Mittelschmerz | Sparrow

Overview

Mittelschmerz is one-sided, lower abdominal pain associated with ovulation. German for “middle pain,” mittelschmerz occurs midway through a menstrual cycle — about 14 days before your next menstrual period.

In most cases, mittelschmerz doesn’t require medical attention. For minor mittelschmerz discomfort, over-the-counter pain relievers and home remedies are often effective. If your mittelschmerz pain is troublesome, your doctor may prescribe an oral contraceptive to stop ovulation and prevent midcycle pain.

Symptoms

Mittelschmerz pain usually lasts a few minutes to a few hours, but it may continue for as long as a day or two. Pain from mittelschmerz may be:

• On one side of your lower abdomen
• Dull and achy, similar to menstrual cramps
• Sharp and sudden
• Accompanied by slight vaginal bleeding or discharge
• Rarely, severe

Mittelschmerz pain occurs on the side of the ovary that’s releasing an egg (ovulating). The pain may switch sides every other month, or you may feel pain on the same side for several months.

Keep track of your menstrual cycle for several months and note when you feel lower abdominal pain. If it occurs midcycle and goes away without treatment, it’s most likely mittelschmerz.

When to see a doctor

Mittelschmerz rarely requires medical intervention. However, contact your doctor if a new pelvic pain becomes severe, if it’s accompanied by nausea or fever, or if it persists — any of which could indicate you have a condition more serious than mittelschmerz, such as appendicitis, pelvic inflammatory disease or even an ectopic pregnancy.

Causes

Mittelschmerz occurs during ovulation, when the follicle ruptures and releases its egg. Some women have mittelschmerz every month; others have it only occasionally.

The exact cause of mittelschmerz is unknown, but possible reasons for the pain include these:

• Just before an egg is released with ovulation, follicle growth stretches the surface of your ovary, causing pain.
• Blood or fluid released from the ruptured follicle irritates the lining of your abdomen (peritoneum), leading to pain.

Pain at any other point in your menstrual cycle isn’t mittelschmerz. It may be normal menstrual cramping (dysmenorrhea) if it occurs during your period, or it may be from other abdominal or pelvic problems. If you have severe pain, see your doctor.

Diagnosis

To diagnose mittelschmerz, your doctor will start by asking you questions to get a clear idea of your medical history, especially regarding your menstrual periods. Your doctor may also perform a physical exam, including a pelvic exam, to check for signs of an underlying condition that could be contributing to the pain.

Treatment

Possible treatments for mittelschmerz include:

• Pain relievers. For the relief of discomfort from mittelschmerz, try an over-the-counter drug such as acetaminophen (Tylenol, others), aspirin, ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve).
• Birth control pills (oral contraceptives). If mittelschmerz causes you a lot of discomfort or occurs monthly, ask your doctor about taking birth control pills. Some types of birth control pills suppress ovulation, which could help ease ovulation pain while you’re taking them.

Lifestyle and home remedies

To ease mittelschmerz discomfort that lasts more than a few minutes, try some home remedies. Because heat increases blood flow, relaxes tense muscles and eases cramping, you might want to:

• Soak in a hot bath
• Use a heating pad where the pain is

Preparing for an appointment

In most cases, you won’t need to see a doctor for mittelschmerz. However, if your pain is especially troublesome, you may make an appointment to confirm a diagnosis of mittelschmerz or to explore treatment options.

What you can do

You may want to write a list that includes:

• Detailed descriptions of your symptoms
• The dates when your last two menstrual periods began
• Information about medical problems you’ve had
• Information about the medical problems of your parents or siblings
• All the medications and dietary supplements you take
• Questions to ask the doctor

Preparing a list of questions for your doctor will help you make the most of your time together. For mittelschmerz, some basic questions to ask include:

• What is likely causing my symptoms?
• Are there other possible causes for my symptoms?
• Are my symptoms likely to change over time?
• Do I need tests?
• What treatments or home remedies might help?
• Do you have brochures or other printed materials I can have? What websites do you recommend?

Don’t hesitate to ask other questions, as well.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

• How many days apart are your menstrual periods, and how long do they last?
• How would you describe your symptoms?
• Where is your pain?
• How long have you been experiencing this pain? Is it constant or does it subside after a few minutes or hours?
• On a scale of 1 to 10, how severe is your pain?
• How long before or after your period does the pain occur?
• Do you have other symptoms, such as nausea, vomiting, diarrhea, back pain, dizziness or headache?

Mittelschmerz – StatPearls – NCBI Bookshelf

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Nathan R. Brott; Jacqueline K. Le.

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Last Update: May 1, 2023.

Definition/Introduction

Mittelschmerz—or ovulation pain, as it is commonly known today—is a benign preovulatory lower abdominal pain that occurs midcycle (between days 7 and 24) in women. Mittelschmerz may affect over 40% of women of reproductive age, and it occurs almost every month in these patients. It generally does not begin until a few years following menarche, when the true ovulatory cycles become established. Pain varies in severity from a mild ache to agonizing pain and is generally felt near the ovaries on the same side as the developing follicle. Mittelschmerz has been found to coincide with the peak in plasma luteinizing hormone (LH) levels when the follicle is enlarging and has not yet ruptured; however, mittelschmerz is unlikely due to follicular distention. Rather, the LH rise increases ovarian perifollicular smooth muscle contractility via a prostaglandin-mediated pathway, potentially producing pain.[1][2][3][4]

Issues of Concern

Mittelschmerz most often presents as an acute lower quadrant (usually right-sided) pain ranging from a mild ache to intense pain. Along with several other gynecologic pathologies, mittelschmerz may present similarly to acute appendicitis, leading to misdiagnosis and unnecessary surgery. Mittelschmerz merits consideration before diagnosing appendicitis in young women of reproductive age. Mittelschmerz should also be given adequate attention from all medical providers so that it can be easily recognized and diagnosed. Interprofessional communication and awareness can help improve patient outcomes and reduce patient harm.[5][6][7]

Clinical Significance

Women who experience mittelschmerz may not experience it every month, and they may not recognize that it is related to their ovulatory cycles. Mittelschmerz can present as pain in either iliac fossa, and it will generally be on the same side as the developing follicle.[8] The pain usually ceases within three to twelve hours, although patients who have undergone ovarian surgery may experience mittelschmerz that persists until the onset of menstruation. The patient may also report mild backache.[5] Mittelschmerz may improve with oral contraceptive use.[9][10] The knowledge that mittelschmerz coincides with peak luteinizing hormone (LH) levels may be useful in identifying the most fertile days of the ovulatory cycle and potentially aid in family planning.[3] 

In female patients of reproductive age, gynecological pathologies can often be mistaken for acute appendicitis. Gynecologic pathologies and acute appendicitis can both present with Rovsing’s sign, defense, elevated leukocyte count, and elevated temperature in a statistically significant number of cases. When working with this population, healthcare teams need to consider the probability of gynecological pathologies when working up a case of acute abdominal pain—doing so can improve patient outcomes and reduce patient harm. [6] [Level 1]

Nursing, Allied Health, and Interprofessional Team Interventions

All interprofessional healthcare team members who work with women of child-bearing age should be familiar with Rovsing’s sign. Clinicians need to be able to differentiate the possible causes of this pain from conditions that mimic it, and nurses can provide patient counsel and act as a primary contact point for patient concerns and questions.

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References

1.

Durai R, Ng PC. Mittelschmerz mimicking appendicitis. Br J Hosp Med (Lond). 2009 Jul;70(7):419. [PubMed: 19584789]

2.

Martin P, Carriere C, Dozier C, Quatannens B, Mirabel MA, Vandenbunder B, Stehelin D, Saule S. Characterization of a paired box- and homeobox-containing quail gene (Pax-QNR) expressed in the neuroretina. Oncogene. 1992 Sep;7(9):1721-8. [PubMed: 1354346]

3.

O’Herlihy C, Robinson HP, de Crespigny LJ. Mittelschmerz is a preovulatory symptom. Br Med J. 1980 Apr 05;280(6219):986. [PMC free article: PMC1601114] [PubMed: 7417773]

4.

Won HR, Abbott J. Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach. Int J Womens Health. 2010 Aug 20;2:263-77. [PMC free article: PMC2990894] [PubMed: 21151732]

5.

CHARLEWOOD GP. Mittelschmerz or ovulation pain. S Afr Med J. 1958 Mar 08;32(10):261-2. [PubMed: 13543465]

6.

Hatipoglu S, Hatipoglu F, Abdullayev R. Acute right lower abdominal pain in women of reproductive age: clinical clues. World J Gastroenterol. 2014 Apr 14;20(14):4043-9. [PMC free article: PMC3983461] [PubMed: 24744594]

7.

Clark JF, Stephens BE. Gynecological problems causing acute abdominal symptoms in adolescent girls. J Natl Med Assoc. 1976 Mar;68(2):117-9. [PMC free article: PMC2609479] [PubMed: 1263271]

8.

Marinho AO, Sallam HN, Goessens L, Collins WP, Campbell S. Ovulation side and occurrence of mittelschmerz in spontaneous and induced ovarian cycles. Br Med J (Clin Res Ed). 1982 Feb 27;284(6316):632. [PMC free article: PMC1496249] [PubMed: 6802266]

9.

Jensen JT, Speroff L. Health benefits of oral contraceptives. Obstet Gynecol Clin North Am. 2000 Dec;27(4):705-21. [PubMed: 11091985]

10.

Premenstrual symptoms. Br Med J. 1973 Mar 24;1(5855):689-90. [PMC free article: PMC1588849] [PubMed: 4735136]

Disclosure: Nathan Brott declares no relevant financial relationships with ineligible companies.

Disclosure: Jacqueline Le declares no relevant financial relationships with ineligible companies.

Copyright © 2023, StatPearls Publishing LLC.

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Intermenstrual pain syndrome. What is Intermenstrual Pain Syndrome?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Intermenstrual pain syndrome is a type of chronic pelvic pain in which pain in the pelvic area occurs during and is associated with ovulation. 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, use the method of measuring basal temperature, folliculometry, ovulation tests. Symptomatic treatment with the use of antispasmodics, analgesics, sedatives is prescribed only for severe symptoms. According to the indications, it is possible to suppress the maturation of follicles with the help of oral contraceptives.

• Causes
• Pathogenesis
• Symptoms
• Complications
• Diagnostics
• Treatment of intermenstrual pain syndrome
• Prognosis and prevention
• Prices for treatment

General

The presence of an intermenstrual pain syndrome in a patient (median pain syndrome, ovulatory pain, Mittelshmerz syndrome) is said to be when an organic basis for the occurrence of uncomfortable sensations is not detected or the clinical manifestations of the detected diseases can cause or intensify painful ovulation. Pulling soreness in the lower abdomen during ovulation at least once in a lifetime was experienced by at least 45-50% of women, in approximately 20% of patients, 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 old it is often associated with inflammation, in women over 35 years of age, adhesive processes and dyshormonal conditions become the leading causes.

Intermenstrual pain syndrome

Causes

Ovulatory pain is a consequence of the physiological changes that occur in the female body at the time the egg is released 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 pain during ovulation is accompanied by extragenital pathology. The immediate causes of the syndrome of intermenstrual pain are:

• Low pain threshold. Normally, the release of the egg should not be felt. However, with a decrease in the pain threshold, nerve impulses resulting from the reaction of the tissues of the ovary, fallopian tubes and pelvic peritoneum to the release of the egg are perceived by the brain as pathological, painful. This cause plays a leading role in impressionable or stressed patients.
• Inflammatory diseases of the reproductive organs. Painful ovulation in women with chronic oophoritis, salpingitis, adnexitis is associated with possible tissue edema, limited organ mobility and the action of inflammatory mediators that reduce the nociceptive threshold. The rupture of the follicle of the inflamed ovary is felt more painful due to the compaction of the organ capsule.
• Extragenital and external genital endometriosis. The cells of endometriotic lesions that develop in the ovaries, fallopian tubes, and pelvic peritoneum change cyclically in response to the action of sex hormones. An intermenstrual drop in the level of estrogen against the background of a low concentration of progesterone causes a menstrual-like effect in the areas of endometriosis with irritation of the surrounding tissues.
• Adhesions in the pelvis. When involved in the adhesive process of the uterine appendages, 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 that support the ovary are reduced. As a result, the adhesions that surround these organs are tightened, and pathological pain impulses are transmitted to the brain.
• Injuries of the pelvis. The syndrome of intermenstrual pain is observed in 51.8% of women who have suffered traumatic injuries of the pelvic bones, especially the sacrococcygeal zone. The appearance of pain 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.

Pathogenesis

The development of the Mittelshmertz syndrome is based on the natural physiological processes that occur during ovulation. There are five components of ovulation that are theoretically capable of provoking pain: tension of the ovarian capsule during follicle maturation, its rupture for the release of the egg, irritation of the peritoneum by the outflow of follicular contents, peristalsis of the fallopian tubes that capture the oocyte, contraction of smooth muscle elements in the ligaments of the ovary.

Normally, afferent impulsation during all these processes takes place at a 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) .

Symptoms

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 diffuse discomfort to acute stabbing pain. Possible irradiation of sensations in the coccyx, sacrum, lower back, inguinal region, rarely – in the inner surface of the thigh. Usually intermenstrual pain is one-sided, localized on the side of the ovary from which the egg came out. Only when two oocytes are maturing is it felt from both sides. Pain during ovulation is usually accompanied by liquid transparent vaginal discharge, increased sexual desire, mastodynia, in some patients – fever up to 37.0-37.4 ° C, nausea, short-term headache, dizziness, mood swings. There may be a few drops of blood on the linen. The duration of clinical manifestations in Mittelshmertz syndrome usually does not exceed 1-2 days.

Complications

There is no danger to a woman’s health with pain intermenstrual syndrome, but severe symptoms worsen the patient’s quality of life, leading to a decrease in productivity and performance. Impressible patients may develop hypochondria, depressive neurosis, carcinophobia. More serious are the consequences of untimely diagnosis of diseases, against which there is intermenstrual pain. In the absence of adequate treatment, pathological processes become chronic, complicated by impaired reproductive and endocrine functions, and the formation of neoplasia.

Diagnostics

The tasks of the diagnostic stage of suspected 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 pain in the pelvic region. When making a diagnosis, the most effective:

• Basal temperature measurement. A simple free method available for self-control at home. On the day of the release of the egg, 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.
• Ultrasonic 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 carried out daily in the first half of the monthly cycle, starting from 5-10 days after menstruation.
• Ovulation test. The technique is based on the determination of the level of luteinizing hormone in the urine and is adapted for simple independent use. The LH level rises until the follicle ruptures, reaches a peak when a mature egg leaves the ovary, after which it begins to decline.

To identify diseases that enhance the clinic of ovulatory pain syndrome, ultrasound of the small pelvis, CT and MRI of the reproductive organs, diagnostic laparoscopy, determination of the level of sex hormones (estradiol, progesterone, FSH, LH), pharmacological hormonal tests, and other methods are prescribed. Differential diagnosis of intermenstrual pain is carried out with a follicular cyst, appendicitis, ectopic pregnancy, ovarian apoplexy, torsion of the legs of its cyst, acute salpingo-oophoritis, ovarian hyperstimulation syndrome with drugs. A gynecologist-endocrinologist, an abdominal surgeon may be involved in the diagnosis.

Treatment of intermenstrual pain syndrome

Specialists in the field of obstetrics and gynecology do not consider ovulatory pain a pathological phenomenon and usually do not prescribe any special therapy for minor or moderate pain. In such cases, exclusion of physical activity, additional rest, and refusal to have sexual contacts during the ovulation period are sufficient if the woman does not plan pregnancy. With an intense pain syndrome or its occurrence on a pathological basis, treatment is recommended aimed at:

• Pain management. On the days of ovulation, the use of antispasmodics and analgesics is possible. Non-steroidal 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 the emotional disturbances associated with ovulation. In the event of neurosis against the background of intermenstrual pain, mild antidepressants, autosuggestion, and psychotherapeutic techniques are effective.
• Ovulation suppression. Oral contraceptives are used to temporarily eliminate the effect of factors that cause pain between menstrual syndrome. 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 regimen is selected taking into account the leading disease that provokes or intensifies the median pain syndrome. For treatment, antibiotics, hormonal drugs, immunomodulators, eubiotics can be used. In some cases, in the presence of volumetric formations, surgical interventions are indicated.

Prognosis and prevention

The prognosis of pain intermenstrual syndrome is favorable, lifestyle correction and reasonable prescribing of drugs can reduce or completely eliminate pain, improve the quality of life of a woman. An important role in the prognostic plan is played by the timely determination of the causes of the disorder and the adequate treatment of the identified organic pathology. To prevent the 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 on the days of the expected release of the egg, eliminate excessive stress and observe sexual rest.

You can share your medical history, what helped you in the treatment of intermenstrual pain syndrome.

Sources

1. self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

   Ovarian Pain: The 7 Most Common Causes

   The ovaries are two small glands located on either side of the lower pelvis. They play a vital reproductive role, the menstrual cycle and, in general, the development of women’s sexual characteristics depend on their condition.

   Every month there is a process known as ovulation, when the rupture of a mature follicle in the ovary releases an egg into the fallopian tube. For most women, this happens regularly from puberty to menopause.

   Here are the seven most common causes of pain in the ovarian region:

   1. Ovulation

   Painful ovulation is called mittelschmerz, which means “median pain” in German.

   Ovulation is the process of the release of an egg from the ovary and occurs on or about day 14 of the average menstrual cycle. Most women experience no discomfort during ovulation, but some may experience severe discomfort or pain during this period for several minutes, hours, or even days.

   Mittelschmertz can be felt on one or both sides of the body and is sometimes accompanied by nausea, bleeding, or profuse vaginal discharge.

   Mittelshmerz does not require treatment. However, be aware that some serious conditions, such as appendicitis and ectopic pregnancy, can mimic the pain of ovulation. A woman should see a doctor if any of these conditions could be the cause of her pain.

   2. Pelvic inflammatory disease

   Pelvic inflammatory disease is caused by an infection that has spread to the uterus, ovaries, or fallopian tubes. In most cases, the bacteria that cause inflammation are sexually transmitted.

   A possible cause of pelvic inflammatory disease may be infection during childbirth, IUD insertion, miscarriage, abortion, or any other invasive procedure.

   Treatment

   In pelvic inflammatory disease, the underlying infection is treated first with antibiotics. Mild inflammation can be treated with just one injection, while more severe inflammation may require hospital treatment with intravenous antibiotics.

   3. Ovarian torsion

   Ovarian torsion is a severe adnexal pathology that develops as a result of torsion of the ligaments that fix the ovary, clamping of its vessels and ischemia of the organ.

   In most cases, ovarian torsion develops with an increase in its volume and mass due to various formations – large cysts and tumors, often benign

   Treatment

   Ovarian torsion causes severe pain and requires urgent medical intervention. Emergency treatment measures are carried out only in a hospital and the only effective method is surgical intervention.

   Late diagnosis due to rapidly developing complications can lead to the most unfavorable consequences.

   4. Endometriosis

   Endometriosis is a disease characterized by the growth of cells of the endometrium, the inner layer of the uterine cavity, on its surface, as well as in the tissues of other organs.

   Since the endometrioid tissue has hormone receptors, the same changes occur in it as in the normal endometrium, manifested by monthly bleeding. These small bleedings lead to inflammation in the surrounding tissues and cause the main manifestations of the disease: pain, an increase in the volume of the organ, and infertility.

   Treatment

   Depending on the severity of the disease, the treatment of endometriosis can be both surgical and hormonal. In most cases, combined treatment is used. Surgical treatment includes various methods, ranging from excision of individual areas of endometriosis during laparoscopy, ending with complete removal of the uterus in complicated cases.

   5. Ovarian cyst

   An ovarian cyst in women is a fluid-filled protrusion that forms on the surface of one or both of a woman’s ovaries, usually from a follicle. An ovarian cyst is a very common disease and in most cases does not cause any symptoms.

   In very rare cases, the disease is accompanied by symptoms such as:

   • pain in the lower abdomen, sometimes very severe and acute;
   • heaviness, pressure in the pelvic region;
   • lingering pain during menstruation;
   • irregular monthly cycle;
   • nausea, vomiting after intense exercise or sexual intercourse;
   • pressure during bladder or rectal emptying;
   • pain in the vagina, accompanied by bloody discharge.

   You should consult a doctor if you experience symptoms that may indicate a rupture of the cyst:

   • temperature over 38 degrees;
   • weakness and dizziness;
   • copious discharge during menstruation;
   • increase in the volume of the abdomen;
   • intense thirst with copious urination;
   • abnormal blood pressure;
   • uncontrolled weight loss;
   • palpable lump in the abdomen;

   In most cases, an ovarian cyst is a neoplasm of a benign nature, in extremely rare cases it can take a malignant form.

   Treatment

   With a functional nature and uncomplicated course of ovarian cysts, both expectant management and conservative treatment with contraceptives are possible.

   In the absence of a positive effect from conservative therapy or with an increase in the size of the ovarian cyst, surgical intervention is indicated – removal of the formation within healthy ovarian tissues and its histological examination.

   6. Ovarian remnant syndrome

   Ovarian remnant syndrome occurs in women only after surgical removal of the uterus and ovaries. If any ovarian tissue remains in the pelvic area, it continues to produce hormones and may grow into a cyst.

   This process causes pain, which may be constant or paroxysmal. Women with ovarian remnant syndrome may also experience pain during sex and when urinating.

   Treatment

   Ovarian remnant syndrome requires treatment to destroy as much of the remaining ovarian tissue as possible. This will reduce the release of hormones produced by the remaining tissue.

   7. Referral pain

   Pain in the ovaries can actually be caused by problems with other organs. So, ovarian pain mimics appendicitis, ectopic pregnancy, kidney stones, or constipation.

   Treatment

   The doctor must determine what exactly is causing the pain, then an appropriate course of treatment is prescribed. For the above reasons, it is surgery to remove the appendix, termination of an ectopic pregnancy, pain relief and removal of stones from the kidneys, taking laxatives to relieve constipation.

   When to see a doctor

   Women should see a doctor if they experience any pain in the pelvic area. Only a specialist who has the necessary diagnostic tools in his arsenal is able to find out the cause of the pain.

   Depending on the cause of the pain, the consequences of late diagnosis can be long-term health problems and even death of the patient.