I've been suffering from excruciating lower pelvic pain. My doctor examined me and found no cysts and told me that either my endometriosis had returned or I was just having "ovarian pain." The pain occurs about two weeks after the last day of my period. If there were no cysts involved, what else could cause "ovarian pain"? Could you also explain "mittelshmertz"?

--Angie

Mittelschmertz is German and means "middle pain." It is a term to denote midcycle pain associated with ovulation, a very common phenomenon. Mittelschmertz is usually on one side (the side that's ovulating that cycle) and is sharp and short-lived, lasting only a few hours. Most women would not consider mittleschmertz to be excruciating.

Ovarian cysts can also cause midcycle pain. Some ovarian cysts happen as a consequence of a small glitch in the normal process of ovulation, when the egg would normally be released from its follicle (the tiny pocket on the ovary in which the egg develops). Sometimes the egg fails to break out of the follicle on schedule, and instead the follicle fills with more and more fluid -- this is a cyst. Or sometimes a blood vessel in the follicle tears, and the follicle fills with blood, forming what we call a hemorrhagic cyst. Both types of cysts may cause pain and may eventually rupture, which is even more painful. Often, after a cyst ruptures, the pain will go away gradually over the course of a few days, without any other treatment. Sometimes birth control pills are used to hasten the resolution of a cyst.

Some cysts, called endometriomas, are due endometriosis. These, too, can cause pain. Endometriomas require intervention, either medical or surgical.

Endometriosis itself, in which uterine lining tissue grows outside the uterus, is classically associated with pelvic pain. Although the pain may vary from person to person, the typical pattern is pain beginning midcycle and escalating through the period. There may be associated symptoms such as pain with bowel movements or diarrhea and pain with intercourse. If you have a history of endometriosis, then it is not at all far-fetched to think it may have returned. Treatment could range from medical therapy (birth control pills, Depo-Provera or Lupron) to surgery.

If you have been having excruciating pain for a while, you may need to talk to your doctor about having a laparoscopy. Another option would be to try the pill or Depo-Provera or Lupron for a few months to see if this will take care of the problem. Together you and your doctor can decide which course is best for you. If the pain persists, ask your doctor for a full workup including imaging studies. It may help determine what is causing the pain.