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Lecture:

The Menstrual Cycle- Anatomy and Physiology

1. Normal menstruation a. Hormonal regulation i. Pituitary hormones 1. Follicle stimulating hormone: stimulates growth and development of ovarian follicles. As follicles grow, increasing estradiol levels within the follicles help them respond to LH with eventual ovulation. The follicles also produce estrogen, which stimulates endometrial growth. 2. Luteinizing hormone: stimulates maturation and ovulation of the Graffian follicle and subsequent development of the corpus luteum. Stimulates progesterone production which peaks after ovulation. When implantation of a conceptus occurs in the endometrium, hCG production signals the corpus luteum to continue secreting progesterone to prevent shedding of the endometrial lining. When implantation does not occur, decreasing progesterone levels permit sloughing of the uterine lining.
Pituitary Hormones
D ec l in in g s er u m es t r ad io l l ev el s

Pit u it ar y

Go n ad o t r o pin s : FS H LH

H ypo t h al amu s Gn RH

Follicle Stimulating Hormone

Pr imit iv e o o c yt es Gr af f ian f o l l ic l e

Luteinizing Hormone

Es tt r o g en Es r g en
Mat u r e f o l l ic l e

Pr o g es tt er o n e es er n

o v u l at io n

Co r pu s al bic an s

Co r pu s l u t eu m

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ii. Ovarian hormones: 1. Estrogen: steroids secreted by the ovaries that prepare the endometrium for implantation; increase motility of fallopian tubes and have other effects on the breasts, behavior and pituitary secretions. a. Estradiol is the major secreted estrogen. Other types are estrone and estriol. b. Inhibits FSH and LH secretion during the early follicular phase. c. Risei e t g n2 h uspi t o u t nit tsteH n s o e 4 o r r ro v l i n i e h L r o ao i a s re ta po u e o u t n ug h t rd c s v l i . ao

Estrogen
Pr epa r es en d o met r iu m f o r impl an t at io n

2. Progesterone: a steroid secreted in large amounts by the corpus luteum. Effects: a. Induces progestational effects on the endometrium. b. Stimulates development of lobules and alveoli in the breast. c. Provide feedback to the hypothalamic and pituitary regulation of the hormonal feedback mechanism. d. Causes rise in BBT at time of ovulation. b. Clinical indicators of ovulation: i. Secretory pattern in endometrium seen on biopsy ii. Rise in basal body temperature (BBT). BBT is the temperature taken on awakening and before activity. Persistent elevation of 0.5 1.0 reflects ovulation. F c. Enzyme Factors: estrogen focuses enzymes to help form the basement membrane of the endometrium. Enzymes also participate in the biochemical process that results in glycogen stores in the endometrium and alter the microvasculature to allow nutrients to flow more easily between cells and blood vessels. d. Vascular factors: coiled arterioles which supply blood to the outer functionalis layer constrict 4-24 hours prior to beginning of menstruation. Cause ischemic changes to the endometrium and eventually sloughing off.

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2. Uterine response a. Menstrual phase (Days 1-5) i. Physiologic changes: endometrial and degenerative changes cause tissue necrosis at the end of the secretory phase. 1. Basalis layer remains 2. About 2/3 of endometrium are lost with each ovulatory cycle and by the time brisk flow ceases, most tissue loss has occurred from shedding of the superficial or functionalis layer. b. Proliferative phase (Days 6-14) i. Physiologic changes: under the influence of estrogen 1. Regeneration of surface and glandular epithelium 2. Thickness increases as phase continues. a. Ovulatory: no appreciable change seen in endometrium in the 24-36 hours following ovulation. Changes become noticeable after progesterone levels increase with the evolution of the corpus luteum. c. Secretory (Progestational) phase i. Physiologic changes: progesterone secretion induces maturational changes in endometrial lining. 1. Presence of glycogen rich fluid in the basal portion. 2. Fluid secretions into glandular lumens. 3. Increasing stromal edema to its maximum which is reached at about 22nd day of cycle when corpus luteum activity reaches its maximum level. 4. In the absence of fertilization and implantation, corpus luteum activity regresses; estrogen and progesterone levels drop; rapid regressive changes in the endometrium occur. 5. Menstruation begins.

Uterine Response

Es tt r o g en Es g en

3. Ovarian response a. Follicular phase: varying number (usually 5 - 8) of follicles may be identified with EV sonography in each ovary. Dominant follicle may identified by about day 8 and measures approximately 10mm. Its size

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begins to exceed that of other antral follicles. Other sonographic considerations of a dominant follicle: i. Any follicle measuring > 11mm will most likely ovulate ii. Grows linearly (approx. 2 - 3 mm/day) iii. Maximum diameter varies between 15 - 30mm iv. Line of decreased reflectivity around follicle suggest ovulation will occur within 24 hours v. Presence of cumulus oophorus suggests ovulation will occur within 36 hours b. Ovulatory phase: Chronologically, ovulation occurs within 24 - 36 hours after onset of the LH surge. Sonographic findings that ovulation has occurred may include: i. Sudden decrease in follicular size ii. Fluid in cul de sac c. Luteal phase: Involution of the follicle into a corpus luteum (yellow body). This structure produces progesterone which will maintain the secretory endometrium should implantation occur. In the absence of hCG, the corpus luteum regresses after 14 days. Sonography may reveal: i. Replacement of dominant, cystic follicle with echogenic structure representing thrombus ii. Small, irregular cystic mass with crenated borders 4. Abnormal uterine bleeding a. Terminology: abnormal menstrual patterns may be characterized as abnormalities of volume or frequency: i. Hypermenorrhea: excessive volume during cyclic menstrual bleeding ii. Hypomenorrhea: an abnormally small amount of menstrual bleeding ii. Polymenorrhea: frequent menstrual bleeding occurring at less than 21 days apart iii. Oligomenorrhea: menstrual bleeding occurring more than 35 days apart iv. Menometrorrhagia: bleeding that is irregular in both frequency and volume b. Dysfunctional uterine bleeding: vaginal bleeding NOT related to estrus or endometrial pathology. i. Causes: many and varied include: functional or organic problems; endocrine disorders; endometrial disorders; others c. Post-menopausal vaginal bleeding: Covered in OBG2 d. Amenorrhea: the absence of menstrual flow: i. Primary: failure of the onset of menstrual periods by age 16. ii. Secondary: the lack of menstrual periods for 6 months in previously menstruating woman.

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