THE MENSTRUAL CYCLE

DR. UTOO, B. TERKIMBI

(MB, BCh; FWACS, FMCOG)
Lecturer/Consultant Obstetrician &
Gynaecological Surgeon
Obstetrics/Gynaecology Department
CHS,BSU /BSUTH, MAKURDI.

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 OUTLINE
 Introduction
 Embryology
 Ovarian cycle
 Endometrial cycle
 Mechanism of menstrual
bleeding
 Menstrual symptoms
UTOO BT
 Conclusion
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 INTRODUCTION
.
 Menstruation- It is the visible
manifestation of cyclical physiological
uterine bleeding due to shedding of the
endometrium.

 This follows invisible interplay of

hormones mainly through the
hypothalamo-pituitary-ovarian axis.
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 Introduction cont.
• Menarche-11-15 years; mean=13years.
• The period extending from the
beginning of a period to the beginning of
the next one is called menstrual cycle.
• Menstrual cycles occur between
menarche and menopause.
• Mean age of menopause is 51 years.
• Cycle length-21 to 35 days, mean=28
days.
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 Introduction cont.
 The cycle is usually irregular just after
menarche and one or two years before
menopause.
 Duration of menstruation- 2 to 7 days.
 Amount of blood loss – 20 to 80 mls
AV.=35mls.
 Menstrual discharge consist of; Dark
altered blood, mucus, vaginal epithelial
cells, fragments of endometrium, PGs,
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 Introduction cont.
 The length of the menstrual cycle varies
considerably among women and does not
remain constant in the same individual.

 Emotional disturbances such as fear, chronic

debilitating disease, abrupt changes in climate
and other environmental factors could cause
menstrual irregularity.

 Menstrual cycle is divided into two phases

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 EMBRYOLOGY
• Germ Cells
• Migrates from endoderm of the york sac in the
region of the hindgut into the genital ridge.
Telopheron directs this migration which is by
amoeboid activity or chemotactic mechanism.
• The germ cells undergo rapid mitotic division and
by 20 weeks the number reaches 7 million.
• Some enter the prophase of the first meiotic
division and are called primary oocytes
• They become surrounded by flat cells from
stroma
( primordial follicles).
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 Embryology cont.
• Primary oocytes are arrested in the diplotene stage of
prophase of first meiotic division, until ovulation.

• Prophase; Leptotene,Zygotene,Pachytene and

Diplotene).

• At 20 weeks intrauterine life – 7million oocytes.

• At birth- 2million.

• At puberty-400,000.

• Only 400 ovulates during entire reproductive period.

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 Morphology of the oocyte

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 Ovarian Cycle
• Development/maturation of a follicle
• Ovulation
• Formation of corpus luteum/degeneration.
• The entire process last for about 4 weeks.

Recruitment (pre antral phase)

• Takes 85 days and spread over 3 ovarian cycles
• About 20 antral follicles(5-10/0vary) devevelop in
each cycle. This is controlled by FSH.

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 Ovarian cycle cont.
Selection of a dominant follicle and its maturation

• DF appear 5-7 days of the cycle.

• Its selection is determine by high E2, low

androgen: E2
ratio, maximum FSH receptors.

• The FSH induces LH receptors on the granulosa

cells of DF. This leads to LH surge in mid cycle
with consequent ovulation, luteinisation and
secretion of P4.
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 Selection & maturation of
DF

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 Ovarian cycle cont.
Ovulation
• The mature follicle which measures 20mm, just
prior to ovulation reaches the surface of the
ovary.
• The cumulus detached from the wall so that the
ovum floats. This eventually escape through a
stigma near the surface of the ovary.
• This is made possible by LH surge, FSH rise
→plasminogen activator → plasminogen
→plasmin→ help lysis of the wall of the follicle.
• A secondary oocyte in 2nd meiotic division
arrested at metaphase is released.
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 A mature graafian follicle

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 Hormonal interplay in
normal ovulatory cycle

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 Ovarian cycle cont.
Corpus luteum formation/degeneration
• Proliferation(immediate)
• Vascularization(24 hours)
• Maturation(7-8days)
• Regression(22-23 days)
• If pregnancy occurs, between 23-28 days
hyperplasia occur due to chorionic gonadotropin .
• The growth peaks at 8th week. Regression occurs
due to low levels of hCG most frequently at 6
months.

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 Endometrial Cycle

 The endometrium is the lining epithelium of the

uterine cavity above the level of the internal
cervical os.

 It consist of surface epithelium, glands, stromal

and blood vessels.

 Two distinct divisions exist-This are; basal

zone(stratum basalis), superficial functional zone.

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 Endometrial cycle cont.
 The functional zone is under the influence of
fluctuating cyclic ovarian hormones, E2 and P4.

 The changes in the endometrium during ovulatory

cycles are divided into 4 phases.

 These are;
 Regenerative phase
 Proliferative phase
 Secretory phase
 Menstruation.

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 Mechanism of menstrual
bleeding

 Degenerative changes vascular in origin

 Stasis of blood and spasm of arterioles

 Leakage of blood through damaged vessels

 Auto digestion of functional zone by proteolytic

enzymes

 Blood and superficial layer shed into uterine

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cavity
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 Mechanism cont.
 Blood coagulates but soon liquefies by plasmin

 Menstrual flow stops as a result of myometrial

contraction, vasoconstriction, local aggregation of
platelets, fibrin deposition

 PGF2α(particularly), PGE2 and PGI2 play various

crucial roles.

 Peptides e.g-inhibin, activin and follistatin and

IGF modulate the action of FSH as well as LH.

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 Menstrual symptoms

 Vaginal bleeding
 Lower abdominal pains
 Dysmenorrhea( incapacitating pains)
 Pelvic discomfort, backache
 Fullness of breast or mastalgia
 Headache, depression
 PMS!!!!

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 An ovular menstruation

 Follicular growth without selection of DF

 Rising E2→ GnRH suppression→ anovulation

 Endometrium remains proliferative or hyperplastic

 The fall of E2 results in synchronous shedding of

endometrium and heavy menstruation.

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 CONCLUSION

 Menstruation is the end result of interplay of

hormones through the Hypothalamo-pituitary-
ovarian axis and local PGs leading to
endometrial shedding through a patent outflow
tract.

 It is a physiological process of cyclical changes

involving the ovaries, endometrium, cervix,
vaginal and other parts of the body in general.

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