Menstrual flow might occur every 21 to 35 days and last two to seven days.

N.b :
- For the first few years after menstruation begins, long cycles are common. However, menstrual
cycles tend to shorten and become more regular as you age.
- Isn't the same for every woman.
- When you get close to menopause, your cycle might become irregular again.

What causes menstrual cycle irregularities?

Menstrual cycle irregularities can have many different causes, including:

 Pregnancy or breast-feeding. A missed period can be an early sign of pregnancy. Breast-feeding

typically delays the return of menstruation after pregnancy.
 Eating disorders, extreme weight loss or excessive exercising. Eating disorders — such as anorexia
nervosa — extreme weight loss and increased physical activity can disrupt menstruation.
 Polycystic ovary syndrome (PCOS). Women with this common endocrine system disorder may have
irregular periods as well as enlarged ovaries that contain small collections of fluid — called follicles —
located in each ovary as seen during an ultrasound exam.
 Premature ovarian failure. Premature ovarian failure refers to the loss of normal ovarian function
before age 40. Women who have premature ovarian failure — also known as primary ovarian
insufficiency — might have irregular or occasional periods for years.
 Pelvic inflammatory disease (PID). This infection of the reproductive organs can cause irregular
menstrual bleeding.
 Uterine fibroids. Uterine fibroids are noncancerous growths of the uterus. They can cause heavy
menstrual periods and prolonged menstrual periods.

ANAMNESIS
If you're concerned about your periods, then also make note of the following every month:

 End date. How long does your period typically last? Is it longer or shorter than usual?
 Flow. Record the heaviness of your flow. Does it seem lighter or heavier than usual? How
often do you need to change your sanitary protection? Have you passed any blood clots?
 Abnormal bleeding. Are you bleeding in between periods?
 Pain. Describe any pain associated with your period. Does the pain feel worse than usual?
 Other changes. Have you experienced any changes in mood or behavior? Did anything new
happen around the time of change in your periods?
Buku Gynecology ilusrated 6 th

Normal menstrual cycles have a length of 21–35 days (mean 28 days). A normal period lasts for

3–7 days. Menstrual blood loss of 30–50 ml/month is normal. Menstrual blood loss is

considered as excessive when it is greater than 80 ml/month.

AMENORRHOEA

Amenorrhoea is the absence of menstruation for 6 months in a woman who had previously

menstruated normally (sometimes called 2 amenorrhoea)

or

amenorrhoea is the term given when a girl has failed to menstruate by the age of 16

(sometimes called 1 amenorrhoea).

MENARCHE

Menarche is the onset of menstruation at puberty. The median age at which menarche occurs

(13 y) is relatively late in the events occurring around puberty. For most young women, the

growth spurt and secondary sexual characteristics, such as breast development (thelarche) and

the growth of pubic and axillary hair, usually precede the onset of menstruation by about

2 years.

Absent or late puberty may present with amenorrhoea. If a girl over the age of 14 presents

with amenorrhoea, investigations should depend on whether or not other signs of puberty are

present.

PREGNANCY
During pregnancy, the levels of oestrogen and progesterone remain high, thus ensuring the
integrity of the endometrium, and causing amenorrhoea. Initially, the corpus luteum is the
source of oestrogen and progesterone. Later in pregnancy, the production of oestrogen and
progesterone is taken over by the placenta. Pregnancy should be considered in the differential
diagnosis of all women who present with amenorrhoea.
LACTATION
Soon after delivery, prolactin is secreted in large quantities by the anterior pituitary. There is
partial suppression of luteinising hormone (LH) production so that ovarian follicles may grow,
but ovulation does not occur, and amenorrhoea is the result. If the mother does not breast
feed, menstruation will return in 2–3 months, but if she does breast feed, the period of
amenorrhoea will be prolonged.
MENOPAUSE
The menopause is the cessation of menstruation (mean age 51 y) due to exhaustion of the
supply of ovarian follicles. Oestrogen production therefore falls. This fall in oestrogen
production is accompanied by a rise in follicle stimulating hormone (FSH) levels, which
continues for a considerable time. In a proportion of women, menstruation ceases abruptly,
but in many, the menstrual cycles alter. Frequently, they become shorter initially, but later
they lengthen and tend to be irregular, before ceasing entirely. This phase is known as the
menopause transition, and the final period is recognised only in retrospect, after 1 year of
amenorrhoea.

PHYSIOLOGY OF REPRODUCTION
OVULATION
Development of the ovarian follicle occurs in response to stimulation from the pituitary gland.
The hypothalamus and pituitary are intimately associated. Together they regulate ovarian
structure and function throughout the menstrual cycle.
The hypothalamus produces gonadotrophin releasing hormone (GnRH) in a pulsatile
fashion and this in turn stimulates production of the gonadotrophins follicle stimulating
hormone (FSH) and luteinising hormone (LH).
PITUITARY CONTROL
OF OVARY
The ovarian changes are controlled mainly by the anterior pituitary which produces three
principal hormones: follicle stimulating hormone (FSH) stimulates follicular growth. Luteinising
hormone (LH) stimulates ovulation and causes luteinisation of granulosa cells after escape of the
ovum. Prolactin is also produced by the anterior pituitary.

At the end of the menstrual cycle oestrogen levels are low. Low oestrogen levels stimulate
production of FSH by the pituitary. FSH in turn acts upon the ovary to stimulate growth of ovarian
follicles. The increasing levels of oestrogen produced by the developing follicles act on the pituitary
to reduce FSH levels by the process of negative feedback. In the majority of cycles only one follicle,
the so-called dominant follicle, is suffi ciently large and has a greater density of FSH receptors to
respond to the lower FSH levels and develops to the stage of ovulation. Non-identical twinning
results when more than one follicle proceeds to ovulation. Oestrogen levels continue to rise. In
the mid-cycle the nature of the ovarian control of pituitary function changes. Increasing oestrogen
levels are required to produce a positive feedback mechanism which causes a surge in FSH and LH
levels. This surge evokes ovulation. LH acts to increase local production of prostaglandins and
proteolytic enzymes to allow oocyte extrusion. LH is responsible for the development of the corpus
luteum which produces progesterone.
These alterations in oestrogen and progesterone levels are responsible for the dramatic changes
in the endometrium throughout the ovarian cycle. At the completion of the menstrual period the
endometrium is only one to two millimetres thick. Under the influence of increasing levels of
oestrogen this increases until by day 12 of the cycle the endometrium is 10 to 12mm thick. This
growth results from an increase in epithelial and stromal cells of the superfi cial layer of
endometrium. This Proliferative Phase is characterised by an increase in oestrogen receptor
content and increase in size of the endometrial glands. As ovulation approaches, the progesterone
receptor content increases. Within two days of ovulation the effect of ovarian production of
progesterone becomes apparent as the endometrium enters the Secretory Phase of the cycle.
During this phase the mitotic activity in the epithelium ceases and the glands become dilated and
tortuous. The blood vessels become more coiled. Glycogen accumulation in the endometrium
reaches a peak under the combined infl uence of oestrogen and progesterone. These processes
prepare the endometrium for embedding of the embryo. If fertilisation does not occur then
progesterone and oestrogen levels decline and menstruation occurs.
Fertilisation, if it occurs, takes place in the fallopian tube. The zygote divides repeatedly to form a
solid sphere of cells as it passes down the fallopian tube and into the uterine cavity. The developing
embryo begins to differentiate into the tissue which will become the fetus and that which will form
the placenta and fetal membranes. The primitive precursor of the chorionic membrane produces
human chorionic gonadotrophin (HCG). HCG has a biological action very similar to LH and takes
over its luteinising function. For the first fourteen days after fertilisation uterine growth and the
development of the decidua (the endometrium of pregnancy) are dictated by the corpus luteum
under the infl uence of the pituitary. Thereafter the pituitary LH levels are reduced in response to
the increasing levels of HCG.

Under the infl uence of chorionic gonadotrophin the corpus luteum continues to grow and to
secrete ovarian steroids for the maintenance of uterine growth. HCG levels reach a peak
around 10 to 12 weeks and thereafter decline to a lower constant level throughout pregnancy.
The response to this reduction is a decrease in ovarian oestrogen and progestogen output. As
the ovarian contribution to maintaining the pregnancy declines, the placenta increases
steroid production. Placental steroid production is impressive and analogues of both
hypothalamic and pituitary hormones are produced. The capacity to produce these
hormones increases as the early placenta develops.