menstruation and menstrual disorders
TRANSCRIPT
MENSTRUATION AND MENSTRUAL DISORDERS
Asomma Kubire
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
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
Organs involved in menstrual cycle
• Hypothalamus
• Anterior pituitary
• Ovary
• Uterus (Endometrium)
Hormones in menstrual cycle
• Gonadotrophin Releasing Hormone (GnRH)
• Follicle Stimulating Hormone (FSH)
• Luteinising Hormone (LH)
• Estrogen
• Progesterone
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
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
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
Hormonal Events
• Negative feedback
• Positive feedback
• LH surge starts 34-36 hours before ovulation
• Peak of LH surge is 10-12 hours before ovulation
Ovarian Events
• Stages of follicle development – primordial, primary, secondary, tertiary, graafian
• Recruitment of follicles
• Emergence of dominant follicle
• Ovulation
• Corpus luteum formation
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
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
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
Menstrual disorders
• Dysmenorrhea
• Menorrhagia
• Amenorrhea
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
Menstrual disorders
• Primary dysmenorrhea is due to abnormalities of prostaglandin metabolism
• Secondary dysmenorrhea – pelvic infection, uterine fibroids, endometriosis, adenomyosis
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 regular intervals
• Dysfunctional uterine bleeding: Excessive uterine bleeding with no demonstrable organic cause
Menstrual disorders
• DUB is due to abnormalities of prostaglandin metabolism
• Menorrhagia – gynaecolgical causes, endocrine causes, haematologic causes
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 spontaneous menses in an individual older than 16
• Secondary amenorrhea: absence of menses in an individual who has previously had spontaneous menstrual periods
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
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
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
Investigation of primary amenorrhea
• History• Examination• Chromosomal studies• FSH, LH assay• Serum prolactin• CT scan• USG• Laparoscopy