Normal and Abnormal Menstruation

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    NORMAL AND ABNORMAL

    MENSTRUATION

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    MENSTRUAL CYCLE

    Menstruation is the cyclical uterine

    bleeding occurring during the

    reproductive age between menarche tomenopause with cyclical changes in the

    endometrium which may be regarded as

    a periodic preparation for fertilization and

    pregnancy.

    Normal Duration : 28 days

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    HYPOTHALAMO-PITUITARY

    OVARIAN AXIS+

    FSH ESTROGEN

    -

    GnRH

    +

    LH PROGESTRONE-

    (Hypothalamus) (pituitary) (ovary)

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    PHASES OF MENSTRUATION

    PHASES :

    1. MENSTRUATION 1-4 DAYS2. PROLIFERATIVEPHASE 5-13 DAYS

    3. PHASE OF OVULATION 14TH DAY

    4. SECRETORYPHASE 15-28 DAYS

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    PROLIFERATIVEPHASE

    This phase is due to estrogen

    Corresponds to proliferative phase or

    estrogenic phase of ovarian cycle Starts when regeneration of endometrium

    is complete lasts until the 14th day of 28

    days cycle

    At the end of menstruation the

    endometrium is represented by basal

    layer and its thickness is about 1mm

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    The uterine glands are short,straight,simple

    tubular glands.

    Uterine glands grow in length and about the

    10th day the glands become slightly sinous

    and their columnar epithelium becomestaller than before.

    Epithelial cells also increase in number bymitosis and stromal blood vessels of the

    endometrium also grow with increase in

    number of coils.

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    OVULATION

    Occurs at the 14th day.

    Due to action of LH,the graffian follicle

    ruptures and ovulates forming CORPUS

    LUTEUM.

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    LUTEALPHASE

    Due to the action of progesterone

    Begins on the 15th day until the onset ofmenstruation

    CHANGES :1. Development of subnuclear vacuolation -

    Day 17

    2. Uterine glands become tortuous (cock

    screw) and glycogen appears in theglandular lumen

    Endometrial thickness : 8-10mm Day 19

    3. Stromal edema-Day 21.

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    Perivascular cuffing Day 23

    Coiled arteries becoming more closelywound,lymphocyte infilteration occur Day

    25

    MENSTRUAL PHASE

    Lasts for 3-5 days

    Superficial endometrium becomes ischemic

    due to vasoconstriction and blood stasis

    Tissue sloughs off and blood vessels open

    up

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    HEMOSTASIS

    Achieved in a normal menstruation by 2

    mechanisms:

    Formation of platelet plug

    Constriction of spiral arterioles

    Vasoconstriction is brought about by means

    of prostaglandins

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    DEFICIENTHEMOSTASIS

    DUETO: Disturbance in prostanoid metabolism

    Increased fibrinolysis in endometrium

    NORMAL:

    In proliferative phase the endometrium

    synthesizes equal amount ofPGE2 & PGF2

    In luteal phase PGF2 increases due toestradiol & progesterone

    PGF2 : PGE2 =2:1

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    Endometrium PGF2, PGE2 & PGD2

    Myometrium PGE2 from arachidonic acid &

    endoperoxidases.

    PHOSPHOLIPID

    FREE ARACHIDONIC ACID

    ENDOPEROXIDES

    PGE2 PGF2

    PGI2

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    1. First, PGF2 produces vasoconstriction

    2. Endoperoxides from endometrium are

    deviated to the myometrium whichproduces PGI2

    3. This then diffuses back into endometriumwhich causes vasodilation followed by

    vasoconstriction of spiral arterioles

    preceding menstruation

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    WITHDRAWAL OFPROGESTERONE

    BREAKDOWN OF LYSOSOMES

    RELEASE OFPHOSPHOLIPASE A2

    PROSTANOID CASCADE

    PREDOMINATION OF VASOCONSTRICTORPROSTANOIDS

    ORDERLY BLEEDING

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    ABNORMALHEMOSTASIS IN DUB

    Failure in vasoconstriction due to

    excessive secretion ofPGE2 & increase in

    PG

    E2 :PG

    F2.

    Failure in formation of adequate

    thrombotic plugs due to PGI2 excess.

    Increased fibrinolysis due to increase in

    the tissue plasminogen activator.

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    Increased endometrial lysosomal enzymeswith excessive prostanoid formation.

    Failure in vascular endothelial proliferationdue to relaxin.

    Delay in endometrial regeneration.

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