Menstrual cycle. Family planning.

Laima Maleckiene

Dept.Ob&Gyn
Lithuanian University of Health Sciences
 Menstrual cycle
Menstrual cycle is a self-regulating process during which female body
undergoes many physiological and endocrine changes.
The menstrual cycle is regulated via feedback mechanism:
• hypothalamus (GnRH secretion in pulsatile manner)
• anterior pituitary
follicle-stimulating hormone (FSH)
luteinizing hormone (LH)
• ovaries (estrogen, progesterone, androgens)
 Menstrual cycle
Menstrual cycle :
ovarian cycle
uterine cycle

Ovarian cycle describes changes that occur in ovarian follicles and is divided
into phases:
follicular phase
ovulation
luteal phase
 Follicular phase
Estrogen and progesterone levels are low at early follicular phase.
Baseline FSH and LH levels rise under the influence of GnRH.
FSH triggers 15-20 primordial follicles differentiate into primary follicles.
Primary follicles at the begining of follicular phase develope under the
influence of FSH and one (or occasionally two) become dominant (graafian
follicle).
Dominant follicle will continue mature into preovulatory follicle.
When oocyte is nearly matured, levels of estradiol reach a threshold level
above which this effect is reversed and estrogen stimulates the production of
a large amount of LH (LH surge).
LH surge starts around cycle day 12 and lasts approximately 48 hours.
 Ovulation
Approximately 24–36 hours after the LH surge, the dominant follicle
releases the secondary oocyte (ovulation).
The mature oocyte has a diameter of about 0.2 mm.
In some women, ovulation has a characteristic pain called
mittelschmerz (German term meaning middle pain).
The sudden change in level of hormones at the time of ovulation
sometimes causes light mid-cycle bleeding.
 Luteal phase
The luteal phase of ovarian cycle corresponds to the secretory phase of
the uterine cycle.
During the luteal phase corpus luteum formates in ovary .
Corpus luteum produces large amount of progesterone.
Under the influence of progesterone, the endometrium prepares for
potential implantation of an embryo.
If implantation does not occurs, corpus luteum degenerates causing
sharp drop in level of progesterone.
Falling level of progesterone triggers a menstruation.
 Ovarian cycle
The length of follicular phase often varies from cycle to cycle.
The length of luteal phase is relatively constant (131 day).
Progesterone causes a rise in body temperature of half a degree Celsius
The peak of progesterone is in midluteal phase (21 cycle day).
An elevated progesterone level (21-32 nmol/l) confirms ovulation in
that cycle.
Dipsticks based on LH surge can be used to detect ovulation.
 Uterine cycle
The uterine cycle describes mainly changes in the endometrium.
The uterine cycle is divided into:
menstruation
proliferative phase
secretory phase
 Uterine cycle
Menstruation (also called menstrual bleeding, menses, or a period) is
the first phase of the uterine cycle.
The flow of menses normally serves as a sign that a woman has not
become pregnant.
The length of menstrual cycle in days is counted starting from the first
day of menstrual bleeding.
The length of regular menstrual cycle varies among women (from 25 to
35 days), with 28 days as the average length.
Normal menstrual bleeding lasts usually 3 - 7 days.
The average blood loss during menstruation is 30-40 ml.
 Proliferative phase

The proliferative phase is the second phase of the uterine cycle when
estrogens cause growth (proliferation) of endometrium.
The estrogens also stimulate crypts in the cervix to produce fertile
cervical mucus.
 Secretory phase
The secretory phase of the uterine cycle corresponds to the luteal
phase of the ovarian cycle.
During the secretory phase under action of progesterone endometrium
becomes secretory and receptive to possible implantation .
Progesterone reduces the contractility of the smooth muscle in the
uterus (myometrium).
Menstrual cycle
 Menarche
The average age of menarche (first menstruation) is 12–13 years
(considered normal between ages 8 and 16).
Factors such as heredity, diet and overall health can accelerate or delay
menarche.
Menarche is followed by 5-7 years period during which the menstrual
cycles become regular (ovulatory).
 Menstrual cycle
A woman who experiences variations of less than 10 days between her
longest cycles and shortest cycles is considered to have regular
menstrual cycles.
Irregular menstrual cycle (anovulatory) is most common in women
under 20 and over 40 years of age.
The most regular menstrual cycles in women 25-35 years of age.
The variability increases slightly for women 40 to 44 years of age.
 Menopause
The cessation of menstrual cycles at the end of a woman's reproductive
period is termed menopause.
The average age of menopause in women is 52 years (range 45-55
years).
Menopause before age 40 is considered premature.
The age of menopause is largely genetically determinated, but some
factors (surgery, medical treatment) may cause menopause to occur
earlier.
 Family planning
Family planning is the planning to have children and the use of
contraception and other techniques to implement such plan.
Family planning allows people to attain their desired number of
children and determine the intervals between pregnancies.
Family planning is achieved through the use of contraceptive methods
and the treatment of infertility.
 Family planning
Natural Methods
• Periodic abstinence
• Withdrawal
• Lactational amenorrhea
Barrier Methods
Hormonal contraception
Intrauterine devices
Surgical contraception
Periodic abstinence
 Lactational amenorrhea
Breastfeeding causes negative feedback on pulse secretion GnRH.
Breastfeeding women may experience complete suppression of
follicular development, follicular development but no ovulation, or
normal menstrual cycles may resume.
Suppression of ovulation is more likely when suckling occurs more
frequently.
The production of prolactin in response to suckling is important to
maintaining lactational amenorrhea.
Women who are fully breastfeeding return to menstruation at 2-14
months postpartum.
 Barrier methods of contraception

Physical barrier methods (male and female condoms, diaphragm,

cervical caps) prevent pregnancy by blocking the entry of sperm into
the upper genital tract.

Chemical barrier methods (spermicides) kill or inactivate sperm on

contact.
 Female condoms
Female condoms contains 2 flexible rings.
The ring at the closed end of the sheath
serves as an insertion mechanism and
internal anchor that is placed inside the
vagina.
Prevents passage of sperm
and infections into the vagina
(protection against STDs).

Can be inserted up to 8 hours

prior to intercourse; can remain in
place up to 8 hours.
 Diaphragm
The diaphragm is a shallow latex cup with a spring mechanism in its rim
to hold it in place in the vagina.
Prevents pregnancy by acting as a barrier to the passage of semen into
the cervix.
Provides effective contraception for 6 hours.
After intercourse, the diaphragm must be left in place for at least 6
hours.
Failure rate is estimated to be 20%.
 Cervical cap
Cervical cup is a shaped latex device that fits over the base of the cervix.
The cap must be filled one third full with spermicide prior to insertion.
Inserted 8 hours before coitus and can be left in place for as long as 48 hours.
Acts as both mechanical barrier to sperm and as a chemical agent with the use of
spermicide .
Pregnancy rates range between 4 and 36 per 100 women per year.
Effectiveness depends on the parity of women due to the shape of the cervical os.
Disadvantages: cervical erosions and vaginal spotting, requires professional fitting
and training for use, high failure rate, candidates must have a history of normal
results of pap smears.
 Spermicides
Spermicides consist of a base combined with either nonoxynol-9 or
octoxynol.
Spermicides destroys the sperm cell membrane.
Available forms: vaginal foams, suppositories, jellies, films, foaming
tablets, creams.
Failure rate is about 26% within the 1st year of use.
Disadvantages: high failure rate, no protection against STDs, risk of
vaginal irritation and allergic reaction.
 Hormonal contraception
Oral hormonal contraceptives
Dermal patches
Injections
Vaginal ring
Implants
 Hormonal contraception

Oral hormonal contraceptives

• Combined oral contraceptive pills (contains ethinylestradiol and progestogen)
• Progestogen only pills (minipills)

Transdermal patch contains ethinylestradiol and progestogen (norelgestromin).

Implants contains progestogen (etonorgestrel).
Injectables contains depo medroxyprogesteron acetate (DMPA)
 Vaginal ring
Contains ethinylestradiol and etonogestrel.
Placement in vagina for 21 days.
Hormones are absorbed though
vaginal epithelium.
 Side effects of hormonal contraception
Mostly caused by estrogen:
• hepatic and gall baldder diseases
• DVT
• myocardial infarction
• stroke
• neoplastic effect
 Side effects of hormonal contraception
Mostly caused by progestin:
• nausea
• breast tenderness
• fluid retention
• depression
• headache
• acne
 Emergency contraception
Indications: unprotected intercourse, failure of condom.
Usage within 72 hours after unprotected intercourse.
Contains levonorgestrel or combined oral contraceptive pills.
Prevention of 75% unplanned pregnancies.

Copper IUD Emergency Contraception (within 5 days after unprotected

intercourse).
 Intrauterine devices (IUD)
IUD most widely used method of reversible birth control.
Copper IUD (T-form)
Progestogen releasing intrauterine system (LNG-IUD)

Mechanism of action LNG-IUD:

inhibition of ovulation
change of cervical mucus
endometrial thinning (inhibits implantation of embryos).
 IUD contraindications
Pregnancy
Puerperal sepsis
Undiagnosed abnormal vaginal bleeding
Suspected gynecological malignancy (cervical cancer, endometrial
cancer)
Current STDs
Current PID
Anatomical abnormalities
 Surgical contraception

Sterilization is permenant highly effective method of contraception.

Female sterilization (tubal ligation)
Male serilization (vasectomy)

Sterilization generally chosen by relatively older couple who are sure

that they completed family planning .
Also individuals who carry a genetic disorder may choose sterilization.
 Tubal ligation
Tubal ligation involve mechanically blockage of both fallopian tubes to
prevent the sperm reaching and fertilizing the oocyte.

Tubal ligation generaly is

performed by laparoscopy.

Failure rate 0.5%

 Tubal ligation
Advantages:
• intended to be permanent
• highly effective
• safe
• quick recovery
• lack of significant long-term side effects
• cost effective
 Tubal ligation
Disadvantages:
• possibility of patient regret;
• difficult to reverse;
• future pregnancy could require assisted reproductive technology
(such as IVF);
• more expensive than vasectomy;
• ectopic pregnancy can be a late complication.
 Vasectomy
Vasectomy involves division of the vas deferens on each side to prevent
the release of sperm during ejaculation.

Usually done under local anesthesia.

Failure rate: 0.1%.

 Vasectomy
Advantages:
• permanent
• highly effective
• safe
• quick recovery
• lack of significant long-term side effects
• cost effective; less expensive than tubal ligation
Disadvantages:
• reversal is difficult, expensive, often unsuccessful