Pgo - 40: Disorders Of Menstrual Cycle - Diagnostics

Front 1

The normal estimated blood loss

Back 1

Approximately 30 ml

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ovulation - how long after onset of mid-cycle LH surge?

Back 2

34 hrs after

Front 3

regulation of MC

Back 3

Interaction between hypothalamus, pituitary & ovaries

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menopause - when

Back 4

51,4

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menarche - when

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12,7

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hypothalamic role in menstrual cycle

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- The hypothalamus secretes GnRH in a pulsatile fashion
- GnRH activity is first evident at puberty
- Follicular phase GnRH pulses occur hourly
- Luteal phase GnRH pulses occur every 90-180minutes
- Loss of pulsatility down regulation of pituitary receptors >> decreased secretion of gonadotropins
- Release of GnRH is modulated by –ve feedback by:
steroids
gonadotropins
- Release of GnRH is modulated by external neural signals

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MATURATION OF THE FOLLICLE (FOLLICULOGENESIS)
1) Primordial
2) 1ry follicle
2) 2ry follicle
3) tertiary follicle

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1) FSH >> primordial follicle
(oocyte arrested in the diplotene stage of the 1st meiotic division surrounded by a single layer of granulosa cells)

2) 1ry follicle
(oocyte surrounded by a single layer of granulosa cells basement membrane & theca cells)

3) 2ry follicle or preantral follicle
(oocyte surrounded by zona pellucida , several layers of granulosa cells & theca cells)

4) tertiary or antral follicle
2ry follicle accumulate fluid in a cavity “antrum”
oocyte is in eccentric position
surrounded by granulosa cells “cumulous oophorus”

Front 8

selection of dominant follicle

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-Selection of the dominant follicle occurs day 5-7
-It depends on
- the intrinsic capacity of the follicle to
synthesize estrogen
-high est/and ratio in the follicular fluid
-As the follicle mature >> increased estrogen >> decreased FSH “-ve feed back on the pituitary” >> the follicle with the highest No. of FSH receptors will
continue to thrive
- The other follicles “that were recruited” will become atretic

Front 9

FSH actions

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-recruitement
-mitogenic effect >> increased No. of granulosa cells & FSH receptor
-stimulates aromatase activity >> conversion of androgens >> estrogens “estrone & estradiol”
- increased LH receptors

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ESTROGEN - Acts synergistically with FSH to

Back 10

- induce LH receptors
- induce FSH receptors in granulosa & theca cells

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LH leading to hormone production

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LH >> theca cells >> uptake of cholesterol & LDL >> androstenedione & testosterone

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inhibin - role in folliculogenesis

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- Local peptide in the follicular fluid
- -ve feed back on pituitary FSH secreation
- Locally enhances LH-induced androstenedione production

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activin - role in folliculogenesis

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- Found in follicular fluid
- Stimulates FSH induced estrogen production
- increased gonadotropin receptors
- decreased androgen
- No real stimulation of FSH secretion in vivo (bound to protein in serum)

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preovulatory period - negative feedback on the pituitary

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- increased estradiol & inhibin >> -ve feed back on pituitary >> FSH
-This mechanism operating since childhood

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preovulatory period - positive feedback on the pituitary

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- increased estradiol (reaching a threshold concentration: 200 pg/ml, for 48 hrs ) >> +ve feed back on the pituitary (facilitated by low levels of progestrone) >> LH surge >> secretion of progestrone
- Operates after puberty
- +ve feed back on pituitary >> FSH

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LH surge

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- Lasts for 48 hrs
- Ovulation occurs after 34hrs
- Accompanied by rapid fall in estradiol level
- Triggers the resumption of meiosis
- Affects follicular wall >> follicular rupture
- Granulosa cells >> lutenization >> progestrone synthesis

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Mechanism of follicular rupture

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1) increased follicular pressure
- Changes in composition of the antral fluid >> increased colloid osmotic pressure

2) Enzymatic rupture of the follicular wall
- LH & FSH >> granulosa cells >> production of plasminogen activator >> increased plasmin >> increased fibrinolytic activity >> breake down of F. wall
- LH >> increased prostglandin E >> increased plasminogen activator >> increased PG F2α >> increased lysosomes under follicular wall

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formation of corpus luteum

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Vascular capillaries cross the basement membrane & grow into the granulosa cells  availability of LDL-cholestrole
- LH >> increased LDL binding to receptors
>> increased 3α OH steroid dehydrogenase activity
>> increased progestrone

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Progestrone actions in lutheal phase

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- suppress follicular maturation on the ipsilateral ovary
-thermogenic activity >> increased basal body temp
-endometrial maturation

Front 20

Progestrone peak ..... days after ovulation (D..... MC)

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Progestrone peak 8 days after ovulation (D22 MC)

Front 21

Corpus luteum is sustained by .......

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Corpus luteum is sustained by LH

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fate of corpus luteum if there is no fertilization

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It looses its sensitivity to gonadotropins >> luteolysis >> decreased estrogen & progestrone level >> desquamation of the endometrium “menses”

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decrease in estrogen and progesterone at end of luteal phase stimulates

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release of FSH & LH

Front 24

what factor maintains CL if pregnancy occurs

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hCG secreation

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layers of the endometrium

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(1) Basal layer of the enometrium
- Adjacent to the mometrium
- Unresponsive to hormonal stimulation
- Remains intact throughout the menstrual cycle

(2) Functional layer of the endometrium
- Composed of two layers:
-zona compacta >> superficial
-Spongiosum layer

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layers of the Functional layer of the endometrium

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-zona compacta >> superficial
-Spongiosum layer

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endometrial changes during the menstrual cycle

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1) Follicular /proliferative phase
Estrogen >> mitotic activity in the glands & stroma >> increased endometrial thickness from 2 to 8 mm
(from basalis to opposed basalis layer)


2) Luteal /secretory phase
Progesterone >>- Mitotic activity is severely restricted
-Endometrial glands produce then secrete
glycogen rich vacules
-Stromal edema
-Stromal cells enlargement
-Spiral arterioles develop, lengthen & coil

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Just before menses the endometrium is infiltrated with .........

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Just before menses the endometrium is infiltrated with leucocytes

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.................. are maximal in the endometrium just before menses

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Prostaglandins are maximal in the endometrium just before menses

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function of prostaglandins in menses

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constriction of the spiral arterioles >> ischemia & desquamation
Followed by arteriolar relaxation, bleeding & tissue breakdown

Front 31

Classification of causes of abnormal uterine bleeding

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PALM-COEIN
- polyp
- adenomyosis
- leiomyoma
- malignancy & hyperplasia
- coagulopathy
- ovulatory dysfunction
- endometrial
- iatrogenic
- not classified

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classification system for causes of abnormal uterine bleeding in nongravid women of reproductive age

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FIGO

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"chronic" AUB have lasted more than

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3 months

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Hypermenorrhoea

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excessive bleeding in a short time

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dymenorrhea
1) primary
2) secondary

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1) Primary – occurs only in ovulatory cycles
High level of prostaglandines

2) Secondary
Endometriosis
Pelvic inflammatory disease
Congenital abnormalities

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menorrhagia: blood loss greater than ......mL and lasting more than ........days

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blood loss greater than 80 mL and lasting more than 7 days

Front 37

Hypermenorrhoea vs. menorrhagia

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both are excessive bleeding, but menorrhagia lasts much longer