Menstrual cycle- ovulation, uterine cycle, cervical cycle

Hormones in menstruation, diagnosis of pregnancy

Abortion & medical termination of pregnancy
Dr. Mitali Srivastava, MBBS, MD
the.besharam.doctor
 Menstrual cycle
Ovulation, uterine cycle, cervical cycle
Hormones in menstruation
 •The word "menstruation" is etymologically related
to "moon“

Menstrual •“Menstruation" and "menses" are derived from the

Cycle • Latin mensis (month), which relates to the

Terminology • Greek mene (moon) and to the roots of the

• English words month and moon—

•Reflecting the fact that the moon also takes 27.32

days to revolve around the Earth

•The synodical lunar month, the period between two

new moons (or full moons), is 29.53 days long
 The menstrual cycle is a cycle of physiological
changes that can occur in fertile females

Overt menstruation:
Menstrual  where there is blood flow from the uterus
Cycle through the vagina
Overt  occurs primarily in humans and close
Covert evolutionary relatives such as chimpanzees

Covert menstruation:

 Females of other species of placental

mammal undergo estrous cycles, in which
the endometrium is completely reabsorbed
by the animal at the end of its reproductive
cycle
This is a series of events, occurring regularly in females every 26 to 30

days throughout the childbearing period of about 36 years

The cycle consists of a series of changes that take place concurrently in

the ovaries and uterine walls stimulated by changes in the blood

concentration of the hormones

Hormones secreted in the cycle are regulated by negative feedback

mechanisms
 Eumenorrhea denotes normal, regular
menstruation that lasts for a few days

Usually 3 to 5 days, but anywhere from 2 to 7

Menstrual days is considered normal
Cycle
Duration & Average blood loss during menstruation is 35
amount
milliliters with 10–80 ml considered normal

Because of this blood loss, women are more

susceptible to iron deficiency than men are

An enzyme called plasmin inhibits clotting in

the menstrual fluid
 It is one of the later stages of puberty in girls.
Menstrual
Cycle Average age of menarche in humans is 12

Menarche years, (Normal 8-16yrs)

Factors such as heredity, diet and overall

health can accelerate or delay menarche.

 The cessation of menstrual cycles at the end

of a woman's reproductive period is termed

Menstrual
Cycle menopause

Menopause
Phases of
menstruation
 Hypothalamus secrets luteinising
Menstrual hormone releasing hormone (LHRH)
Cycle
which stimulates the anterior pituitary to
Hormonal cycle
secrete:

 FSH

 LH
  Follicle Stimulating Hormone (FSH)

 which promotes the maturation of ovarian

Menstrual
Cycle follicles and the secretion of estrogen, leading

Hormonal cycle to ovulation.

 Luteinising Hormone (LH)

 which stimulates the development of corpus

luteum and the secretion of progesterone.

 The hypothalamus responds to changes in the
Menstrual
Cycle blood levels of estrogen and progesterone. It is

Hormonal cycle
depressed by high levels and stimulated when they

are low.
 e s i n
m o n n
H o r ati o
st r u
me n
Phases of
menstruation
 How does menstruation occur?
Begin by understanding that an ovum
1. is released and is not fertilized…
Menstrual
phase
 Ovum not fertilized

Progesterone causes –ve feedback

LH production falls

Corpus luteum degenerates

Progesterone production falls

Lining of the uterus breaks down

P falls below
critical levels

Menstruation
+ve feedback  FSH new ovarian
follicle stimulated for ovulation Consists of secretions from
endometrial glands, endometrial
cells, blood from the broken down
capillaries and the unfertilised ovum
 The spiral arteries that supply blood to the inner 2/3rd of mucosa

undergo vasoconstriction, with result ischemia & necrosis of

endometrium

 Mucosa gets sloughed off

 Spiral arteries open, producing bleeding over a period of 5 days

 Once it is sloughed off regeneration starts

 Destructive & regenerative processes take place simultaneously

 Women experience pain during this phase due to stimulation of pain

fibers either by chemicals released or by the contraction of myometrium

2.
Proliferative At this stage an ovarian follicle, stimulated by
phase/
follicular FSH, is growing towards maturity and is
phase
producing estrogen
Menstruation occurs

FSH stimulates new ovarian follicle

Ovarian follicle begins to mature and release Estrogen

Estrogen (E) promotes proliferation of

endometrium to receive fertilized ovum

Cell multiplication + increase in the numbers of

mucus-secreting glands and blood capillaries

Raised E causes +ve feedback LH

surge (both LH and FSh are elevated)

Mature follicle ruptures and releases

ovum = ovulation

Estrogen levels fall

 Immediately after ovulation

3. Lining cells of the ovarian follicle are stimulated by

Secretory LH

phase/
Luteal phase  To develop the corpus luteum produces
progesterone

Endometrium become edematous

Secretory glands produce increased amount of
watery mucous

Assists the passage of the sperm through the

uterus to the uterine tubes where the ovum is
usually fertilised
 The ovum may survive in a fertilizable form for a
Secretory
phase/ very short time after ovulation
Luteal
phase Sperms deposited in the vagina are capable of

fertilizing the ovum for only about 24 hours

But, sperms can survive for several days.

 The period in each cycle during which
Secretory
phase/ fertilisation can occur is relatively short
Luteal
phase If the ovum is not fertilised menstruation occurs

and a new cycle begins

Menorrhagia :
Excess discharge of first blood during menstrutaion
Dysmenorrhoea :
Excessive pain & other difficulties associated with
menstrual cycle
Oligomenorrhoea :
Scanty menstrual bleeding
Amenorrhoea :
No menstrual cycles
Metrorrhagia :
bleeding in the middle of menstrual cycle
Diagnosis of pregnancy
 Amenorrhoea: 4 weeks +
Symptoms
of Symptoms:

Pregnancy  Nausea

 Poor appetite

 Breast changes- heaviness, pain etc

 Increased frequency of micturtition

 An ultrasound will confirm:

 Intrauterine/ Ectopic

Ultrasound  Bulky endometrium

 G Sac, yolk sac

 Gestational age

 Singleton/ multiple pregnancy

 Fetal heartbeat
What is
β hCG
The principle behind
all pregnancy tests
 It is a glycoprotein

Heterodimeric in nature

Beta hCG  α subunit: resembles LH, FSH, TSH

 β subunit: unique

 Therefore the beta subunit is used for

confirmation of pregnancy
 Urine pregnancy test: Qualitative

 Immunoassay anti hCG reacts with hCG

Beta hCG antigen in the urine to give a colored

Qualitative reaction

 +ve/ -ve/ weak positive

 Result within 2 minutes

 Stale tests not valid

 Detects >20- 100 mIU/mL

 Blood test/ beta hCG test: Quantitative

 Immunoassay to determine levels of hCG in

Beta hCG blood

Quantitative  >5mIU/mL

 Doubles in 24 hours
  Doubtful cases:

 Beta hCG 0

 Beta hCG 48 hrs

Beta hCG  If levels double, or increase significantly:
+ve

 If levels increase, but not near double:

Miscarriage/ blighted ovum/ ectopic
pregnancy

 Excessively high levels: hyadatidiform

mole/ gestational trophoblastic disease
(GTD)
Abortion & medical termination of
pregnancy
 Deliberate termination of pregnancy either by
Definition the medical & surgical method before the
of MTP/
viability of the fetus is called induction of
abortion
abortion
 The Indian abortion laws falls under the Medical
Termination of Pregnancy (MTP) Act

Enacted by the Indian Parliament in the year 1971

MTP act with the intention of reducing the incidence of
1971 illegal abortion and consequent maternal mortality
and morbidity

The MTP Act came into effect from 1 April 1972 and
was amended in the years 1975 and 2002

Recently, the Supreme Court permitted a rape

survivor to terminate her pregnancy at 24 weeks,
which is beyond the permissible 20 weeks limit
prescribed under the Medical Termination of
Pregnancy Act, 1971
Medical
Termination MTP is the induction of abortion

Of Legal
Pregnancy
Act Illegal

In India the abortion was legalized by

 MTP Act, 1971

 Enforced in 1972
 Termination is performed by the medical

practitioners

 Assisted in at least 25 MTP + MS/ DGO

Legal
Abortion  Termination is done at the place approved under

the act

 Done for condition & within the gestation week

prescribed by the act

 Abortion has to be reported to the director of

health service of the state

 Women whose physical and/or mental health were

endangered by the pregnancy

Indications Women facing the birth of a potentially

for MTP handicapped or malformed child

Rape

Pregnancies in unmarried girls under the age of

eighteen with the consent of a guardian

Pregnancies that are a result of failure in

sterilization
 MTP kits

 Always confirm whether pregnancy is in

1st trimester the uterus or in the fallopian tubes by an

abortions ultrasound and under the guidance of an

Conservative obstetrician

 Follow up with an ultrasound to confirm

whether the products of conception have
cleared

 History of previous delivery- normal or

LSCS, D & E etc can affect the methodology
of taking drugs to abort
 Methotrexate for Ectopic pregnancy

Menstrual regulation
1st trimester  Aspiration of the endometrial cavity within
abortions
Surgical 14 days of missed period in a woman with

previous normal cycle

D&E with manual vacuum aspiration (MVA) or

electric vacuum aspiration (EVA)

 D & C- dilation and curettage
2nd
Trimester Hysterotomy: Extracting the products of

Abortions conception out of the womb before 28th

Surgical week by cutting through the anterior wall of

the uterus
 Injury to the cervix (cervical lacerations)

Uterine perforation during D and E

Complication
s of MTP Hemorrhage and shock due to trauma,
Immediate
incomplete abortion, atonic

Uterus or rarely coagulation failure

Thrombosis or embolism
 Gynecological complications include

Complications
of MTP
Remote  Menstrual disturbances
Gynecological
complications
Chronic pelvic inflammation

Scar endometriosis (1%)

 Obstetrical complications include

Ectopic pregnancy (three fold increase)

Complications Preterm labor
of MTP Rupture uterus
Remote
Obstetric
complications
Summary
Phases of
menstruation
 e s i n
m o n n
H o r ati o
st r u
me n
 Diagnosis of pregnancy

Summary MTP

Complications of MTP