Menstruation

Episodic uterine bleeding in response to cyclic hormonal changes

Brings an ovum to maturity and renews uterine tissue bed Process that allows for conception and implantation
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Characteristics of Normal Menstrual Cycles

Beginning (menarche) average of onset 12 -13 yrs; average range 9 -17 years
Interval between cycles Average 28 days; cycles of 23 35 days not unusual Duration of menstrual flow ( menses ) Average flow 4-6 days ,may have short periods as 2days,long periods as 7 days; ranges 1-9 days not abnormal
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Characteristics of Normal Menstrual Cycles

Amount of menstrual flow difficult to estimate;
average 30-80 ml Color of menstrual flow dark red; combination of blood, mucus and endometrial cells Odor- similar to that of marigolds

HORMONES
1. Estrogen - female secondary sexual characteristics, such as breast development, increased adipose tissue deposition, and increased vascularization of the skin, widening and lightening of pelvis 2. Progesterone - triggers uterine changes during the menstrual cycle
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4 Body Structures involved in Physiology of Menstrual Cycle Hypothalamus, Pituitary gland, Ovaries, Uterus 1. Hypothalamus- release GnRH ( luteinizing hormone-releasing hormone or LHRH) initiates the menstrual cycle. transmitted to anterior pituitary glandsignals the gland to produce gonadotropic hormones 1. FSH, 2.LH (GnRH is cyclic thus menstrual periods is also cyclic.

4 Body Structures involved in Physiology of Menstrual Cycle cont.

2. Pituitary gland under the influence of GnRH, ant
pituitary gland ( adenohypophysis) produces 2 hormones That act on ovaries 1. FSH, 2, LH a. FSH- follicle stimulating hormone- resp maturation of Ovum -active early of the cycle a. LH -Luteinizing Hormone resp for ovulation, release of mature egg cells, growth of the uterine lining midpoint of the cycle

4 Body Structures involved in Physiology of Menstrual Cycle cont.

3. Ovaries one primodial follicle (every month) activated by the FSH to begin to grow and maturecells produce a clear fluid ( follicular fluid ) contains degree of estrogen ( estradiol ) and some progesteronefollicle reaches its maximum size, propelled towards the surface of the ovarystage of maturation, small ovum and surrounding follicle membrane and fluid becomes Graafian follicle. 4. Uterus uterine changes occurs every month as a result of stimulation from the hormones produced by ovaries.

3. Ovaries
Day 14 before the end of menstrual cycle, ovum divided by mitotic div 2 separete bodies 1. primary oocyte ( contains the bulk of the cytoplasm, 2. secondary oocyte ( contains so little of cytoplasm.meitotic div reducing the number of chromosomes to haploid number of 23. LH from the pituitary, prostaglandinsreleasedGraafian follicle ruptures ovum is set free ( process of Ovulation ) swept into the open end of the fallopian tube

3. Ovaries
after the ovum and the follicular fluid have been discharged in the ovary, the cell of the follicle remain hollow, empty pit FSH has done its work and in amt. LH cont to I amt acts on the follicle cells in the ovaryinfluences cell to produce lutein ( bright yellow fld ) = progesterone. fluid fills the empty follicle ( Corpus luteum or yellow body ) If conception occurs, ovum proceeds down a fallopian tube implants on the endometrium of the uterus

Corpus luteum remains troughout the pregnancy ( approx 16 to 20 weeks ) If conception does not occur, unfertilized ovum atrophies after 4 to 5 days and corpus luteum ( false corpus luteum ) remains only 8 to 10 days Corpus luteum regresses replaced by white fibrous tissue ( corpus albicans ) or white body.

Uterine cycle
4 phases 1.Proliferative phase 2.Secretory phase 3. Ischemic Phase

4. Menses
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Proliferative Phase
Immediately after a menstrual flow- day 4-5 Endometrium, or lining of the uterus is very thin Ovary begins to produce estrogen (FSH) endometrium begins to proliferate Growth is very rapid and increases the thickness of the endometrium (this increase continuous for the first half of menstrual cycle
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Secretory Phase
After the ovulation, the formation of progesterone in the Corpus luteum causes the glands of the uterine endometrium to become corkscrew or twisted appearance and dilated with quantities of glycogen and mucin. Day 15- day 28 Capilliaries of Endometrium increase in amount Uterus is prepared for implantation

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Ischemic Phase
If fertilization does not occur , the corpus luteum in the ovary begins to regress after 8 to 10 days, as it regresses, progesterone and estrogen decreases. Endometrium begins to degenerate ( approx 24 or 25 day ) Capillaries rupture, with minute hemorrhages and the endometrium sloughs off.

Menstrual Phase
Menses menstrual flow Composed of: blood from the rupture capilliaries,mucin from the gonads,fragments of the endometrial tissues,microscopic, atropied, and unfertilized ovum Day 1- day 5 First day of bleeding is the first day of cycle Around 60 ml average

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Ovarian cycle
3 phases

1. Pre-ovulatory : follicular phase

2. Ovulatory phase

3. Post-ovulatory : Luteal phase

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Ovarian Cycle; preovulatory/follicular

Variable in length: day 6- day 13 Dominant follicle matures and becomes graafian follicle with primary oocyte FSH increases initially then decreases because of estrogen increase

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Ovarian cycle: Ovulatory phase

Day 14 Rupture of the graafian follicle releasing the secondary oocyte Due to the LH surge

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OVARIAN cycle:
Post-ovulatory: luteal phase
Day 15- day 28

MOST CONSTANT 14 days after ovulation

Corpus luteum secretes Progesterone

If no fertilization, corpus luteum will become corpus

albicans then degenerate Decreased estrogen and progesterone production

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MARY LOURDES NACEL G. CELESTE, RN, MD

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Hormonal cycle
1. Menstrual phase Decreased Estrogen, decreased progesterone, decreased FSH and decreased LH

2. Proliferative/Pre-ovulatory phase

Increased FSH and Estrogen in small amounts

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3. Ovulatory phase Increased LH (surge); Increased Estrogen

4. Post ovulatory/luteal Phase Increased Estrogen, increased progesterone until corpus luteum degenerates

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MARY LOURDES NACEL G. CELESTE, RN, MD

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Education

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Menopause
Cessation of menstruation for at least one year occurring

at the age of 40-55 due to cessation of ovarian function.

Mean age of 51.3 Decreased estrogen and progesterone Genetically determined May occur earlier in smokers, nulliparous and patients who underwent hysterectomy
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Menopause cont.
Change of life Role change psychological stress Ovaries begin to atrophy, reducing estrogen = hot flashes, vaginal dryness or osteoporosis, urinari incontinence Hormonal Replacement (HR) decrease menopausal symptoms

Concerns
1. Loss of childbearing capacity 2. Loss of youth 3. Skin changes-related to estrogen deficiency that has a role in collagen storage and restoration 4. Depression-related to changes in relationship w/ children, spouse and other life events 5. Anxiety and irritability climacteric syndrome; psychocial 6. Loss of libido- related to vaginal atrophy secondary to decreased estrogen

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7. Abnormal bleeding irregular, heavy or prolonged related to to anovulatory cycles * rule out pregnancy, malignancies and polyps

8. Hot flashes/flushes recurrent, transient flushing, sweating,

palpitations, anxiety, chills 9. Urinary symptoms dysuria, urgency and recurrent UTI 10. Difficulty in concentration and short term memory loss 11. Cardiovascular disease

12. Osteoporosis

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TARGET ORGAN RESPONSE TO DECREASED ESTROGEN:

VAGINA - becomes smaller and the size of the upper vagina diminishes - epithelium becomes pale, thin, and dry - labia minora has a pale , dry appearance; reduction in fat content of labia majora

UTERUS - endometrial tissue become sparse, with numerous small petecchial hemorrhages, has atrophic appearance - myometrium atrophies, uterus decreases in size

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 Breast - general loss of turgor, form, fullness of the breast Bones - gradual loss of calcium, lading to osteoporosis, characterized by reduction in bone density and fracture

Hair
- with the loss of estrogen, there is relative decrease in

circulating androgens; increase quantity of hair with male

pattern distribution
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Sequelae of reduced estrogen:

A. vasomotor symptoms: - Hot flash/ flush, is the hallmark of the menopausal woman - last for a few seconds or several minutes - more frequent and severe at night or during time of stress

- coincides with a surge of luteinizing hormones

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 Altered menstrual function: Oligomenorrhea followed by amenorrhea Amenorrhea for 6 to 12 months If vaginal bleeding occurs after 12 months of amenorrhea, endometrial biopsy must be ruled out Osteoporosis: Main health hazard associated with menopause

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Menopausal syndrome: Such as fatigue, headache, nervousness, loss of libido, insomia, depression, irritability, palpitation, muscle pain

Atrophic changes:
- atrophy of the vaginal mucosa leads to atrophic vaginitis, pruritus of vulvovaginal area, dyspareunia and stenosis

- urethral changes
- increased frequency of cystitis - vaginal, urethral and bladder symptoms

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Treatment:
Estrogen replacement therapy
Advantages:

Eliminate hot flashes Reversal of atrophic vaginitis, dyspareunia, affective symptoms Prevention and treatment of osteoporosis

Prevention of cardiovascular disease

Retention of youthful skin
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 disadvantages:

Can cause acute liver disease Acute vascular thrombosis Seizure disorder Hypertension Migraine headache Breast cancer

Endometrial cancer

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Menstrual cycle irregularities

Oligomenorrhea infrequent, irregular bleeding at intervals > 35 days Polymenorrhea frequent, regular bleeding at intervals < 21 days Amenorrhea cessation of menses x 6 months Menorrhagia regular bleeding that is excessive in amount and duration > 5 days Metrorrhagia irregular bleeding Menometrorrhagia excessive prolonged bleeding at irregular intervals

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