Basics
Description
Midcycle left (LLQ) or right lower quadrant (RLQ) pain associated with ovulation that lasts 24 " 48 hours
Epidemiology
Prevalence
Approximately 20% of menstruating women experience mittelschmerz either each month or intermittently.
Risk Factors
Menstruating females
Pathophysiology
- The mechanism is not clearly understood.
- Theories include:
- An ovarian follicle releasing blood, follicular fluid, and prostaglandins causing local irritation.
- Increased fallopian tube peristalsis during ovulation
- Rapid expansion of the dominant follicle causing pain
Diagnosis
History
- Sudden onset of RLQ or LLQ pain that occurs on days 12 " 16 of the menstrual cycle (1)[B].
- Occasionally there is midcycle vaginal bleeding.
- Pain can be described as intense, dull, or aching pelvic pain.
- Symptoms typically last 24 " 48 hours.
Physical Exam
- Tenderness to palpation in the RLQ or LLQ.
- Normal gynecologic exam except for occasional midcycle bleeding
Tests
Lab
- Serum ²-human chorionic gonadotropin " +/ " transvaginal ultrasound to rule out ectopic pregnancy (2)[C]
- Rule out infection (cervicitis, pelvic inflammatory disease) (2)[C]
Imaging
- May need pelvic ultrasound to rule out other ovarian or uterine pathology
- CT to rule out appendicitis, if RLQ tenderness, or other GI pathology
Differential Diagnosis
- Ectopic pregnancy
- Pelvic inflammatory disease
- Adnexal cysts or masses with bleeding, torsion, or rupture
- Uterine infection
- Infarction or torsion of leiomyomas
- Appendicitis if pain is in RLQ
- Endometriosis
Treatment
Medication
First Line
Analgesics, generally NSAIDs or acetaminophen, are sufficient (1,2,3)[C].
Second Line
For recurrent symptoms, oral contraceptives, which suppress ovulation, are helpful (1)[C].
Additional Treatment
General Measures
Patient education regarding diagnosis
Issues for Referral
Referral is necessary only if diagnosis is uncertain.
Ongoing Care
Follow-Up Recommendations
Once diagnosed, patients can be treated as an outpatient.
Patient Education
Activity " as tolerated
Prognosis
- Symptoms may recur.
- Patients should be educated regarding symptoms and treatment.
References
1Stenchever MA Comprehensive gynecology, 4th ed. St. Louis, MO: Mosby Inc., 2001.2Gerber-Zimmerman P. Triaging lower abdominal pain. RN 2002;65:52 " 58.3Myers DL, Aguilar VC. Gynecologic manifestations of interstitial cystitis. Clin Obstet Gynecol 2002;45:233 " 241. [View Abstract]
Codes
ICD9
625.2 Mittelschmerz
ICD10
N94.0 Mittelschmerz
SNOMED
43548008 Mittelschmerz (finding)
Clinical Pearls
- History of midcycle pelvic pain is key to diagnosis.
- Need to rule out other causes of pelvic pain.
- First line treatment consists primarily of analgesics such as NSAIDs or acetaminophen.