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Menstrual cycle

The phrase menstrual cycle refers to the recurring physiological changes in a female's body that come under the control of the reproductive hormone system and which play a vital role in reproduction. In the human, menstrual cycles occur typically on a monthly basis between puberty and menopause.

Contents

Overview

During the menstrual cycle, the sexually mature, female body develops one or more eggs and releases them at the time of ovulation. The lining of the uterus, the endometrium, builds up in a synchronised fashion. After ovulation, this lining changes to prepare for potential implantation of the fertilized egg to establish a pregnancy. If fertilisation and pregnancy do not ensue, the uterus sheds the lining and a new menstrual cycle begins. Medical science calls the process of the shedding of the lining menstruation. Menstruation manifests itself to the outer world in the form of the menses ( also menstruum): essentially part of the endometrium and blood products that pass out of the body through the vagina.

Common usage refers to menstruation and menses as a period. This bleeding, which typically lasts 2 to 5 days in women, serves as a sign that pregnancy has not taken place. During the reproductive years, failure to receive a menses may provide the first indication to a woman that she may have become pregnant. A woman may say that her "period is late" when an expected menstruation has not started and she might have become pregnant.

Menstruation forms a normal part of a natural cyclic process occurring in healthy, adult women between puberty and end of the reproductive years. The onset of menstruation, known as menarche, normally occurs between the ages of 8 and 16, and the last period, menopause, between the ages of 45 and 55. Deviations from this pattern deserve medical attention. Amenorrhea refers to a prolonged absence of menses during the reproductive years of a woman for reasons other than pregnancy. The presence of menstruation does not prove that ovulation took place, and women who do not ovulate may have menstrual cycles. Those anovulatory cycles tend to take place less regularly and show greater variation in cycle length.

The normal menstrual cycle in humans

While cycle length may vary, 28 days generally classes as representative of the normal ovulatory cycle in women. Convention uses the onset of menstrual bleeding to mark the beginning of the cycle and the first day of bleeding as "Cycle Day one". One can divide the menstrual cycle into four phases:

Menstruation

Menstruation lasts for a few days and involves the loss of about 50 millilitres of blood (including shed lining). An enzyme called plasmin—contained in the endometrium—inhibits the blood from clotting. Because of this blood loss, women have higher dietary requirements for iron than do males—to prevent iron deficiency. Many women experience uterine cramps, also referred to as dysmenorrhea, during this time. A vast industry has grown to provide sanitary products to help women to manage their menses.

Follicular phase

Under the influence of follicle stimulating hormone (FSH) a number of follicles in the ovary start to grow and, in turn, produce estrogens, primarily estradiol. These estrogens initiate the development of a new layer of endometrium with the development of a typical histologic pattern termed the proliferative endometrium. The estrogens provide a negative feed-back loop to the pituitary gland and decrease the secretion of FSH. Inhibin secreted by the largest follicle also decreases FSH. Typically only the most advanced follicle (lead follicle) can develop further as it has more FSH receptors ; the other follicles stop growing. This way, normally only one egg will mature in a given cycle.

Ovulation


When the follicle has matured, it secretes enough estradiol to trigger the acute release of luteinizing hormone (LH). In the 28-day cycle this LH surge starts around cycle day 12 and may last 48 hours. The release of LH matures the egg and weakens the wall of the follicle in the ovary. This process leads to ovulation: the release of the now mature ovum, the largest cell of the body (with a diameter of about 0.5 mm). Which of the two ovaries—left and right—ovulates appears essentially random; no known left/right co-ordination exists. The Fallopian tube needs to capture the egg and provide the site for fertilization. A characteristic clear and stringy mucus develops at the cervix, ready to accept sperm from intercourse. In some women, ovulation features a characteristic pain called Mittelschmerz which lasts for several hours. Many women perceive the vaginal and cervical mucus changes at ovulation. An unfertilised egg will disintegrate.

Luteal phase

After ovulation, the residual follicle transfoms into the corpus luteum under the support of the pituitary homones. This corpus luteum will produce progesterone in addition to estrogens for the next 2 weeks. Progesterone plays a vital role in converting the proliferative endometrium into a secretory lining receptive for implantation and supportive of the early pregnancy. It raises the body temperature slightly, thus woman who record their temperature on a daily basis will notice that they have entered the luteal phase. If fertilisation of an egg has occurred, it will travel as an early embryo through the tube to the uterine cavity and implant itself about 5 to 7 days after ovulation. Shortly after implantation, the growing embryo will signal its existence to the maternal system . One very early signal consists of human chorionic gonadotropin (hCG), a hormone that pregnancy tests can measure. This signal has an important role in maintaining the corpus luteum and enabling it to continue to produce progesterone. In the absence of a pregnancy and without hCG, the corpus luteum demises and inhibin and progesterone levels fall. This will set the stage for the next cycle. Progesterone withdrawal leads to menstrual shedding (progesterone withdrawal bleeding), and falling inhibin levels allow FSH levels to rise to raise a new crop of follicles.

Menstrual symptoms

In many women, various unpleasant symptoms caused by the involved hormones and by cramping of the uterus can precede or accompany menstruation. More severe symptoms may include significant menstrual pain (dysmenorrhea), abdominal pain, migraine headaches, depression and irritability. Some women encounter premenstrual stress syndrome (PMS or premenstrual syndrome), a cyclic clinical entity. The list of symptoms experienced varies from person to person. Furthermore, within an individual, the severity of the symptoms may vary from cycle to cycle.

The fertile window

While the length of the follicular phase—and consequently the menstrual cycle—may vary, the luteal phase almost always takes 14 days. Sperm can survive for 3 to 4 days (possibly up to 7 days) inside a woman, so the most fertile period (the time with the highest likelihood of sexual intercourse leading to pregnancy) covers the time from some 5 days before ovulation until 1-2 days after ovulation. In a normal, four-week cycle, this corresponds to the second and the beginning of the third week of the cycle. Various natural family planning methods of birth control attempt to determine the precise time of ovulation in order to find the relatively fertile and the relatively infertile days in the cycle.

People who have heard about the menstrual cycle and ovulation may commonly and mistakenly assume, for contraceptive purposes, that menstrual cycles always take a regular 28 days, and that ovulation always occurs 14 days after beginning of the menses. This assumption may lead to unintended pregnancies. Note too that not each bleeding event counts as a menstruation, and this can mislead people in their calculation of the fertile window.

If a woman wants to conceive, the most fertile time occurs between 16 to 14 days prior to the expected menses. Many women use ovulation detection kits that detect the presence of the LH surge in the urine to indicate the most fertile time. Other ovulation detection systems rely on the subtle temperature shift that progesterone induces.

Among women living closely together, the onsets of menstruation tend to synchronize somewhat. Researchers first described this phenomenon in 1971, and explained it by the action of pheromones in 1998 (Stern and McClintock 1998).

Hormonal control

Extreme intricacies regulate the menstrual cycle. For many years, researchers have argued over which regulatory system has ultimate control: the hypothalamus, the pituitary, or the ovary with its growing follicle; but all three systems have to interact. In any scenario, the growing follicle has a critical role: it matures the lining, provides the appropriate feed-back to the hypothalamus and pituitary, and modifies the mucus changes at the cervix. Two sex hormones play a role in the control of the menstrual cycle: estradiol and progesterone. While estrogen peaks twice, during follicular growth and during the luteal phase, progesterone remains virtually absent prior to ovulation, but becomes critical in the luteal phase and during pregnancy. Many tests for ovulation check for the presence of progesterone. These sex hormones come under the influence of the pituitary gland, and both FSH and LH play necessary roles. FSH stimulates immature follicles in the ovaries to grow. LH triggers ovulation. The gonadotropin-releasing hormone of the hypothalamus controls the pituitary, yet both the pituitary and the hypothalamus receive feed-back from the follicle. After ovulation the corpus luteum—which develops from the burst follicle and remains in the ovary—secretes both estradiol and progesterone. Only if pregnancy occurs do hormones appear in order to suspend the menstrual cycle, while production of estradiol and progesterone continues. Abnormal hormonal regulation leads to disturbance in the menstrual cycle.

Hidden ovulation

Unlike the case in other species, ovulation remains hidden in the human. The fact that a woman may sense her own ovulation while it remains indiscernible to others has sociobiological significance. In contrast, other species often signal receptivity. In this context, note that evidence suggests that women's preferences for men may change during their most fertile days, before and shortly after ovulation. During this time, they will prefer different male scents, more masculine faces, and social presence and competitiveness in males considered as short-term partners. (Gangestad 2004)

The ovary as an egg-bank

An estimated 400,000 to 450,000 immature eggs reside in each ovary at puberty. The menstrual cycle, as a biologic event, allows for ovulation of one egg typically each month. Thus over her lifetime a women will ovulate approximately 400 to 450 times. All the other eggs disappear by a process called atresia . During the reproductive life, no new eggs supplement those eggs already "banked" in the ovary.

The anovulatory menstrual cycle

Not all menstruations result from an ovulatory menstrual cycle. In some women, follicular development may start but not complete, nevertheless estrogens will form and will stimulate the uterine lining. Sooner or later the uterus will shed this lining. As no ovulation and no progesterone involvement occurs, doctors call this type of bleeding an estrogen breakthrough bleeding, and cannot always predict its duration or frequency. Anovulatory bleeding commonly occurs prior to menopause (premenopause) or in women with polycystic ovary syndrome.

Cycle abnormalities

Frequency

The "normal menstrual cycle" occurs every 28 days 7 days. Doctors term cycles with intervals of 21 days or fewer as polymenorrhea and, on the other hand, call cycles with intervals exceeding 35 days oligomenorrhea (or amenorrhea if intervals exceed 180 days).

Flow

The normal menstrual flow amounts to 50 ml 30 ml. Flow in excess of 80 ml (hypermenorrhea or menorrhagia) may stem from hormonal disturbance, uterine abnormalities, including uterine leiomyoma or cancer, and other causes. Doctors call the opposite phenomenon hypomenorrhea.

Duration

Prolonged bleeding (metrorrhagia, also meno-metrorrhagia) does not show a clear interval pattern anymore. Dysfunctional uterine bleeding refers to hormonally-caused bleeding abnormalities, typically anovulation. All these bleeding abnormalities need medical attention. As pregnant patients may bleed, a pregnancy test forms part of the evaluation of abnormal bleeding.

The birth control pill

Estrogens and progesterone-like hormones make up the main active ingredients of birth control pills. Typically they tend to mimic a menstrual cycle in appearance, but to suppress the critical event of the ovulatory cycle, namely ovulation. Normally, a woman takes hormone pills for 21 days, followed by 7 days of non-functional placebo sugar pills; then the cycle starts again. During the 7 placebo days, a withdrawal bleeding occurs; this differs from ordinary menstruation, and skipping the placebos and continuing with the next batch of hormone pills may suppress it. (Two main versions of the pill exist: monophasic and triphasic. With triphasic pills, skipping of the placebos can remove the pill's pregnancy protection.) In 2003 the United States Food and Drug Administration (FDA) approved low-dose monophasic birth control pills which induce withdrawal bleedings only every 3 months.

Etymology and the lunar month

The terms "menstruation" and "menses" come from the Latin mensis (month), which in turn relates to the Greek mene (moon) and to the roots of the English words month and moon—reflecting the fact that the moon also takes close to 28 days to revolve around the Earth. (The synodical lunar month, the period between two new moons, lasts about 29 and a half days). Although some women's menstrual periods may conform to the lunar cycle, no necessary connection exists between lunar months and menstrual periods: humans show considerable variation in the lengths of their menstrual cycle, and the length of the menstrual cycle differs in different animals (see below).

Sanitary issues

A whole industry has evolved to cater to menstruating women. Women commonly use sanitary towels (worn outside the vagina) or pads to prevent the soiling of clothes. Tampons (inserts made from absorbent material and inserted into the vagina) have become popular in Europe and in America, though not in Asia. A small number of women use reusable menstrual cups. Pharmaceutical companies also provide products—commonly Non-steroidal anti-inflammatory drugs (NSAIDs)—to relieve menstrual cramps.

Culture and menstruation

Mysticism

Mystics have sometimes elaborated "equivalencies", analogizing the waxing and waning of the moon with influences on human menstruation. In this spiritual, moon goddess, or astrological context some women call menstruation their "moontime". Some ancient views also regarded menstruation as a cleansing of the body: compare bloodletting as a major medical treatment of pre-modern times.

Religion

Some religions consider women "unclean" during menstruation.

Islam on menstruation

The Islamic world considers a woman "not in a state to have intercourse" during menstruation. A verse from the Holy Qur'an (with parenthesised interpolations by Dr. Muhammed Muhsin Khan ) affirms this: "They ask you concerning menstruation. Say: that is an Adha (a harmful thing for a husband to have sexual intercourse with his wife while she is having her menses), therefore keep away from women during menses and go not unto them till they have purified (from menses and have taken a bath). And when they have purified themselves, then go in unto them as Allh has ordained for you (go in unto them in any manner as long as it is in their vagina). Truly, Allh loves those who turn unto Him in repentance and loves those who purify themselves (by taking a bath and cleaning and washing thoroughly their private parts, bodies, for their prayers, etc.)." (Al-Baqarah 2:222)

See an Islamic review on the subject.

Judaism on menstruation

Main article: Niddah.

A ritual exclusion applies to a woman while menstruating and for about a week thereafter, until she immerses herself in a mikvah (ritual bath).

Menstruation in other mammals

A regular menstrual cycle as described here only occurs in the great apes. Menstrual cycles vary in length from an average of 29 days in orangutans to an average of 37 days in chimpanzees.

Females of other mammalian species go through certain episodes called "estrus" or "heat" in each breeding season. During these times, ovulation occurs and females become receptive to mating, a fact advertised to males in some way. If no fertilization takes place, the uterus reabsorbs the endometrium: no menstrual bleeding occurs. Significant differences exist between the estrous and the menstrual cycle.

External links

  • Harry Finley: Online museum of menstruation and women's health, http://mum.org/
  • Track your likely ovulatory date with this free Ovulation Calendar
  • Free Software to watch the menstrual cycle etc. http://www.natuerliche-verhuetung.de/en.htm
  • Leslie Botha-Williams, Women's Health Educator: A Woman's Guide to Understanding Her Hormone Cycle, http://www.holyhormones.com
  • An Islamic answer for the ruling of women menstruating

References

Last updated: 07-31-2005 19:31:22
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