Ovulation & Dysmenorrhea

By : Mohammad Faiz Taqiyuddin BMD 108812D

The menstrual cycle

Starts when girls are about 12 years old, but can be anytime between 8 and 16. Cycle lasts about 28 days. In young girls just reaching puberty, it may be irregular but as they grow older it usually settles down.

Structure of ovary
Fibrous capsule is called tunica albuginea Outer cortex houses developing gametes the oocytes, within follicles Inner medulla is loose connective tissue with largest vessels and nerves

Days 1-5
The uterus wall breaks down and comes out the vagina. It contains lots of blood. It can be accompanied by pain in the stomach. This is called the PERIOD or MENSTRUATION

Day 5 14
The blood loss from the vagina stops. The uterus wall builds up again. The ovary gets an egg cell ready to be released.

Day 14
The uterus lining is at its thickest again. The egg cell is released by the ovary. It travels down the egg tube towards the uterus. We call this OVULATION.

Day 14 - 28
The uterus lining remains thick so it is ready if a fertilised egg arrives. If an unfertilised egg arrives, it passes through the uterus and out the body through the vagina. The uterus lining starts to break down and the cycle repeats.

The Ovarian Cycle

Follicular phase 1st approx 14 days but variable Egg develops in a follicle Stimulated by FSH (see next slide) Estrogen produced Ovulation Egg released from follicle (LH surge) Egg in abdominal cavity Picked up by fimbria of fallopian tube Not necessarily halfway point Luteal phase Postovulatory phase 14 days (more constant) Corpus luteum develops from exploded follicle Produces progesterone as well as estrogen Progesterone stimulates uterus to be ready for baby If no pregnancy, corpus luteum degenerates into corpus albicans

OVULATION
OVULATION is the release of a secondary oocyte from a mature follicle. Occurs in response to high concentrations of FSH and LH. Signal for ovulation is LH surge Secondary oocyte is ejected from ovary directly through mass of ovarian wall. Fimbria directs oocyte into fallopian tube, preventing movement into coelom. Ovarian wall ruptures and egg released, surrounded by its corona radiata

HIGH LEVELS OF ESTROGEN FURTHER STIMULATE SECRETION OF LH BY ANTERIOR PITUITARY. This plus FSH also causes ovulation of the secondary oocyte leaving follicle without egg (the corpus luteum). (Approximately day 15.)

Nearly mature follicle

Oocyte develops the zona pellucida

Glycoprotein coat Protective shell (egg shell) Sperm must penetrate to fertilize the oocyte

Thecal cells stimulated by LH to secrete androgens Granulosa cells (with FSH influence) convert androgens to estrogen (follicular cells called granulosa cells now) Clear liquid gathers to form fluid-filled antrum: now a secondary follicle Surrounding coat of granulosa cells: corona radiata Fully mature, ready to ovulate, called: Graafian follicle12

From point of ovulation (about day 15) to the point where the corpus luteum begins to degenerate (about day 25), fertilization can take place. The potential for fertilization is highest during the first three days of this 10-day period. Sperm with X-chromosome tend to be more robust, and can last longer than those with Y-chromosome. AND, females can be capable of sperm storage. So...if intercourse takes place a bit before ovulation and more robust sperm (with X-chromosome) are stored while weaker (Y-chromosome) sperm die off waiting for ovulation, the chance of having a baby girl increases.

SPERM STORAGE IN THE FEMALE

Apparently, females can store sperm up to four days. This explains in part why the rhythm method works poorly to avoid pregnancy. (Also, it turns out that unused oocytes are actively scavanged.) With sex before ovulation, sperm can be stored for use. So, even though ovulation hasnt occurred, pregnancy can occur because the female is holding on the the sperm. Sex AFTER ovulation actually has a slightly lower chance for inducing pregnancy, as the egg could have been scavanged.

Hypothesis : Dysmenorrhea

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 Primary dysmenorrhea
which is defined as painful menses in women with normal pelvic anatomy, usually begins during adolescence. It is characterized by crampy pelvic pain beginning shortly before or at the onset of menses and lasting one to three days. Pain can typically last 12 to 72 hours and can be accompanied by nausea, vomiting, fatigue, and even diarrhea. Common menstrual cramps usually become less painful as a woman ages and may stop entirely if the woman has a baby.
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 Secondary dysmenorrhea is pain that is caused by a disorder in the woman's reproductive organs
Endometriosis Adenomyosis uterine fibroids infection.

Pain from secondary dysmenorrhea usually begins earlier in the menstrual cycle and lasts longer than common menstrual cramps. The pain is not typically accompanied by nausea, vomiting, fatigue, or diarrhea.

 The prevalence of dysmenorrhea is highest in adolescent women, with estimates ranging from 20 to 90 percent, depending on the measurement method used. A longitudinal study of a representative cohort of Swedish women found a prevalence of dysmenorrhea of 90 percent in women 19 years of age and 67 percent in women 24 years of age.
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 Dysmenorrhea is thought to be caused by the release of prostaglandins in the menstrual fluid, which causes uterine contractions and pain. Vasopressin also may play a role by increasing uterine contractility and causing ischemic pain as a result of vasoconstriction.
Elevated vasopressin levels have been reported in women with primary dysmenorrhea.

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Age < 20 years Attempts to lose weight Depression/anxiety Disruption of social networks Heavy menses Nulliparity Smoking
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 History and physical examination

perform only an abdominal examination in young adolescents with a typical history who have never been sexually active

Always R/O secondary dysmenorrhea

Pelvic mass, abnormal vaginal discharge

Ultrasonography laparoscopy or laparotomy with biopsy

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How can I relieve mild menstrual cramps?

To relieve mild menstrual cramps: For best relief, you should take ibuprofen as soon as bleeding or cramping starts, You may take aspirin or another pain reliever such as acetaminophen Place a heating pad or hot water bottle on your lower back or abdomen. Rest when needed. Avoid foods that contain caffeine. Avoid smoking and drinking alcohol. Massage your lower back and abdomen. Women who exercise regularly often have less menstrual pain. To help prevent cramps, make exercise a part of your weekly routine. oral contraceptives may be prescribed because women who take oral contraceptives have less menstrual pain.

How does secondary dysmenorrhea causes menstrual cramps?

Menstrual pain from secondary dysmenorrhea is caused by a disease in the woman's reproductive organs. Conditions that can cause secondary dysmenorrhea include: Endometriosis - A condition in which the tissue lining the uterus (the endometrium) is found outside of the uterus. Adenomyosis A condition where the lining of the uterus grows into the muscle of the uterus. Pelvic inflammatory disease - An infection caused by bacteria (a type of germ) that starts in the uterus and can spread to other reproductive organs. Cervical stenosis - Narrowing of the opening to the uterus Tumors (also called "fibroids") - Growths on the inner wall of the uterus

 A = consistent, good-quality, patientoriented evidence B = inconsistent or limited quality patientoriented evidence C = consensus, disease-oriented evidence, usual practice, opinion, or case series.

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 NSAIDs are the initial therapy of choice in patients with presumptive primary dysmenorrhea.Because all NSAIDs are equal in efficacy, agent selection should be guided by cost, convenience, and patient preference,with ibuprofen or naproxen being a good choice for most patients.

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