When Ovary Pain isn't Coming from your Ovary

"It hurts when I ovulate"

This is a common complaint in the Gyn's office. Up to 50% of women get pelvic pain mid-cycle, some every month. But is ovary pain really coming from your ovary? Sometimes it's not!

What is normal mid-cycle pain?

The most common cause of ovary pain is just plain ovulation and hormones (Mittelscherz). When the egg releases from the ovary, a small amount of fluid and blood comes with it. This fluid is irritating to the inside of your pelvis and can cause a quick sharp pain, then a mild ache.

The pain can also be considered normal if it is caused by uterine or tubal irritation just before or just after ovulating. This is more like mild period cramps and only lasts for a few minutes to a few hours, but can last up to 2 days. It won't interfere with your ability to function.

When is mid-cycle pain NOT normal?

When the pain is severe, or accompanied by any of the following, then regular ovary pain may not be the cause: 

Nausea and/or vomiting
Diarrhea
Pain that radiates to your back or groin
Burning sensation or numbness
Located under or around an old incision (like from a C-section)
Happens during intercourse (sex)
Happens with urinating or having a bowel movement
Affects your ability to go to work or school
You are on fertility medications

What else can cause mid-cycle pain?

There are many causes of consistent mid-cycle pain other than just ovulating. These include ovarian cysts, endometriosis, tubal infections, interstitial cystitis, irritable bowel syndrome, muscle or fascial pain, and nerve injuries.


After regular ovulatory pain, the most common cause I see in my practice is muscle/fascial pain. This is also known as pelvic floor dysfunction or levator ani syndrome. There's a lot of muscle and fascia in your pelvis; it's a really busy place! The muscles and fascia in your pelvis serve to hold up your insides when you sit and stand, as well as helping you go to the bathroom. Think of it like a hammock.





These muscles can get overworked for any number of reasons, from endometriosis, bladder problems, after having a bad urinary tract infection or surgery. Sometimes it's just stress related too! When the muscles work too hard for too long of a time, they can get tight and form something called trigger points. These are like muscle knots, the same kind you may get in your back or neck. Once they've formed, the trigger points themselves are causing the pain. They're tricky little guys too, and can cause your body to grow more nerves around them to transmit the pain back to the brain. They can also cause urinary and bowel symptoms, back pain, and buttocks pain.

Why do trigger points cause ovary pain?

That's a great question! The pelvis is a tight area, with lots of stuff in it, including your bladder, uterus, tubes, ovaries, bowel, muscles, nerves, and fascial tissue. The body has to transmit information from all these things to the brain for processing. Because it's such a tight area, there's only a few spots in the spinal cord that are available to transmit ALL of this information. Once the information gets to the spine, the pain signals all get thrown in together. What your brain reads is "there's pain somewhere in my pelvis". Every body feels that different. Some people feel it as bladder pain or bowel pain, some feel it as ovary pain.
What happens if I don't treat the pain?


Over time your body will get sensitized to the pain. The areas that are transmitting the pain actually grow more nerves by releasing a hormone called nerve growth factor. The brain can also up-regulate the pain by developing bigger centers to process it.

Think of it like a fire alarm. Normally the alarm only goes off if there's a lot of smoke. When the body and brain get sensitized to the pain, now lighting a match, or turning on your oven will set off the alarm. Things that didn't used to cause pain, like having a bowel movement, coughing, or having sex, will now cause pain too. It can get so bad that people quit work and go on disability. 

How are trigger points treated?

One of the most important factors that determine the treatment for trigger points is figuring out what is causing them in the first place. Trigger points don't usually form without a reason. They're a reaction to the pelvis tightening over time due to pain or stress. Once the source gets treated, the pain may stick around due to trigger points or sensitization. If trigger points are found, we treat them with a lot of different methods. It's best to use multiple methods to get relief, as most people won't get relief with just one thing. The treatments with the best evidence for relief are:
Physical therapy done by a trained female pelvic PT
Photobiomodulation therapy (near infrared lasers specially designed for the female pelvis)
Trigger point injections using anesthetics and steroids
Trigger point injections using Botox
Dry needling, acupuncture
Behavioral therapy
Medications to reduce nerve pain and sensitization 

Where can I go to get treated?

My name is Dr. Stoehr and I specialize in seeing the whole picture of pelvic pain. If you think you may have trigger points that need to be treated, or mid-cycle pain that may be related to this, please make an appointment to see me at Nurture Womens Health.


Resources:
ACOG bulletin #51
Relating Chronic Pelvic pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction. Aredo JV, et al.
A Randomized Clinical Trial for Women with Vulvodynia: Cognitive-behavioral Therapy vs. Supportive psychotherapy. Masheb RM, et al.
Improvement in pelvic pain with botulinum toxin type A- Single vs repeat injections. Nesbitt-Hawes EM, et al.
Chronic Pelvic Pain Syndrome: reduction of medication use after pelvic floor physical therapy with an internal myofascial trigger point wand. Anderson RU, et al.
Myofasical trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy. Moldwin RM, et al.
Role of nerve growth factor in pain. Mizumura K, et al.