Menstruation

Menstruation

Understanding Menstruation

Menstruation is the periodic bleeding of the uterus that begins approximately 14 days after ovulation (Bobak, 2004)

Menstruation is the periodic vaginal bleeding due to the release layer of the uterine endometrium. Normal menstrual function is the result of interaction between the hypothalamus, pituitary, and ovary with associated changes in the target tissue in the normal reproductive tract, the ovary plays an important role in this process, because it seems responsible for setting cyclic changes and long menstrual cycle (Greenspan , 1998).

Menstrual Cycle

1) Clinical menstrual

Most mid-reproductive age women, menstrual bleeding occurs every 25-35 days with a median cycle length was 28 days. Women with ovulatorik cycle, time interval between the beginning of menstruation until ovulation - follicular phase - varying length. Cycle observed in women who ovulate. Time interval between the beginning of menstrual bleeding - luteal phase - relatively constant with an average of 14 ± 2 days in most women (Grenspan, 1998).

Length of menstrual blood discharge also varies; in general the length of 4 to 6 days, but between two to eight days can still be considered normal. Menstrual blood expenditure consisted of fragments of Flaking endrometrium mixed with blood that number does not necessarily. Normally blood is liquid, but if the blood flow velocity is too large, clots of various sizes are very likely to be found. Unfreeze menstrual blood is caused by an active local fibrinolytic system in the endometrium.

The average amount of blood lost during normal women during a menstrual period has been determined by several research groups, ie 25-60 ml. Normal Hb concentration of 14 g per dl, and iron content of 3.4 mg per g Hb, blood volume contains 12-29 mg of iron and describes the loss of blood the same with 0.4 to 1.0 mg of iron per day, or 150 cycles up to 400 mg per year (Cunningham, 1995).

2) Hormonal aspects during the menstrual cycle

Mammals, especially humans, their reproductive cycle involving various organs, ie uterus, ovaries, vagina, and mammary held within a certain time or the existence of synchronization, it is possible the arrangement, coordination, called hormones. Hormones are chemical substances produced by endocrine glands, which are directly channeled in circulation and affect specific organs called target organs. The hormones that are related to the menstrual cycle,

a) The hormones produced by the pituitary gonadotropin:

o The luteinizing hormone (LH)

o Follicle Stimulating Hormone (FSH)

o Prolactin Releasing Hormone (PRH)

b) Ovarian Steroids

Ovaries produce progestrin, androgens, and estrogens. Many of the resulting steroid is also secreted by the adrenal gland or can be formed in peripheral tissue via the conversion of other steroid precursors; consequence, plasma levels of these hormones may not directly reflect the steroidogenic activity of ovaries.

3) Phases of the menstrual cycle

Every one there is four phases of the menstrual cycle changes that occur in the uterus. These phases are the result of highly coordinated cooperation between the anterior pituitary, ovaries, and uterus. Phases are:

a) Phase menstruation or deskuamasi

This phase, the endometrium regardless of the uterine wall accompanied by bleeding and layers that are still intact only the stratum basale. This phase lasts for 3-4 days.

b) post-menstrual phase or phases of regeneration

This phase there was healing of wounds caused by the escape of the endometrium. This condition started since the phase of menstruation occurred and lasted for ± 4 days.

c) Phase intermenstum or proliferative phase

After the wound healed, will occur in endometrial thickening ± 3.5 mm. This phase lasted from day 5 to day 14 of the menstrual cycle.

Proliferative phase is divided into three stages, namely:

·         The early proliferative phase, occurred on day 4 to day 7. This phase can be recognized from the thin surface epithelium and the presence of epithelial regeneration.

·         The proliferation of intermediate phase, occurred on day 8 today-to-10. This phase is a transitional form and can be recognized from the epithelial surface of the piston-shaped high.

·         late proliferative phase, lasting between day-to-11 until day 14. This phase can be recognized from the uneven surfaces and found the number of mitosis.

d) The premenstrual phase or secretory phase

This phase lasted from day 14 until the 28th. This phase is approximately fixed endometrial thickness, but the shape of the gland turned into a long and winding out the sap increasingly real. The interior of the endometrial cells are glycogen and lime needed as food for a fertilized egg.

Secretory phase were divided into two stages, namely:

·         The early secretory phase, this phase endometrium thinner than the previous phase because of the loss of fluid.

·         Phase secretion further, at this phase in the endometrial glands to grow and become more serpentine and secretion began to sap that contains glycogen and fat. The end of this period, the endometrial stromal cells to change direction; decidua, particularly those surrounding the arterial vessels. This situation allows the nidasi (Hanafiah, 1997).

4) Mechanism of the menstrual cycle

During menstruation, the day is taken as the beginning of the first day of the new cycle. Will happen again increase until it reaches levels of FSH 5 ng / ml (equivalent to 10 MUI / ml), under the synergistic effect of both gonadotropins, these developing follicles produce estradiol in significant amounts. Increased serum constantly in the late follicular phase would suppress FSH from the pituitary. Two days before ovulation, estradiol levels reached 150-400 pg / ml. Content exceeds the threshold value for the expenditure excitatory pre-ovulatory gonadotropin. As a result of FSH and LH in serum increased and reached a peak one day before ovulation. The same time, levels of estradiol will be back down. Maximum levels of LH ranged between 8 and 35 ng / ml, equivalent to 30-40 MUI / ml, and FSH between 4-10 ng / ml, equivalent to 15-45 MUI / ml.

Occurrence of peak LH and FSH on day 14, then the follicle at this time will start one day later rupture and ovulation will occur. Along with this began the formation and maturation of the corpus luteum is accompanied by rising levels of progesterone, whereas gonadotropins began to fall again. Increased progesterone does not always give the sense, that ovulation has occurred with the good because in some women that do not occur ovulation basal body temperature remains were found and in accordance with the luteal phase endometrium.

Early luteal phase, along with the maturation of the corpus luteum. Progesterone secretion continuously increased and reached levels of between 6 and 20 ng / ml. Estradiol is released mainly from large follicles that have not undergone atresia, also seen in the luteal phase and the concentrations were higher than during the early or mid-follicular phase. Maximal estradiol and progesterone production were found between day 20 and 23