Puberty in girls typically follows a predictable course of thelarche (breast development) to pubarche (pubic hair) to a growth spurt and, finally, menarche.

The follicular phase of the menstrual cycle is marked by rising estrogen levels produced by the enlarging dominant follicle (ie, a large cyst with multiple smaller cysts), resulting in:

• An increase in quantity of cervical mucus, which facilitates the transfer and maturation of sperm for fertilization
• A thickened endometrium in preparation for implantation
• Enlarge adnexa may be appreciated on physical exam especially late follicular phase

Normal U/S→Pelvic ultrasound shows the left ovary with a 3-cm cyst with several subcentimeter cysts in the periphery. There is normal Doppler blood flow with a small amount of free fluid in the posterior cul-de-sac.

A normal menstrual cycle lasts approximately 3 to 8 days and occurs every 24 to 38 days. Light periods do not typically indicate pathology. In patients on oral contraceptive pills, the total duration and volume of a woman’s menstrual cycle may decrease over time. This patient should be reassured that the change in the volume of her menstrual periods is typical and that her menstrual cycles fall within normal parameters.

• The cervical mucus in the late follicular phase (10-14 days after the last menstrual period) and leading up to the point of ovulation is clear, thin elastic, and often perceived by patients as abnormal vaginal discharge (particularly in those who have previously been anovulatory).

Mittelschmerz

• Ovulatory vs non-ovulatory cycles
• The initial menstrual cycles in adolescents are irregular and anovulatory.

<aside> 💡 During the first year after menarche, adolescents often have anovulatory cycles with heavy, irregular menstrual bleeding due to an immature hypothalamic-pituitary axis

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