Differential Diagnosis

In addition, many women experience characteristic symptoms associated with the phases of the cycle. The most common of these is lower abdominal midline cramping pain, referred to as dysmenorrhea, which typically begins on the first day of bleeding and spontaneously resolves by the second or third day. Dysmenorrhea that is newly worse or longer lasting can be associated with the conditions that cause menorrhagia. Most women also experience premenstrual symptoms in the week before the onset of bleeding; among the most common are breast tenderness, bloating, food cravings, insomnia, and mood changes. Although negative mood symptoms such as irritability and mood lability are common, many women actually experience an increase in energy during this phase. Finally, a smaller proportion of women experience periovulatory symptoms. Cervical mucus, under the influence of the midcycle surge in estradiol, becomes thin and copious just before ovulation and becomes thick and viscid just after ovulation in response to progesterone secretion. Some women also have transient unilateral pelvic discomfort at midcycle, referred to as mittelschmerz and thought to be due to peritoneal irritation associated with ovulation.

Sometimes the history alone will be inconclusive regarding ovulation; in these cases, additional methods can be helpful. Recording of basal body temperature can be used to determine whether the expected postovulatory rise in basal temperature is present. Serum progesterone, measured in the midluteal phase, should be greater than 2 U/mL if ovulation has occurred. The level of luteinizing hormone rises just before ovulation, and this surge can be measured in the urine with an over-the-counter home testing kit. Finally, the endometrium undergoes predictable histologic changes in response to progesterone secretion, and these can be identified in a sample of the endometrium obtained by office biopsy or aspiration.

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