Menstruation:

Menarche- denotes the first menstruation. Average age is 13 years old but varies for different
females. Can start as early as 8-11years old.
Puberty- a broader term that denotes the entire transitional stage between childhood and sexual
maturity.
-Initially menstrual periods are irregular, unpredictable, painless, and anovulatory, where in after
a year or so, a hypothalamic-pituitary rhythm develops, and the ovary produces enough cyclic
estrogen to make a mature ovum.
The menstrual cycle is the preparation of a woman's body for a possible pregnancy. This series
of events occurs monthly during the woman's reproductive years (from puberty to menopause).
The length of the menstrual cycle is counted from the first day of menstrual bleeding until the
day before the first day of the next menstrual bleeding. The menstrual cycle prepares the uterus
for pregnancy, but when pregnancy doesnt occur, menstruation follows. However, womens
menstrual cycles vary in their length and amount of bleeding, according to the womans age,
physical and emotional status, as well as an environmental influence.
Menstruation- the periodic uterine bleeding that begins approximately 14 days after ovulation.
-Its controlled by a feedback of three cycles: endometrial, hypothalamic, pituitary, and ovarian.
-Average length- 28 days, but variations are normal
-Average duration of menstrual flow- 5 days (ranging from 3 to 6 days)
-An average blood loss of 50 ml (ranging from 20-80 ml)

Endometrial Cycle:
1. Menstrual phase: The endometrium breaks down and blood, mucus, tissue, and the egg
(functional two thirds of the endometrium( the compact and spongy layers) ) which sheds
through the vagina.
- Initiated by periodic vasoconstriction In the upper layers of the endometrium .
-The basal layer is always retained, and regeneration begins near the end of the cycle from cells
derived from the remaining glandular remnants or stromal cells in this layer.
2. Proliferative phase: a period of rapid growth lasting from about the fifth day to the time of
ovulation.
- Endometrial surface is completely restored in approximately 4 days, or slightly before
bleeding ceases. an eightfold to tenfold thickening occurs w/ a leveling off or growth at
ovulation
-The proliferative phase depends on estrogen stimulation derived from the ovarian follicles.
3. Secretory phase: extends from the day of ovulation to about 3 days before the next menstrual
period.
-After ovulation, large amounts of progesterone are produced An apparent edematous,
vascular, functional endometrium. fully matured secretory endometrium reaches the thickness
of heavy, soft velvet.
4. Ischemic phase: the blood supply to the to the functional endometrium is blocked necrosis
develops the functional layer separates from the basal layer menstrual bleeding begins
marking the 1
st
day or the next cycle.



Hypothalamic-Pituitary Cycle
-Towards the end of the normal menstrual cycle, blood levels of estrogen and progesterone
decrease stimulation of the hypothalamus secrete GnRH stimulates anterior pituitary
gland secretion of FSH development of ovarian graafian follicles and production of
estrogen.
-Estrogen levels decrease hypothalamic GnRH anterior pituitary release of LH marked
surge of LH and a small peak of estrogen expulsion of the ovum from the graafian follicle
(w/in 24-36 hrs)
-LH peaks at about day 13 or 14 of a 28 day cycle
-If fertilization and implantation of the ovum doesnt occur by this time regression of the
corpus luteum follows levels of estrogen and progesterone decline menstruation occurs
GnRH secreted again.

Ovarian Cycle
- The primitive graafian follicles contain immature oocytes.
- Follicular phase: Before ovulation, from 1 to 30 follicles begin to mature in each ovary
under the influence of FSH and estrogen. preovulatory surge of LF affects a selected
follicle oocyte matures ovulation occurs empty follicle begins transforming into
the corpus luteum.
- After ovulation estrogen levels drop
- Luteal Phase(postovulatory phase): begins immediately after ovulation and starts of
menstruation, usually requires 14 days.
- The corpus luteum reaches its peak of functional activity 8days after ovulation
secretes streoids estrogen and progesterone.
- Coincidentally this is when the fertilized ovum is implanted in the endometrium, but if no
implantation occurs, the corpus luteum regress and steroid levels drop two weeks after
ovulation if fertilization doesnt occur the layer of the uterine endometrium is shed
through menstruation.

Climacteric:
- A transitional phase during which ovarian function and hormone production decline.
- Spans from the years of the onset of premenopausal to the postmenopausal time when
symptoms stop.
- Perimenopausal: a period of 2-8 years before menopause (onset age of 39-51)
Menopause:
- Refers only to the last menstrual period.
- Average age: 51.4 years old (ranging from 35-60 years)

Menstrual Disorders:
Amenorrhea: Absence of menstrual flow, is a clinical symptom of a variety of disorders.
- Most common the result of pregnancy.
- Not a disease, but is often a sign of disease.
- Causes: from any defect or interruption in the hypothalamic-pituitary-ovarian-uterine
axis, anatomic abnormalities, other endocrine disorders, eating disorders, strenuous
exercise, emotional stress, and oral contraceptive use.
- Assess: history and PE, (pregnant?, age( adolescent, adult, perimonpausal), and whether
she has previously menstruated)
- Primary amenorrhea: Absence of menstruation by age 16, regardless of normal growth
and development.
- Secondary amenorrhea: Absence of menstruation for 3-6 months after a period of
menstruation.
- Hypogonadotropic amenorrhea: reflects a problem in the central hypothalamic-
pituitary axis. In rare instances, a pituitary lesion or genetic inability to produce FSH and
LH is at fault.
- Often results from hypothalamic suppression as a result of stress, or a sudden and severe
weight loss, eating disorders, strenuous exercise, or mental illness.
- -Management: Address the stressor, plan together with the women on how she could
decrease or discontinue medication known to affect menstruation, correct, weight loss,
deal, more effectively with psychologic stress, address emotional distress and alter
exercise routine.

Dysmenorrhea: Menstrual cramping/pain
- More common in women who smoke or who are obese
- The range and severity of symptoms differ from woman to woman and from cycle to
cycle in the same woman, lasting several hours or several days.
- Primary dysmenorrhea: a condition associated with abnormally increased uterine
activity, is due to myometrium contractions induced by prostaglandins in the second half
of the menstrual cycle. (not cause by underlying pathology)
o Usually appears within 6-12 months after menarche when ovulation is
established.
o During the luteal phase and subsequent menstrual flow secretion of
prostaglandin increases amplitude and frequency of uterine contractions and
causes vasospasm of the uterine arterioles ischemia and cyclic lower
abdominal cramps.
o Management (varies on the severity of the problem and the womens response to
various treatments): Heating pad/hot bath, Massaging the lower back, Guided
imagery, yoga, meditation, exercise, maintain good nutrition, medication
(NSAIDs,OCP)
- Secondary dysmenorrhea: menstrual pain that develops later in life usually after age 25,
associated with pelvic inflammatory disease, endometrial polyps, or submucous or
interstitial myomas.
o Unlike primary dysmenorrhea pain in secondary dysmenorrhea is described as
dull, lower abdominal aching that radiates to the back or thighs.
o Tx: directed towards removal of the underlying pathology.
Premenstrual Syndrome (PMS): a complez, poorly understood condition that includes a
number of cyclic symptoms occurring in the luteal phase of the menstrual cycle.
- Sx: fluid retention ( abdominal bloating, pelvic fullness, breast tenderness, weight gain),
behavioral or emotional changes, premenstrual cravings, headache, fatigue, and
backache.
- Symptoms will resolve within a few days of onset of menses.
- Management: Diet and exercise, use of diuretics, yoga, acupuncture, hypnosis,
chiropractic therapy, and massage therapy
Abnormal Uterine Bleeding: is any form of uterine bleeding that is irregular in amount,
duration, or timing and not related to regular menstrual bleeding.
- Possible Causes: Anovulation, Pregnancy-Related Conditions, Lower Reproductive Tract
Infections, Neoplasms, Trauma, Systemic Diseases, Latrogenic Causes.
Oligomenorrhea/Hypomenorrhea: Decreased menstruation either in amount, time or both.
Infrequent menstrual periods characterized by intervals of 40 to 45 days or longer, whereas
hypomeorrhea is to scanty bleeding at normal intervals.
Menorrhagia: Regular menstrual intervals, excessive flow and duration
- May have a single episode of heavy bleeding, or regular flooding as a pattern in which
she changes tampons or pads every few hours for several days.
- Cause: early pregnancy, hormonal disturbances, systemic disease, blood dyscraias,
benign and malignant neoplasm, infection, and IUDs.
- Management: May be hospitalized and given conjugated estrogens IV until bleeding
stops or slows significantly, long term treatment of oral conjugated estrogen will help
prevent recurrence of the pattern of dysfunction uterine bleeding and hemorrhage.
- Dysfunctional uterine bleeding: Irregular bleeding due to anovulation or anovulatory
cycle
Metrorrhagia: Irregular menstrual intervals, excessive flow and duration
- Intermenstrual bleeding, any episode of bleeding, whether spotting, menses, or
hemorrhage, that occurs at time other than the normal menses.
- May be due to: intake of OCPs, use of IUDs, pregnancy problems, reproductive
disorders, and infections.