Menstrual Cycle

Question 1

Objectives

1. Define features of the average menstrual cycle
2. Verbalize the key elements of a menstrual history.
3. Understand the anatomy and physiology of the menstrual cycle: HPO-axis, ovarian cycle, endometrium cycle
4. Define functional, ovarian cysts
5. Recognize common non-pharmacologic and pharmacologic interventions for dysmenorrhea and PMDD (premenstrual dysmorphic disorder)

Question 2

Is Monthly Menses Necessary?

Answer 2

NO

Not necessary IF we’re disrupting the cycle with exogenous hormones (birth control pills, something else with esrogen/progesterone)

Question 3

Average Menstrual Cycle

1. ​Ave age of menarche =
2. WNL cycle length =
3. WNL days of bleeding =
4. WNL amount of flow per day =
5. Ave age of menopause =

Answer 3

1. 12-13 (range: 10-15)
2. 21-38 days (ave 25-35)
3. 2-8 days (ave 4-6)
4. 5-80mL (30-60mL)
5. 51 (range 45-55)

Menopause: 12 full months of no period to be post-menopausal

Question 4

Menstrual History

1. Current ____
2. Age at _____
3. _ _ _, _ _ _
4. Bleeding _____
   
   1. Cycle l_____, r_____
   2. ______ of flow
   3. _____ of flow
5. Moliminal (_______) symptoms
6. Associated ____
7. Other ______ symptoms
8. ___menstrual bleeding

Answer 4

1. Age
2. Menarche
3. LMP, PMP (previous menstrual period)
4. Pattern
   
   1. length, regularity
   2. Duration
   3. Amount
5. Premenstrual
6. Pain
7. Associated sx
8. Intermenstrual bleeding

Question 5

Characteristics of Menses

(4)

Answer 5

Frequency

Regularity

Duration of Flow

Volume of Blood

Question 6

Frequency of Menses*

1. Frequent =
2. Normal =
3. Infrequent =

Answer 6

1. <21d
2. 21-38d
3. >38d

Question 7

Regularity of Menses*

1. Absent =
2. Regular =
3. Irregular =

Answer 7

1. —-
2. + 2-20d
3. >20d

Question 8

Duration of Flow*

1. Prolonged =
2. Normal =
3. Shortened =

Answer 8

1. >8d
2. 4-8d
3. <4d

Question 9

Volume of Blood*

1. Heavy* =
2. Normal =
3. Light =

Answer 9

1. >80mL
2. 5-80mL
3. <5mL

Question 10

HEAVY FLOW*

Changing pads/tampons > ?

Use of > ___ tampons for single menses

Have to change at _____

Clots > ___ inch

A_____

______ with daily _______

Answer 10

>Q3h

20

night

Clots >1 inch

Anemia

Interferes w Activity

Question 11

Anatomy

(3)

Answer 11

Brain - Hypothalamus/Pituitary

Ovaries - Follicles/Oocyte

Uterus - Endometrium

Target Organ: Ovaries, Brain-> Ovary -> Uterus

Question 12

Ovarian Cycle

OVUM/OVULATION

1. D1-14
2. D14
3. D14-28

Answer 12

1. Follicular
2. Ovulation
3. Luteal

Ovarian cycle -> to produce the egg (high in estrogen production)

Question 13

Uterine (Endometrial) Cycle

LINING PREP

1. Menses =
2. Proliferative =
3. Secretory =

Answer 13

1. D1-6
2. D6-14
3. D14-28

preparation/buildup of uterus lining (progestrone dominant)

Question 14

Ovarian Follicles

Follicle = ____ sac containing an ____ (oocyte)

At puberty ____-_____

that will be ovulated ____ - ______

Follicles recruited q month __-__

Stages of development (4)

____ dominant follicle ovulates each month (______ follicle)

Answer 14

Fluid, egg

300-400,000

300-400

10-40

Primordial, Primary, Secondary, Tertiary/Antral

One dominant ovulates each month = Graafian follicle

Question 15

Folliculogenesis

Stages of Follicular Development

_____ _____ (yellow body) is what produces _____ (2nd half of cycle)

Answer 15

Corpus Luteum, progesterone

Question 16

Pics of Tertiary/Antral Follicle and Graafian Follicle

Answer 16

Question 17

Ovarian Cycle- Follicular Phase

FSH targest ______ Cells -> to make ______

LH targets _____ Cells -> to make ______

1st stage: All produces _____ in the end

Answer 17

Granulosa Cells -> Aromatase

Theca Cells -> Androstenoedione (Androgen)

Estradiol (Estrogen)

Question 18

Ovarian Cycle: Ovulation

• __ peaks: __-___ hrs prior to ovulation ->
• _____ in follicular fluid digest follicle ____ and release _____ ->
• Ovulation =

2nd stage

Answer 18

• LH, 10-12
• Enzymes, wall, prostaglandins
• Release of Ovum

Question 19

Ovary, Follicle, Egg Pictures

Answer 19

Question 20

Ovarian Cycle: Early Luteal Phase

(3)

Increased ___ ->

Inhibits what?

Answer 20

Ruptured Follicle, Corpus Luteum, Progesterone and Estrogen

Progesterone

Inhibits Hypothalamus and pituitary from produsing GnRH, FSH, LH

High lvl of progesterone in early Luteal Phase stimulates negative feedback loop to the hypothalamus to stop producing GnRH, FSH, and LH bc we have ovulated already

Question 21

Ovarian Cycle Late Luteal Phase

4 Steps

Answer 21

Corpus Luteum Degenerates ->

Corpus Albicans ->

RAPID decline in E and P ->

Hypothalamus and Pituitary secrete GnRH, FSH, LH

Cycle starts again so stimulates HPO axis again

Question 22

Ovarian Cysts

Functional (Simple) Ovarian Cysts

Follicular:

Luteal:

Answer 22

: Follicle fails to release Egg - Majority asymptomatic

Corpus Luteum fails to break down, reseals, fills with fluid- Majority asymptomatic

We don’t really worry about them too much - extremely common and usually resolves on its own

Question 23

Menstrual Cycle Anatomy: Uterus

Top of the uterus = _____

Answer 23

fundus

Question 24

Uterus: Endometrium

=

(2) types of cells
(2) types of glands stroma

______ changes over the course of the menstrual cycle, by how much?

Answer 24

Innermost lining of the uterus (is the FUNCTIONAL layer)

Columnar and Eptihelial Cells

Functionalis and Basalis

Thickness, 2mm-16mm

Question 25

Uterine/Endometrial Cycle: Menstrual Phase ## Footnote **\_\_\_\_\_\_ in Estrogen and Progesterone -\>** **\_\_\_\_\_ release from lysosomes -\>** **D\_\_\_\_\_\_ of functional layer** **B\_\_\_\_\_ in endometrial cavity** **\_\_\_\_\_\_ release** **Smooth muscle \_\_\_\_\_\_\_**

Answer 25

Decline -\> Enzyme -\> Dissolution Blood Prostaglandin Contraction

Question 26

Uterine/Endometrial Cycle: Proliferative Phase ## Footnote * _Early:_ **Endometrium = \_\_\_\_\_** * **​**Endometrial glands:s\_\_\_, n\_\_\_\_, sh\_\_\_\_ * _Late:_ **Endometrium = \_\_\_\_\_** * **​**Endometrial glands: \_\_\_\_plasia, **\*\_\_\_\_\_\_\*,** l\_\_\_\_, enmeshed * _Ends with:_ **\_\_\_\_\_\_\_\_**

Answer 26

* **Thin** * **​**short, narrow, short * **Thick** * hyperplasia, **PROLIFERATE,** long, enmeshed * **Ovulation**

Question 27

Uterine/Endometrial: Secretory Phase ## Footnote Corpus Luteum **SECRETES** \_\_\_\_\_\_ Endometrial glands \_\_\_\_\_, fill w **\_\_\_\_\_\_\_** Th\_\_\_, c\_\_\_\_ny, nut\_\_\_\_: favorable environment for ______ of ____ egg

Answer 27

Progesterone dilate, **secretions** Thick, cushiony, nutritive, implantation of fertilized egg

Question 28

Menstrual Cycle: Associated Changes ## Footnote Focus on cervical fluid changes * Day 1-5 = * Day 6-9 * Day 10-11 = * Day 12-13 = * Day 14-15 = * Day 16-27 = * Day 28 =

Answer 28

* Period * Dry * Sticky * Cloudy * Egg White\*\*\* * Sticky * Period

Question 29

Ultrasound Transvaginal

Answer 29

Question 30

Ultrasound Endometrium ## Footnote Is the Endometrium Thin or Thick? What phase?

Answer 30

Thin Early proliferative

Question 31

Endometrium Ultrasound ## Footnote Is the endometrium thin or thick? What stage?

Answer 31

Thick Proliferative stage

Question 32

Endometrium Ultrasound ## Footnote What stage?

Answer 32

Secretory phase- BRIGHT Since we don't get a secretory phase unless ovulation has occurred, we can also tell if someone is not pregnant through this image in an US

Question 33

Primary Dysmenorrhea Treatment Options ## Footnote 1. **Lifestyle changes** (3) 2. **Prostaglandin Inhibition** 1. **​**\_\_\_\_\_\_\_ (initiate day ____ to bleeding) 2. ______ 400-800mg q6 hrs 3. _______ Acid 250mg q8hrs 4. ______ 550mg q12hrs 3. **Endometrial \_\_\_\_\_; \_\_\_orrhea:** through hormonal \_\_\_\_\_\_\_ 4. **Complimentary Therapies (5)**

Answer 33

1. Heat, Stress reduction, Exercise 2. Prostaglandin inhibition 1. NSAIDs (day before) 2. Ibuprofen 3. Mefanic Acid 4. Naproxen 3. **Thinning: Amenorrhea**: hormonal contraception (probably the best bet) 4. CAM 1. Herb: Shirazi Thymus Vulgaris 2. Vit B1 3. Vit E 4. Ginger 5. Acupunture/Accupressure

Question 34

PMDD Premenstrual Dysphoric Disorder ## Footnote DSM IV Criteria * In most menstrual cycles during the past year, _____ or more of the following symptoms were present for most of the time during the last week of the _____ phase, begin to remit within a few days after the onset of the _____ phase, and were absent in the week of post\_\_\_\_\_, with at least one of the symptoms being either 1, 2, 3, or * Understand that there is a connection between the ____ and ____ systems -\> therefore mood changes when there's a functuation in these hormones

Answer 34

* 5 sx, luteal, follicular, postmenses * Serotonin and Gonadotropic

Question 35

PMS/PMDD Treatment Options ## Footnote \_\_\_\_\_\_ Most Effective 1. Any Lvl of Symptoms: 2. Mild Symptoms: 3. Mod-Severe Symptoms: 4. Severe and unresponsive to SSRI or COC:

Answer 35

Multimodal 1. Self care/health promotion, social support, psychosocial strategies, complimentary therapies 2. Exercise, Relaxation techniques, vitamins B6, E, Calcium, Magnesium, Tumeric 3. 1) SSRI's (Zoloft, Paxil, CelXA, Prozac) daily luteal phase only, or premenstrual to onset of menses, 2) HC/OCP: Drosperinone containing 4. 1) GnRH Agonist, 2) Surgery (bilateral oopherectomy/hysterectomy)