basic mekanisme of menstruasi

8/13/2019 Basic Mekanisme of Menstruasi

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MENSTRUAL CYCLEPHYSIOLOGY ND P THOPHYSIOLOGY

Dr. Supriyatiningsih, M.Kes, SpOG

Department of Obstetrics & GynecologyFaculty of Medicine Muhammadiyah University

Yogyakarta Indonesia


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THE NORMAL MENSTRUAL CYCLES ISDETERMINED B Y A COMPL EX INTERA CTION

B ETWEEN REPRODUCTIVE ENDOCRINE ORGA N

HYPOTHALAMUS ANTERIOR PITUITARY GLAND

OVARYENDOMETRIUM

But the main regulation isintraovarian


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The Menstruation Cycle

3 activity during Menstrual Cycle :

Hypothalamus and Pituitary activity

Ovarian activity

Uterine activity


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Uterus

Menses

Ovary

Anterior pituitary

Hypothalamus

CNS

Environment

Compartemen I

Compartemen II

Compartemen III

Compartemen IV

Estrogen Progesterone

FSH LH

GnRH


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To survive, the follicle must be exposed to a waveof gonadotropic hormone release


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Ovulasi


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Number of oocytes at different ages

Age # of cells

3-6 weeks ofgestation

Endoderm of theyolk sac

10,000

8 weeks Proliferation bymitosis

600,000

8-20 Mitosis, meiosis,atresia

6-7,000,000

20-40 weeks 80% loss 1-2,000,000Birth to puberty Loss to atresia 300,000

Reproductiveyears

Ovulation 400-500


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Membran sel

LISOSOM

Asam fosfataseEnzim litik

Prostaglandin

Penurunanaliran darah

Vasokonstriksia. spiralis

Iskemia

VEGF & FGFRegenerasi endometrium

Makrofag

PMN

LImfosit granulasi

Sel Mast

Sekresi danaktivasi sitokin

Upregulated MMP

DegranulasiTriptase &kimase

Menstruasi


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Norm al m ens t rual b leed ing

Occurs approximately once a month(every 26 to 35 days).

Lasts a limited period of time (3 to 7 days). May be heavy for part of the period, but

usually does not involve passage of clots. Often is preceded by menstrual cramps,

bloating and breast tenderness, althoughnot all women experience thesepremenstrual symptoms.


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DefinitionsNormal:

Mean interval is 28 days+/- 7 days.

Mean duration is 4 days.More than 7 days is

abnormal.


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A bn orm al Bleed ing

Abnormal bleeding (DUB or dysfunctionaluterine bleeding) includes:

Too frequent periods (more often than every 26

days). Heavy periods (with passage of large, egg-sizedclots).

Any bleeding at the wrong time, including

spotting or pink-tinged vaginal discharge Any bleeding lasting longer than 7 days. Extremely light periods or no periods at all


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Dysfunctional Uterine Bleeding(DUB)

Most common menstrual disorder. Can affect any women from menarche to

menopause. Often the first clinical diagnosis for any

excessive menstrual bleedings.

Diagnosis has to be confirmed by aprocess of exclusion of pathologicalcauses.


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Term Definition Pattern

Amenorrhea No uterine bleeding for at least 6 monthsMenorrhagia Excessive amount (>80 mL/cycle) or

prolonged duration >7days, also calledhypermenorrhea

Occurs atirregularintervals

Metrorrhagia Uterine bleeding occuring at irregular but

frequent interval, amount variesirregular

Menometrorrhagi

Irregular, heavy, and prolonged menstrualbleeding

irregular

Oligomenorrhea

Decreased, scanty flow, the termhypomenorrhea is used for regular timingwith scanty amount.

Interval > 36-40days

Polymenorrhea Regular, frequent menstruation Interval


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Average blood loss with

menstruation is 35-50cc.

95% of women lose


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DefinitionsMenorrhagia:

Prolonged > 7 days or > 80 ccoccurring at regular intervals.

Synonymous with

hypermenorrhea


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Menorrhagia occurs in 9-14% of healthy women.


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DefinitionsMetrorrhagia:

Uterine bleeding occurringat irregular but frequent

intervals.


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Etiologies AUB Organic

Systemic Reproductive

tract disease Iatrogenic

Dysfunctional Ovulatory

Anovulatory


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Reproductive TractCauses of Benign Origin

Atrophy Leiomyoma Polyps Cervical lesions Infection


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60% of women with PMBwill be found to haveatrophy. 10% will have

polyps and 10% will havehyperplasia.

Karlsson, et al ., 1995


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Incidence of Endometrial Cancer

in Premenopausal Women

2.3/100,000 in 30-34 yr old6.1/100,000 in 35-39 yr old36/100,000 in 40-49 yr old

ACOG Practice Bulletin #14, 2000


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DUB Abnormal uterine bleeding

for which an organicetiology has been excluded.

It is either ovulatory oranovulatory in origin.


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PUD

Perdarahan dari uterus yang didasari oleh gangguan hormonal porosHipotamus-hipofisis-ovarium semata, tanpa dijumpai kelainan organik,sistemik, metabolik, keganasan maupun gangguan kehamilan dini

elainan Organik

Sistemik Metabolik

Keganasan Ggn kehamilan dini


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Premenstrual Syndrome

Premenstrual Syndrome (PMS) is defined as the cyclicrecurrence in the luteal phase of the menstrual cycle of acombination of distressing physical, psychological,and/or behavioral changes of sufficient severity to resultin deterioration of interpersonal relationships and/orinterference with normal activities. Nearly 200symptoms have been associated with this definition andit is the clustering of these signs and symptoms that isthe hallmark of PMS.


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Catamenial

The term catamenial is derived from the Greek

and signifies around menses. In general aninstance where a single recognized medicalcondition presented in the premenstruum wasreferred to as a catamenial disorder while a

cluster of symptoms was referred to as PMS.


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Premenstrual Magnification

Many patients with psychiatric disorders also complain ofworsening of their symptoms around the premenstrualphase, called premenstrual magnification (PMM).


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PMS

Milder symptoms are believed to occur in about 30% to80% of reproductive-age women, while severesymptoms are estimated to occur in 3% to 5% ofmenstruating women.


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Concordance Rate

The concordance rate (if both twins have PMS)was found to be significantly higher in

monozygous twins (93%) than dizygous twins(44%) and in non-twin control women (31%).


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Common Symptoms of PMS

Women with PMSSymptom Showing Symptoms (%)Behavioral

Fatigue 92

Irritability 91Labile mood with alternating

sadness and anger 81Depression 80Oversensitivity 69Crying spells 65Social withdrawal 65Forgetfulness 56Difficulty concentrating 47


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Common Symptoms of PMS(Continued)

Physical Abdominal bloating 90Breast tenderness 85

Acne 71 Appetite changes and

food cravings 70Swelling of the extremities 67

Headache 60Gastrointestinal upset 48


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Differences Between PMS and PMDD

Dia nostic criteria Tenth Revision of the International Classification of

Disease (ICD-10)

Diagnostic and Statistical Manual of Mental

Disorders, 4 th ed.(DSM-IV)

Providers usingthese criteria

Obstetrician/gynecologists, primary

care physicians

Psychiatrists, other mental health care

providersNumber of symptomsrequired

One 5 of 11 symptoms


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Differences Between PMS and PMDD(Continued)

Functionalimpairment

Prospectivecharting of symptoms

Not required

Not required

Interference withsocial or rolefunctioningrequired

Prospectivedaily charting of symptomsrequired for twocycles


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Patterns of PMS

Premenstrual symptoms can begin at ovulation withgradual worsening of symptoms during the luteal phase(pattern 1).

PMS can begin during the second week of the lutealphase (pattern 2).


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Patterns of PMS(Continued)

Some women experience a brief, time-limited episode ofsymptoms at ovulation, followed by symptom-free daysand a recurrence of premenstrual symptoms late in theluteal phase (pattern 3).

The most severely affected women have symptoms thatat ovulation worsen across the luteal phase and remitonly after menses cease (pattern 4). These women

describe having only one week a month that is symptom-free.


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Differential Diagnosis

Psychiatric disorders Major depression Dysthymia

Generalized anxiety Panic disorder Bipolar illness (mood

irritability)

Other

Medical disorders Anemia Autoimmune disorders Hypothyroidism

Diabetes Seizure disorders Endometriosis Chronic fatigue syndrome Collagen vascular

disease


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Differential Diagnosis(Continued)

Premenstrualexacerbation

Of psychiatric disorders Of seizure disorders Of endocrine disorders Of cancer Of systemic lupus

erythematosus Of anemia Of endometriosis

Psychosocial spectrum Past history of sexual

abuse Past, present, or current

domestic violence


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Diagnosis of PMS

PMSA. Does not meet DSM-IV criteria

but does meet ICD-10 criteriafor PMS

B. Symptoms occur only in theluteal phase, peak shortlybefore menses, and ceasewith menstrual flow or soonafter

C. Presence of one or more ofthe following symptoms

Mild psychological discomfort Bloating and weight gain Breast tenderness Swelling of hands and feet Aches and pains Poor concentration Sleep disturbance Change in appetite


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PMDD (DMS-IV Criteria)

A. At least five of the symptoms below, with at leastone being a core symptom, are present a weekbefore menses and remit a few days after onset ofmenses:

Depressed mood or dysphoria (core symptom) Anxiety or tension (core symptom) Affective lability (core symptom) Irritability (core symptom) Decreased interest in usual activities


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PMDD (DMS-IV Criteria)(Continued)

Concentration difficulties Marked lack of energy Marked change in appetite, overeating, or food

cravings Hypersomnia or insomnia Feeling overwhelmed Other physical symptoms (e.g., breast

tenderness, bloating, headache, joint or musclepain)


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Treatment of PMS

Oral contraceptives Vitamin B 6 Bromocriptine Monoamine oxidase inhibitors Synthetic progestational agents Spironolactone Massage therapy Chiropractic therapy Calcium


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MENOPAUSE


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Gejolak panas


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Osteoporosis

Tulang keropos Ngilu-ngilu Patah tulang Bungkuk Tambah pendek


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Kerusakan bag tulang NORMAL

The good ne s


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The good newsMenopause and

postmenopauseosteoporosis


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Kulit keriput


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Sukar tidur


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Jantung berdebar

PusingMudah pingsan


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Gangguan fungsi seks

Vagina kering Hub. Seks sakit Lendir sedikit Nafsu sek turun


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Libido menurun


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Gangguan berkemih

InkontinensiaNgompol

Some benefits of estrogen replacement


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Some benefits of estrogen replacementtherapy (ERT) for treating menopausal

related health problem Estrogen replacement therapy (ERT) results in the relief

of menopausal symptoms such as hot flushes andatrophy of genital tract

ERT halts postmenopausal bone loss, increases bonemineral density (BMD) and reduces the incidence offractures

ERT reduces levels of total cholesterol and low-densitylipoprotein (LDL) cholesterol

Nelson H. JAMA 2004;291:1610-20

B fi f l i i


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Benefits of estrogen plus progestin inpostmenopausal women

WHI study. JAMA 2002;288:321-33

Estrogen + progestin

Plasebo


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Weight gain during traditionalHRT has been one of the main

reasons for discontinuation

Although it may not be the onlyreason, it contributes to poor

compliance

Van Seumeren I. Maturitas 2000;34(Suppl 1):3 8

LIVER ESTROGEN


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Na+ / water retention(= weight gain)K+ elimination

Aldosterone

KIDNEY ADRENAL GLAND

LIVER ESTROGEN

HRT

Increased edema

Increased body weight

Changes in body weight with


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Changes in body weight with Angeliq and estradiol alone

1.5

1.0

0.5

0

0

-0.5

0

-1.5

Mean weightchange (kg)

Angeliq (n = 224)

Estradiol (n = 225)

1 2 3 4 5 6 7 8 9 10 11 12 13

-1.0


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The end

basic mekanisme of menstruasi

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