Pii: s0015-0282(02)03167-9

FERTILITY AND STERILITY௡
Copyright 2002 American Society for Reproductive Medicine Printed on acid-free paper in U.S.A.
Mean versus individual hormonal profiles
in the menstrual cycle
Marı´a Elena Alliende, M.D., M.Sc. Centro de Planificacio´n Natural Familiar, Departamento de Obstetricia y Ginecologı´a, Hospital Clı´nicoUniversidad de Chile, Santiago, Chile Objective: To evaluate hormonal profiles of normal menstrual cycles.
Design: Prospective, descriptive study of a case series.
Setting: University-based natural family planning center.
Patient(s): Twenty-five natural family planning users for three or more cycles (n ϭ 78). These women were
healthy, contraception-free, parous, with regular ovulatory cycles.
Intervention(s): Immunoassays for estrone glucuronide, LH, and pregnanediol glucuronide were done in
daily timed and measured samples of early morning urine.
Main Outcome Measure(s): Estrone glucuronide, LH, and pregnanediol glucuronide levels were measured
during the menstrual cycle.
Result(s): All cycles showed an ovulatory pattern configuring classic hormonal mean curves. Most (77%)
differed from the mean curve pattern. All had estrone glucuronide peaks, LH peaks, and pregnanediol
glucuronide increases. Estrone glucuronide and LH peaks were not always clear; some lasted more than 1 day
(long peak: estrone glucuronide 19%, LH 9%) or fluctuated (double peak: estrone glucuronide 4%, LH 6%;
small LH peak: 19%). There were also prepeak estrone glucuronide surges, and pre- and postpeak LH surges.
Pregnanediol glucuronide increased more clearly (6% fluctuated 1 day). Some women had repeated cycles
with long estrone glucuronide peaks (16%) and fluctuations in LH surge (44%).
Conclusion(s): Normal menstrual cycle hormonal profiles generally differ from mean curves, which are
usually considered standard. (Fertil Steril௡ 2002;78:90 –5. 2002 by American Society for Reproductive
Medicine.)
Key Words: Menstrual cycle, hormonal profile, ovulation detection, urinary glucuronides
study to evaluate a cervicovaginal fluid aspira- monal profile—the mean of the curves and tor as a fertile period indicator (5). The study fluctuations of the different hormones—is de- was approved by the Medical Faculty Ethics scribed and accepted as normal (1– 4). In clin- Committee at the University of Santiago de ical practice any deviation from this mean pat- Chile. Each woman gave written informed con- sent. Twenty-five women who experienced pe- available information comes from animal stud- riodic abstinence and were natural family plan- Partial support of theWorld Health Organization, ies, sometimes primates, and from women with ning users were selected to evaluate at least ovulatory pathology or undergoing ovarian three cycles. They identified their fertile period stimulation. There are few complete daily fol- by perceiving changes in their cervicovaginal low-ups of spontaneous normal cycles, free fluid at the vulva, using a variant of the ovula- from contraception. Moreover, these studies tion method that includes basal body tempera- generally include unexplained infertility cases ture (BBT) (6). These women were aged 24 to or attributed to nonhormonal causes, and sel- 37 years. The pregnancies occurred spontane- dom include women with proven fertility.
ously with minimal delay before or after the Santiago, Chile (FAX: 56-2-3811635; E-mail: MATERIALS AND METHODS
The sample phase of this study was done in cies (last child 9 months to 8 years old; mean, 0015-0282/02/$22.00PII S0015-0282(02)03167-9 collaboration with a multicenter prospective 2 years 3 months). After the study, 17 of the women had another pregnancy after the first (n ϭ 13) or second attempted cycle (n ϭ 4). This includes two women Double peak: two separate days with similar high values with an older child before the study cycles (7 and 8 years old). Four women did not attempt another pregnancy and Long peak: peak that lasts for more than 1 day with two were lost to follow-up; the last child was on average 2 years 6 months old for these 6 women. Two women had notattempted a pregnancy before the study but achieved one Values with differences of Ͻ9 nmol/L/24 h for estrone spontaneously a few months after the end of the study.
glucuronide and Յ5 U/L/24 h for LH were considered sim-ilar. The day with the highest numerical value among the All women had regular menstrual cycles, 25 to 35 days in days with similar values was chosen as the peak day.
the previous six cycles. These six previous cycles had ovu-lation method records with an ovulatory pattern and biphasic Prepeak estrone glucuronide surge: prepeak estrone gluc- BBT graphs. They were not taking any form of hormonal uronide surge is not close to the LH peak and the preg- contraception or intrauterine device in the previous six cy- cles, did not use any barrier method or spermicide, did not Prepeak and postpeak LH surge: LH surge is not close to have any history or evidence of liver or kidney disease or the estrone glucuronide peak and the pregnanediol glucuro- dysfunction, did not have any form of chronic drug therapy, were not working night shifts, and did not have a pregnancy Small LH peak: LH surge smaller than LH peak, before or after the LH peak; also close to the estrone glucuronide peak Each user collected a daily sample of early morning urine and the pregnanediol glucuronide increase.
during the entire cycle, beginning on day 1. They measuredthe urine volume, noted the last urine void, collection time, and froze the sample. They also recorded the ovulationmethod and BBT.
In 25 recruited women (mean age, 30 years; SD Ϯ4 years), a total of 82 cycles were studied. The cycles lasted a Estrone glucuronide, LH, and pregnanediol glucuronide mean of 28 days (23–35 days; SD Ϯ2.5 days). An ovulatory in the urine samples were analyzed by noncompetitive ra- pattern was identified in all the cycles with an ovulation dioimmunoassays. The Matched Reagents Programme of the method peak and biphasic BBT. Four incomplete cycles World Health Organization (WHO) (Queen Charlotte and were excluded; 22 women supplied three cycles and 3 Chelsea hospitals, Goldhawk Road, London, UK) provided women, four cycles (n ϭ 78 cycles). In each cycle, a urinary reagents and assay protocols. The laboratory implemented its sample for hormonal study was obtained almost every day.
own internal quality control procedures and participated in a Only 4 luteal phase samples (0.2%) were missing after day WHO international program of external quality assessment Ϫ6 from LH peak. The follicular phase mean was 16 days for the measurement of these hormones, and their perfor- (11–24 days; SD Ϯ2.6 days). The luteal phase had a mean of mance was closely monitored. For each hormone, all of the 13 days (10 –17 days; SD Ϯ1.5 days). With mean values samples from a same cycle were measured in a single assay.
corresponding to each cycle day, classic mean curves for Assay results in units per liter were multiplied by the total each hormone were developed (Fig. 1). A widespread of volume (in liters) of the sample originally collected by the patient and the product divided by the time (in hours) be- Only 23% (n ϭ 18) of the cycles presented estrone tween collections. Final results were expressed as nanomoles glucuronide, LH, and pregnanediol glucuronide hormonal per liter per 24 hours for estrone glucuronide, units per liter profiles similar to mean curves. The rest of them (77%, n ϭ per 24 hours for LH, and micromoles per liter per 24 hours 60 cycles) had a different pattern, in at least one of the hormones studied. These differences consisted of double or Definitions
long peak of estrone glucuronide or LH, small LH peak, Estrone glucuronide peak day: estrone glucuronide in- prepeak estrone glucuronide surge, prepeak or postpeak LH crease and decrease day with the highest estrone glucuronide surge, or fluctuation in pregnanediol glucuronide increase numerical value, close to the LH peak and the pregnanediol (see Definitions section). In 48% (n ϭ 38) of the cycles there were difficulties in detecting estrone glucuronide or LH peakday because of double or long peaks. Small LH peaks also Luteinizing hormone peak: day with the highest LH nu- merical value, close to the estrone glucuronide peak and thepregnanediol glucuronide increase.
Estrone Glucuronide
In 69% cycles, the estrone glucuronide profile was similar Pregnanediol glucuronide increase: 150% increase over to the mean curve. Variations observed and percentages are detailed in Figure 2A. An estrone glucuronide peak was The results obtained led to the formulation of other def- identified in all cycles on cycle days 11–23 (mean cycle day FERTILITY & STERILITY௡
Mean hormonal values of estrone glucuronide (EG) (-●-.), LH (-Ⅺ-), and pregnanediol glucuronide (PG) (-‚-) by cycle daythroughout 78 ovulatory cycles from 25 women. Days are numbered from the LH peak (day 0).
Alliende. Menstrual cycle hormonal profiles. Fertil Steril 2002. 14.5; mean peak value 104 nmol/L/24 h, SD Ϯ48). In most Long LH peaks lasted from 2 to 4 days, with a mean of of the cycles, a peak day was clearly identified. In some 2.6 days. Small LH peaks had a mean of 29 (11 to 52) cycles, identification of a peak day was more difficult for a U/L/24 h less than the LH peak. Clinical periovulatory double peak or because the peak lasted for more than 1 day.
indicators (ovulation method peak, BBT shift) associated There were also some estrone glucuronide surges before the more (n ϭ 9; 60%) with small LH peaks than with LH peaks.
One woman repeated a long LH peak in two cycles and 11 Long estrone glucuronide peaks lasted between 2 and 4 (44%) repeated fluctuating LH patterns (pre- or postpeak days, with a mean of 2.5 days. Four women (16%) repeated surge, double peak, small peak), 10 in two cycles and 1 in a long estrone glucuronide peak pattern (three women in two three cycles. Three women had a long estrone glucuronide cycles and one woman in three cycles). Almost half of the cycles presented postpeak estrone glucuronide values higher Pregnanediol Glucuronide
(n ϭ 24; 31%) or similar (n ϭ 13; 17%) to that of the estrone In all women a pregnanediol glucuronide increase was identified on cycle days 11–24 (mean cycle day 17; mean Luteinizing Hormone
first increase 3.7 ␮mol/L/24 h, SD Ϯ2). Only in 5 cases (6%) In 44% of cycles individual curves were similar in shape did pregnanediol glucuronide increase and decrease the fol- to the mean curve. Figure 2B shows the main variations lowing day, to increase definitively the next day (Fig. 2C).
observed and percentages. In all cycles a LH peak wasobserved on cycle days 11–24 (mean cycle day 16; mean DISCUSSION
peak value 97 U/L/24 h, SD Ϯ78). In most of the cases apeak day could be determined without problems. A few of The results obtained show that patterns for the mean these were more difficult because they presented double or values of the different hormones were similar to the classic long peaks. Small peaks as well as pre- and postpeak LH profiles described by Moghissi et al. (7) and Collins (8). A widespread of values, as observed by Brown et al. (9), was Alliende
Estrone glucuronide and LH peaks were not always clear, sometimes fluctuated or lasted more than 1 day. Other in-vestigators have also found these alterations marginally.
Characteristics of hormonal profiles during the menstrual
cycle in 78 cycles. (A), Estrone glucuronide (EG); three cycles
In a collaborative WHO study (10), serum E and LH with a long peak also had a prepeak estrone glucuronide peak definitions considered the first peak only when two or surge; total prepeak estrone glucuronide surges ϭ 9. (B), LH;
more peaks were present. Garcı´a et al. (11) also has found one cycle with long LH peak also had a postpeak LH surge;total prepeak surges peaks in serum. Brown has observed estrone ϭ 7, total postpeak surges ϭ 11. (C),
glucuronide surges in urine samples before the peak (12) anddouble estrone glucuronide peaks (13, 14). Similar urineestrone glucuronide patterns to those observed in this study,with multiple or distended peaks, have been described byHarlow et al. (15) in long follicular phase cycles. In thepresent study it was observed that certain women tended tohave long estrone glucuronide peaks. In the luteal phase,estrone glucuronide levels are often similar or higher than inthe late preovulatory phase and consequently the estroneglucuronide “peak” is about half the time only an estroneglucuronide increase and decrease temporally related to anLH peak, as mentioned previously (5).
Garcı´a et al. (11) have also observed small serum LH peaks preceding the definitive peak and double peaks, with awide surge range and low LH levels necessary for ovulation.
Moghissi et al. (7) also described these small serum LHpeaks, just before or immediately after the LH peak. Mar-tinez et al. (16) observed spontaneous cycles with two uri-nary LH surges, associated with an atresic pattern and newfollicular development. They also observed cycles with along urinary LH surge. Lemay et al. (17) have reportedcycles with extended serum LH peaks.
In primates and women, the gonadotrophic midcycle surge lasts 48 –50 hours, considerably more than 10 –16hours in other animals. The duration of the ovulatory stim-ulus is important in completing oocyte maturation and gran-ulosa cell luteinization. Luteinizing hormone hypersecretionduring follicular growth can resume meiosis prematurely(18). The gonadothropic surge inhibitor/attenuator factorcould play a role in these premature LH fluctuations (19). Inthe present study it was observed that some women tended tohave these LH fluctuations.
It is also important to account for variations in urinary concentration (20). If not considered, the variable values ofthe LH peak, the presence of prepeak surges, and small,double, and long peaks would limit the reliability of pro-spective LH tests based on threshold values (21, 22).
Pregnanediol glucuronide increased more clearly, with less fluctuation. Therefore, adding pregnanediol glucuronidewould make ovulation detection home kits based on urinary Alliende. Menstrual cycle hormonal profiles. Fertil Steril 2002. estrone glucuronide and LH detection more reliable (23).
Blackwell et al. (24) have defined a threshold value forpregnanediol glucuronide as a marker for the end of the noted. When analyzing individually complete cycles from potentially fertile period. The WHO has sponsored a multi- apparently healthy woman, hormonal profiles that departed center trial using an ovarian monitor (25), whose results are considerably from the mean curves were also observed.
being prepared for publication. It measures estrone glucuro- FERTILITY & STERILITY௡
nide and pregnanediol glucuronide with homogeneous en- termine potential fertility: a multicentre preffectiveness study of the theRovumeter. Hum Reprod 1997;12:1826 –31.
zyme immunoassays, considering urinary concentration.
6. Mena P, Alliende ME, Jensen L, Barros ML, Morande´ V, Castillo L, et al. Methodology of teaching natural methods of birth regulation (special The ovarian activity can be accurately monitored by the reference to the Billings ovulation method). Rev Chil Obstet Ginecol analysis of early morning urine samples (26, 27) in an ap- 7. Moghissi KS, Syner FN, Evans TN. A composite picture of the men- proach that is feasible for the patient. Serum LH, E , and P strual cycle. Am J Obstet Gynecol 1972;114:405–18.
correlate very well with urinary LH (28 –30), estrone gluc- 8. Collins WP. Biochemical indices of potential fertility. Int J Gynecol uronide (31–34), and pregnanediol glucuronide (31–35). A 9. Brown JB, Blackwell LF, Holmes J, Smyth K. New assays for identi- similar dispersion has been observed in serum LH, E , P, and fying the fertile period. Int J Gynecol Obstet 1989;(Suppl. 1):111–22.
10. World Health Organization. Temporal relationships between ovulation urinary LH (36), estrone glucuronide (37), pregnanediol and defined changes in the concentration of plasma estradiol-17B, LH, glucuronide (7, 36) mean hormonal profiles. The use of FSH and P. I. Probit analysis. Am J Obstet Gynecol 1980;138:383–90.
11. Garcı´a JE, Jones JS, Wright GL. Prediction of the time of ovulation.
urinary LH, estrone glucuronide, and pregnanediol glucuro- nide assays opens the possibility of gaining insights into the 12. Brown JB. Use of the Home Ovarian Monitor in pregnancy avoidance.
dynamic endocrine events that may underlie human ovula- Am J Obstet Gynecol 1991;165:2008 –11.
13. Brown JB. Timing of ovulation. Med J Aust 1977;2:780 –3.
14. Billings JJ. Cervical mucus: the biological marker of fertility and infertility Int J Fertil 1981;26:182–95.
The present study confirms what various researchers have 15. Harlow SD, Baird DD, Weinberg CR, Wilcox AJ. Urinary estrogen patterns in long follicular phases. Hum Rep 2000;15:11– 6.
found secondarily. Renaud et al. (39), studying cycles they 16. Martinez AR, Bernardus RE, Kucharska D, Schoemaker J. Urinary supposed were normal, discarded 44% of the cycles obtained luteinizing hormone testing and prediction of ovulation in spontaneous, for being atypical. This is close to the 48% of cycles with clomiphene citrate and human menopausal gonadotropin-stimulatedcycles. A clinical evaluation. Acta Endocr 1991;124:357– 63.
estrone glucuronide or LH peaks with an atypical pattern that 17. Lemay A, Bastide A, Lambert R, Rioux JE. Prediction of human were found in our study. Queenan et al. (40) found ultra- ovulation by rapid LH radioimmunoassay and ovarian ultrasonography.
Fertil Steril 1982;38:194 –201.
sound and biochemical data that did not overlap in 22% 18. Danforth DR. Endocrine and paracrine controls of oocyte development.
cycles from healthy volunteers with regular cycles. Polan et Am J Obstet Gynecol 1995;172:747–52.
19. de Koning J. Gonadotrophin surge-inhibiting/attenuating factor governs al. (41) considered abnormal 36% of the spontaneous cycles LH secretion during the ovarian cycle: physiology and pathology. Hum with biphasic BBT and normal length. Some investigators, 20. Kesner JS, Knecht EA, Krieg EF, Wilcox AJ, O’Connor JF. Detecting such as, De Cherney et al. (42), have questioned normality preovulatory LH surges in urine. Hum Rep 1998;13:15–21.
21. Martinez AR, Bernardus RE, Vermeiden JPW, Schoemaker J. Reliabil- ity of home urinary LH tests for timing of insemination: a consumer’s It is clear from this study that hormonal profiles that differ 22. Vermesh M, Kletzky OA, Davajan D, Israel R. Monitoring techniques from the classic mean curves are frequently found in healthy to predict and detect ovulation. Fert Steril 1987;47:259 – 64.
fertile women. Consequently, more research is needed with 23. Bonnar J, Flynn A, Freundl G, Kirkman R, Royston R, Snowden R.
Personal Home Monitoring for contraception. Br J Fam Plann 1999; this type of population to clarify menstrual cycle variants.
Subsequent studies would benefit from the inclusion of con- 24. Blackwell LF, Brown JB, Cooke D. Definition of the potentially fertile period from urinary steroid excretion rates. Part II. A Threshold value for pregnanediol glucuronide as a marker for the end of the potentiallyfertile period in the human menstrual cycle. Steroids 1998;63:5–13.
25. Brown JB, Blackwell LF, Holmes J, Smyth K. New assays for identi- fying the fertile period. Int J Gynecol Obstet 1989;(Suppl 1):111–22.
26. Metcalf MG. Are 24-hour collections necessary for the measurement of steroid excretion rates? NZ Med J 1976;84:150 –3.
27. Collins WP, Collins PO, Kilpatrick MJ, Manning PA, Pike JM, Tyler JPP. The concentrations of urinary oestrone-3-glucuronide, LH andpregnanediol 3-␣-glucuronide as indices of ovarian function. Acta Acknowledgments: The author is grateful to Patricio Mena, M.D., for his advice during the preparation of this manuscript, to Marcela Va´squez and 28. Collins WP, Branch CM, Collins PO, Sallam HN. Biochemical indices of the fertile period in women. Int J Fertil 1981;26:196 –202.
Vero´nica Nu´n˜ez for their help in data collection, to Carmen Romero, Leticia 29. Frydman R, Testart J, Feinstein MC, Roger M. Interrelationship of Luna, and collaborators for technical assistance performing hormonal as- plasma urinary luteinizing hormone preovulatory surge. J Steroid Bio- says, to Luis Jensen, M.D., and Sergio Valenzuela, M.D., for their support, and to the World Health Organization.
30. Cano A, Aliaga R. Characteristics of urinary LH during the induction of LH surges of different magnitude in blood. Hum Rep1995;10:63–7.
31. Pepperell RJ, Brown JB, Evans JH, Rennie GC, Burger HG. The investigation of ovarian function by measurement of urinary estradiol References
and pregnanediol excretion. Br J Obstet Gynaecol 1975;82:321–32.
1. Fritz MA, Speroff L. The endocrinology of the menstrual cycle: the 32. Stanczyk FZ, Miyakawa I, Goebelsmann U. Direct radioimmunoassay interaction of folliculogenesis and neuroendocrine mechanisms. Fertil of urinary estrogen and pregnanediol glucuronides during the menstrual cycle. Am J Obstet Gynecol 1980;137:443–50.
2. Yen SSC. The human menstrual cycle: neuroendocrine regulation. In: 33. Denari JH, Farinati Z, Casas PRF, Oliva A. Determination of ovarian Yen SS, Jaffe RB, eds. Reproductive endocrinology. Philadelphia: WB function using first morning urine steroid assays. Obstet Gynecol 1981; 3. Speroff L, Glass RH, Kase NG. Regulation of the mentrual cycle. In: 34. Cekan SK, Baksac MS, Wang E, Shi S, Masironi B, Landgren BN, et Clinical gynecologic endocrinology and infertility. Baltimore: Williams al. The prediction and/or detection of ovulation by means of urinary steroid assays. Contraception 1986;33:327– 45.
4. Ferin MJ. The menstrual cycle and integrative view. In: Adashi EY, 35. Stanczyck FZ, Gentzschein E, Ary BA, Kojima T, Ziogas A, Lobo RA.
Rock JA, Rosenwaks Z, eds. Reproductive endocrinology, surgery and Urinary progesterone and pregnanediol. Use for monitoring progester- technology. Vol. 1. Philadelphia: Lippincott-Raven, 1996:103–21.
one treatment. J Reprod Med 1997;42:216 –22.
5. Flynn AM, Collins WP, Royston P, Barbato M, Mena Gonzalez P, 36. Usuki S, Kondoh K, Kubo T. Plasma endothelin and LH-RH, LH, FSH, Alliende ME. Volumetric self-sampling of cervicovaginal fluid to de- prolactin, progesterone, 17␣-hydroxyprogestrerone, estrone, 17␤-estra- Alliende
diol, ⌬4-androstenedione, testosterone, active renin, angiotensin-II, and al. Echograpic study of follicular maturation and ovulation during the ANP levels in blood and LH, estrone and 17␤-estradiol and preg- normal menstrual cycle. Fertil Steril 1980;33:272– 6.
nanediol in urine of normal cycling women. J Cardiovasc Pharmacol 40. Queenan JT, O’Brien GD, Bains LM, Simpson J, Collins WP, Camp- bell S. Ultrasound scanning of ovaries to detect ovulation in women.
37. Lasley BL, Shideler SE, Munro CJ. A prototype for ovulation detection: pros and cons. Am J Obstet Gynecol 1991;165:2003–7.
41. Polan M, Totora M, Caldwell BV, DeCherney AH, Haseltine FP, Kase 38. Lasley BL, Stabenfeld GH, Overstreet JW, Hanson FW, Czekala N, N. Abnormal ovarian cycles as diagnosed by ultrasound and serum Munro C. Urinary hormone levels at the time of ovulation and implan- estradiol levels. Fertil Steril 1982;37:342–7.
tation. Fertil Steril 1985;43:861–7.
42. DeCherney AH, Romero R, Polan ML. Ultrasound in reproductive 39. Renaud RL, Macler J, Dervain I, Ehret MC, Aron C, Plas-Roser S, et endocrinology. Fertil Steril 1982;37:323–33.
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