CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107

CHAPTER 2: MENSTRUATION

MENSTRUATION • GNRH then stimulates the pituitary gland to send the

• A menstrual cycle (the female reproductive cycle) is episodic gonadotropic hormone to the ovaries to produce estrogen.
uterine bleeding in response to cyclic hormonal changes. • When the level of estrogen rises, release of GNRH is repressed
• The purpose of a menstrual cycle is to bring an ovum to and no further menstrual cycles will occur.
maturity and renew a uterine tissue bed that will be necessary 2. THE ANTERIOR LOBE OF THE PITUITARY GLAND (THE
for the ova’s growth should it be fertilized. ADENOHYPOPHYSIS)
MENARCHE • Under the influence of GNRH, produces two hormones:
• First menstruation. 1) FSH, a hormone active early in the cycle that is
• May occur as early as 9 years of age. responsible for maturation of the ovum.
• It is good to include health teaching information on 2) LH, a hormone that becomes most active at the midpoint
menstruation to both school-age children and their parents as of the cycle and is responsible for ovulation, or release of
early as fourth grade as part of routine care. the mature egg cell from the ovary.
THE LENGTH OF MENSTRUAL CYCLES - It also stimulates growth of the uterine lining during
• Differs from woman to woman. the second half of the menstrual cycle.
• Average length is 28 days (from the beginning of one menstrual 3. THE OVARIES
flow to the beginning of the next). • Every month during the fertile period of a woman’s life (from
• It is not unusual for cycles to be as short as 23 days or as long as menarche to menopause), one of the ovary’s oocytes is
35 days. activated by FSH to begin to grow and mature.
THE LENGTH OF THE AVERAGE MENSTRUAL FLOW (TERMED • As the oocyte grows, its cells produce a clear fluid (follicular
MENSES) fluid) that contains a high degree of estrogen and some
progesterone.
• 4 to 6 days
• As the follicle surrounding the oocyte grows, it is propelled
• Although women may have flows as short as 2 days or as long
toward the surface of the ovary.
as 9 days (Ledger, 2012).
• At full maturity, the follicle is visible on the surface of the
MENSTRUATION ovary as a clear water blister approximately 0.25 to 0.5 in.
CHARACTERISTIC DESCRIPTION • At this stage of maturation, the small ovum (barely visible to
Beginning (menarche) Average age at onset, 12.4 the naked eye, about the size of a printed period) with its
years; average range, 9–17 surrounding follicular membrane and fluid is termed a graafian
years. follicle.
Interval between cycles Average, 28 days; cycles of 23–
35 days not unusual.
Duration of menstrual flow Average flow, 4–6 days; ranges
of 2–9 days not abnormal
Amount Difficult to estimate.
Average 30–80 ml per
menstrual period; (1 gram = 1
ml).
Saturating a pad or tampon in
less than 1 hr is heavy
bleeding.
Color Dark red
A combination of blood,
mucus, and endometrial cells
Odor Similar to marigolds
THE PHYSIOLOGY OF MENSTRUATION
• FOUR BODY STRUCTURES ARE INVOLVED:
1. Hypothalamus • By day 14 or the midpoint of a typical 28-day cycle, the ovum
2. Anterior pituitary gland has divided by mitotic division into two separate bodies:
3. Ovaries 1) A primary oocyte, which contains the bulk of the
4. Uterus cytoplasm, and
• For a menstrual cycle to be complete, all four organs must 2) A secondary oocyte (immature ovum) contains big
contribute their part. cytoplasm, nutrients & organelles.
• Inactivity of any part results in an incomplete or ineffective • The structure also has accomplished its meiotic division,
cycle. reducing its number of chromosomes to the haploid (having
1. THE HYPOTHALAMUS only one member of a pair) number of 23.
• Release of the GNRH (also called luteinizing hormone–
releasing hormone [LHRH]) from the hypothalamus initiates
the menstrual cycle.
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 2: MENSTRUATION
• After an upsurge of LH from the pituitary at about day 14,
prostaglandins are released and the graafian follicle ruptures.
(*mittelschmerz)
• The ovum is set free from the surface of the ovary, a process
termed ovulation. It is swept into the open end of a fallopian
tube.
• It is important to teach women that ovulation does not
necessarily occur on the 14th day of their cycle.
o It occurs 14 days before the end of their cycle.
• If their menstrual cycle is only 20 days long, for example, their
day of ovulation would be day 6 (14 days before the end of the
cycle).
• If their cycle is 44 days long, ovulation would occur on day 30,
not at the halfway point—day 22.
• After the ovum and the follicular fluid have been discharged
from the ovary, the cells of the follicle remain in the form of a
hollow, empty pit.
• The FSH has done its work at this point and now decreases in
amount.
• The second pituitary hormone, LH, continues to rise in amount
and directs the follicle cells left behind in the ovary to produce
lutein, a bright-yellow fluid high in progesterone.
• With lutein production, the follicle is renamed a corpus luteum
(yellow body).
• The basal body temperature of a woman drops slightly just
before the day of ovulation because of the extremely low level
of progesterone that is present at that time.
• Your body temperature dips a bit just before your ovary
releases an egg. Before ovulation, a woman's BBT averages
between 97°F (36.1°C) and 97.5°F (36.4°C).
• 24 hours after ovulation, it rises to 97.6°F (36.4°C) to 98.6°F
(37°C) and stays up for several days.
• The woman’s temperature remains at this elevated level until
approximately day 24 of the menstrual cycle, when the
progesterone level again decreases (Huether & Mccance, 2012).
• If conception (fertilization by a spermatozoon) occurs as the
ovum proceeds down a fallopian tube and the fertilized ovum
implants on the endometrium of the uterus, the corpus
luteum remains throughout the major portion of the pregnancy
(to about 16 to 20 weeks).
• If conception does not occur, the unfertilized ovum atrophies
after 4 or 5 days, and the corpus luteum (now called a “false”
corpus luteum) remains for only 8 to 10 days.
• As the corpus luteum regresses, it is gradually replaced by
white fibrous tissue, and the resulting structure is termed a
corpus albicans (white body).
4. THE UTERUS
• Uterine changes that occur monthly is a result of stimulation
from the estrogen and progesterone produced by the ovaries.
CERVICAL CHANGES
• The mucus of the uterine cervix also changes in structure and
consistency each month during a menstrual cycle.
• At the beginning of each cycle, when estrogen secretion from
the ovary is low.
o Cervical mucus is thick and scant.
o Sperm survival in this type of mucus is poor.
• At the time of ovulation, when the estrogen level has risen to a
high point:
o Cervical mucus becomes thin, stretchy (spinnbarkeit), and
copious.
• Spinnbarkeit
o Sperm penetration and survival in this thin mucus are
both excellent.
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 2: MENSTRUATION

• The second half of the cycle
o Progesterone becomes the major influencing hormone.
o Cervical mucus again thickens.
o Sperm survival is again poor.
• During ovulation
o The body of the cervix is softer.
o The cervical os is slightly open.
• A ferning pattern of cervical mucus occurs with high estrogen
levels.
• The capillaries rupture, with minute hemorrhages, and the
endometrium sloughs off.
4. THE FOURTH PHASE OF THE MENSTRUAL CYCLE (MENSES)
• Menses, or a menstrual flow, is composed of
1) A mixture of blood from the ruptured capillaries;
2) Mucin;
3) Fragments of endometrial tissue; and
4) The microscopic, atrophied, and unfertilized ovum.
• Because it is the only external marker of the cycle, the first day
of menstrual flow is used to mark the beginning day of a new
menstrual cycle.
• A menstrual flow contains only 30 to 80 ml of blood;
• If it seems to be more, it is because of the accompanying mucus
and endometrial shreds.
• The iron loss in a typical menstrual flow is approximately 11
mg.
o This is enough loss that many adolescent women could
benefit from a daily iron supplement to prevent iron
depletion during their menstruating years (Bitzer, Sultan,
Creatsas, et al., 2014).
MENSTRUAL CYCLE

THE PHYSIOLOGY OF MENSTRUATION

1. THE FIRST PHASE OF THE MENSTRUAL CYCLE
(PROLIFERATIVE)
• Immediately after a menstrual flow (which occurs during the
first 4 or 5 days of a cycle)
• The endometrium, or lining of the uterus, is very thin,
approximately one cell layer in depth.
• As the ovary begins to produce estrogen (in the follicular fluid,
under the direction of the pituitary FSH), the endometrium
begins to proliferate so rapidly the thickness of the
endometrium increases as much as eightfold from day 5 to day
14.
• Also called the proliferative, estrogenic, follicular, or
postmenstrual phase.
2. THE SECOND PHASE OF THE MENSTRUAL CYCLE
(SECRETORY)
• After ovulation, the formation of progesterone in the corpus
luteum (under the direction of LH) causes the glands of the
uterine endometrium to become corkscrew or twisted in
appearance and dilated with quantities of glycogen (an
elementary sugar) and mucin (a protein).
• It takes on the appearance of rich, spongy velvet.
• Is termed the progestational, luteal, premenstrual, or
secretory phase.
3. THE THIRD PHASE OF THE MENSTRUAL CYCLE (ISCHEMIC)
• If fertilization does not occur, the corpus luteum in the ovary
begins to regress after 8 to 10 days, and therefore, the
production of progesterone decreases.
• With the withdrawal of progesterone, the endometrium of the
uterus begins to degenerate (at about day 24 or day 25 of the
cycle).