MENSTRAL CYCLE And It's Abnormalities

1. MENSTRAL CYCLE AND IT’S
ABNORMALITIES
FACILITATOR: DR.GACHUNO
PRESENTER: DR.DORIS
Group 2 Members: DR.CHARLES
DR.MUGAMBI
DR.TEHUNZER
DR.ZAHRA
19th October 2023

2. Outline
 Introduction/Overview
 Physiology of menstrual cycle
 Ovarian cycle
 Endometrial cycle
 Cervical, tubal and vaginal cycles
 Abnormalities of the menstrual cycle
 References

3. Overview
 Menstruation: is the visible manifestation of cyclic physiologic uterine bleeding
due to shedding of the endometrium.Requires
• HPO axis to be actively coordinated
• Endometrium responsive to ovarian hormones (estrogen,progesterone)
• Patent outflow tract
 Menarche: The first menstruation . Occurs between 11- 15 years, with a mean of
13 years.Studies show age of menarche is gradually declining with improvement of
nutrition and environmental condition.
 Menstrual cycle: the period extending from the beginning of a period to the
beginning of the next period.
 Menopause: is the permanent cessation of menstruation that result from loss of
ovarian follicular activity.

4. Important Numbers
 Menarche: 11-15 years
 Menstrual cycle: 21-35 days with a mean of 28 days.
 Duration: 4-5 days
 Estimated blood loss: 20-80ml with an average of 35mls. Nearly 70% of total blood loss
occurs in the first 2 days..
 Menopause: 45-50 years

5. Ovarian Cycle
These ovarian changes constitute the:
(1) The follicular phase (day 1 to 13),
(2) Ovulatory phase (day 13 to 15)
(3) The luteal phase (day 15 to 28).
 The luteal phase is always constant 14
days(secretory phase)

6. Follicular phase
 Constitutes the development and maturation of a
follicle,ovulation,formation of corpus luteum
 Consists of :
 Recruitment of groups of follicles
 Selection of dominant follicle and its
maturation
 Ovulation
 Corpus luteum formation

7. Follicular phase
 Recruitment of groups of follicles-(5 to 20 preantral)
Initial recruitment and growth of primordial follicles are not under the
control of any hormone.
 FSH(due to low estrogen and progesterone) needed for eventual
maturation
 Granulosa cells develop FSH receptors
 Selection of dominant follicle(day 5-7) and its maturation
 Follicle with highest antral concentration of estrogen and low
androgens and highest FSH receptors
 Enlargement of granulosa cells with lipid inclusion
 FSH induces LH receptors
 Theca cells become more vascular than those of other antral
follicles.. Separated from granulosa cells by membrana granulosa

8.  A fully mature graafian follicle prior to ovulation measures about 20mm.
 Composed of(outside inward)
 theca externa
 theca interna
 membrana granulosa
 discus proligerus
 antrum containing vesicular fluid

9. Ovarian cycle
 Ovulation
 Dominant follicle reaches surface of ovary
 LH surge(24-48hrs prior to ovulation) from anterior pituitary
 Cumulus detaches from wall of follicle
 Stigma develops and penetrates the outer surface layer of
ovary.
 Oocyte oozes out with corona radiata takes about 60-
120secs
 Completion of 1st meiotic division.

11. Corpus Luteum formation
 Ruptured graffian follicle develops into corpus luteum and undergoes
four stages of development(under the influence of LH)
 Proliferation: granulosa cells undergo hypertrophy, become lipid
filled
 Vascularization: capillaries grow into granulosa layer, within 24hrs
of rupture of follicle.
 Maturation: attains full size of 1-2cm, approximately 7-8 days
following ovulation.theca interna cells become hypertrophied.
 Regression: starts on 22-23rd day of cycle if fertilization doesn’t
occur. Life span is about 12-14 days.If fertilization occurs,its
converted into corpus luteum of pregnancy.
Main function of CL is production of progesterone and estrogen

12. Corpus luteum of pregnancy
-In pregnancy: There is a surge of hyperplasia of
all layers between 23rd-28th day due to chorionic
gonadotropin.
-hCG also stimulates the corpus luteum to
secrete progesterone. The growth reaches peak
at about the 8th week.
-The turnover function from corpus luteum of
pregnancy to placenta is called luteal-placental
shift and continues from 7- 10 weeks.

13. Ovarian Cycle

16. Endometrial Cycle
The endometrium consist of surface epithelium, glands, stroma and blood vessels. It has two distinct
divisions:
 Basal zone
 1/3rd of the total depth
 Lies in contact with the myometrium
 Uninfluenced by hormones and as such no cyclic changes are observed
 Measures about 1mm
 Functional zone
 Under the influence of fluctuating cyclic ovarian hormones
 Estrogen
 Progesterone
 Undergoes 4 phases

17. Phase of Regeneration
• Starts even before menstruation ceases
• Ends 2-3 days after menstruation ceases
• Vessels grow from stumps in the basal zone
• Stroma and glands regenerate from remnants in
the basal zone
• Thickness averages 2mm
• Glands are lined by cuboidal epithelium and lie
parallel to the surface

18. Phase of proliferation
 Extends from 5th or 6th day to 14th day (till ovulation)
 Glands become tubular, lie perpendicular to the surface
 The epithelium becomes columnar
 The epithelium of one gland becomes continuous with the neighbouring gland.
 Stromal cells become spindled shaped with evidence of mitosis
 Spiral vessels extend unbranched to a region below the epithelium where they
form loose capillary networks
 Thickness measures 10-12mm at time of ovulation.

19. Secretory phase
 Begins day 15 and ceases 5-6 days prior to menstruation
 Endometrium has receptors for progesterone which are
primed by estrogen
 Blood vessels undergo marked spiraling
 Glands become engorged, cock screw shaped and secrete
nutritive fluids
 Stromal cells become swollen and large

20. Menstrual phase
• Regeneration of corpus luteum leads to regression of estrogen and progesterone
levels
• Stasis of blood and spasms lead to damage of arteriolar walls
• Auto-digestion by proteolytic enzymes
• Leukocyte and monocyte invasion occurs
• Bleeding from damaged arteries, veins and capillaries and stromal hematoma
• Coagulated blood in uterine cavity broken down by plasmin enabling it to flow
• Endometrial flow stops due to prolonged vasoconstriction, myometrial contraction,
platelet aggregation
• Estrogen facilitates clot formation at blood vessel stumps
• Prostaglandins aid in arteriolar constriction and myometrial contraction

21. - Composition of menstrual discharge;
 Dark altered blood
 Mucus
 Vaginal epithelial cells
 Fragments of endometrium
 Prostaglandins
 Enzymes
 Bacteria; lactobacillus spp

22. Cervical cycle
 Progesterone rises the tone of the muscles of the
isthmus and internal os so the cervical ‘sphincter’ is
tighter and more competent during the luteal than
follicular phase
 The glandular elements proliferate during the follicular
phase and the epithelial cells become taller and
secrete a mucus which will stretch into threads
 During the follicular phase the cervical mucus absorbs
water and salts and when allowed to dry, deposits
crystals of sodium chloride and potassium chloride in a
characteristic fern pattern

23. Cervical cycle cont.
The cervical mucus is so profuse at the time of
ovulation that it may be noticed as a vaginal
discharge
Its special character at this time, (low protein
content) makes it easy for spermatozoa
penetration
During luteal phase, cervical glands become
more branched, and their secretion becomes
mores viscous forming a secure cervical plug.

24. Cervical cycle
Cervical characters Follicular phase Luteal phase
Internal os Funnel-shaped Tightly closed
Mucus Thin and watery Thick and viscid
Stretchability Increased to beyond 10cm Lost
Fern tree pattern Present Lost
Glycoprotein network Parallel, thus facilitating sperm
penetration
Interlacing bridges, preventing
sperm penetration
Glandular epithelium Taller Glands-more branched

25. Vaginal cycle
 The fully oestrogenic smear, evident during the late
follicular phase, contains a preponderance of large
cornified epithelial cells with pyknotic (condensed)
nuclei.
 These stain pink with eosin.
 During the luteal phase the smear shows evidence of
increased desquamation, many of the cells having
rolled edges, and is characterized by the
reappearance of clumps of intermediate cells and the
presence of leucocytes.
 The maturation index, which is the percentage of
superficial, intermediate and parabasal cells in a
vaginal smear is used as a measure of the levels of
hormones in circulation. It is a useful guide but is not
so precise as assaying the estrogen in blood.

26. Vaginal cycle
Cellular characters Follicular phase Luteal phase
Cytology Showing preponderance of
superficial large cornified cells
with pyknotic nuclei
Preponderance of intermediate
cells with folded edges
(navicular cells)
Background of the smear Clear Dirty due to presence of
leucocytes and bacilli.

27. Fallopian tube cycle
 The muscle of the fallopian tube behaves like the myometrium at
the time of ovulation. This is an estrogen effect
 The follicular phase is marked by slight proliferation, and
continuing to premenstrual phase then regresses
 During menstruation there is further shrinkage and slight shedding
of the surface epithelium.
 The secretory activity of the tubes is also cyclical, being highest
before ovulation and in response to oestrogen.

28. Menstrual Symptoms
 Vaginal bleeding
 Pelvic discomfort
 Mastalgia
 Breast fullness
 Headache
 Depression
 Low back pain
 Lethargy, Headaches

29. DISORDERS OF MENSTRUATION

30. Dysmenorrhoea
 painful menstruation of sufficient magnitude so as to
incapacitate day-to-day activities.
 Primary (spasmodic)
 Secondary(congestive)
 Other disorders of menstrual pain
 Premenstrual syndrome
 Mittelschmerz’s syndrome (ovulation pain)

31. Prevalence.
 Primary dysmenorrhea is the most commonly reported gynecological and
menstrual disorder.
 Primary dysmenorrhea is a significant contributor to approximately 10% of
incapacitating severe menstrual pain among females during adolescence and
early adulthood.
 It affects millions of women during their reproductive years
 Globally, the previous epidemiological investigations have reported that the
magnitudes of dysmenorrhea ranges from 41.7% to 94%.
 In sub-Saharan Africa, the prevalence of primary dysmenorrhea ranges also
from 51.1% to 88.1%.
 In addition, it is severe enough to result in a significant socioeconomic
dysfunction and disability particularly in adolescents and young women

32. Primary/idiopathic dysmenorrhea
(Spasmodic)
• Recurrent crampy lower abdominal pain.
• No identifiable pelvic pathology
• Almost always in adolescents
• Confined to Ovulatory cycles
• Related to dysrhythmic uterine contractions and
hypoxia.

33. Causes of primary dysmenorrrhoea
• Psychosomatic factors
• Uterine myometrial hyperactivity
• Over activity of sympathetic nerves 
hypertonicity of isthmus and internal os
• Increased prostaglandin production,vasopressin
and endothelin.
• Platelet activating factor

35. Signs and symptoms
• Usually in teenage girls.
• Pain starts just before or at onset of menstrual period.
Lasts 24 to 48hrs
• May radiate to back or medial aspect of thighs
• Associated symptoms: nausea, vomiting, fatigue, diarrhea,
headache and tachycardia
• Rarely syncope and collapse
• Pelvic and abdominal exam normal

36. Management
 Expectant management
 Assurance
 Local heat
 Weight reduction
 Encourage activities
 Drugs
 Prostaglandin synthetase inhibitors
 Oral contraceptives
 NSAIDs
 Surgery
 Transcutaneous electrical nerve stimulation (TENS)
 Cervical dilatation
 Laparoscopic presacral neurectomy
 Laparascopic uterine nerve ablation(LUNA)

38. Secondary/acquired dysmenorrhea
(Congestive)
Menstruation associated pain attributed to an underlying pelvic pathology.
 Causes:
 Cervical stenosis,
 chronic pelvic infection,
 pelvic endometriosis,
 pelvic adhesions,
 adenomyosis,
 uterine fibroid,
 endometrial polyp,
 IUCD in utero
 Pelvic congestion
 Obstruction due to Mullerian anomalies

39. Clinical features
• Dull pain in the front and back no radiation
• Older/parous women
• Appears 7-10 days before period and disappears
with onset of bleeding
• Usually, no systemic discomfort
• Abdominal and vaginal examinations reveal
underlying pathology
• May be associated with dyspareunia and abnormal
bleeding.

40. Diagnosis of secondary dysmenorrhoea
-Bimanual exam:
• uterine or adnexal tenderness,
• fixed uterine retroflexion,
• uterosacral nodularity, pelvic mass, enlarged irregular
uterus
-Investigation using ultrasound scan, biopsy, cervical and
vaginal cultures may be required

41. Treatment
 The treatment aims at the cause rather than the
symptoms.
Endometriosis: COCP, progesterone GnRH
analogues
Antibiotics for PID
Relief of obstruction (usually surgical)
Therapeutic laparoscopy for
endometriosis,adhesions and complicated PID.
Symptom control-Analgesics,mefenamic acid.

42. Premenstrual syndrome
• Is a psychoneuro- endocrine disorder of unknown
etiology
• Often noticed just prior to menstruation
• cyclic appearance of symptoms during the last 7-10
days of menstrual cycle.
• Common in women aged 30-45years.
• When these symptoms dysrupt daily functioning they
are grouped under the name: Premenstrual
Dysphoric Disorder (PMDD)

43. Diagnostic criteria PMDD (ACOG)
 Not related to any organic lesion.
Regularly occurs during the luteal phase of each ovulatory
menstrual cycle.
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.

44. Signs and symptoms

45. Treatment
 Nonpharmacological:
 Assurance, Yoga, Stress management, Diet manipulation.
 Avoidance of salt, caffeine and alcohol specially in second
half of cycle
 Non hormonal:
 Tranquilizers or antidepressant drugs
 Pyridoxine – 100 mg twice daily
 Diuretics in the second half of the cycle
 Anxiolytic agents -Alprazolam 0.25 mg, BID
 Selective Serotonin Reuptake Inhibitors (SSRI)

46. Treatment cont.
 Hormones
 Oral contraceptive pills: suppress ovulation and maintain a uniform
hormonal milieu.
 Progesterone: not effective in treating PMS.
 Spironolactone: given in the luteal phase (25–200 mg/day)
 Bromocriptine: to relieve the breast complaints. (2.5mg/ day)
 Suppression of ovarian cycle
 Danazol
 GnRH analogues: zoladex, decapeptyl, prostap
 Oopohrectomy:
 last resort

47. Mittelschmerz’s syndrome (ovulation
pain)
 Appears in the mid menstrual period
 Situated in the hypogastrium or in either of the iliac fossa
 Rarely last more than 12 hours
 Maybe associated with slight vaginal bleeding or excessive
mucoid vaginal discharge.
 Exact cause is unknown, probable factors:
 Increase tension of graffian follicle prior to rupture
 Peritoneal irritation by the follicular fluid following
ovulation
 Contraction of the tubes and uterus

48. AMENORRHOEA
 Amenorrhoea means absence of menstrual periods.
 Primary amenorrhea:
Lack of menstruation by age 16years in the presence of
secondary sexual characteristics.
Lack of menstruation by age 14 years in the absence of
secondary sexual characteristics.
 Secondary amenorrhea: absence of menstruation for 6
months or more in a woman that previously had established
menstrual cycle.

49. There are at least 5 basic factors involved in
the onset and continuation of normal
menstruation:
I. Normal female chromosomal pattern
II. Coordinated HPO axis
III. Anatomical presence and patency of outflow tract
IV. Responsive endometrium
V. Support from thyroid and adrenal glands

50. Causes of primary Amenorrhoea
1) Anatomical defects/developmental defects of genital tract.
-Mullerian agenesis
-Gonadal agenesis e.g., in Turner’s Syndrome (Abnormal sex chromosomes leading to hypergonadotropic
hypogonadism)
-Imperforate hymen
-transverse vaginal septum
-isolated absence of uterus, vagina or cervix
-Atresia upper third of vagina and cervix
2) Elevated Follicle-stimulating Hormone
-High levels of FSH can cause ovarian failure
3)Hyperprolactinemia
-High prolactin levels causes inhibition of Gonadotropin releasing hormone which negatively modulates the secretion of
pituitary gonadal secretion.
-Can be caused by Pituitary Tumors like Prolactinomas

51. Causes of amenorrhoea
4) Hypothalamic Amenorrhea
-Hypothalamic dysfunction causes decrease/inhibits GnRH secretion which affects the pulsatile
release of FSH and LH resulting in anovulation or abnormal release of hormones (functional
hypothalamic amenorrhea)
5) Abnormal chromosomal patterns
 Turner’s symdrome
 Partial deletion of X chromosome
6) Polycystic Ovary Syndrome
-most common cause of amenorrhea in women
-It is the result of excessive androgens
7) Metabolic disorders and other systemic illnesses
8) Other Endocrine disorders that cause hypogonadotropic hypogonadism include; congenital
adrenal hyperplasia and Cushing Syndrome,dysfunction of the thyroid.

52. Assessment of primary amenorrhoea
 Always exclude pregnancy in all females with
amenorrhoea—pregnancy test
 Initial hormone tests
- Prolactin
-TFT’s
-LH and FSH
-Testosterone
-Progesterone withdrawal test
 Karyotyping for those with absent uterus,primary
ovarian insufficiency and chromosomal abnormalities.
 Radiological imaging-pelvic ultrasound.
-Management is treatment of underlying cause

54. Secondary amenorrhoea

55. Table 54-1 current diagnosis & treatment obstetrics
&gynecology 11th edition

56. Polycystic ovarian syndrome(PCOS)
 Syndrome of ovarian dysfunction along with cardinal features of
hyperandrogenism and polycystic ovary morphology (Rotterdam
criteria 2003)
 Clinical syndrome causing; menstrual irregularities,
hirsutism,acne,pelvic pains, obesity, insulin resistance,
subfertility, recurrent miscarriage, acanthosis migrans,
 Laboratory investigations: serum levels of
 FSH
 LH
 TSH
 Total testosterone
 Prolactin
 OGTT
 laparascopy
 Ultra sound scan: eight or more sub capsular follicular cysts
>10mm with increased ovarian stroma

57. Diagnosis of PCOS

58. PCOS management
 Oligomenorrhoea and amenorrhea:
 Medroxy progesterone acetate 10mg for ten days
 Insulin resistance
 Metformin
 Hirsutism
 Cyproterone acetate: competitive inhibition of androgen
receptor 2mg with 35mcg of ethinylestradiol
 GnRH analogues reserved for resistant cases
 Laser therapy to destroy hair follicle
 Subfertility
 Clomiphene or letrozole
 Weight loss with dietary modification or medication.

59. Abnormal uterine bleeding (AUB)
 Any uterine bleeding outside the normal
volume,duration, regularity or frequency outside of
pregnancy.
 Patterns of AUB
Menorrhagia-(heavy periods>80mls or >7 days)
Metrorrhagia ( intermenstrual bleeding)
Polymenorrhea (shorter cycles <21 days)
Oligomenorrhea(cycles >35days)
Hypomenorrhea(light/scanty periods)

60. Etiology of AUB
 PALM-COEIN (FIGO-2021)
 The acronym PALM-COEIN subdivides all the causes of AUB into 9 categories.
 PALM- are structural or histologic causes
 COEIN- nonstructural causes
 In this classification the acronym AUB is followed by PALM-COEIN and a subscript 0 or 1 to
indicate absence or presence of the abnormality.
 Example patient with AUB due to adenomyosis
 AUB:P0A1 L0 M0 -C0O0E0I0N0

62. Heavy menstrual bleeding (HMB)
• Is the most common type of AUB disorder
• Blood loss of greater than 80mls per period.
• Common causes:
• Fibriods
• Pelvic endometriosis
• Adenomyosis
• Chronic tubo-ovarian mass

63. HMB Associated Symptoms
• Irregular bleeding
• Symptomatic or non symptomatic anaemia
• Intermenstrual bleeding
• Postcoital bleeding
• History of PPH
• Unusual vaginal discharge
• Abdominal mass

64. AUB Investigations
• Pelvic and cervical exam.
• FBC
• Coagulation screening
• Pregnancy test.
• Pelvic USS
• High vaginal and endometrial swabs
• TFT
• Endometrial biopsy
• Hysteroscopy

65. AUB Management
• Tranexamic acid 3 times daily/mefenamic
acid
• COCP
• Progesterone
• Endometrial ablation
• Hysterectomy/umbilical atery ebolization
• Myomectomy
• Correct anaemia

66. REFERENCES
 DC Dutta’s textbook of gynaecology
 Basic science in obstetrics and gynaecology
 Gudipally, P.R. and Sharma, G.K. (2021). Premenstrual Syndrome. [online] PubMed.
Available at: https://www.ncbi.nlm.nih.gov/books/NBK560698/.
 Doctorlib.info. (n.d.). Amenorrhea - Current Diagnosis & Treatment Obstetrics &
Gynecology, 11th Ed. [online] Available at: https://doctorlib.info/gynecology/current-
diagnosis-treatment-obstetrics-gynecology/54.html.
 International journal of Women’s health.ISSN: (Print) (Online) Journal
homepage: https://www.tandfonline.com/loi/djwh20
https://doi.org/10.2147/IJWH.S384275