Sei sulla pagina 1di 23

THE MENSTRUAL CYCLE

DR. UTOO, B. TERKIMBI


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

1 UTOO BT 14/10/2014
OUTLINE
 Introduction
 Embryology
 Ovarian cycle
 Endometrial cycle
 Mechanism of menstrual
bleeding
 Menstrual symptoms
UTOO BT
 Conclusion
2 14/10/2014
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.
3 UTOO BT 14/10/2014
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.
4 UTOO BT 14/10/2014
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,
5 enzymes
UTOO BT and bacteria. 14/10/2014
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


6 UTOO BT 14/10/2014
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).
7 UTOO BT 14/10/2014
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.


8 UTOO BT 14/10/2014
Morphology of the oocyte

9 UTOO BT 14/10/2014
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.

10 UTOO BT 14/10/2014
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.
11 UTOO BT 14/10/2014
Selection & maturation of
DF

12 UTOO BT 14/10/2014
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.
13 UTOO BT 14/10/2014
A mature graafian follicle

14 UTOO BT 14/10/2014
Hormonal interplay in
normal ovulatory cycle

15 UTOO BT 14/10/2014
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.

16 UTOO BT 14/10/2014
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.

17 UTOO BT 14/10/2014
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.

18 UTOO BT 14/10/2014
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


19
cavity
UTOO BT 14/10/2014
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.

20 UTOO BT 14/10/2014
Menstrual symptoms

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

21 UTOO BT 14/10/2014
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.

22 UTOO BT 14/10/2014
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.

23 UTOO BT 14/10/2014