The Mysteries of Ovulation Pain

What is that mysterious twinge you feel on your lower abdomen, but it doesn't coincide with your period? It's the one that comes back every month, roughly at the middle of your cycle. This is pain that's associated with ovulation or, in medical terms, mittelschmerz.

According to Dr. Jenna Turocy of Columbia University, it is difficult to determine the prevalence of ovulation symptoms because they are so mild. Women don't usually report them. According to some estimates, up to 40 percent of women in reproductive age experience it nearly every month. The pain can be hard to pinpoint; it may last for several minutes or even for several hours. Sometimes it feels like mild pain, but for others it can be so severe that they mistake it for appendicitis.

Only a few papers have been published on mittelschmerz. Many of these date back to early 1900s, or are small, and focus on rare medical complications. Dr. Daniel Breitkopf is a Mayo Clinic gynecologist. He said that there is not much research on why mittelschmerz occurs. "And very little research is concerned with day-today experiences." Some women do not experience any pain during ovulation.

Why can ovulation be painful?

According to Dr. Elizabeth Ginsburg of Harvard Medical School, vice president of American Society for Reproductive Medicine, ovulation is an extremely complex process. In a few days, one follicle, a fluid-filled sac that contains a single egg, grows from four millimeters in diameter to more than 10 millimeters. The egg is released from the follicle when it has reached maturity. "Every ovulation, in essence, is a ruptured cyst," Dr. Ginsburg explained. Dr. Ginsburg explained that ultrasounds showed that ovulation is accompanied by a small eruption of fluid, and sometimes even blood, on the ovary's surface. Ovulation can occur in either of the ovaries. Those who experience pain will find that the side they feel it on changes from cycle to cycle.

'My patients are mostly infertile and trying to get pregnant. So they're sort of reassured by this pain.' This is often an indicator of their highest chances in a cycle of becoming pregnant, said Dr. Ginsburg.

There is no way to know which part of the ovulation cycle might cause pain. In a 1980 study that measured hormone levels and the size of the follicle, women reported feeling pain before the egg emerged. This suggests that the pain could be a "pre-ovulatory" event. Dr. Ginsburg suggested that cramping can be caused by the follicle expanding.

Aparna Sridhar is an OB/GYN from U.C.L.A. She said that there are two more potential culprits. Health: LH (luteinizing hormone), which causes follicle rupture. Prostaglandins are hormone-like substances which cause muscle contractions and pain, including around the bowel. She said that the surge in LH leads to a surge of prostaglandins.

Dr. Sridhar explained that teens who are just starting to menstruate, for instance, do not feel any ovulatory discomfort. This is because even though their follicles are expanding, they do not ovulate yet and so their levels of LH and prostaglandins are low.

What can you do to relieve pain?

Dr. Breitkopf explained that ovulation pain shouldn't be debilitating. Severe pain that persists after 24 hours could indicate a bigger problem. He said that he has seen people who have come to him with severe pain and it is affecting their lives. Sometimes it is so bad that people may need to take some time off from work.

In some cases the pain could be a sign of internal bleeding caused by a ruptured follicle that may require surgery. Women who suffer from endometriosis, or have had a previous surgery scarring their ovaries, tend to experience more pain during ovulation.

Experts believe that over-the counter pain medication and the treatment for period cramps can help to manage mild ovulation symptoms. Dr. Turocy added that a heat pack could also be beneficial.

Dr. Sridhar says that hormonal birth control can be an option for those who don't want to become pregnant but are experiencing pain in their daily lives. This is because it stops ovulation. It can be a life-saver.