MENSTRUATION

Menstrual cycle

- AKA Female reproductive cycle

- Episodic uterine bleeding in response to cyclic hormonal changes
- is the periodic discharge of blood, mucus and epithelial cells from the uterus.
- Blood loss: approximately 30 – 80 ml of blood
- Iron loss: approximately 11 mg
- Menstrual Cycle – periodic uterine bleeding in response to cyclic hormonal changes. A process that allows
for conception and implantation of new life.
- It is usually determined by counting as day 1 the 1st day of a menstrual period until the last day before
the next menstrual period.

Purposes:
- Bring an ovum into maturity
- Renew uterine tissue bed that will be responsive to fetal growth
- To prepare the uterus for pregnancy

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 CHARACTERISTICS OF NORMAL MENSTRUAL CYCLES

Characteristics Description

Menarche Average age of onset, 12 or 13 years, average range of 9

– 17 years old

Interval between cycles Average 28 days, cycles of 23 to 35 days not unusual

Duration of Menstrual flow Average flow, 2-7 days. Ranges of 1-9 days not unusual

Amount of menstrual flow 30-80 mL per menstrual period

Color of menstrual flow Dark red, a combination of blood, mucus and

endometrial cells

Discomforts of Menstruation

- Breast tenderness and feeling of fullness

- Tendency towards fatigue
- Temperament and mood changes – because of hormonal influence and decreased levels of estrogen and
progesterone
- Discomfort in pelvic area, lower back and legs
- Retained fluids and weight gain

Abnormalities of Menstruation

- Amenorrhea – absence of menstrual flow

- Dysmenorrhea – painful menstruation
- Oligomenorrhea – scanty menstruation
- Polymenorrhea – too frequent menstruation
- Menorrhagia -excessive menstrual bleeding
- Metrorrhagia – bleeding between periods of less than 2 weeks
- Hypomenorrhea – abnormally short menstruation
- Hypermenorrhea – abnormally long menstruation

Four Body Structures involved in the Physiology of the Menstrual Cycle

- Hypothalamus
- Pituitary gland
- Ovaries
- Uterus

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HYPOTHALAMUS

 Release of GnRH by the hypothalamus initiates the menstrual cycle

- Repressed by presence of estrogen
- Cyclical

PITUITARY GLAND

 Produces 2 gonadotrophic hormones:

FSH
- Active early in the cycle
- Responsible for the maturation of the ovum

LH
 Active at midpoint of the cycle
 Responsible for ovulation and growth of the uterine lining dring the second half of
the menstrual cycle

REPRODUCTIVE HORMONES

 Gonodotropin-Releasing Hormone (GnRH)

- Stimulates release of FSH and LH initiating puberty and sustaining menstrual cycle.

 Follicle-stimulating Hormone (FSH)

- secreted by anterior pituitary gland during the 1st half of menstrual cycle
- stimulate growth and maturation of graafian follicle before ovulation
- thins the endometrium

 Luteinizing Hormone (LH)

- secreted by the anterior pituitary gland

- stimulates final maturation of graafian follicle
- surge of LH about 14 days before next menstrual period causes ovulation
- stimulates transformation of graafian follicle into corpus luteum
- thickens the endometrium

 Estrogen

- secreted primarily by the ovaries, corpus luteum, adrenal cortex and placenta in pregnancy
- considered the Hormone of Women
- stimulates thickening of the endometrium; causes suppression of FSH secretion
- responsible for the development of secondary sex characteristics
- stimulates uterine contractions
- increases water content of uterus
- high estrogen concentration inhibits secretion of FSH and Prolactin but stimulates secretion of
LH.
- low estrogen concentration after pregnancy stimulates secretion of Prolactin

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  Progesterone

- secreted  by the ovary, corpus luteum and placenta during pregnancy

- inhibits secretion of LH
- has thermogenic effect (increases body temperature)
- relaxes smooth muscles thereby decreases contractions of uterus
- causes cervical secretion of thick mucus
- maintain thickness of endometrium
- allows pregnancy to be maintained = Hormone of Pregnancy
- prepares breasts for lactation

 Prolactin
- secreted by the anterior pituitary gland
- stimulates secretion of milk

 Oxytocin
- secreted by the posterior pituitary gland
- stimulates uterine contractions during birth and compress uterine blood vessels and control
bleeding
- stimulates let-down or milk-ejection reflex during breastfeeding

 Prostaglandins
- fatty acids’ categorized as hormones
- produced by many organs of the body, including the endometrium
- affects menstrual cycle
- influences the onset and maintenance of labor

PHASES
Menstruation is a complex process. For better understanding it can be classified in different ways.

On the basis of changes that occur in the ovaries

- Follicular phase or the phase before ovulation.

- Ovulatory phase or the phase of ovulation
- Postovulatory (Luteal) phase or the phase after ovulation.

On the basis of changes that take place in the linings of the uterus

- Proliferative Phase
- Ovulatory phase
- Secretory Phase
- Menstrual Phase

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ENDOCRINE MECHANISM OF MENSTRUATION

- Play of sex hormones from hypothalamus in brain, anterior pituitary gland, ovary causes menstrual
bleeding from uterine endometrium.
- This is called hypothalamus- pituitary-ovarian-uterine axis

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STEPS ARE –

1. In the brain, hypothalamus acts as switch to endocrine mechanism of menstruation and starts the process
by secreting gonadotrophin releasing hormone (GnRH).

Groh flows down from hypothalamus via pituitary portal vessels to----

2. Anterior pituitary gland liberating follicle stimulating Hormone (FSH) and Luteinizing hormone (LH) in
blood circulation to initiate growth of ovarian follicles in both ovaries.

Ovarian Cycle

 Ovarian follicles (20 in number) are grown in a menstrual cycle in three steps.

(a) ovarian follicles are grown from primordial follicles. A single graafian follicle matures and becomes
dominant by effect of FSH while other follicles undergo atresia.

b) Oestradiol is secreted by maturing ovarian follicle in the circulation ' stimulates hypothalamus and
anterior pituitary to cause surge of LH and FSH hormones in blood (Positive feed back) on day 12 of
menstrual cycle.

(c) Ovulation (discharge of ovum from ovary) occurs on day 14 of menstrual cycle. Corpus luteum (yellow
body) is formed in the shell of mature graafian follicle ovulation due to LH effect.

 Corpus luteum remains mature from day 19-26, degenerates on day 27 and 28 if no pregnancy occurs in
menstrual cycle.
 Plasma prolactin (from anterior pituitary) rises during luteal phase and appears to maintain corpus
luteum.

Uterine cycle

(a) Proliferative phase

- Oestradiol from ovarian follicles causes proliferative changes in uterine endometrium (day 7-14).
- All the endometrial tissue elements of I mm thick proliferate.

(b) Secretory phase.

-Progesterone (from corpus luteum) causes secretory changes in endometrium (day 15 - 26 to receive
fertilized ovum for embedding.
- Glycogen appears as subnuclear vacuoles in endometrial gland followed by secretion of glycogen and
mucus on the lumen of gland.
- Glands become Corkscrew .
- Endometrial vessels become coiled, stroma becomes vascular and oedematous.
- Endometrium thickens to 5 mm into three layer
- superficial compact layer with neck of glands
- spongy layer with dilated glands
- basal layer in contact with myometrial layer.
 Stage of regression occurs in secretory endometriurn on day 27 to 28.

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 (c) Menstrual bleeding phase occurs for 4 - 5 days after day 28 of the cycle due to shedding away of
endometrial bits and bleeding from endometriaI bed.

- Necrosis and shedding of endometrial bits extend from region to region during first 2 days of menses.

 Bleeding occurs as

(a) capillary bleeding with or without the formation of subepithelial haematoma

(b) venous haemorrhage and
(c) diapidesis.

- Menstrual phase is caused by withdrawal of oestradiol and progesterone support to endometrium.

- FSH rises again to start another, cycle.
- Cause of menstrual bleeding. Exact cause is still obscure.

The sequence of events are :

1. Withdrawal of estrogen and progesterone due to degeneration of corpus luteum
2. rapid shrinkage and regression of secretory endometrium overcoiling of endometrial spiral
arterioles
3. stasis of circulation in the functional layer of endometrium '
4. necrobiosis of vessels.

- Prostaglandins elaborated by endometrium also cause vasospasm of spiral vessels – reason for
dysmenorrhea
- In the shedding process, clotting and fibrinolysis at bleeding site occur so that unclotted dark red
blood with endometrial tissue bits are discharged for 4-5 days.

CERVIX

- Mucus of the cervix also changes each month during the menstrual cycle.
- Changes in cervical mucus are helpful in establishing fertility.
- During the first half of the cycle, when the hormone is very low, the cervical mucus is thick and scant
- At the time of ovulation when estrogen level is high, cervical mucus is thin and copious
- During the second phase of the menstrual cycle when progesterone level is high, cervical mucus becomes
thick.

FERN TEST
- Visible if there is presence of high estrogen level
- Seen before ovulation
- Cervical mucus forms fernlike patterns when placed on a glass slide

Significance:
◦ Women who do not ovulate continually show the fern pattern throughout the menstrual
cycle(no progesterone influence) OR
◦ Never demonstrate ferning pattern because their estrogen level never rise

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SPINNBARKEIT TEST

 Test for ovulatiOn

 At the height of estrogen secretion, the cervical mucus not only becomes thin and water, but it also can
be stretched into long strands
 Indication that ovulation is about to occur.
 Done by stretching a mucus sample between thumb and finger or by smearing cervical mucus specimen
on a slide and stretching the mucus between the slide and cover slip

SIGNS OF OVULATION

1. Mittelschmerz - a certain degree of pain felt at the lower left or right iliac.
2. Cervical mucus method or Billing’s method - changes in cervical mucus secretions to clear, elastic and
watery (most reliable sign)
3. SPINNBARKHEIT TEST – test for elasticity of cervical mucus.
4. Increase in Basal body temperature
5. Mood changes
6. Breast changes and enlargement
7. Increased libido

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EDUCATION REGARDING MENSTRUATION

- Dispel menstruation myths

- Educate boys about menstruation
- Continue doing moderate exercise
- Sexual relations is not contraindicated during menses
- Activities of daily life is not contraindicated during menses
- Using mild analgesics is helpful
- More rest may be helpful if dysmenorrhea interferes with sleep at night
- Nutrition: iron supplementation may be needed to replace iron lost in menses
- Eating sour or cold foods does not cause dysmenorrhea.

MENSTRUAL DISORDERS

1. Amenorrhea – temporary absence of menstrual flow

2. Dysmenorrhea - painful menstruation
3. Oligomenorrhea - markedly diminished menstruation
4. Polymenorrhea - too frequent menstruation occurring at intervals of less than three weeks
5. Menorrhagia - excessive menstrual bleeding
6. Metrorrhagia - bleeding between periods
7. Hypo menorrhea - abnormally short menstruation
8. Hypermenorrhea - abnormally long menstruation

Premenstrual Dysphoric Syndrome

- Severe form of premenstrual syndrome

- Although the absence of menses causes no harm to the body in a woman who is not pregnant or
postpartum, it is abnormal and thus is a source of concern. For this reason, women usually seek
medical assistance when this condition occurs.

DEFINITION OF TERMS

Primary amenorrhea - absence of menses in a woman who has never menstruated

by age 16 ½ years
Secondary amenorrhea - absence of menses for an arbitrary period, usually 6 to 12 months
Intermenstrual bleeding is bleeding at variable amounts occurring between regular menstrual periods

ONSET OF MENARCHE

- The mean interval between breast budding and menarche is 2-3 years.
- The absence of breast budding is indicative of a lack of estradiol synthesis.
- The ratio of fat to both total body weight and lean body weight is the most relevant factor that
determines onset of puberty and menstruation.
- Moderately obese individuals have earlier menarche than non-obese women.
- Malnutrition is known to delay onset of puberty.

EVALUATION OF SECONDARY AMENORRHEA

- Pregnancy
- Instrumentation for intrauterine adhesions

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 - Use of OCP
- Diet, weight loss, stress and exercise
- Hot flushes, vaginal dryness, etc

Laboratory Examination

- complete blood count

- urinalysis
- serum chemistries
- Serum TSH
- prolactin levels
- FSH

ABNORMAL UTERINE BLEEDING

Abnormal uterine bleeding is a clinical problem of great magnitude – affecting women of all ages.
Sequelae include anemia, lassitude, and associated social, economic, and psychological consequences that
result in a diminished quality of life.

What causes endometrial bleeding during menses?

The systemic trigger of menstrual bleeding is progesterone withdrawal from an estrogenically primed
endometrium

What are the causes of abnormal uterine bleeding?

1. Organic cause which can be systemic or reproductive

2. Dysfunctional or endocrinologic cause

DYSMENORRHEA
a severe, painful cramping sensation in the lower abdomen often accompanied by other symptoms as
sweating, tachycardia, headaches, nausea, vomiting, diarrhea, and tremulousness all occurring just before
or during the menses.

Primary – reserved for women who had no obvious pathologic condition, almost always occurs in women
younger than 20
Secondary – associated with conditions or pathology that causes pelvic pain in conjunction with menses

Factors Affecting Dysmenorrhea

- A significant positive correlation is seen between the severity of dysmenorrhea and the duration of
menstrual flow, amount of menstrual flow, and early menarche
- Dysmenorrhea is significantly increased among mothers and sisters of women with dysmenorrhea

Aetiology

a) Prostaglandins theory: Secretory endometrium produces excessive PGF2a which stimulates uterine
contractions, sensitises pain nerve endings, and decrease uterine blood flow leading to ischaemia.

b) Uterine ischaemia theory: Ischaemia of the myometrium during menstrual contractions results in
accumulation of acid metabolites that can stimulate type C- pain neurons. Passage of menstrual blood
with clots or casts results in increased uterine contractions.

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 c) Mullerian anomalies: e.g. bicornuate uterus, cervical stenosis and imperforate hymen

d) Psychological: psychological factors influence the patient reactions to discomfort.

TREATMENT OF PRIMARY DYSMENNORHEA

 Nonsteroidal anti-inflammatory drugs (NSAIDs) are prostaglandin synthetase inhibitors and are
considered the treatment of primary dysmenorrhea.
 Other therapy include oral contraceptives, analgesics and transcutaneous electrical nerve stimulation.

Causes of Secondary Dysmenorrhea

Cervical stenosis
Endometriosis and adenomyosis
Pelvic infection and adhesions
Pelvic congestion
Conditional behavior
Stress and tension

Treatment of Secondary Dysmenorrhea

These consists mainly of

◦ medical management of pain
◦ Counseling
◦ relief from stress and tension

PREMENSTRUAL TENSION

 Premenstrual syndrome occurs in 40% of women at one time or another. It can be severe and interferes
with work and personal relationships.
 PMS is defined as a group of symptoms, both physical and behavioral, that occur in the second half of the
menstrual cycle, and that often interfere with work and personal relationships

SYMPTOMS OF PREMENTSRUAL SYNDROME

1. Somatic symptoms
◦ Bloated feeling
◦ Feeling of weight increase
◦ Breast pain or tenderness
◦ Skin disorders
◦ Hot flushes
◦ Headache
◦ Pelvic pain
◦ Change in bowel habits

2. Psychologic symptoms
◦ Irritability
◦ Aggression
◦ Tension
◦ Anxiety
◦ Depression
◦ Lethargy
◦ Insomnia
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 ◦ Change in appetite
◦ Crying
◦ Change in libido
◦ Thirst
◦ Lost of concentration
◦ Poor coordination, clumsiness, accidents

Common mistakes of the use of sanitary napkins

 Use of unwashed hand throughout the whole process of handling the napkins
 Storing sanitary napkins in moist area, such as bathroom.
 Using expired sanitary napkins.
 Selecting sanitary napkins without consider the quality of the sanitary napkins.
 Using medicated or deodorized sanitary napkins.
 Sanitary napkin is not changed regularly

MENOPAUSE

- MENOPAUSE
o Cessation of menstrual cycles

- POSTMENOPAUSAL PERIOD
o Time following menopause

- PERIMENOPAUSAL
o Period during which menopausal changes are occuring

- Occurs between 40 and 55 years old

- Familia
- Thea earlier the age of menarch, the earlier menopause tends to occur.

S/SX OF MENOPAUSE:

1. Hot flahes – sensation of heat that begins in the face to the chest and profuse perspiration.
2. Loss of breast mass and firmness, atrophy of reproductive organs.
3. Dyspareunia (painful intercourse) due to decreased vaginal lubrication.
4. Osteoporosis Estrogen promotes calcium disposition in the body. A fall in estrogen levels will liberate
calcium form the bones making them brittle and prone to fractures. Osteoporosis is considered the main
health hazard of menopause. Most significant sign of bone degeneration is decrease in height. After
menopause, women may lose two inches of their height.
5. Mood instability
6. Loss of sexual desire
7. Depression
8. Anxiety due to fluctuating hormone levels.

MX

1. Estrogen replacement therapy ( HRT; ERT)

2. Calcium (1g/day at Hs) and Vit. D Supplementation
3. Liberal fluid intake to dilute urine as more calcium is liberated from the bones and could cause renal
calculi.
4. Weight bearing exercises

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MX OF HOT FLASHES:

1. DRESS IN LAYERED LOOK, REMOVE OUTER CLOTHING DURING ATTACKS.

2. AVOID HOT ENVIRONMENT
3. AVOID EMOTIONAL STRESS
4. AVOID FOODS THAT COULD TRIGGER HOT FLUSHES: SPICY FOODS, COFFEE, TEA, ALCOHO
5. USE COOLING TECHNIQUES: FANS, SHOWERS, ICE CUBES

NURSING CARE:

1.ENCOURAGE WOMAN TO ENGAGE IN REGULAR EXERCISE PROGRAM TO MAINTAIN MUSCLE TONE

2. EMPHASIZE ADEQUATE INTAKE OF CALCIUM
3. VIT D FOR BETTER CALCIUM ABSORPTION.
4.INSTRUCT ON PROPER USE OF WATER SOLUBLE.
5. VAGINAL LUBRICANT FOR PAINFUL INTERCOURSE.
6. INSTRUCT TO AVOID SMOKING & ALCOHOL
7. REGULAR PHYSICAL EXAMINATION.

Health teaching during menopause

 Help women appreciate that loss of uterine function may make almost no change in their life.
 Teach patient about hormone replacement therapy

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