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
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
the middle of the back and water retention (edema) may
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
Based on the menstrual history and physical
examination, the doctor will recommend a number of tests
Irregular Menstrual Periods or Amenorrhea
Several basic tests will help determine why your periods
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 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
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
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
Positive Withdrawal to Estrogen/Progesterone
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
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
4. Other hormonal imbalances are tricking the pituitary
into “thinking” that it is doing a good job when, in fact,
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
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
Ovarian failure may be caused by a number of conditions
including infection, chemical toxins, medications, radiation
exposure, tumor, surgery, immunologic dysfunction and
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
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?
No comments:
Post a Comment
اكتب تعليق حول الموضوع