients in the week prior to and during menses
as they may have increased sensitivity to examination. A patient in the midst of an IBS attack may have slight
abdominal distension due to gas and mild discomfort to palpation.
Treatment: Involves behavior and dietary modifications. Patients often respond to increased dietary fiber
(psyllium powder/Metamucil). Fluid intake is often inadequate and should be increased, caffeine should be
minimized. Patients should identify and avoid food triggers. Common food triggers include fried and other
excessively fatty foods, milk products, rice and beans (in patients not used to a primarily vegetarian diet).
Increased aerobic activity may be helpful. Warm baths or heating pads to the abdomen are often helpful
during acute exacerbations.
See Abdominal Pain section for more in depth discussion of the above.
Plan:
Diagnostic Tests
- Urine culture, cervical cultures to rule out gonorrhea and chlamydia.
- A pain diary is extremely helpful and diagnostic in many cases. The patient should chart the days of
menstruation. She should note pain on a scale of 1-10 and any other accompanying symptoms, including
physical and psychological symptoms. If she did something that made the pain better or worse it should
also be noted. Episodes of intercourse are important to mark down. Women with significant pelvic pain
will often limit their intercourse. - If available, radiographs of the pelvis and lumbo-sacral spine can identify other potential explanations
of chronic pelvic pain.