Ovulation Pain, or ‘Mittelschmerz’
Written by Matilda Wilkinson, Pelvic Health Physiotherapist, Pelvic Project Co-founder
Mittelschmerz is (a very cool) german word for ‘middle pain’ - the clinical term for the (less cool) mysterious pain that pops out of nowhere bang in the middle of our cycle, it turns out, when we check our period tracker. Just as we’re regaining our glow and energy it reminds us that hormones are everything - the good the bad the ugly.
40% of women experience ovulation pain at some point
For many of us it’s inconsistent, not every month, it may develop in our 20s and mysteriously vanish by our 30s. It may come unannounced twice a year for no particular reason. Or it may ebb and flow in line with periods of stress.
What is it?
Ovulation pain typically shows up around two weeks before your period, lasting anywhere from a few minutes to a couple of days. It's usually one-sided, tends to switch sides month to month depending on which ovary released the egg, and can range from a mild niggle to something sharp enough you want to lie on the floor.
Possible Causes
Hormonal - The LH surge and prostaglandins: The luteinizing hormone (LH) surge that triggers ovulation also increases prostaglandin activity around the ovary. Prostaglandins are the same inflammatory messengers responsible for period cramps, and here they cause the smooth muscle around the developing follicle, and sometimes the fallopian tube, to contract.
Mechanical - Follicle stretch and rupture: As the follicle grows to release the egg, the ovary's surface stretches. When it ruptures, a small amount of fluid, and occasionally a little blood, spills into the pelvic cavity. This can irritate the peritoneum, the lining of the abdominal cavity, producing a dull, achy sensation that can linger for hours afterwards.
Neuromuscular - Muscle tightness and nervous system sensitivity: This is where physiotherapy can really make a difference. Tightness in the pelvic floor, deep hip rotators, abdominals or lower back can irritate the nerves running through the pelvis. Once a nerve pathway becomes sensitised, it can effectively "turn up the volume" on normal physiological events - so a process that shouldn't hurt much starts to register as significant pain.
Structural - Tissue restriction from scarring or adhesions: Your ovaries, tubes and uterus are designed to glide and move freely. Where there's scarring or adhesions - commonly from endometriosis, previous surgery, or pelvic infection - that mobility is reduced, which can translate into more noticeable pain during the normal stretch of ovulation. Many people with this pattern don't yet have an endometriosis diagnosis, which is why it's worth getting checked rather than assuming it's "just ovulation".
Where physiotherapy comes in
Assessing pelvic floor, hip and abdominal muscle tension - which can be contributing to nerve irritation and referred pain around the ovary and lower abdomen.
Manual therapy for tissue restriction - gently releasing adhesions or tightness around the pelvic organs and their supporting ligaments where this is a factor.
Calming an overactive nervous system - using breathwork, graded movement and desensitisation techniques where pain has become disproportionate to what's actually happening physiologically.
Postural and movement assessment - to help avoid compensatory patterns elsewhere in the body, such as the lower back and hips, which can feed into pelvic tension over time.
Working alongside your GP or gynaecologist - particularly where there's a suspected underlying condition like endometriosis. Physiotherapy complements medical management rather than replacing it.
N.B. When it's more than "just ovulation"
Most ovulation pain is harmless and doesn't need treatment beyond rest, heat and simple pain relief. But it's worth flagging to your GP or gynaecologist if any of the following apply.
▶Pain severe enough to disrupt your daily life or work
▶Pain lasting longer than 1–2 days, or worsening over successive cycles
▶Accompanied by fever, heavy or irregular bleeding, dizziness, or pain during sex
▶Over-the-counter pain relief isn't touching it
These features don't necessarily point to something serious, but they do warrant a proper look - conditions like endometriosis, ovarian cysts, or pelvic inflammatory disease can all mimic or overlap with mittelschmerz, and are far more manageable the earlier they're picked up.
If you want to learn more or discuss your experience of Mittelschmerz book in with one of our specialist pelvic health physiotherapists
1. Hendrix J, Nelson D. Mittelschmerz. StatPearls [Internet]. NCBI Bookshelf, 2023. ncbi.nlm.nih.gov/books/NBK549822
2. Cleveland Clinic. Ovulation Pain (Mittelschmerz): Causes & Treatment. 2026. my.clevelandclinic.org
3. Wikipedia contributors. Mittelschmerz. Wikipedia, The Free Encyclopedia. en.wikipedia.org/wiki/Mittelschmerz
4. Equilibria Physiotherapy & Nutrition. Ovulation Pain or Mittelschmerz. 2020. equilibriahealth.com.au
5. Muñoz-Gómez et al. (2023). Effectiveness of a Manual Therapy Protocol in Women with Pelvic Pain Due to Endometriosis: A Randomized Clinical Trial. Journal of clinical medicine, 12(9), 3310. https://doi.org/10.3390/jcm12093310
6. Pelvic Rehabilitation Medicine. Mittelschmerz: What You Need to Know About Ovulation Pain. 2024. pelvicrehabilitation.com
