Menstruation physiology

What is menstruation & menstrual cycle?

The female reproductive system undergoes cyclical changes which may be
regarded as periodic preparation for fertilisation and pregnancy. These periodic
changes constitute the menstrual cycle. The periodic vaginal bleeding which
occurs as a result of the shedding of uterine mucosa is referred to as
menstruation.

The length of the cycle can be variable but on an average it is 28 days.

Summary of what exactly causes menstruation:

Every month one of the ovaries releases an ovum (female gamete). The uterus
prepares itself for pregnancy by receiving a thick lining of blood, i.e., the
endometrium. If the ovum doesn’t get fertilised by the sperm within 24 hours, it
gets disintegrated and the uterine lining, i.e., endometrium is then shed which
leads to menstruation.In addition to blood, the menstrual flow contains
disintegrated endometrial tissue, vaginal secretions, cervical mucus, and the
unfertilized egg.

MENSTRUAL CYCLE IN DETAIL:

Ovarian cycle (periodic changes in the ovary)

Right from the time of birth there are various immature follicles called as
primordial follicles are present beneath the ovarian capsule. Each follicle contains
an immature ovum. At the beginning of each cycle, several follicles begin to
enlarge, however only one of the follicles becomes dominant on the 6th day of the
cycle and the rest undergo regression. It is uncertain how one follicle is selected to
be the dominant follicle in this follicular phase of the menstrual cycle, but it seems
to be related to the ability of the follicle to secrete the estrogen inside it that is
needed for final maturation. When women are given highly purified human pituitary
gonadotropin preparations by injection, many follicles develop simultaneously.
At about the 14th day of the cycle, under the influence of luteinizing hormone and
follicle stimulating hormone the distended follicle (Graafian follicle) ruptures, and
the ovum is extruded into the abdominal cavity. This is the process of ovulation.
The ovum is picked up by the fimbriated ends of the uterine tubes (oviducts). It is
transported to the uterus in case of fertilisation otherwise, it gets disintegrated and
is shed out through the vagina.

The follicle that ruptures at the time of ovulation promptly fills with blood, forming
what is sometimes called a corpus hemorrhagicum. Minor bleeding from the
follicle into the abdominal cavity may cause peritoneal irritation and fleeting lower
abdominal pain (“mittelschmerz”). The clotted blood is rapidly replaced with
yellowish, lipid rich luteal cells, forming the corpus luteum. This initiates the luteal
phase of the menstrual cycle, during which the luteal cells secrete estrogen and
progesterone, which are responsible for maintaining the endometrium and
sustenance of the pregnancy. If pregnancy occurs, the corpus luteum persists and
usually there are no more periods until after delivery. If pregnancy does not occur,
the corpus luteum begins to degenerate about 4 days before the next menses
(24th day of the cycle) and is eventually replaced by scar tissue, forming a corpus
albicans.
Uterine cycle
At the end of menstruation, all but the deep layers of the endometrium have sloughed. A new
endometrium then regrows under the influence of estrogens from the developing follicle. The
endometrium increases rapidly in thickness from the 5th to the 14th days of the menstrual
cycle.These endometrial changes are called proliferative, and this part of the menstrual cycle
is sometimes called the proliferative phase. It is also called the preovulatory or follicular
phase of the cycle. After ovulation, the endometrium becomes more highly vascularized and
slightly edematous under the influence of estrogen and progesterone from the corpus
luteum. The glands become coiled and tortuous and they begin to secrete a clear fluid.
Consequently, this phase of the cycle is called the secretory or luteal phase. The
endometrium is supplied by two types of arteries. The superficial two thirds of the
endometrium that is shed during menstruation, the stratum functionale, is supplied by long,
coiled spiral arteries, whereas the deep layer that is not shed, the stratum basale, is supplied
by short, straight basilar arteries.
When the corpus luteum regresses, hormonal support for the endometrium is withdrawn.
The endometrium becomes thinner, which adds to the coiling of the spiral arteries. Foci of
necrosis appear in the endometrium, and these coalesce. In addition, spasm and
degeneration of the walls of the spiral arteries take place, leading to spotty hemorrhages that
become confluent and produce the menstrual flow.

The proliferative phase of the menstrual cycle represents restoration of the epithelium from
the preceding menstruation, and the secretory phase represents preparation of the uterus for
implantation of the fertilized ovum. The length of the secretory phase is remarkably constant
at about 14th day, and the variations seen in the length of the menstrual cycle are due for the
most part to variations in the length of the proliferative phase. When fertilization fails to
occur during the secretory phase, the endometrium is shed and a new cycle starts.

Normal Menstruation
Menstrual blood is predominantly arterial, with only 25% of the blood being of
venous origin. It contains tissue debris, prostaglandins, and relatively large
amounts of fibrinolysin from endometrial tissue. The fibrinolysin lyses clots, so
that menstrual blood does not normally contain clots unless the
flow is excessive. The usual duration of the menstrual flow is 3 to 5 days, but flows
as short as 1 day and as long as 8 days can occur in normal women. The amount
of blood lost may range normally from slight spotting to 80 mL; the average
amount lost is 30 mL. Loss of more than 80 mL is abnormal. Obviously, the
amount of flow can be affected by various factors, including the thickness of the
endometrium, medication, and diseases that affect the clotting mechanism.

Anovulatory cycle
In some instances, ovulation fails to occur during the menstrual cycle. Such
anovulatory cycles are common for the first 12 to 18 months after menarche and
again before the onset of the menopause. When ovulation does not occur, no
corpus luteum is formed and the effects of progesterone on the endometrium are
absent. Estrogens continue to cause growth, however, and the proliferative
endometrium becomes thick enough to break down and begins to slough. The
time it takes for bleeding to occur is variable, but it usually occurs in less than 28
days from the last menstrual period. The flow is also variable and ranges from
scanty to relatively profuse.

Cyclical changes in cervix

Although it is continuous with the body of the uterus, the cervix of the uterus is
different in a number of ways. The mucosa of the uterine cervix does not undergo
cyclical desquamation, but there are regular changes in the cervical mucus.
Estrogen makes the mucus thinner and more alkaline, changes that promote the
survival and transport of sperms. Progesterone makes it thick, tenacious, and
cellular. The mucus is thinnest at the time of ovulation, and its elasticity, or
spinnbarkeit, increases so that by mid cycle, a drop can be stretched into a long,
thin thread that may be 8 to 12 cm or more in length. In addition, it dries in an
arborizing, fern-like pattern when a thin layer is spread on a slide. After ovulation
and during pregnancy, it becomes thick and fails to form the fern pattern.
Cyclical changes in vagina
Under the influence of estrogens, the vaginal epithelium becomes cornified, and
cornified epithelial cells can be identified in the vaginal smear. Under the influence
of progesterone, a thick mucus is secreted, and the epithelium proliferates and
becomes infiltrated with leukocytes.

Cyclical changes in breast

Although lactation normally does not occur until the end of pregnancy, cyclical
changes take place in the breasts during the menstrual cycle. Estrogens cause
proliferation of mammary ducts, whereas progesterone causes growth of lobules
and alveoli. The breast swelling, tenderness, and pain experienced by many women
during the 10 d preceding menstruation are probably due to distention of the ducts,
hyperemia, and edema of the interstitial tissue of the breast. All these changes
regress, along with the symptoms, during menstruation.