Ovulation pain

Around one woman in five feels a pull or a twinge low down on one side of the abdomen somewhere in the middle of the cycle. This is ovulation pain and in itself it is harmless: the body is marking the release of an egg, nothing is breaking and there is nothing to treat. The trouble lies elsewhere. Mid-cycle is the most convenient place to file any lower abdominal pain, and that is exactly how time gets lost in ectopic pregnancy, ovarian torsion and endometriosis. So the point of this page is not the description of ovulation pain but its boundaries: what the genuine article looks like, and by what signs you can tell it is something else.

What genuine ovulation pain looks like

Ovulation pain sits inside a fairly narrow and recognisable frame. It:

• falls in the middle of the cycle — roughly a fortnight before the next period rather than a fortnight after the last one, which means different days in a long cycle and a short one;
• is felt on one side of the lower abdomen, left or right, and usually changes side from cycle to cycle, because the ovaries take turns;
• may be a dull dragging ache or a sharp stab, but stays bearable;
• lasts from a few minutes to a day, rarely two;
• is sometimes accompanied by light spotting or by a change in discharge, which becomes clear and stretchy;
• repeats from cycle to cycle in a similar way, so that in time a woman comes to recognise it.

That is precisely the test: the picture has to fit entirely inside the frame. If the pain is not mid-cycle, or is into its fourth day, or is worse than before, or has been joined by fever, vomiting, bleeding or a missed period, the frame is broken, and from that point the thinking has to move off ovulation and onto everything else. "But I'm right in the middle of my cycle" is not enough on its own.

Why the middle of the cycle hurts

Through the whole first half of the cycle a follicle ripens in the ovary — a fluid-filled sac with the egg inside it. By the time ovulation comes it has grown to about two centimetres and is stretching the capsule of the ovary, and the capsule is sensitive to stretch: hence the dragging sensation in the hours before the egg is released.

Then the follicle opens. A little fluid and a drop of blood pass into the abdominal cavity and irritate the peritoneum, and that gives a short sharp pain. On top of this, the wall of the ovary and the tube contract under the influence of prostaglandins, the same substances responsible for period cramps. All three mechanisms are brief, which is why the pain is brief too.

One useful caveat: this pain cannot be used as contraception. It may be felt before ovulation and equally after it, and sperm survive several days in the genital tract, so "the pain has passed, therefore it is safe" is a line of reasoning that regularly ends in pregnancy. As a rough guide when trying to conceive it is fine; as a method of contraception it is not.

When hours count

Call an ambulance on the single European number 112 if:

• severe lower abdominal pain comes with weakness, dizziness, pallor, cold sweat, a racing heart or fainting. A warning sign in its own right is pain going up into the shoulder or under the collarbone: that is how blood inside the abdomen makes itself known, by irritating the diaphragm;
• a very severe one-sided pain has come on suddenly, comes with vomiting and does not settle;
• the pain came on with a missed period and there is bleeding;
• the abdomen has become hard and painful at the lightest touch.

Ectopic pregnancy. The fertilised egg implants outside the womb, most often in the fallopian tube, and stretches it as it grows. The classic combination is a missed period, pain on one side and light bleeding unlike a normal period. What makes it treacherous is that the delay can be short, the woman may not yet have done a test, and the timing of the pain lands exactly where ovulation pain is expected. Hence a simple rule: with any new lower abdominal pain in a woman of childbearing age, the first step is a pregnancy test, even where pregnancy seems impossible — it happens on contraception and after tubal surgery, and after tubal surgery in particular the risk of it being ectopic is higher. The diagnosis is made with a blood test and a scan, and the earlier it is made, the better the chances of managing it with medicine rather than an operation. A ruptured tube is life-threatening and it happens fast.

Ovarian torsion. The ovary hangs on ligaments and can twist round on them, taking the vessels that supply it with it. The blood flow stops and the tissue starts to die. The picture is dramatic: sudden, very severe one-sided pain, often with nausea and vomiting, sometimes in waves, frequently after a sharp movement, a jump or physical exertion. It happens most often where there is already a cyst in the ovary, and also in pregnancy and after ovarian stimulation. Here the hours genuinely count: a twisted ovary is untwisted surgically, and the sooner that is done, the greater the chance of saving it. Waiting for it to "let go" is not an option — the pain sometimes does ease for a while, once the organ has already died.

A cyst rupturing with bleeding. The rupture of a functional cyst often leaves no consequences and is managed with rest and pain relief. But if a vessel tears, blood fills the abdominal cavity: the pain is abrupt, and then weakness, pallor and dizziness build. That is the case from the first list where an ambulance is needed.

What else disguises itself as ovulation

Not everything that is not ovulation needs an ambulance. But waiting for the next cycle is not the answer in these cases either.

• Appendicitis. It usually starts as a vague pain around the navel and moves down and to the right over a few hours. The distinguishing feature is that the pain builds rather than fades, and worsens on walking, on coughing and with the jolts of a bus ride; appetite disappears and nausea and a mild fever appear. It is regularly confused with right-sided ovulation pain, and the difference lies exactly in how it develops.
• Pelvic inflammatory disease. Lower abdominal pain on one or both sides together with fever, unusual discharge with an odour, pain during sex and bleeding between periods. It follows unprotected sex or a change of partner more often than not, because behind it there is usually a sexually transmitted infection. It is treated with antibiotics and cannot be left: untreated inflammation leaves adhesions, chronic pelvic pain and difficulty conceiving.
• Ovarian cysts. Small functional cysts form normally and usually disappear on their own within a couple of cycles. A large cyst causes heaviness and a dragging ache on one side, a feeling of fullness, needing to pass urine often, and disturbance of the cycle. It is checked with a scan.
• Adhesions after surgery or infection. A dragging pain that depends on posture and movement rather than on the day of the cycle.
• Nothing gynaecological at all. A stone in the ureter (severe pain in the flank going down into the groin, blood in the urine), a bladder infection, irritable bowel syndrome, constipation, a hernia, a pulled muscle in the abdominal wall. All of these give one-sided lower abdominal pain and land in mid-cycle by coincidence.

When "it's just ovulation" is not normal

Mid-cycle pain that does not fit into a day or two and gets in the way of your life is not something to be endured. Almost every woman has heard "everyone gets that", and it is precisely because of that phrase that a diagnosis of endometriosis arrives on average many years after the first complaints.

Endometriosis is a condition in which tissue resembling the lining of the womb grows outside it: on the peritoneum, on the ovaries, on the bowel. It responds to the same hormones, bleeds every month into a closed space and causes inflammation and adhesions. Reasons to suspect it:

• the pain starts several days before a period and does not let go;
• period pain is bad enough to keep you lying down and away from work or study, and painkillers at usual doses do not cope;
• discomfort with deep penetration during sex;
• pain on opening the bowels or passing urine, particularly during a period, sometimes with blood;
• lower abdominal pain outside periods, day after day;
• marked fatigue and bloating;
• pregnancy has not happened after more than a year.

It is also worth seeing a doctor in the other situations where the frame of ovulation pain is plainly broken: the pain gets worse with each cycle; it is always on the same side; mid-cycle pain has appeared for the first time after forty or already in the menopause; it comes with a change in the cycle, bleeding between periods, weight loss, bloating that does not settle and a constant feeling of fullness after eating. That last combination — bloating, filling up quickly, an abdomen that has changed, needing to pass urine often — deserves checking separately and without delay: an ovarian tumour can begin this way, and in the early stages it declares itself with exactly these vague complaints.

What helps if it really is ovulation

• Warmth on the lower abdomen: a hot water bottle through a cloth or a warm shower. It works the same way as for period cramps, and often that is all that is needed.
• A painkiller — paracetamol or a non-steroidal anti-inflammatory. The latter is usually more effective for this pain because it acts on prostaglandins. Agree the choice and the dose with a doctor or pharmacist, particularly with stomach or kidney problems and in pregnancy.
• A quiet few hours — but there is no need to spend the day in bed; gentle movement is tolerated well.
• Keep a short diary: day of the cycle, side, character and duration of the pain. Over two or three cycles it becomes clear whether it recurs in the same phase. That answers the main question for you and saves the doctor time.
• If the pain recurs and gets in the way, hormonal contraception is worth discussing with a doctor: it suppresses ovulation and the pain with it. A doctor chooses it taking your contraindications into account — it is not something to prescribe for yourself.
• One sign that should raise a flag: a painkiller at a normal dose does not work. Ovulation pain responds to it; if it does not respond, the cause is most likely not ovulation.

How mid-cycle pain gets sorted out

The work-up here is short and mostly painless.

It starts with a pregnancy test — with acute pain that is the first step, regardless of what the calendar says and what contraception is being used. Then the doctor asks about the day of the cycle, the side, the duration, any link with sex and with opening the bowels, about discharge and fever, and examines you. The main investigation is a pelvic ultrasound scan, preferably transvaginal: it shows a cyst, free fluid in the pelvis and signs of disturbed blood flow in the ovary. Depending on the situation, a full blood count and inflammatory markers, a urine test and swabs for chlamydia and gonorrhoea are added, and where an ectopic pregnancy is suspected, a blood test for chorionic gonadotrophin, usually twice with a gap, because what matters is not the figure but the way it moves.

One clarification that costs women years: a normal scan does not rule out endometriosis. Many deposits are not visible on it, and "the scan is clear" does not mean the symptoms are imagined. If the picture is typical, the doctor goes further — starting a trial of treatment or referring on to a specialist, rather than sending you home.

Online consultation

Telling ovulation pain apart from everything else is largely done through the history, which makes it convenient to start working it out from home rather than waiting for an appointment. The Oladoctor doctor will establish which day of the cycle the pain fell on, which side it is, how long it lasts, whether the side changed on previous occasions, whether there is a missed period, discharge or fever, and from those answers will say whether it all fits an ordinary ovulation. They will advise whether a pregnancy test is needed right now, which pain relief suits you, whether a scan is worthwhile and which day of the cycle to book it for, and where the pain is prolonged and severe they will explain what the path to a diagnosis of endometriosis looks like and what can be done straight away. And they will name outright the situations in which the conversation has to stop: sudden severe pain with vomiting, pain with a missed period and bleeding, weakness and dizziness are a reason to call an ambulance, not to finish typing a message.

This material is for information only and does not replace medical advice.