MENSTRUATIO N

Prepared by: Lirio, Riza D. BSN 2-1

Pathophysiology:

Four body structures involved: Hypothalamus, pituitary gland, ovaries, uterus For a cycle to be complete, all structures must contribute their part.

Hypothalamus
releases GnRH(luteinizing hormone-releasing hormone, LHRH) which initiates the menstrual cycle When the level of estrogen ( produced by ovaries) rises, release of hormone is repressed, and the cycle does not occur. CHILDHOOD: apparently so sensitive to the small amount of estrogen produced by adrenal glands that release of the hormone is suppressed. PUBERTY: less sensitive to estrogen feedback which results in the initiation every month of hormone GnRH.

GnRH
Transmitted from hypothalamus to pituitary gland and signals gland to begin producing gonadotropic hormones FSH AND LH. Its production is cyclic.

Inhibitory feedback mechanism of estrogen and progesterone:

Disease of the hypothalamus causing deficiency of releasing factor can result to delayed puberty Disease causing early activation of GnRH can lead to abnormally early sexual development Other factors inhibiting GnRH production: High levels of pituitary based hormones such as prolactin, FSH, or LH

Pituitary Gland
Under the influence of GnRH, the anterior lobe of the PG (adenohypophysis) produces 2 hormones: 1. FSH active early in the cycle and responsible for maturation of the ovum 2. LH most active at the midpoint of cycle and is responsible for ovulation and growth of uterine lining during second half of menstrual cycle. = are called gonadotropic hormones because they cause growth (trophy) in the gonads(ovaries).

OVARY
FSH activates one primordial follicle to begin growth and maturity. As it grows, its cells produce a clear fluid(follicular fluid) that contains a high content of estrogen and some progesterone. It is then propelled when reached maximum size toward the surface of ovary. Full maturity: primordial follicle is visible on the surface of ovary as clear water blister approx. 0.250.5 inches across; small ovum with surrounding follicle membrane and fluid is called graafian follicle.

 Day 14: ovum has divided by mitotic division into two separate bodies: (1)primary oocyte (2) secondary oocyte Primary oocyte contains the bulk of the cytoplasm Secondary oocyte contains so little cytoplasm that it is not functional Haploid having only one member of a pair Prostaglandin released and graafian follicle ruptures. Ovulation process of setting ovum free from surface of ovary; occurs on approx. The 14th day before onset of next cycle Ovum swept into the open end of fallopian tube END OF FSH ROLE

 LH acts on the follicle cells of the ovary. This influence causes the follicle cells to become lutein Lutein a bright-yellow fluid instead of follicular fluid; high in progesterone and contains some estrogen; fills empty follicle Follicular Fluid -- high in estrogen with some progesterone Corpus Luteum filling up of lutein into empty follicle Basal Body Temperature drops slightly (by 0.5 to 1F) just before the day of ovulation because of extremely low level of progesterone present. It rises by 1F on the day after because of progesterone concentration( which is thermogenic). Temperature remains at this level until progesterone level again decreases.

 Conception fertilization by a spermatozoon Corpus albicans white bodies If conception occurs as the ovum proceeds down to fallopian tube and fertilized ovum implants on the endometrium of the uterus, the corpus luteum remains thorughout the MAJOR portion of pregnancy(approx. 1620 weeks). If conception does not occur, unfertilized ovum atrophies after 4-5 days and the corpus luteum remains for only 810 days. As the corpus luteum decreases, it is gradually replaced by white abicans.

Uterus

Stimulation from the hormones produced by the ovaries causes specific monthly effects on the uterus.

First Phase: Proliferative

Immediately after a menstrual flow (4 or 5 days of cycle) Endometrium or lining is very thin and approximately one cell layer in depth Endometrium begins to proliferate as the ovary begins to produce estrogen under FSH Very rapid growth and increases thickness of endometrium approx. 8 fold. Increase continues for the 1st half of cycle (approx. 5-14 days) Termed interchangeably as estrogenic, follicular, postmenstrual phase.

Second Phase: Secretory

Formation of progesterone in the corpus luteum (LH) causes glands of endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen (elementary sugar) and mucin (protein) Capillaries of endometrium increase in an amount until lining takes on the appearance of rich, spongy velvet. Also termed as progestational, luteal, premenstrual

Third Phase: Ischemic

If fertilization does not occur: corpus luteum begins to regress after 8-10 days Production of progesterone and estrogen decreases Endometrium begins to degenerate (24 or 25 days of cycle) Capillaries rupture, with minute hemorrhages, endometrium slouhs off

Final Phase: Menses

Discharges from the uterus: (1)blood from the ruptured capillaries (2)mucin from the glands (3) fragments of endometrial tissue (4)microscopic, atrophied, and unfertilized ovum

Final Phase: Menses

End of an arbitrarily defined menstrual cycle because it is the only external marker of the cycle. First day of menstrual flow: marks the beginning day of a new menstrual cycle contains only approx. 30-80 mL blood Amount is added by mucus and endometrial shreds Iron loss approx. 11 mg which is enough Loss than many women need to take a daily iron supplement to prevent iron depletion during menstrual years.

Menses
In women going to menopause, menses may typically consist of a few days of spotting before heavy flow, or heavy flow followed by a few days of spotting because progesterone withdrawal is more sluggish or tends to staircase rather than withdraw smoothly.

Cervix
First half of cycle: hormone secretion from ovary is low; cervical mucus is thick and scant poor sperm survival Ovulation: estrogen level high; cervical mucus is thin and copious excellent sperm penetration and survival Progesterone major influencing hormone during second half of cycle ; mucus is thick with poor sperm survival

Fern Test
High Estrogen cervical mucus forms fernlike patterns when placed on a glass slide and allowed to dry. Patterns are caused by the crystalization of sodium chloride on mucus fibers and known as arbortization of ferning.

High Progesterone fern pattern no longer discernable; mucus can be examined at midcycle to detect whether ferning is present. * Women who do not ovulate continue to show fern patterns or they never demonstrate it because of low estrogen levels.

Spinnbarkeit Test: At the height of estrogen secretion, cervical mucus not only becomes thin and watery, but can also be stretched into long strands. This stretchability is in contrast to its thick, viscous state when progesterone is the dominant hormone. Performing such test at the midpoint of a menstrual cycle is another way to demonstrate that high levels of estrogen are produced which causes ovulation.

Education for Menstruation

Many myths about menstruation still exist. Early preparation for menstruation to dispel myths is important because it teaches the girl to trust her body and think of menstruation as a mark of pride and development and growing up rather than a burden. Equally important for boys so they can appreciate the cyclic process and can be active participants in helping plan or prevent the conception of children.

Teaching about menstrual Health

Area of Concern Exercise Teaching Points Its good to continue moderate exercise during menses for a general sense of well-being. Sustained excessive exercise, such as professional athletes maintain, can cause amenorrhea. Not contraindicated during menses (use of condoms for males to prevent exposure to body fluid). Heightened or decreased sexual arousal may be noticed during menstruation. Orgasm may increase menstrual flow. It is improbable but not impossible for conception to occur from coitus during menses. Nothing is contraindicated.

Sexual Relations

Activities of daily life

Area of Concern Pain relief

Teaching Points Prostaglandin inhibitors such as ibuprofen are specific for menstrual pain. Applying local heat may also be helpful. If a migraine headache occurs, specific drugs for this are now available such as sumatriptan. More rest may be helpful if dysmenorrhea interferes with sleep at night. Many women need iron supplementation to replace iron loss in menses. Eating pickles or cold food DOES NOT cause dysmenorrhea.

Rest

Nutrition

Menopause
Cessation of menstrual cycle Postmenopausal period is the life after menopause Perimenopausal period during which menopausal changes are occuring Age range: 40-55 years Familial like menarche age Often referred to as change of life because it marks the end of ability to bear children especially if falling estrogen levels result in hot flashes or osteoporosis. May be a welcome change

Terminologies:
Menarche start of menstrual cycle ; familial Dysmenorrhea painful menstruation Menorrhagia abnormally heavy menstrual flows Metorrhagia- bleeding between menstrual periods Coitus sexual intercourse

Note: Use of tampons usually cause infection because of the released toxins which may be reabsorbed by the mucus membranes.