Hormonal Profiles of Menstrual Bleeding Patterns During the Luteal-Follicular Transition.

CONTEXT: Menstrual cycle function is determined by a complex endocrine axis that controls the ovaries and endometrium. While the late luteal phase is characterized by declining progesterone and estrogen, how these hormonal profiles relate to menstrual bleeding patterns is not well understood. OBJECTIVE: Characterize associations between luteal phase hormonal profiles and subsequent menstrual bleeding patterns, specifically spotting before bleeding. DESIGN, SETTING, AND PARTICIPANTS: We examined creatinine-adjusted urinary estrone 3-glucuronide (E13G) and pregnanediol 3-glucuronide (Pd3G) levels in relation to spotting in 116 premenopausal women (ages 20-47) who kept daily menstrual diaries and collected first morning urine samples for ≥ 2 consecutive cycles or 1 luteal-follicular transition (n = 283 transitions). We used linear mixed models to estimate associations between luteal phase hormone levels and spotting before bleeding. MAIN OUTCOME MEASURE(S) AND RESULTS: Transitions with ≥ 1 days of spotting before menstrual bleeding (n = 118) had greater luteal phase Pd3G levels vs nonspotting transitions (n = 165). Differences in Pd3G between spotting and nonspotting transitions were largest at menses onset (34.8%, 95% confidence interval, 18.9%, 52.7%). Pd3G levels for spotting transitions dropped to similar levels as nonspotting transitions an average of 1 day later, which aligned with the first day of bleeding for transitions with contiguous spotting. Spotting transitions were preceded by slower rates of Pd3G decline than nonspotting transitions, whereas E13G declines were similar. CONCLUSIONS: Self-reported bleeding patterns may provide insight into luteal phase Pd3G levels. First bleed appears to be the best choice for defining the end of the luteal phase and achieving hormonal consistency across transitions.

Ovulatory status and menstrual cycle duration assessed by self-collection of urine on pH strips in a population-based sample of French women not using hormonal contraception.

BACKGROUND: Assessing menstrual cycle function in the general population using a non-invasive method is challenging, both in non-industrialized and industrialized countries. SUBJECTS AND METHODS: The Observatory of Fecundity in France (Obseff) recruited on a nationwide basis a random sample of 943 women aged 18-44 years with unprotected intercourse. A sub-study was set up to assess the characteristics of a menstrual cycle by using a non-invasive method adapted to the general population. Voluntary women were sent a collection kit by the post and requested to collect urine samples on pH strips, together with daily recording of reproductive-related information during a full menstrual cycle. A total of 48 women collected urine every day, whereas 160 women collected urine every other day. Immunoassays were used to measure pregnanediol-3-α-glucuronide, estrone-3-glucuronide and creatinine. Ovulation occurrence and follicular phase duration were estimated using ovulation detection algorithms, compared to a gold standard consisting of three external experts in reproductive medicine. RESULTS: Every other day urine collection gave consistent results in terms of ovulation detection with every day collection (intraclass coefficient of correlation, 0.84, 95% confidence interval, 0.76-0.98). The proportion of anovulatory menstrual cycles was 8%. The characteristics of the ovulatory cycles were length 28 (26-34), follicular phase 16 (12-23), luteal phase 13 (10-16) days median (10th-90th percentiles). DISCUSSION-CONCLUSION: Assessing menstrual cycle characteristics based on urine sample spot only collected every other day in population-based studies through a non-invasive, well accepted and cost-limited procedure not requiring any direct contact with the survey team appears feasible and accurate.

Characterization of hormonal profiles during the luteal phase in regularly menstruating women.

OBJECTIVE: To characterize the variability of hormonal profiles during the luteal phase in normal cycles. DESIGN: Observational study. SETTING: Not applicable. PATIENT(S): Ninety-nine women contributing 266 menstrual cycles. INTERVENTION(S): The women collected first morning urine samples that were analyzed for estrone-3-glucuronide, pregnanediol-3-alpha-glucuronide (PDG), FSH, and LH. The women had serum P tests (twice per cycle) and underwent ultrasonography to identify the day of ovulation. MAIN OUTCOME MEASURE(S): The luteal phase was divided into three parts: the early luteal phase with increasing PDG (luteinization), the midluteal phase with PDG ≥10 µg/mg Cr (progestation), and the late luteal phase (luteolysis) when PDG fell below 10 µg/mg Cr. RESULT(S): Long luteal phases begin with long luteinization processes. The early luteal phase is marked by low PDG and high LH levels. Long luteinization phases were correlated with low E1G and low PDG levels at day 3. The length of the early luteal phase is highly variable between cycles of the same woman. The duration and hormonal levels during the rest of the luteal phase were less correlated with other characteristics of the cycle. CONCLUSION(S): The study showed the presence of a prolonged pituitary activity during the luteinization process, which seems to be modulated by an interaction between P and LH. This supports a luteal phase model with three distinct processes: the first is a modulated luteinization process, whereas the second and the third are relatively less modulated processes of progestation and luteolysis.

Regulatory T cells vary over bleeding segments in asthmatic and non-asthmatic women.

Sex hormones may play an important role in observed gender differences in asthma incidence and severity. Regulatory T cells (Treg cells) are presumed to be involved in asthma and may vary with hormone levels. To investigate the effects of sex hormones on levels of Treg cells (percentage of CD4+CD25+Foxp3+ lymphocytes that are CD127-), a cohort of 13 women (6 with and 7 without an asthma diagnosis) had blood drawn multiple times over the course of a bleeding segment (bleeding interval plus the following bleeding-free interval) and collected urine samples daily for measurement of estrogen (estrone E1C) and progesterone (pregnanediol-glucuronide PDG) metabolites. The samples from non-asthmatic women indicated no association between bleeding segment day and Treg cells. Asthmatic women showed a 3% increase in Treg cell percentage with each successive day over the bleeding segment. Among non-asthmatic women, Treg cell percentages were not associated with PDG levels on the same day, or 1, 2 or 3 days before Treg cell measurement. E1C was positively correlated with the Treg cell percentage measured only on the same day - a 5% increase in E1C was associated with a 1.4% increase in Treg cell percentage. Among asthmatic women, only E1C was associated with Treg cell percentages after adjusting for PDG on the same day and 1 and 2 days before Treg cell measurement. A 5% increase in E1C was associated with a 2.3% increase in Treg cell percentage. A larger study of contiguous cycles to better determine within-woman cyclicity of the observed patterns is needed.

Effects of menstrual cycle phase on metabolomic profiles in premenopausal women.

BACKGROUND: Characterization of the normal degree of physiological variation in the metabolomic profiles of healthy humans is a necessary step in the development of metabolomics as both a clinical research and diagnostic tool. This study investigated the effects of the menstrual cycle on (1)H nuclear magnetic resonance (NMR) derived metabolomic profiles of urine and plasma from healthy women. METHODS: In this study, 34 healthy women were recruited and a first void urine and fasting blood sample were collected from each woman at four different time points during one menstrual cycle. Serum hormone levels were used in combination with the menstrual calendar to classify the urine and plasma samples into five different phases i.e. menstrual, follicular, periovulatory, luteal and premenstrual. The urine and plasma samples were analysed using (1)H NMR spectroscopy and subsequent data were analysed using principal component analysis (PCA) and partial least squares discriminant analysis. RESULTS: PCA of the urine spectra showed no separation of samples based on the phases of the menstrual cycle. Multivariate analysis of the plasma spectra showed a separation of the menstrual phase and the luteal phase samples (R(2) = 0.61, Q(2) = 0.41). Subsequent analysis revealed a significant decrease in levels of glutamine, glycine, alanine, lysine, serine and creatinine and a significant increase in levels of acetoacetate and very low density lipoprotein (VLDL CH(2)) during the luteal phase. CONCLUSIONS: These results establish a need to control for metabolic changes that occur in plasma due to the menstrual cycle in the design of future metabolomic studies involving premenopausal women.

Variability in the phases of the menstrual cycle.

OBJECTIVE: To determine variability in the phases of the menstrual cycle among healthy, regularly cycling women. DESIGN: A prospective descriptive study of a new data set with biological markers to estimate parameters of the menstrual cycles. PARTICIPANTS: One hundred forty one healthy women (mean age 29 years) who monitored 3 to 13 menstrual cycles with an electronic fertility monitor and produced 1,060 usable cycles of data. MEASURES AND OUTCOMES: Variability in the length of the menstrual cycle and of the follicular, fertile, and luteal phases, and menses. The estimated day of ovulation and end of the fertile phase was the peak fertility reading on the monitor (i.e., the urinary luteinizing hormone surge). RESULTS: Mean total length was 28.9 days (SD = 3.4) with 95% of the cycles between 22 and 36 days. Intracycle variability of greater than 7 days was observed in 42.5% of the women. Ninety-five percent of the cycles had all 6 days of fertile phase between days 4 and 23, but only 25% of participants had all days of the fertile phase between days 10 and 17. CONCLUSIONS: Among regularly cycling women, there is considerable normal variability in the phases of the menstrual cycle. The follicular phase contributes most to this variability.

Secretion and excretion of human chorionic gonadotropin during early pregnancy.

OBJECTIVE: To characterize the profiles of human chorionic gonadotropin (hCG) secretion in blood and its subsequent excretion in urine during conceptive cycles that ended in successful pregnancy and in spontaneous abortion. DESIGN: A prospective study. SETTING: University fertility clinic and research laboratories. PATIENT(S): Healthy, spontaneously ovulating women with regular menses, no history of infertility, and either no male partner or an azoospermic partner. INTERVENTION(S): Blood and urine samples were collected daily from 63 spontaneously ovulating women during 167 cycles of artificial insemination (AI) with donor semen; hCG concentrations were measured in blood and urine, and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) concentrations were measured in blood by immunoassay. MAIN OUTCOME MEASURE(S): Fecundity, the day of ovulation, the day of hCG detection, and the concentration of hCG on the day of detection in blood and urine. RESULT(S): In 62 conceptions detected, 14 resulted in clinical spontaneous abortion (CAB) and 8 resulted in early pregnancy loss (EPL). When successful pregnancies and pregnancy losses were compared, no significant differences existed between the days of hCG appearance in serum or in urine, the concentrations of hCG on the day of detection, or the incremental change in hCG concentration on the day of detection. CONCLUSION(S): These data validate the use of urinary hCG as a biomarker for assessing peri-implantation pregnancy events.

Urinary hormone levels during the natural menstrual cycle: the effect of age.

A number of studies have identified hormonal changes in women during their reproductive lifespan, many focusing upon changes in women over the age of 40 years. The present study has determined the effect of increasing age on hormone levels over three decades. Daily early morning urine samples were assayed for estrone-3-glucuronide (E3 G), pregnanediol-3-glucuronide (P3 G), testosterone-17-glucuronide (T17 G), FSH and LH. An examination of the validity of using creatinine as a volume adjuster in urine samples formed an integral part of the analysis. Volunteers were healthy women who had regular (25-35 days) cycles, were not taking oral contraceptives, hormone therapies or any other medication. Three age groups were compared: 20-29 years (n=13), 30-39 years (n=9) and 40-49 years (n=13). Statistical analyses were carried out using two-way ANOVA and post hoc t-tests. Creatinine excretion, despite revealing no cycle-related variation in any age group, showed a decline with increasing age. Creatinine output was significantly lower in the 40-49 years age group in all phases of the cycle than in the 20-29 and 30-39 groups (P<0.0001). Uncorrected levels of E3 G were significantly higher in the 30-39 years group when compared with the 40-49 age group (P<0.0001). Uncorrected P3 G output was significantly higher in women aged 20-29 years than in women aged 40-49 years (P<0.001) and levels of uncorrected T17 G were higher in the 20-29 year age group when compared with the 30-39 or 40-49 years age group (P<0.0001). The present study is consistent with previous reports that have revealed a decline in creatinine clearance with increasing age, and therefore casts into some doubt the validity of using creatinine clearance as a procedure to correct for volume fluctuations in differing age groups of women. The study also demonstrates unequivocally that age-related variations in hormone levels are not restricted to women over 40 years of age. The novel finding of highly significant differences in mean levels of T17 G between the age groups is of considerable interest. It is presently unclear whether this resulted from specifically increased ovarian and/or adrenal secretion. The possible impacts of changes in testosterone levels during the female reproductive lifespan merits further study.

Deficiency of tumor necrosis factor alpha in a subclass of menstrual migraineurs.

OBJECTIVE: The objective of this study was to determine whether differences in urinary proinflammatory cytokines, interleukin-1beta (IL-1beta), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-alpha), exist between migraineurs and nonheadache control subjects, and between nonhormonal migraine and menstrual migraine. Any differences noted would expand and clarify a neuroimmune hypothesis of migraine pathogenesis and lead to future diagnostic markers or therapeutic options or both for the disorder. BACKGROUND: Current theories of migraine pathogenesis focus on biochemical abnormalities in the central nervous system resulting in sterile inflammation of meningeal blood vessels. Vasoactive substances involved in this process may include substance P, calcitonin gene-related peptide, neurokinin A, serotonin, and nitric oxide. Immune cell products, such as histamine, leukotrienes, and cytokines, also have vascular inflammatory properties. METHODS: A study of proinflammatory cytokines, IL-1beta, IL-6, and TNF-alpha, was undertaken in menstrual migraineurs. During and outside of menses, 24-hour urine samples of 19 women with migraine were taken during a menstrual migraine, a nonmenstrual migraine, and a headache-free day, and compared with 24-hour urine samples taken of 10 nonheadache controls during and outside of menses. RESULTS: A neuroimmune mechanism for migraine was tested with expected increases in proinflammatory cytokines tested during a migraine. This hypothesis was not validated. Mean IL-6 levels were increased in all three samples of migraineurs versus controls, but did not achieve statistical significance. No differences were found in IL-1beta levels between samples. Interestingly, marked differences were found in TNF-alpha values in menstrual migraineurs. Twelve (63%) of 19 migraineurs had at least one urine sample with undetectable TNF-alpha levels, whereas none of the 20 samples given by the 10 nonheadache controls in this study had undetectable levels. Thirty-two samples from men with cluster headache and nonheadache control subjects in prior studies had detectable levels. CONCLUSIONS: This deficiency of TNF-alpha levels in women with migraine may signal a disordered neuroimmune communication network and predisposition to migraine.

The predictive value of five different urinary LH kits in detecting the LH surge in regularly menstruating women.

OBJECTIVES: To compare the predictive value of five different urinary LH kits at detecting the LH surge in regularly menstruating, reproductive-age women. DESIGN: Single center, prospective study. SETTING: University of Tennessee, Obstetrics and Gynecology department. INTERVENTION: Eleven regularly menstruating women collected urine daily from cycle days 10 through 18. Urinary LH was quantitated by radioimmunoassay. Transvaginal sonography was performed to document ovulation. Three different lots of Clear Plan Easy, OvuKit, OvuQuick, Sure Step, and EZ LH were evaluated. MAIN OUTCOME MEASURE: Correlation of urinary LH test kit results with urine LH value determined by RIA. RESULTS: Peak urinary LH values by RIA ranged from 13.5 mIU/mL to 73.0 mIU/mL. The lowest level detected as positive by LH kits ranged from 25.5 mIU/mL to 48.7 mIU/mL. Lot-to-lot variations were rare. Follicular collapse occurred within 24 hours of the urinary LH peak in 8 of 10 (80%) and by 48 hours in the remaining 2 subjects. CONCLUSIONS: The percentage of LH surges detected by urinary LH kits ranged from 50% to 100%. The lowest LH value detected as positive varied almost twofold between different kits. Manufacturers should indicate the detection limit of their kits in mIU/mL.

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 potentially fertile period in the human menstrual cycle.

Application of time series analysis to a database containing serial pregnanediol data from 113 complete ovulatory menstrual cycles contributed by 83 women of proven fertility and 68 cycles for which pregnanediol values were available over the ovulatory period, detected the first statistically significant risk in pregnanediol excretion for all cycles for which a baseline was available (n = 170). However, even at the 99% confidence level, for 22% of cycles a rise was observed before the presumed day of ovulation. Therefore, a threshold value for pregnanediol was sought from the database as a better marker for the end of fertility. A value of 1.4 mg per 24 h was not reached before day 2 after the pre-ovulatory estrogen peak day for 96% of the cycles. In the remaining 4% of cycles it was reached one day after the total estrogen peak day. The validity of this threshold was confirmed in extensive studies using the Ovarian Monitor where the equivalent is 6.3 mumol per 24 h of pregnanediol glucuronide and measurements are performed on timed urine specimens with a minimum collection time of three hours. These studies were as follows: 1) a World Health Organization study on the use of the Ovarian Monitor as a fertility self test in the home (108 cycles), 2) a multicenter study on returning fertility during breast feeding conducted by Family Health International (73 women), and 3) the general application of the Ovarian Monitor for pregnancy achievement and avoidance during the past ten years (over 250,000 PdG assays performed in ten countries). With rare exceptions, the use of these threshold values is applicable for all women provided correction is made for urine volume.

The usefulness of a urinary LH kit for ovulation prediction during menstrual cycles of normal women.

OBJECTIVE: To assess the predictive value of monitoring urine LH at home using a rapid, colorimetric enzyme immunoassay test (Ovuquick) once every evening. METHODS: Twenty-six strictly defined normal women with no history of infertility were enrolled in studies involving urine LH tests. Each subject had transvaginal sonography and serum LH tests performed two times per day beginning in the middle of a normal menstrual cycle. All subjects performed urine LH testing at home every evening. The time of the peak serum LH measurement was considered the surge. Ovulation was determined using sonographic criteria with confirmation by normal luteal-phase progesterone levels (3 ng/mL or greater). Two clinically relevant intervals were determined: interval I, time from peak serum LH to positive urine LH, and interval II, time from positive urine LH to follicular collapse by ultrasonography. RESULTS: All 26 cycles examined were ovulatory, based on sonographic and progesterone level criteria. The mean time (+/- standard error of the mean [SEM]) for interval I was 2 +/- 2 hours (95% confidence interval [CI] -2 to 6). The mean time (+/- SEM) for interval II was 20 +/- 3 hours (95% CI 14-26). Positive predictive values for follicular collapse within 24 or 48 hours after positive urine LH testing were 73 and 92%, respectively. CONCLUSION: Urine LH testing every evening is a reliable method of predicting ovulation within the ensuing 48 hours.

Radioimmunoassay of 2-hydroxyestrone in urine.

Catechol estrogens such as 2-OH estrone are interesting estrogen metabolites formed in several human tissues and excreted in urine. We developed and thoroughly validated a radioimmunoassay for urinary 2-OH estrone that has several advantages over published RIAs. Because we developed a relatively specific antiserum, we did not include a preliminary chromatographic step to eliminate cross-reacting urinary steroids. We hydrolyzed urinary steroid conjugates with beta-glucuronidase from Helix pomatia because recoveries after acid hydrolysis were only 49.6% compared with 73.8% after enzyme hydrolysis. Published RIAs for urinary 2-OH estrone use acid hydrolysis. Our RIA measured 2-OH estrone independently of the volume of sample, and the detection limit was between 100 and 240 ng/L (10-24 pg per tube). The ED50 was 370 ng/L, and inter- and intraassay CVs for low, medium, and high concentrations were 22.5%, 22.8%, and 19.9%, and 17.4%, 14.3%, and 10.8%, respectively. Median concentrations measured in 14 controls and 33 postmenopausal patients with breast cancer were 0.96 and 1.55 micrograms/g creatinine, respectively, but there was considerable overlap between values from controls and patients.

Laparoscopic segmental bladder resection for endometriosis: a report of two cases.

BACKGROUND: The proper treatment of bladder endometriosis is unknown. CASE: Two women with endometriosis involving the full thickness of the bladder wall experienced persistent hematuria during menstruation. They had not responded to previous conservative medical or surgical therapy, so we performed laparoscopic segmental resection, with satisfactory results. CONCLUSION: Hematuria during menstruation due to endometriosis of the bladder is uncommon. In the two cases presented, good results followed laparoscopic segmental resection.

Cigarette smoking and urinary excretion of markers for platelet/vessel wall interaction in healthy women.

1. Cigarette smoking is known to increase the risk of cardiovascular disease in both men and women. Experimental and epidemiological studies have demonstrated that cigarette smoking is associated with several indices of increased platelet activation and platelet/vessel wall interaction in men. The aim of the present study was to test the hypothesis that cigarette smoking is linked to an increased platelet activity in women also. 2. In 26 healthy smoking and non-smoking women (age 21-49 years) the urinary excretion of the thromboxane A2 metabolite 2,3-dinor-thromboxane B2 (an index of platelet activation) and of the prostacyclin metabolite 2,3-dinor-6-keto-prostaglandin F1 alpha (an index of platelet/vessel wall interaction) were analysed by g.c.-m.s. in samples collected on days 3, 10 and 20 of their respective menstrual cycles. 3. The urinary excretion of 2,3-dinor-thromboxane B2 did not vary significantly during the menstrual cycle, either in the smokers or in the non-smokers. It was consistently higher (P less than 0.004) in the group of smokers (average of day 3, 10 and 20, 395 +/- 61 pg/mg of creatinine; mean +/- SEM) than in the group of non-smokers (average 188 +/- 22 pg/mg of creatinine). 4. The urinary excretion of 2,3-dinor-6-keto-prostaglandin F1 alpha did not differ between the groups on any of the days studied (average on days 3, 10 and 20 in the smokers and non-smokers was 281 +/- 50 and 227 +/- 30 pg/mg of creatinine, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Repeated serum and urinary androgen measurements in premenopausal and postmenopausal women.

Intra-individual variability for serum and urinary hormones has been inadequately considered in previous studies. Therefore, in the planning phase of a prospective study of Hormones and Diet in the Etiology of Breast Cancer (ORDET study), androgen levels have been examined at two different times in 56 women (26 in premenopause and 30 in postmenopause). Hormonal measurements in serum showed a good level of agreement for both premenopause (pre) and postmenopause (post): androstenedione pre r = 0.70 (p less than 0.0001), post r = 0.77 (p less than 0.0001); testosterone pre r = 0.73 (p less than 0.0001), post log values r = 0.74 (p less than 0.0001). Dihydrotestosterone showed a good level for premenopause only: log values pre r = 0.82 (p less than 0.0001), post r = 0.41 (p less than 0.05). Agreement levels in urine were inferior to those of serum: testosterone pre r = 0.53 (p less than 0.05), post r = 0.41 (p less than 0.05); androstanediol log values r = 0.46 (p less than 0.001), post log values r = 0.57 (p less than 0.05). Correlation between the two measurements improves considering age, parity, time of blood collection and, for urine, the interval of sample collections.