A cross section of a human ovar

Ovary Graafian follicles X45

A human ovary in the active phase X30

A cross section of a human ovary in the active phase X75

A cross section of human ovary follicles X2

Section of a human female: post menopause ovary. X80

Human female showing developing follicles in an ovary. X15

Human Graafian follicle in the ovary containing an oocyte and a small primary
follicle, H#caption#E stain. LM X26
Primordial follicle containing on oocyte in cortex of ovary of adult human female, h
and e stain X64

Cortex of a human ovary. Densely packed ovarian stroma consist of spindle cells in
interlacing patterns, h and e stain X50

Human ovary X16

Left ovary and uterus

Laparoscopic view of adenofibroma of the ovary

Human sperm X1000

What is menstruation?
Menstruation is a woman's monthly bleeding. It is also called menses, menstrual
period, or period. When a woman has her period, she is menstruating. The menstrual
blood is partly blood and partly tissue from the inside of the uterus (womb). It flows
from the uterus through the small opening in the cervix, and passes out of the body
through the vagina. Most menstrual periods last from three to five days.

What is the menstrual cycle?

Menstruation is part of the menstrual cycle, which helps a woman's body prepare for
the possibility of pregnancy each month. A cycle starts on the first day of a period.
The average menstrual cycle is 28 days long. However, a cycle can range anywhere
from 23 days to 35 days.

The parts of the body involved in the menstrual cycle include the brain, pituitary
gland, uterus and cervix, ovaries, fallopian tubes, and vagina. Body chemicals
called hormones rise and fall during the month and make the menstrual cycle
happen. The ovaries make two important female hormones, estrogen and
progesterone. Other hormones involved in the menstrual cycle include follicle-
stimulating hormone (FSH) and luteinizing hormone (LH), made by the pituitary
gland.

What happens during the menstrual cycle?

In the first half of the menstrual cycle, levels of estrogen rise and make the lining of
the uterus grow and thicken. In response to follicle-stimulating hormone, an egg
(ovum) in one of the ovaries starts to mature. At about day 14 of a typical 28-day
cycle, in response to a surge of luteinizing hormone, the egg leaves the ovary. This is
called ovulation.

In the second half of the menstrual cycle, the egg begins to travel through the
fallopian tube to the uterus. Progesterone levels rise and help prepare the uterine
lining for pregnancy. If the egg becomes fertilized by a sperm cell and attaches itself
to the uterine wall, the woman becomes pregnant. If the egg is not fertilized, it
either dissolves or is absorbed into the body. If pregnancy does not occur, estrogen
and progesterone levels drop, and the thickened lining of the uterus is shed during
the menstrual period.

In the illustration below, an egg has left an ovary after ovulation and is on its way
through a fallopian tube to the uterus.
 Image Source: U.S. Food and Drug Administration

What is a typical menstrual period like?

During the menstrual period, the thickened uterine lining and extra blood are shed
through the vaginal canal. A woman's period may not be the same every month, and
it may not be the same as other women's periods. Periods can be light, moderate, or
heavy, and the length of the period also varies. While most menstrual periods last
from three to five days, anywhere from two to seven days is considered normal. For
the first few years after menstruation begins, periods may be very irregular. They
may also become irregular in women approaching menopause. Sometimes birth
control pills are prescribed to help with irregular periods or other problems with the
menstrual cycle.

Sanitary pads or tampons, which are made of cotton or another absorbent material,
are worn to absorb the blood flow. Sanitary pads are placed inside the panties;
tampons are inserted into the vagina.

What kinds of problems do women have with their periods?

Women can have various kinds of problems with their periods, including pain, heavy
bleeding, and skipped periods.

• Amenorrhea - the lack of a menstrual period. This term is used to describe

the absence of a period in young women who haven't started menstruating by
age 16, or the absence of a period in women who used to have a regular
period. Causes of amenorrhea include pregnancy, breastfeeding, and extreme
weight loss caused by serious illness, eating disorders, excessive exercising,
or stress. Hormonal problems (involving the pituitary, thyroid, ovary, or
adrenal glands) or problems with the reproductive organs may be involved.
• Dysmenorrhea - painful periods, including severe menstrual cramps. In
younger women, there is often no known disease or condition associated with
the pain. A hormone called prostaglandin is responsible for the symptoms.
Some pain medicines available over the counter, such as ibuprofen, can help
with these symptoms. Sometimes a disease or condition, such as uterine
 fibroids or endometriosis, causes the pain. Treatment depends on what is
causing the problem and how severe it is.
• Abnormal uterine bleeding-vaginal bleeding that is different from normal
menstrual periods. It includes very heavy bleeding or unusually long periods
(also called menorrhagia), periods too close together, and bleeding between
periods. In adolescents and women approaching menopause, hormone
imbalance problems often cause menorrhagia along with irregular cycles.
Sometimes this is called dysfunctional uterine bleeding (DUB). Other causes
of abnormal bleeding include uterine fibroids and polyps. Treatment for
abnormal bleeding depends on the cause.

At what age does a girl get her first period?

Menarche is another name for the beginning of menstruation. In the United States,
the average age a girl starts menstruating is 12. However, this does not mean that
all girls start at the same age. A girl can begin menstruating anytime between the
ages of 8 and 16. Menstruation will not occur until all parts of a girl's reproductive
system have matured and are working together.

How long does a woman have periods?

Women usually continue having periods until menopause. Menopause occurs around
the age of 51, on average. Menopause means that a woman is no longer ovulating
(producing eggs) and therefore can no longer become pregnant. Like menstruation,
menopause can vary from woman to woman and may take several years to occur.
Some women have early menopause because of surgery or other treatment, illness,
or other reasons.

When should I see a health care provider about my period?

You should consult your health care provider for the following:

• If you have not started menstruating by the age of 16.

• If your period has suddenly stopped.
• If you are bleeding for more days than usual.
• If you are bleeding excessively.
• If you suddenly feel sick after using tampons.
• If you bleed between periods (more than just a few drops).
• If you have severe pain during your period.

How often should I change my pad/tampon?

Sanitary napkins (pads) should be changed as often as necessary, before the pad is
soaked with menstrual flow. Each woman decides for herself what is comfortable.
Tampons should be changed often (at least every 4-8 hours). Make sure that you
use the lowest absorbency of tampon needed for your flow. For example, do not use
super absorbency on the lightest day of your period. This can put you at risk for
toxic shock syndrome (TSS). TSS is a rare but potentially deadly disease. Women
under 30, especially teenagers, are at a higher risk for TSS. Using any kind of
tampon - cotton or rayon of any absorbency - puts a woman at greater risk for TSS
than using menstrual pads. The risk of TSS can be lessened or avoided by not using
tampons, or by alternating between tampons and pads during your period.

The Food and Drug Administration (FDA) recommends the following tips to help
avoid tampon problems:
 • Follow package directions for insertion.
• Choose the lowest absorbency for your flow.
• Change your tampon at least every 4 to 8 hours.
• Consider alternating pads with tampons.
• Know the warning signs of toxic shock syndrome (see below).
• Don't use tampons between periods.

If you experience any of the following symptoms while you are menstruating and
using tampons, you should contact your health care provider immediately:

• High fever that appears suddenly

• Muscle aches
• Diarrhea
• Dizziness and/or fainting
• Sunburn-like rash
• Sore throat
• Bloodshot eyes

What You Need To Know About Menstruation

If you're a teenage girl you probably have started having a period. If you have not,
you might be anxious about the subject or a bit concerned. This whole menstruation
thing might seem a bit mysterious, it is to many young women. It's actually very
complex, but interesting too.

Menstruation is the outward proof that a girl is becoming a woman. Having a period
is your body's way of saying it’s functioning properly.

During puberty, hormones are released from the brain that stimulate the ovaries.
The ovaries then produce estrogen and progesterone -- hormones that cause the
eggs in the ovaries to mature so the woman can become pregnant when she chooses
to. Here's how the process goes:

Every month, one egg leaves one of the ovaries on its way to the uterus via the
fallopian tubes. Meanwhile, in preparation for the egg, the uterus starts to develop a
thicker lining and it’s walls become cushiony (the endometrial lining). If the egg
reaches the uterus and is fertilized by a sperm cell, it attaches to this cushiony wall.

Most of the time the egg just passes right through without fertilization. Since the
uterus no longer needs the extra blood and tissue which made up the walls thick, it
sheds them by way of the vagina. This cycle will happen nearly every month until the
ovaries stop releasing eggs, usually several decades later. (Menopause).

Periods are different for every woman. Some girls start menstruation when they're 9
or 10; some in their late teens. The length of the cycle also varies. Some periods last
longer than 28 days, some shorter. If you have just begun your menstruation, your
body will need time to regulate itself to these changes. Your periods might be a bit
erratic at first. You may have two cycles in one month and miss having one the next
month. How long your period lasts also varies . Some girls have their periods for only
3 or 4 days, others as long as a week. The menstrual flow of blood can vary from
woman to woman also.
Some girls may have body and or mood changes around the time of their period.
Menstrual cramps are pretty common during the first few days of your period. These
are most likely caused by prostagladins. Prostaglandins causes the muscles of the
uterus to contract. These cramps tend to become less uncomfortable and sometimes
even disappear completely as a girl gets older. Over-the-counter pain medication like
ibuprofen or acetaminophen can often give relief; if not, a health care provider can
help. If your cramps are very severe, see a gynecologist.

As your period approaches, you may experience premenstrual syndrome (PMS). You
may find your emotions amplified during this time. Many women get depressed,
irritated, angry, and others cry more than usual or get cravings for certain foods.
PMS may be related to changes in hormones. Hormone levels rise and fall during a
menstrual cycle, affecting the way a female feels both mentally and physically.

Emotions can become more intense than usual, and many women may feel bloated
because of water retention. When your period begins, PMS usually goes away. You
may also have acne flare-ups.

Periods are a complex part of puberty, but also your body's way of telling you it is
functioning properly and you have taken good care of it. You can still exercise, swim
and do everything you enjoy. If you have any questions about periods, ask a parent,
health teacher, health care provider, or nurse. You can also ask friends or sisters
who have already had their periods. In time you will see that periods are a normal
and routine part of your life.

The Menstrual Cycle

The "typical" menstrual cycle occurs regularly over 28 days. Most women have cycles
with an interval that lasts from 21 to 35 days. Frequently cycles are unusually short
or long during adolescence.

THE FIRST HALF OF THE MENSTRUAL CYCLE (Day 1 to About Day 14 in a 28-Day
Cycle)

The Menstrual Phase

The first day of your menstrual period is considered Day 1 of your cycle. The
menstrual phase includes your period. During this time, the endometrium (the built-
up lining of the uterus) is shed, along with a little blood. Many of the problems that
women experience with their menstrual cycle occur during this phase. For example,
some women experience menstrual disorders such as dysmenorrhea (painful
periods) or menorrhagia (unusually heavy periods).

The Follicular/Proliferate Phase

During the proliferate phase, the body produces a hormone called follicle-stimulating
hormone (FSH). Follicle-stimulating hormone promotes the growth of a follicle (egg
sac) within the ovary. An ovum (egg) matures in the follicle during the proliferative
phase. FSH also stimulates the ovary to produce increasing amounts of estrogen. In
turn, the estrogen causes endometrial tissue to build up (or proliferate), lining the
interior of the uterus.

THE MIDPOINT OF THE MENSTRUAL CYCLE (About Day 14 in a 28-Day Cycle)

The mature ovum bursts from the follicle about midway (approximately 2 weeks
before onset of next menstrual period) through the menstrual cycle. This process is
known as ovulation. The ovum then travels from the ovary down the fallopian tube,
and into the uterus.

The Luteal/Secretory Phase

Once the ovum has been released, the follicle becomes a sac known as the corpus
luteum ("yellow body," because it contains yellowish, fatty matter). A hormone called
luteinizing hormone (LH) causes the corpus luteum to grow and to secrete
progesterone, another female hormone.

During the secretory phase, progesterone makes the endometrial lining stronger and
spongy in texture. Progesterone also stimulates glands in the endometrium. These
glands produce uterine fluid, and their purpose is to support embryonic development
if fertilization has occurred at or around the time of ovulation. It is in this phase of
the menstrual cycle that women who suffer from premenstrual syndrome (PMS) may
begin to experience their symptoms. Generally symptoms are worse during the last
seven to ten days of the cycle, ending at or soon after the start of the menstrual
period. In a woman who hasn't become pregnant, the level of progesterone peaks
about a week after ovulation and then begins to drop along with the estrogen level.
The flow of blood to the endometrium decreases, and its upper portion is broken
down and shed during menstruation. At the same time, the corpus luteum withers.

The dip in estrogen and progesterone at the end of the cycle help let the body know
that it's time to start the cycle all over again. The menstrual cycle doesn't have to be
a drag, it actually shows how complex your body is and a sign that it is functioning
properly! Congratulations, you are a woman and being a woman is terrific!

The Charts
The Ovarian Cycle chart shows the maturation and deterioration of the ovum and
how it occurs every month.
The Endometrial Cycle chart shows how the endometrial lining builds up during the
normal menstrual cycle and then is broken down and shed during menstruation
(menses). Meanwhile at the same time back at the Ovarian Cycle chart, the corpus
luteum withers.

Aren't women amazing! The menstrual cycle is actually a very cool and very complex
process that results from the many parts of the body working together. The brain,
the ovaries, the adrenal glands and even the thyroid, all have to come together with
their different hormonal and chemical influences. I guess you could say it is kind of
like a small orchestra in your body.

Do you know how many hormones play a role each month in causing your periods to
be normal or abnormal? Can you name all of the parts of the female reproductive
system? There is a delicate interaction between your reproductive organs and your
hormones that influence the timing and amount of blood flow you experience during
your monthly menstrual cycle. To understand how your reproductive organs and
hormones interact first you should know something about the biology behind your
menstrual cycle. Any change in your hormones or reproductive organs can have a
significant affect the timing of your periods, the amount of blood flow you experience
during menstruation, and your fertility.

What Are the Reproductive Organs?

The uterus is a pear-shaped organ which, in its non-pregnant state, is collapsed and
about the size of your fist. It is located between the bladder and the lower intestines.

The lower third of the uterus is called the cervix. The cervix has an opening called
the os which opens into the vaginal canal and permits your period to flow out.

Extending from each side of the uterus are the fallopian tubes. Near the end of each
fallopian tube is an ovary.

The ovaries are almond-sized organs which produce eggs. Each ovary contains from
200,000 to 400,000 follicles. These follicles contain the material necessary to
produce eggs.

The inner lining of the uterus is called the endometrium. The endometrium sheds
during menstruation. Your menstrual flow also contains blood and mucus from the
cervix and vagina. When pregnancy occurs, the endometrium thickens and fills with
blood vessels that mature into the placenta that contains the growing fetus.

What Hormones Interact with the Reproductive Organs?

The area of the brain called the hypothalamus, together with the pituitary gland,
control the hormones necessary for reproductive health.

Six hormones serve as chemical messengers to your reproductive system. These

hormones include:

• Gonadotropin-releasing hormone (GnRH)

• Follicle-stimulating hormone (FSH)
• Luteinizing hormone (LH)
• Estrogen
• Progesterone
• Testosterone

During your menstrual cycle, GnRH is released first by the hypothalamus. This
causes a chemical reaction in the pituitary gland and stimulates the production of
FSH and LH. Estrogen, progesterone, and testosterone (yes, the "male" hormone)
are produced by the ovaries in reaction to stimulation by FSH and LH. When these
hormones work in unison, normal menstrual cycles occur.

Your Menstrual Cycle in Phases

The menstrual cycle is divided into two phases--the follicular or proliferative phase;
and the luteal or ovulatory phase. The follicular phase includes the time when
menstruation occurs and is followed by proliferation or the growth and thickening of
the endometrium. This phase typically lasts from 10-14 days, starting with the first
day of menstruation.

Estrogen and progesterone levels are at their lowest during menstruation. When
bleeding stops, the proliferative phase begins causing the endometrium to grow and
thicken in preparation for pregnancy. During the next (approximately) two weeks,
FSH levels rise causing maturation of several ovarian follicles and the size of the
eggs triple.

FSH also signals the ovaries to begin producing estrogen which stimulates LH levels
until around day 14 of your cycle when one of the follicles bursts, and the largest egg
is released into one of the fallopian tubes.

This phase is followed by the premenstrual phase, known as the luteal phase. This
premenstrual period lasts approximately 14 days. After ovulation, LH causes the
corpus leuteum to develop from the ruptured follicle. The corpus leuteum produces
progesterone.

Together estrogen and progesterone stimulate the endometrium to prepare a thick

blanket of blood vessels that will support a fertilized egg should pregnancy occur.
When pregnancy occurs this blanket of blood vessels becomes the placenta which
surrounds the fetus until birth.

When pregnancy does not occur, the corpus leuteum deteriorates and becomes the
corpus albicans. Once this occurs, progesterone and estrogen levels decline, and the
endometrial lining is shed during menstruation.

Did You Know?

• Periods can vary greatly from woman to woman and from month to month
and still be normal. Generally, the length of your menstrual cycle can
fluctuate from 3 weeks to 5 weeks, without alarm.
• When counting the days in your cycle, always count the first day of your
period as day one. The average period lasts about 6 days, although some
women may experience slightly shorter or longer periods and be perfectly
normal.
• Variations in the amount of menstrual flow and the timing of menstruation are
quite normal in young women during the first few years following the onset of
menstruation. Periods may be irregular or very light. The use of oral
contraceptives can often cause fluctuations in menstruation which include
either light periods or spotting/bleeding between periods.
• It is not uncommon for young women to feel frightened when dark clumps of
tissue is discovered in their menstruation. However, this is usually nothing
abnormal and just a part of the endometrium ir uterine lining shedding.
• The average age of the onset of menstruation is about 12 or 13, however it
may begin as young as 8 for some girls or not until 14 or 15 for others. If
your period has not started by the time you are 16, see your physician to
determine whether there may be an underlying condition causing your period
not to start occuring.

The menstrual cycle

 P. Bischof

INTRODUCTION

In women, the fertile period starts at the menarche (first menstrual period) and ends
with the menopause. This period is divided in cycles of 28 to 35 days in length
separated by menstruation. It is more by convenience than by physiological truth
that the cycle starts on the first day of menstruation and ends on the day preceding
the next menstruation.

The cycle is divided in two periods of unequal length: the phase that precedes
ovulation (or follicular rupture) is called the follicular phase whereas the period which
follows ovulation is termed the luteal phase.. The length of the follicular phase
depends on the velocity of growth of the ovarian follicles and is thus variable from
one woman to another. In contrast, the length of the luteal phase depends on the life
span of the corpus luteum, it is thus less variable. In the 20 women whose hormonal
results are presented below, the mean duration (+ SD) of the follicular phase was
15.4 + 2.5 days and the mean duration of the luteal phase was 13.6 + 1.2 days).

THE HORMONES OF THE MENSTRUAL CYCLE

The ovarian cycle is part of an integrated system which includes the hypothalamus,
the pituitary, the ovary and the uterus (fig. 1). The biological clock which is
responsible for the rhythmicity of the cycles consists in the pulsatile release of an
hypothalamic decapeptide: the Gonadotropin Releasing Hormone (GnRH). The
pulsatile secretion of GnRH depends not only on external events (psychological
factors or the nyctaehemeral rhythm) which reach the hypothalamus from the cortex
through the limbic system but depends also on the ovarian events through the feed-
back effect that the sexual steroids exert on the hypothalamus and the pituitary. This
modulated secretion of GnRH controls the release and synthesis of the polypeptidic
pituitary gonadotropins: Follicle Stimulating Hormone (FSH) and Luteinising Hormone
(LH).

FSH allows recruitment and growth of the ovarian follicles as well as the selection of
the dominant follicle whereas LH induces follicular rupture and sustains the corpus
luteum. Oestradiol and Progesterone are produced respectively by the follicles and
the corpus luteum where their secretion is gonadotropin-dependent. Bound to
transport proteins, these steroids are carried in the blood stream and regulate the
secretion of GnRH, FSH and LH and induce proliferation and differentiation of the
uterine endometrium in order to guarantee implantation of the embryo if fertilisation
has taken place.

THE REGULATION OF THE MENSTRUAL CYCLE

Ovarian follicles are composed of an outer layer of thecal cells and an inner layer of
granulosa cells which engulf the oocyte and host an antrum (fig.2). The thecal cells
have LH receptors, and produce androgens (testosterone and androstenedione) in
response to LH. The androgens cross the basement membrane to reach the
granulosa cells where aromatase transforms them into oestrogens (oestradiol and
oestrone respectively). Aromatase is an FSH dependant enzyme and the FSH
receptors are located on the granulosa cells.
At the end of the preceding cycle, the drop in oestradiol and progesterone (due to
the demise of the corpus luteum) decreases the negative feed-back on FSH and this
hormone increases in the blood before menses appear. This increase recruits a
cohort of follicles which become sensitive to FSH and start to grow.

During the first week after menses (in a 28 days cycle), FSH continues to increase,
the follicles grow intensely and FSH increases the expression of its own receptor and
of the LH receptor on the granulosa cells. During this period, the follicles produce
relatively small amounts of oestradiol and the circulating concentration of this steroid
is relatively constant (fig. 3).

During the second week, the follicles continue to grow and since they have increased
their FSH receptors on the granulosa cells their aromatase actively transforms the
thecal androgens into oestrogens and the circulating oestradiol levels increase. This
increase induces a negative feed-back on FSH which decreases slightly in the blood.
The follicle which has the highest number of FSH receptors, the maximal aromatase
activity and thus produces the highest concentration of oestradiol is named the
dominant follicle and will be selected for ovulation, the others gradually degenerate
during a process called atresia. Oestradiol continues to increase (particularly due to
the activity of the dominant follicle) and reaches a peak about 72h before ovulation.
These high levels of oestradiol induce by positive feed-back, a brisk release of LH
and FSH (the LH and FSH peaks, fig. 3).

Follicular rupture (ovulation) occurs about 36h after the LH peak. It is due to the fact
that granulosa cells have acquired LH receptors (effect of FSH) and are now
responsive to LH. This peptide induces the secretion of enzymes which digest the
follicular wall. The initial rise of LH (at the beginning of the peak) is sufficient to allow
the granulosa cells to secrete small amounts of progesterone which participate in the
mechanism of induction of the LH peak.

Once the oocyte has been expelled from the ruptured follicle, LH induces the
secretion of progesterone from the remaining granulosa cells which organise
themselves in a new gland called the corpus luteum (a process known as
luteinisation). Progesterone and oestradiol increase and reach a plateau around day
22. This induces a negative feed-back on LH and FSH which decrease in the
circulation. If implantation does not occur, Human Chorionic Gonadotropin (hCG) is
not present, the corpus luteum is not sustained any longer and oestradiol and
progesterone decline. This decline induces an increase in FSH which will recruit the
follicles for the next cycle. Endometrial bleeding occurs because the progesterone
levels have fallen below those required to maintain a secretory endometrium.

THE NORMAL VALUES OF HORMONES DURING THE MENSTRUAL CYCLE

Definitions

The Early Follicular Phase starts on the first day of the cycle and ends when
oestradiol begins to increase. It is characterised by increasing LH and FSH and
constant low levels of oestradiol (fig. 4).

The Late Follicular Phase starts with the increase in oestradiol and ends at its
preovulatory peak. It is characterised by increasing oestradiol and decreasing FSH
and LH levels (fig. 4).
The Early Luteal Phase starts on the day of ovulation (the day after the LH peak) and
ends when progesterone has reached its plateau. It is characterised by increasing
progesterone and decreasing LH and FSH levels (fig. 4).

The Mid Luteal Phase corresponds to plateauing progesterone levels. It is

characterised by constant elevated progesterone and constant low levels of LH and
FSH (fig. 4).

The Late Luteal Phase starts when progesterone decreases and ends on the day
preceding the next menses. It is characterised by decreasing progesterone and
increasing LH and FSH levels (fig. 4).

Volunteers and Method

Our study included 20 normal healthy women aged 20 to 35 who have not been
taking oral contraceptives for at least 3 months before the start of the study. Daily
morning blood samples (10ml) were taken on heparin starting on the first day of
their menses and continued to the first day of their next menses. After
centrifugation, the plasma samples were aliquoted and stored at -20o C until
assayed. Starting on day 10, three urine samples per day (morning, afternoon,
evening) were also obtained and urine collection continued until the day after the LH
peak. Urinary LH was measured daily to determine the LH peak.

For each volunteer, 3 vaginal ultrasound scans were performed according to the
following schedule: day 10, day 13 and two days after the LH peak. A cycle was
declared as ovulatory if the dimensions of the corpus luteum as measured 2 days
after the LH peak were smaller than the dimensions of the dominant follicle as
measured on day 13. All 20 cycles were ovulatory according to this criteria.

LH, FSH, oestradiol and progesterone were measured on Kryptor and statistical
evaluation of the results was performed on a Macintosh computer using the Statview
program from Abascus.

Results

Concentrations of pituitary gonadotropins and ovarian steroids stratified by functional

phases are presented in figure 4 and in tables I to VI. The functional periods of the
cycle as defined above are compared to the days of the cycle either calculated from
the day of the LH peak or estimated for a 28 and a 35 days cycle. The distribution of
the observed values is given by the concentration of each hormone at the 2.5th,
50th (median) and 97.5th percentile. By definition, 95% of the normal population is
between the 2.5th and the 97.5th percentiles of the distridution.

Table I: FSH values in IU/l during the functional periods of the cycle

Days
28 Days 50th
Days days 35 days 2.5th Centile 97.5th
Period from LH Cycle Cycle Mean Centile Median Centile
Early -15 to
1-9 1-15 5.59 2.33 5.64 8.88
Follicular -5

Late
-4 to 0 10-14 16-20 4.09 1.21 3.97 7.71
Follicular

Ealy Luteal 1-3 15-17 21-23 5.20 1.76 4.60 13.32

Mid Luteal 4-9 18-23 24-29 2.71 0.78 2.59 6.15

Late Luteal 10-15 24-29 30-35 2.48 0.20 2.31 7.52

Table II: LH values in IU/l during the functional periods of the cycle

Days
28 Days 50th
Days days 35 days 2.5th Centile 97.5th
Period from LH Cycle Cycle Mean Centile Median Centile

Early -15 to
1-9 1-15 3.40 1.12 3.25 5.90
Follicular -5

Late
-4 to 0 10-14 16-20 5.65 2.34 4.43 16.11
Follicular

Ealy Luteal 1-3 15-17 21-23 7.00 1.91 6.03 17.30

Mid Luteal 4-9 18-23 24-29 3.64 0.73 3.12 8.56

Late Luteal 10-15 24-29 30-35 2.77 0.59 2.40 7.51

Table III: Oestradiol values in pg/ml during the functional periods of the cycle

Days
28 Days 50th
Days days 35 days 2.5th Centile 97.5th
Period from LH Cycle Cycle Mean Centile Median Centile

Early -15 to
1-9 1-15 57.6 11.7 48.5 167.2
Follicular -5

Late
-4 to 0 10-14 16-20 196.3 31.8 167.7 559.1
Follicular

Ealy Luteal 1-3 15-17 21-23 129.0 31.5 120.9 294.0

Mid Luteal 4-9 18-23 24-29 203.5 58.3 211.6 342.3

Late Luteal 10-15 24-29 30-35 132.8 16.1 118.7 347.4

Table IV: Oestradiol values in pmol/l during the functional periods of the cycle

Days
28 Days 50th
Days days 35 days 2.5th Centile 97.5th
Period from LH Cycle Cycle Mean Centile Median Centile

Early -15 to
1-9 1-15 211.4 42.9 178.0 613.6
Follicular -5

Late
-4 to 0 10-14 16-20 720.4 116.7 615.5 2051.9
Follicular

Ealy Luteal 1-3 15-17 21-23 473.4 115.6 443.7 1079.0

Mid Luteal 4-9 18-23 24-29 746.9 214.0 776.6 1256.2

Late Luteal 10-15 24-29 30-35 487.4 59.1 435.6 1275.0

Table V: Progesterone values in ng/ml during the functional periods of the cycle

Days
28 Days 50th
Days days 35 days 2.5th Centile 97.5th
Period from LH Cycle Cycle Mean Centile Median Centile

Early -15 to
1-9 1-15 0.58 0.05 0.49 1.64
Follicular -5

Late
-4 to 0 10-14 16-20 0.50 0.02 0.44 1.34
Follicular

Ealy Luteal 1-3 15-17 21-23 4.49 0.81 4.00 10.82

Mid Luteal 4-9 18-23 24-29 11.09 6.60 11.07 16.90

Late Luteal 10-15 24-29 30-35 5.38 0.51 4.47 14.61

Table VI: Progesterone values in nmol/l during the functional periods of the cycle

Days
28 Days 50th
Days days 35 days 2.5th Centile 97.5th
Period from LH Cycle Cycle Mean Centile Median Centile

Early -15 to
1-9 1-15 1.84 0.16 1.56 5.22
Follicular -5
Late
-4 to 0 10-14 16-20 1.59 0.06 1.40 4.26
Follicular

Ealy Luteal 1-3 15-17 21-23 14.28 2.58 12.72 34.41

Mid Luteal 4-9 18-23 24-29 35.27 21.00 35.20 53.74

Late Luteal 10-15 24-29 30-35 17.11 1.62 14.21 46.46

fig 1(aboue pic)

Fig 2

Fig 3 down pic

The menstrual cycle is the female reproductive cycle that makes eggs available for
fertilization. Menstruation involves the hypothalamus, pituitary and ovary, and in
humans lasts roughly 28 days (this can vary greatly between individuals).
The menstrual cycle can be divided into approximately two halves:

• the follicular phase. In the follicular phase, the biochemical and

physiological events (secretions of LH, FSH and estrogen) support the growth
of the follicle (the cell complex that surrounds and nurtures the egg) in the
ovary and build up the lining of the uterus to receive a fertilized egg. At mid-
cycle, when the egg is ready, a chemical signal -- a surge of LH and FSH --
tells the ovary to release the egg. This stage is called ovulation, and is the
optimum time for fertilization to take place.
• the luteal phase. In the luteal phase, the remnants of the follicle (corpus
luteum) keep secreting estrogen and progesterone to maintain the readiness
of the uterus. If the egg is fertilized, then the luteal phase continues
throughout pregnancy. If the egg is not fertilized, then the corpus luteum
dies, the uterus sheds its lining, menses begins and another menstrual cycle
ensues.

Click on the play button to learn more about the menstrual cycle.
If the animation above isn't working, click here to get the Shockwave player.
Here is a very detailed look at the events that occur during the menstrual cycle:
• Menses (approx. Day 0 to 5)
Typically, the menstrual cycle begins with the onset of menses, bleeding and
loss of the tissue lining of the uterus, which lasts from 5 to 7 days (variable
among women). During menses:
 The levels of estrogen and progesterone in the blood from the previous
cycle begin to drop to their lowest levels.
 Small episodic pulses of GnRH from the hypothalamus lead to small
pulses of LH and FSH from the pituitary. LH and FSH stimulate several
follicles (each containing an egg cell) to develop in the ovaries.
 The follicles secrete estrogen. The follicle that develops first
(dominant follicle) secretes greater amounts of estrogen than the
others, and this hormones suppresses the development of the other
follicles. The dominant follicle develops outer layers of cells, called
granulosa cells, and a fluid-filled space called the antrum. It also
continues to secrete estrogen.
• Follicular Phase: Part I (approx. Day 6 to 10)
 The primary follicle continues to develop and grow larger. The antrum
gets bigger, and pressure develops inside the follicle. The follicle
secretes estrogen at a faster rate.
 Estrogen levels in the blood rise. The rising estrogen levels will
eventually signal the brain that the egg is ready to be released.
 The rising estrogen levels stimulate growth in the tissue and blood
vessels that line the uterus. The uterus lining gets thicker in
preparation to receive a fertilized egg.
 LH and FSH levels remain low but steady, supporting the development
of the follicle.
• Follicular Phase: Part II (approx. Day 11 to 14 )
 The primary follicle continues to develop, grow larger and is about
ready to be released. The antrum grows,
and pressure is near its highest level Ovulation: Primate vs. Non-
inside the follicle. The follicle continues primate
to secrete estrogen at a faster rate. In all mammals except
 Estrogen levels are at their highest, primates (humans are
signaling that the egg is ready to be primates), fully-developed
released. eggs sit in the ovaries at
 LH and FSH levels remain low but certain times of the year,
steady, supporting the development of waiting for the brain to
the follicle. signal ovulation. The brain
 The uterine lining continues to grow in assesses information such as
response to stimulation by estrogen. The temperature and day length
mucus plug in the cervix becomes thin to determine when to send
and watery. the signal. At ovulation time,
the female enters a period of
estrus, or heat, and mates
• Ovulation (approx. Day 15)
with one or more males.
The high estrogen levels have signaled the
In primates, the ovary tells
brain that it is time to ovulate.
the brain when it is ready to
 The hypothalamus secretes massive
ovulate and mate. Primates
amounts of GnRH, stimulating the
can ovulate monthly all year
anterior pituitary to secrete massive
round.
amounts of LH and FSH (mid-cycle
LH/FSH peak). This surge lasts only 24 hours.
  The LH and FSH stimulate enzymes in the follicle. The enzymatic
reactions, along with the pressure of the antrum, release the egg from
the follicle. The egg travels into the Fallopian tube, where fertilization
can take place. The egg can survive for about 12 to 24 hours after
ovulation. The remainder of the follicle, the corpus luteum, stays in
the ovary. The corpus luteum secretes estrogen and progesterone.
 The lining of the uterus approaches its thickest and is ready to receive
a fertilized egg.
 The cervical mucus is at its thinnest.

This is the optimum time for fertilization to occur.

• Luteal Phase (approx. Day 16 to 28)

The corpus luteum degenerates.
 The egg gets swept along by gradual wave-like motions of the finger-
like projections in the walls of the Fallopian tube.
 LH and FSH levels fall back to their low, steady levels.
 Estrogen levels fall somewhat after the LH/FSH surge, but rebound
due to continued secretion of estrogen and progesterone by the corpus
luteum.
 The uterine lining remains thick and ready to host a fertilized egg or
growing embryo.
 The corpus luteum shrinks and begins to die. It is programmed to die
in 14 days unless it receives stimulation from human chorionic
gonadotropin (hCG), a hormone secreted from a growing embryo.
o If fertilization occurs, and the embryo implants in the lining of
the uterus, hCG rescues the corpus luteum and it continues to
secrete estrogen and progesterone throughout the pregnancy.
o If fertilization does not occur, the corpus luteum dies at the end
of the luteal phase. The unfertilized egg also dies and passes
out of the uterus when menses begins. Estrogen and
progesterone levels fall, menses starts and the uterine lining is
shed. A new cycle begins.

THE NORMAL MENSTRUAL CYCLE AND THE CONTROL OF OVULATION

Menstruation is the cyclic, orderly sloughing of the uterine lining, in response to the
interactions of hormones produced by the hypothalamus, pituitary, and ovaries. The
menstrual cycle may be divided into two phases: (1) follicular or proliferative phase,
and (2) the luteal or secretory phase (Fig. 1).

The length of a menstrual cycle is the number of days between the first day of
menstrual bleeding of one cycle to the onset of menses of the next cycle. The
median duration of a menstrual cycle is 28 days with most cycle lengths between 25
to 30 days.1-3 Menstrual cycles that occur at intervals less than 21 days are called
polymenorrheic, and menstrual cycles, which are prolonged more than 35 days, are
called oligomenorrheic. The menstrual cycle is typically most irregular around the
extremes of reproductive life, menarche and menopause, due to anovulation and
inadequate follicular development.4-6 The luteal phase is relatively constant with a
duration of 14 days. The variability of cycle length is usually derived from varying
lengths of the follicular phase of the cycle, ranging from 10 to 16 days.
 Figure 1. Hormonal, Ovarian, endometrial, and basal body
temperature changes and relations throughout the normal
menstrual cycle. (From Carr BR, Wilson JD. Disorders of the
ovary and female reproductive tract. In: Braunwald E,
Isselbacher KJ, Petersdorf RG, et al, eds. Harrison's
Principles of Internal Medicine. 11th ed. New York:
McGraw-Hill, 1987: 1818-1837.
THE FOLLICULAR PHASE

The follicular phase begins from the first day of menses until ovulation. Lower
temperatures on a basal body temperature chart and more importantly, the
development of ovarian follicles characterize this phase. Folliculogenesis begins
during the last few days of the preceding menstrual cycle until the release of the
mature follicle at ovulation. Declining steroid production by the corpus luteum and
the dramatic fall of Inhibin A and B levels allows for FSH to rise during the last few
days of the menstrual cycle.7 This event allows for the recruitment of a cohort of
ovarian follicles in each ovary, one of which is destined to ovulate during the next
menstrual cycle. Once menses ensues, FSH levels decline due to the negative
feedback of estrogen and the negative effects of inhibin produced by the developing
follicle.8,9 FSH activates the aromatase enzyme in granulosa cells, which converts
androgens to estrogen. A decline in FSH levels leads to the production of a more
androgenic microenvironment within adjacent follicles to the growing dominant
follicle. Also, the granulosa cells of the growing follicle secrete a variety of peptides
that may play an autocrine/paracrine role in the inhibition of development of the
adjacent follicles.

Development of the dominant follicle has been described in three stages: (1)
Recruitment, (2) Selection, and (3) Dominance (Fig.2). During days 1 through 4 of
the menstrual cycle, a cohort of follicles is recruited from a pool of nonproliferating
follicles in response to FSH. Between cycle days 5 and 7 and only one follicle is
selected from the cohort of recruited follicles to ovulate and the remaining follicles
will undergo atresia. By cycle day 8, one follicle exerts its dominance by promoting
its own growth and suppressing the maturation of the other ovarian follicles.

Figure 2. Time course for recruitment,

selection, and ovulation of the dominant
ovarian follicle (DF) with onset of atresia
among other follicles of the cohort (N-1).
(From Hodgen GD. The dominant ovarian
follicle. Fertil Steril 1982; 38:281-300).
During the follicular phase, serum estrogen levels rise in parallel to the growth of
follicle size as well as to the increasing number of granulosa cells. FSH receptors
exist exclusively on the granulosa cell membranes. Increasing FSH levels during the
late luteal phase leads to an increase in the number of FSH receptors and ultimately
to an increase in estradiol secretion by granulosa cells. The increase in FSH receptor
numbers is due to an increase in the population of granulosa cells and not due to an
increase in the concentration of FSH receptors per granulosa cell. Each granulosa cell
has approximately 1500 FSH receptors by the secondary stage of follicular
development and FSH receptor numbers remains relatively constant for the
remainder of development.10 The rise in estradiol secretion appears to increase the
number of estradiol receptors.11 In the presence of estradiol, FSH stimulates the
formation of LH receptors on granulosa cells allowing for the secretion of small
quantities of progesterone and 17-hydroxyprogesterone (17-OHP) which may exert a
positive feedback on the estrogen-primed pituitary to augment LH release .12 FSH
also stimulates several steroidogenic enzymes including CYP19, aromatase, and 3-B-
hydroxysteroid dehydrogenase.13,14 In Table 1, the production rates of sex steroids
during the follicular phase, luteal phase, and at the time of ovulation are presented.
 Table 1. Production Rate of Sex Steroids in Women at Different
Stages of the Menstrual Cycle
DAILY PRODUCTION RATE
Early
SEX STEROIDS* Preovulatory Midluteal
Follicular
Progesterone (mg) 1 4 25
17-
Hydroxyprogesterone 0.5 4 4
(mg)
Dehydroepiandrosterone
7 7 7
(mg)
Androstenedione (mg) 2.6 4.7 3.4
Testosterone (g) 144 171 126
Estrone (g) 50 350 250
Estradiol (g) 36 380 250
From Baird DT. Fraser IS. Blood production and ovarian secretion rates of
esuadiol-17  and estrone in women throughout the menstrual cycle. J Clin
Endocri-nol Metab 38: l009-1017. 1974. @ The Endocrine Society.
*Values are expressed in milligrams or micrograms per 24 hours.
Luteinizing hormone receptors are located on theca cells during all stages of the
menstrual cycle in contrast to granulosa cells. LH principally stimulates
androstenedione production and to a lesser degree testosterone production in the
theca cells. In the human, androstenedione is then transported to the granulosa cells
where it is aromatized to estrone and finally converted to estradiol by 17-b-
hydroxysteroid dehydrogenase type I. This is known as the two-cell, two-
gonadotropin hypothesis of regulation of estrogen synthesis in the human ovary (Fig
3).

Figure 3. Two-cell, two-gonadotropin hypothesis of regulation of estrogen

 synthesis in the human ovary. Adapted by Carr, BR. Diseases of the ovary
and Reproductive Tract. In Wilson JD, Foster DW, Kronenberg HM, Larsen
PR, eds. Williams Textbook of Endocrinology 9th edition. WB Saunders,
Philadelphia, p.751-817.
The primordial follicle is surrounded by a single layer of granulosa cells and is
arrested in the diplotene stage of the first meiotic division. After puberty, the
primordial follicle enlarges and develops into a preantral follicle. It then develops a
cavity and is known as an antral follicle. Finally, it becomes a preovulatory follicle on
its way towards ovulation. Due to the presence of 5-a-reductase, preantral and early
antral follicles produce more androstenedione and testosterone in relation to
estrogens.15 5-a-reductase is the enzyme responsible for converting testosterone to
dihydrotestosterone (DHT). Once testosterone has been 5- -reduced, DHT can not be
aromatized. However, the dominant follicle is able to secrete large quantities of
estrogen, primarily estradiol, due to high levels of CYP19. This shift form an
androgenic to an estrogenic follicular microenvironment may play an important role
in selection of the dominant follicle from those follicles that will become atretic.
Development of the follicle to the preantral stage is gonadotropin independent and
any follicular growth beyond this point will require gonadotropin interaction.
Gonadotropin secretion is regulated by gonadotropin releasing hormone (GnRH),
steroid hormones, and various peptides released by the dominant follicle. FSH is
elevated during the early follicular phase and then begins to decline until ovulation.
In contrast, LH is low during the early follicular phase and begins to rise by the
midfollicular phase due to the positive feedback from rising estrogen levels. For the
positive feedback effect of LH release to occur, estradiol levels must be greater than
200 pg/ml for approximately 50 hours in duration.16 The gonadotropins are secreted
in a pulsatile fashion and the frequency and amplitude of the pulses vary according
to the phase of the menstrual cycle (Table2). During the early follicular phase, LH
secretion occurs at a pulse frequency of 60 to 90 minutes with relatively constant
pulse amplitude. During the late follicular phase prior to ovulation, the pulse
frequency increases and the amplitude may begin to increase. In most women, the
LH pulse amplitude begins to increase after ovulation.17

Table 2. Mean (SEM) Luteinizing Hormone Secretory Burst

Characteristics During Phases of the Menstrual Cycle*
NUMBER PERODICITY AMPLITUDE** HALF- LH TOTAL
(24 hr) (min) (mlU/ml/min) DURATIONS HALF- DAILY
(min) LIFE SECRETION
(min) (mlU/ml/24
hr)
Early 80 ± 3a 0.43 ± 0.02a 6.5 ± 1.0a 131 ± 49 ± 6a
follicular 13a
175±1.4a

Late 53 ± 1b 0.70 ± 0.03b 3.5 ± 0.9b 128 ± 56 ± 8a

folicular 12a
26.9±1.6b

Midluteal 177 ± 15# 0.26 ± 0.02c# 11.0 ± 1.1e 103 ± 52 ± 4a

10.1±1.0c 7a

395 ± 37d# 0.95 ± 0.05d#

 *Entries in each column identified by a, b, c, d differ significantly (Duncan's
multiple-range test, P <.05). Periodicity is itersecretory burst interval. LH,
Luteinizing hormone.
**Duration of the deconvolution-resolved LH secretory burst at half-maximal
amplitude.
#
Maximal rate of LH secretion attained with the deconvolution-resolved LH
secretory burst. The midluteal phase has been divided into small (less than 0.65
mIU/ml/min) and large (greater than 0.65 mIU/ml/min) secretory burst
amplitudes.
Data from Sollenberger MJ, Carlsen EC, Johnson ML, et al. Specific physiological
regulation of LH secretory events throughout the human menstrual cycle. New
insights into the pulsatile mode of gonadotropin release. J Neuroendocrinol
2:845, 1990.
There are numerous substances found in follicular fluid that regulate the
microenvironment of the ovary and that regulate steroidogenesis in granulosa cells,
such as steroids, pituitary hormones, plasma proteins, proteoglycans and non-
steroidal ovarian factors. Growth factors such as insulin-like growth factor 1 and 2
(IGF1, IGF2) and epidermal growth factor (EGF) are recognized as playing important
roles in oocyte development and maturation.18,19 The concentration of ovarian
steroids is much higher in follicular fluid in comparison to plasma concentrations.
There are 2 populations of antral follicles: (1) large follicles, which are greater than
8mm in diameter, and (2) small follicles, which are less than 8mm. In the large
follicles, the concentrations of FSH, estrogen, and progesterone are high while
prolactin concentration is low. In the small follicles, prolactin and androgen levels are
higher than in large antral follicles.20

OVULATION

Ovulation occurs approximately 10-12 hours after the LH peak.21 The LH surge is
initiated by a dramatic rise of estradiol produced by the preovulatory follicle (Figure
4). To produce the critical concentration of estradiol needed to initiate the positive
feedback, the dominant follicle is almost always >15mm in diameter on
ultrasound.22 The LH surge occurs 34 to 36 hours prior to ovulation and is a
relatively precise predictor for timing ovulation. The LH surge stimulates luteinization
of the granulosa cells and stimulates the synthesis of progesterone responsible for
the midcycle FSH surge. Also, the LH surge stimulates resumption of meiosis and the
completion of reduction division in the oocyte with the release of the first polar body.
It has been demonstrated in cultured granulosa cells that spontaneous luteinization
can occur in the absence of LH. It is hypothesized that the inhibitory effects of
factors such as oocyte maturation inhibitor or luteinization inhibitor are overcome at
ovulation.23
 Figure 4. Changes in gonadotropins
and ovarian steroids at midcycle, just
prior to ovulation. The initiation of LH
surge is at time 0. Abbreviations: E2,
estrogen; P, progesterone (From Hoff
JD, Quigley ME, Yen SCC. Hormonal
dynamics at midcycle: A re-evaluation.
J Clin Endocrinol Metab. 57:792, 1983.

Prostaglandins and proteolytic enzymes such as collagenase and plasmin, are

increased in response to LH and progesterone. Although the precise mechanism is
not known, proteolytic enzymes and prostaglandins are activated and digest collagen
in the follicular wall, leading to an explosive release of the oocyte-cumulus
complex.24. Prostaglandins may also stimulate ovum release by stimulation of
smooth muscle within the ovary. The point of the dominant follicle closest to the
ovarian surface where this digestion occurs is called the stigma. There is no evidence
to support the theory that follicular rupture occurs as a result of increased follicular
pressure, although precise measurements precisely at rupture have not been
performed.25 In humans, ovulation probably occurs randomly from either ovary
during any given cycle, not preferentially in the contralateral ovary during the next
menstrual cycle as in the primate model.26,27
The concentrations of prostaglandins E and F series and hydroxyeicosatetraenoic acid
(HETE) reach a peak level in follicular fluid just prior to ovulation.28,29
Prostaglandins may stimulate proteolytic enzymes while HETEs may stimulate
angiogenesis and hyperemia.30 Patients treated with high dose prostaglandin
synthetase inhibitors such as indocin, can block prostaglandin production and
effectively block follicular rupture. This gives rise to what is known as the luteinized
unruptured follicle syndrome and it presents in fertile and infertile patients
equally.31 Therefore, infertility patients are advised to avoid taking prostaglandin
synthetase inhibitors, as well as cyclo-oxygenase (COX)-2 inhibitors, especially
around the time of ovulation.32 A schematic diagram illustrating the proposed
mechanisms involved in follicular rupture is presented in figure 5.

Figure 5. Proposed mechanisms involved in follicular rupture. From

Tsafriri A, Chun S-Y. Ovulation. In: Adashi E, Rock JA, Rosenwaks Z.
Reproductive Endocrinology, Surgery and Technology. Philadelphia:
Lippincott-Raven, 1996:236-249.
Estradiol levels fall dramatically immediately prior to the LH peak. This may be due
to LH downregulation of its own receptor or because of direct inhibition of estradiol
synthesis by progesterone. Progesterone is also responsible for stimulating the
midcycle rise in FSH. Elevated FSH levels at this time are thought to free the oocyte
from follicular attachments, stimulate plasminogen activator, and increase granulosa
cell LH receptors. The mechanism causing the postovulatory fall in LH is unknown.
The decline in LH may be due to the loss of the positive feedback effect of estrogen,
due to the increasing inhibitory feedback effect of progesterone, or due to a
depletion of LH content of the pituitary from downregulation of GnRH receptors.33

LUTEAL PHASE

After ovulation, the granulosa cells continue to enlarge, become vacuolated in

appearance, and begin to accumulate a yellow pigment called lutein. The luteinized
granulosa cells combine with the newly formed theca-lutein cells and surrounding
stroma to become what is known as the corpus luteum. The corpus luteum is a
transient endocrine organ that predominately secretes progesterone and its primary
function is to prepare the estrogen primed endometrium for implantation of the
fertilized ovum. The basal lamina dissolves and capillaries invade into the granulosa
layer of cells in response to secretion of angiogenic factors by the granulosa and
thecal cells.34 Eight or nine days after ovulation approximately around the time of
expected implantation, peak vascularization is achieved. This time also corresponds
to peak serum levels of progesterone and estradiol. The central cavity may
accumulate with blood and become a hemorrhagic corpus luteum. The life span of
the corpus luteum depends upon continued LH support. Corpus luteum function
declines by the end of the luteal phase unless human chorionic gonadotropin is
produced by a pregnancy. If pregnancy does not occur, the corpus luteum undergoes
luteolysis under the influence of estradiol and prostaglandins, and forms a scar
tissue- the corpus albicans.

Estrogen levels rise and fall twice during the menstrual cycle. Estrogen levels rise
during the midfollicular phase and then drop precipitously after ovulation. This is
followed by a secondary rise in estrogen levels during the midluteal phase with a
decrease at the end of the menstrual cycle. The secondary rise in estradiol parallels
the rise of serum progesterone and 17-hydroxyprogesterone levels. Ovarian vein
studies confirm that the corpus luteum is the site of steroid production during the
luteal phase.35

The mechanism by which the corpus luteum regulates steroid secretion is not
completely understood. Regulation may be determined in part by LH secretory
pattern and LH receptors or variations in the levels of the enzymes regulating steroid
hormone production, such as 3-ß-HSD, CYP17, CYP19, or side chain cleavage
enzyme. The number of granulosa cells formed during the follicular phase and the
amount of readily available LDL-cholesterol may also play a role in steroid regulation
by the corpus luteum. The luteal cell population consists of at least two cell types,
the large and small cells.36 Small cells are thought to have been derived from thecal
cells while the large cells from granulosa cells. The large cells are more active in
steroidogenesis and are influenced by various autocrine/paracrine factors such as
inhibin, relaxin, and oxytocin.37,38

In studies looking into the mechanisms regulating the menstrual cycle, LH was
established as the primary luteotropic agent in a cohort of hypophysectomized
women.39 After induction of ovulation, the amount of progesterone secreted and the
length of the luteal phase is dependant on repeated LH injections. Administration of
LH or HCG during the luteal phase can extend corpus luteum function for an
additional two weeks.40

The secretion of progesterone and estradiol during the luteal phase is episodic, and
correlates closely with pulses of LH secretion (figure 6).41 The frequency and
amplitude of LH secretion during the follicular phase regulates subsequent luteal
phase function and is consistent with the regulatory role of LH during the luteal
phase.42 Reduced levels of FSH during the follicular phase can lead to a shortened
luteal phase and the development of a smaller corpus lutea.43 Also, the life span of
the corpus luteum can be reduced by continuous LH administration during the
follicular or luteal phase, reduced LH concentration, decreased LH pulse frequency,
or decreased LH pulse amplitude.44-46 The role of other luteotropic factors such as
prolactin, oxytocin, inhibin and relaxin is still unclear.47,48
 Figure 6. Episodic secretion of LH (top) and progesterone
(bottom) during the luteal phase of a woman.
Abbreviations: LH, luteinizing hormone: P, progsterone E2,
estradiol; LH + 8, LH surge plus 8 days. (From Filicori M,
Butler JP, Crowley WF Jr. Neuroendocrine regulation of the
corpus luteum in the human. J Clin Invest. 73:1638 1984.
The corpus luteum function begins to decline 9-11 days after ovulation. The exact
mechanism of how the corpus luteum undergoes its demise is unknown. Estrogen is
believed to play a role in the luteolysis of the corpus luteum.49 Estradiol injected into
the ovary bearing the corpus luteum induces luteolysis while no effect is noted after
estradiol injection of the contralateral ovary.47 However, the absence of estrogen
receptors in human luteal cells does not support the role of endogenous estrogen in
corpus luteum regression.50 Prostaglandin F2a appears to be luteolyic in nonhuman
primates and in studies of women.51-53 Prostaglandin F2a exerts its effects via the
synthesis of endothelin-1 which inhibits steroidogenesis and stimulates the release of
a growth factor, tumor necrosis factor alpha (TNFa), which induces cell apoptosis.54
Oxytocin and vasopressin exert their luteotropic effects via an autocrine/paracrine
mechanism.55 Finally, luteinizing hormone's ability to downregulate its own receptor
may play a role in termination of the luteal phase.
Not all hormones undergo marked fluctuations during the normal menstrual cycle.
Androgens, glucocorticoids, and pituitary hormones, excluding LH and FSH, undergo
only minimal fluctuations.56-59 Due to extra-adrenal 21-hyroxylation of
progesterone, plasma levels of deoxycorticosterone are increased during the luteal
phase.60,61

HORMONAL EFFECTS ON THE REPRODUCTIVE TRACT

A. Endometrium
The effects of varying concentrations of estrogen and progesterone through the
course of the menstrual cycle have characteristic effects on the endometrium (Fig
7).62 This allows for histologic dating of the endometrium and is most accurately
accomplished by performing an endometrial biopsy 2-3 days prior to menstruation.
The proliferative phase is more difficult to date accurately in comparison to the luteal
phase. The glands during the proliferative phase are narrow, tubular, and some
mitosis and pseudostratification is present. The endometrium thickness is usually
between 0.5 and 5mm. In a classical 28 day menstrual cycle, ovulation occurs on
day 14. On cycle day 16, the glands take on a more pseudostratified appearance
with glycogen accumulating at the basal portion of the glandular epithelium and
some nuclei are displaced to the midportion of the cells. In a formalin fixed
specimen, glycogen is solubulized resulting in the characteristic basal vacuolization
at the base of the endometrial cells. This finding confirms the formation of a
functional progesterone producing corpus luteum. In the luteal phase, progesterone
decreases the biologic activity of estradiol on the endometrium by: decreasing the
concentration of estradiol receptors, increasing the enzymatic activity of 17-ß-
hydroxysteroid dehydrogenase type II, the enzyme responsible for the conversion of
estradiol to estrone, and by increasing the activity of estrone sulfotransferase.63,64
 Figure 7. Dating of the Endometrium. From Noyes RW, Hertig AW, Rock
J. Dating the endometrial biopsy. Fertil Steril 1950; 1:3.
On cycle day 17, the endometrial glands become more tortuous and dilated. On cycle
day 18, the vacuoles in the epithelium decrease in size and are frequently located
next to the nuclei. Also, glycogen is now found at the apex of the endometrial cells.
By cycle day 19, the pseudostratification and vacuolation almost completely
disappear and intraluminal secretions become present. On cycle day 21 or 22, the
endometrial stroma begins to become edematous. On cycle day 23, stromal cells
surrounding the spiral arterioles begin of enlarge and stromal mitoses become
apparent. On cycle day 24, predecidual cells appear around the spiral arterioles and
stromal mitoses become more apparent. On cycle day 25, the predecidua begins to
differentiate under the surface epithelium. On cycle day 27, there is a marked
lymphocytic infiltration and the upper endometrial stroma appears as a solid sheet of
well-developed decidua-like cells. On cycle day 28, menstruation begins.

B. Cervix

The mucous secreting glands of the endocervix are affected by the changes in steroid
hormone concentration. Immediately after menstruation, the cervical mucous is
scant and viscous. During the late follicular phase, under the influence of rising
estradiol levels, the cervical mucous becomes clear, copious and elastic. The quantity
of cervical mucous increases 30 fold compared to the early follicular phase.65 The
stretchability or elasticity of the cervical mucous can be evaluated between two glass
slides and recorded as the spinnbarkeit. Under the microscope, the cervical mucous
displays a characteristic ferning or palm-leaf arborization appearance. After
ovulation, as progesterone levels rise, the cervical mucous once again becomes
thick, viscous and opaque and the quantity produced by the endocervical cells
decreases.

C. Vagina

The changes in hormonal levels of estrogen and progesterone also have

characteristic affects on vaginal epithelium. During the early follicular phase,
exfoliated vaginal epithelial cells have vesicular nuclei and are basophilic. During the
late follicular phase, the vaginal epithelial cells display pyknotic nuclei and are
acidophilic due to the influence of rising estrogen levels.66 As progesterone rises
during the luteal phase, the acidophilic cells decrease in number and are replaced by
an increasing number of leukocytes.

MENSTRUATION

In the absence of a pregnancy, steroid hormone levels begin to fall due to declining
corpus luteum function. Progesterone withdrawal results in increased coiling and
constriction of the spiral arterioles. This results in tissue ischemia due to decreased
blood flow to the superficial endometrial layers, the spongiosa and compacta. The
endometrium releases prostaglandins that cause contractions of the uterine smooth
muscle and sloughing of the degraded endometrial tissue. The release of
prostaglandins may be due to decreased stability of lysosomal membranes in the
endometrial cells.67 Infusions of prostaglandin F2-a in women during the luteal
phase has been shown to induce endometrial necrosis and bleeding.68 The use of
prostaglandin synthetase inhibitors decreases the amount of menstrual bleeding, and
can be used as therapy in women with menorrhagia. Menstrual fluid is composed of
desquamated endometrial tissue, red blood cells, inflammatory exudates, and
proteolytic enzymes. Within two days after the start of menstruation, estrogen
stimulates the regeneration of the surface endometrial epithelium, while concomitant
endometrial shedding is occurring. The estrogen secreted by the growing ovarian
follicles, causes prolonged vasoconstriction enabling the formation of a clot over the
denuded endometrial vessels.69 Also, the regeneration and remodeling of the uterine
connective tissue is regulated in part by the matrix metalloproteinase (MMP)
system.70
The average duration of menstrual flow is between four to six days, but the normal
range in woman can be from as little as two days up to eight days. The average
amount of menstrual blood loss is 30 ml and greater than 80 ml is considered
abnormal.71

INTRODUCTION
The pubertal process is the period of transitional growth bridging the childhood years
and adulthood. The genetic blueprint housed within the genome of the individual has
long before set in motion a number of critical processes. The end result is the
maturation of a multitude of endocrine axes necessary for (1) secondary sexual
development and, (2) the attainment of the immediate capacity for reproduction.
Intrinsic to this reproductive maturation is yet another important process of puberty:
(3) a secondary wave of skeletal growth and the attainment of adult stature.
Abnormal puberty, whether premature or delayed, may adversely influence each of
these events resulting in an untimely or altered ability for spontaneous secondary
sexual development and spontaneous reproduction or abnormal growth.

In recent years numerous advances have been made in molecular medicine and the
assisted reproductive technologies. The impact of these advances has had a
tremendous effect on the care of patients with abnormal puberty by: changing the
initial counseling provided to our patients; allowing for new treatments during the
time of altered pubertal growth; and, providing reproductive options to individuals
previously known to be infertile and some considered sterile. In addition, new insight
about the genetics of these disorders has been accumulated. The focus of this
chapter will be on our expanded knowledge of both the genotypes and phenotypes of
the disorders presenting as abnormal puberty.

NORMAL PUBERTY FOR GIRLS (ITS OCCURRING EARLIER!): A BASIS FOR

THE DEFINITION OF ABNORMAL PUBERTY

Onset of Normal Pubertal Landmarks

The first somatic change associated with the initiation of puberty in girls is an
increase in growth velocity. It is during the initial increment in growth velocity that
the first sexual sign of puberty occurs. It has long been held that thelarche (breast
budding) develops between ages 9-11 years for American girls and is usually
followed by adrenarche, the appearance of pubic hair. Additionally, it was considered
that in approximately 15% of adolescent Caucasian girls adrenarche preceded
thelarche. However, it is important to remember that the normal sequence of
pubertal signs as published by Marshal and Tanner was taken from studies of British
Caucasian girls not long after WW II [1, 2]. A study of African girls in the 1970s,
however, noted that for the majority of them adrenarche preceded thelarche. Even
more important is the recent data published from the Pediatric Research in Office
Settings Network [3]. This data was taken from a cross-sectional study of 17,077
American girls of whom 9.5% were African-American and 90.4% were Caucasian
(note that Hispanic girls were included in both African-American and white groups).
Surprisingly, nearly 30% of the African-American girls had evidence of breast and/or
pubic hair development at age 7 years and nearly 50% by age 8 years. For
Caucasian girls, 15% had started puberty by age 8 and nearly 40% by age 9. This
data suggests that puberty is occurring earlier in American girls than has previously
been thought; for both breast and pubic hair development, African-American girls
are more advanced that are Caucasian girls at the same age. For African-American
girls, pubic hair development begins slightly earlier than does breast development.
While it is reasonable to consider that the British data is likely different from the
heterogeneous American population at the end of the 20th century, the data of the
recent Pediatric Research in Office Settings Network study has also been viewed with
mixed feelings. Some have criticized the study for the methodology used in staging
pubertal development. The examiners staged pubertal development on visual and
not palpatory changes. While pubic hair assessment was likely accurate, it is possible
that girls with "chubby chests" may have been miss-staged and, therefore, that the
mean timing for onset of breast development reported in this study may be
prematurely inaccurate.

After thelarche and adrenarche, growth velocity continues to increase and peak, a
landmark termed the adolescent growth spurt. A peak height velocity of 9 cm/year is
attained at that time. Subsequently, with near closure of the epiphyses there is a
deceleration phase for growth. It is in this deceleration phase of growth that
menarche occurs. The first menstrual period was previously reported to occur at an
average of 12.8 years for American girls. The recent cross-sectional data
demonstrated that while the average age of menarche for Caucasian girls remains
unchanged, African-American girls start menstruation earlier and at a mean age of
12.16 years [3]. Since it often is at least 5 years after menarche, (i.e., nearly age 18
years) that the majority of menstrual cycles are ovulatory, we cannot consider that
puberty is normal until this reproductive mechanism is well established.

Determinants of Normal Pubertal Growth

From conception to the fusion of epiphyses during the later stages of puberty, a
number of maturational processes occur for formation and modeling of the skeleton.
Intrinsic to these processes are the initial mesenchymal cell condensation and
differentiation into cartilage that serves as a template for subsequent bone
formation. Osteoblast differentiation occurs on the surface of this cartilaginous
template and endochondral bone formation results when such differentiation occurs
on calcified cartilage at the growth plate.

Both genetic and hormonal determinants exist which are critical for the attainment of
adult stature. A number of genes have been identified which mediate bone growth. If
all of these genes are functional, parental growth genes determine the final adult
height attained by an individual. One can estimate this height by a calculation of
mid-parental height. For females this is determined by subtracting 5 inches from the
father's height, adding this to the mother's height and then dividing by 2. For males,
this is determined by adding 5 inches to the mother's height, adding this sum to the
father's height and then dividing by 2.

Under pathophysiologic situations, an individual may be taller or shorter than would

be dictated by parental height determinants. Sometimes these differences are
genetically determined and in other situations abnormal hormonal influences alter an
otherwise intact genetic predisposition. For example, some statural genes are
present on both X and Y-chromosomes with Y individuals being taller than X
individuals. From tallest to shortest one can generalize the following: XYY > (taller
than) XY > (taller than) XXX > (taller than) XX > (taller than) X individuals. A few
genes have been implicated in these differences. One set of genes, the SHOX genes
exist on the distal X chromosome [4-6]. Mutations have resulted in short stature and
deletion of this locus is associated with short stature in Turner syndrome (45,X).

Hormonal Determinants of Growth (Some gene mediated)

No doubt, a normal endocrine environment critically influences bone growth. For
example it is essential that intact and normal growth hormone and thyroid hormone
production, among others, be present. This is demonstrated by the fact that growth
hormone and thyroid hormone deficiency separately result in short stature until
corrected [7]. Growth hormone excess results in such conditions as a gigantism and
acromegaly.

In addition to these known growth-promoting hormones, sex steroids are essential

for mediating the pubertal growth spurt and attainment of final adult stature.
Premature sex hormone production in children with congenital adrenal hyperplasia
causes premature epiphyseal growth and fusion: thus, tall as children and short as
adults. Precocious puberty similarly causes premature pubertal growth with the risk
of short adult stature unless corrected. The lack of pubertal development (delayed
puberty) allows for continued long bone growth since the epiphyseal centers remain
open longer than normal. Usually, in these situations, growth is normal until the
expected age onset of puberty and the growth spurt is not noticed; however, linear
growth continues in the absence of epiphyseal closure. This results in eunuchoid
body proportions: an arm span which exceeds the height by >6 cm and
disproportionately long legs.

While it had always been accepted that estrogen mediated pubertal bone growth in
females, it was only recently that it was established that estrogen and not
testosterone mediated the same function for males. Inactivating mutations in either
the estrogen receptor gene or the aromatase gene (preventing conversion from
androgens to estrogens) in males have resulted in lack of normal bone growth at
puberty and lack of epiphyseal closure with resultant tall stature (i.e., taller than
predicted) [8-11]. These findings establish that estrogen is essential for initiation of
pubertal growth, closure of the growth plate, and augmentation accrual of bone
during puberty. The presence of both alpha and beta estrogen receptors have been
identified in the growth plate but the exact mechanism of action has yet to be
delineated. Studies on estrogen receptor knock out mice are underway.

Definition of Abnormal Puberty

The definitions of abnormal puberty, whether premature or delayed, are based on

those times that are considered to be 2.5 standard deviations removed from the
mean. Previously, the definition of precocious puberty for girls was the appearance of
secondary sexual development before the age of 8 years, an age felt to represent
2.5 standard deviations earlier than the mean. Recent revised recommendations
have been made based on the findings of the Pediatric Research in Office Settings
Network [12]. These new guidelines propose that precocious puberty be defined by
the presence of breast or pubic hair development before age 6 in African-American
Girls and before age 7 years in Caucasian girls. In addition to taking into
consideration the findings of earlier puberty for American girls, treatment of
precocious puberty in girls after age 8 years has not been shown to alter final adult
stature. Recent reports of isolated cases of girls who were found to have a significant
pathologic etiology which would have been missed had the physicians followed
strictly the new definition guidelines, have been viewed by some as reason not to
institute them [13, 14]. A more reasonable interpretation of the occurrence of these
etiologies during later childhood years would be to follow the new guidelines only in
the absence of other CNS findings or behavioral changes that would warrant
evaluation and possible treatment and for those children not evaluated to always
keep in mind this possibility.

Recommendations based on the findings of the Pediatric Research in Office Settings

Network have not been made for revising the definition of delayed puberty in girls as
they have for precocious. As such, the absence of thelarche by age 13 years for girls
signifies an abnormality, and remains the definition of pubertal delay. While some
patients present strictly with the absence of the onset of pubertal development,
others have abnormalities in the tempo and sequence of puberty that has seemingly
begun on time. For example, the absence of menarche by age 15 or 16 years is
considered as 2.5 and 3 standard deviations deviated from the mean, respectively. It
is equally as abnormal for a young girl who started puberty on time not to have had
menarche by age 16 years as it is for another who never initiated the pubertal
process.

Age definitions should be seen as only guidelines, and for delayed puberty, the age
at which an evaluation should ideally have already been completed. Rather than wait
until these young women meet the strict definitions for delayed puberty to initiate an
evaluation, it has been suggested that all adolescents be followed annually
throughout the pubertal process. It would be better to begin a partial evaluation
during earlier adolescent years at the time that abnormalities are first suspected
than it would to wait until these young women are significantly different from their
peers. No doubt, adolescence is one of the most difficult time periods in growth and
development. It is potentially very harmful for an individual's psychosexual
development to allow significant delays in secondary sexual development or onset of
menses to continue without evaluation, treatment and appropriate counseling. Given
that puberty appears to be initiated earlier than previously recorded and the
definition of pubertal delay has not yet been revised, it is even more important that
one avoid the time-held reassuring delays of watchful waiting under the guise of
being "a late bloomer!"

PRECOCIOUS PUBERTY

Overview

The classic definition of sexual precocity is the appearance of secondary sexual

characteristics before the age of 8 years in girls. The overall incidence of sexual
precocity for that definition has been estimated to be 1:5,000 to 1:10,000 children.
The female to male ratio is approximately 10:1. Recent data from the Herman-
Giddens study suggests that this age for girls falls less than two standard deviations
from the mean [15]. These findings prompted the suggestion that the definition be
changed and that the onset of puberty not be considered precocious unless it occurs
prior to age 6 for African American girls or age 7 for Caucasian girls [12]. As
discussed above, even when puberty occurs between these ages and age 8, it is
important to consider evaluation of all children [13, 14]. The child may be suffering
from a serious CNS disorder associated with precocious puberty [14]. In addition,
psychosexual maturation remains concordant with chronological age, and
unfortunately early physical sexual maturation places these young girls at a
significant risk for sexual abuse. It is thus important not only to make a reasoned
judgment as to when to initiate an evaluation but also to institute the appropriate
therapy and support to prevent these potential long-term sequelae, even in selected
girls who fall outside the new recommendations.
The appearance of the secondary sexual characteristics of precocity results from
increased sex steroid production. This increase may be secondary to aberrant
gonadotropin stimulation or intrinsic disease of the ovary or adrenals. True
precocious puberty, also known as complete precocious puberty, refers to puberty
that appears early and either progresses through each of the pubertal landmarks
including menarche or, in the absence of treatment, would progress through each of
these stages. A GnRH challenge test that demonstrates the pubertal response of
gonadotropins (i.e., LH response > FSH response) is the hallmark of this diagnosis as
is the usual ability to suppress pubertal development with GnRH agonists.
Incomplete precocious puberty refers to the appearance of one phase of the pubertal
process: thelarche, adrenarche, or menarche. Isolated precocious thelarche, isolated
precocious adrenarche, and isolated menarche are the three forms of incomplete
precocious puberty. Sexual precocity has been further categorized according to
whether the pubertal signs are concordant or discordant with the sex of the
individual: isosexual precocity referring to early sexual development consistent with
the sex of the individual (i.e., feminization of a female); heterosexual or
contrasexual precocity indicating precocious pubertal development that is limited to
those physical signs not characteristic for the sex of the individual when presenting
as isolated findings (i.e., virilization of a female). GnRH dependent and GnRH
independent precocious puberty (GIPP) refer to those causes of precocity that do or
do not respond to GnRH analogue treatment, respectively. Finally, central precocious
puberty (CPP) refers to precocity of CNS origin. A summary of the causes of sexual
precocity is presented in Table I below, followed by a numeric breakdown of the
frequency of occurrence of these disorders in Table II.

Table I. Classification of Female Precocious Puberty

I. Complete isosexual precocity (true precocious puberty: gonadotropin

dependent)
A. Idiopathic
B. CNS lesions: Hamartomas, Craniopharyngioma, etc
C. Primary hypothyroidism
D. Post treatment for CAH

II. Incomplete isosexual precocity (GnRH independent)

A. Isolated precocious thelarche
B. Isolated precocious menarche
C. Estrogen-secreting tumors of the ovary or adrenals in girls
D. Ovarian cysts
E. McCune-Albright syndrome
F. Peutz-Jeghers syndrome
G. Iatrogenic

III. Contrasexual precocity (Isolated virilization)

A. Isolated precocious adrenarche
B. Congenital adrenal hyperplasia
C. Androgen-secreting ovarian or adrenal neoplasm
D. Iatrogenic
 Table II. Numeric breakdown of etiologies for precocious puberty in a
large series of girls (N=438) evaluated from 1988-1999 by the
classic definition (pubertal onset < 8 years)[16]

I. Central Precocious Puberty 428 (97.7%)

Incompletely Evaluated 124

Completely Evaluated 304

Idiopathic 226 (74.4%)

CNS Pathology 56 (18.4%)

Hydrocephalus 11 (19.6%)

Encephalocele 2 (3.6%)

Neurofibromatosis 3 (5.4%)

Encephalitis 1 (1.7%)

Intracranial hemorrhage 1 (1.7%)

Hypothalamic hamartoma 7 (12.5%)

Pituitary microadenoma 5 (8.95%)

Optic chiasma astrocytomas 3 (5.4%)

Optic chiasm glioma 1 (1.7%)

CNS Vascular Malformation 1 (1.7%)

Other miscellaneous CNS 21 (37.5%)

disorders/ lesions

(100%)

Coincidental/ Associated 22 (7.2%)

Disorders

(100%)

II. GnRH Independent (GIPP) 10 (2.3%)

McCune Albright syndrome 3 (30%)

Ovarian "hyperfunction"/ 4 (40%)

follicular cyst

Ovarian tumors 3 (30%)

Juvenile granulose cell tumor (2)

Theca-granulosa cell tumor (1)

In this review of 438 girls examined between 1988-1998, the incidence of central
precocious puberty (CPP) was noted to be 97.7% and GnRH independent precocious
puberty (GIPP) was 2.3% [16]. Neurogenic abnormalities were noted in 18.4%, and
idiopathic CPP in 74% of the girls in this study. The frequency of neurogenic CPP
tended to be higher in the youngest girls (i.e., those under 4 years of age) and the
frequency of idiopathic CPP tended to be higher in girls presenting at older ages (i.e.,
between 7-7.9 years). Those girls identified with idiopathic precocious puberty after
7 years may, in fact, represent the recent observations of earlier onset of normal
puberty by Herman-Giddens [3].

Central Precocious Puberty

This results from early maturation of the hypothalamic- pituitary-gonadal axis.

Serum gonadotropins, gonadal pulsitality and sex steroid concentrations are in the
normal postpubertal range. As mentioned previously, idiopathic precocious puberty
seems to be the most common cause of CPP. Neurogenic CPP seems to be found
more frequently in extremely young girls with the earliest onset of puberty. CNS
lesions identified include neoplasms, trauma, hydrocephalus, postinfectious
encephalitis, congenital brain defects, and such genetic disorders as
neurofibromatosis type 1 and tuberous sclerosis. The most commonly identified
neurogenic neoplasms found in CPP include hamartomas, astrocytomas, and pituitary
microadenomas [16]. Hamartomas are congenital hypothalamic malformations that
histologically contain fiber bundles, glial cells and GnRH- secreting neurons and often
act as a mini-hypothalamus. Less frequently identified tumors include
epipendymomas, gliomas, pinealomas. While the craniopharyngioma has usually
been associated with delayed puberty, it can rarely cause precocity as well.

Girls with severe primary hypothyroidism can develop true precocious puberty. These
girls have elevated gonadotropins in addition to high TSH levels. The associated
precocity may result from cross-activation of the FSH receptor by the high circulating
TSH or from direct stimulation of the ovary by the gonadotropins. Occasionally,
treatment and correction of long standing virilizing congenital adrenal hyperplasia
will be followed by the development of true precocious puberty. It has been
hypothesized that GnRH secretion and gonadotropin stimulation of the ovary may
ensue in these patients after the removal of hypothalamic androgenic suppression.

Contemporary Issues for Management of CPP

The management of true precocious puberty requires identification of underlying CNS

lesions, if present, or in other children identification of a pubertal gonadotropin
response to GnRH that is usually associated with idiopathic true precocious puberty
and occasionally with a hamartoma. The mainstay, therefore, of evaluation is
imaging of the CNS and a GnRH challenge test. In addition, bone age X-rays are
helpful to identify the advance physiologic age associated with true precocious
puberty. Ovarian imaging, thyroid and hCG testing may also compliment the
evaluation. While some CNS lesions will need treatment, the majority of remaining
causes of true precocious puberty (i.e., idiopathic) respond to GnRH analogues. It
has also been demonstrated that precocity associated with hamartomas may be
effectively treated with GnRH agonists [17].

Predicted height has been shown to improve with long-term GnRH agonist therapy
and the absence of treatment is associated with reductions of these height
predicitions, [18, 19]. Studies have consistently demonstrated that not all children
with precocious puberty will benefit from the GnRH analogues [20]. Those children
who do not benefit may have the following characteristics: slowly progressive
puberty, the precocity of which does not adversely affected the child; a normal
predicted height prognosis; and a lack of evidence for gonadal activation [21]. While
consideration should be given to withholding treatment for these children, studies
consistently demonstrate that girls presenting under age six are able to subsequently
achieve normal adult height because of the GnRH agonist therapy [22, 23].

GnRH agonist therapy initially increases circulating gonadotropin and estradiol

concentrations for short periods of time. Chronic therapy is associated with
suppression of pulsatile gonadotropin secretion and a blockade to the LH response of
endogenous GnRH. Suppression is best monitored with GnRH challenge tests.
Additionally, measurement of serum estradiol (if elevated on prior analysis), height,
bone age, and assessment of secondary sexual characteristics may be helpful.
Evaluation of ovarian morphology and uterine size by pelvic ultrasonography may, in
some cases, provide additional evidence of such suppression. Cessation of menses,
regression in physical pubertal signs (i.e., breast size and pubic hair), and a
diminution of uterine and ovarian size usually occur within the first 6 months of
therapy. True precocious puberty has been associated with the same GH secretory
dynamics that accompany normal puberty; use of GnRH agonists generally decreases
this aberrant and increased GH secretion. Since some have suggested that GnRH
analogue treatment may significantly suppress growth velocity enough to
compromise the predicted improvement in height, studies have been performed to
evaluate whether addition of GH to GnRH analogue treatment will be beneficial [24].

Incomplete, Isosexual, or Gonadotropic Independent Preococious Puberty

(GIPP)

GIPP can originate from the gonads, the adrenals, from extragonadal or intragonadal
sources of human chorionic gonadotropin, or from exogenous sources. In girls,
functionally autonomous ovarian cysts are the most common cause of GIPP. Ovarian
follicles up to 8mm in diameter are common in normal prepubertal girls and may
appear or regress spontaneously, but rarely secrete significant amounts of estrogen
[25, 26]. A recent finding of the somatic cell mutation associated with McCune
Albright syndrome in the cells of one such cyst sheds new light on this occurrence
[27]. GnRH agonists are not effective in treating autonomous cysts.
Medroxyprogesterone acetate has been utilized.

Juvenile granulosa cell tumors or theca cell tumors of the ovary are a rare cause of
GIPP. Other ovarian neoplasms even more rarely seen in this age group that may
also secrete either estrogens an/or androgens include gonadoblastomas, lipoid
tumors, cystadenomas, and ovarian carcinomas [28]. Peutz-Jeghers syndrome has
been associated with GIPP; the mucocutaneous pigmentation and gastrointestinal
polyposis seen in this disorder has been rarely associated with gonadal sex-cord
tumors [29].

McCune-Albright syndrome classically includes the triad of hyperpigmented café-au-

lait spots, progressive polyostotic fibrous dysplasia of the bones and GnRH-
independent sexual precocity [30]. At least 2 of these features must be present to
consider the diagnosis. This disorder is caused by postzygotic somatic cell mutations
of the gene encoding the alpha-subunit of the stimulatory guanine nucleotide binding
protein Gs. These activating mutations stimulate constitutive G protein activation in
affected cells with aberrant cyclic AMP production [31]. The mutations may occur at
various times in fetal development with a patchy tissue distribution of affected cells.
Each of the associated findings is affected by these mutations: granulose cells in the
ovary, melanocytes of the skin [32], and the dysplastic bone cells [33, 34]. In
addition to the classic triad, other endocrine cells may also be similarly affected and
associated with their autonomous hyperfunction: pituitary adenomas, usually growth
hormone secreting, hyperthyroid goiters [35], and rarely adrenal hyperplasia [36].
Another recent finding is the presence of these same somatic cell mutations in cells
from isolated hyperfunctioning ovarian cysts of GIPP patients who do not exhibit
other findings of McCune Albright Syndrome [27]. This may account for the findings
of "ovarian hyperfunction" in patients with GIPP as reported in the series of Table II
above [16].

The sexual precocity of McCune Albright syndrome is due to autonomously

functioning follicular cysts. These patients can progress form GnRH independent to
GnRH dependent puberty; when their bone age reaches the physiologic age of the
normal time-onset for puberty, awakening of the arcuate nucleus for pulsatile GnRH
secretion may occur and progress to the establishment of ovulatory cycles.
Testolactone, an aromatase inhibitor, has been shown to be effective treatment for
the GnRH independent phase of this condition. When the shift from gonadotropin
independent to gonadotropin dependent puberty takes place, GnRH analog therapy
then becomes effective.

Iatrogenic sexual precocity

In prepubertal children, exogenous intake of estrogen has been shown to cause

precocious pubertal development. A number of estrogen containing products have
been previously reported including hair products, lotions, and creams. Ingestion of
estrogen containing meat has also been implicated. In actuality, these causes are
extremely rare today.

Premature Thelarche

Isolated precocious thelarche is a common entity and associated with unilateral or

bilateral breast enlargement without other signs of sexual maturation. It occurs at
early ages up to 4 years and regresses spontaneously after diagnosis [37].
Gonadotropin levels rise in the newborns after delivery and remain elevated for up to
four years of age. While most newborns rarely exhibit a dramatic ovarian response to
these elevated levels, it is likely that isolated precocious thelarche is a result of this
physiologic process. The uterus remains prepubertal in size during this time,
however, the ovaries may develop temporary follicular activity, often correlating with
the breast enlargement. This is usually a benign self-limiting disorder not associated
with bone age progression.

Premature Menarche

Premature menarche has been reported as periodic vaginal bleeding without other
signs of secondary sexual development [38]. While this entity has been repeatedly
yet rarely reported, pediatric vaginal bleeding can occur as the first manifestation of
sexual precocity in most causes of GIPP listed above. These etiologies should be
excluded before one considers premature menarche as the diagnosis.

Contrasexual precocity
Virilizing precocious puberty in girls and isolated precocious adrenarche

Most girls with contrasexual precocious puberty present with early appearance of
pubic hair or hirsuitism. The most common cause is a mild form of 21-hydroxylase
deficiency, which is present in 0.1-1.0% of the population. Other more rare forms of
congenital adrenal hyperplasia have also been identified in these patients. Virilizing
adrenal (occasionally malignant) and ovarian tumors (e.g., Leydig or Sertoli cell
tumors) in young girls can similarly present with virilizing precocious puberty. In
actuality, most girls with appearance of pubic hair likely have isolated precocious
adrenarche. While many of them have only early yet normal pubertal development
[3], recent evidence shows that the prevalence of ovarian hyperandrogenism,
hyperinsulinism and dyslipidemia is increased in this population [39]. These findings
suggest that that premature pubarche in girls may be a childhood marker for insulin
resistance and polycystic ovary syndrome.

DELAYED PUBERTY

An Overview of Delays within the H-P-O Circuit (Delays of Secondary Sexual

Development and Menarche)

Several large descriptive studies have been published which have categorized the
causes of pubertal/ menarchal delay. In 1981, a series of 252 female adolescents
evaluated over 20 years at the Medical College of Georgia from a large referral area
in Georgia was published [40]. It included all patients seen with either delay of the
onset of puberty or menarchal delay. The series was subsequently expanded to
include 326 patients. In this series the most common causes of abnormal puberty
were: (1) ovarian failure (42%); (2) congenital absence of the uterus and vagina
(14%), and (3) constitutional delay of puberty (10%). While these 3 disorders
comprised 2/3 of all patients seen, a host of less frequent disorders was also
diagnosed (see Table III below); the most common of these included PCOD and
idiopathic hypogonadotropic hypogonadism (IHH), both at 7% each.

Table III. Etiologic breakdown of 326 patients with abnormal

puberty
(pubertal and menarchal delay) (Medical College of Georgia Series)
[41]

Group total No. %

Hypogonadism (Pubertal Delay) Hypergonadotropic hypogonadism:

Turner Syndrome 84 26

Chromosomally Normal 57 16

46,XX 48 15

46,XY 9 2

Total 141 57 41

Hypo (eu) gonadotropic hypogonadism:

Reversible 62 18
 Constitutional delay 32 10

Systemic illness 7 2

Eating disorders 9 3

Primary hypothyroidism 4 1

CAH 3 1

Cushing syndrome 1 0.5

Pseudopseudohypo- 1 0.5
parathyroidism

Hyperprolactinemia 5 1.5

Irreversible 37 13

Congenital Deficiency Syndromes

Isolated GnRH 23 7
deficiency

Forms of 6 2
hypopituitarism

Congenital CNS 2 0.5

defects

Acquired anatomic lesions

Unclassified pituitary 2 0.5

adenoma

Craniopharyngioma 3 1

Unclassified malignant 1 0.5

tumor

Total 99 31

Eugonadism: (Menarchal Delay)

Anatomic 59 18

Mullerian aplasia 45 14

Outlet

Transverse vaginal 10 3
septum

Imperforate hymen 2 0.5

Cervical atresia 1 0.5

Inappropriate feedback 22 7

Intersex disorders 5 1.5

 Androgen insensitivity 4 1

17-ketoreductase 1 0.5
deficiency

Total 86 28
In April of 2002, a contemporary series of both male and female patients evaluated
for delayed puberty at Children's Hospital in Boston between 1/96 and 7/99 was
published [42]. This study, like the MCG study, included patients with delayed onset
of puberty; it, however, did not include patients with menarchal delay. For the
females reported (N=74), the 3 most common causes were: (1) constitutional delay
of puberty (30%); (2) ovarian failure (26%); and permanent hypogonadotropic
hypogonadism (20%). Over 20 other numerically less frequently reported disorders
were identified and listed below (see Table IV).

Table IV. Etiologic breakdown of 74 females with delayed puberty

(Children's Hospital Series, 2002) Revised from [42].

Group total No. %

Hypogonadism (Pubertal Delay) Hypergonadotropic hypogonadism:

Turner Syndrome 5 7

Chromosomally Normal 14 19

46,XX 13 17

46,XY 1 2

Total 19 14 26

Hypo (eu) gonadotropic hypogonadism:

Reversible (Functional)

Constitutional delay 22 10

Systemic illnes 1

Giardiasis 1

Rheumatoid Arthritis 1

Systemic lupus 1
erythematosis

Sickle cell disease 1

Congenital heart 1
disease

Isolated seizure 1
disorder

Eating disorders
 Endocrine disorders 2

Growth hormone 1
deficiency

Hyperprolactinemia 1

Irreversible (Permanent) 15 20

Congenital/ Genetic Syndromes

Kallmann syndrome 1

Idiopathic Hypo Hypo 2

CHARGE syndrome 2

Forms of hypopituitarism

Rathke's pouch 2

Hypophysitis 1

Hypopituitarism 1

Panhypopituitarism with 1
hearing loss

Acquired anatomic lesions

Craniopharyngioma 3

Germinoma 1

Ologodenrdroglioma 1

Total 51 67

Other 4 5
Numerical and physical clues to the disorders presenting with delays in
pubertal development: organizing the approach to the patient

The numerical findings in these series point out several useful facts. First, most
practitioners confronted with females presenting with pubertal delays can identify a
few disorders that present in the majority of patients: ovarian failure, constitutional
delay, and permanent hypogonadotropic hypogonadism (as frequent causes of
delayed onset of puberty) and vaginal agenesis (as the most frequent cause of
menarchal delay). Rather than wait until the ages defining female pubertal or
menarchal delay (ages 13 and 15 or 16, respectively), a physical examination with
inspection of the introitus, plotting the patients on growth charts (longitudinal and
velocity), and obtaining gonadotropins values will identify many of these disorders
even before these age definitions are met. Idiopathic hypogonadotropic
hypogonadism (IHH), however, is the exception being more difficult to diagnose in
the younger patients. It is often a diagnosis of exclusion in the late teenage years.
Second, the "late bloomer" occurs in less than 1/3 of patients in any series. While
constitutional delay is a frequent cause of delayed puberty in females it does not
occur with the very high frequency seen in males (i.e., approximately 2/3 of
patients). For 2/3 of female patients, disorders with more serious implications are
usually found! Finally, pubertal delay can be an ascertainment for the identification
of a rare disorder (See Table 2). Similarly, should any diagnosis be made during
childhood years and in advance of the time for normal puberty, plans can be made
prior to the pubertal years to allow for the most normal pubertal progression as is
possible. At least in the Children's Hospital setting, this appears to be the case for
Turner syndrome.

The physical findings of the patients in these series also provide clues for helping us
to form a differential diagnosis and organizing our diagnostic approach. First,
classification according to estrogen as in the MCG series allows for a separation of
major etiologies.

Table V. Classification of Pubertal Abnormalities

I. Hypoestrogenism/ Hypogonadism (Delayed Onset of Puberty)

A. Ovarian failure (Hypergonadotropic)
B. Hypothalamic-Pituitary Immaturity or Suppression (Hypogonadotropic)

II. Normal estrogen milieu/ Eugonadism (Delayed Menarche)

A. Congenital absence of uterus and vagina (CAUV)
B. Chronic Anovulation (e.g., PCOD)
C. Intersex Disorders (e.g., Androgen Insensitivity)
The absence of breast development suggests a cause of hypogonadism: ovarian
failure or a hypothalamic-pituitary problem. The practitioner can further narrow
these possible etiologies by obtaining an FSH level; high levels suggest ovarian
failure and low normal values direct one to etiologies that have their effect at the
level of the hypothalamus or pituitary. The presence of breast development usually
directs one towards causes of menarchal delay suggesting the ongoing production of
estrogen. One should remember, however, that some patients may have initiated
puberty only then to have this process (and estrogen production) suppressed. A
vaginal smear which demonstrates greater than 15% superficial cells or a positive
progestin challenge test will confirm the suspicion of ongoing estrogen production.
Patients demonstrating breast development but not evidence of ongoing estrogen
production by either of these two tests should be treated like any other hypogonadal
patients.

Second, absence of pubic hair after age 13 years is a very significant clue of several
specific abnormalities. Pubic hair growth results from both adrenal and gonadal
androgen production. One should remember that even when the H-P-O circuit
appears delayed, the H-P-A (adrenal) circuit should still be functioning and providing
adrenal androgens. For most disorders of delayed onset of puberty, at least some
pubic hair should be present because this H-P-A circuit is unaffected by the defect
(ovarian failure and IHH). When pubic hair is absent after 13 years, it suggests a
defect of: (1) pituitary function (i.e., the inability to stimulate both ovarian and
adrenal androgen production as in pituitary insufficiency); (2) steroidogenesis (i.e.,
the inability to convert cholesterol to androgens as in 17-hydroxylase deficiency); or
(3) androgen receptors (i.e., the inability to translate the hormone signal into end
organ androgenization as in androgen insensitivity syndrome or AIS). The first two of
these disorders occur in the hypogonadal patients (Tables III and IV) and
demonstrate defects within both H-P-O and H-P-A circuits, the common denomonator
being pituitary insufficiency or a steroid enzyme block. When examined they are
found to have a nomal mullerian system. Androgen receptor defects are found in
patients with normal breast development and absence of the vagina (i.e., Androgen
Insensitivity Syndrome (AI S)). Thus, for the patient with absent pubic hair after age
13, the most critical portions of the examination include the breasts and introitus.

Third, the apparent absence of a mullerian system (i.e., vaginal agenesis) can occur
for either 46,XX or 46,XY patients. However, an examination, not a karyotype, is the
most cost effective initial screen. Patients may present with absence of the vagina
yet also demonstrate normal pubertal breast and pubic hair development. If a rectal
examination is unrevealing for them, the likely diagnosis is congential absence of the
uterus and vagina (CAUV) also known as mullerian aplasia or Rokitansky-Keuster-
Hauser syndrome. If, instead, a bulging midline mass is identified just above the
"absent vagina," the patient likely has either a transverse vaginal septum (TVS) or
imperforate hymen. None of these findings warrant chromosomal studies as they
clinically suggest the presence of a 46,XX karyotype. The patient found to have
breast development and absence of both pubic hair and a mullerian system likely has
AIS. These later findings alone warrant a karyotype to confirm the 46,XY compliment
and the need for gondadal extirpation.
Fourth, identification of stature significantly shorter than one would expect for an
individual whose growth was interrupted only by the delayed onset of puberty often
reveals a genetic cause of both disorders (e.g., Turner syndrome) or an endocrine
cause which stopped growth several years earlier than the usual time onset for
puberty in addition to preventing or slowing the onset of secondary sexual
development (i.e., growth hormone deficiency, thyroid deficiency, or pituitary
insufficiency).

DISORDERS IDENTIFIED IN PATIENTS WITH EITHER DELAYED PUBERTY OR

MENARCHE

The remainder of this chapter will address specific concerns of the most common
causes of the pubertal abnormalities identified in the two series described above. It
will primarily refer to the data of the MCG updated series of 326 patients presenting
with either delayed pubertal onset or delayed menarche tabulated in Table III and
classified according to Table V above [41]. In addition to discussing the common
findings associated with these etiologies it will point out recent findings from
molecular medicine and summarize contemporary treatment strategies.

Hypogonadism

Hypergonadotropic Hypogonadism

The single most common cause of delayed puberty in all prior delayed puberty series
has been primary ovarian failure [40, 41]. Forty three % of all patients seen in the
MCG series had hypergonadotropic hypogonadism. The fact that ovarian failure
presenting at puberty was numerically less frequent (i.e., 26%) in the recent
Children's Hospital series suggests that more children are being diagnosed with
Turner syndrome and other forms of ovarian failure before the adolescent years and
that treatment may be presently initiated at an earlier age [42].

Turner syndrome
Numerically, more patients with ovarian failure and delayed puberty have a form of
Turner syndrome than they do with either 46,XX or 46, XY gonadal dysgenesis.
Approximately 30% of the Turner patients have the classic 45,X karyotype with the
remainder of patients having mosaic forms of Turner syndrome (Table VI below).
Mosaicism refers to the presence of two or more cell lines, which originated from a
single cell line. Patients with mosaic forms of Turner syndrome usually have a 45,X
cell line associated with another cell line such as 46,XX or 46,XY. Other cell lines
exist which represent structural abnormalities of the X chromosome such as
isochromosome for the long arm of X, i.e., [i(Xq)] ; they may occur either as single
cell lines or as mosaicism in association with 45,X.

Table VI. Karyotypes of patients with CIOF. Reproduced with

permission [40]

Classical Turner Syndrome (45,X) 28*

Y Cell Lines 16

46,XY 1*

45,X/46,XY 12

45,X/47,XY 1

45,X/46,X?del(Y) 1

45,X/46,X,i dic(Y)/47,XY,i dic(Y)/ 1

46,XY/47,XYY

Structural abnormalities of X 31

Isochromosome

46,X,i(Xq) 7*

45.X/46,X,i(Xq) 10

45,X/46,X,i dic(Xq) 2

45,X/46,X,i (Xq)/46,i (Xq),i (Xq) 1

45,X/46,X,i (Xq)/47,X,i (Xq),i (Xq) 2

Other

46,X,t (X;X)qter-p22 1*

45,X/46,X,del X (q13) 2

46,X,Xq+ 1*

45,X/46,X,Xq+ 1

45,X/46,X,r(X) 1

45,X/46,XX/46,X,r (X)/ 47,X,r (X),R (X) 1

45,X/46,X,r 1
 46,X,del X (q25) 1*

Other X mosaic cell lines 9

45, X/46, XX 8

45,X/47,XXX 1

Total 84

* Single cell lines.

+ Turner phenotype with intra-abdominal streak gonad and contra-lateral
intra-abdominal testis.
All of the chromosomal findings in mosaic and non-mosaic patients with Turner
syndrome have a common denominator: privation of either the entire X chromosome
or a portion of the X chromosome. Fetuses with Turner syndrome have as many
germ cells at mid gestation as do 46,XX fetuses. However, because of the absence of
ovarian determinant genes accelerated loss of germ cells occur. Many of these
individuals lose all of their germ cells before birth. Some of them lose the remaining
germ cells during childhood years and before puberty. Less than 15% of patients
with Turner syndrome will lose their germ cells either during or after the pubertal
process [40]. Five % of patients with Turner syndrome will have enough germ cells
remaining at puberty to not only initiate the pubertal process but also have regular,
cyclic menses during at least a portion of their adolescent or adult years and 1%
may spontaneously become pregnant.

Once the germ cells are prematurely depleted from the ovaries, the only remaining
tissue present is the connective stroma of the gonads. It is usually a ribbon of white
connective stroma located beneath the fallopian tubes and along the pelvic sidewalls.
These residual gonads have the appearance of "streaks" and are referred to as
streak gonads. The presence of a Y cell line in a patient with Turner syndrome brings
with it a 15-25% risk of developing malignant germ cell tumors within those streak
gonads. In those particular patients the streaks need to be surgically removed as
soon as a diagnosis is made. For all other patients with Turner syndrome, privation
of X chromosomal material is associated with the variable stigmata noted in Turner
patients, cardiovascular and renal abnormalities, and the development of a number
of specific medical problems. Turner stigmata include high arched palate, low hair
line and webbed neck, multiple pigmented nevi, short fourth metacarpals, shield
chest, increased carrying angle of the arms (cubitis valgus) and lymphadema of
ankles to name a few. While these stigmata related to loss of X-chromosomal
material are variably present and phenotypic-karyotypic correlations cannot be made
[43], one consistent finding for these patients is limited adult height [40]. The MCG
series was reported prior to the treatment of Turner patients with growth hormone.
The fact that none of the patients in that series was taller than 63 inches in height
supported the tenet that statural genes were surely located on both arms of the X
chromosome. The knowledge of consistent short adult stature, often under 5 feet,
and the potential psychological effect it has in combination with other features of
Turner syndrome, provided impetus for identifying therapies independent from
estrogen treatment for these patients. Many hundreds of Turner patients have now
been treated with growth hormone pushing the final adult stature beyond this 63-
inch mark for some and certainly past the predicted final height for many other
women. Cardiac malformations have been reported to exist in up to 50% of patients
and include coarctation and bicuspid aortic valves (separately between 30 and 45%
incidence), and dilation of the ascending aorta [44]. The later pathophysiologic entity
appears to be acquired in at least 10% of patients in one series and unfortunately
has usually resulted in the past in misdiagnosis and death after dissection and
rupture of the ascending aorta [44]. It is associated with the pathohistologic entity of
cystic medical necrosis of the vessel wall, the culprit of similar clinical outcomes in
patients with Marfan syndrome [44]. The recent reports of at least 4 deaths during
or immediately after pregnancy in Turner patients who became pregnant from oocyte
donation and embryo transfer suggests a special risk to these patients from the
increased cardiovascular demands of pregnancy [45].

Horseshoe kidney is the most common renal abnormality seen in Turner patients. A
number of autoimmune disorders have been identified in patients with Turner
syndrome, the most common being Hashimoto thyroiditis and rarely diabetes.

Normal Chromosomes

The second largest group of young women with primary ovarian failure has a 46,XX
karyotype (46,XX gonadal dysgenesis). For them, a few have a genetic etiology. In
particular, an autosomal recessive form of this disorder was previously suggested by
the presence of sibships reported in which several non-twin sisters are affected with
ovarian failure [40]. While an autosomal recessive form may well exist, the recent
finding that approximately 14% of familial cases of 46,XX ovarian failure have
permutations for the fragile X syndrome makes this genetic cause identifiable [46]. A
number of known genetic disorders have also been associated with ovarian failure
including myotonia dystrophica, ataxia telangectesia, galactosemia, and more
recently and numerically more frequently, permutations of the fragile X gene.
Infiltrative diseases such as mucopolysaccharidoses have also been associated with
primary ovarian failure. It is considered that environmental etiologies such as
childhood viral illnesses may also cause premature depletion of oocytes from the
ovaries. This is suspected in identical twins reported to be discordant for ovarian
failure [40]. While mumps can cause orchitis in males, it is suspected that viruses
such as mumps may cause oophoritis and loss of oocytes as well. Patients previously
treated for childhood malignancies such as Wilms tumor, may develop germ cell
depletion as a result of radiation therapy or chemotherapy (e.g., alkylating agents).
Probably the most common cause of premature primary ovarian failure in women
with a 46,XX karyotype is autoimmune. For the group of patients for whom an
abnormality is not identified, autoimmune is considered the most likely cause. These
patients have an increased risk for developing other autoimmune endocrine
abnormalities such as Hashimoto thyroiditis, hypoparathyroidism and adrenal
insufficiency. In addition, pernicious anemia has been reported in some of these
patients. They should be screened on a routine basis for hypothyroidism and the
other endocrinopathies if symptomatic.

As one would suspect, in the absence of a genetic etiology for depletion of the
oocytes, more patients present at puberty with residual germ cells after the initial
insult. In the MCG series of patients, nearly 40% of them had enough follicles at
puberty to mount a pubertal response before presenting with amenorrhea and
ovarian failure [40]. A number of patients with 46,XX gonadal dysgenesis will
actually go through the pubertal process and have cyclic menses before developing
ovarian failure and amenorrhea in their late teens or 20's.
Rare patients present with 46,XY gonadal dysgenesis. These are patients who likely
have mutations in a gene controlling testicular morphogenesis such as the SRY gene,
which initiates testicular development in-utero. In the absence of testicular
development, the germ cells that arrive at the genital ridge will organize in the
cortical, rather than medullary region of the undifferentiated gonad. For these
patients with a 46,XY karyotype, however, germ cell loss is complete before birth.
Since they never develop testes, they will not produce mullerian inhibiting substance
to ablate the developing mullerian system. They will also not produce androgens to
allow for masculinization of the external genitalia. These 46,XY individuals have
Swyer syndrome and at birth have a normal female phenotype with a normal vagina,
uterus and fallopian tubes. At puberty, they do not initiate pubertal development and
are found to have elevated gonadotropin levels. These 46,XY individuals have the
highest risk for developing germ cell tumors of their streak gonads of any individuals
with gonadal dysgenesis and a Y chromosome cell line. The streaks must be removed
as soon after diagnosis as is reasonable. They do not have other phenotypic
abnormalities like the patients with Turner syndrome. They are often tall because of
the presence of a Y chromosome.

Molecular Findings

While Turner syndrome is considered to result from haploinsufficiency of critical loci

or regions of the X chromosome and a number of putative genes have been
identified, a molecular understanding of mechanisms involved is far from understood.
A number of the stigmata and malformations of Turner syndrome have been thought
to be caused by edema present during development because of an abnormal
lymphatic drainage to the heart. As such, the abnormalities are actually
deformations. For example, edema of the nail beds causes nail hypoplasia, edema of
the neck causes cystic hygromas and webbed neck, and edema of the kidneys
prevents them from migrating around the aortic bifurcation and results in horseshoe
kidney. The presence of cystic hygromas during fetal life is also associated with
coarctation of the aorta; lymphatic drainage back to the heart is sufficiently
abnormal during development to cause this cardiac malformation. One region of the
X chromosome, Xp11.2-p22.1, has been thought to include "Turner syndrome loci",
as a number of associated features including ovarian failure, short stature, high-
arched palate, and autoimmune disease have been mapped here [47]. Deletions of
the X-chromosome linked SHOX gene has explained many of the dysmorphic skeletal
features of Turner syndrome including the short stature [6].

Prior karyotypic/pheontype correlations have suggested that the proximal regions of

both the p and q arms of the X chromosomes are most critical for maintenance of
the germ cell compliment [43]. However, terminal deletions at the telomeric regions
of these arms are also associated with oocyte depletion, although to a lesser degree.
Deletion of these regions are more likely to result in premature ovarian failure after
some period of ovarian function rather than a complete loss of germ cells evident at
the start of the teenage years as is seen with the proximal deletions. While putative
genes such as POF1 [48], POF2 [49, 50], the human homologue of the Drosophila
melanogaster diaphanous gene, and the fragile X locus have been recently implicated
for these ovarian determinants, the mechanisms mediated by their gene products
which normally allows for ovarian development and preservation are far from
understood [46]. It would appear that a double dosage of these genes is required for
normal ovarian function. Interruption, deletion and likely mutation of such ovarian
determinant genes, even on one X chromosome, results in premature loss of germ
cells from the ovaries. It is possible that mutations within these loci are responsible
for ovarian failure in women with intact X chromosomes. The most studied of them is
the FMR 1 gene, the locus mutated by a CGG triple nucleotide repeat expansion in
fragile X syndrome. As in many triple nucleotide repeat disorders, areas of normal
repeat sequence may be predisposed to expansion during or before meiosis. Function
of the gene is maintained within a given number of these triple repeats but when a
certain threshold is reached gene function may be adversely altered. For the fragile X
gene, a CGG repeat sequence occurs with up to 60 such repeats being normal.
Expansion to over 200 such repeats leads to fragile X syndrome; the high level of
repeats causing hypermethylation of the promoter and silencing of the gene.
Interesting observations were made that female carriers of the permutation of this
locus, an unstable intermediary level of repeats (i.e., 60-199), often had premature
ovarian failure. Recent evidence suggests that this premutaton is associated with a
21 fold greater chance of developing premature ovarian failure and that 2% of
sporadic and 14% of familial ovarian failure patients harbor this unstable
intermediate trinucleotide repeat. Another triple repeat disorder that has been
associated with premature ovarian failure is myotonic dystrophy.

Our understanding of Swyer syndrome (46,XY gonadal dysgenesis/ sex reversal)

together with 46,XX sex reversal helped to identify the SRY gene on the Y
chromosome short arm [51]. Expression of this gene appears to be one of the first
signals in the process of testicular morphogenesis. Approximately 15% of women
with 46,XY gonadal dysgenesis have been found to have mutations in this gene [52,
53]. The fact that the remaining 46,XY gonadal dysgenesis patients have intact Y
chromosomes and that only rare 46,XX true hermaphrodites studied have been
found to harbor SRY sequences provides evidence that other genes are present and
necessary either upstream or downstream in expression to SRY. Mutations of WT 1
[54, 55], SOX9 [54, 56-59], DSS [60], SF-1 [61], and DAX-1 [59] have all been
associated with specific syndromes and 46,XY sex reversal. Of these, the most
frequently reported and best characterized involves the SOX-9 gene and the
accompanying syndrome of Campomelic dwarfism.

A molecular understanding of genes involved in steroid signaling and production has

clarified better those disorders that present as pseudo-ovarian failure. Several classic
hypergonadotropic hypogonadal syndromes have been long described for which germ
cell depletion is not the cause of the elevation of gonadotropins. Rather, in these
patients, the inability for steroid production is the cause of the hypergonadotropic
state; hence the classification of ovarian failure. The first such classic syndrome,
Savage syndrome, was initially described as gonadotropin resistance. More recently
a number of families have been identified in Finland in which 46,XX individuals with
gonadotropin resistance have been found to be homozygous for a single mutation of
the FSH receptor gene [62-64]. Subsequently, other 46,XX hypergonadotropic
patients have been identified with mutations in the LH receptor [65-69], the FSH b
[70, 71], and the LH b genes. Overall the result of these disorders is a lack of
estrogen production and variable hypergonadotropic states. 46,XY individuals with
homozygous or compound heterozygous mutations of the LH receptor gene do not
masculinize in-utero and present during adolescence with a female phenotype,
delayed puberty, and hypergonadotropic hypogonadism. Their gonads, however, are
testes not ovaries. The second classic hypergonadotropic state that has long been
described in association with otherwise normal gonads is 17 a-hydroxylase
deficiency. Both 46,XX and 46,XY individuals present with delayed puberty and a
female phenotype, and ovaries and testes, respectively. Mutations have been also
found in this gene [72, 73]. More recently mutations of the aromatase gene in 46,XX
individuals have been similarly identified and associated with delayed puberty and
hypergonadotropism in these individuals [8, 74-76]. In contradistinction to the other
hypoestrogenic syndromes, aromatase deficiency, however, is associated with
elevations of androgens in-utero and at puberty and the predictable but variable
degrees of masculinization in these otherwise phenotypic females.

Contemporary Issues for Management

Patients identified with ovarian failure will need evaluation for associated medical
disorders. For Turner syndrome, the most commonly identified acquired medical
condition is Hashimoto thyroditis. For them, the most dangerous abnormalities
involve cardiovascular malformations. While previously it has been well known that
coarctation of the aorta occurs more frequently for these patients as does bicuspid
aortic valves, it is now evident that these patients are at increased risk of developing
dilation of the ascending aorta (and less commonly at other vascular sites) with
subsequent dissection and, if undiagnosed and untreated, rupture. Like patients with
Marfan syndrome, they appear to have cystic medial necrosis as the predisposing
vascular histopathology. Similar to Marfan syndrome, the increased cardiovascular
demands of pregnancy also appear to increase significantly this risk. It is
recommended that cardiac ultrasound studies be performed every 3 - 5 years and
perhaps during each trimester of pregnancy if patients are willing to take a risk
estimated to be at least 2% for maternal mortality. Recommendations for counseling
and pregnancy by donor oocytes are being developed and will be forthcoming from
the American Society of Reproductive Medicine. All Turner patients should be
counseled about their increased risk of dilation, dissection and rupture of the
ascending aorta. Since most previous deaths occurred after misdiagnosis, Turner
patients should be counseled to make health care providers aware of this possible
diagnosis when being evaluated for disproportionate symptoms of indigestion and
upper abdominal or chest pain. It is possible that most deaths could have been
avoided with timely diagnosis and surgical repair. Turner syndrome patients need
evaluation for horseshoe kidney and occasionally for other less frequently diagnosed
autoimmune disorders such as diabetes.

Treatment of patients with Turner syndrome includes not only hormone replacement
for pubertal progression and health maintenance at least through age 50 years, but
an even earlier consideration for growth hormone treatment. While there have been
some conflicting reports, general consensus is that the use of growth hormone for
enhancing adult stature is a worthwhile endeavor [77-84]. The initiation of estrogen
therapy at an age concordant with normal endogenous ovarian production, i.e., at
least by ages 9 to 11 years, has always been considered important for normal
psychosexual development of the adolescent. However, it is also believed that such
early estrogen replacement might also result in an earlier closure of epiphyses and a
potential limitation of final adult stature. The use of growth hormone therapy
initiated during the childhood years may allow a more normal childhood stature
(concordant with mid parental height) and the earlier initiation of estrogen therapy
obviating these concerns [80, 85, 86].

Patients with 46,XX gonadal dysgenesis should be evaluated for premutations of the
fragile X gene. This finding should prompt counseling for themselves and other
family members and limit use of their similarly affected sisters as oocytes donors. In
addition, 46,XX ovarian failure patients should be screened regularly for the
development of Hashimoto thyroiditis and, with symptoms, for hypoparathyroidism,
adrenal insufficiency, and other autoimmune disorders such as pernicious anemia. All
gonadal dysgenesis patients with a Y cell line need extirpation of their gonads
including Turner patients with 45,X/46,XY (or those with a Y chromosome fragment)
gonadal dysgenesis and the 46,XY Swyer syndrome patients. One should remember
that rare patients with seeming 45,X single cell line Turner syndrome might have
undetected mosaicism for a Y cell line. Screening 45,X single cell line patients and
those individuals with an unidentified chromosomal fragment with Y-DNA centromeric
probes may be prudent to uncover those additional individuals at-risk for gonadal
malignancies.

All patients with premature gonadal failure need estrogen therapy for initiation and
completion of pubertal progression and subsequently for the maintenance of a
multitude of health processes. While the continued accrual and remodeling of bone is
of utmost importance, it remains likely that numerous other physiologic processes
are dependent on normal estrogen status as well, at least through 50 years of age.
The recent findings and concerns for long term hormone replacement of the
Women's Health Initiative do not apply to these or any other patient prior to the age
of 50 years and should not be used to prematurely stop their hormone replacement.
Counseling is of utmost importance for these individuals and should cover
expectations for all aspects of these young women's lives including alternatives for
reproduction. While the use of donor oocytes and IVF has proven safe for 46,XX and
46,XY gonadal dysgenesis patients, a maternal death rate of up to 2% may exist for
the Turner syndrome patients. While it is often easier to include this form of
pregnancy as an alternative during counseling, until more information is available
such discussions should be framed with these concerns. One should also turn to
patient guidelines of national organizations such as the American Society for
Reproductive Medicine (ASRM) and the American College of Obstetricians and
Gynecologists (ACOG) as they are developed about these issues. The use of "buddy
programs" in which these patients are paired with others who have previously
confronted the same issues during adolescence and support groups (e.g., Turner
Syndrome Society) is an excellent compliment to this counseling.

Hypogonadotropic Hypogonadism

A number of young women will present with delay of the onset of pubertal
development who have no evidence of ongoing estrogen production, because
something has interrupted either GnRH or gonadotropin secretion from the
hypothalamus/pituitary. Patients with constitutional delay of puberty represent the
most common of these disorders. Other disorders are clearly congenital or acquired.

Constitutional delay

Constitutional delay of puberty refers to a common condition for which patients will
go through puberty but at a time that is more than 2.5 standard deviations delayed
from the mean (Tables III and IV) [40-42]. A number of these patients often have a
family history of delayed puberty [42]. Their physiologic age (i.e., bone age) lags
behind that of their peers and is manifested by a delay in the adolescent growth
spurt and temporary short stature. At a physiologic age of 9-11 years, they will enter
the pubertal process. Most of these patients present between 13 and16 years of age
and at that time have very early signs of thelarche. Their gonadotropins are in the
low to normal range and their workup is otherwise unrevealing. An intravenous GnRH
challenge test will usually confirm early awakening of the hypothalamic-pituitary-
ovarian circuit by demonstrating a pubertal gonadotropin response, i.e., a greater
release of LH than FSH. Such a response is seen only after endogenous GnRH
secretion occurs and puberty is in its very early stages. At the same time, this early
gonadotropin release produces the multifollicular ovarian appearance of early
puberty; the ultrasound appearance of which is likely as reassuring that puberty will
march onward as is the LH response of a GnRH challenge.
In males, 60% of pubertal delay is constitutional. In females, however, no more than
30% have this benign reproductive condition. While constitutional delay represents a
leading cause of female pubertal delay, prior emphasis on this statistic has led to the
false diagnosis for many young women and the misguided reassurance that they
were simply "late bloomers." As many as 2/3 of females presenting with delayed
puberty will have an irreversible etiology for reproductive failure, not constitutional
delay [40]. For this reason, any patient presenting with delayed puberty and given
the label of constitutional delay should be scrutinized very carefully for other
etiologies, especially if they are beyond age 16 years and have yet to initiate
pubertal development. Hopefully, in this century, it will be the exception that an
adolescent would reach mid adolescence without spontaneous or exogenously
induced pubertal development!

Acquired Abnormalities

A number of acquired medical conditions may interfere with either the production of
GnRH and/or gonadotropin secretion producing a hypogonadotropic hypogonadal
state (Tables III and IV) [40, 42]. The Children's Hospital series refers to many of
these as functional disorders [42]. Endocrine disorders such as hypothyroidism,
congenital adrenal hyperplasia, Cushing syndrome, and idiopathic hyperprolactinemia
that begin before or during the early pubertal process may arrest gonadotropin
secretion. While only some cases of growth hormone deficiency are acquired, this
disorder is included here with the other endocrinopathies. Patients with particularly
short stature, pubertal delay, and low gonadotropin levels should be considered as
having one of the endocrinopathies that also affects growth (i.e., hypothyroidism and
growth hormone deficiency). Treatment of these disorders will allow the resumption
of puberty. Systemic illnesses including malabsorption states, eating disorders,
active autoimmune diseases, and the rare hypoxemic states related to congenital
heart malformations or severe anemias (i.e., sickle cell) are also occasionally
etiologic for hypogonadotropism and pubertal delays. Most of these conditions are
similarly reversible. Finally, pituitary tumors are consistently reported in rare
patients of all descriptive delayed puberty series [40]. The craniopharyngioma occurs
usually between the ages of 6-14 years prior to the usual time onset of puberty. It is
an aggressive tumor that causes early destruction of the pituitary and suprasellar
regions and usually delays any pubertal development. On the other hand, it can also
be an indolent tumor not becoming apparent until the late teenage years or even the
mid 20's. The typical calcification of these tumors makes them easily diagnosed
radiologically. Unlike the craniopharyngioma, the prolactinoma usually does not
develop until after puberty is initiated. Estrogen is known to increase messenger RNA
for prolactin and its increase at puberty is seemingly associated with the
development of prolactinomas. For these patients, the prolactinoma usually arrests a
pubertal process that has begun on time. These tumors are extremely slow growing
and rarely interfere with other pituitary functions, if at all. If a dopamine agonist is
given to lower the prolactin levels, puberty or menstrual function will usually proceed
normally. In most recent series, the prolactinoma outnumbers the
craniopharyngioma as a cause of hypogonadotropic hypogonadism.
Congenital Abnormalities

A number of irreversible disorders are found in patients with hypogonadotropic

hypogonadism, some of which are associated with fractional or complete pituitary
insufficiency; the majority are not. Previously, this later group was categorized as
idiopathic hypogonadotropic hypogonadism (IHH), of which many patients were felt
to have isolated deficiency of GnRH. However, unlike the hypogonadal mouse found
to have deletion of a large portion of the GnRH gene, such mutations in humans
have yet to be found. A few specific gene mutations have been identified in some of
these patients to better understand the disorders. While mutations of the X-linked
Kal gene are associated with the anosmia and hypogonadotropic state of some men
with Kallmann syndrome, they have yet to be identified in female patients. The most
common mutations in other patients with IHH have been found in the GnRH receptor
gene. Other disorders are also associated with the hypogonadotropic state and
include mutations of DAX 1 and Prop1 genes [87-91]. A number of other genetic
defects have been found to cause hypogonadotropic hypogonadism including
congenital forms of hypopituitarism, genetic disorders such as Prader-Willi
Syndrome, the CHARGE syndrome, and Laurence-Moon and Bidel-Bardet Syndromes.
Finally, other forms of hypopituitarism exist some of which are associated with
anatomic abnormalities such as Rathke's pouch cysts, anterior encephalocele, and
hydrocephalus [40].

Molecular Findings

As in the patients with hypergonadotropic hypogonadism, molecular research has

provided new insight into the clinical findings of a number of patients with
hypogonadotropism. In particular, these studies have helped to better understand
the variation of clinical presentation and gonadotropin levels, and the different
responses to exogenous GnRH reported in these patients. For men with Kallman
syndrome, mutations of a cell surface adhesive gene, the KAL gene, have helped to
understand the anosmia and hypogonadotropic state; they prevent development of
the neurologic tract responsible for transport of GnRH to the median eminence and
normal olfactory bulb development [90, 92-94]. Subsequently, a number of these
men were also found to have unilateral renal agenesis. While similar mutations have
not yet been identified in anosmic females, it is likely that a few will ultimately be
uncovered. The most common molecular finding in patients with very low
gonadotropins has been mutations in the GnRH receptor gene [95-98]. Finally,
mutations of DAX1 and PROP1 have more recently been described in patients with
hypogonadotropic hypogonadism [87-91].

Contemporary Issues for Management

Numerous different disorders exist for patients presenting with hypogonadotropic

hypogonadism. Many of these are rare and best managed by specialists who treat
the specific disorder, each disorder having very specific individual clinical concerns. It
should be determined early whether treatment of the disorder will allow subsequent
pubertal progression or whether an irreversible form of hypogonadotropism exists
which warrants sex steroid replacement to allow as timely a pubertal progression as
possible. A part of treatment involves individual counseling about expectations for
pubertal development, associated problems, reproductive options, and chance of
recurrence. No doubt, this may require a multidisciplinary team approach. An
interesting finding of the Children's Hospital study was that it provided evidence that
there may be an association between hypogonadotropic hypogonadal causes of
delayed puberty and attention deficit disorder with or without hyperactivity [42].

Eugonadism

The MCG series presented a third group of females with pubertal abnormalities and
evidence of ongoing estrogen production. These patients primarily present with
delayed menarche.

Anatomic abnormalities

Congenital absence of the uterus and vagina (CAUV), also known as mullerian
aplasia or Rokitansky-Kuster-Hauser-syndrome, is the second most common cause
of pubertal aberrancy in the MCG series [41]. In particular, these patients present
with delayed menarche. They have fusion failure of the two mullerian anlagen during
embryogenesis. The normal fusion process is usually followed by canalization of the
vagina. In its absence, small uterine remnants and their attached normal fallopian
tubes remain; the vaginal plate is uncannalized. These patients progress through
puberty at the normal time. They present with delayed menarche and on
examination are found to have absence of the vagina. They have normal ovarian
function. Nearly 30% of these patients have concomitant renal abnormalities, the
most common being unilateral renal agenesis. From 12-50% of these patients will
have associated skeletal abnormalities, scoliosis being the most common. Other
abnormalities may also occur.

Another group of patients who present with an anatomic cause of delayed menarche
have an imperforate hymen or a transverse vaginal septum. These patients also
initiate the pubertal process at the normal time and even menstruate. Their menses,
however, are concealed behind the obstructing membrane or septum producing
initially a hematocolpus and later a hematometra. These patients usually present
within one year of normal menarche with cyclic pelvic pain. On examination they are
found to have an obstructing membrane, the imperforate hymen often bulging on
valsalva maneuver. Once these obstructing membranes are surgically excised normal
menstrual function usually follows.

Molecular Findings

Because patients with CAUV were never previously able to have children, the
inheritance pattern for most of them has been generally unknown and clues for
potential candidate genes have remained elusive. The majority of these patients are
sporadic occurrences within their family. Rare sibships with several nontwin sisters
affected have been reported and twins both concordant and discordant for CAUV also
exist [40]. A recent report of the outcome of pregnancy for these patients who were
able to have their own biological children through IVF utilizing a gestational host
suggests that this condition is not commonly autosomal dominant; none of the
female babies were found to be similarly affected [99]. Our laboratory has performed
mutation analyses for a number of candidate genes in these patients including the
cystic fibrosis transmembrane conductance regulator (CFTR) [100], WNT7, anti-
Müllerian hormone (AMH) [101], anti-Müllerian hormone receptor (AMHR) [101],
HOXA10 [102], HOXA13 [103], galactose-1-phosphate uridyl transferase (GALT),
PAX2 [104], and Wilms tumor transcription factor (WT1) [105]. To date none of
these analyses have revealed a convincing association. For the transverse vaginal
septum and imperforate hymen patients, molecular analysis has been essentially
nonexistent.

Contemporary Issues for Management

The diagnosis of CAUV is essentially clinical. The classic finding of vaginal absence or
a vaginal pouch (usually developed through prior coital attempts) associated with
otherwise Tanner V breast and pubic hair development is unlikely anything else but
CAUV. A search for associated physical findings of bony malformations (commonly
scoliosis) and rarely inguinal hernias or scars from prior repair should be conducted.
The inguinal hernias occur because the round ligaments can pull the unconnected
uterine remnants and associated fallopian tubes and ovaries into the inguinal canals.
The diagnosis of CAUV can be confirmed simply by a pelvic ultrasound study that
demonstrates the presence of ovaries with follicular activity. The midline uterus will
not be seen. Neither a karyotype nor laparoscopy is necessary for the diagnosis in
the majority of CAUV patients. The prepubertal patient could be misdiagnosed with
androgen insensitivity syndrome (AIS). However, postpubertally the clinical findings
for CAUV and AIS are sufficiently different that diagnosis of each is usually
straightforward. If in doubt, a serum total testosterone level is the least expensive
method of resolving the confusion; levels within the female and male ranges will
differentiate the two conditions.

Treatment of this condition has previously been surgical; a number of different

surgical techniques have been utilized for creation of the vagina. In the United
States, the McIndoe vaginoplasty remains the most commonly performed surgery for
neovaginal creation. This is the classic procedure in which a skin graft is sewn
around a mold and inserted into a newly dissected vaginal space. After a skin graft
take the patient wears a vaginal mold for an extended period of time and until
regular coitus to prevent scarring down of the neovagina. In other parts of the world,
the Vecchietti procedure is more commonly performed. In this procedure an olive
shaped instrument is placed at the perineal dimple and pulled inward under tension
by attached wires, sutures, or threads stretching the perineal skin in the direction of
the normal vaginal axis. The tension cords have been placed by abdominal surgery
and more recently laparoscopy [106-110]. The majority of patients, however, can
avoid surgery altogether and should be encouraged to attempt creation of a
neovagina first by the Ingram dilation technique [111, 112]. A vaginal dilator is held
in place at the vaginal dimple with athletic underwear. The patient then sits on a
bicycle seat of a stationary bicycle or a specially designed chair for regular periods of
time. The size of the mold is increased over time and until a normal sized vagina is
created or coitus can be initiated. With motivated patients and careful instructions
and encouragement the majority of patients will succeed. When new patients are
paired up with prior successful CAUV patients for support, this method rarely fails.
Patient pairing is particularly helpful for the emotional support and personal advice
that only women who have weathered the various challenges of this condition can
provide.

The assisted reproductive technologies have provided these women a means of

having their own biological children. The use of gestational carriers with IVF after
oocyte retrieval and fertilization has made this possible. Given that the CAUV patient
and her husband are the biological parents of these children, legal issues involving
the gestational carriers are certainly better delineated and problems arising from
them much less likely than were the initial uses of surrogacy.
The imperforate hymen and the transverse vaginal septum are surgically treated by
one of a number of procedures described in most gynecologic textbooks. These
procedures are usually straightforward. Occasionally the transverse vaginal septum
is difficult and requires more involved surgery including an abdominal approach, a Z-
plasty, or skin graft. None-the-less, an experienced surgeon should perform all of
these procedures.

Chronic anovulation

Polycystic ovarian syndrome (PCOS) and a number of other endocrine abnormalities

may result in chronic anovulation and present as delayed menarche as reported in
the MCG series [113]. These patients may not have their first menses until given a
progestin challenge. While most of them have classic PCOS, other endocrinopathies
and hypothalamic dysfunction need to be ruled out. The contemporary management
of PCOS and its associated gynecologic and metabolic disorders includes
consideration for treatment of it as an insulin resistant state in addition to the classic
management considerations of ovarian suppression, endometrial protection, as well
as androgen targeted treatments. This topic is covered in greater detail elsewhere in
this text.

Intersex Disorders

Patients with androgen insensitivity present at puberty with normal onset of breast
development, absent pubic hair, and delayed menarche. These 46,XY women have
been found to harbor mutations in their androgen receptor genes that render their
androgen receptors nonfunctional. Despite normal testes development and normal
male testosterone production, they are unable to convert the testosterone signal into
the end organ events of masculinization of the external genitalia in-utero or at
puberty. They present with a normal female phenotype and a small blind vaginal
pouch. At puberty, their androgens are converted to estrogens with normal breast
development. They are usually taller than predicted by mid parental height for
females because of the presence of the Y chromosome and its associated statural
genes. The presence of the Y chromosome places them at risk for developing
malignancies of their gonads and dictates removal. Unlike gonadal dysgenesis
patients, the risk does not increase until after puberty; additionally, these tumors are
usually seminomas rather than the gonadoblastomas or germ cell tumors. Unless the
testes are located within the inguinal canals, they are usually left in place until after
breast development is complete.

Molecular Findings

Androgen insensitivity syndrome has been extensively studied by molecular analysis

[114, 115]. A number of intriguing and frustrating findings have been made. First,
mutations have been found in virtually every portion of the androgen receptor (AR)
gene [116]. Mutations in the hormone binding region of the AR gene have explained
those classic patients previously determined to have nonfunctional androgen
receptors. Mutations in the DNA binding domain helped explain why other AIS
patients with the same classic phenotype had normally functioning androgen
receptors. Second, many families studied have mutations unique to their specific
family [114]. Until gene sequencing is routine, this precludes studying patients with
a suspicious AIS phenotype for a specific AR mutation. Third, identification of
mutations in this gene has widened the spectrum of incomplete AIS phenotypes to
include phenotypic females with genital ambiguity, phenotypic males separately with
undermasculinization [117], gynecomastia, breast cancer [118], prostatic cancer or
azoospermia/ severe oligospermia [119]. Fourth, individuals with the same
mutations have exhibited varying phenotypes [116, 120, 121]. Finally, clinical
correlations have been made between specific mutations and the ability to
masculinize further with exogenous androgens for those individuals with a male sex
of rearing and not presenting as delayed female puberty [122, 123].

Contemporary Issues for Management

For the classic patient with AIS who presents with delayed menarche, absent pubic
hair, and a vaginal pouch, an expedient evaluation and diagnosis is necessary. Unlike
the CAUV patients, once the diagnosis of AIS is suspected, chromosomal analysis is
necessary to document a 46,XY karyotype. This will then necessitate removal of the
testes either by laparatomy or laparoscopy. No doubt, the most important issue
related to this syndrome is counseling. No longer is it possible or advisable to hide
the presence of the 46,XY finding from these patients. However, a multidisciplinary
and well thought out approach and close follow-up is needed for such counseling.
Many of these patients have a vaginal pouch, the embryonic remnant of the prostatic
utricle. For them coital attempts will enlarge the vagina and surgery is not needed.
For others a similar, although somewhat different, approach can be utilized as was
described for the patients with CAUV. Furthermore, once gonadectomy is performed,
estrogen replacement therapy is essential for all of the obvious reasons.