Mittelschmerz

Definition/Introduction:

• Mittelschmerz, also known as ovulation pain, is a benign preovulatory lower abdominal pain occurring mid-cycle (between days 7 and 24) in women.
• Affects over 40% of women of reproductive age, often recurring monthly.
• Typically begins a few years post-menarche when true ovulatory cycles are established.
• Pain severity ranges from a mild ache to agonizing pain, generally felt near the ovaries on the same side as the developing follicle.
• Coincides with the peak in plasma luteinizing hormone (LH) levels, increasing ovarian perifollicular smooth muscle contractility via a prostaglandin-mediated pathway.

Issues of Concern:

• Presentation: Acute lower quadrant pain, usually right-sided, ranging from mild to intense.
• Differential Diagnosis:
  • Can mimic acute appendicitis, leading to potential misdiagnosis and unnecessary surgery.
  • Should be considered in differential diagnosis before diagnosing appendicitis in young women of reproductive age.
• Recognition: Essential for all medical providers to recognize and diagnose mittelschmerz to avoid unnecessary interventions.
• Interprofessional Communication: Important to improve patient outcomes and reduce harm.

Clinical Significance:

• Frequency: Women may not experience mittelschmerz every month and may not associate it with their ovulatory cycles.
• Location: Pain can present in either iliac fossa, typically on the same side as the developing follicle. , ‘horse-kick pain’, tends to move centrally, heavy feeling.
• Duration: Average duration of pain 5 hours, usually ceases within three to twelve hours but may persist until menstruation in patients with a history of ovarian surgery.
• Associated Symptoms: Mild backache may also be reported.
• Management:
  • Oral contraceptive use may improve symptoms.
  • Understanding the timing with peak LH levels can aid in identifying fertile days, useful for family planning.
• Differential Diagnosis:
  • Must consider gynecological pathologies when diagnosing acute abdominal pain to avoid mistaking it for appendicitis.
  • Both gynecological pathologies and appendicitis can present with similar symptoms like Rovsing’s sign, defense, elevated leukocyte count, and elevated temperature.
• Patient Outcomes: Awareness and proper diagnosis of mittelschmerz can improve patient outcomes and reduce unnecessary interventions.