Mensturation

1. Dr.Chaduvula Suresh Babu
Professor
Department of OBGYN
GIMSR
Visakhapatnam, AP, India

2.  Definition: The visible manifestation of
cyclic physiologic uterine bleeding due to
shedding of the endometrium.
 Due to invisible interplay of hormones
through hypo-thalamo-pituitary-ovarian axis.
 For menstruation to occur axis should be
active , endometrium should be receptive
and outflow tract should be patent.

3.  The period extending from first day of period
until the 1st day of next period.
 Normal length of a cycle is between 28-32
days. Mean – 28 days.
 It occurs cyclically between 21-35 days.
 Menarche: First menstruation
 Age of onset – 11-15 years &average is 13
years

4. Ovaries
Reproductive tract
Other targets
Steroids
Feedback
Hypothalamus
GnRH (gonadotrophin
releasing hormone)
Pituitary
LH
FSH
+ (“gonadotrophins”)
Menstruation is an
external indicator of
ovarian events
controlled by the
hypothalamic-pituitary
axis
Roles of the ovary
1. Gametes (ova)
2. Hormones
MENSTRUATION
(oestradiol,
progesterone).

5.  Menstruation ceases between 45-50 years.
 Duration – 4-5 days
 Amount – 20-80 ml
 Menstrual discharge consists of blood,
mucus,
epithelial cells, fragments of endometrium,
prostaglandins, enzymes and bacteria.

6.  Menstrual cycle is divided into
 1] Ovarian
 2] Endometrial cycle

7. 0 4 8 12 16 20 24 28
Day 1
Menstruation
Day 1
LH
OVULATION
Days before Days after
Follicular
phase
Luteal
phase

8.  Development and maturation of a follicle,
ovulation and formation of corpus luteum
and its degeneration
 All these events occur in 4 weeks
 1] Recruitment of group of follicles
 2] Selection and maturation of dominant
follicle
 3] Ovulation
 4] Corpus luteum formation and
degeneration

9.  Out of many primordial follicles only 20
antral follicles are developed in each cycle.
 All these follicles from 2-5 mm size are
influenced by FSH.
 Those follicles not influenced by FSH will
become atretic.
 Oocyte of each follicle grow out of
proportion.Oocyte is surrounded by acellular
glycoprotein from follicular cells called Zona
pellucida

10.  Flattened outer pregranulosa cells will
become Granulosa cells. These cells contain
FSH receptors.

11.  Dominant follicle is called as Graafian
Follicle out of 30-50 follicles from many
primordial follicle.
 Starts from 5-7 days
 Follicle with high oestrogen and with
maximum FSH receptors in granulosa cells
will become a dominant one.
 Rest of follicles will become atretic by 8th
day.

12. 0 4 8 12 16 20 24 28
LH
Day 1
Menstruation
OVULATION
Animated ovarian events
Oestradiol
1. Follicular
growth
Key events in the ovarian
cycle

13. Growth of follicles:
Primordial
follicle
Antral follicle Graafian
follicle
Granulos
a cells Thecal
cells
Oocyte
Antrum
(fluid filled
space)
Ovulation

14. Menstruation
Ovulation
How many follicles are
growing at the start of
the cycle?
Many! 30-50
2-3
months
earlier!
Why is only 1
selected and
becomes
“dominant”?

15. Menstruation
Ovulation
OVULATORY FOLLICLE
FSH
+ LH
??????
Gonadotrophin
independent

16. Menstruation
Ovulation
OVULATORY FOLLICLE
As each follicle grows, it produces
increasing amounts of oestradiol.
FSH
+ LH
OESTRADIOL

17.  Cumulus oophorus or Discus proligerous
anchors the ovum to to the wall of follicle
 Corona radiata – radially arranged cells around
the ovum
 At this stage FSH induces LH receptors in
granulosa cells of dominant follicle
 LH receptor induction is essential for mid cycle
LH surge for ovulation and lutenisation of
granulosa cells to form corpus luteum and
secretion of progesterone

18.  Graafian follicle measures 20 mm before
ovulation
 It has following layers from outside inward
 1] Theca externa
 2] Theca interna
 3] Membrana granulosa
 4] granulosa cell layer
 5] discus proligerous
 6] corona radiata woth ovum inside
 And 7] antrum with fluid

19. Theca
Granulosa
cells
Cumulus
cells
Blood vessels
Antrum
Oocyte
Zona pellucida
(non-cellular glycoprotein coat)
The follicle is the fundamental element of the
ovary:

20.  Fluid contains:
 1]Oestrogens
 2] FSH
 3] traces of androgens
 4] Prolactin
 5] OMI-oocyte maturation inhibitor
 6] LI – lutenisation inhibitor
 7] Inhibin
 8] Proteolytic enzymes
 9] Plasmin

21.  Total duration - 3 months
 Upto antral stage of 1mm – 2months
 Upto 5 mm stage – 2 weeks
 Upto 20 mm – 2 weeks

22.  Causes:
 1] LH surge – secondary to sustained peak
level of estrogens in the late follicular phase.
This will cause completion of reduction
division in the oocyte and lutenisation of
granulosa cells, synthesise progesterone
andprostaglandins.
 2] FSH rise- leads to plasminogen and it
helps in lysis of follicle.

23.  3] Stretching factor – Necrobiosis of wall due
to passive stretching
 4] Contraction of micromuscles in theca
externa

24.  Following ovulation the follicle is changed to
corpus luteum.
 Ovum will be picked up by fallopian tube and
may fertilise or degenerate.

25.  Life cycle is divided into 4 stages:
 1] stage of proliferation
 2] stage of vascularisation
 3] stage of maturation and
 4] stage of regression

26.  Stage of Proliferation:
 Granulosa cells will become polyhedral and enlarged and
with lipids –looks greyish yellow called granulosa lutein
cells
 Stage of vascularisation: small capillaries grow towards
granulosa layer.
 Stage of maturation:
 After 1 week reaches 1-2cm and a carotene pigment will
give a yellow color
 Stage of regression: on 22 -23 day regression starts.Lutein
cells become atrophic and will become white called
Corpus Albicans / if pregnancy occurs it will become
Corpus luteum of pregnancy.

27.  1] FSH induces LH receptors and LH surge
causes lutenisation of granulosa cells and
progesterone secretion.LH scretion should be
continuous for function of corpus luteum
 2]17 alfa–OH–progesterone and estradiol
 3] Low level of prolactin
 Life span of Corpus luteum is 12-14 days.

28.  1] Progesterone
 2] Oestrogen
 3] Inhibin
 4] Relaxin
 In absence of pregnancy levels of O+P+I
decreases leading to rise in FSH and this in
turn leads to recruitment of new follicles

29.  At 7- 10 weeks corpus luteum function will
be taken up by Placenta

30.  Endometrium contains
 surface epithelium,
 glands,
 stroma and
 blood vessels
 Endometrium has 2 zones:
 1] Basal [ stratum basalis ]
 2] Superficial functional zone

31. 0 4 8 12 16 20 24 28
Menstruation
OVULATION
Oestradiol
causes an
increase in
thickness (the
“proliferative
phase”)
More secretion
from the glands –
hence the term
“secretory phase”
Endometria
l depth

32. 0 4 8 12 16 20 24 28
Menstruation
Characteristic “spiral
arteries”
Terminal differentiation of
stromal cells –
“decidualisation”
Optimal time for
implantation

33.  Stratum Basalis:[ 1mm ]
 Ocupies 1/3 of endometrium – basal arteries+
 Not influenced by hormones
 Regeneration occurs from it.
 Functional zone:
 Responds to hormones like O+P
 In an ovulatory cycle four stages are seen.

34.  1] Stage of regeneration
 2] Stage of Proliferation
 3] Secretory phase
 4] Menstrual phase

35.  Stage of regeneration:
 Starts before menstruation and completes after 2-3
days after periods. Measures 2mm.
 Glands are lined by cubical cells
 Stage of Proliferation:
 Extends from 5-6th day to 14th day due to
Estrogens.Glands are tubular and perpendicular to
surface.
 Epithelium is columnar with nuclei at base, stromal
cells are spindle shaped with spiral vessels upto
epithelium. Subepithelial congestion +. Measures 3-
4 mm.

36.  Secretory Phase:
 Effects of O+P
 Oestrogen induces Progesterone receptors and
progesterone is responsible for secretory phase.
 Starts at 15th day to 5-6 days prior to
menstruation.
 Epithelium is more columnar and ciliated.
 Glands increase in size with taller epithelium
with vacuoles formation- subnuclear
vacuolation.

37.  First and earliest effect of progesterone is
appearence of subnucleolar vacuolation.It will
persist upto 21 days.
 Saw toothed glandular epithelium, glands
become corkscrew shaped with marked spiralling
of vessels.
 Measures 6-8 mm.
 Regresssion of endometrium starts 24-48 hrs
prior to periods.
 Marked spiralling of vessels and withdrawl of
hormones causes tissue hypoxia and anoxia.

38.  Degeneration and casting off endometrium
due to regression of corpus luteum with fall
in level of O+P.
 Degeneration is due to stasis of blood and
spasm of vessels leading to damage of vessels
with escape of blood.
 Proteolytic enzymes from lysosomes causes
local damage.[ Enzymatic autodigestion ]

39. Steroid
levels
fall This is followed
by the onset of
menstruation

40.  Prolonged vasoconstriction
 Myometrial contraction
 Local aggregation of platelets
 Endothelin and platelet activating factor are
potent vasoconstrictors.

41.  Oestrogens
 Growth factors

42.  At menstruation Oestrogen and inhibin are at low levels and high
FSH.
 Oestrogen increases gradually and FSH decreases and remains
static at day 5.
 O+ LH and androgen increases.
 Matuaration of follicle is combined effect of FSH and LH/
 Peptides –Inhibin, Activin and Follistatin
 Growth Facors – IGF, EGF from theca cells – modulate FSH,LH and
peptide actions.
 IGF stimulates aromatase activity and progesterone synthesis.
 Progesterone will increase in secretory phase until 5 days before
periods.
 LH will start declining

43.  It occurs after 10-12 hrs following LH surge.
 It occurs after 24-36 hrs following Oestradiol
peak of 200 pg/ml
 Progesterone peaks at 8th day after LH surge.

44.  Datting of endometrium – Examination of
endometrium
 Luteal phase defect – A discrepancy of more
than 2 days in the postovulatory phase when
endometrium is examined
 A woman can have periods without ovulation.

45. 0 4 8 12 16 20 24 28
Menstruation
OVULATION
Cervical
mucus
Variable
number of
“dry” days
Production
of low
viscosity
mucus
increases
Abundant mucus -
like “raw egg white”
Thick, rubbery, high
viscosity - impenetrable
to sperm.

46. With increasing oestradiol:
1. The mucus becomes more abundant - up to
30x more and its water content increases.
2. Its pH becomes alkaline.
3. Increased elasticity – ("spinnbarkeit test")
5. “Ferning pattern” caused by the interaction of
high concentrations of salt and water with
the glycoproteins in the mucus.
Characteristic fernlike pattern as
the mucus dries on a glass slide.

47. 0 4 8 12 16 20 24 28
Menstruation
OVULATION
LH
36
36.2
36.4
36.6
36.8
37
37.2
37.4
37.6
37.8
38
A small (0.5 oC) rise in BBT
typically follows
ovulation.
Basal body temperature

48. Basal body temperature
Plasma oestradiol
Plasma progesterone
Volume of cervical mucus – and
sperm penetration
Uterine endometrium

49. a) Calendar Method - which is essentially based on
the previous menstrual history.
b) Temperature method - using a midcycle rise in
body temperature as a sign when ovulation has
occurred.
c) Cervical changes - which can be detected by
feeling the cervix and cervical mucus.
d) Hormonal methods - using over-the-counter "kits"
to assess urinary hormone levels.
There are a number of potential ways of trying to
identify the “fertile” period..: