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Physiology of Menstruation
Menstruation (Greek Word, men – month) is monthly uterine bleeding flowing through the vagina to the vulva for 4-5 days every 28 days during a woman’s reproductive life from menarche to menopause. Menstruation is a normal uterine function by which the endometrium prepares to receive pregnancy.
Bleeding comes from estrogen progesterone primed endometrium. A woman gets 13 periods in a year and about 400 periods in her reproductive life.
The 28-day period begins on the day of onset of menstruation (day 1) and ends on day 28 at the start of next menses.
Menstruation signals that fertilization and implantation of a fertilized egg did not occur during the previous menstrual cycle. Anovulatory menstruation is cyclic monthly bleeding from an estrogen-only endometrium. This happens a few years after the onset of menstruation (menarche) and before the final cessation of menstruation (menopause).
Menstruation is a normal bodily function. Most women only experience vaginal bleeding for 3 to 5 days without discomfort. However, about a quarter of women experience menstrual discomforts. These discomforts do not interfere with the usual daily activities. Only 5-10 percent develop during some part of their approximately 30-year menstrual life painful men interfering with daytime activities (dysmenorrhea). The menstrual cycle is like:
1. Feeling of heaviness and discomfort in the pelvis, lower abdomen and small of the back.
2. Sensation of stinging and fullness in the breasts.
3. Frequency of urination and constipation.
4. Feeling tired, irritable and headache. The above symptoms vary in severity from individual to individual. Rarely, nosebleeds can occur as vicarious menstruation’ because blood viscosity drops in men.
1. A sudden drop in temperature of about 1 degree F but with individual variations.
2. Pulse rate and blood pressure tend to drop.
3. Weight gain occurs during the premenstrual fortnight up to about 1 Kg. due to retention of water and salt; it happens in about half of women. There is a loss of weight with the onset of flow.
4. Menstrual loss (men). The vaginal menstrual bleeding is mainly arterial, partly venous is dark reddish liquid (not coagulated) blood with shed endometrial tissue pieces. The discharge has an unpleasant odor due to the secretion of vulvar sebaceous glands and decomposition of blood elements. Menstrual blood is deficient in prothrombin, and fibrinogen but rich in calcium. Microscopically, it contains red blood cells, a large number of leukocytes, vaginal epithelium, cervical mucus, fragments of endometrium with macrophages, histiocytes, mast cells and bacteria. Menstrual discharge also contains cholesterol, estrogen, lipids and prostaglandins. Menstrual blood from the endometrial clots in the uterine cavity by its thromboplastic property. The clots are dissolved by the fibrinolytics released from the endometrium. Fibrin degradation products therefore circulate in increased quantity during menstruation. Clots are passed when menstrual bleeding becomes excessive.
Interval and Duration
The menstrual cycle lasts an average of twenty-eight days. A deviation of 2 to 3 days can be frequently encountered. The extremes of a 21 and 35 day range can also be found. In the menstrual life of any woman, the interval can vary. The usual duration is three to five days with essentially normal extremes of two and seven days. Every woman needs sex education in this normal range of menstrual pattern so that she does not suffer from miseducation about normal menstrual pattern taken as menstrual irregularity.
The average total blood loss during menstruation was estimated at 35 ml (range 5 60 ml); average loss of iron was found to be 12 mg. A rough clinical estimate is that normally no more than three fresh pads are needed in the twenty-four hours two during the day and one at night, thus requiring a total of 12 15 pads during rnens. This loss varies widely and becomes greater in women living in hot climates than those living in cold climates.
Proper education about men is important. She should be educated that menstruation is not the draining of a poisonous substance from the body but a normal manifestation of femininity. During menstruation, she should continue her usual activities including daily bathing, playing. Personal hygiene is maintained by changing sanitary pads regularly. Intravaginal tampons can be used by the married as long as she does not forget to leave it behind. A healthy couple can have sex during menstruation. Delay or advance of menstruation. This sometimes becomes necessary for an important social reason such as marriage. This is not recommended on weak ground. The hormone therapy used is the following:
1. Progesterone norethisterone one tab. three times a day from the 20th day of the menstrual cycle until after the date of delay.
2. Estrogen progestogen birth control pills, two a day starting from the 20th day. Menstrual flow is expected 2 to 3 days after the treatment is suspended. Menstruation can be brought prematurely by starting hormone therapy from the 5th day of men for 14 days, The therapy is (a) Estrogen ethinylestradiol 0.05 mg. tds or (b) Estrogen progestogen oral pill once daily. Anovulax menstrual flow is likely to begin within 2 3 days after stopping therapy.
Endocrine mechanism of menstruation
Play of sex hormones from hypothalamus in brain, anterior pituitary gland, ovary causes menstrual bleeding from uterine endometrium.
This is called the hypothalamus-pituitary-ovary-uterine axis
Steps are –
1. In the brain, hypothalamus acts as a switch to the endocrine mechanism of menstruation and starts the process by secreting gonadotrophin releasing hormone (GnRH) or (LHRH) through a peptidergic neuron. The latter is controlled by an aminergic neuron. Environment influences menstruation through cerebral cortex and hypothalamus.
GnRH flows down from hypothalamus via pituitary portal vessels to
2. Anterior pituitary (gonadotrophic cells) releasing Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) into bloodstream to initiate growth of ovarian follicles in both ovaries.
Ovarian Cycle Ovarian follicles (20 in number) grow in a menstrual cycle in three steps.
(a) ovarian follicles are grown from primordial follicles. A single graarian follicle matures and becomes dominant through the effect of FSH while other follicles undergo atresia.
(b) Estradiol is secreted by maturation of ovarian follicle in the circulation ‘stimulates hypothalamus and anterior pituitary gland to cause increase of LH and FSH hormones in blood (Positive reaction) on day 12 of menstrual cycle.
(c) Ovulation (discharge of egg from ovary) occurs on day 14 of menstrual cycle. Corpus luteum (yellow body) forms in the shell of mature graafian follicle ovulation due to LH effect.
Corpus luteum remains mature From day 19-26, degenerates on day 27 and 28 if no pregnancy occurs in a menstrual cycle’. Plasma prolactin (from anterior pituitary) rises (causing luteal phase and appears to maintain corpus luteum. Abundant progesterone hormone., some estradiol and inhibin (peptide hormone) are secreted by corpus luteum. Estradiol causes luteolysis while inhibin depresses FSH.
(a) Proliferative phase
Estradiol from ovarian follicles causes proliferative changes in uterine endometrium (day 7-14). All endometrial tissue elements of 1 mm thick proliferate. Before beginning of proliferative phase, repair phase. runs with men’s bleeding and ends at 48 hours after men.
(b) Secretory phase. Progesterone (from corpus luteum) causes secret changes in endometrium (day 15 – 26 to receive fertilized egg for implantation. Glycogen appears as subnuclear vacuoles in endometrial gland followed by secretion of glycogen and mucus on the lumen of gland. Glands become corkscrew . coils , stroma becomes vascular and oedernate. Endometrium thickens up to 5 mm into three layers (a) superficial compact layer with neck ot’glands (b) spongy layer with dilated glands (c) basal layer in contact with myometrial layer.
A stage of regression occurs in secretory endometrial urn on day 27 to 28.
(c) Menstrual bleeding phase occurs for 4 – 5 days after day 28 of the cycle due to shedding of endometrial pieces and bleeding from endometrial I bed. Necrosis and shedding of endometrial pieces extends from region to region during first 2 days of menstruation. Bleeding occurs as (a) capillary bleeding with or without the formation of a subepithelial hematoma (b) venous hemorrhage and (c) diapedesis.
Menstrual phase is caused by withdrawal of estradiol and progesterone support to endometrium.. FSH rises again to start another, cycle.
Cause of menstrual bleeding. The exact cause is still unclear. The sequence of events is:
Withdrawal of estrogen and progesterone due to degeneration of corpus luteum “rapid shrinkage and regression of secretory endometrium overcoiling of endometrial spiral arterioles” stasis of circulation in the functional layer of endometrium “necrobiosis of vessels. Prostaglandins produced by endometrium also cause vasospasm from the ischemic necrosis of spiral vessels from a piece of endometrium supplied by spiral artery relaxation of spiral vessel bleeding from spiral vessel end These vascular changes are described by Markee (1940)
In the shedding process, coagulation and fibrinolysis at the bleeding site occur so that uncoagulated dark red blood with endometrial tissue pieces are discharged over 4-5 days. Endometrial dating. Endometrium dates from its histological appearance especially during secretory phase e.g. prenuclear vacuoles – 16th day, basal nuclei, secretion in gland lumen – 20th day.
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