Mittelschmerz

Specialty: Gynecology and breast.

• Ovulation pain
• intermenstrual pain
• pelvic pain mid-cycle
• acute follicular pain

Why it occurs

• Rupture of the ovarian follicle with release of follicular fluid or irritative microbleeding into the peritoneal cavity
• Contraction of the fallopian tubes and ovary mediated by prostaglandins during ovulation
• Rapid growth of the dominant follicle that stretches the ovarian albuginea just before rupturing

Initial workup

Bimanual gynecological examination (usually shows slight unilateral adnexal sensitivity without masses). Transvaginal ultrasound performed during the painful episode to document the presence of a collapsed follicle or a small amount of free fluid in the pouch of Douglas, without other relevant adnexal abnormalities. Complete blood count and PCR to rule out acute inflammatory/infectious processes.

Standard management

• Ibuprofen 400-600 mg orally every 8 hours at the first painful symptoms for 1 or 2 days
• Naproxen 250-500 mg every 12 hours orally
• Paracetamol 1000 mg orally if there is a contraindication for anti-inflammatories
• Combined hormonal contraceptives orally, patch or vaginal ring to completely suppress ovulation if the pain is recurrent, severe and disabling every month (note: the detailed explanation and reassurance provided to the patient about the benign nature of the process constitute a fundamental pillar of management).