Understanding Menstruation Cycle.

Front 1

definition of menstruation cycle

Back 1

visible manifestation of cyclic physiologic uterine bleeding due to shedding of endometrium.

Front 2

layers of uterus.

Back 2

Endometrium, myometrium, parametrium, perimetrium.

Front 3

zones of endometrium.

Back 3

basal zone.
functional zone.

Front 4

characteristics of basal zone.

Back 4

~1/3 of total depth of endometrium.
~supplied by basal arteries.
~in contact to myometrium.
~components: stromal cell, base part of endometrial glands.
~uninfluenced by hormones.
~regeneration starts here.

Front 5

characteristics of functional zone.

Back 5

~component: endometrial glands.
~influenced by hormones.
~changes occur on this layer in 4 different stages during menstruation cycle: regeneration, proliferation, secretory, menstruation stage.

Front 6

type of epithelium lining endometrium. type of gland.

Back 6

simple columnar epithelium.
+ simple tubular glands.

Front 7

definition of menarche.

Back 7

the first occurence of menstruation.

Front 8

age of menarche.

Back 8

11-15 years.

Front 9

length of menstruation cycle.

Back 9

21-35 days.
mean: 28 days.

Front 10

days of menstruation.

Back 10

3-7 days.

Front 11

amount of blood loss.

Back 11

20-80ml.
mean: 50ml

Front 12

content of mensruation discharge.

Back 12

blood.
mucous.
fragments of endometrial cells.
epithelial cells of vagina (dutta).
prostaglandin.
enzyme (fibrinolysin).

Front 13

blood supply of uterus.

Back 13

ovarian arteries, uterine arteries.
vasculatature:
oa, ua->arcuate aa->radial aa->basal aa, spiral aa.

Front 14

menstruation axis.

Back 14

hypothalamo-pituitary-ovarian axis.

Front 15

primordial follicle consist of:

Back 15

oocyte.
single layer, flattened granulosa cell.

Front 16

factor that inhibit mitosis of primordial follicle.

Back 16

OMI (oocyte maturation inhibitor).

Front 17

transformation of primary oocyte to secondary oocyte. process.

Back 17

in attendance of midcycle LH surge,
primary oocyte->1st meiotic->secondary oocyte + polar body.

transformation occur near ovulation.

formation of secondary oocyte occur with full maturation of graafian follicle, which occur near ovulation.

after 1ry oocyte transformed into 2ry oocyte, 2nd meiotic takes place but 2ry oocyte stop dividing at metaphase and will continue only after fertilization.

Front 18

difference between secondary oocyte and polar body.

Back 18

size: polar body smaller.

cytoplasm: scanty in polar body.

#both are haploid. (23,x)

Front 19

what is antrum?

Back 19

fluid-filled follicular cavity.

Front 20

events in ovarian cycle.

Back 20

~recruitment of groups of follicles.
~selection of dominant follicle and its maturation.
~ovulation.
~corpus luteum formation.
~death of corpus luteum.

Front 21

selection of dominant follicle is influenced by:

Back 21

FSH.

Follicle-stimulating hormone (FSH) is a hormone found in humans and other animals. It is synthesized and secreted by gonadotrophs of the anterior pituitary gland. FSH regulates the development, growth, pubertal maturation, and reproductive processes of the body. FSH and Luteinizing hormone (LH) act synergistically in reproduction.

Front 22

dominant follicle profile.

Back 22

~appear within day 5th-7th.
~highest antral concentration of estrogen.
~granulosa cell contain higher FSH receptors.

~enlargement of granulosa cells with lipid inclusion.
~FSH induce LH receptors formation on granulosa cell.

~formation of cumulus oophorus, corona radiata.

~follicular fluid increased amount. it content estrogen, FSH, trace amount of androgen, prolactin, OMI, LI (luteinization inhibitor).

Front 23

importance of LH receptor induction by FSH.

Back 23

midcycle LH surge to induce ovulation, luteinization of granulosa cells to form corpus luteum, secretion of progesterone.

Front 24

luteinizing hormone.

Back 24

Luteinizing hormone (LH, also known as lutropin) is a hormone produced by the anterior pituitary gland.

In females, an acute rise of LH called the LH surge triggers ovulation and development of the corpus luteum. In males, where LH had also been called interstitial cell-stimulating hormone (ICSH), it stimulates Leydig cell production of testosterone. It acts synergistically with FSH.

Front 25

Luteinization.

Back 25

the formation of the corpus luteum from an ovarian follicle that has recently discharged an ovum. The process involves the hypertrophy of the follicular lutein cells and the development of blood vessels and connective tissue at the site.

Front 26

Mature graafian follicle profile.

Back 26

~about 20mm.
~theca ex->theca in->membrana granulosa->granulosa cell layer->cumulus oophorus.

~antrum.

Front 27

definition of ovulation.

Back 27

Ovulation is the process in a female's menstrual cycle by which a mature ovarian follicle ruptures and discharges an ovum (also known as an oocyte, female gamete, or casually, an egg). Ovulation also occurs in the estrous cycle of other female mammals, which differs in many fundamental ways from the menstrual cycle. The time immediately surrounding ovulation is referred to as the ovulatory phase or the periovulatory period.

Front 28

process in ovulation.

Back 28

dominant follicle reach the surface of ovary.

cumulus is detached from wall, causing the ovum with its corona radiata floats freely in the follicular fluid.

thinning of the follicular wall which draws nearer to the ovarian wall.

stigma (conical projection) penetrates the ovarian wall, releasing the ovum. (by oozing process, for 1-2 minutes)

stigma is closed by plug of plasma.

Front 29

causes of ovulation.

Back 29

Endocrinology cause.

stretching factor.

contraction of micro muscle in theca externa and ovular stroma due to increased local prostaglandin secretion.

Front 30

endocrinology cause of ovulation.

Back 30

LH surge.
~in late follicular stage, there is sustained peak level of estrogen. this result in LH surge from anterior pituitary.

~LH surge stimulates completion of reduction division of oocyte, and initiate luteinization of granulosa cells, synthesis of progesterone and prostaglandin.

FSH rise.
~FSH surge->increase in plasminogen activator->plasminogen->plasmin->help lysis of follicular wall.

Front 31

combination effects of LH and FSH.

Back 31

final stage of maturation.

rupture of follicle.

expulsion of oocyte.

Front 32

is menstruation related to ovulation?

Back 32

NO!

Front 33

post ovulation effects.

Back 33

follicle changed into corpus luteum.

ovum is picked up by fimbriae of fallopian tube.

Front 34

life cycle of corpus luteum.

Back 34

1. Proliferation.
2. Vascularisation.
3. Maturation.
4. Regression.

Front 35

proliferation cycle of corpus luteum.

Back 35

collapsed wall of empty follicle is twisted.

cells become larger, polyhedral, with pale vesicular nuclei and frothy cytoplasm. its called granulosa lutein cells.

color of corpus luteum at this stage is greyish yellow due to presence of lipid.

the opening through which ovum escaped is plugged with fibrin.

granulosa cells undergo hyperthrophy without multiplication.

Front 36

vascularisation cycle of corpus luteum.

Back 36

in 24 hours of rupture of follicle, small capillaries grow into granulosa layer towards lumen.

this sprouting vessels may rupture and bleed in the cavity.

Front 37

maturation cycle of corpus luteum.

Back 37

by 4th day usually luteal cell attained maximum size.

hypertrophy of theca interna cells.

k cells=lutein cells which greatly enlarged and invade granulosa layer.

yellow color due to pigment carotene.

Front 38

regression cycle of corpus luteum.

Back 38

22/23rd day of ovarian cycle, retroregression starts.

vacuolation in cells.
deposition of fat in lutein cells and appearance of hyaline tissue between them.
lutein cells atrophied.
corpus luteum become corpus albicans.

regression of corpus luteum is due to withdrawal of tonic LH support.

if during this stage fertilization occur, regression wont occur, instead it will turn into corpus luteum of pregnancy.

Front 39

pregnancy corpus luteum.

Back 39

The corpus luteum produces progesterone.
Progesterone makes the lining of the uterus thick for implantation and is necessary to sustain a healthy pregnancy.
The corpus luteum produces progesterone until the placenta begins to take over progesterone production around ten weeks gestation.

Front 40

survival of corpus luteum.

Back 40

After a woman ovulates, the corpus luteum only lasts for about 12-14 days unless it begins receiving HCG (human chorionic gonadotropin) from a developing embryo.

If the egg is not fertilized, the corpus luteum dies and progesterone production stops.

When progesterone levels drop, the uterus lining stops thickening and is consequently shed during menstruation.

If the egg is fertilized, the corpus luteum will begin receiving HCG from the embryo. HCG tells the corpus luteum to keep producing progesterone.

Front 41

luteal-placental shift.

Back 41

turn over of function from corpus luteum of pregnancy to placenta (secretion of progesterone).

Front 42

hormonal regulation during menstrual cycle.

Back 42

1) regular, pulsatile secretion by the hypothalamus of luteinizing hormone-releasing hormone (LH-RH), which, in turn, liberates follicle stimulating hormone (FSH) and luteinizing hormone (LH);

2) the FSH makes possible the ovarian action of LH, which, in turn, permits the synthesis of estradiol (by the follicle);

3) negative feedback of estradiol and inhibin on the hypophysis cerebri;

4) ovulation is caused by a peak level of LH, but is dependent on progesterone levels;

5) synthesis of progesterone by the corpus luteum;

6) negative biofeedback of progesterone at the hypothalamic level; and

7) at the endometrial level increase in the number of estradiol receptors during the follicular phase and decrease of cytoplasmatic progesterone receptors during the luteal phase.

The discovery of the mechanism of the menstrual cycle has helped women with hypothalamic disorders by using a pump releasing LH-RH in a pulsatile fashion.

Front 43

3 phases of uterine-endometrial cycle.

Back 43

follicular phase/ proliferative stage

luteal phase/ secretory

menstruation.

#regeneration.

Front 44

regeneration stage.

Back 44

starts even before the menstruation stop.

completion of this stage 2/3 days after mens stop.

cubical surface epithelium derived from lumina of gland and stromal cells.

new blood vessels grow from stump of old one.

gland regenerated from remnant in basal zone. glands are lined by cubical epithelium, lie parallel to the surface.

thickness average 2mm.

Front 45

proliferation stage.

Back 45

day 5th/6th-14th.(till ovulation)

due to increase of ovarian estrogen.

proliferation of all elements. at first slowly then rapidly.

gland become tubular and lie perpendicular to surface.

epithelium become columnar with nuclei placed at the base.

thickness 3-4mm.

Front 46

secretory stage.

Back 46

changes in this stage are due to combined effect of estrogen and progesterone liberated from corpus luteum after ovulation.

endometrium contain receptors for progesterone which are induced by estrogen.

*progesterone can only act on endometrium previously primed by estrogen.

Front 47

changes before menstruation stage start.

Back 47

surface epithelium. more columnar, ciliated at places.

gland. increase size,lining epithelium become taller.

subnuclear vacuolation. appearance of vacuole due to secretion of glycogen between nuclei and basement membrane, this is earliest evidence of ovulation.

gland. change into corkscrew shaped,

blood vessels. spiralling.

stromal cells. swollen, large, polyhedral.

thickness of endometrium reach 5-6mm. endometrial growth stop 5/6 days before menstruation (in infertile cycle).

Regressive changes in endometrium pronounced 24/48 hours before menstruation.

marked spiralling of aa. marked withdrawal of estrogen and progesterone cause intense SPASM of spiral aa at basal part.
this lead to stasis and tissue anoxaemia. also evidence of leukocytes and monocytes infiltration in stroma.

Front 48

menstruation stage.

Back 48

shedding off of endometrium.
regressive changes continues.

Front 49

mechanism of mesntrual bleeding.

Back 49

spasm of vessels.
this cause stasis of blood, anoxaemia, and lead to damage of arteriole walls. after spasm, relaxation of vessels causins the blood to leak out through the damage wall.

proteolytic enzyme.
released from breakdown of lysosome.

reason of bleeding: broken arteries, broken veins, hematoma in stroma.

blood is shed into uterine cavity together with superficial functional layer.

coagulation of blood occur in case: very fast and rapid bleeding. usually no coagulation due to action of liquify by plasmin.

Front 50

stop of menstrual flow mechanism.

Back 50

prolonged vasoconstriction.

myometrial contraction.

local aggretation of platelets with deposition of fibrin around them.

potent vasoconstriction which present in endometrium: endothelin, platelet activating factor.

starting of estrogen secretion lead to clot formation over decapitated stumps of endometrial vessels.

Front 51

what is dysfunctional uterine bleeding?

Back 51

Dysfunctional Uterine Bleeding (DUB) is abnormal genital tract bleeding based in the uterus and found in the absence of demonstrable structural or organic pathology.

usually due to hormonal disturbances. AGE: extrmes of reproductive life i.e at puberty and menopause.

Diagnosis must be made by exclusion, since organic pathology must first be ruled out.

Front 52

classification of dysfunctional uterine bleeding.

Back 52

It can be classified as ovulatory or anovulatory, depending on whether ovulation is occurring or not

Front 53

ovulatory dysfuntional uterine bleeding.

Back 53

10% of cases occur in women who are ovulating, but progesterone secretion is prolonged because estrogen levels are low. This causes irregular shedding of the uterine lining and break-through bleeding. Some evidence has associated Ovulatory DUB with more fragile blood vessels in the uterus.

It may represent a possible endocrine dysfunction, resulting in menorrhagia or metrorrhagia. Mid-cycle bleeding may indicate a transient estrogen decline, while late-cycle bleeding may indicate progesterone deficiency.

Front 54

anovulatory DUB.

Back 54

About 90% of DUB events occur when ovulation is not occurring (Anovulatory DUB). Anovulatory menstrual cycles are common at the extremes of reproductive age, such as early puberty and perimenopause (period around menopause).

In such cases, women do not properly develop and release a mature egg. When this happens, the corpus luteum, which is a mound of tissue that produces progesterone, does not form.

As a result, estrogen is produced continuously, causing an overgrowth of the uterus lining.

The period is delayed in such cases, and when it occurs menstruation can be very heavy and prolonged. Sometimes anovulatory DUB is due to a delay in the full maturation of the reproductive system in teenagers.

Usually, however, the mechanisms are unknown.

The etiology can be psychological stress, weight (obesity, anorexia, or a rapid change), exercise, endocrinopathy, neoplasm, drugs, or it may be otherwise idiopathic.

Assessment of anovulatory DUB should always start with a good medical history and physical exa

Front 55

management of DUB

Back 55

progesterone.

Front 56

menstrual symptoms

Back 56

bleeding per vaginam.

colicky pain at beginning due to uterine contraction.

dysmenorrhoea.

premonitory symptoms: pelvic discomfort, backache, fullness of breasts, mastalgia,

Pre-menstrual syndrome is a condition when the pre-monitory symptoms are predominant.