Menstrual cycle

In a healthy post pubertal, premenopausal,

non-pregnant woman, menstrual cycle is a 28-
35 day cycle. The Hypothalamic-pituitary-
ovarian axis regulates menstruation.
The normal menstrual cycle is divided into:
 Ovarian cycle
o Follicular phase
o Luteal phase
 Uterine/ endometrial cycle
o Proliferative phase
o Secretory phase
During the ovarian follicular phase, the
endometrium is in the proliferative phase;
During the ovarian luteal phase, endometrium
is in the secretory phase.

Ovarian cycle
The follicular phase starts with the development of a small pool of pre-antral follicles under
the influence of elevated FSH level. The theca cells and granulosa cells respond to LH and
FSH stimulations respectively, increasing oestradiol productions. The fluctuation of
hormones allows a dominant follicle to emerge while the remaining undergo atresia. As
oestradiol build up to a critical level, it triggers a LH surge and hence ovulation. The follicular
phase ends at ovulation and luteal phase starts after.

After the release of oocyte, corpus luteum is formed from the remaining granulosa and
theca cells. Corpus luteum formed begins to secrete oestradiol and progesterone, stabilizing
the endometrium in preparation for pregnancy. In the absence of beta human chorionic
gonadotrophin, corpus luteum will regress and undergo luteolysis. The luteal phase is more
constant than the follicular phase, at a mean duration of 14 days. The follicular phase can
range from 10-18 days. The variation in the total cycle length is often due to the variability
of the follicular part of the cycle.

Endometrial cycle
The fall in progesterone trigger menstruations. Prostaglandins present in high
concentrations produce myometrial contractions and constriction of spiral arterioles. Distal
ischemia result in tissue breakdown and loss of superficial layers of the endometrium.
Menstruation cease after 5-7 days and the endometrium enters the proliferative phase.

Oestradiol stimulates the growth of the endometrium. Single layer columnar cells become
pseudostratified epithelium. Endometrial thickness increases rapidly from 0.5mm to 3.5-
5mm. After ovulation, oestrogen-induced cellular proliferation is inhibited and the
endometrium enters the secretary phase of the cycle. The high progesterone level
stimulates the endometrial glands to become more tortuous, accumulate glycogen in
vacuoles and increase mucus secretion. The stoma becomes oedematous. Spiral arteries
elongate more and become coiled.
Diagnosing a pregnancy
The diagnosis of early pregnancy is based primarily upon laboratory assessment of human
chorionic gonadotropin (hCG) in urine or blood. History and physical examination are not
highly sensitive methods for early diagnosis.

The diagnosis of pregnancy is based on the presence of any of the following:

1. Detection of human chorionic gonadotropin in blood or urine
2. Identification of pregnancy by ultrasound examination
3. Identification of fetal cardiac activity by Doppler ultrasound

HCG
Hcg is a placental derived glycoprotein. Measurement of plasma hCG is more accurate than
urine hcg concentration. A negative urine test should be followed up with a second one a
week after.

Ultrasound
The earliest structure that can be identified in a pregnant woman through transvaginal
ultrasound is the gestational sac. Gestational sac can be seen at 4.5-5 weeks of gestation.
Yolk sac appears at 5-6 week and remains until approximately 10 weeks. Fetal pole with
cardiac activity can first be detected at 5.5-6 weeks gestations via transabdominal approach.

Home pregnancy test

Positive result on a home-based test should always be confirmed with a beta hcg(serum/
urine) in a clinical setting/ ultrasounds. Home pregnancy kits are fast and easily available,
but they are affected by user’s technique and interpretation. HPT kits may show a false
negative if it’s being carried out too soon before sufficient hCG could build up to a
detectable level. It is often recommended that the user repeat the test in one week if the
first test shows up negative.

References:
https://www-uptodate-com.ezproxy.lib.monash.edu.au/contents/clinical-manifestations-and-diagnosis-
of-early-
pregnancy?search=diagnosing%20a%20pregnancy&source=search_result&selectedTitle=1~150&usa
ge_type=default&display_rank=1#H12
Textbooks: Gynaecology by Ten teachers, Obstetrics and gynaecology - an evidence-based guideline