CHAPTER 14

Menstruation

Puberty 208
SECONDARY SEX CHARACTERISTICS 208
TANNER STAGES 208
PRECOCIOUS PUBERTY 208

Menstrual Cycle 208

DAYS 1–14: FOLLICULAR PHASE 210
DAY 14: OVULATION 210
DAYS 14–28: LUTEAL PHASE 210

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 P U B E RT Y

 Puberty is the transition from childhood to the final stage of maturation

What is the order of that allows for reproduction.
 Puberty is believed to begin with disinhibition of the pulsatile gonado-
pubertal landmarks? tropin-releasing hormone (GnRH) secretion from the hypothalamus
Thelarche, pubarche, (mechanism is unknown).
menarche

Secondary Sex Characteristics

Development of the secondary sexual characteristics proceeds in the following
CHARACTERISTIC AGE HORMONE order:
Thelarche 10 Estradiol 1. Thelarche (breast budding). Average age 10 years. Due to increase in estradiol.
Pubarche 11 Adrenal 2. Pubarche (axillary and pubic hair growth). Average age 11 years. Due to
hormones increase in adrenal hormones.
Menarche 12 Estradiol 3. Menarche (first menses). Average age 12 years. Due to increase in estradiol.
H IG H-YI E LD FACTS

Tanner Stages
The Tanner stages of development refer to the sequence of events of breast
and pubic hair development.
 Stage 1: Prepubertal child.
 Stages 2–4: Development stages.
 Stage 5: Adult.

A female age 13 or older Precocious Puberty

without any breast
development has estrogen Appearance of the secondary sexual characteristics before 8 years of age is re-
deficiency and needs ferred to as precocious puberty and requires investigation into the etiology.
evaluation.
Menstruation

ETIOLOGY (NOT AN EXHAUSTIVE LIST)

 Idiopathic: Most common.
 Tumors of the hypothalamic-pituitary stalk: Prevent negative feedback.
 Inflammation of the hypothalamus: ↑ GnRH production.
 21-hydroxylase deficiency.
 Estrogen-secreting tumors.
 Excess exogenous estrogen.

M E N ST R UA L C YC LE

The menstrual cycle is the cyclical changes that occur in the female repro-
ductive system (see Figure 14-1 and Table 14-1). The hypothalamus, pituitary,
ovaries, and uterus interact to allow ovulation approximately once per month
(average 28 days [+/–7 days]). The following description is based on a 28-day
menstrual cycle.
 Many follicles are stimulated by follicle-stimulating hormone (FSH),
but the follicle that secretes more estrogen than androgen will be released.

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T A B L E 1 4 - 1 . Summary of Menstrual Cycle

Menstruation: Withdrawal of progesterone causes endometrial sloughing.

Follicular phase:
 FSH causes follicle maturation and estrogen secretion.
 Estrogen causes endometrial proliferation.

Ovulation: LH surge causes oocyte to be released.

Luteal phase: Corpus luteum secretes progesterone, which causes:

 Endometrial maturation.
 ↓ FSH, ↓ LH.

This dominant follicle releases the most estradiol so that its positive

H IG H-YI E LD FACTS
feedback causes an LH surge.
 Average menses = 4 days. More than 7 days is abnormal.
 Blood loss in menstruation averages 30–50 mL and should not form
clots; > 80 mL is an abnormally high amount of blood loss. Prostaglandins released
from the endometrium
cause dysmenorrhea.

Follicular phase Luteal phase

Ovulation

P
Endocrine
cycle E2

Menstruation
LH

FSH

Ovarian
histology
Follicular Corpus
recruitment Dominant follicle luteum

Menses
Endometrial
histology

37.0
Body
temperature 36.5
(° C)
36.0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Days

F I G U R E 1 4 - 1 . The menstrual cycle.

(Modified, with permission, from Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison’s Prin-
ciples of Internal Medicine, 14th ed. New York: McGraw-Hill, 1998: 2101.)

209

Ovulation takes place
24–36 hr after LH surge
and 12 hr after LH peak.
The follicular phase is
highly variable. The luteal
phase is usually about 11
days due to the length of
H IG H-YI E LD FACTS
time the corpus luteum
is able to secrete
progesterone.
The corpus luteum is
maintained after
fertilization by hCG,
released by the embryo.
Menstruation
Days 1–14: Follicular Phase
 The follicular phase begins on the first day of menses. All hormone lev-
els are low. Without any negative feedback, GnRH from the hypothala-
mus causes FSH release from the pituitary.
 FSH stimulates maturation of granulosa cells in the ovary. The granu-
losa cells secrete estradiol in response.
 Estradiol inhibits luteinizing hormone (LH) and FSH due to negative
feedback. In the meantime, the estradiol secretion also causes the en-
dometrium to proliferate.
 LH acts on the theca cells to ↑ secretion of androgens (which are con-
verted to estradiol), prepare the cells for progesterone secretion, and
cause further granulosa maturation.
Day 14: Ovulation
 A critical level of estradiol triggers an LH surge.
 The LH surge causes the oocyte to be released from the follicle. The
ruptured follicle then becomes the corpus luteum, which secretes pro-
gesterone.
Days 14–28: Luteal Phase
 The corpus luteum secretes progesterone for only about 11 days in the
absence of human chorionic gonadotropin (hCG).
 Progesterone causes the endometrium to mature in preparation for pos-
sible implantation. It becomes highly vascularized and ↑ glandular se-
cretions (see Table 14-2).
 Progesterone also causes inhibition of FSH and LH release.
 If fertilization does not occur, the corpus luteum involutes, progeste-
rone and estradiol levels fall, with subsequent endometrial sloughing
(menses). The hypothalamic-pituitary axis is released from inhibition,
and the cycle begins again.
T A B L E 1 4 - 2 . Ovarian Hormone Effect on Uterus
OVARIAN PHASE DOMINANT HORMONE UTERINE PHASE
Before ovulation Follicular Estrogen Proliferative
After ovulation Luteal Progesterone Secretory
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