"Mittelschmerz"

ALLPeer reviewersCecilia Bottomley, MBBChir, MD, MRCOGConsultant Gynaecologist and Clinical Lead for Gynaecology Governance University College London Hospitals NHS Foundation Trust London UK DisclosuresCB declares that she has no competing interests. * * Differentials * Ectopic pregnancy * Mittelschmerz due to ruptured graafian (dominant) follicle * Urolithiasis More Differentials * Guidelines

pregnancy. * Endometriosis — dysmenorrhoea, cyclical abdominal/pelvic/back pain, often 1–2 weeks before menstruation and during menstruation. For more information, see the CKS topic on Endometriosis. * Miscarriage — lower abdominal cramping or vaginal bleeding. For more information, see the CKS topic on Miscarriage. * Mittelschmerz — one-sided, sharp, and usually lasts less than a few hours in the middle

magnets Sepsis Testicular Torsion DKA Appendicitis Mesenteric adenitis Meckels GORD/gastritis Coeliac Pneumonia HSP Pancreatitis UTI EBV HUS Poisoning- venoms, paracetamol, lead, iron FB- beware button battery, multiple magnets Porphyria Familial Mediterranean Fever Sepsis Gonadal Torsion DKA Appendicitis Mesenteric Adenitis Obstetric and Gynae • Dysmenorrhoea • Mittelschmerz • PID • Endometriosis

Sidwell, Comorbidities Editor, BMJ Best PracticeDisclosuresAS declares that she has no competing interests.Adam Mitchell, Drug Editor, BMJ Best PracticeDisclosuresAM declares that he has no competing interests. * * * Differentials * Ectopic pregnancy * Mittelschmerz due to ruptured graafian (dominant) follicle * Urolithiasis More Differentials * Guidelines * Imaging in gynecological

/ intestines / PREGNANCY * Hx and physical are insufficient to rule in or out pathology * ask about high risk sexual features * use of fertility treatments or surgery * Most acute serious pathologies have less than 48 hrs of pain * Symptoms * Lateral pain = ovary or tube pathology * may also be appendix, diverticulitis or colic * benign: mittelschmerz, luteum cyst * Central pain = uterus

, schistosomiasis.Gynaecological - eg, pelvic malignancy, uterine fibroids, endometriosis, mittelschmerz (ovulation pain), pelvic inflammatory disease, genital atrophy, overactive bladder.Urological - eg, bladder cancer, radiation cystitis, overflow incontinence, chronic pelvic pain syndrome, bladder outlet obstruction, urolithiasis, urethritis, chronic prostatitis, prostate cancer.Neurological - eg, detrusor overactivity

, exacerbating or relieving factors. These points can be remembered with the mnemonic 'SOCRATES': [Site] [Onset] [Character] [Radiation] [Associated symptoms][Time] [Exacerbating/relieving] [Severity]. * Onset - establish how, when and where. * Ask whether the patient has had any previous investigation or treatment. * Discuss relationship to menses (eg, dysmenorrhoea, Mittelschmerz). * Discuss relationship

ovarian cyst is a common phenomenon, with presentation ranging from no symptoms to symptoms mimicking an acute abdomen. [1] Sequelae vary. Menstruating women have rupture of a follicular cyst every cycle, which is either asymptomatic or with mild transient pain (mittelschmerz). In less usual circumstances, the rupture can be associated with significant pain. In very rare circumstances, intraperitoneal

in 90% of cases.RuptureThe outcome of ovarian cyst rupture is evaluated based on associated symptoms and will dictate whether the patient is discharged or admitted for laparoscopy.Ovarian cyst rupture commonly occurs with corpus luteal cysts. They involve the right ovary in two thirds of cases and usually occur on days 20-26 of the woman’s menstrual cycle. Mittelschmerz is a form of physiologic cyst

are correlated to individual compliance. Rates range from 0.1% with perfect use to 5% with typical use.AdvantagesOral contraceptives are used as treatment for menstrual irregularity because menses is more regular and predictable. In the prevention of ovulation, oral contraceptives can reduce and sometimes eliminate mittelschmerz. Women with anemia secondary to menorrhagia increase their iron stores. Women can

3. Timing 1. Mid-cycle pain 1. Mittelschmerz 4. Associated Symptoms: Miscellaneous 1. Fever 1. Pelvic Inflammatory Disease 2. Urinary Tract Infection including Pyelonephritis 3. Postpartum Endometritis 4. Diverticulitis 2. Nausea or Vomiting 1. Appendicitis 2. Ovarian Torsion 5. Associated Symptoms

. Round ligament pain 12. Fertility treatment specific conditions (with or without current pregnancy) 1. Ovarian Hyperstimulation Syndrome 2. Heterotopic Pregnancy (rare) III. Causes: Gynecologic Causes of Acute Pelvic Pain 1. Mittelschmerz 2. Ovarian Cyst (Hemorrhage or rupture) 3. Ovarian Torsion 4. Acute Pelvic Inflammatory Disease or Tubo-Ovarian Abscess 5. Endometriosis 6

. Endometriosis 2. Chronic Pelvic Inflammatory Disease 3. Pelvic Adhesions 4. Mittelschmerz 5. Pelvic Relaxation 6. Ovarian Remnant Syndrome 7. Pelvic Congestion Syndrome 8. Cyclic Pelvic or Uterine pain 1. Primary Dysmenorrhea 2. Secondary Dysmenorrhea VIII. References 1. Speer (2016) Am Fam Physician 93(5):380-7 [PubMed] 2. Zondervan (1999) Br J Obstet Gynaecol 106(11):1149-55 [PubMed] 3

2. Mid-cycle Symptoms Include 1. Spotting 2. Increased vaginal secretions 3. Increased libido 4. Nausea 5. Abdominal Pain (Mittelschmerz) 3. Identification of Ovulation Timing 1. See Ovulation 2. See Fertility Tracking 3. See Basal Body Temperature 4. Fertilization (pregnancy) 1. Ovum (egg) fertilized typically within one day of Ovulation 2. Sperm

. Normal cycles typically vary by only 1-2 days per month III. History: Suggesting Ovulation 1. Keep a menstrual Diary for several months 1. Record days of uterine bleeding and amount 2. Record associated symptoms 2. Document premenstrual and Menstrual Symptoms 1. Breast tenderness 2. Menstrual Cramps 3. Depressed mood 4. Mid-cycle pelvic cramping (Mittelschmerz) IV

, dull, vague and diffuse Abdominal Pain 3. Recurrent, Associated with debilitation 2. Common Causes 1. Constipation 2. Lactose intollerance 3. Mittelschmerz 4. Psychogenic (See Recurrent Abdominal Pain Syndrome) 1. Secondary Gain 2. Sexual abuse 3. School Phobia IV. History: Red

Abdominal Pain in Children 5. Constipation 6. Lactose Intolerance 7. Helicobacter Pylori VI. Causes: Adolescent (age 12 to 18 years) 1. Surgical and serious causes 1. Appendicitis 2. Testicular Torsion 3. See Gallbladder disease above 2. Gynecologic cause 1. Pregnancy (or Ectopic Pregnancy) 2. Mittelschmerz 3. Dysmenorrhea 4. Pelvic Inflammatory Disease

ovarian cyst is a common phenomenon, with presentation ranging from no symptoms to symptoms mimicking an acute abdomen. [1] Sequelae vary. Menstruating women have rupture of a follicular cyst every cycle, which is either asymptomatic or with mild transient pain (mittelschmerz). In less usual circumstances, the rupture can be associated with significant pain. In very rare circumstances, intraperitoneal

ovarian cyst is a common phenomenon, with presentation ranging from no symptoms to symptoms mimicking an acute abdomen. [1] Sequelae vary. Menstruating women have rupture of a follicular cyst every cycle, which is either asymptomatic or with mild transient pain (mittelschmerz). In less usual circumstances, the rupture can be associated with significant pain. In very rare circumstances, intraperitoneal

stress and maintain a normal body mass index.For patient education resources, seeWomen's Health Center, as well asVaginal BleedingandPainful Ovulation (Mittelschmerz).Previous Clinical Presentation References 1. Abbas T, Husain A. Emergency department management of abnormal uterine bleeding in the nonpregnant patient. Emerg Med Pract. 2021 Aug. 23 (8):1-20. [QxMD MEDLINE Link]. 2. Frick KD