Different gonadotropin pulsatile fashions in anovulatory cycles of young girls indicate different maturational pathways in adolescence

Menstrual Patterns in the First Gynecological Year: A Systematic Review

STUDY OBJECTIVE

Understanding what constitutes a normal menstrual cycle during the first gynecological year (GY1) is a common concern of adolescents and clinicians. However, limited high-quality evidence exists. We aimed to summarize published literature regarding menstrual and ovulatory patterns in GY1. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Electronic databases (MEDLINE, Pre-MEDLINE, Embase, Web of Science, CINAHL, Cochrane Library) were systematically searched from database inception to 2018. Eligible studies described menstrual cycles, symptoms, or validated ovulatory data in healthy adolescents in GY1. Two authors independently screened studies, extracted data, and assessed methodological quality.

RESULTS

Twenty-two studies involving more than 2000 adolescents were included. Thirteen recorded menstrual cycle and/or symptom data and 14 measured ovulation. Mean cycle length ranged from 32 to 61 days and decreased throughout GY1. Mean menses length was 4.9 to 5.4 days. Frequent menstrual bleeding was reported in up to 23% of participants, infrequent menstrual bleeding in up to one-third, and "irregular menstrual bleeding" in up to 43%. Dysmenorrhea was reported by 30%-89% of participants. Prevalence of ovulatory cycles identified using luteal phase serum or salivary progesterone or urinary pregnanediol was 0 to 45% and increased throughout GY1. However, all used definitions that would be considered subovulatory in clinical practice.

CONCLUSION

Menstrual and ovulatory patterns in GY1 are diverse and differ from those of adults. A transitional phase of menstrual and ovulatory immaturity is common. However, ovulation, irregular cycles, and dysmenorrhea are not uncommon. As such, safe sexual practice should be advocated and prompt medical management should be accessible.

The influence of sporadic anovulation on hormone levels in ovulatory cycles

STUDY QUESTION

Do ovulatory hormone profiles among healthy premenopausal women differ between women with and without sporadic anovulation?

SUMMARY ANSWER

Women with one anovulatory cycle tended to have lower estradiol, progesterone and LH peak levels during their ovulatory cycle.

WHAT IS KNOWN ALREADY

Anovulation occurs sporadically in healthy premenopausal women, but the influence of hormones in a preceding cycle and the impact on a subsequent cycle's hormone levels is unknown.

STUDY DESIGN, SIZE, DURATION

The BioCycle Study was a prospective cohort including 250 healthy regularly menstruating women, 18-44 years of age, from Western New York with no history of menstrual or ovulation disorders. The women were followed with up to eight study visits per cycle for two cycles, most of which were consecutive.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

All study visits were timed to menstrual cycle phase using fertility monitors and located at the University at Buffalo women's health research center from 2005 to 2007. The main outcomes measured were estradiol, progesterone, LH and follicle-stimulating hormone levels in serum at up to 16 visits over two cycles. Anovulation was defined as peak serum progesterone concentrations ≤5 ng/ml and no serum LH peak detected during the mid- or late-luteal phase visit.

MAIN RESULTS AND THE ROLE OF CHANCE

Reproductive hormone concentrations were lower during anovulatory cycles, but significant reductions were also observed in estradiol (-25%, P = 0.003) and progesterone (-22%, P = 0.001) during the ovulatory cycles of women with one anovulatory cycle compared with women with two ovulatory cycles. LH peak concentrations were decreased in the ovulatory cycle of women with an anovulatory cycle (significant amplitude effect, P = 0.004; geometric mean levels 38% lower, P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

Follow-up was limited to two menstrual cycles, and no ultrasound assessment of ovulation was available. Data were missing for a total of 168 of a possible 4072 cycle visits (4.1%), though all women had at least five visits per cycle (94% had seven or more per cycle).

WIDER IMPLICATIONS OF THE FINDINGS

These results suggest a possible underlying cause of anovulation, such as a longer-term subclinical follicular, ovarian or hypothalamic/pituitary dysfunction, even among healthy, regularly menstruating women.

Puberty and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous familial disorder characterized by chronic anovulation and hyperandrogenism. This multi-system, polygenic, multi-factorial disorder is associated with an increased risk for metabolic abnormalities such as type 2 diabetes mellitus. Signs and symptoms of PCOS often emerge during the peri-pubertal years with premature pubarche (PP) being the earliest manifestation for some girls. Insulin resistance and hyperinsulinemia are important pathophysiological features that are common to both PP and PCOS. Future investigations are needed to uncover the relevant genetic and hormonal factors and identify effective interventions.

Treatment of the adolescent patient with polycystic ovary syndrome

Frequently, a multidisciplinary approach is needed in the management of the adolescent with PCOS. Treatment must be provided in a supportive environment. Because adolescent females are concerned about their appearance any image, short-term treatment goals are usually directed toward the amelioration of hirsutism, acne, and irregular menstruation. Although not immediately concerning to the adolescent, the prevention of long-term sequelae from anovulation and hyperinsulinemia is also important. Multiple concomitant therapies are often necessary to address the variety of symptoms and achieve better results. Recent studies have investigated the role of the insulin-sensitizing agent, metformin, in the treatment of PCOS. Although most studies show a benefit, the conclusions are limited owing to the small numbers of select patients, observational designs, and short durations of follow-up. In addition, there are few data comparing insulin-sensitizing drugs with traditional therapies for PCOS. More long-term, randomized controlled trials are needed to determine the utility of insulin-sensitizing agents, their long-term benefits, and the ideal patient population for their use.

Chronobiologic evolution of luteinizing hormone secretion in adolescence: developmental patterns and speculations on the onset of the polycystic ovary syndrome

OBJECTIVE

To investigate the long-term evolution of the LH circadian profile in adolescent women with anovulatory cycles and normal or elevated LH levels in the first evaluation.

DESIGN

Prospective controlled clinical study.

SETTING

Reproductive endocrinology unit of an academic medical center.

PATIENT(S)

Twelve healthy anovulatory adolescent girls aged 12 to 17 years (5 subjects with high plasma LH level and 7 subjects with normal LH level) and four ovulatory subjects as controls.

INTERVENTION(S)

Blood samples were drawn every 20 minutes for 24 hours beginning at 10:00 A.M. at early and late gynecologic ages.

MAIN OUTCOME MEASURE(S)

Luteinizing hormone, FSH, E2, T, androstenedione, ovarian volume.

RESULT(S)

In the first evaluation, the highest plasma LH levels and greatest pulse amplitude were found early in the morning in the normal-LH group and late in the afternoon in the high-LH group. Controls did not display any significant circadian variation in LH secretion. The second evaluation revealed ovulatory cycles in six of seven subjects (85.7%) in the normal-LH group with the disappearance of the circadian rhythm. Two of five (40%) patients with high LH in the first evaluation became ovulatory with a significant decrease of mean LH levels and the disappearance of the circadian rhythm. Girls of both groups who remained anovulatory still displayed the accentuated circadian profiles that were seen at the first evaluation.

CONCLUSION(S)

An accentuated 24-hour LH periodicity is typical of puberty but disappears in adulthood. The persistence of these rhythms in persistently anovulatory adolescents may indicate a maturational arrest. In particular, the persistence of the high LH circadian profile with the highest values during the day is very similar to that found in polycystic ovary syndrome.

Menstrual dysfunction in hirsute women

Hirsutism in women is frequently associated with increased levels of androgens. Studies of biochemical changes, however, have yielded conflicting results. This study compares the findings in 30 hirsute women with normal menses and those of 30 hirsute women with abnormal cycles. Of the women with abnormal menstruation, 73% had oligoamenorrhea only and the others had dysfunctional uterine bleeding. The abnormally menstruating group had a similar mean age but tended to have heavier body weights than those with normal cycles. Free and total testosterone levels were significantly higher in the abnormal group (total testosterone, 54 +/- 35 ng/dl vs 35 +/- 12 ng/dl, p = 0.004; free testosterone, 7.8 +/- 4.9 pg/ml vs 4.2 +/- 1.4 pg/ml, p = 0.002). The abnormal group tended to have higher levels of androstenedione than the normal group (227 +/- 116 ng/dl vs 139 +/- 59 ng/dl) but dehydroepiandrosterone sulfate (DHEAS) levels were similar (320 +/- 142 mg/dl vs 298 +/- 169 pg/dl). Levels of thyroxin, thyrotropin, and prolactin were comparable in the two groups. Among hirsute women those with abnormal menses tended to be heavier and to have higher levels of total testosterone, free testosterone, and androstenedione. This is consistent with the clinical impression, not previously documented, that of hirsute women, those with abnormal menses have more severe endocrine abnormalities than those with normal cycles.