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The menstrual cycle

Last updated: May 2, 2025

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The menstrual cycle is a highly regulated physiological process required for conception and pregnancy. From the start of menstruation (menarche) to its cessation (menopause), menstrual bleeding (menstruation) is regulated by the coordinated release of hormones from the hypothalamus, pituitary gland, and ovaries. These hormones trigger simultaneous changes in the ovaries (ovarian cycle) and the uterus (uterine cycle). Mittelschmerz is a physiological condition experienced by some individuals characterized by unilateral lower abdominal pain during ovulation; it may be initially misdiagnosed as appendicitis, ectopic pregnancy, or ovarian torsion in individuals who present with acute pelvic pain or acute abdomen. Management involves reassurance and nonopioid analgesics.

Menstrual cycle abnormalities include changes in the frequency and intensity of menstruation as well as symptoms such as pronounced abdominal discomfort, gastrointestinal issues, and psychiatric symptoms. Amenorrhea, dysmenorrhea, abnormal uterine bleeding, and premenstrual disorders are discussed separately.

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Overview of the menstrual cycletoggle arrow icon

Menstrual cycle

Ovarian and uterine changes during the menstrual cycle

Menstrual cycle changes
Phase Mechanism
Ovarian cycle
Uterine cycle

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Ovarian cycletoggle arrow icon

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Uterine cycletoggle arrow icon

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Physiological age-related changes in the menstrual cycletoggle arrow icon

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Mittelschmerztoggle arrow icon

Mittelschmerz (also known as midcycle pain or ovulatory pain) is physiological pain experienced by some individuals during ovulation. [10][11]

Epidemiology

Mittelschmerz occurs at least once in > 50% of premenopausal individuals. [12]

Etiology [12]

Clinical features

  • Unilateral lower abdominal pain (often recurrent) [12][13]
    • Pain occurs mid-cycle (days 14–16 of the menstrual cycle) in individuals with regular cycles.
    • Usually located in the iliac fossa but may be generalized [13][14]
    • Can last from minutes up to 48 hours [10][14]
    • May be accompanied by ovulation bleeding: light bleeding or blood-stained discharge during the midpoint of the menstrual cycle [15]
  • Physical examination

Diagnostics

It may be difficult to distinguish between symptoms of mittelschmerz and those of acute appendicitis or other adnexal emergencies. [12][16]

Management

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Abnormalities of the menstrual cycletoggle arrow icon

Abnormal menstrual patterns include changes in the frequency, intensity, and/or onset of bleeding. Common manifestations of menstrual cycle abnormalities include:

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