Group E: Presentation DR Odowaa DR Danan DR Khadija Bule

1
Group E
presentation
dr odowaa
dr danan
dr khadija bule
Thursday, July 09, 2020

outline
2
 Introduction
 Defi nition
 Characteristics of normal menstruation
 T h e hypothalamic-pituitary-ovarian axis
 O v a r i a n cycle
 Menstrual cycle
changing that occur during menstrual period

Introduction
3
Typically, a woman of childbearing age or

reproductive age (15-45) should menstruate every 28 days or
so unless she's pregnant or moving into menopause. But
numerous things can wrong with the normal menstrual cycle.
The menstrual cycle is essential for the production of eggs,
and for the preparation of the uterus for pregnancy
Note The flow of menses normally serves as a sign that a
woman has not become pregnant. (However, this cannot be
taken as certainty, as a number of factors can cause
bleeding during pregnancy

Definition
4
Menstruation means cyclic uterine bleeding caused

by shedding of progestational endometrium it occurs
between menarche and menopause
 Menstruation (also called menstrual bleeding,
menses, or a period)

Characteristics of normal menstruation
5
 1-Menarche: 10-16 years. average 13 years.

 2-Duration: 2-7 days (<2days is hypomenorrhea
and
>7 days is menorrhagia
 3-Amount: 30-80 ml., uses3
napkins per day, >80 ml. is menorrhagia
and < 30 ml. is hypomenorrhea
Note Factors such as heredity, diet and overall
health can accelerate or delay menarche

6
 4-Normally menstrual blood doesn’t coagulate as a

result of secretion of fibrinolysin enzyme (plasmin)
secreted by the endometrium.
5-Menstrual molimina refers to mild symptoms of 7-10day
beforemenstruationrelievedoncemenstruationoccursexaggeratedconditioncaledpremenstrualsyndreome

The hypothalamic-pituitary-ovarian axis:
7
T h e re Are two main components of the menstrual
cycle, the changes that happen in the ovaries in
response to pituitary hormones (the ovarian cycle)
 and the variations that take place in the
uterus,but it is important to remember that both
cycles work together simultaneously to produce the
menstrual cycle.
 Changes in cervical mucus also take place during
the course of the menstrual cycle.

8

Ovarian Cycle:
9
 The ovarian cycle refers to Periodic changes that

occur in the ovary every month during the ♀
reproductive life.
 Cyclical changes in the
ovareis occur in response to two anterior
pituitary hormones:
 Follicle-stimulating hormone(FSH)
 Luteinizing hormone (LH).

Ovarian follicular development
10
 Fetus:6-7 million in 20 wks.

 At birth:1-2 million
 At puberty:300,000
 Release during ovulation:400-500
 At menopause: rare

11
The changes that occur in the ovary during each

cycle can be divided into three phases:
1) Follicular phase (day 1-13 )

2) Ovulatory phase(day 13-15)**
3) The luteal phase (day 15-28).
These phases run in parallel with the phases of
the uterine cycle and together comprise the
menstrual cycle.

:FOLLICULAR PHASE-1
12


13
A t the beginning of each menstrual cycle, the

hypothalamus secretes -----< GnRh in a pulsatile
manner to stimulate ----< ant. Pit. gland to secretes
------< FSH & LH. F S H is responsible for the growth
of several primary follicle
 The follicular phase is
controlled by FSH, encompasses
days 1 to 13 of a 28-day cycle

14
 o n l y one follicle on one of the ovaries reaches

maturity (graafian follicle) which secretes oestrogen.
 Estrogen has negative feedback on the pituitary to stop
FSH
 Estrogen causes the uterine lining
(endometrium) to grow thicker

2- ovulatory
15 phase


16
 The estrogen peak stimulates secretion of LH.

The LH peak leads to :
The follicle to burst open, releasing
the mature ovum into abdominal cavity the process
called ovulation. And curpous luteum formation.
Ovulation occurs on day 14 of a 28-day cycle.
Note : High estrogen also suppress
FSH
secretion so no further follicles grow

17
mittelschmerz
Mid-cycle pain
• Due to:
• Enlargement of follicle or follicular rupture with
bleeding
• Usually mild, unilateral pain
• Usually resolves in hours to days
• Can mimic other disorders (appendicitis

3-Luteal phase:
18

19
 A f t e rovulation, LH levels remain elevated and

cause the remnants of the follicle to develop into a
yellow body called the corpus luteum.
 + In addition to producing oestrogen, the corpus

luteum secretes a hormone called progesterone

20
 w h e n progesterone reaches a high level ti

inhibits the secretion of LH leads
degeneration of the corpous luteum (If
fertilization does not take place),
and so oestrogen and progesterone drop &
separation of the endometrium (menstruation) &
stimulates the hypothalamus to secrete more GnRH,
a new cycle is started.

21

22

Uterine Cycle – Endometrium Overview
23
 Two layered
Superficial layer that sheds during the menstrual cycle
Basal layer that doesn’t take part, but regenerates the superficial
layer
The basal layer has straight arterioles where as the
superficial layers has spiral ones – important in the
process of shedding

II -Uterine Cycle:
24
 T h e uterine cycle refers to the changes that are

found in the uterine lining of the uterus. These
changes come about in response to the ovarian
hormones estrogen and progesterone. There are 4
four phases to this cycle:
1. Menstrual,
2. proliferative,
3. secretory and
4. ischemic.

1-Proliferative Phase
25
 W h e n estrogen levels are high enough, the

endometrium begins to regenerate.
 Estrogen stimulates blood vessels to develop. The
blood vessels in turn bring nutrients and oxygen to
the uterine lining, and it begins to grow and become
thicker.
 T h e proliferative phase ends with ovulation on
day 14.

2-Secretory Phase
26
 After ovulation, the corpus luteum begins

to produce progesterone. This hormone causes
 the uterine lining to become rich in nutrients n
i
preparation for pregnancy.
 Estrogen levels also remain high so that the lining
is maintained pregnancy doesn’t occur, the If corpus
lute gradually degenerate and ischemic phase start.

3-Ischemic Phase.
27
 O n days 27 and 28, estrogen and progesterone

levels fall because the corpus luteum is no longer
producing them.
Without these hormones to maintainthe blood
vessel network, the uterine lining becomes ischemic.
When the lining start slough, the woman has come
full cycle and is once again at day 1 of the menstrual
cycle.

4-Menstrual Phase
28
Day 1 of the menstrual cycle is marked by the onset

of menstruation. During the menstrual phase of the
uterine cycle, the uterine lining is shed because of
low levels of progesterone & estrogen. At the same
time, follicle is beginning to develop and starts
producing.
The menstrual phase ends when the menstrual
period stops on approximately day 5.
Duration 1-5 days

29


30

Cervical Mucus
31
Important to stop ascending infection

Changes during the menstrual cycle
Early follicular phase – viscid and impermeable
Late follicular phase – increasing oestrogen levels  mucus
becomes watery and easily penetrated, allowing spermatozoa to get
through. Change is known as Spinnbarkheit
Post-ovulation – progesterone from corpus luteum counteracts
oestrogens effects  mucus becomes impermeable and the
cervical os contracts

32
 A s the time of ovulation becomes near, the mucus

becomes progressively clear, thin and lubricative, with
the properties of raw egg white. At the peak of
fertility(i.e., during ovulation), the mucus has a
distensible, stretchable called spinbarkheit. After
ovulation the mucus becomes scanty, thick, and
opaque.

Other Changes
33
Body temperature – Rise of 0.5°C after ovulation till

onset of menstruation. Due to progesterone levels. If
conception occurs – this temperature is maintained
throughout pregnancy
Breast changes – breast swelling during luteal
phase due to increasing progesterone levels
Psychological changes – change in mood and
an increase in emotional lability. Might be due
to falling progesterone levels.

Fig. 34-1: Events of the Menstrual Cycle
34
Hypothalamus secretes GnRH Anterior pituitary
secretes LH and FSH

Graafian follicle stimulated Ovaries release
estrogen
 High estrogen levels inhibit FSH secretion, stimulate LH production
LH makes mature follicle burst: ovulation
LH makes corpus luteum secrete progesterone
 Progesterone inhibits LH secretion Decreased LH
and FSH levels

Corpus luteum atrophies, stops making progesterone Decreased estrogen
and progesterone levels stimulate GnRH secretion

Dysmenorrhea
35
Outline
Definition of dysmenorrhea
Classification o dysmenorrhea
Risk factors of dysmenorrhea
Pathogenesis of pain
Clinical evaluation
Investigation
management

definition
36
Dysmenorrhea is painful menstruation.

The pain can be two types; spasmodic and congestive
dysmenorrhea.
o Spasmodic dysmenorrhea
 stars before menstruation
 Colicky pain
 Suprapubic pain

37
o Congestive dysmenorrhea
 Starts in luteal phase
 Increase with menstruation
 Constant pelvic pain

Classification of dysmenorrhea
38
Primary dysmenorrhea
 Presence of recurrent, cramp, lower abdominal pain that
occurs during menstruation, in the absence of pelvic
pathology
 Occurs few years after menarche when ovulatory cycle is
established.
 Pain starts with menstruation gradually decrease 12-
72hours.
 Women with anxiety and stress are more comon
 Primary dysmenorrhea generally disappear after vaginal
delivery

Characteristics of primary dysmenorrhea
39
Occurs before 20years of age

Usually spasmodic
Pain is suprapubic; radiates to the back and thight
Associated with other symptoms;
nausea
vomiting
diarrhea
syncope
No pelvic pathology
Occurs only in ovulatory cycles

Risk factors of primary dysmenorrhea
40
Age less then 20years

BMI<20kg/m²
Early menarche
Anxiety and stress
Heavy menstrual flow
Increased duration of menstruation

Pathogenesis of pain
41
Primary amenorrhea increase prostaglandin f2 alpha

level.
In ovulatory cycle increases progesterone level after
ovulation cause increase PGF2 alpha in the
myometrium leads increase tone of myometrium and
uterine contraction. Also increase level of
leukotrienes and vasopressins results
vasoconstriction results ischemia results pain

Secondary dysmenorrhea
42
Secondary amenorrhea is recurent lower abdominal

pain associated with menstruation that occurs
women with pelvic pathology.
Occurs several years after menarche (>20yrs)
Starts with 1-2weaks before menstruation
Increases onset with menstruation
Associated with heaviness and bachache

Causes of secondary dysmenorrhea
43
Endometriosis
Adenomyosis
Chronic pelvic infection
Cervical stenosis
Leiomyoma of uterus
Ovarian mass
Mullerian anomalies
Pelvic congestion syndrome

Clinical evaluation
44
History  Syncope
 age  Heaviness in pelvis
 Age of onset of pain and back pain
 Age of menarche  Menstrual cycle
 Type of pain  Duration of flow
 Spasmodic or  Amount of
congestive  flow
 Location of pain  Regularity
 Other associated  dyspareuria
symptoms
 Gastrointestinal
symptoms like
diarrhea Thursday, July 09, 2020
Physical examination
45
General examination
Abdominal examination
 Tenderness
 Mass
Pelvic examination
 Uterine size
 Adnexal mass
 Tenderness
Rectal examination
 Rectovaginal nodule
 tenderness

investigations
46
ultrasound-abdomen and pelvic

 Leiomyoma
 Endometeriosis
 Ovarian mass
 Cervical stenosis with haematometra
Sonosalpingography
 Intrauterine lesion
 Mullerian anomalies
Laporoscopy
 Endometriosis
 Chronic Pelvic inflammatory disease
 Pelvic congestion syndrome

Management
47
Primary dysmenorrhea
Non medical management
 Counselling to anxiety and lifestyle modification
 Low fatty diet and supplement with vitamine E, D3,
B1 and fish oil.
 During menses the bowel should kept empty.

48
Medical management
 The main stay of treatment is NSAIDS and
prostaglandin synthase inhibitory
Aspirin
Mefenamic acid
Naproxin
Cox2 inhibitor
 Celecoxib 200mg twice daily

49
Contraceptive drugs-inhibits ovulation therefore no

progesterone production (oesterogen-progesterone
combination-patch)
Progestin
 Injection depot medroxyprogesterone acetate
(DMPA) ONCE in three months causes amenorrhea
and alleviate pain
 Levonorgestrel intrauterine system

50
Transcutaneous electrical nerve stimulation (TENS)

to reduce pain
Surgical management
 Laparoscopic uterine nerve abalation (LUNA)
 Laparoscopic presacral neurectomy (LPSN)
Secondary dysmenorrhea management

Treat the cause

PREMENSTRUAL SYNDROME
51
Premenstrual syndrome (PMS) is the occurrence of

cyclical somatic, psychological and emotional
symptoms that occur in the luteal (premenstrual)
phase of the menstrual cycle and resolve by the time
menstruation ceases. Premenstrual symptoms occur
in almost all women of reproductive age.

52
Psychoneuroendocrine disorder of unknown

etiology,
criteria (ACOG) :
Not related to any organic lesion.
 Regularly occurs during the luteal phase of each
ovulatory menstrual cycle.

53
Symptoms must be severe enough to disturb the life

style of the woman or she requires medical help.
 Symptom-free period during rest of the cycle.
When these symptoms disrupt daily functioning they
are grouped under the name premenstrual
dysphoric disorder (PMDD).

Pathophysiology:
54
The exact cause is not known but

The following hypotheses are postulated
(a) Alteration in the level of estrogen and progesterone
starting from the midluteal phase there is altered
estrogen : progesterone ratio or
diminished progesterone level.

55
(b) Neuroendocrine factors

Serotonin is an important neurotransmitter in
the CNS. During the luteal phase, decreased
synthesis of serotonin is observed in women
suffering from PMS.
 Endorphins: The symptom complex of PMS
is thought to be due to the withdrawal of endorphins
(neurotransmitters) from CNS during the luteal
phase.

56
 γ-aminobutyric acid (GABA) suppresses the

anxiety level in the brain. Medications that are GABA
agonist, are effective
(c) Psychological and psychosocial factors may be
involved to produce behavioral changes.

57
(d) Others: Variety of factors have been mentioned

to explain the symptom complex of PMS. These are
thyrotrophin releasing hormone (TRH) prolactin,
renin, aldosterone, prostaglandins, and others.

58
Clinical features
Clinical features: PMS is more common in women
aged 30–45

59 Thursday, July 09, 2020

Group E: Presentation DR Odowaa DR Danan DR Khadija Bule

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1

Thursday, July 09, 2020

 Characteristics of normal menstruation

Thursday, July 09, 2020

Typically, a woman of childbearing age or

Thursday, July 09, 2020

Menstruation means cyclic uterine bleeding caused

Thursday, July 09, 2020

 1-Menarche: 10-16 years. average 13 years.

Thursday, July 09, 2020

 4-Normally menstrual blood doesn’t coagulate as a

Thursday, July 09, 2020

Thursday, July 09, 2020

Thursday, July 09, 2020

 The ovarian cycle refers to Periodic changes that

Thursday, July 09, 2020

 Fetus:6-7 million in 20 wks.

Thursday, July 09, 2020

The changes that occur in the ovary during each

1) Follicular phase (day 1-13 )

Thursday, July 09, 2020

Thursday, July 09, 2020

A t the beginning of each menstrual cycle, the

Thursday, July 09, 2020

 o n l y one follicle on one of the ovaries reaches

Thursday, July 09, 2020

Thursday, July 09, 2020

 The estrogen peak stimulates secretion of LH.

Thursday, July 09, 2020

Thursday, July 09, 2020

Thursday, July 09, 2020

 A f t e rovulation, LH levels remain elevated and

 + In addition to producing oestrogen, the corpus

Thursday, July 09, 2020

 w h e n progesterone reaches a high level ti

Thursday, July 09, 2020

Thursday, July 09, 2020

Thursday, July 09, 2020

Thursday, July 09, 2020

 T h e uterine cycle refers to the changes that are

Thursday, July 09, 2020

 W h e n estrogen levels are high enough, the

Thursday, July 09, 2020

 After ovulation, the corpus luteum begins

Thursday, July 09, 2020

 O n days 27 and 28, estrogen and progesterone

Thursday, July 09, 2020

Day 1 of the menstrual cycle is marked by the onset

Thursday, July 09, 2020

Thursday, July 09, 2020

Thursday, July 09, 2020

Important to stop ascending infection

Thursday, July 09, 2020

 A s the time of ovulation becomes near, the mucus

Thursday, July 09, 2020

Body temperature – Rise of 0.5°C after ovulation till

Thursday, July 09, 2020

secretes LH and FSH

 Progesterone inhibits LH secretion Decreased LH

and FSH levels

and progesterone levels stimulate GnRH secretion

Thursday, July 09, 2020