Menstruation (2) PDF

MENSTRUATION Harriet Jimenez, MN LPT  Menstrual cycle AKA Female reproductive cycle Episodic uterine bleeding in response to cyclic hormonal changes Complex interplay of events that occur simultaneously in the endometrium, hypothalamus and pituitary glands, and ovaries Purpose:...

MENSTRUATION Harriet Jimenez, MN LPT  Menstrual cycle AKA Female reproductive cycle Episodic uterine bleeding in response to cyclic hormonal changes Complex interplay of events that occur simultaneously in the endometrium, hypothalamus and pituitary glands, and ovaries Purpose: ▫ Bring an ovum into maturity ▫ Renew uterine tissue bed Factor affecting regularity of menstrual cycle: 1. Age 2. physical and emotional status 3. environmental influence Key Terms graafian follicle - one of the ovary's oocytes that is activated by FSH grows and matures is now called an ovum with surrounding follicular membrane and fluid Ovulation - is when a mature egg is released from the ovary, pushed down the fallopian tube, and is made available to be fertilized at about day 14 days from the end of the cycle not on the 14th day of the cycle Corpus luteum - after ovulation the follicle left behind in the ovary produces lutein a bright-yellow fluid rich in progesterone (yellow body) Progesterone is thermogenic Corpus albicans - as the corpus luteum regresses, it is replaced by white fibrous tissue (white body) How to get your average menstrual cycle? - Keep a record of your menstruation for at least 3 consecutive months  Menarche and Puberty Puberty - Transitional stage between childhood and sexual maturity Menarche - First menstruation Initially menstrual periods are irregular, unpredictable, painless, and anovulatory. Tends to be regular after 1 or more years.  The length of menstrual cycles differs from woman to woman Average is 28 days Length of average menstrual flow is 4-6 days How to count? - from the beginning of one menstrual flow to the beginning of the next 23 24 25 26 27 1 2 3 4 5 6 28 1 2 3 4 5 6 8 11 12 13 7 9 10 7 14 15 16 17 18 19 20 21 22 Characteristics of Normal Menstrual Cycles Characteristics Description Menarche Average age of onset, 12 or 13 years; average range of 9 – 17 years old Interval between cycles Average 28 days; cycles of 23 to 35 days not unusual Duration of menstrual flow Average flow, 5 days with a range of 3 – 6 days Amount of menstrual flow 50 mL (20 – 80 mL) per menstrual period Color of menstrual flow Dark red; a combination of blood, mucus, and endometrial cells The Physiology of Menstrual Cycle Four Body Structures involved in the Physiology of the Menstrual Cycle 1. Hypothalamus 2. Pituitary gland 3. Ovaries 4. Uterus release GnRH: initiate FSH stimulates LH triggers ovulation, menstrual cycle the ovarian thereby not only releasing production of the egg from the follicle, but ESTROGEN by also initiating the conversion under the influence of the granulosa of the residual follicle into a GnRH the anterior cells of the corpus luteum that, in turn, pituitary gland produces ovarian follicles produces PROGESTERONE to LH & FSH and corpora prepare the endometrium lutea for a possible implantation FSH stimulates the growth of ovarian follicles in the ovary before the release of an egg from one follicle at ovulation LH triggers ovulation and development of the corpus luteum.  If your average menstrual cycle is 28 days, you ovulate around day 14 28-14= 14, day 14 of the cycle 23 24 25 26 27 1 2 3 4 5 6 28 1 2 3 4 5 6 8 11 12 13 7 9 10 7 8 9 10 11 12 13 14 15 16 17 18 19 20 14 15 16 21 22  If your average menstrual cycle is 30 days, ovulation happens around day 16 30-14= 16, day 16 of the cycle 24 25 26 1 2 3 4 5 27 28 29 30 1 2 3 6 7 8 9 10 11 12 4 5 6 7 8 9 10 13 14 15 16 17 18 19 11 12 13 14 15 16 17 20 21 22 23 HOW DOES MENSTRUAL CYCLE OCCUR? Menses Menstrual Flow Consists of: ▫ Blood from ruptured capillaries ▫ Mucin from glands ▫ Fragments of endometrial tissue ▫ Microscopic, atrophied, and unfertilized ovum First day of the menstrual flow is used to mark the beginning day of a new menstrual cycle  Blood loss: approximately 20 – 80 ml of blood Iron loss: approximately 11 mg A. Ovarian Cycle 4 phases of the endometrial cycle 1. Follicular Phase 2. Ovulation Phase 3. Luteal Phase 4. Menstrual Phase OVARY The Ovarian Cycle of Menstrual Cycle 1. Follicular Phase Every month one oocyte is activated by FSH to begin to grow and mature Its cells produce a clear fluid (follicular fluid) that contains high estrogen level As it grow it is propelled to the surface of the ovary At the stage of maturation it is called graafian follicle 2. Ovulation Phase By day 14 or the midpoint of a typical 28-day cycle mitotic cell division occur There is upsurge of LH, prostaglandins are released and the graafian follicles rupture The ovum is set free a process called Ovulation 3. Luteal Phase Event after the ova and follicular fluid have been discharge from the ovary LH will rise and directs the formation of lutein (yellow body) which is high in progesterone The follicles remnants is now called corpus luteum The egg cell released during the ovulation phase stays in the fallopian tube for 24 hours. If a sperm cell does not impregnate the egg cell within that time, the egg cell disintegrates. Corpus luteum If fertilization has occurred and implantation happened in the endometrium of the uterus the corpus luteum remains throughout the major portion of the pregnancy (16 – 20 weeks) Corpus albicans If conception does not occur it regresses and is gradually replaced by white fibrous tissue called corpus albicans or white body 4. Menstrual Phase If conception does not occur, the unfertilized ovum atrophies after 4 – 5 days and will it will disintegrate and be absorbed in the endometrial lining This leads to a decrease in hormone levels (estrogen and progesterone), which triggers the shedding of the uterine lining, resulting in menstruation. This marks the start of a new cycle. B. Endometrial/Uterine Cycle 4 phases of the endometrial cycle 1. Proliferative phase 2. Secretory phase 3. Ischemic phase 4. Menstrual phase Uterine Cycle  1. Proliferative Phase Also known as estrogenic, follicular, or postmenstrual phase. Immediately after the menstrual flow Lasts from the 5th day to the time of ovulation Eightfold to tenfold thickening occurs  1. Proliferative Phase The ovary begins to produce ESTROGEN under the influence of FSH The thickness of the endometrium begins to proliferate as much as eightfold from day 5 – day 14 2. Secretory Phase Progestational, luteal, premenstrual phase. Extends from the day of ovulation to about 3 days before the next menstrual period Larger amount of progesterone are produced Progesterone causes the glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen and mucin. Edematous, vascular, functional endometrium is apparent 2. Secretory Phase Endometrium is rich, spongy velvety and is suitable protective and nutritive bed for a fertilized ovum. The lining has quantities of glycogen (sugar) and mucin (protein) 3. Ischemic Phase If fertilization and implantation does not occur ▫ Usually occurs 7 – 10 days after ovulation Due to regression of corpus luteum which secretes progesterone and estrogen ▫ Spiral arteries go into spasm ▫ blood supply to the endometrium is blocked and necrosis develops ▫ functional layer separates from the basal layer ▫ menstrual bleeding begins. 4. Menstrual Phase Starts day one of the cycle or day one of menses Shedding of the functional 2/3 of the endometrium (compact and spongy layer) Initiated by periodic vasoconstriction in the upper layers of the endometrium Regeneration of the functional endometrium begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells. Simultaneously the ovarian cycle and uterine cycle in phase 1 - Follicular - Proliferative Simultaneously the ovarian cycle and uterine cycle in phase 2 - Ovulation - Secretory Simultaneously the ovarian cycle and uterine cycle in phase 3 - Luteal - Ischemic Simultaneously the ovarian cycle and uterine cycle in phase 4 - Menstrual  Menstrual Phase Follicular Phase Ovulation Phase Luteal Phase Ovarian Cycle Formation of ↓ Estrogen Estrogen begin Progesterone in the Production of ↓ to rise (FSH) Corpus luteum (LH) Progesterone ↓ Progesterone Day 1 of Day Day 28 period 14 Proliferative/Estrogenic/ Secretory/Progestational Uterine Menstrual Follicular/Post-mestrual Phase Ischemic Phase Cycle Phase Phase CERVICAL CHANGES Mucus of the cervix also changes each month during the menstrual cycle. Changes in cervical mucus are helpful in establishing fertility During the first half of the cycle, when the hormone is very low, the cervical mucus is thick and scant - Sperm survival is poor At the time of ovulation when estrogen level is high, cervical mucus is thin, stretchy and copious - Sperm penetration and survival is excellent Second half of the cycle, progesterone is the major hormone, cervical mucus again thickens - sperm survival is again poor Test for Ovulation 1. Fern Test An interesting property of cervical mucus just before ovulation Cervical mucus forms fernlike patterns when placed on a glass slide (a.k.a arborization or ferning) Significance: ▫ Women who do not ovulate continually show the fern pattern throughout the menstrual cycle(no progesterone influence) OR ▫ Never demonstrate ferning pattern because their estrogen level never rise Test for Ovulation 2. Spinnbarkeit Test Test for ovulation At the height of estrogen secretion, the cervical mucus not only becomes thin and watery, but it also can be stretched into long strands Indication that ovulation is about to occur. Done by stretching a mucus sample between thumb and finger or by smearing cervical mucus specimen on a slide and stretching the mucus between the slide and cover slip Health Education for Menstruation Common Myths on Menstruation Women should not wash their hair during menses They should not plant vegetables or they all will die They should not eat sour foods as it can cause cramping Importance of Education regarding Menstruation: Girls - elevate girl's concept of herself because it teaches her to trust her body or to think of menstruation as a mark of pride rather than as a burden Boys - they can appreciate the cyclic process a woman's reproductive system activates and can be active participants in helping plan or prevent conception Health Teaching during Menstruation Exercise - moderate exercise during menses promote a general sense of well-being - Sustained excessive exercise such what professional athletes maintain, can cause amenorrhea Health Teaching during Menstruation Sexual relations -Not contraindicated during menses although the male should wear a condom to prevent exposure to body fluid - Heightened or decreased sexual arousal may be noticed - Orgasms may increase the amount of menstrual flow - It is improbable but not impossible for conception to occur Health Teaching during Menstruation ADL - Nothing is contraindicated - Many people believe incorrectly activities such as running or bathing are harmful Health Teaching during Menstruation Rest - more rest may be helpful if dysmenorrhea interferes with sleep at night Health Teaching during Menstruation Nutrition - many women need iron supplementation during menses to replace iron lost - Eating pickles or cold food does not cause dysmenorrhea Health Teaching during Menstruation Pain relief -Prostaglandin inhibitors such as ibuprofen (Motrin): reduce inflammation and relieve pain - applying local heat MENSTRUAL DISORDERS  DYSMENORRHEA Painful menstruation Pain during or shortly before menstruation Symptoms usually begin with menstruation, although some women have discomfort several hours before the onset of flow. Severity differ from woman and from cycle to cycle Symptoms lasts from several hours or several days Types of Dysmenorrhea 1. Primary Dysmenorrhea A condition associated with abnormally increased uterine activity Due to contractions induced by prostaglandins in the second half of the menstrual cycle Signs and Symptoms: ▫ Lower abdominal cramps ▫ Backache ▫ Weakness ▫ Sweating ▫ Gastrointestinal symptoms ▫ Central nervous system symptoms Management: Client education Dispel menstruation myths Educate boys about menstruation Continue doing moderate exercise Sexual relations is not contraindicated during menses Activities of daily life is not contraindicated during menses  Management – cont- ▫ Client education Using mild analgesics is helpful More rest may be helpful if dysmenorrhea interferes with sleep at night Nutrition: iron supplementation may be needed to replace iron lost in menses Eating sour or cold foods does not cause dysmenorrhea. ▫ Reduce discomfort Heat (heating pad or hot bath) Massaging the lower back Soft rhythmic rubbing of the abdomen (effleurage) Guided imagery Progressive relaxation Yoga Meditation exercise Secondary Dysmenorrhea Menstrual pain that develops later in life than primary dysmenorrhea, typically after age 25 Associated with pelvic pathology such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, or submucous or interstitial myomas (fibroids) Symptom: ▫ Dull, lower abdominal aching that radiates to the back or thighs ▫ Feeling of bloating ▫ Pelvic floating PREMENSTRUAL SYNDROME A complex, poorly understood condition that includes a number of cyclic symptoms occurring in the luteal phase of the menstrual cycle. Symptoms ▫ Fluid retension ▫ Behavioral or emotional changes ▫ Premenstrual cravings ▫ Headache ▫ Fatigue ▫ backache  Management ▫ Diet and exercise changes ▫ Regular exercise ▫ Yoga, acupuncture, hypnosis, chiropractic therapy, and massage therapy  Premenstrual Dysphoric Syndrome ▫ Severe form of premenstrual syndrome ▫ causes severe irritability, depression, or anxiety in the week or two before your period starts. Symptoms usually go away two to three days after your period starts  ABNORMAL UTERINE BLEEDING Any form of uterine bleeding that is irregular in amount, duration, or timing and not related to regular menstrual bleeding. Causes: ▫ Anovulation ▫ Pregnancy related conditions ▫ Lower reproductive tract infections ▫ Neoplasms ▫ Trauma ▫ Systemic diseases ▫ Iatrogenic causes  Dysfunctional uterine bleeding ▫ Excessive uterine bleeding with no demonstrable organic cause, genital or extragenital. ▫ Most frequently caused by anovulation  Oligomenorrhea/hypomenorrhea Often used to describe decreased menstruation, either in amount, time, or both. Infrequent menstrual period characterized by intervals of 40 – 45 days or longer  Polymenorrhea Frequent cycles regular bleeding at intervals of less than 21 days  Menorrhagia ▫ Abnormally heavy menstrual flow ▫ Blood loss greater than 80 mL or more than 7 days  Metrorrhagia ▫ Bleeding between menstrual periods ▫ also known as Hypermenorrhea MENOPAUSE - Cessation of menstrual cycles POSTMENOPAUSAL PERIOD ▫ Time following menopause PERIMENOPAUSAL ▫ Period during which menopausal changes are occuring Menopause Occurs between 40 and 55 years old Thea earlier the age of menarche, the earlier menopause tends to occur. causes physical changes like hot flahes, vaginal dryness and osteoporosis it marked the end of a woman's ability to bear children Health teaching during menopause Help women appreciate that loss of uterine function may make almost no change in their life. Teach patient about hormone replacement therapy