Female Reproductive Physiology-wasihun.pptx

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1. Female Reproductive Physiology By Wasihun A. OB/GYN

2. THE MENSTRUAL CYCLE Menstruation is the physiologic shedding of the endometrium associated with uterine bleeding that occurs at monthly intervals from menarche to menopause. Each menstrual cycle represents a complex interaction between the hypothalamus, pituitary gland, ovaries, and endometrium . Between menarch and menopause, menstruation will occur 400 to 500 times in the average woman.

3. HYPOTHALAMIC-PITUITARY AXIS HYPOTHALAMUS- Produces biogenic amine that affect the reproductive cycle- GnRH . It is responsible for the synthesis and release of both LH and FSH. GnRH reaches the anterior pituitary via the hypophyseal portal vessels and stimulates the synthesis of both FSH and LH. GnRH is secreted in a pulsatile fashion throughout the menstrual cycle.

4. HYPO-PITU… PITUITARY GLAND - is divided into two major portions The neurohypophysis, which consists of the posterior lobe- serves primarily to transport oxytocin and vasopressin (antidiuretic hormone) The adenohypophysis, which consists of anterior lobe-contains different cell types that produce six protein hormones: FSH, LH, TSH, Prolactin, GH, and ACTH. The gonadotropins, FSH and LH, are synthesized and stored in cells called gonadotrophs

5. GONADOTROPIN SECRETORY PATTERNS Decreasing levels of estradiol and progesterone from the regressing corpus luteum of the preceding cycle initiate a rise of FSH by a negative feedback mechanism, which stimulates follicular growth and estradiol secretion. At lower levels of estradiol there is a negative feedback effect on the ready-release form of LH from the pool of gonadotropins in the pituitary gonadotrophs.

6. GONADOTROPIN… As estradiol levels rise later in the follicular phase, there is a positive feedback on the release of storage gonadotropins, resulting in the LH surge and ovulation. Ovulation occurs 36Hrs after the onset of this mid-cycle LH surge. During the luteal phase, both LH and FSH are significantly suppressed through the negative feedback effect of elevated circulating estradiol and progesterone. This inhibition persists until progesterone and estradiol levels decline near the end of the luteal phase as a result of CL regression , should pregnancy fail to occur.

7. OVARIAN CYCLE ESTROGENS - early follicular development, circulating estradiol levels are relatively low, at first increase slowly, then rapidly. The levels generally reach a maximum 1 day before the mid-cycle LH peak. After this peak and before ovulation, there is a marked fall. During the luteal phase, estradiol rises to a maximum 5 to 7 days after ovulation and returns to baseline shortly before menstruation.

8. OVARIAN… PROGESTINS - During follicular development, the ovary secretes only very small amounts of progesterone. The bulk of the progesterone comes from the peripheral conversion of adrenal pregnenolone and pregnenolone sulfate. Just before ovulation, the unruptured but luteinizing graafian follicle begins to produce increasing amounts of progesterone.

9. OVARIAN… The elevation of basal body temperature is temporally related to the central effect of progesterone. As with estradiol, secretion of progestins by the corpus luteum reaches a maximum 5 to 7 days after ovulation and returns to baseline shortly before menstruation. Should pregnancy occur, progesterone levels, and therefore basal body temperature, remain elevated.

10. Follicular phase From birth, there are many primordial follicles under the ovarian capsule. At the start of each cycle, several of these follicles enlarge and 1 of the follicles in 1 ovary starts to grow rapidly on about the sixth day and becomes the dominant follicle. The others regress, forming atretic follicles. It is not known how 1 follicle is singled out for development during this follicular phase of the menstrual cycle, but it seems to be related to the ability of the follicle to secrete the estrogen inside it that is needed for final maturation.

11. Follicular… Follicular atresia occurs independent of gonadotropin stimulation. There is continuous growth and atresia of primordial follicles occurring from fetal life through menopause. Pregnancy and oral contraception (i.e., anovulation ) do not stop this process.

12. Follicular… The cells of the theca interna of the follicle are the primary source of circulating estrogens. The follicular fluid has a high estrogen content, and much of this estrogen comes from the granulosa cells. At about the 14th day of the cycle, the distended follicle ruptures, and the ovum is extruded into the abdominal cavity. This is the process of ovulation.

13. Luteal phase The follicle that ruptures at the time of ovulation promptly fills with blood, forming corpus hemorrhagicum . Minor bleeding from the follicle into the abdominal cavity may cause peritoneal irritation and fleeting lower abdominal pain (" mittelschmerz "). The granulosa and theca cells of the follicle lining promptly begin to proliferate, and the clotted blood is rapidly replaced with yellowish, lipid-rich luteal cells, which secrete estrogens and progesterone & form the corpus luteum.

14. Luteal… If pregnancy occurs, the corpus luteum persists, and there are usually no more menstrual periods until after delivery. If there is no pregnancy, the corpus luteum begins to degenerate about day 24 of the cycle and is eventually replaced by fibrous tissue, forming a corpus albicans .

15. Uterine/Endometrial Cycle Under the influence of estrogens from the developing follicles, the endometrium regenerates from the deep layer and increases rapidly in thickness from 5-14dys. As the thickness increases, the uterine glands are drawn out so that they lengthen, but they do not secrete to any degree. These endometrial changes are called proliferative, and this part of the menstrual cycle is called the proliferative phase

16. Uterine… After ovulation, the endometrium becomes more highly vascularized and slightly edematous under the influence of estrogen and progesterone from the corpus luteum. The glands become coiled and tortuous, and they begin to secrete a clear fluid. Consequently, this phase of the cycle is called the secretory phase.

17. Uterine… The endometrium - 2 types of arteries. The superficial 2/3 that is shed during menstruation, the stratum functionale , is supplied by spiral arteries, whereas the deep layer, the stratum basale , which is not shed, is supplied by short basilar arteries. When the corpus luteum regresses, hormonal support for the endometrium is withdrawn. The endometrium becomes thinner, & Foci of necrosis appear in the endometrium, and these coalesce leading to spotty hemorrhages that become confluent and produce the menstrual flow.

18. Uterine… Vasospasm occurs for hemostasis and probably is produced by locally released prostaglandins. The length of the secretory phase is remarkably constant, at about 14 days, and the variations seen in the length of the menstrual cycle are mostly due to variations in the length of the proliferative phase.

19. Normal Menstruation Menstrual blood is predominantly arterial, only 25% venous origin. It contains tissue debris, prostaglandins, and fibrinolysin from the endometrial tissue. The fibrinolysin lyses clots, so menstrual blood does not normally clot unless the flow is excessive. The usual duration of the menstrual cycle is 3–5 days, but flows as short as 1 day and as long as 8 days can occur in normal women. Average 28dys and may range from 21-35dys. The average amount of blood lost is 30-50 mL but normally may range from slight spotting to 80 mL.

20. Cyclic Changes in the Cervix There are regular changes in the cervical mucus during the MS. Estrogen makes the mucus thinner and more alkaline, changes that promote the survival and transport of sperms & Progesterone makes it thick, tenacious, and cellular.

21. Cervix… The mucus is thinnest at the time of ovulation, and its elasticity, or spinnbarkeit , increases so that by midcycle , a drop can be stretched into a long, thin thread that may be 8–12 cm. In addition, it dries in an arborizing , fernlike pattern when a thin layer is spread on a slide. After ovulation and during pregnancy, it becomes thick and fails to form the fern pattern is b\c of progestrone effect on cervical mucus

22. Vaginal & Breasts Cycle Under the influence of estrogens, the vaginal epithelium becomes cornified . Under the influence of progesterone, a thick mucus is secreted, and the epithelium proliferates and becomes infiltrated with leukocytes. There are cyclic changes in the breasts during the menstrual cycle. Estrogens cause proliferation of mammary ducts , whereas progesterone causes growth of lobules and alveoli .

23. Vaginal & Breasts… The breast swelling, tenderness, and pain experienced by many women during the 10 days preceding menstruation are due to distention of the ducts, and edema of the interstitial tissue of the breasts. All of these changes regress, along with the symptoms, during menstruation

24. Indicators of Ovulation A rise in the basal body temperature taken orally, vaginally, or rectally in the morning before getting out of bed. Probably is due to the increase in progesterone secretion, as progesterone is thermogenic . Spinnbarkeit test, arborizing , fernlike pattern mucus A rise in urinary LH occurs during the rise in circulating LH that causes ovulation, and this increase can be measured using dipsticks or simple color tests for detection of urinary LH - available for home use.

25. Menstrual Cycle-Influenced Disorders Regular ovulatory cycles cause dysfunction of other organ systems. In these disorders, the causative factors are not abnormal concentrations of the hormones of the HPO axis, but rather the factors are atypical end-organ responses to normal levels of gonadotropins and sex steroids.

26. 1. PREMENSTRUAL SYNDROME-PMS Patients experience adverse physical, psychologic, and behavioral symptoms during the luteal phase of the menstrual cycle. There is a crescendo of symptom intensity up to the time that menses begins with quick resolution thereafter. As many as 80% of regularly ovulating women experience some degree of physical and psychologic premenstrual symptomatology

27. PMS… In 5% symptoms are so severe that they seriously interfere with usual daily functioning or personal relationships. These women are characterized as having PREMENUSTRAL DYSPHOIC DISORDER . Common symptoms include depressed mood, anxiety, irritability, decreased interest in regular activity, difficulty concentrating, fatigue, change of appetite, sleep disturbance.

28. PMS… Physical symptoms include breast swelling and tenderness, bloating, weight gain, edema , and headache. The diagnosis of these disorders is confirmed by the predominant occurrence of symptoms in the luteal phase as documented on a menstrual calendar of two consecutive cycles.

29. TREATMENT Reassurance and mild diuretics for symptoms such as bloating The most effective therapy studied for women with PMDD is the SSRI class of antidepressants. Some individuals may derive relief from continuous oral contraceptives.

30. 2. Dysmenorrhea Is a common gynecologic disorder affecting as many as 50% of menstruating women. Primary dysmenorrhea refers to menstrual pain without pelvic pathology, whereas secondary dysmenorrhea is defined as painful menses associated with underlying pathology. Primary dysmenorrhea usually appears within 1 to 2 years of menarche, when ovulatory cycles are established.

31. Dysmenorrhea… Secondary dysmenorrhea usually develops years after menarche. The cause of primary dysmenorrhea is increased endometrial prostaglandin production - found in higher concentrations in secretory endometrium than in proliferative endometrium. The pain of primary dysmenorrhea usually begins a few hours after the onset of a menstrual period and may last 48 to 72 hours.

32. Dysmenorrhea… The pain is similar to labor, with suprapubic cramping, and may be accompanied by lumbosacral backache, nausea, vomiting, diarrhea, and rarely syncopal episodes. The pain of dysmenorrhea is colicky in nature and, unlike abdominal pain, it is relieved by abdominal massage, or movement of the body.

33. Signs On examination, the vital signs are normal. The suprapubic region may be tender to palpation. Bimanual examination at the time of the dysmenorrheic episode often reveals uterine tenderness; but no CMT or adnexal tenderness. The pelvic organs are normal in primary dysmenorrhea. To diagnose primary dysmenorrhea, rule out underlying pelvic pathology and confirm the cyclic nature of the pain.

34. Treatment NSAIDs, are effective - taken before or at the onset of pain and then every 6 to 8 hours to prevent reformation of prostaglandin. The medication should be taken for the first few days of menstrual flow. OCPs more effective and resulted in less absence from work or school. If the patient does not respond to this regimen, hydrocodone or codeine may be added for 2 to 3 days per month.

35. 3. Mastodynia Pain of the breasts caused by edema and engorgement of the vascular and ductal systems is termed mastodynia . Mastodynia specifically refers to a cyclical occurrence of severe breast pain, usually in the luteal phase of the menstrual cycle. It is common in women with PMS/PMDD, and it may be the primary symptom of this syndrome in some.

36. Management Management of painful breasts Topical NSAIDs, Oral contraceptives Tamoxifen , danazol , Bromocriptine , Occasional use of a mild diuretic.

37. OTHERS MENSTRUAL MIGRAINE HEADACHES CATAMENIAL EPILEPSY PREMENSTRUAL ASTHMA PREMENSTRUAL ACNE

38. The end!