Fisiologi Haid : Fisiologi Haid dr.

Reza Tigor Manurung, SpOG Menstruasi/haid : Menstruasi/haid Peristiwa keluarnya cairan darah dari vagina perempuan berupa luruhnya lapisan dinding dalam rahim yang banyak mengandung pembuluh darah Siklik Panjang siklus: jarak antara mulainya haid yang lalu dan mulainya haid berikutnya Slide 3: pertengahan siklus sulit dinilai Variasi tinggi Ovulasi Akibat penurunan kadar progesteron/ovulasi Siklik: 25 31 hari sekali Lama: 3 6 hari Banyaknya: 30 60 cc (ganti pembalut 2 5 pembalut/hari) Haid normal Haid Normal : Haid Normal Siklus haid dipengaruhi oleh berbagai hormon: GnRH LH, FSH Estrogen Progesteron HYPOTHALAMIC- PITUITARY- OVARIAN AXIS : HYPOTHALAMIC- PITUITARY- OVARIAN AXIS HYPOTHALAMIC ROLE IN THE MENSTRUAL CYCLE : secretion of gonadotropins Release of GnRH is modulated by ve feedback by: steroids gonadotropins Release of GnRH is modulated by external neural signals down regulation of pituitary receptors HYPOTHALAMIC ROLE IN THE MENSTRUAL CYCLE The hypothalamus secretes GnRH in a pulsatile fashion GnRH activity is first evident at puberty Follicular phase GnRH pulses occur hourly Luteal phase GnRH pulses occur every 90 minutes Loss of pulsatility Slide 10: GnRH (gonadotropin releasing hormone) dihasilkan oleh hipotalamus, memicu hipofisis anterior mengeluarkan hormon FSH (follicle-stimulating hormone) dan LH (leuteinizing hormone) Slide 11: hipofisis mengeluarkan LH proliferasi endometrium Estrogen sintesis estrogen meningkat Estrogen FSH memicu pematangan folikel di ovarium Slide 13: menstruasi korpus rubrum, progesteron akan turun Akibatnya estrogen dan progesteron akan turun korpus luteum akan mengalami degenerasi menghambat sekresi LH dan FSH hipofisis Bila tidak terjadi kehamilan endometrium sekretorik Progesteron Progesteron Progesteron Korpus luteum Ovulasi LH yang meningkat PHASES OF THE MENSTRUAL CYCLE : PHASES OF THE MENSTRUAL CYCLE Ovulation divides the MC into two phases: 1-FOLLICULAR PHASE -Begins with menses on day 1 of the menstrual cycle & only one reaches maturity maturation of a cohort of ovarian follicles recruitment ends with ovulation RECRUITMENT FSH FOLLICULAR PHASE : 1ry follicle (oocyte surrounded by a single layer of granulosa cells basement membrane primordial follicle (oocyte arrested in the diplotene stage of the 1st meiotic division surrounded by a single layer of granulosa cells) FOLLICULAR PHASE MATURATION OF THE FOLLICLE (FOLLICULOGENESIS) FSH & 2ry follicle or preantral follicle (oocyte surrounded by zona pellucida , several layers of gran ulosa cells thica cells) & thica cells) FOLLICULOGENESIS (2) : tertiary or antral follicle 2ry follicle accumulate fluid in a cavity antrum oocyte is in eccentric position surrounded by granulosa cells cumulous oophorusFOLLICULOGENESIS (2) FOLLICULOGENESIS (2) : the follicle with the highest No. of FSH receptors will continue to thrive The other follicl es that were recruited will become atretic FSH -ve feed back on the pituitary estrogen FOLLICULOGENESIS (2) SELECTION Selection of the dominant follicle occurs day 5-7 It depends on - the intrinsic capacity of the follicle to synthesize estrogen -high est/and ratio in the follicular fluid Ss the follicle mature Slide 20: estrogens estrone conversion of androgens FSH receptor -stimulates aromatase activity No. of granulosa cells FSH ACTIONS -recruitement mitogenic effect & LH receptors ESTROGEN Acts synergistically with FSH to - induce LH receptors - induce FSH receptors in granulosaestradiol - & uptake of cholesterol theca cells thica cells LH & androstenedioneLDL & testosterone TWO CELL THEORY : TWO CELL THEORY FOLLICULOGENESIS (3) :

androgen No real stimulation of FSH secretion in vivo (bound to protein in serum) gonadotropin receptors FOLLICULOGENESIS (3) OTHER FACTORS THAT PLAY A ROLE IN FOLLICULOGENISIS -INHIBIN Local peptide in the follicular fluid -ve feed back on pituitary FSH secreation Locally enhances LH-induced androstenedione production -ACTIVIN Found in follicular fluid Stimulates FSH induced estrogen production PREOVULATORY PERIOD : estradiolPREOVULATORY PERIOD NEGATIVE FEEDBACK ON THE PIUITARY - & FSH secretion of progestrone Operates after puberty +ve feed back on pituitary LH surge +ve feed back on the pituitary (facilitated by low levels of progestrone) estradiol (reaching a threshold concentration) FSH -This mechanism operating since childhood POSITIVE FEEDBACK ON THE PITUITARY -ve feed back on pituitary inhibin PREOVULATORY PERIOD : progestrone synthesis lutenization follicular rupture Granulosa cells PREOVULATORY PERIOD LH SURGE Lasts for 48 hrs Ovulation occurs after 36 hrs Accompanied by rapid fall in estradiol level Triggers the resumption of meiosis Affects follicular wall OVULATION : colloid osmotic pressure 2-Enzymatic rupture of the follicular wall LH Follicular pressure Changes in composition of the antral fluid OVULATION The dominant follicle protrudes from the ovarian cortex Gentle release of the oocyte surrounded by the cumulus granulosa cells Mechanism of follicular rupture 1- & lysosomes under follicular wall PG F2 plasminogen activator prostglandin E breake down of F. wall LH fibrinolytic activity plasmin production of plasminogen activator granulosa cells FSH LUTEAL PHASE : LUTEAL PHASE LASTS 14 days FORMATION OF THE CORPUS LUTEUM After ovulation the point of rupture in the follicular wall seals Vascular capillaries cross the basement membrane & progesterone corpus luteum luteal cells progestrone Granulosa cells 3 OH steroid dehydrogenase activity LDL binding to receptors availability of LDL-cholestrole LH grow into the granulosa cells LUTEAL PHASE : estrogen luteolysis basal body temp -endometrial maturation Progestrone peak 8 days after ovulation (D22 MC) Corpus luteum is sustained by LH It looses its sensitivity to gonadotropins in progestrone secretion Progestrone actions: -suppress follicular maturation on the ipsilateral ovary -thermogenic activity LUTEAL PHASE Marked & desquamation of the endometrium mensesprogestrone level LUTEAL PHASE : estrogenLUTEAL PHASE & FSH progestrone & maintain the corpus luteum hCG secreation LH The new cycle stars with the beginning of menses If prgnancy occurs HORMONAL PROFILES DURING THE MENSTRUAL CYCLE : HORMONAL PROFILES DURING THE MENSTRUAL CYCLE ENDOMETRIAL CHANGES DURING THE MENSTRUAL CYCLE : superficial -Spongiosum layerENDOMETRIAL CHANGES DURING THE MENSTRUAL CYCLE 1-Basal layer of the endometrium -Adjacent to the miometrium -Unresponsive to hormonal stimulation -Remains intact throughout the menstrual cycle 2-Functional layer of the endomietrium Composed of two layers: -zona compacta ENDOMETRIAL CHANGES DURING THE MENSTRUAL CYCLE : mitotic activity in the glandsENDOMETRIAL CHANGES DURING THE MENSTRUAL CYCLE 1-Follicular /proliferative phase Estrogen & - Mitotic activity is severely restricted -Endometrial glands produce then secrete glycogen rich vacules -Stromal edema -Stromal cells enlargement -Spiral arterioles develop, lengthen enometrial thickness from 2 to 8 mm (from basalis to opposed basalis layer) 2-Luteal /secretory phase Progestrone stroma & coil MENSTRUATION : ischemia constriction of the spiral arterioles MENSTRUATION Periodic desquamation of the endometrium The external hallmark of the menstrual cycle Just before menses the endometrium is infiltrated with leucocytes Prostaglandins are maximal in the endometrium just before menses Prostaglandins & desquamation Followed by arteriolar relaxation, bleeding & tissue breakdown Slide 42: Dismenore Menarkhe Rata-rata: 12 tahun, range 10 16 tahun Menopause Mastodinia Mittleschmerz Premenstrual syndrome Haid tidak Normal : Haid tidak normal, dan perdarahan yang menyerupai haid dapat dikelompokkan menjadi: Gangguan irama (normal 21-35 hari): Polimenore: haid dengan interval < 21 hari Oligomenore: haid dengan interval > 35 hari Amenore: tidak terjadi haid Perdarahan haid tidak teratur, dimana interval datangnya haid tidak menentu. Haid tidak Normal Slide 44: 2. Jumlah perdarahan tidak normal (normal 2-5 kali ganti pembalut/hari): Hipermenore: ganti pembalut > 6x perhari Hipomenore: ganti pembalut < 2x/hari 3. Gangguan dalam lama perdarahan (normal 2-5 hari): Menoragi: lama perdarahan > 6 hari dan jumlahnya banyak (> 80 cc) pada interval yang teratur Brakimenore: lama perdarahan < 2 hari 4. Perdarahan bercak (spotting) prahaid, pertengahan siklus, pasca haid Slide 45:

Metroragi: Gangguan haid dengan perdarahan menyerupai siklus haid yang terjadi di luar siklus haid normal. Menometrohagia: Gangguan haid dengan perdarahan yang banyak dan lama yang terjadi di luar siklus haid normal/tidak teratur Perdarahan Uterus Abnormal : Perdarahan Uterus Abnormal Penyebab: Organik: Non-organik: Perdarahan Uterus Disfungsional (PUD) Slide 47: Penyebab Organik: Kelainan Jinak Rahim: mioma, polip serviks Keganasan: kanker mulut rahim, kanker rahim Komplikasi dari kehamilan: kehamilan anggur, keguguran Infeksi: servisitis, endometritis Gangguan sistemik: penyakit darah, ggn hormon tiroid, stress Obat-obatan/iatrogenik: IUD, KB hormonal Trauma: laserasi Slide 48: Penyebab Non-organik Perdarahan yang terjadi semata-mata hanya karena gangguan fungsional mekanisme kerja hipotalamus-hipofisis-ovatiumendometrium Bukan disebabkan oleh kelainan organik alat reproduksi Disebut juga sebagai Perdarahan Uterus Disfungsional (PUD) Merupakan penyebab perdarahan abnormal yang paling sering Terjadi pada usia perimenars, usia reproduksi, dan usia perimenopause