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MENSTRUATION AND
MENSTRUAL DISORDERS
Asomma Kubire
Objectives
• Understand hormonal changes in menstrual
cycle
• Understand ovarian changes in menstrual
cycle
• Understand e...
Stages of menstrual cycle
•
•
•
•
•
•

Follicular phase (Proliferative phase)
Luteal phase (Secretory phase)
Cycle ranges ...
Organs involved in menstrual
cycle
•
•
•
•

Hypothalamus
Anterior pituitary
Ovary
Uterus (Endometrium)
Hormones in menstrual cycle
• Gonadotrophin Releasing Hormone
(GnRH)
• Follicle Stimulating Hormone (FSH)
• Luteinising Ho...
Pituitary and Hypothalamic events
• Atrophy of the corpus luteum with falling
progesterone and estrogen levels initiates t...
Ovarian events
• FSH causes development of 18-20 follicles
• Developing follicles produce estrogen through
action of FSH a...
Post ovulatory events
• Corpus luteum (CL) is formed after
ovulation
• CL produces progesterone and estrogen
• Hormones fr...
Hormonal Events
• Negative feedback
• Positive feedback
• LH surge starts 34-36 hours before
ovulation
• Peak of LH surge ...
Ovarian Events
• Stages of follicle development – primordial,
primary, secondary, tertiary, graafian
• Recruitment of foll...
Endometrial Events
• Changes are due to estrogen and
progesterone
• Proliferative phase is characterised by
increase in gr...
Endometrial events
• Luteal phase changes are used to date the
the cycle
• Day 16 – pseudostratification and
subnuclear va...
Endometrial events
• Day 21,22 – edematous endometrial stroma
• Day 23 – stromal mitosis starts
• Day 24 – predecidual cel...
Menstrual disorders
• Dysmenorrhea
• Menorrhagia
• Amenorrhea
Menstrual disorders
• Dysmenorrhea: Painful lower abdominal
cramps occurring just before or during the
menses
• Primary dy...
Menstrual disorders
• Primary dysmenorrhea is due to
abnormalities of prostaglandin metabolism
• Secondary dysmenorrhea – ...
Treatment of dysmenorrhea
• Primary: NSAIDS and oral contraceptives
• Secondary: Treatment of underlying cause
Menstrual disorders
• Menorrhagia is prolonged (more than 7
days) or excessive (over 80ml) uterine
bleeding occrring at re...
Menstrual disorders
• DUB is due to abnormalities of
prostaglandin metabolism
• Menorrhagia – gynaecolgical causes,
endocr...
Causes of menorrhagia
•
•
•
•
•

Uterine fibroids
Adenomyosis
Endometrial CA
Hypothyroidism
Bleeding disorders
Menstrual disorders
• Amenorrhea: absence of menses during the
reproductive years
• Primary amenorrhea: Absence of
spontan...
Causes of secondary amenorrhea
•
•
•
•
•
•
•
•

Pregnancy
Anovulation
PCOS
Intrauterine synechiae
Secondary Vaginal atresi...
Causes of primary amenorrhea
• Turner’s syndrome
• CNS tumours
• Androgen insensitivity
(Testicular feminisation
syndrome)...
Investigation of secondary
amenorrhea
•
•
•
•
•
•
•
•
•

History and examination
Pregnancy test
Progesterone challenge
FSH...
Investigation of primary amenorrhea
•
•
•
•
•
•
•
•

History
Examination
Chromosomal studies
FSH, LH assay
Serum prolactin...
Menstruation and menstrual disorders
Menstruation and menstrual disorders
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Menstruation and menstrual disorders

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Menstruation and menstrual disorders

  1. 1. MENSTRUATION AND MENSTRUAL DISORDERS Asomma Kubire
  2. 2. Objectives • Understand hormonal changes in menstrual cycle • Understand ovarian changes in menstrual cycle • Understand endometrial changes in menstrual cycle • Identify, diagnose and treat some abnormalities of menstruation
  3. 3. Stages of menstrual cycle • • • • • • Follicular phase (Proliferative phase) Luteal phase (Secretory phase) Cycle ranges between 25 and 32 days Menstrual flow is for 4-6 days Luteal phase lasts between 12 and 16 days Luteal phase is usually reported to be of constant duration – 14 days
  4. 4. Organs involved in menstrual cycle • • • • Hypothalamus Anterior pituitary Ovary Uterus (Endometrium)
  5. 5. Hormones in menstrual cycle • Gonadotrophin Releasing Hormone (GnRH) • Follicle Stimulating Hormone (FSH) • Luteinising Hormone (LH) • Estrogen • Progesterone
  6. 6. Pituitary and Hypothalamic events • Atrophy of the corpus luteum with falling progesterone and estrogen levels initiates the menstrual cycle • Low estrogen and progesterone levels cause GnRH secretion by the hypothalamus • GnRH acts on the pituitary to secrete FSH and LH • FSH initiates development of the follicles in the ovary
  7. 7. Ovarian events • FSH causes development of 18-20 follicles • Developing follicles produce estrogen through action of FSH and LH • One follicle becomes dominant follicle • Rising estrogen levels inhibit FSH and LH • All follicles except dominant follicle undergo atresia • Rising estrogen levels from dominant follicle cause LH surge • LH surge brings about ovulation
  8. 8. Post ovulatory events • Corpus luteum (CL) is formed after ovulation • CL produces progesterone and estrogen • Hormones from CL maintain endometrium until CL undergoes atresia • Atresia of CL leads to shedding of endometrium – menses- and initiation of another cycle
  9. 9. Hormonal Events • Negative feedback • Positive feedback • LH surge starts 34-36 hours before ovulation • Peak of LH surge is 10-12 hours before ovulation
  10. 10. Ovarian Events • Stages of follicle development – primordial, primary, secondary, tertiary, graafian • Recruitment of follicles • Emergence of dominant follicle • Ovulation • Corpus luteum formation
  11. 11. Endometrial Events • Changes are due to estrogen and progesterone • Proliferative phase is characterised by increase in growth of endometrium – primarily glandular growth • Glands are narrow and tubular with mitoses and pseudostratification
  12. 12. Endometrial events • Luteal phase changes are used to date the the cycle • Day 16 – pseudostratification and subnuclear vacuoles: first sign of ovulation • Day 17 – glands are tortuous and dilated • Day 18 –vacuoles are beside nuclei • Day 19 – pseudostratiication and vacuoles have disappeared
  13. 13. Endometrial events • Day 21,22 – edematous endometrial stroma • Day 23 – stromal mitosis starts • Day 24 – predecidual cells surrounded by spiral arterioles and numerous stromal mitoses • Day 25 – predecidual cells begin to differentiate under surface epithelium • Day27 – upper portion of endometrial stroma made up of well-diffrentiated decidua-like cells
  14. 14. Menstrual disorders • Dysmenorrhea • Menorrhagia • Amenorrhea
  15. 15. Menstrual disorders • Dysmenorrhea: Painful lower abdominal cramps occurring just before or during the menses • Primary dysmenorrhea begins at or shortly after menarche • Secondary dysmenorrhea occurs well after menarche and is associated with pelvic pathology
  16. 16. Menstrual disorders • Primary dysmenorrhea is due to abnormalities of prostaglandin metabolism • Secondary dysmenorrhea – pelvic infection, uterine fibroids, endometriosis, adenomyosis
  17. 17. Treatment of dysmenorrhea • Primary: NSAIDS and oral contraceptives • Secondary: Treatment of underlying cause
  18. 18. Menstrual disorders • Menorrhagia is prolonged (more than 7 days) or excessive (over 80ml) uterine bleeding occrring at regular intervals • Dysfunctional uterine bleeding: Excessive uterine bleeding with no demonstrable organic cause
  19. 19. Menstrual disorders • DUB is due to abnormalities of prostaglandin metabolism • Menorrhagia – gynaecolgical causes, endocrine causes, haematologic causes
  20. 20. Causes of menorrhagia • • • • • Uterine fibroids Adenomyosis Endometrial CA Hypothyroidism Bleeding disorders
  21. 21. Menstrual disorders • Amenorrhea: absence of menses during the reproductive years • Primary amenorrhea: Absence of spontaneous menses in an individual older than 16 • Secondary amenorrhea: absence of menses in an individual who has previously had spontaneous menstrual periods
  22. 22. Causes of secondary amenorrhea • • • • • • • • Pregnancy Anovulation PCOS Intrauterine synechiae Secondary Vaginal atresia Hyperprolactinaemia Pituitary tumours Cushing’s syndrome • Hyperthyroidism • Premature ovarian failure • Hypothalamic pituitary dysfunction • Stress • Severe weight loss • General medical disorders • Adrenal tumours
  23. 23. Causes of primary amenorrhea • Turner’s syndrome • CNS tumours • Androgen insensitivity (Testicular feminisation syndrome) • Hyperprolactinaemia • Congenital adrenal hyperplasia • • • • • • • • Vaginal atresia Imperforate hymen Mullerian abnormalities Hyperthyroidism Late development Stress Low body weight Adrenal tumours
  24. 24. Investigation of secondary amenorrhea • • • • • • • • • History and examination Pregnancy test Progesterone challenge FSH, LH assay Serum prolactin Thyroid function tests CT scan / lateral skull X-ray Hysterosalpingogram USG
  25. 25. Investigation of primary amenorrhea • • • • • • • • History Examination Chromosomal studies FSH, LH assay Serum prolactin CT scan USG Laparoscopy

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