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
To evaluate hormonal profiles of normal menstrual cycles.
Prospective, descriptive study of a case series.
University-based natural family planning center.
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.
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.
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%).
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
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,
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
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.
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
(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
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
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
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
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
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FERTILITY & STERILITY
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