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MENSTRUAL CYCLE

PHYSIOLOGY AND PATHOPHYSIOLOGY

Dr. Supriyatiningsih, M.Kes, SpOG

Department of Obstetrics & Gynecology Faculty of Medicine Muhammadiyah University Yogyakarta Indonesia

THE NORMAL MENSTRUAL CYCLES IS DETERMINED BY A COMPLEX INTERACTION BETWEEN REPRODUCTIVE ENDOCRINE ORGAN

HYPOTHALAMUS ANTERIOR PITUITARY GLAND OVARY ENDOMETRIUM

But the main regulation is intraovarian

The Menstruation Cycle
3 activity during Menstrual Cycle : Hypothalamus and Pituitary activity Ovarian activity

Uterine activity

Environment CNS Compartemen IV Hypothalamus GnRH Compartemen III FSH Compartemen II Estrogen Compartemen I Ovary Progesterone Anterior pituitary LH Uterus Menses .

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To survive. the follicle must be exposed to a wave of gonadotropic hormone release .

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Ovulasi .

Number of oocytes at different ages Age # of cells 3-6 weeks of gestation 8 weeks 8-20 20-40 weeks Birth to puberty Reproductive years Endoderm of the yolk sac Proliferation by mitosis Mitosis. atresia 80% loss Loss to atresia Ovulation 10.000 600.000.000.000 400-500 . meiosis.000 6-7.000 1-2.000 300.

Membran sel LISOSOM Asam fosfatase Enzim litik Penurunan aliran darah Vasokonstriksi a. spiralis Prostaglandin Iskemia Upregulated MMP Sekresi dan aktivasi sitokin Makrofag PMN LImfosit granulasi Menstruasi Triptase & kimase Regenerasi endometrium Degranulasi Sel Mast VEGF & FGF .

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• Lasts a limited period of time (3 to 7 days). . • May be heavy for part of the period. but usually does not involve passage of clots. bloating and breast tenderness.Normal menstrual bleeding • Occurs approximately once a month (every 26 to 35 days). although not all women experience these premenstrual symptoms. • Often is preceded by menstrual cramps.

Mean duration is 4 days. . More than 7 days is abnormal.7 days.Definitions Normal: Mean interval is 28 days +/.

Abnormal Bleeding • Abnormal bleeding (DUB or dysfunctional uterine bleeding) includes: • Too frequent periods (more often than every 26 days). • Extremely light periods or no periods at all . including spotting or pink-tinged vaginal discharge • Any bleeding lasting longer than 7 days. • Any bleeding at the wrong time. egg-sized clots). • Heavy periods (with passage of large.

• Often the first clinical diagnosis for any excessive menstrual bleedings.Dysfunctional Uterine Bleeding (DUB) • Most common menstrual disorder. . • Diagnosis has to be confirmed by a process of exclusion of pathological causes. • Can affect any women from menarche to menopause.

<21 Polymenorrhea Regular. amount varies at Metrorrhagia Menometrorrha Irregular. also called irregular “hypermenorrhea” intervals Uterine bleeding occuring at irregular but irregular frequent interval. Interval days.Abnormal Uterine Bleeding: Terminology & Definitions Term Amenorrhea Definition No uterine bleeding for at least 6 months Pattern Menorrhagia Excessive amount (>80 mL/cycle) or Occurs prolonged duration >7days. and prolonged menstrual irregular gi bleeding Oligomenorrhe a Decreased. frequent menstruation Intermenstrual Bleeding periode or spotting between normal Between periods (usually light flow) . scanty flow. heavy. the term Interval > 36-40 “hypomenorrhea” is used for regular timing days with scanty amount.

95% of women lose <60cc. .Average blood loss with menstruation is 35-50cc.

Definitions Menorrhagia: Prolonged > 7 days or > 80 cc occurring at regular intervals. Synonymous with hypermenorrhea .

Menorrhagia occurs in 914% of healthy women. .

.Definitions Metrorrhagia: Uterine bleeding occurring at irregular but frequent intervals.

Etiologies AUB • Organic – Systemic – Reproductive tract disease – Iatrogenic • Dysfunctional – Ovulatory – Anovulatory .

Reproductive Tract Causes of Benign Origin • • • • • Atrophy Leiomyoma Polyps Cervical lesions Infection .

et al. 10% will have polyps and 10% will have hyperplasia..60% of women with PMB will be found to have atrophy. Karlsson. 1995 .

000 in 30-34 yr old 6.3/100.000 in 40-49 yr old ACOG Practice Bulletin #14.Incidence of Endometrial Cancer in Premenopausal Women 2. 2000 .1/100.000 in 35-39 yr old 36/100.

.DUB Abnormal uterine bleeding for which an organic etiology has been excluded. It is either ovulatory or anovulatory in origin.

metabolik. sistemik.PUD - Kelainan • Organik • Sistemik • Metabolik • Keganasan • Ggn kehamilan dini Perdarahan dari uterus yang didasari oleh gangguan hormonal poros Hipotamus-hipofisis-ovarium semata. keganasan maupun gangguan kehamilan dini . tanpa dijumpai kelainan organik.

and/or behavioral changes of sufficient severity to result in deterioration of interpersonal relationships and/or interference with normal activities.Premenstrual Syndrome Premenstrual Syndrome (PMS) is defined as “the cyclic recurrence in the luteal phase of the menstrual cycle of a combination of distressing physical. psychological. Nearly 200 symptoms have been associated with this definition and it is the clustering of these signs and symptoms that is the hallmark of PMS. .

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In general an instance where a single recognized medical condition presented in the premenstruum was referred to as a catamenial disorder while a cluster of symptoms was referred to as PMS. .Catamenial The term “catamenial” is derived from the Greek and signifies around menses.

called “premenstrual magnification” (PMM).Premenstrual Magnification Many patients with psychiatric disorders also complain of worsening of their symptoms around the premenstrual phase. .

while severe symptoms are estimated to occur in 3% to 5% of menstruating women. .PMS Milder symptoms are believed to occur in about 30% to 80% of reproductive-age women.

Concordance Rate The concordance rate (if both twins have PMS) was found to be significantly higher in monozygous twins (93%) than dizygous twins (44%) and in non-twin control women (31%). .

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Common Symptoms of PMS Women with PMS Symptom Behavioral Fatigue Irritability Labile mood with alternating sadness and anger Depression Oversensitivity Crying spells Social withdrawal Forgetfulness Difficulty concentrating Showing Symptoms (%) 92 91 81 80 69 65 65 56 47 .

Common Symptoms of PMS (Continued) Physical Abdominal bloating Breast tenderness Acne Appetite changes and food cravings Swelling of the extremities Headache Gastrointestinal upset 90 85 71 70 67 60 48 .

primary mental health care care physicians providers One 5 of 11 symptoms . other ologists.Differences Between PMS and PMDD Diagnostic criteria Tenth Revision of the International Classification of Disease (ICD-10) Diagnostic and Statistical Manual of Mental th Disorders. 4 ed. (DSM-IV) Providers using these criteria Number of symptoms required Obstetrician/gynec Psychiatrists.

Differences Between PMS and PMDD (Continued) Functional impairment Not required Interference with social or role functioning required Prospective daily charting of symptoms required for two cycles Prospective charting of symptoms Not required .

Patterns of PMS • Premenstrual symptoms can begin at ovulation with gradual worsening of symptoms during the luteal phase (pattern 1). • PMS can begin during the second week of the luteal phase (pattern 2). .

time-limited episode of symptoms at ovulation. followed by symptom-free days and a recurrence of premenstrual symptoms late in the luteal phase (pattern 3). .Patterns of PMS (Continued) • Some women experience a brief. • The most severely affected women have symptoms that at ovulation worsen across the luteal phase and remit only after menses cease (pattern 4). These women describe having only one week a month that is symptomfree.

Differential Diagnosis Psychiatric disorders • Major depression • Dysthymia • Generalized anxiety • Panic disorder • Bipolar illness (mood irritability) • Other Medical disorders • Anemia • Autoimmune disorders • Hypothyroidism • Diabetes • Seizure disorders • Endometriosis • Chronic fatigue syndrome • Collagen vascular disease .

Differential Diagnosis (Continued) Premenstrual exacerbation • Of psychiatric disorders • Of seizure disorders • Of endocrine disorders • Of cancer • Of systemic lupus erythematosus • Of anemia • Of endometriosis Psychosocial spectrum • Past history of sexual abuse • Past. or current domestic violence . present.

Does not meet DSM-IV criteria but does meet ICD-10 criteria for PMS B. Symptoms occur only in the luteal phase. peak shortly before menses. Presence of one or more of the following symptoms • Mild psychological discomfort • Bloating and weight gain • Breast tenderness • Swelling of hands and feet • Aches and pains • Poor concentration • Sleep disturbance • Change in appetite .Diagnosis of PMS PMS A. and cease with menstrual flow or soon after C.

with at least one being a core symptom. At least five of the symptoms below. are present a week before menses and remit a few days after onset of menses: • Depressed mood or dysphoria (core symptom) • Anxiety or tension (core symptom) • Affective lability (core symptom) • Irritability (core symptom) • Decreased interest in usual activities .PMDD (DMS-IV Criteria) A.

or food cravings • Hypersomnia or insomnia • Feeling overwhelmed • Other physical symptoms (e.PMDD (DMS-IV Criteria) (Continued) • Concentration difficulties • Marked lack of energy • Marked change in appetite.g. joint or muscle pain) .. headache. breast tenderness. overeating. bloating.

Treatment of PMS • • • • • • • • • Oral contraceptives Vitamin B6 Bromocriptine Monoamine oxidase inhibitors Synthetic progestational agents Spironolactone Massage therapy Chiropractic therapy Calcium .

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MENOPAUSE .

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Irreguler menstruation .

Gejolak panas .

Osteoporosis • • • • • Tulang keropos Ngilu-ngilu Patah tulang Bungkuk Tambah pendek .

NORMAL Kerusakan bag tulang .

The good news
Menopause and postmenopauseosteoporosis

Kulit keriput .

Sukar tidur .

Jantung berdebar Pusing Mudah pingsan .

Gangguan fungsi seks • • • • Vagina kering Hub. Seks sakit Lendir sedikit Nafsu sek turun .

Libido menurun .

Gangguan berkemih Inkontinensia Ngompol .

JAMA 2004.291:1610-20 . increases bone mineral density (BMD) and reduces the incidence of fractures • ERT reduces levels of total cholesterol and low-density lipoprotein (LDL) cholesterol Nelson H.Some benefits of estrogen replacement therapy (ERT) for treating menopausal related health problem • Estrogen replacement therapy (ERT) results in the relief of menopausal symptoms such as hot flushes and atrophy of genital tract • ERT halts postmenopausal bone loss.

JAMA 2002.288:321-33 .Benefits of estrogen plus progestin in postmenopausal women Estrogen + progestin Plasebo WHI study.

it contributes to poor compliance Van Seumeren I.34(Suppl 1):3–8 . Maturitas 2000.Weight gain during traditional HRT has been one of the main reasons for discontinuation Although it may not be the only reason.

LIVER ESTROGEN HRT KIDNEY ADRENAL GLAND Na+/ water retention (= weight gain) K+ elimination Aldosterone Increased edema Increased body weight .

0 -1.5 -1.5 Angeliq® (n = 224) 0 1 2 3 4 5 6 7 Estradiol (n = 225) 8 9 10 11 12 13 .Changes in body weight with Angeliq® and estradiol alone Mean weight change (kg) 1.0 0.5 1.5 0 0 -0.

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