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The Menstrual Cycle- Anatomy and Physiology

1. Normal menstruation
a. Hormonal regulation(3
i. Pituitary hormones
1. Follicle stimulating hormone: stimulates growth and development
of ovarian follicles. As follicles grow, increasing estradiol levels
within the follicles help them respond to LH with eventual
ovulation. The follicles also produce estrogen which stimulates
endometrial growth.
2. Luteinizing hormone: stimulates maturation and ovulation of the
Graffian follicle and subsequent development of the corpus
luteum. Stimulates progesterone production which peaks after
ovulation. When implantation of a conceptus occurs in the
endometrium, hCG production signals the corpus luteum to
continue secreting progesterone to prevent shedding of the
endometrial lining. When implantation does not occur, decreasing
progesterone levels permit sloughing of the uterine lining.
Pituitary Hormones Pituitary Hormones
Hypot hal amus Hypot hal amus
Pit uit ar y Pit uit ar y
GnRH GnRH
Gonadot r opins: Gonadot r opins:
FSH FSH
LH LH
Decl ining ser umest r adiol l evel s Decl ining ser umest r adiol l evel s
Follicle Stimulating Hormone Follicle Stimulating Hormone
Est r ogen Est r ogen
Pr imit ive oocyt es
Gr af f ian f ol l icl e
Mat ur e f ol l icl e
LuteinizingHormone LuteinizingHormone
Pr ogest er one Pr ogest er one
ovul at ion
Cor pus l ut eum Cor pus al bicans
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ii. Ovarian hormones:
1. Estrogen: steroids secreted by the ovaries that prepare the
endometrium for implantation; increase motility of fallopian tubes
and have other effects on the breasts, behavior and pituitary
secretions.
a. Estradiol is the major secreted estrogen. Other types are
estrone and estriol.
b. Inhibits FSH and LH secretion during the early follicular phase.
c. Rise in estrogen 24 hours prior to ovulation initiates the LH
surge that produces ovulation.



Estrogen Estrogen
Pr epar es endomet r ium f or impl ant at ion Pr epar es endomet r ium f or impl ant at ion
2. Progesterone: a steroid secreted in large amounts by the corpus
luteum. Effects:
a. Induces progestational effects on the endometrium.
b. Stimulates development of lobules and alveoli in the breast.
c. Provide feedback to the hypothalamic and pituitary regulation
of the hormonal feedback mechanism.
d. Causes rise in BBT at time of ovulation.
b. Clinical indicators of ovulation:
i. Secretory pattern in endometrium seen on biopsy
ii. Rise in basal body temperature (BBT). BBT is the temperature
taken on awakening and before activity. Persistent elevation of 0.5 -
1.0 F reflects ovulation.
c. Enzyme Factors: estrogen focuses enzymes to help form the basement
membrane of the endometrium. Enzymes also participate in the
biochemical process that results in glycogen stores in the endometrium
and alter the micro-vasculature to allow nutrients to flow more easily
between cells and blood vessels.
d. Vascular factors: coiled arterioles which supply blood to the outer
functionalis layer constrict 4-24 hours prior to beginning of menstruation.
Cause ischemic changes to the endometrium and eventually sloughing off.
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2. Uterine response
a. Menstrual phase (Days 1-5)
i. Physiologic changes: endometrial and degenerative changes cause
tissue necrosis at the end of the secretory phase.
1. Basalis layer remains
2. About 2/3 of endometrium are lost with each ovulatory cycle and
by the time brisk flow ceases, most tissue loss has occurred from
shedding of the superficial or functionalis layer.
b. Proliferative phase (Days 6-14)
i. Physiologic changes: under the influence of estrogen
1. Regeneration of surface and glandular epithelium
2. Thickness increases as phase continues.
a. Ovulatory: no appreciable change seen in endometrium in the 24-36
hours following ovulation. Changes become noticeable after progesterone
levels increase with the evolution of the corpus luteum.
c. Secretory (Progestational) phase
i. Physiologic changes: progesterone secretion induces maturational
changes in endometrial lining.
1. Presence of glycogen rich fluid in the basal portion.
2. Fluid secretions into glandular lumens.
3. Increasing stromal edema to its maximum which is reached at
about 22
nd
day of cycle when corpus luteum activity reaches its
maximum level.
4. In the absence of fertilization and implantation, corpus luteum
activity regresses; estrogen and progesterone levels drop; rapid
regessive changes in the endometrium occur.
5. Menstruation begins.

Uterine Response Uterine Response
Est r ogen Est r ogen
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3. Ovarian response
a. Follicular phase: varying number (usually 5 - 8) of follicles may be
identified with EV sonography in each ovary. Dominant follicle may
identified by about day 8 and measures approximately 10mm. Its size
begins to exceed that of other antral follicles. Other sonographic
considerations of a dominant follicle:
i. Any follicle measuring >11mm will most likely ovulate
ii. Grows linearly (approx. 2 - 3 mm/day)
iii. Maximum diameter varies between 15 - 30mm
iv. Line of decreased reflectivity around follicle suggest ovulation will
occur within 24 hours
v. Presence of cumulus oophorus suggests ovulation will occur within
36 hours
b. Ovulatory phase: Chronologically, ovulation occurs within 24 - 36 hours
after onset of the LH surge. Sonographic findings that ovulation has
occurred may include:
i. Sudden decrease in follicular size
ii. Fluid in cul de sac
c. Luteal phase: Involution of the follicle into a corpus luteum (yellow body).
This structure produces progesterone which will maintain the secretory
endometrium should implantation occur. In the absence of hCG, the corpus
luteum regresses after 14 days. Sonography may reveal:
i. Replacement of dominant, cystic follicle with echogenic structure
representing thrombus
ii. Small, irregular cystic mass with crenulated borders
4. Abnormal uterine bleeding
a. Terminology: abnormal menstrual patterns may be characterized as
abnormalities of volume or frequency:
i. Hypermenorrhea: excessive volume during cyclic menstrual
bleeding
ii. Hypomenorrhea: an abnormally small amount of menstrual bleeding
ii. Polymenorrhea: frequent menstrual bleeding occurring at less than
21 days apart
iii. Oligomenorrhea: menstrual bleeding occurring more than 35 days
apart
iv. Menometrorrhagia: bleeding that is irregular in both frequency and
volume
b. Dysfunctional uterine bleeding: vaginal bleeding NOT related to estrus or
endometrial pathology.
i. Causes: many and varied include: functional or organic problems;
endocrine disorders; endometrial disorders; others
c. Post-menopausal vaginal bleeding: Covered in OBG2
d. Amenorrhea: the absence of menstrual flow:
i. Primary: failure of the onset of menstrual periods by age 16.
ii. Secondary: the lack of menstrual periods for 6 months in previously
menstruating woman.
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