View source for Mittelschmerz

{{Short description|Medical term for ovulation pain}}{{italic title}}
{{Infobox medical condition
| name            =  
| synonyms        = Ovulation pain,<ref name=NHS2024>{{cite web |title=Ovulation pain |url=https://www.nhs.uk/conditions/ovulation-pain/ |website=nhs.uk |accessdate=11 January 2024 |language=en |date=19 October 2017 |archive-date=4 July 2023 |archive-url=https://web.archive.org/web/20230704050241/https://www.nhs.uk/conditions/ovulation-pain/ |url-status=live }}</ref> mid-cycle pain<ref name=Be2018/>
| image           = AbdoPainDif.png
| width           = 
| alt             = 
| caption         = Approximate location of abdominal pain based on potential causes
| pronounce       = 
| specialty       = [[Gynecology]]
| symptoms        = One sided lower [[abdominal pain]], [[vaginal bleeding|spotting]]<ref name=NHS2024/><ref name=Be2018/>
| complications   = 
| onset           = Mid [[menstrual cycle]]<ref name=NHS2024/>
| duration        = Minutes to days<ref name=NHS2024/>
| types           = 
| causes          = Related to [[ovulation]] but mechanism unclear<ref name=Be2018/>
| risks           = 
| diagnosis       = After ruling out other potential causes<ref name=Do2013/>
| differential    = [[Appendicitis]], [[endometriosis]], [[ovarian cyst]], [[ectopic pregnancy]], [[sexually transmitted infections]]<ref name=NHS2024/><ref name=Stat2023/>
| prevention      = [[Birth control pills]]<ref name=NHS2024/>
| treatment       = [[Paracetamol]], [[ibuprofen]]<ref name=NHS2024/>
| medication      = 
| prognosis       = None serious<ref name=Do2013/>
| frequency       = 40% of women<ref name=Stat2023/>
| deaths          = 
| video1          = 
}}
<!-- Definition and symptoms -->

'''''Mittelschmerz''''' ({{IPA|de|ˈmɪtl̩ʃmɛʁt͡s|lang|audio=De-Mittelschmerz.ogg}}) is a term for [[pain]] due to [[ovulation]]. It occurs mid-cycle (between days 7 and 24) and can last minutes to up to several days.<ref name=Stat2023/> The pain affects one side of the lower abdomen and may be dull or sharp in nature.<ref name=NHS2024/><ref name=Be2018>{{cite book |last1=Bekaert |first1=Sarah |last2=Bright |first2=Phil |title=Women's Health: Medical Masterclass Questions and Explanatory Answers, Pt. 1 |date=19 April 2018 |publisher=CRC Press |location=81 |isbn=978-1-4987-9064-2 |url=https://books.google.com/books?id=wD0PEAAAQBAJ&pg=PA81 |accessdate=11 January 2024 |language=en |archive-date=15 January 2024 |archive-url=https://web.archive.org/web/20240115200909/https://books.google.ca/books?id=wD0PEAAAQBAJ&pg=PA81#v=onepage&q&f=false |url-status=live }}</ref> Other symptoms may include [[vaginal bleeding|spotting]].<ref name=NHS2024/> Often it occurs monthly and may alternate sides.<ref name=Stat2023/><ref name=Be2018/>

<!-- Cause and diagnosis -->
The underlying mechanism is unclear but may involve irritation due to release of blood and fluid from the [[Ovarian follicle|follicle]] or high blood levels of [[luteinizing hormone]] causing contraction of [[smooth muscle]].<ref name=Be2018/><ref name=Stat2023/><ref name=Do2013/> Diagnosis involves ruling out other potential causes such as [[appendicitis]], [[endometriosis]], [[ovarian cyst]]s, [[ectopic pregnancy]], and [[sexually transmitted infections]].<ref name=NHS2024/><ref name=Stat2023/><ref name=Do2013/>

<!-- Treatment and epidemiology -->
Treatment may involve [[paracetamol]] or [[ibuprofen]].<ref name=NHS2024/> [[Birth control pills]] may be used for prevention.<ref name=NHS2024/> It is not serious, though may reoccur.<ref name=Do2013/> ''Mittelschmerz'' affects about 20–40% of women.<ref name=Be2018/><ref name=Stat2023>{{cite journal |last1=Brott |first1=NR |last2=Le |first2=JK |title=Mittelschmerz. |journal=StatPearls |date=January 2023 |pmid=31747229 |url=https://www.ncbi.nlm.nih.gov/books/NBK549822/ |accessdate=11 January 2024 |archive-date=28 May 2021 |archive-url=https://web.archive.org/web/20210528022522/https://www.ncbi.nlm.nih.gov/books/NBK549822/ |url-status=live }}</ref> The term is from the [[German language|German]] for "middle pain".<ref name=Do2013>{{cite book |last1=Dolan |first1=Brian |last2=Holt |first2=Lynda |title=Accident & Emergency: Theory into Practice |date=4 June 2013 |publisher=Elsevier Health Sciences |isbn=978-0-7020-4315-4 |page=452 |url=https://books.google.com/books?id=Y1T-TlzllUIC&pg=PA452 |accessdate=11 January 2024 |language=en |archive-date=15 January 2024 |archive-url=https://web.archive.org/web/20240115200913/https://books.google.ca/books?id=Y1T-TlzllUIC&pg=PA452#v=onepage&q&f=false |url-status=live }}</ref> Its presence has been used to manage [[fertility]].<ref name=Stat2023/>

==Signs and symptoms==
Mittelschmerz is characterized by lower [[abdominal]] and [[human pelvis|pelvic]] pain that occurs roughly midway through a woman's [[menstrual cycle]]. The pain can appear suddenly and usually subsides within hours, although it may sometimes last two or three days.<!--
 --><ref name="kippley">{{cite book | first=John | last=Kippley |author2=Sheila Kippley | year=1996 | title=The Art of Natural Family Planning | edition=4th | publisher=The Couple to Couple League | location=Cincinnati, OH | isbn=0-926412-13-2 | pages=83–84 }}</ref>{{ums|date=December 2017}} In some cases it can last up to the following cycle. In some women, the mittelschmerz is localized enough so that they can tell which of their two [[Ovary|ovaries]] provided the egg in a given month.{{citation needed|date=June 2012}}  Because ovulation occurs on a random ovary each cycle, the pain may switch sides or stay on the same side from one cycle to another.

===Other ovulation symptoms===
Women may notice other physical symptoms associated with their mittelschmerz, during or near ovulation.  The most common sign is the appearance of fertile cervical mucus in the days leading up to ovulation.  Cervical mucus is one of the primary signs used by various fertility awareness methods.  Other symptoms are sometimes called ''secondary fertility signs'' to distinguish from the [[Fertility awareness#Primary fertility signs|three primary signs]].<ref name="tcoyf" />{{ums|date=December 2017}}

* Mid-cycle or ovulatory bleeding is thought to result from the sudden drop in estrogen that occurs just before ovulation.  This drop in hormones can trigger withdrawal bleeding in the same way that switching from active to placebo [[combined oral contraceptive pill|birth control pills]] does.  The rise in hormones that occurs after ovulation prevents such mid-cycle spotting from becoming as heavy or long lasting as a typical menstruation.  Spotting is more common in longer cycles.<ref name="tcoyf" />{{ums|date=December 2017}}
* A woman's [[vulva]] may swell just prior to ovulation, especially the side on which ovulation will occur.<ref name="tcoyf" />{{ums|date=December 2017}}
* One of the groin lymph nodes (on the side on which ovulation will occur) will swell to about the size of a pea, and may become tender.<ref name="tcoyf" />{{ums|date=December 2017}}

==Causes==
Mittelschmerz is believed to have a variety of causes:

*'''Follicular swelling''': The swelling of follicles in the ovaries prior to [[ovulation]].  While only one or two eggs mature to the point of being released, a number of follicles grow during the [[Menstrual cycle#Follicular phase|follicular phase]] of the menstrual cycle (non-dominant follicles atrophy prior to ovulation).  Because follicles develop on both sides, this theory explains mittelschmerz that occurs simultaneously on both sides of the abdomen.<!--
 --><ref name="tcoyf">{{cite book | first=Toni | last=Weschler | year=2002 | title=Taking Charge of Your Fertility | url=https://archive.org/details/takingchargeofyo00toni/page/65 | url-access=registration | pages=[https://archive.org/details/takingchargeofyo00toni/page/65 65–68, 228] | edition=Revised | publisher=HarperCollins | location=New York | isbn=0-06-093764-5 }}</ref>{{ums|date=December 2017}}

*'''Ovarian wall rupture''': The ovaries have no openings; at ovulation the egg breaks through the ovary's wall.  This may make ovulation itself painful for some women.<ref name="tcoyf" />{{ums|date=December 2017}}
*'''Fallopian tube contraction''': After ovulation, the [[fallopian tube]]s contract (similar to [[peristalsis]] of the esophagus), which may cause pain in some women.<ref name="kippley" />{{ums|date=December 2017}}
*'''Smooth muscle cell contraction''': At ovulation, this pain may be related to smooth muscle cell contraction in the ovary as well as in its ligaments.  These contractions occur in response to an increased level of prostaglandin F2-alpha, itself mediated by the surge of luteinizing hormone (LH).<!--
 --><ref>{{cite book | author1 = Michael H. Ross | author2 = Wojciech Pawlina | title = Histology: A Text and Atlas | publisher = Lippincott Williams & Wilkins | location = Hagerstown, MD | year = 2006 | edition = 5th | isbn = 978-0-7817-7221-1 | page = [https://archive.org/details/histologytextatl0000ross_i4i2/page/788 788] | url = https://archive.org/details/histologytextatl0000ross_i4i2/page/788 }}</ref>

*'''Irritation''': At the time of ovulation, [[blood]] or other [[Bodily fluid|fluid]] is released from the ruptured egg follicle. This fluid may cause irritation of the abdominal lining.<ref name="kippley" /><ref name="tcoyf" />{{ums|date=December 2017}}

==Diagnosis==
Diagnosis of mittelschmerz is generally made if a woman is mid-cycle and a pelvic examination shows no abnormalities. If the pain is prolonged and/or severe, other diagnostic procedures such as an abdominal [[Medical ultrasonography|ultrasound]] may be performed to rule out other causes of abdominal pain.

The pain of mittelschmerz is sometimes mistaken for [[appendicitis]] and is one of the [[differential diagnosis|differential diagnoses]] for appendicitis in women of child-bearing age.

==Treatment==
The pain is not harmful and does not signify the presence of disease. No treatment is usually necessary. Pain relievers ([[analgesic]]s) such as NSAIDs (non-steroidal anti inflammatories) may be needed in cases of prolonged or intense pain.<ref name=adam>{{cite web|url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002472/|title=Mittelschmerz|website=PubMed Health|date=April 12, 2009|archive-url=https://web.archive.org/web/20110219124244/https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002472/|archive-date=2011-02-19}}</ref>

[[Hormonal contraception|Hormonal forms of contraception]] can be taken to prevent ovulation<ref name=adam />—and therefore ovulatory pain—but otherwise there is no known prevention.

==Usefulness==
Women charting with some form of [[fertility awareness]] may find mittelschmerz to be a helpful secondary sign in detecting ovulation.  Because normal sperm life is up to five days, however, mittelschmerz alone does not provide sufficient advance warning to avoid pregnancy.  Because other causes of minor abdominal pain are common, mittelschmerz alone also cannot be used to confirm the beginning of the post-ovulatory infertile period.<ref name="kippley" />{{ums|date=December 2017}}<ref name="tcoyf" />{{ums|date=December 2017}}

==References==
{{reflist}}

== External links ==
{{Medical resources
|   DiseasesDB     = 8310 
|   ICD11          = {{ICD11|GA34.20}}
|   ICD10          = {{ICD10|N|94||N|00}} 
|   ICD9           = {{ICD9|625.2}} 
|   ICDO           = 
|   OMIM           = 
|   MedlinePlus    = 001503 
|   eMedicineSubj  = 
|   eMedicineTopic = 
|   MeshID         = 
}}
{{Menstrual cycle}}
{{Diseases of the pelvis, genitals and breasts}}

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[[Category:Syndromes]]
[[Category:German words and phrases]]