Mittelschmerz

Patient Presentation
AB, a 24 year-old woman presented to her OB/GYN with cramp-like pain on her lower right abdomen.  Pt stated that the pain started sharp and was often sudden.  Pt stated that the “pain was so bad that I could barely sit from the pressure.” Pt also reported episodes of vomiting along with the pain. This happened once per month but not every month, and the pt stated that the pain had also occurred on her left side.  Pt stated mild vaginal bleeding and some discharge along with the pain.  The duration of the pain was anywhere from one to three days.  Pt stated taking Tylenol® “two pills,” daily with the pain, and that “helped a little.” A pelvic exam showed no abnormal presentations, as did an abdominal ultrasound. VS were stable, with no fever present.  Pt denies smoking and illegal drugs, drinks two drinks per week, is a waitress and student, no allergies, and “usually healthy.”  Pt was sexually active and in a monogamous heterosexual relationship, currently using only condoms.  LMP  was two weeks prior to visit.

Differential diagnoses
Pt differential diagnosis included ectopic pregnancy, pelvic inflammatory disease, appendicitis, ovarian cysts, ovarian cancer, UTI, endometriosis, and endometritis.

Diagnosis
A CBC did not show any abnormal values, or indicate an infection.  A urine analysis ruled out pregnancy. There was also no family history of ovarian or endometrial cancer.  Other abdominal differentials were ruled out due to the subjective data and pt denying any change in appetite, bowels, and any weight gain or loss.  Additionally, the ultrasound did not show any abnormal findings.  Upon further questioning the patient stated that her periods were regular and the next one was two weeks away.  The patient did recall that the pain seemed to happen in the middle of her periods, which is during the time of ovulation.  The pt was diagnosed with Mittelschmerz, a German word that means “middle pain,” and is pain associated with ovulation.

Treatment
The pt was sent home instructed to take 600 mg Ibuprofen or aspirin when the pain started.  The pt was also prescribed an oral contraceptive to help prevent ovulation, and thus the pain occurring with ovulation

Outcome
Pt was instructed to monitor the pain as it occurred during the month, and to return if the pain changed, lasted longer, or there was an increase of vaginal bleeding.