By I. Korda

The menstrual cycle is a cycle of physiological changes that occurs in fertile females.

The female menstrual cycle is determined by a complex interaction of hormones.

Menstrual cycle:

Days 1-5: Estrogen Falls, FSH Rises.

Menstrual bleeding begins on Day 1 of the cycle and lasts approximately 5 days. During the last few days prior to Day 1, a sharp fall in the levels of estrogen and progesterone signals the uterus that pregnancy has not occurred during this cycle. This signal results in a shedding of the endometrial lining of the uterus.

Days 6-14: Estrogen Is Secreted, FSH Falls.

Estrogen is secreted by the follicle during this phase of the menstrual cycle. It stimulates the endometrial lining of the uterus suppresses the further secretion of FSH.

At about mid-cycle (Day 14), the estrogen helps stimulate a large and sudden release of luteinizing hormone (LH).

This LH surge, which is accompanied by a transient rise in body temperature, is a sign that ovulation is about to happen.

The LH surge causes the follicle to rupture and expel the egg into the Fallopian tube.

Days 14-28: Estrogen And Progesterone Secretion First Rise, then Fall.

After rupture of the follicle, it is transformed into the corpus luteum and produces progesterone.

P supports to prepare the endometrial lining for implantation of the fertilized egg.

(If the egg is fertilized, a small amount of human chorionic gonadotrophin (hCG) is released that stimulates further progesterone production.)

After implantation, the trophoblast will secrete human Chorionic Gonadotropin (hCG) into the maternal circulation.

HCG keeps the corpus luteum viable.The corpus luteum continues to produce estrogen and progesterone, which keep the endometrial lining intact.

By about week 6 to 8 of gestation, the newly formed placenta takes over the secretion of progesterone.

If the egg is not fertilized, the corpus luteum shrinks, and the levels of estrogen and progesterone drop, the uterus sheds its lining, and menstruation begins.

In addition, with no estrogen to suppress it, FSH levels again start to rise. Thus, one cycle ends and another begins.

Normal Menses:Flow lasts 2-7 daysCycle 21-35 days in

lengthTotal menstrual blood

loss 20-60 mLThe menstruation must

be regular, painless.

puberty is the process of physical changes by which a child's “body becomes an adult body capable of reproduction.

menarche - A woman's first menstruation is termed, and occurs typically around age 12. The menarche is one of the later stages of puberty in girls.

menopause - the end of a woman's reproductive phase, which commonly occurs somewhere between the ages of 45 and 55. Climacteric: 47-55 years

Premenopause: 5 years before Postmenopause starts 1 year after menopause

Perimenopause: transitional phase between pre- and postmenopause: 2 years before and 1 year after

Menstrual cycle irregularities:Menstrual cycle irregularities:1. abnormal frequency1. abnormal frequency

Kaltenbach chart:

Normal cycle

Abnormal frequency:oligomenorrhea

Abnormal frequency:polymenorrhea

Duration: 28 d 5Amount: 3-5 pads or tampons (35 mL)

Duration > 35 days

Duration < 22 days

Menstrual cycle irregularities:Menstrual cycle irregularities: 2. abnormal amount of duration 2. abnormal amount of duration

Kaltenbach chart:

Normal cycleDuration: 28 d 5Amount: 3-5 pads or tampons 35 mL)

Hypomenorrhea

Hypermenorrhea

Menorhagia

Amount < 2 per day

Amount > 5 per day

Duration 7-14 daysat regular intervals

Differential Diagnosis Differential Diagnosis Primary amenorrhea

Gonadal failure Anorexia nervosa

Secondary amenorrhea -Hypothalamic disorders 49

62%PPPPPPPPP - 7 1 6 %

Ovarian disorder 10%

Ascherman’s syndrome 7%

Dysorder of Dysorder of HypothalamusHypothalamus

Abnormalities Affecting Release of Abnormalities Affecting Release of- Gonadotropin Releasing Hormone- Gonadotropin Releasing Hormone

Variable Estrogen Status Anorexia nervosa -Exercise induced -Stress inducedPseudocyesis(false pregnancy )Malnutrition Chronic diseases :

Renal, Lung, Liver, Chronic infection, Addison’s disease

Hyperprolactinemia Thyroid dysfunction

ObesityHyperandrogenism

Cushing’s syndrome (impaired cortisol rhythm)

Congenital adrenal hyperplasia

Androgen secreting adre nal tumor

Androgen secreting ovar ian tumor

Granulosa cell tumoridiopatic

Polycystic Ovary Syndrome Polycystic Ovary Syndrome (PCOS)(PCOS)

The ovaries contain many small follicles or cysts. Each has an egg, but they do not grow normally and shrink before ovulation. Each month, new follicles develop and shrink into cysts.

The fertility is reduced.

Most PCOS cases are unexplained.

• The disorder may be inherited.

• Deficiency in luteinizing hormone (LH)

• Resistance to insulin. A similar effect on the ovaries can occur in women with eating disorders (anorexia or bulimia), or women whose bodies do not properly make estrogen and other steroids (for example, women with congenital adrenal hyperplasia).

Polycystic Ovar Polycystic Ovaryy SyndromeSyndrome (PC (PCOOSS))

Clinical consequences of pers istent anovulation

1. Infertility

P PPPPPPPP PPPPPP2

PPPPP

3 . Hirsutism, Alopec PPPP,

4 . Riskofendometri alcancer ,breast cancer

5 . RiskofCVSdiseasP

PPPP PP P P PP PPPP6

ent s wi t h i nsul i n resi stance

Prolactin Secreting Adeno Prolactin Secreting Adenomama

Most common pituit ary tumor

50% identified at autopsy

Disruption of the rep roductive mechanis

mAmenorrhea

- Visual field defect Galactorrhea

-Headache Treatment

Medical : dopamine aPPPPPP

PPPPPPPP

Surgical TreatmentDilation and

Curettage quickest way to

stop bleeding in patients who are hypovolemic

appropriate in older women (>35)to exclude malignancy but is inferior to hysteroscopy

follow with medroxyprogesterone acetate, OCP’s, or NSAID’s to prevent recurrence

Surgical Treatment:Laser ablationLoop electrode resection

Roller electrode ablation

Hysterectomy

Sheehan’s syndrome Sheehan’s syndrome Postpartum hemorrhag

e Acute infar ction and ne

crosis Hypopituitarism= earl

y in the PP period Failure of lactation Loss of pubic and axilla

ry hair Deficiencies :

GH, Gn (FSH,LH), ACTH, TSH (in frequency)

Turner’s Syndrome Gonadal dysgenesis associated with 4

5,XO Most commonchromosomal abnormal i t

y i n spont aneous abor t i onPPPPPPPPPPPPPPP

Sexual infantilism-PPPP PPP P PP

Short stature Autoi mmuneP PPPPP PPPP CVSanomal i es

cubitus valgus Renal anomal i es

Mosai ci smPPPPPP PPP

1. Asherman’s Syndrome

Cause : Curettage,

Uterine surgery Diagnosis :

HSGHysteroscope S/S :

Miscarriage Dysmenorrhea

Hypomenorrhea

2. Mullerian anomalies 2. Mullerian anomalies

Lack of Mullerian Development

Ovaries : Normal Associated anoma

liesurinaryskeleton

Investigation : U/S , MRI, Laparos

cope

ImperforatImperforatee HHymensymens

3. Androgen Insensitivity 3. Androgen Insensitivity ( ( FF))

Male Pseudohermaphrodite

Gonadal Sex :46xy Phenotype Female

Blind vaginal canal Uterus absent Absent or meager pubic and a

xillary hair Malignancy, Hormone :

T or slightly LH

Premenstrual Syndrome

Case20 year old Jessica

Episodes of irritability and moodiness

Lead to huge arguments with her boyfriend.

Sleeps away the day and miss school or work

Her boyfriend jokes and makes off-the-wall remarks about PMS. She comes to you for advice.

Bloated, tired and hungry during the days just prior to menses.

Symptoms

Anger Outbursts

Symptoms

Cravings

Irritability

Mood Lability

Approach

Thank you for your attention!