anovulatory woman’s BBT chart will be flat (monophasic) and her cervical mucus will fern, indicating that progesterone (produced by the corpus luteum that forms after ovulation) never opposes the estrogen stimulation.

one should look at other areas of the reproductive system

for a breakdown in the fertility formula (Fig. 24.11).

Irregular Menstrual Periods or

Amenorrhea for Six or More Months

This is the most common complaint found with fertility

problems. The woman’s menstrual periods occur

infrequently and at unpredictable intervals. Some

women, even report that at some point their periods

stopped altogether. Because these women are capable of

menstruating (as demonstrated by their history), there is a

good chance that with the proper treatment ovulation and

a regular menstrual cycle will resume.

Nonexistence of the Menstrual Period

Women who have never menstruated may have genetic

abnormalities, congenitally deformed reproductive

organs, delayed puberty, or a pituitary malfunction. If

by the age of 16 a woman has not started menstruating,

she should be concerned. It is important to diagnose the

problem early and to determine if such women will res -

pond to hormonal therapy or surgical correction.

Clues from Physical Examination

The Physical Examination

During the physical examination, the doctor looks for

evidence that the woman is ovulating, that her mucus

allows sperm to reach the egg in good shape, and that

the fertilized egg can successfully implant and grow in

her uterus. A number of things may go wrong during this

process. The sperm may not be able to journey through

inhospitable cervical mucus or, having reached the egg,

they may be unable to penetrate its surface. The egg may

get lost in the body cavity and never find its way into the

fallopian tube. Fallopian tubes, damaged by infection or

trapped in adhesions, may not be capable of moving the

egg toward the uterus. The growing, fertilized egg may

become entangled in webs of intratubal adhesions caused

by infection and develop into an ectopic pregnancy. Or the

uterine lining may fail to nourish the early embryo. Once

the doctor determines where these processes are breaking

down, he has a good chance of restoring her fertility.

During the physical examination, the doctor would

look for evidence of systemic disease: jaundiced (yellow)

FIG. 24.11: The menstrual cycle

766 Concise Book of Medical Laboratory Technology: Methods and Interpretations skin and eyes are indicative of liver disease; tenderness in

the middle of the back and water retention (edema) may

indicate kidney malfunction.

The body build and secondary sex characteristics

may provide additional clues to hormonal imbalance.

Undersized breasts, scanty pubic hair, and underdeveloped

hips all suggest a female hormone deficiency. An enlarged

clitoris and abnormal hair growth such as a mostache may

suggest excess male hormones. Rarer conditions such

as ambiguous genitalia (not clearly male or female) and

duplicate reproductive organs may point to genetic or

enzyme defects that can interfere with ovulation. Although

breast size, body conformation, and hair distribution are

not conclusive evidence, they may corroborate suspicions

created by other clues.

Based on the menstrual history and physical

examination, the doctor will recommend a number of tests

to confirm this diagnosis.

Diagnostic Approaches for

Irregular Menstrual Periods or Amenorrhea

Several basic tests will help determine why your periods

are abnormal.

Pregnancy Test

This may seem surprising, but pregnancy is the single most

common reason for women reporting that their periods

have stopped. Always conduct a pregnancy test to rule out

the possibility of pregnancy.

Progesterone Withdrawal Test

The progesterone withdrawal test will confirm if the

uterus is capable of menstruating. If it is, then the cause of

menstrual irregularity lies with the hormonal systems. If

the uterus cannot “bleed,” then the problem lies with the

uterus itself.

The doctor can bring period either by giving you oral

progesterone over a 5- or 10-days period or by giving a

progesterone injection. After taking the progesterone, the

period should begin within 14 to 20 days.

Positive Response to Progesterone Withdrawal

If progesterone withdrawal causes the period to start up,

then a number of things are clear.

First, we know that the ovaries are producing enough

estrogen to build up the uterine lining. We also know

that the uterus is capable of responding to estrogen and

progesterone stimulation. Since the uterus is functioning

normally, the fertility problem lies somewhere in the

hormonal system.

Second, the failure to menstruate is because of failure to

ovulate. For some reason, the pituitary is not producing the

LH spike necessary to release the ovum from the follicle.

Two conditions must exist before the pituitary will

release an LH surge: the follicles growing in the ovaries

must release enough estrogen to signal the pituitary that

it is time to release the LH surge—in other words, that

at least one egg has reached maturity. And the pituitary

gland must be capable of generating the LH spike.

One can suspect that the hypothalamus just isn’t

prodding pituitary well enough. If the follicles do not grow

to maturity, there will never be enough estrogen to trigger

the LH spike to release the egg and thus ovulate. A pituitary

malfunction can cause the same problem.

Negative Response to Progesterone Withdrawal

Most women will “bleed” in response to progesterone

withdrawal. However, if one does not, it is possible that the

estrogen supply is not adequate to stimulate uterine lining

growth. If the uterus is normal, taking estrogen to prime

the growth of the uterine lining should guarantee that one

will have a period after progesterone withdrawal. So repeat

the progesterone withdrawal after estrogen stimulation.

If the estrogen/progesterone-stimulated cycle fails to

produce a “bleed,” it means that the uterus cannot respond

to estrogen and progesterone stimulation: we can pinpoint

the uterus as the problem.

Positive Withdrawal to Estrogen/Progesterone

Stimulation

When one has a period after taking estrogen and

progesterone, we know that the uterus is capable of

menstruating. The reason the patient had not been

menstruating is that her ovaries were not producing

adequate amounts of estrogen. At this stage in the

diagnostic procedures, we do not know for certain why

the ovaries are not producing estrogen, but several

possibilities exist:

1. The ovaries are not capable of producing estrogen.

2. The hypothalamus is not stimulating the pituitary

to release FSH and LH, which control follicular

development and estrogen production.

3. The pituitary is unable to produce adequate amounts

of LH and FSH.

4. Other hormonal imbalances are tricking the pituitary

into “thinking” that it is doing a good job when, in fact,

it is not.

Since, estrogen stimulation is vital for the growth of the

uterine lining, one should measure estrogen hormone

levels to confirm this diagnosis before venturing into new

diagnostic territories. In addition, measure FSH level to

rule out ovarian failure (A high FSH level indicates that

the ovaries have been severely damaged or have run out of

eggs).

The Endocrine System 767

Detecting Ovarian Failure

Ovarian failure occurs when the ovaries are severely

damaged or when they run out of eggs. When this happens,

the pituitary gland tries to force the ovary to manufacture

estrogen and to ovulate by working overtime to produce

FSH. The pituitary gland’s signals fall on deaf ears, though,

because the damaged ovaries cannot respond to the extra

FSH stimulation.

Ovarian failure may be caused by a number of conditions

including infection, chemical toxins, medications, radiation

exposure, tumor, surgery, immunologic dysfunction and

genetic abnormalities.

Diagnosing Anovulation

Once uterine abnormalities and ovarian failure are ruled

out, we confirmed that the periods are irregular because of

not ovulating (anovulation). For some reason, the pituitary

is not sending adequate amounts of LH and FSH to the

ovaries.

Symptoms of Anovulation

Although a few anovulatory women will have normal

periods, most will have a few or no periods at all

(amenorrhea). Prolonged or heavy periods (menorrhagia),

spotting during the middle of the cycle (metrorrhagia),

and prolonged spotting may also occur. Women with

anovulatory menstrual periods do not experience the

typical menstrual discomforts often found in ovulatory

women: breast soreness, mood changes, or cramping. The

anovulatory woman’s BBT chart will be flat (monophasic)

and her cervical mucus will fern, indicating that

progesterone (produced by the corpus luteum that forms

after ovulation) never opposes the estrogen stimulation.

Tests Used to Determine the Cause of Anovulation

In the next phase of testing, the doctor will try to determine

why the pituitary gland is not stimulating the ovaries to

ovulate. He needs to answer a number of questions:

¾ Is the hypothalamus not “beating the drum” by

producing regular pulses of GnRH?

¾ Is the pituitary gland damaged?

¾ Is the pituitary gland getting misleading feedback

messages about ovarian function?

Several tests will give me the additional answers he

needs.