Diseases, Disorders information

Those that are dysfunctional or hormonal in etiology, we can classify into two basic parts; ovulatory, which means that the patient is releasing an egg on a monthly basis, and anovulatory problems where a patient does not ovulate on a regular basis or does not ovulate at all.
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The normal physiology is the important thing that we should all keep in mind when we are evaluating the abnormal bleeding. The first phase of the menstrual cycle is what is called the follicular phase and this is dependent upon a communication between the hypothalamus sending information to the pituitary which then sends FSH and LH to the ovaries telling it to produce estrogen, which then feeds back to the hypothalamus. The estrogen also acting in concert on the ovaries with the developing follicles, produces a primary follicle that actually produces more estrogen and the estrogen also causes the endometrium to proliferate. So this is also called the proliferative phase of the menstrual cycle. Here we can see a depiction of this. The estrogen is produced continually. The follicles develop, the primary follicle takes charge, then you have the ovulation right at about 14 days prior to the next menses. This is where you don’t have your estrogen levels going up. It may drop down a little bit and you may have your intermenstrual spotting. After ovulation we get into what’s called the secretory phase or the luteal phase of the menstrual cycle, where the endometrium thickens even more, becomes very lush, ready for implantation of a fertilized ovum. If there is no implantation then the progesterone and estrogen levels drop off and you see the menses start.
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I think, as I said, that the menstrual period starts 14 days after ovulation and this is important in that the amount of tissue that you see shed at the time of menstruation is related to the duration of estrogen exposure during the proliferative or follicular phase. This means that if a woman menstruates every 28 days she will shed X amount of menstrual tissue. If her friend menstruates every 35 days - in other words, doesn’t ovulate until day 21 of the cycle - she has another week of endometrial growth and consequently will have a heavier menstrual period. So this is an important concept. If the patient is not ovulating on a regular basis, if she doesn’t ovulate at all, she can have a real prolonged follicular phase where eventually the amount of estrogen she is producing cannot support the endometrium, and she begins to have a lot of spotting, bleeding and other problems that can get very difficult to control.