Endometriosis and Ovulation Pain: Why it Hurts

It may not seem fair that as women, most of us experience period cramps once a month. But for about 40% of the female population, they are hit with a double whammy – ovulation pain. So many of us experience cramp-like symptoms not once, but TWICE during our cycles!

Whether you’ve experienced ovulation pain or not, you still may not understand or realize what it is! 

While getting “cramps” twice a month definitely sucks, ovulation pain is normal and typically not as severe as period pain. 

Then, there is the population of women who live with endometriosis. You may be one of them. If you have endometriosis, you may know all too well the pain that comes during ovulation. 

If you have been diagnosed with endometriosis (or suspect you may have it), then this article is going to be beneficial to you. We are going to talk about:

  • What ovulation pain is and what causes it
  • An overview of endometriosis
  • Why ovulation pain is worse with endometriosis
  • What endometriosis ovulation pain feels like and how to detect it
  • When you should see a doctor
  • Coping with the pain
  • Trying to conceive with endometriosis and ovulation pain

So what is ovulation pain?

Mittelschmerz”. That’s the term used for ovulation pain. It’s actually a German word that means, “middle pain”, because it occurs mid-cycle, just before ovulation.

Ovulation pain is typically felt in the lower abdomen, but you’ll experience this just before you are about to ovulate. So roughly about 12 to 14 days before your next period is due. 

Ovulation pain differs from period pain. It’s typically less intense and is often very localized. 

You’ll likely end up feeling ovulation pain on either the right or left side of your lower abdomen, so it depends on which ovary is releasing an egg that month. 

What causes ovulation pain (Mittelschmerz)?

While the exact cause is unknown, there are a few different theories that might explain ovulation pain. 

Eggs grow inside fluid-filled sacs known as follicles. At ovulation, one follicle ruptures open and the egg is released for fertilization. That teeny tiny follicle rupturing open may be behind ovulation pain. 

In fact, the hormone LH (luteinizing hormone) triggers the follicle to release an egg. So when LH quickly surges right before ovulation, muscles in the ovary contract. The result? Mittelschmerz! 

It’s also possible that pain is a result of fluid that gets released from the ruptured follicle, and is collected in the inner lining of the abdomen (this might also be why some women experience ovulation spotting!). 

These causes are a normal part of your menstrual cycle. But it makes it hard to determine what precisely causes mid-cycle discomfort! Especially since some women don’t experience ovulation pain at all!

Know more: Ovulation pain: what to know about Mittelschmerz 

Now we need to connect the dots between endometriosis and ovulation pain. But first, let’s talk about what endometriosis actually is. 

Endometriosis: An overview

Endometriosis is a complex, chronic disorder that is overwhelmingly misunderstood.

It can take years of tests, doctor visits, and worsening symptoms to get a diagnosis.

Endometriosis is an inflammatory condition where the uterine tissue grows outside the uterus. 10-15% of women in the childbearing age suffer from endometriosis.

This tissue can grow anywhere – on the ovaries, fallopian tubes, pelvic lining, and ligaments around the uterus. In extreme cases, it can even surround nearby organs like the intestines and bladder.

It’s important to discuss how endometriosis affects ovulation pain, or vice versa. That way, you can determine normal pain from abnormal pain.

If you’re reading this and experience severe mid-cycle pain, you may want to chat with your doctor about the possibility of endometriosis.

Ovulation pain with endometriosis. Why is it worse?

Fact: Ovulation pain with endometriosis for many women can be much more severe. 

Also fact: We don’t actually know why the pain is much more severe. 

But here is what we do know about the possible connection between ovulation pain and endometriosis…

Formation of scar tissue or adhesions:

Just like normal uterine tissue, the displaced endometrial tissue responds to hormonal changes throughout your cycle as well. And we know that when women menstruate, the inner uterine lining or endometrium sheds. But the tissue growing outside of the uterus doesn’t have an exit strategy. This can lead to adhesions or scar tissue formation, which leads to friction and pain. 

Pain at the site of egg release:

If the displaced endometrial tissue grows on the ovaries, you might experience pain when the egg ruptures and is released at ovulation. 

Chocolate cysts:

There’s also the problem of chocolate cysts or endometriomas. While their nickname makes them sound harmless, they are cysts caused by the extra-endometrial tissue. The name stems from the fact that the cysts are filled with dark brown menstrual blood, so they look almost … chocolate-filled. Their presence often indicates a more advanced stage of endometriosis.

If endometriomas are near the site of egg release, they can create pain.

The patterns and severity of ovulation pain vary from person to person. Not all women with endometriosis suffer from ovulation pain each month. There are several reasons that explain why ovulation is extra painful for women with endometriosis. So narrowing it down for each individual is difficult.

That’s why, if you suspect you may have endometriosis because then it’s best to speak with your doctor ASAP.

Ouch! What does ovulation pain actually feel like for someone with endometriosis?

Let’s start with what’s considered to be normal ovulation pain – dull, aching, mild to moderate pain felt in the lower abdomen.

This pain may come and go and while it can be a nuisance, it is usually manageable. It should not last longer than one or two days.

But ovulation pain when you have endometriosis? It can be much more severe. To the point it stops you in your tracks and negatively impacts your daily activities. It might also last longer than just a day or two. And it can be persistent even if your doctor has prescribed painkillers.

There are several other characteristics of endometriosis pain during ovulation:

  • Feeling sick to your stomach:

Nausea to the point of vomiting might also accompany pain. Heavy spotting or even bleeding mid-cycle are signs of endometrial ovulation pain.

  • Back Pain:

Endometriosis can cause back pain during ovulation. While this happens in women without endometriosis as well, if it’s more than just a dull ache and makes you feel immobilized, endometriosis is probably exacerbating the situation.

  • Pain with other bodily functions:

Finally, if you feel pain while urinating, pooping, or during sexual intercourse mid-cycle. Then you are experiencing common, albeit abnormal endometrial ovulation pain.

How can I tell if my ovulation pain is due to endometriosis? 

Take a look at the below chart. It will show an apples-to-apples comparison of normal ovulation pain, versus someone with endometriosis.

Normal ovulation pain

Endometriosis ovulation pain

Intensity: mild-moderate, dull-aching sensation 

Severe crippling pain 

Lasts 1-2 days

Lasts for more than 2 days

Usually lessens with medications (if needed)

Doesn’t go away with medications

Mild nausea

Severe nausea and vomiting

Light spotting, if any

Heavy ovulation bleeding

When should I see a doctor?

If you know or suspect you may have endometriosis, it’s important to speak to your doctor. Endometriosis manifests differently in every individual. It requires surgery to definitively diagnose. As a result, it largely goes undetected in so many women, for so many years.

If you identify with any of the “endometriosis ovulation pain” points in the above chart, you should consult with your doctor.

If you already have endometriosis, your doctor can help you come up with a treatment plan to manage pain. If you experience one or more of the above painful ovulation symptoms, you need to discuss your concerns with your doctor.

Does it ever hurt to have sex? Are your periods also debilitating? Call the doctor. We’re not meant to live like that, and it’s not normal. These things are manageable with care.

How can I cope with endometriosis-related ovulation pain?

Ovulation pain caused by endometriosis can be treated and controlled in a number of ways, depending on the severity.

Home treatments:

A hot bath or heating pad placed on the abdomen can do wonders to provide you temporary relief.

Daily movement and hydration can help with inflammation of the displaced tissue. Sticking to an anti-inflammatory diet helps to alleviate painful endometriosis systems. Examples of some anti-inflammatory foods to include in your diet are beans, dark leafy greens, and avocados. Avoiding trans fats and sugars is also beneficial.


Over-the-counter painkillers are often used for period pain. They can be helpful too when experiencing bouts of ovulation pain triggered by endometriosis. However, for severe pain, they may not always work. 

Birth control pills are often prescribed to treat and reduce endometriosis symptoms. Birth control’s main purpose however is to prevent pregnancy. So this might not be the best option for everyone, and it isn’t a long-term solution. 

Birth control pills help manage endometriosis symptoms, stopping the growth of displaced tissue. The pill also prevents ovulation. The conflict between the ovulation process and endometriosis ends. So often does the pain.

But they are counterproductive when you want to start a family. On one hand, you’re not going to get pregnant on the pill. On the other hand, it’s hard to get pregnant when endometriosis symptoms impede your quality of life.


There is no cure for endometriosis. Surgery, however, is the most definitive treatment option for women with severe cases, when their quality of life is impacted.

Laparoscopic surgery is an option to remove scar tissue, discarded endometrial tissue, and adhesions. This might improve someone’s fertility odds and relieve a lot of painful symptoms. Often a laparoscopy is used to determine an endometriosis diagnosis!

Laparoscopy is minimally invasive. Tiny incisions are made and a camera is used to see inside the abdomen. Recovery time is also quite quick. Overall, it’s best to chat with your doctor about your options and what might be best for you.

TTC with endometriosis

For women with endometriosis, getting pregnant is a lot more challenging for a plethora of reasons. The severity of ovulation pain paired with infertility hurdles, can be super frustrating.

Trying to conceive with endometriosis becomes more challenging because: 

  • Pain during sexual intercourse
  • Blocked Fallopian tube(s)
  • Medications used to manage endometriosis like birth control are counterproductive
  • Abnormalities in ovulation 
  • Impaired implantation

Many women need to undergo fertility treatments when they have endometriosis. Depending on the severity of the disease, natural conception isn’t impossible. It might just be more challenging. Pursuing IUI or IVF is often needed and not uncommon for endometriosis patients.

Know more: Your Guide to Getting Pregnant With Endometriosis 

The Takeaway

While women are often told that pain is normal, it is important to reiterate that severe pain at any time in your cycle, is NOT normal. Severe pain is a sign that something isn’t right. Women with endometriosis often suffer in silence. It also doesn’t help that women have been conditioned to “suck it up” and carry on without complaint.

“Sucking it up” should never be the only option. Understanding what is normal and what is not, is the first step to finding treatment. “Common” is not the same as “normal”.

Let’s recap some of the most important thoughts to take away…

  • Ovulation pain is a dull-aching sensation for most women who experience it. However, if it’s affecting your day-to-day life, it might be because of endometriosis. Ovulation pain with endometriosis can be a debilitating experience. 
  • Ovulation pain with endometriosis can cause severe pain that lasts longer than 2 days, heavy spotting, nausea, and vomiting, and it typically does not subside with painkiller use.
  • Home remedies like a heating pad on the abdomen, a relaxing hot bath, and just rest and relaxation may help ease ovulation pain. 
  • Birth control pills and surgery are effective treatments for endometriosis pain relief.
  • Endometriosis causes a variety of fertility problems too, from constant pain to treatments that prevent pregnancy altogether. It is important to talk to your doctor about a unique pathway to pregnancy for you.

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