Menstruation Lecture Notes PDF

# Menstruation **Presented by** Dr/ Ola Abdel-wahab Afifi Araby Assistant professor of obstetrics and gynecological nursing ## General Objective: At the end of this lecture the students should be able to acquire essential knowledge, practice and attitude that enable them to understand the physio...

# Menstruation **Presented by** Dr/ Ola Abdel-wahab Afifi Araby Assistant professor of obstetrics and gynecological nursing ## General Objective: At the end of this lecture the students should be able to acquire essential knowledge, practice and attitude that enable them to understand the physiology of menstruation and apply effective nursing care to females. ## Specific Objectives: At the end of this lecture the student should be able to: - Define the menstrual cycle. - Identify Criteria of normal menstruation. - List phases of menstrual cycles. - Explain the characteristics of each phase. - Discuss nursing health education about menstruation. ## Introduction: Menstruation (also known as a period) is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. Menstruation is the cyclical shedding of the lining and is triggered by falling progesterone levels. It is a sign that pregnancy has not occurred. The menstrual cycle occurs due to the rise and fall of hormones. Periods stop during pregnancy and typically do not resume during the initial months of breastfeeding. In humans, the first period, a point in time known as menarche, usually begins between the ages of 11 and 13. Menstruation stops occurring after menopause, which usually occurs between 45 and 55 years of age. ## Layers of Uterus The image shows the different layers of the uterus, including the following from top to bottom: - Uterine fundus - Perimetrium - Myometrium - Endometrium - Endocervical canal - Cervix - Pap brush - Vagina ## Definition of Menstruation: Menstruation is defined as cyclic shedding of the uterine lining (bleeding) in response to cyclic hormonal changes. Menstruation occurs when the ovum is not fertilized. ## Criteria of Normal Menstruation: | Criteria | Description | |---|---| | Age of menarche and menopause | From puberty to menopause = (11-12) to 45-55 years old | | Amount of blood loss | 30-100 cc with no blood clots. The amount of flow can be affected by various factors, including thickness of the endometrium, medication and diseases that affect the clotting mechanism. | | Duration | 3-5 days | | Rhythm | Regular | | Cycle frequency | Every 28 days, but with normal range from 21 to 35 days (3-5 weeks) | | Key of menstruation | D/C = duration of bleeding / cycle frequency, normally 3-5 days/ 3-5 weeks | ## Other Characteristics: - **Daily loss of iron:** the average is 0.5 to 1 mg, decreasing the body's iron supplies resulting in the need for iron. - **Content:** blood mixed with cervical and vaginal secretion, mucus, leukocytes, bacteria and other cellular debris - **Colour & odor:** dark red & has a distinctive odor. - **Menstrual molimina (premenstrual syndrome PMS):** mild symptoms, most women suffer from 7 days before menses which usually relieved by occurrence of menstruation, these symptoms are: Headache, depression and anxiety, nausea and vomiting, palpitation, breast fullness and increase sweating....etc ## Abnormal Menstruation = (abnormal uterine bleeding) | Category | Description | |---|---| | **Duration** | - <2days → hypomenorrhea <br> - >7days → menorrhagia | | **Frequency** | - Every <3weeks → polymenorrhea <br> - Every > 3weeks → oligomenorrhea | | **Amount** | - <30 cc → hypomenorrhea<br> - > 100 cc→ menorrhagia | ## Clinical Types of Abnormal Menstruation: - **Polymenorrhea:** Too frequent menstruation. The menstrual cycle is less than 21 days. - **Menorrhagia:** Excessive amount or prolonged duration of menstruation or both with fixed intermenstrual period. - **Metrorrhagia:** Irregular or continuous bleeding not related to menstruation. **N.B.:** More than one type may be present in the same patient e.g., - *Polymenorrhea + menorrhagia = Polymenorrhagia* - *Metrorrhagia + menorrhagia = Menometrorrhagia* ## Hypothalamo-pituitary ovarian axis (H.P.O axis) An illustration shows the female HPG axis, which consists of a cycle of hormones produced by the hypothalamus, pituitary, and ovaries. - The hypothalamus secretes GnRH, which stimulates the anterior pituitary to release LH and FSH. - LH and FSH stimulate the ovaries to produce estrogen and progesterone. - Estrogen and progesterone feed back to the hypothalamus and pituitary to regulate the release of GnRH, LH, and FSH. ## Menstrual Cycle The menstrual cycle can be considered as two intermittent cycles: 1. One cycle takes place in the ovary (**ovarian cycle**). 2. The other cycle takes place in the uterus (**uterine or endometrial cycle**). ## I- Ovarian Cycle: **Definition:** Cyclic changes which occur in the cortex of the ovary every month, and are under the influence of certain hormones secreted by anterior pituitary gland. These hormones are follicle stimulating hormone (FSH) and the luteinizing hormone (LH). **Ovarian cycle consists of three phases:** 1) Follicular phase 2) Ovulation phase 3) Luteal phase ### 1) Follicular Phase: (1st half of cycle) The follicular phase of the ovarian cycle lasts from approximately the 1st to the 14th day. The ovary is under the influence of FSH secreted by the pituitary. Its function is to stimulate a number of ovarian follicles to grow, develop, and produce estrogen. - This maturing follicle is called the grafian follicle. - This follicle and other ovarian tissue are filled with estrogenic fluid, which is secreted in relatively large amounts into the blood. - One of the functions of estrogen at this time is to build up or thicken the lining of the uterus. - As the follicle enlarge it pushed to the surface of the ovary to create a blister bulge that may be clearly seen if the ovary is observed directly. - Finally with the peak in LH at mid-cycle ovulation occurs. - The empty follicle begins its formation into the corpus luteum. - This follicular phase of the ovarian menstrual cycle varies in length from woman to women. ### 2) Ovulation Phase: (middle of cycle / 14th day) It occurs at about the 14th day of the cycle. During which shedding of the ovum from the ruptured Graafian follicle occurs. ### 3) Luteal Phase: (2nd half of cycle) The luteal phase of the ovarian cycle begins on approximately the 15th day of the menstral cycle and ends on approximately the 28th day. The luteal phase begins when the graafian follicle rupture and the ovum is released. The precise mechanism cause rupture is not known, but the following factors contribute: 1. Increased pressure of fluid within the graafian follicle. 2. Compression of the surrounding blood vessels. - The luteal phase, this post-ovulatory phase of the ovarian cycle, usually requires 14 days (Range of 13 to 15 days). - The corpus luteum continue, to produce estrogen but, in addition, manufactures the hormone progesterone, which further prepares the uterus for pregnancy if fertilization occur. The corpus leutum continuous to produce hormone estrogen and progesterone until placenta formation. - But when the ovum is not fertilized the corpus luteum degenerates, becoming a dry, a scarred areas called the corpus albican. It produces no hormones, estrogen and progesterone level drop. As result, the endometrium being to shed and menstrual flow begins. ## II- Endometrial Cycle: **Definition:** Cyclic changes which occur in the endometrium lining of the uterus that end with bleeding from vagina (menstruation), and are under the influence of certain hormones. These hormones are estrogen and progestrone. **The Endometrial cycle consists of four phases:** 1) Menstrual phase 2) Regenerative and Proliferative phase 3) Secretory phase 4) Ischemic phase. ### 1) Menstrual Phase: lasts 3-5 days When pregnancy does not occur, the menstrual phase begins and the functional layer of the uterine lining is shed. The first day of menses marks the beginning of another menstrual cycle. **Mechanism of menstruation:** - Corpus luteum degenerates if pregnancy does not occur. - ↓(E) And (P). - ↓ Edema of endometrium stroma. - Shrinkage of the endometrium. - Spiral arteries has to be shorten by increasing coiling. - Ischemia and hypoxia of spiral arterioles. - Necrosis of spiral arterioles. - Necrosis of endometrium. - Shedding of endometrium. - Prostaglandin (PG) control of the amount of bleeding, by causing vasoconstriction and myometrial contraction. ### 2) Regenerative and Proliferative (follicular) phase: lasts 3-4 days & lasts 5-6 days respectively - Start just after menses & end with ovulation - Under the influence of estrogen hormone secreted by the developing grafian follicle **The regenerative phase:** Regeneration of the surface epithelium occurs from the bases of the uterine gland to cover the raw endometrium by flat cells. **The proliferate phase:** - The endometrium grows and becomes 4 mm in thickness with cuboidal cells. - The endometrial glands become longer and strait. - +ve spinnbarkiet test (artery forceps): cervical mucus will stretch from 5-10 cm ### 3) Secretory (luteal) phase: lasts 10-14 days Start with ovulation & end at start of menses Under the influence of progesterone hormone secreted by the corpus luteum. - The endometrium increase in thickness six fold to eight folds (6-8 mm). - The endometrium forms three (3) layers: superficial compact, middle spongy and deep basal layers. - The cells become columnar. - The endometrial glands become convoluted and full of secretion (mucous and glycogen). - The blood vessels become prominent, dilated and tortuous. ### 4) Ischemic Phase: lasts about 2 days On the twenty-sixth (26) day of the menstrual cycle, if pregnancy has not occurred: - The corpus luteum begins to degenerate. - Approximately 2 days later, the thickened lining of the uterus starts to disintegrate. - Menstrual bleeding marks the **end** of the ischemic phase and the **beginning** of a new-menstrual cycle. ## Hygienic Menstrual Practices: - **Girls should use of sanitary pads during menstrual flows.** Disposable pads need to be changed regularly, at least every six hours. If a girl uses pads, she can bring a few spare in her bag so she's ready if her period suddenly starts or a friend needs help. - **Girls should wash outside her genital area at least once a day.** If the girl does not have access to a shower or bath, advise her to use a small amount of water, soap and a soft cloth. - **A used pad should always be placed in the bin, and never down the toilet.** And when a girl changes her pad at school, she should take the soiled one home in a bag to wash. - **Girls should always wash her hands with soap after using the toilet or changes a pad or cloth.** - **Girls must continue to take a shower during menses to avoid risk of infections.** ## Exercises and Activities of Daily Life: - **Nothing of daily life activities is contraindicated** - **Avoid violent and excessive exercise** - **It's good to continue moderate exercise during menses because it increases abdominal tone as:** - **Walking:** This is an easy exercise that doesn't require any special equipment, clothing, or location. Girls can take as much time as they need. - **Light cardio or aerobic exercise:** such as jogging, cycling, swimming, dancing or anything else, take it easy and/or consider a shorter workout than normal. - **Stretching:** Simple stretches at home can be beneficial than just rolling on the bed to relax the body muscles. ## Pain Relief Methods: - **Applying local heat:** Applying heat to the abdomen and lower back may relieve pain (hot-water bottle or heating pad, take a warm bath or use a hot towel). - **Massage therapy with essential oils:** Pressing specific points while the therapist's hands move around your abdomen, side, and back. Adding essential oils (lavender, peppermint and rose) for an aromatherapy style of massage may have additional benefits. - **Herbal remedies:** contain anti-inflammatory and antispasmodic compounds that can reduce the muscle contractions and swelling associated with menstrual pain as (ginger and chamomile tea). - **Relaxation techniques:** as Bensons relaxation technique and breathing exercises. - **Exercise is a good way to help prevent cramps, and gentle exercise like a walk can also help relieve pain** - **Analgesics and antispasmodics:** Any mild analgesic is helpful. Prostaglandin inhibitors such as ibuprofen are specific to menstrual pain. Applying heat may also be helpful. ## Diet and Nutrition: - **Eating a well-balanced diet,** because this will help give you the energy for training and sport, while also reducing bloating and managing cravings. - **Eating foods rich in iron and folic acid.** - **Taking iron supplementation to replace iron lost in menses.** - **Drinking plenty of water is also important,** as it will help to reduce bloating. - **Eating at least five portions of fruit and vegetables every day.** - **Avoid eating too many processed foods such as takeaways, sugary drinks and crisps.** ## Rest and Sleep: - **Getting eight hours of sleep every night and two hours nap.** - **Avoiding stress and anxiety** - **More rest and relaxation when feeling tired is helpful.**