CHAPTER 03:

THE MENSTRUAL
CYCLE

Dr. Vigette Valdez MD, MPH

 Menstruation
■ a series of rhythmic reproductive
cycle that begins from the onset
of menstrual bleeding to the
day before the next bleeding
day.
■ It is characterized by changes in
the ovaries and the uterus,
influenced by normal hormonal
variation mediated by
the hypothalamus and anterior
pituitary gland (APG) via a
negative feedback mechanism.
■ This cycle functions to prepare
for the release of egg,
fertilization, and implantation.
 Menstruation
■ Begins recurring cyclically at
puberty with the first
menstruation
called menarche and ceasing
at menopause.
■ The duration of the cycle is
highly individualized, but the
average/mean cycle length is
28 days; as short as 21 days or
as long as 40 days.
■ The regularity of the cycle is
also individualized, as some
experience irregular
(fluctuating length) cycles.
 Menstruation
■ The only fairly constant interval
is the time from ovulation to
the beginning of menses,
which is almost always 14 to
15 days.
 Hormonal Control of the
Menstrual Cycle
■ Hypothalamic Hormones: the hypothalamus
secretes gonadotrophin-releasing (GnRF/GnRH) or
inhibiting factors (GnIF) that stimulate the pituitary
gland to secrete or inhibit the secretion of
corresponding gonadotrophins (Gn).
Hormonal Control of the
Menstrual Cycle
■ Anterior Pituitary Hormones (APG): the producer
of gonadotrophins (Gn), follicle-stimulating
hormones (FSH), and luteinizing hormone (LH).
Hormonal Control of the
Menstrual

Cycle
FSH is secreted in response to the hypothalamic
follicle-stimulating hormone releasing factor
(FSHRF) triggered by low blood levels of
estrogen during the first half of the menstrual
cycle. Estrogen, by the fourth to fifth day, is at its
lowest in a regular 28-day cycle.
Hormonal Control of the
Menstrual

Cycle
LH, also called interstitial-cell stimulating
hormone, is secreted in response to the
hypothalamic luteinizing hormone releasing
factor (LHRF) triggered by low blood levels of
progesterone. Progesterone, by the thirteenth
day, is at its lowest. Progesterone is
responsible for the rise in basal body
temperature found on the fourteenth day,
and the drop on the thirteenth day in a
regular 28-day cycle.
Hormonal Control of the
Menstrual
■ Cycle
Ovarian Hormones: Estrogen and Progesterone
– Estrogen is secreted by the ovaries, adrenal cortex,
and placenta (during pregnancy).It is responsible for
the development of secondary sexual
characteristics
– Progesterone is secreted by the corpus luteum (non-
pregnant/early pregnancy) and placenta (as early as the
sixth week of pregnancy until parturition)
Hormonal Control of the
Menstrual
■ Cycle
Ovarian Hormones: Estrogen and Progesterone
– Estrogen
■ It is responsible for the development of secondary sexual
characteristics
■ Assists in the maturation of ovarian follicles
■ Inhibits secretion of FSH (negative feedback)
■ Stimulates secretion of LH (positive feedback)
■ It is responsible for the proliferative phase of the
menstrual cycle.
■ It is responsible for the fertile cervical mucus that is
conducive to fertilization; the change of cervical mucus to thin,
clear, colorless, stringy, stretchable, slippery, and lubricative,
returning a positive ferning test.
■ In pregnancy, it increases vascularization, maintains
the highly-specialized endometrium (decidua),
Hormonal Control of the
Menstrual Cycle
■ Ovarian Hormones: Estrogen and Progesterone
– Progesterone
■ Inhibits secretion of LH (negative feedback)
■ Helps maintain the endometrium by facilitating the
secretory phase of the menstrual cycle in preparation
for nidation (implantation)
■ Relaxes smooth muscles, including the myometrial muscle
of the uterus:
– Maintains pregnancy by maintaining decidua. If
progesterone levels drops in pregnancy, abortion (early
pregnancy) or premature labor (late pregnancy) may occur.
– One of the main theories of labor onset is when progesterone
levels drop at term, giving way for the myometrium to
contract easily from stimulation by rising stimulants such as
oxytocin and prostaglandin.
Hormonal Control of the
Menstrual Cycle
■ Ovarian Hormones: Estrogen and Progesterone
– Progesterone
■ Increases body temperature (Thermogenic)
■ Water-retaining, anti-diuretic action; decreases
hemoglobin and hematocrit levels
■ Increases fibrinogen level, increasing coagulability
■ Responsible for infertile cervical mucus: thick, opaque,
sticky, non-stretchable
■ Antagonizes insulin along with estrogen, human placental
lactogen (HPL), and cortisol.
Stages/Phases of the
Menstrual Cycle
■ Menstrual Phase
■ Follicular/Proliferative Phase
■ Luteal/Secretory Phase
 Stages/Phases of the
■Menstrual
Menstrual Phase or Cycle the Bleeding Phase, also known as menstruation.
Day 1 to 4, lasting for 3 to 5 or 4 to 6 days. It is the terminal phase of the
cycle.
– Characterized by vaginal bleeding as the uterine endometrium is shed
down to the basal layer along with blood from the capillaries and with the
unfertilized ovum.
– Periodic discharge of blood, mucus, and cellular debris from the
uterine mucosa and occurs at regular, cyclic, and predictable intervals
from menarche to menopause.
– The period of absolute infertility
– Menarche is the first onset of menstruation, occurring between 12 to 13
years of age; usually anovulatory, infertile, and irregular.
– 25 to 60 mL of blood, with about 0.4 to 1.0 mg of iron is lost every
day.
– Menstrual blood is incoagulable due to fibrinolytic activity.
 Stages/Phases of the
■Menstrual Cycle
Follicular/Proliferative Phase: Day 5 to 14, ending in ovulation;
lasts about 9 days.
– This phase is controlled by estrogen, where the endometrium
thickens by 8 to 10 times during the first few days, known as
the regenerative phase.
– After changes level off at ovulation, the endometrium consists of three
layers:
■ Basal Layer: 1 mm, thick, never alters
■ Functional Layer: 2.5 mm, contains tubular glands, consistently
changes according to hormonal influences of the ovary
■ Cuboidal Ciliated Epithelium Layer: uppermost layer, covers the
functional layer, and dips down to line the tubular glands
 Stages/Phases of the
■Menstrual Cycle
Follicular/Proliferative Phase : Day 5 to 14, ending in ovulation; lasts
about 9 days.
– Ovulation is present in the middle of the cycle; monthly growth and
release of a mature, non-fertilized ovum from the ovary. It is the period of
absolute fertility. This usually occurs 13 to 15 (average of 14) days prior
to the next cycle. At this point, estrogen is high while progesterone is low.
– Signs of ovulation include breast tenderness, slight rise in BBT (0.3°C to
0.5°C; 0.4°F to 0.8°F) preceded by a slight drop (0.2°F) 24 to 36 hours
before, related to changes in progesterone levels.
– The most fertile time is 3 to 4 days before and 1 to 2 days after
ovulation.
– Positive Spinnbarkeit/Creighton/Billings/Cervical Mucus Test
– Mittelschmerz, left or right lower quadrant pain corresponding to the
rupturing of the Graafian follicle.
– Positive Ferning Test
 Stages/Phases of the
■Menstrual Cycle
Follicular/Proliferative Phase: Day 5 to 14, ending in ovulation;
lasts about 9 days.
– Estimating ovulation time: subtract 14 days from the menstrual cycle
length e.g. it occurs on the 14th day in a 28-day cycle, and on the 16th
day in a 30-day cycle.
– The period of fertility is calculated as five days before and two
days after the day of ovulation. In a 28-day cycle, the period of
fertility is from 9 to 17th day counting from the first day of bleeding.
 Stages/Phases of the
■Menstrual Cycle
Luteal/Secretory Phase: Day 15 to 28; lasts about 12 days.
– This phase is initiated by ovulation in response to a surge in LH
that promotes the development of corpus luteum from the
ruptured follicle, the yellow body that secretes high levels of
progesterone and estrogen.
– Progesterone stimulates the already-proliferated
endometrium, causing the functional layer to become thicker
(2.5 mm → 3.5 mm), more spongy, and softer with glands
becoming more tortuous as the endometrial capillaries get
distended with blood in preparation for reception/implantation
and nourishment of the fertilized ovum.
 Stages/Phases of the
■Menstrual Cycle
Luteal/Secretory Phase: Day 15 to 28; lasts about 12 days.
– If fertilization occurs, implantation follows 6 to 9 or 7 to 10 days
(average 7 days) after. The corpus luteum lives longer and secretes
progesterone and estrogen in early pregnancy, which is later
replaced by the placenta. The normal lifespan for the corpus luteum
is 10 to 14 days.
– If fertilization does not occur, the corpus luteum involutes after 7 to
8 days after ovulation, becoming white (corpus albicans) which persists
up to 10 to 12 days after ovulation. This causes a drop in estrogen
and progesterone, leading to the endometrial
ischemic/premenstrual phase.
 Implementation

■ Promptly refer for evaluation and diagnosis if

there is excessive menstrual flow, intermenstrual or
post-menopausal bleeding, absence of menarche at
age 17, and severe pre-menstrual tension
syndrome. Promote relief of discomfort from
dysmenorrhea through rest, mild sedatives, leg lifts,
external heat to the lower abdomen, hot drinks, and
treatment as ordered (antiemetics, prostaglandin
inhibitors)
 Menstrual Problems and
■Disorders
Premenstrual Syndrome
– activity with rest (aerobic exercises), relaxation techniques,
stress management, pharmacotherapy as prescribed (SSRIs,
Progesterone Supplementation)
■ Amenorrhea: the absence of menstruation; primary if
menarche never occurred, and secondary if menses ceased for
more than 3 months after a regular cycle has been
established. Pregnancy is the most frequent cause of
secondary amenorrhea. It may also be related to stress,
malnutrition, obesity, and hormonal imbalance (ovarian,
pituitary, thyroid, adrenal)
– Causes of primary amenorrhea include thyroid gland
abnormalities (typically hyperthyroidism; first suspect even
without other S/S), or other endocrine dysfunctions or
 Menstrual Problems and
■Disorders
Dysmenorrhea: in Greek, literally “painful monthly bleeding”.
It usually corresponds to the secretory phase of the
endometrium indicating that ovulation has occurred; absent
when ovulation is suppressed.
– Primary: pain not associated with other diseases or
pathology; treat with rest, heat application, distraction,
exercise, hormonal therapy, NSAIDs, and analgesia,
especially prostaglandin inhibitors (Ibuprofen) as
Prostaglandin F is the main contributor in this disorder. It
may also be caused by acute uterine anteflexion,
retroflexion, and cervical stenosis.
– Secondary: pain associated with a malpositioned uterus,
PID, IUD, endometriosis, or endometritis
 Menstrual Problems and
■Disorders
Metrorrhagia: abnormal bleeding between menses/period or
intercyclic bleeding. May be related to PID, uterine fibroids,
corpus carcinoma, erosion, and cancer of the cervix.
■ Monometrorrhagia: excessive or prolonged menstrual
bleeding that may lead to or cause hypovolemia and anemia.
■ Menorrhagia: excessive, profuse menstrual flow; may be
caused by hormonal imbalance, infection, or uterine tumors.
■ Oligomenorrhea: infrequent menses.
■ Polymenorrhea: too frequent menses.
■ Hypomenorrhea: abnormally short menstrual cycle.
■ Hypermenorrhea: abnormally long menstrual cycle.
 Menopause
■ Menopause is a transitional phase for women
marking the end of their reproductive abilities.
■ Menopause is to the climacteric as menarche is to
puberty. It occurs between 45 to 50 years in 50% of
women; can be from 35 to 60 years with an
average of 53 years; not completed until 2 years
since the last period.
■ Ovulation ceases two years prior to
menopause with some individual variation.
■ Initially, menstruation becomes irregular, then
it ceases altogether.
 Menopause
■ The drop in estrogen attributed to menopause causes
physical symptoms:
– Hot flashes: a cluster of symptoms due to vasomotor
disturbances related to hormonal changes and
cessation of menses. It is characterized by a heat
arising in the chest and spreading to the neck
and face (caused by vasodilation), sweating,
occasional chills, dizzy spells, palpitations, and
weakness.
– Emotional changes, such as mood swings or emotional
lability.
– Sleep disturbances
– The tendency to obesity is not because of a change in
Menopause
– Sexual drive may not be diminished; it may even improve as
the need for contraception disappears.
– Atrophic changes in the vagina, vulva, and urethra and in
the trigonal area of the bladder, which may result in
dyspareunia, but can be overcome with lubricating gel, or
saliva, the most common vaginal lubricant.
– The breasts become pendulous and decrease in size and
firmness.
– Long-range physical changes may include osteoporosis
associated with low estrogen and androgen levels, lack of
physical exercise, and low dietary intake of calcium.
 Menopause
■ Treatment, if necessary, include:
– Estrogen replacement therapy if there is no history
of cancer in the family (this treatment is controversial.
Short-term low-dose estrogenic therapy may be used
for troublesome vasomotor disturbances (hot flashes).
Sustained high-dose estrogen therapy has been
reported to predispose women to reproductive tract
cancer. Hormonal vaginal creams/lubricants (K-Y jelly)
for painful coitus or dyspareunia
– Vitamin B complex and E for hot flashes and other
symptoms
– Increased calcium and phosphorus
intake for osteoporosis intervention
END….

Thank you!!!