1. MENSTRUATION AND
MENSTRUAL DISORDERS
Asomma Kubire

2. Objectives
• Understand hormonal changes in menstrual
cycle
• Understand ovarian changes in menstrual
cycle
• Understand endometrial changes in
menstrual cycle
• Identify, diagnose and treat some
abnormalities of menstruation

3. Stages of menstrual cycle
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Follicular phase (Proliferative phase)
Luteal phase (Secretory phase)
Cycle ranges between 25 and 32 days
Menstrual flow is for 4-6 days
Luteal phase lasts between 12 and 16 days
Luteal phase is usually reported to be of
constant duration – 14 days

4. Organs involved in menstrual
cycle
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Hypothalamus
Anterior pituitary
Ovary
Uterus (Endometrium)

5. Hormones in menstrual cycle
• Gonadotrophin Releasing Hormone
(GnRH)
• Follicle Stimulating Hormone (FSH)
• Luteinising Hormone (LH)
• Estrogen
• Progesterone

6. Pituitary and Hypothalamic events
• Atrophy of the corpus luteum with falling
progesterone and estrogen levels initiates the
menstrual cycle
• Low estrogen and progesterone levels cause
GnRH secretion by the hypothalamus
• GnRH acts on the pituitary to secrete FSH and LH
• FSH initiates development of the follicles in the
ovary

7. Ovarian events
• FSH causes development of 18-20 follicles
• Developing follicles produce estrogen through
action of FSH and LH
• One follicle becomes dominant follicle
• Rising estrogen levels inhibit FSH and LH
• All follicles except dominant follicle undergo
atresia
• Rising estrogen levels from dominant follicle
cause LH surge
• LH surge brings about ovulation

8. Post ovulatory events
• Corpus luteum (CL) is formed after
ovulation
• CL produces progesterone and estrogen
• Hormones from CL maintain endometrium
until CL undergoes atresia
• Atresia of CL leads to shedding of
endometrium – menses- and initiation of
another cycle

10. Hormonal Events
• Negative feedback
• Positive feedback
• LH surge starts 34-36 hours before
ovulation
• Peak of LH surge is 10-12 hours before
ovulation

11. Ovarian Events
• Stages of follicle development – primordial,
primary, secondary, tertiary, graafian
• Recruitment of follicles
• Emergence of dominant follicle
• Ovulation
• Corpus luteum formation

13. Endometrial Events
• Changes are due to estrogen and
progesterone
• Proliferative phase is characterised by
increase in growth of endometrium –
primarily glandular growth
• Glands are narrow and tubular with mitoses
and pseudostratification

14. Endometrial events
• Luteal phase changes are used to date the
the cycle
• Day 16 – pseudostratification and
subnuclear vacuoles: first sign of ovulation
• Day 17 – glands are tortuous and dilated
• Day 18 –vacuoles are beside nuclei
• Day 19 – pseudostratiication and vacuoles
have disappeared

15. Endometrial events
• Day 21,22 – edematous endometrial stroma
• Day 23 – stromal mitosis starts
• Day 24 – predecidual cells surrounded by spiral
arterioles and numerous stromal mitoses
• Day 25 – predecidual cells begin to differentiate
under surface epithelium
• Day27 – upper portion of endometrial stroma
made up of well-diffrentiated decidua-like cells

16. Menstrual disorders
• Dysmenorrhea
• Menorrhagia
• Amenorrhea

17. Menstrual disorders
• Dysmenorrhea: Painful lower abdominal
cramps occurring just before or during the
menses
• Primary dysmenorrhea begins at or shortly
after menarche
• Secondary dysmenorrhea occurs well after
menarche and is associated with pelvic
pathology

18. Menstrual disorders
• Primary dysmenorrhea is due to
abnormalities of prostaglandin metabolism
• Secondary dysmenorrhea – pelvic infection,
uterine fibroids, endometriosis,
adenomyosis

19. Treatment of dysmenorrhea
• Primary: NSAIDS and oral contraceptives
• Secondary: Treatment of underlying cause

20. Menstrual disorders
• Menorrhagia is prolonged (more than 7
days) or excessive (over 80ml) uterine
bleeding occrring at regular intervals
• Dysfunctional uterine bleeding: Excessive
uterine bleeding with no demonstrable
organic cause

21. Menstrual disorders
• DUB is due to abnormalities of
prostaglandin metabolism
• Menorrhagia – gynaecolgical causes,
endocrine causes, haematologic causes

22. Causes of menorrhagia
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Uterine fibroids
Adenomyosis
Endometrial CA
Hypothyroidism
Bleeding disorders

23. Menstrual disorders
• Amenorrhea: absence of menses during the
reproductive years
• Primary amenorrhea: Absence of
spontaneous menses in an individual older
than 16
• Secondary amenorrhea: absence of menses
in an individual who has previously had
spontaneous menstrual periods

24. Causes of secondary amenorrhea
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Pregnancy
Anovulation
PCOS
Intrauterine synechiae
Secondary Vaginal atresia
Hyperprolactinaemia
Pituitary tumours
Cushing’s syndrome
• Hyperthyroidism
• Premature ovarian failure
• Hypothalamic pituitary
dysfunction
• Stress
• Severe weight loss
• General medical disorders
• Adrenal tumours

25. Causes of primary amenorrhea
• Turner’s syndrome
• CNS tumours
• Androgen insensitivity
(Testicular feminisation
syndrome)
• Hyperprolactinaemia
• Congenital adrenal
hyperplasia
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Vaginal atresia
Imperforate hymen
Mullerian abnormalities
Hyperthyroidism
Late development
Stress
Low body weight
Adrenal tumours

26. Investigation of secondary
amenorrhea
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History and examination
Pregnancy test
Progesterone challenge
FSH, LH assay
Serum prolactin
Thyroid function tests
CT scan / lateral skull X-ray
Hysterosalpingogram
USG

27. Investigation of primary amenorrhea
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History
Examination
Chromosomal studies
FSH, LH assay
Serum prolactin
CT scan
USG
Laparoscopy