Menstrual cycle

•Assistance professor Dr. Wissam Akram

•Fifth year lecture
•2020-2021
Menstruation with clinical considerations

Menstruation is defined as monthly

shedding of endometrial dead tissue
which herald failure to achieve
pregnancy.
Menstrual blood is a mixture of dead
endometrial tissue, blood components
and pus cells.
The normal limits of human cycle are 3-
7 days in duration, with frequency 21-
35 days with average 28 days
The total blood loss should not exceed
70- 80 ml and usually above 30- 40 ml.
 Anatomical overview of the limbic system, hypothalamus and
pituitary as related to menstruation
• Pituitary composed of 2
parts
• Anterior [art
• Posterior part
• Oxytocin and vasopressin
are secreted from the
posterior pituitar
• LH and FSH are secreted
from anterior pituitary gland
after stimulation with GnRH
hormone
• The later is trensmitted to the
pituitary via portal system
 The hypothalamus hormones inducing
menstruation
• GnRH is a deca peptide
• Usually secreted in pulsatile
manner every 30 munutes
• They icrease in intensity and
frequency throughout the cycle
• And reduced at time of
menstruation’
• GnRH analogue are synthesized
by manpulating amino acids
number 6 and 10
• Used in the treatment of
endometriosis or IVF
 Hypothalamic specific causes which inhibits
GnRH only

• There are specific causes

which inhibits LH and FSH or
GnRH only from the
thalamus
• 1- athletes
• Anorexia nervosa
• Heavy job like light
attendants, female pilot,
ballet dancers
 Craniophapharyngioma
• On the other hand all hormones
secreted rom the pituitary may
be depressed like in
cranyopharyngioma
• Inclusion cyst arise from Rathkes
pouch
• Usually increase is size with age
and symptomes appear at early
therties
 Pituitary gland
• Anterior pituitary
cells are stained
either blue or red
• Basophilic cells
secrets FSH, LH, TSH,
ACTH
• While acidophil cells
secretes growth
hormones and
prolactin during
lactation
 Endometriosis
• Endometriosis is a disease in
which endometrial tissue
present anywhere outside the
endometrial cavity.
• Inhibition of the menstruation
for 6 months by GnRH
analogues is used to induce
amenorrhea.
 Contraceptive pills
• Combined contraceptive
pills are used for family
control or contraception’s
contains estrogen and
synthetic progesterone.
• They act by complete
inhibition of FSH- LH
secretion
 IVF
• In vitro fertilization FSH and
LH which can be mixed or FSH
alone can be given in various
protocols to induce
maturation of the ovarian
follicle
• and then extracted under U/S
guidance so the ova is
fertilized under the
microscope.
• Usually 3-5 morula stage
embryos are returned to the
uterus.
• Down regulation of the
pituitary is essential to give
exogenous gonadotrophins
 Enometrial carcinom
• In endometrial carcinoma
since the famous reports
by Novak’s in USA that
cannon balls in the lung
have disappeared by
progesterone;
• progestational agents may
be part of the treatment of
advanced endometrial
carcinoma
 Primary dysmenorrhea
• Primary dysmenorrheal a
disease associated with
menstruation with severe
colicky abdominal pain.
• Contraceptive pills may be
used as a second line.
 Anatomical overview of the ovary related to
menstruation
• The ovaries are
suspended by peritoneal
fold containing the
suspensory ligament of
the ovary
• The fact that its blood
supply is different from
the uterus is a key stone
in the development of
endometrial gland and
implantation of the
zygot
 Ovary under microscop
• Primordial ovarian follicle
• Seconday ovarian follicle
• Tertiary ovarian follicle
• Immature and mature ovarian
foliicle
• Corpus luteum
• Corpus albicans
 Mullerian inhibiting factor as predictor of
menstrual age of woman

• Women from biological point of

view have 2 ages
• The age of survival and has nothing
to do with ovulation
• The fertility age is the number of
years spent while she can become
pregnant
• Menopause has no exact time to
come and MIF have been used
extensively to predict the age of
meopause
 Mittelschmerz
• Pain simulating acute abdomen
which is usually coincide with
ovulation
• Caused by the few drops of blood
which accompany rupture of the
mature follicle
• Frequently misdiagnosed as
appendicitis and operated upon s
Ovulation and fertilization
 Polycystic ovarian syndrome
• PCO was described first by 2 scientist stein
and levinthal as syndrome of obesity
• Hirsutism
• Hypo oligomenorrhea
• Infertility
• Nowadays it has been discovered to be
one of the insulin resistance diseases
• The increased testosterone among those
women is to facilitate or sensitize insulin
receptor to the high insulin levels
• Androgens on the other hand impairs the
process of follicle development and both
ovaries contain large number of immature
follicles after which its naming come
 Premature menopause
• Menopause when occur at
age less than 40 years.
• Auto immune diseases are
significantly associated
with.
• Family associated
sometime seen.
• Such women are those
with highest risk of
ischemic heart disease,
CVA and osteoporosis.
Hormone replacement
therapy is the available
treatment.
Proliferative phase and luteal
 Anatomical overview of the fallopian tubes
related to menstruation

Progesterone and ciliary movement of tte tube cilia

•Immediately after ovulation the level of progesterone secreted is start to increase in
the blood
•This affects the cilia push by the ciliated columnar epithelium in fallopian tbes
•In case serum progesterone> 15 ug/ml the cilia push the zygote to the tube
•Otherwise the cilia push the zygote to the fambiria causing ectopic pregnancy or
infertility
 Simple test to confirm ovulation
• Body temperature
• Spinbarkeit test
• Vaginal cells aspiration and staining with
eosin and hematoxylin.
• Aspiration of the endometrial lining for
histopathology.
• Serum progesterone at day 21 or mid
luteal phase above 20 ug/ ml is highly
associated with ovulation.
• Ultrasounds scan at day 14 and 21 of the
cycle
• The modern widely used kits which stains
according to the instructions coming with
those kits may be used.
Squamocolmnar junction and uterine cervix

•The juction between endervical canal with single columnar epithelium

and ecto cervix with stratified squamous epithelium is almost always the
origi of vervical carcinoma.
•Scarping of cells with special metal or wooden spatula may alert to
premalignant possibility and this is called CIN cervical intra epithelia
carcinoma