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Mittelschmerz

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 ovulationRapid 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.