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Physiology of Menstruation
Menstruation (Greek word, men – month) is monthly uterine bleeding that flows out through the vagina to the vulva for 4-5 days every 28 days during a woman’s reproductive life from menarche to menopause. Menstruation is normal uterine function whereby the endometrium prepares to receive pregnancy.
Bleeding comes from estrogen progesterone primed endometrium. A woman has 13 periods in a year and about 400 periods in her reproductive life.
The menstrual cycle of 28 days starts on the day of the onset of menstruation (day 1) and ends on day 28 at the start of the next period.
Menstruation signals that fertilization and implantation of a fertilized egg has not occurred in the previous menstrual cycle. Anovular menstruation is cyclical monthly bleeding from estrogen-only primed endometrium. This happens for a few years after the onset of menstruation (menarche) and before the final cessation of menstruation (menopause).
Menstruation is a normal bodily function. Most women only experience vaginal bleeding for 3-5 days without discomfort. But about a quarter of women get menstrual discomfort menstruation molimina. These discomforts do not interfere with the usual daytime activity. Only 5 10 percent develop during some part of their approximately 30-year menstrual life painful men that interfere with daily activities (dysmenorrhoea). Menstrual molimina is like:
1. Feeling of heaviness and discomfort in the pelvis, lower abdomen and small of the back.
2. Feeling of tingling and fullness in the breasts.
3. Frequency of urination and constipation.
4. Feeling tired, irritable and headache. The above symptoms vary in severity from individual to individual. Rarely, bleeding from the nose can occur as a substitute for menstruation, as the viscosity of the blood decreases in men.
1. Sudden drop in temperature of about 1 degree F, but with individual variations.
2. Heart rate and blood pressure tend to drop.
3. Weight gain occurs during the premenstrual 14 days up to approx. 1 kg. due to retention of water and salt; it occurs in about half of women. There is weight loss with the onset of flow.
4. Menstrual loss (men). The vaginal menstrual bleeding, mainly arterial, partly venous, is a dark reddish liquid (non-coagulated) blood with shed pieces of endometrial tissue. The discharge has an unpleasant odor due to the secretion of the vulva sebaceous glands and the breakdown of blood elements. Menstrual blood lacks prothrombin and fibrinogen, but is rich in calcium. Microscopically, it contains red blood cells, a large number of leukocytes, vaginal epithelium, cervical mucus, fragments of endometrium with macrophages, histiocytes, mast cells and bacteria. Menstrual discharge also contains cholesterol, estrogen, lipids and prostaglandins. Menstrual blood from the endometrium coagulates in the uterine cavity by its thromboplastic property. The clots are dissolved by the fibrinolysins released from the endometrium. Fibrin breakdown products therefore circulate in increased quantity during menstruation. Blood clots pass when menstrual bleeding becomes excessive.
Interval and duration
The menstrual cycle lasts an average of twenty-eight days. A deviation of 2 to 3 days can frequently occur. The extremes of the 21 and 35 day range can also be found. In every woman’s menstrual life, the interval can vary. The usual duration is three to five days, with essentially normal extremes of two and seven days. Every woman needs sex education within this normal menstrual pattern so that she does not suffer from miseducation of a normal menstrual pattern taken as menstrual irregularity.
The average total blood loss during menstruation has been estimated at 35 ml (range 5-60 ml); average loss of iron was found to be 12 mg. A rough clinical estimate is that usually no more than three fresh pads are needed during the twenty-four hours, two during the day and one at night, thus requiring a total of 12 15 pads during a cleanse. This loss varies widely and is greater in women living in hot climates than in those living in cold climates.
Correct teaching about men is important. She should be informed that menstruation is not the draining of harmful substances from the body, but a normal manifestation of femininity. During menstruation, she should continue her usual activities, including daily bathing, playing games. Personal hygiene is maintained by changing sanitary napkins regularly. Intravaginal tampons can be used by married women, provided she does not forget to leave them. A healthy couple can have intercourse during menstruation. Postponement or advancement of menstruation. This sometimes becomes necessary for important social reasons like marriage. This should not be defended on flimsy grounds. The hormone treatment used is the following:
1. Progesterone norethisterone one tab. three times daily from the 20th day of the menstrual cycle until after the postponement date.
2. Estrogen progestin birth control pills, two a day are started from the 20th day. Menstrual flow is expected 2 to 3 days after treatment is stopped. Menstruation can be brought too early by starting hormone treatment from the 5th day of men for 14 days. The treatment is (a) Estrogen ethinylestradiol 0.05 mg. tds or (b) estrogen progestogen oral pill once daily. Anovulax menstrual flow is likely to begin within 2 3 days of stopping treatment.
Endocrine mechanism of menstruation
Play of sex hormones from the hypothalamus in the brain, pituitary gland, ovary causes menstrual bleeding from the endometrium of the uterus.
This is called the hypothalamus-pituitary-ovary-uterus axis
1. In the brain, the hypothalamus acts as a switch to endocrine menstrual mechanism and starts the process by secreting gonadotropin-releasing hormone (GnRH) or (LHRH) by peptidergic neuron. The latter is controlled by aminergic neuron. The environment affects menstruation via the cerebral cortex and hypothalamus.
GnRH flows down from the hypothalamus via the portal vessels of the pituitary gland to
2. Anterior pituitary (gonadotrophic cells) release follicle-stimulating hormone (FSH) and luteinizing hormone (LH) into the bloodstream to initiate ovarian growth in both ovaries.
Ovarian cycle. Ovarian follicles (20 in number) are cultured in a three-stage menstrual cycle.
(a) ovarian follicles are cultured from primordial follicles. A single graarian follicle matures and becomes dominant by the effect of FSH, while other follicles undergo atresia.
(b) Estradiol is secreted by maturing ovarian follicle into the circulation ‘ stimulating the hypothalamus and pituitary gland to cause rise of LH and FSH hormones in the blood (positive feed-back) on day 12 of the menstrual cycle.
(c) Ovulation (discharge of egg from the ovary) takes place on day 14 of the menstrual cycle. Corpus luteum (yellow body) is formed in the shell of mature graafian follicle egg solution due to the LH effect.
Corpus luteum remains mature From days 19-26, degenerates on days 27 and 28 if pregnancy does not occur in menstrual cycle’. Plasma prolactin (from anterior pituitary) increases (induces the luteal phase and appears to maintain the corpus luteum. Abundant progesterone hormone., some estradiol and inhibin (peptide hormone) are secreted by the corpus luteum. Estradiol causes luteolysis, while inhibin lowers FSH.
(a) Proliferative phase
Estradiol from ovarian follicles causes proliferative changes in the endometrium of the uterus (days 7-14). All endometrial tissue elements of I mm thick proliferate. Before start of proliferative phase, repair phase. starts with period bleeding and ends with 48 hours after period.
(b) Secretory phase. Progesterone (from the corpus luteum) causes secretory changes in the endometrium (day 15 – 26 to receive fertilized egg for implantation. Glycogen appears as subnuclear vacuoles in the endometrial gland followed by secretion of glycogen and mucus on the lumen of the gland. Glands become corkscrew vessels. becomes twisted, stroma becomes vascular and ovoid Endometrium thickens to 5 mm in three layers (a) superficial compact layer with neck glands (b) spongy layer with enlarged glands (c) basal layer in contact with myometrial layer.
The regression stage occurs in the secretory endometrium on days 27 to 28.
(c) The menstrual bleeding phase occurs for 4 – 5 days after day 28 of the cycle due to shedding of endometrial bits and bleeding from the endometrial bed. Necrosis and shedding of endometrial bits extends from region to region during the first 2 days of menstruation. Bleeding occurs as (a) capillary bleeding with or without subepithelial hematoma formation (b) venous bleeding and (c) diapedesis.
The menstrual phase is caused by the withdrawal of estradiol and progesterone support the endometrium. FSH rises again to start another cycle.
Cause of menstrual bleeding. The exact cause is still unclear. The sequence of events is:
Withdrawal of estrogen and progesterone due to degeneration of corpus luteum ‘rapid shrinkage and regression of secretory endometrium overcoiling of endometrial spiral arterioles ‘stasis of circulation in the functional layer of endometrium’ necrobiosis of vessels. Prostaglandins produced by the endometrium also cause vasospasm in spiral vessels ‘ischemic necrosis of some endometrium supplied by spiral artery relaxation of spiral vessel bleeding from the spiral vessel end. These vascular changes are described by Markee (1940)
In the shedding process, coagulation and fibrinolysis occur at the bleeding site, so that uncoagulated dark red blood with endometrial tissue fragments is drained for 4-5 days. Dating of the endometrium. The endometrium is dated from its histological appearance, especially in the secretory phase, e.g. prenuclear vacuoles – 16th day, basal nuclei, secretion in glandular lumen – 20th day.
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