Ovulatory pain is a type of chronic pelvic pain, in which painful sensations in the pelvic area are observed during ovulation and are associated with it. It is manifested by pain of varying intensity that occurs in the lower abdomen in the middle of the ovulatory cycle, accompanied by psychovegetative disorders. To make a diagnosis, the method of measuring basal temperature, folliculometry, ovulation tests are used. Symptomatic treatment with the use of antispasmodics, analgesics, sedatives is prescribed only with severe symptoms. According to the indications, it is possible to suppress the maturation of follicles with the help of oral contraceptives.
The presence of ovulatory pain in the patient (median pain syndrome, ovulatory pain, Mittelschmertz syndrome) is said when the organic basis for the occurrence of uncomfortable sensations is not detected or the clinical manifestations of the detected diseases can cause or enhance painful ovulation. Pulling soreness in the lower abdomen against the background of ovulation was experienced at least once in a lifetime by at least 45-50% of women, approximately 20% of patients have intermenstrual pain occurs regularly. In adolescent girls and girls under 20 years of age, the disorder is usually functional, in patients from 20 to 35 years of age it is often associated with inflammation, in women over 35 years of age, the leading causes are adhesions and dishormonal conditions.
Ovulatory pain is a consequence of physiological changes occurring in the female body at the time of the release of an egg from the ovary. In 85% of cases, it periodically or constantly appears in gynecologically healthy women, in 14% of patients it indicates diseases of the reproductive organs. In 1% of clinical situations, sudden soreness during ovulation is accompanied by extragenital pathology. The immediate causes of intermenstrual pain syndrome are:
- Low pain threshold. Normally, the output of the egg should not be felt. However, with a decrease in the threshold of pain, nerve impulses resulting from the reaction of the tissues of the ovary, fallopian tubes and pelvic peritoneum to the output of the egg are perceived by the brain as pathological, painful. This reason plays a leading role in impressionable or stressed patients.
- Inflammatory diseases of the reproductive organs. The painfulness of ovulation in women with chronic oophoritis, salpingitis, adnexitis is associated with possible tissue edema, limited mobility of organs and the action of inflammatory mediators that reduce the nociceptive threshold. Rupture of the follicle of an inflamed ovary feels more painful due to the sealing of the organ capsule.
- Extragenital and external genital endometriosis. Cells of endometrioid foci developing in the ovaries, fallopian tubes, pelvic peritoneum, cyclically change in response to the action of sex hormones. An intermenstrual drop in estrogen levels against a background of low progesterone concentration causes a menstrual-like effect in the zones of endometriosis with irritation of the surrounding tissues.
- Adhesions in the pelvis. When the uterine appendages are involved in the adhesive process, their mobility is significantly limited. After the rupture of the follicle, peristaltic movements of the fallopian tubes occur, the smooth muscle fibers of the ligaments supporting the ovary contract. As a result, the adhesions that surround these organs are stretched, pathological pain impulses are transmitted to the brain.
- Pelvic injuries. Intermenstrual pain syndrome is observed in 51.8% of women who have suffered traumatic injuries to the pelvic bones, especially the sacrococcygeal zone. The appearance of soreness during ovulation in such patients is associated with a violation of the innervation of the pelvic organs, a decrease in the threshold of pain, post-traumatic neuroendocrine disorders.
The development of Mittelschmertz syndrome is based on natural physiological processes occurring during ovulation. There are five components of ovulation that are theoretically capable of provoking the occurrence of pain: tension of the ovarian capsule during follicle maturation, its rupture for the release of the egg, irritation of the peritoneum with spilled follicular contents, peristalsis of the fallopian tubes capturing the oocyte, contraction of smooth muscle elements in the ovarian ligaments.
Normally, afferent impulses in all these processes take place at the subthreshold level. Intermenstrual pain becomes noticeable with congenital or acquired disorders in the antinociceptive system, when the threshold of pain sensitivity is reduced due to functional disorders (increased excitability of the cerebral cortex, post-traumatic changes in nerve fibers) or there is an organic basis for the formation of pathological sensations (inflammation, pathological secretion, adhesive process).
The key manifestation of ovulatory pain is considered to be soreness and discomfort in the lower abdomen 13-15 days before the start of the next menstruation. The intensity of the pain syndrome can be different — from pulling spilled discomfort to acute stabbing pain. Possible irradiation of sensations in the coccyx, sacrum, lower back, groin area, rarely — in the inner thigh. Usually, intermenstrual pain is unilateral, localized on the side of the ovary from which the egg came out. Only when two oocytes mature, it is felt from both sides. Pain syndrome during ovulation is usually accompanied by liquid transparent discharge from the vagina, increased sexual desire, mastodynia, in some patients — an increase in temperature to 37.0-37.4 ° C, nausea, short-term headache, dizziness, mood fluctuations. There may be several drops of blood on the underwear. The duration of clinical manifestations in Mittelschmerz syndrome usually does not exceed 1-2 days.
There is no danger to the health of a woman with painful ovulatory pain, but pronounced symptoms worsen the quality of life of the patient, leads to a decrease in productivity and efficiency. Impressionable patients may develop hypochondria, depressive neurosis, and carcinophobia. More serious are the consequences of untimely diagnosis of diseases, against which intermenstrual pain occurs. In the absence of adequate treatment, pathological processes are chronicled, complicated by a violation of reproductive and endocrine functions, the formation of neoplasms.
The tasks of the diagnostic stage of suspicion of intermenstrual pain syndrome are to confirm the connection of sensations with ovulation, to identify possible pathological causes of the disorder, to exclude other genital and extragenital diseases accompanied by pelvic soreness. When making a diagnosis , the most effective:
- Measurement of basal temperature. A simple free method available for self-monitoring at home. On the day of egg release, the rectal or vaginal temperature measured after a night’s sleep decreases by approximately 0.3 ° C, after which it rises to 37 ° C and above.
- Ultrasound folliculometry. Sonographic monitoring of the growth and development of the dominant follicle allows you to accurately determine the day of release of a mature oocyte. Transvaginal examination is performed daily in the first half of the monthly cycle, starting from 5-10 days after menstruation.
- Ovulation test. The technique is based on determining the level of luteinizing hormone in urine and is adapted for simple independent use. The level of LH increases until the follicle ruptures, reaches a peak when a mature egg leaves the ovary, after which it begins to decrease.
To identify diseases that enhance the clinic of ovulatory pain syndrome, pelvic ultrasound, CT and MRI of reproductive organs, diagnostic laparoscopy, determination of the level of sex hormones (estradiol, progesterone, FSH, LH), pharmacological hormonal tests, and other techniques are prescribed. Differential diagnosis of intermenstrual pain is carried out with follicular cyst, appendicitis, ectopic pregnancy, ovarian apoplexy, torsion of the leg of his cyst, acute salpingoophoritis, ovarian hyperstimulation syndrome with medications. Gynecologist-endocrinologist, abdominal surgeon may be involved in the diagnosis.
Specialists in the field of obstetrics and gynecology do not consider ovulatory pain to be a pathological phenomenon and usually do not prescribe any special therapy for minor or moderate painful sensations. In such cases, it is sufficient to exclude physical exertion, additional rest, refusal of sexual contact during ovulation, if the woman is not planning pregnancy. In case of intense pain syndrome or its occurrence on a pathological basis, treatment aimed at:
- Relief of pain. On the days of ovulation, it is possible to use antispasmodics and analgesics. Nonsteroidal anti-inflammatory drugs are often used, which reduce the level of inflammatory mediators, effectively affect peripheral and central nociceptive mechanisms, increasing the pain threshold and reducing the intensity of pathological impulses.
- Reduction of psychovegetative disorders. In most cases, the prescription of herbal sedatives is sufficient to correct emotional disorders associated with ovulation. When neurosis occurs against the background of intermenstrual pain, mild antidepressants, autosuggestion, and psychotherapeutic techniques are effective.
- Suppression of ovulation. Oral contraceptives are used to temporarily exclude the effect of factors that cause pain ovulatory pain. When they are taken, the maturation of the follicles stops, the cycle becomes anovulatory. Subsequently, after the restoration of a normal menstrual cycle, the intensity of symptoms often decreases.
- Treatment of genital and extragenital pathology. A specific therapeutic scheme is selected taking into account the leading disease that provokes or enhances the syndrome of median pain. Antibiotics, hormonal drugs, immunomodulators, and eubiotics can be used for treatment. In some cases, in the presence of volumetric formations, surgical interventions are indicated.
Prognosis and prevention
The prognosis of pain ovulatory pain is favorable, lifestyle correction and reasonable prescription of medications can reduce or completely eliminate painful sensations, improve a woman’s quality of life. An important role in the prognostic plan is played by timely determination of the causes of the disorder and adequate treatment of the identified organic pathology. For the prevention of negative manifestations of intermenstrual pain, the patient is recommended to visit an obstetrician-gynecologist at least twice a year, monitor the monthly cycle so that during the days of the expected release of the egg, excessive loads are excluded and sexual rest is observed.