THE MENSTRUAL CYCLE

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DR. UTOO, B. TERKIMBI
(MB, BCh; FWACS, FMCOG)

Lecturer/Consultant Obstetrician &
Gynaecological Surgeon
Obstetrics/Gynaecology Department
CHS,BSU /BSUTH, MAKURDI.
OUTLINE
Introduction
Embryology
Ovarian cycle
Endometrial cycle
Mechanism of menstrual
bleeding
Menstrual symptoms
Conclusion
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INTRODUCTION
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.
Menstruation- It is the visible
manifestation of cyclical physiological
uterine bleeding due to shedding of the
endometrium.

This follows invisible interplay of
hormones mainly through the
hypothalamo-pituitary-ovarian axis.


Introduction cont.
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Menarche-11-15 years; mean=13years.
The period extending from the
beginning of a period to the beginning of
the next one is called menstrual cycle.
Menstrual cycles occur between
menarche and menopause.
Mean age of menopause is 51 years.
Cycle length-21 to 35 days, mean=28
days.

Introduction cont.
The cycle is usually irregular just after
menarche and one or two years before
menopause.
Duration of menstruation- 2 to 7 days.
Amount of blood loss 20 to 80 mls
AV.=35mls.
Menstrual discharge consist of; Dark
altered blood, mucus, vaginal epithelial
cells, fragments of endometrium, PGs,
enzymes and bacteria.


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Introduction cont.
The length of the menstrual cycle varies
considerably among women and does not
remain constant in the same individual.

Emotional disturbances such as fear, chronic
debilitating disease, abrupt changes in climate
and other environmental factors could cause
menstrual irregularity.

Menstrual cycle is divided into two phases
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EMBRYOLOGY
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Germ Cells
Migrates from endoderm of the york sac in the
region of the hindgut into the genital ridge.
Telopheron directs this migration which is by
amoeboid activity or chemotactic mechanism.
The germ cells undergo rapid mitotic division and
by 20 weeks the number reaches 7 million.
Some enter the prophase of the first meiotic
division and are called primary oocytes
They become surrounded by flat cells from
stroma
( primordial follicles).
Embryology cont.
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Primary oocytes are arrested in the diplotene stage of
prophase of first meiotic division, until ovulation.

Prophase; Leptotene,Zygotene,Pachytene and
Diplotene).

At 20 weeks intrauterine life 7million oocytes.

At birth- 2million.

At puberty-400,000.

Only 400 ovulates during entire reproductive period.
Morphology of the oocyte
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Ovarian Cycle

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Development/maturation of a follicle
Ovulation
Formation of corpus luteum/degeneration.
The entire process last for about 4 weeks.

Recruitment (pre antral phase)
Takes 85 days and spread over 3 ovarian cycles
About 20 antral follicles(5-10/0vary) devevelop in
each cycle. This is controlled by FSH.
Ovarian cycle cont.
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Selection of a dominant follicle and its maturation

DF appear 5-7 days of the cycle.

Its selection is determine by high E
2
, low
androgen: E
2

ratio, maximum FSH receptors.

The FSH induces LH receptors on the granulosa
cells of DF. This leads to LH surge in mid cycle
with consequent ovulation, luteinisation and
secretion of P
4
.

Selection & maturation of
DF
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Ovarian cycle cont.
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Ovulation
The mature follicle which measures 20mm, just
prior to ovulation reaches the surface of the
ovary.
The cumulus detached from the wall so that the
ovum floats. This eventually escape through a
stigma near the surface of the ovary.
This is made possible by LH surge, FSH rise
plasminogen activator plasminogen
plasmin help lysis of the wall of the follicle.
A secondary oocyte in 2nd meiotic division
arrested at metaphase is released.

A mature graafian follicle
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Hormonal interplay in
normal ovulatory cycle
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Ovarian cycle cont.
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Corpus luteum formation/degeneration
Proliferation(immediate)
Vascularization(24 hours)
Maturation(7-8days)
Regression(22-23 days)
If pregnancy occurs, between 23-28 days
hyperplasia occur due to chorionic gonadotropin .
The growth peaks at 8
th
week. Regression occurs
due to low levels of hCG most frequently at 6
months.
Endometrial Cycle

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The endometrium is the lining epithelium of the
uterine cavity above the level of the internal
cervical os.

It consist of surface epithelium, glands, stromal
and blood vessels.

Two distinct divisions exist-This are; basal
zone(stratum basalis), superficial functional zone.
Endometrial cycle cont.
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The functional zone is under the influence of
fluctuating cyclic ovarian hormones, E
2
and P
4
.

The changes in the endometrium during ovulatory
cycles are divided into 4 phases.

These are;
Regenerative phase
Proliferative phase
Secretory phase
Menstruation.
Mechanism of menstrual
bleeding

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Degenerative changes vascular in origin

Stasis of blood and spasm of arterioles

Leakage of blood through damaged vessels

Auto digestion of functional zone by proteolytic
enzymes

Blood and superficial layer shed into uterine
cavity
Mechanism cont.
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Blood coagulates but soon liquefies by plasmin

Menstrual flow stops as a result of myometrial
contraction, vasoconstriction, local aggregation of
platelets, fibrin deposition

PGF
2
(particularly), PGE
2
and PGI
2
play various
crucial roles.

Peptides e.g-inhibin, activin and follistatin and
IGF modulate the action of FSH as well as LH.
Menstrual symptoms

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Vaginal bleeding
Lower abdominal pains
Dysmenorrhea( incapacitating pains)
Pelvic discomfort, backache
Fullness of breast or mastalgia
Headache, depression
PMS!!!!
An ovular menstruation

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Follicular growth without selection of DF

Rising E
2
GnRH suppression anovulation

Endometrium remains proliferative or hyperplastic

The fall of E
2
results in synchronous shedding of
endometrium and heavy menstruation.
CONCLUSION
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Menstruation is the end result of interplay of
hormones through the Hypothalamo-pituitary-
ovarian axis and local PGs leading to
endometrial shedding through a patent outflow
tract.

It is a physiological process of cyclical changes
involving the ovaries, endometrium, cervix,
vaginal and other parts of the body in general.