MENSTRUATION

 menstrual cycle (the female reproductive cycle) is episodic uterine bleeding in response to cyclic hormonal changes.
 The purpose of a menstrual cycle is to bring an ovum to maturity and renew a uterine tissue bed that will be necessary for the ova’s growth should it be
fertilized.
 The length of menstrual cycles differs from woman to woman, but the average length is 28 days (from the beginning of one menstrual flow to the beginning
of the next). It is not unusual for cycles to be as short as 23 days or as long as 35 days.
 The length of the average menstrual flow (termed menses) is 4 to 6 days, although women may have flows as short as 2 days or as long as 9 days (Ledger,
2012).
Function:
1. Preparation for ovulation
2. Preparation for fertilization
3. Preparation for implantation
Abnormalities of Menstruation
1. Amenorrhea – temporary absence of menstruation
2. Dysmenorrhea – painful menstruation
3. Oligomenorrhea – markedly diminished menstruation
4. Polymenorrhea – too frequent menstruation occurring intervals less than 3 weeks
5. Menorrhagia – excessive menstrual bleeding
6. Metrorrhagia – bleeding between periods; intercyclic bleeding
7. Hypomenorrhea – abnormally short menstruation
8. Hypermenorrhea – abnormally long menstruation

Physiology of Menstruation
Four body structures are involved in the physiology of the menstrual cycle: the hypothalamus, the pituitary gland, the ovaries, and the uterus. For a
menstrual cycle to be complete, all four organs must contribute their part; inactivity of any part results in an incomplete or ineffective cycle (Fig. 5.11).
 Pituitary hormones which regulate menstrual cyclic activity
1. Follicle stimulating hormone (FSH)
2. Luteinizing hormone (LH)
 Ovarian hormones which regulate menstrual cycle activity:
1. Estrogen
2. Progesterone
The Hypothalamus
The release of GnRH (also called luteinizing hormone–releasing hormone [LHRH]) from the hypothalamus initiates the menstrual cycle. GnRH then
stimulates the pituitary gland to send the gonadotropic hormone to the ovaries to produce estrogen. When the level of estrogen rises, release of GnRH is repressed
and no further menstrual cycles will occur (the principle that birth control pills use to eliminate menstrual flows). Excessive levels of pituitary hormones can also
inhibit release.
During childhood, the hypothalamus is apparently so sensitive to the small amount of estrogen produced by the adrenal glands, release of GnRH is
suppressed. Beginning with puberty, the hypothalamus becomes less sensitive to estrogen feedback, so every month in females, the hormone is released in a cyclic
pattern.
Diseases of the hypothalamus, which cause deficiency of this releasing factor, can result in delayed puberty. Likewise, a disease that causes early activation
of GnRH can lead to abnormally early sexual development or precocious puberty

The Pituitary Gland

Under the influence of GnRH, the anterior lobe of the pituitary gland (the adenohypophysis) produces two hormones:
 FSH, a hormone active early in the cycle that is responsible for maturation of the ovum
  LH, a hormone that becomes most active at the midpoint of the cycle and is responsible for ovulation, or release of the mature egg cell from the ovary.
It also stimulates growth of the uterine lining during the second half of the menstrual cycle.
The Ovaries
1. Preovulatory/follicular phase
-Days 6 to day 13
-dominant follicle matures graafian follicle with primary oocyte
-FSH increases initially then decreases because of estrogen increase
2. Ovulatory phase
-ruptures of graafian follicle releasing secondary oocyte
-due to the LH surge
-Mittelschemerz or pain during rupture of follicle
3. Post-ovulatory luteal phase
-day 15 to day 28
-most constant 14 days after ovulation
-corpus luteum secretes progesterone
-if nor fertilization occurs, corpus luteum will become corpus albicans then degenerate
-decreased estrogen and progesterone
FSH and LH are called gonadotropic hormones because they cause growth (trophy) in the gonads (ovaries). Every month during the fertile period of a
woman’s life (from menarche to menopause), one of the ovary’s oocytes is activated by FSH to begin to grow and mature. As the oocyte grows, its cells produce a
clear fluid (follicular fluid) that contains a high degree of estrogen and some progesterone. As the follicle surrounding the oocyte grows, it is propelled toward the
surface of the ovary. At full maturity, the follicle is visible on the surface of the ovary as a clear water blister approximately 0.25 to 0.5 in. across. At this stage of
maturation, the small ovum (barely visible to the naked eye, about the size of a printed period) with its surrounding follicular membrane and fluid is termed a
graafian follicle.
By day 14 or the midpoint of a typical 28-day cycle, the ovum has divided by mitotic division into two separate bodies: a primary oocyte, which contains
the bulk of the cytoplasm, and a secondary oocyte, which contains so little cytoplasm that it is not functional. The structure also has accomplished its meiotic
division, reducing its number of chromosomes to the haploid (having only one member of a pair) number of 23.
After an upsurge of LH from the pituitary at about day 14, prostaglandins are released and the graafian follicle ruptures. The ovum is set free from the
surface of the ovary, a process termed ovulation. It is swept into the open end of a fallopian tube. It is important to teach women that ovulation does not necessarily
occur on the 14th day of their cycle; it occurs 14 days before the end of their cycle. If their menstrual cycle is only 20 days long, for example, their day of
ovulation would be day 6 (14 days before the end of the cycle). If their cycle is 44 days long, ovulation would occur on day 30, not at the halfway point—day 22.
After the ovum and the follicular fluid have been discharged from the ovary, the cells of the follicle remain in the form of a hollow, empty pit. The FSH has
done its work at this point and now decreases in amount. The second pituitary hormone, LH, continues to rise in amount and directs the follicle cells left behind in
the ovary to produce lutein, a bright-yellow fluid high in progesterone. With lutein production, the follicle is renamed a corpus luteum (yellow body).
The basal body temperature of a woman drops slightly (by 0.5° to 1°F) just before the day of ovulation because of the extremely low level of progesterone
that is present at that time. It rises by 1°F on the day after ovulation because of the concentration of progesterone, which is thermogenic. The woman’s temperature
remains at this elevated level until approximately day 24 of the menstrual cycle, when the progesterone level again decreases (Huether & McCance, 2012).
Therefore, taking body temperature daily is one method of assessing if ovulation has occurred. If conception (fertilization by a spermatozoon) occurs as the ovum
proceeds down a fallopian tube and the fertilized ovum implants on the endometrium of the uterus, the corpus luteum remains throughout the major portion of the
pregnancy (to about 16 to 20 weeks).
If conception does not occur, the unfertilized ovum atrophies after 4 or 5 days, and the corpus luteum (now called a “false” corpus luteum) remains for only
8 to 10 days. As the corpus luteum regresses, it is gradually replaced by white fibrous tissue, and the resulting structure is termed a corpus albicans (white body).
Figure 5.12A summarizes the times when ovarian hormones are secreted at peak levels during a typical 28-day menstrual cycle to cause these changes.

The Uterus
1. The First Phase of the Menstrual Cycle (Proliferative)
Immediately after a menstrual flow (which occurs during the first 4 or 5 days of a cycle), the endometrium, or lining of the uterus, is very thin, approximately
one cell layer in depth. As the ovary begins to produce estrogen (in the follicular fluid, under the direction of the pituitary FSH), the endometrium begins to
proliferate so rapidly the thickness of the endometrium increases as much as eightfold from day 5 to day 14. This first half of a menstrual cycle is
interchangeably termed the proliferative, estrogenic, follicular, or postmenstrual phase
-day 1-5
-first day of bleeding is the first day of cycle
Stratum fucntionale is shed
Around 60 mL average

2. The Second Phase of the Menstrual Cycle (Secretory)

After ovulation, the formation of progesterone in the corpus luteum (under the direction of LH) causes the glands of the uterine endometrium to become
corkscrew or twisted in appearance and dilated with quantities of glycogen (an elementary sugar) and mucin (a protein). It takes on the appearance of rich,
spongy velvet. This second phase of the menstrual cycle is termed the progestational, luteal, premenstrual, or secretory phase
-day 15-28
-edometrium becomes thicker and glands secrete nutrients
-uterus is prepared for implantation
-If nor fertilization -> constriction of vessels -> menstruation
 3. The Third Phase of the Menstrual Cycle (Ischemic)
If fertilization does not occur, the corpus luteum in the ovary begins
to regress after 8 to 10 days, and therefore, the production of
progesterone decreases. With the withdrawal of progesterone, the
endometrium of the uterus begins to degenerate (at about day 24 or
day 25 of the cycle). The capillaries rupture, with minute
hemorrhages, and the endometrium sloughs off.

4. The Fourth Phase of the Menstrual Cycle (Menses)

Menses, or a menstrual flow, is composed of a mixture of blood from
the ruptured capillaries; mucin; fragments of endometrial tissue; and
the microscopic, atrophied, and unfertilized ovum.

 Menses is actually the end of an arbitrarily defined menstrual

cycle. Because it is the only external marker of the cycle,
however, the first day of menstrual flow is used to mark the
beginning day of a new menstrual cycle.
 Contrary to common belief, a menstrual flow contains only 30 to
80 ml of blood; if it seems to be more, it is because of the
accompanying mucus and endometrial shreds.
 The iron loss in a typical menstrual flow is approximately 11 mg.
This is enough loss that many adolescent women could benefit
from a daily iron supplement to prevent iron depletion during
their menstruating years.

Hormonal cycle
1. Menstrual phase
-decreased estrogen, decreased progesterone, decreased FSH and LH
2. Proliferative/pre-ovulatory phase
-increased FSH and estrogen in small amounts
3. Ovulatory phase
-increased FSH, surge LH, increased estrogen
4. Post ovulatory/luteal phase
-increased estrogen, increased progesterone, decreased FSH and LH
Signs of ovulation
1. Mittleschemerz: a certain degree of pain felt at the lower left or right
iliac
2. Cervical mucus method or billing method: changes in cervical
musuc secretions o clear, elastic and eatery
3. Spinnbarkeit test: test for elasticity of cervical mucus
4. Increase in basal body temperature
5. Mood changes
6. Breast changes and enlargement
7. Increased libido

QSEN Checkpoint Question 5.4 INFORMATICS

The nurse documents the fact that Suzanne Matthews typically has a menstrual cycle of 34 days. If she had coitus on days 8, 10, 15, and 20 of her last cycle, which is
the day on which she most likely conceived?

a. The 8th day

b. The 10th day
c. Day 15
d. Day 20

D. The nurse could help the patient calculate the ovulation date by teaching that ovulation usually occurs on the 14th day from the end of the menstrual cycle, or in this
instance, 14 from 34 or on the 20th day.

Functions of Estrogen
 Assist with the maturation of primary follicle
 Causes proliferation of the endometrium
 Responsible for the development of secondary sex characteristics (breast development)
 Inhibits FSH production
 Increase contractions of the myometrium
 Increase contraction of the fallopian tubes
 Increase quantity and ph of cervical mucus causing it to become thin and watery and be stretched to a distance of 10-13 cm
 Stimulates uterine contractions
Function of Progesterone
 Increase BBT
 Prepares the endometrium for implantation by increasing glycogen, arterial blood, secretory glands, amino acid and water
 Maintains pregnancy by inhibiting uterine contractions
 Inhibits the production of LH
 Increase endometrial tortuosity
Premenstrual syndrome
 Emotional and physical manifestation that occur cyclically before menstruation and regress thereafter
 Peak 30-40 y/o
 No specific hormone, treatment, markers
 Mood and behavioral changes inherent to menstrual cycle
Etiology and Risk Factor
1. Caffeine
2. Smoking
3. Lack of exercise
4. Improper diet
5. Inadequate sleep
6. Stress
*management : support

Menopause
-the permanent cessation of menstrual cycle that occurs between 45 and 55 y/0. Average 50
-point at which no functioning oocyte remain in the ovaries
Signs and Symptoms of Menopause:
 Hot flashes – sensation of heat that begin in the face to the chest and profuse respiration
 Loss of breast mass and firmness, atrophy of productive organs
 Dyspareunia (painful intercourse) due to decrease vaginal lubrication
 Osteoporosis – estrogen promotes calcium deposition in the body. A fall in estrogen level will liberate calcium from the bones making them brittle
Management:
1. Estrogen replacement therapy
2. Calcium 1g a day and vitamin d supplement
3. Liberal fluid intake to dilute urine as more calcium is liberated from the bones and could cause renal calculi
4. Weight bearing exercises
Management of hot flashes:
 Dress in layered look, remove outer clothing during attacks
 Avoid hot environment
 Avoid emotional stress
 Avoid food that could trigger hot flashes like spicy foods, coffee, tea, alcohol
 Use cooling technique like fans, showers, and ice cubes
Nursing Care
1. Encourage woman to engage in regular exercise program to maintain muscle tone
2. Emphasize adequate intake of calcium
3. Vitamin D for better calcium absorption
4. Instruct on proper use of water-soluble vaginal lubricant for painful intercourse
5. Instruct to avoid smoking and alcohol
6. Regular physical examination

Sexual Health
Sexuality is a multidimensional phenomenon that includes feelings, attitudes, and actions. It has both biologic and cultural diversity components. It encompasses
and gives direction to a person’s physical, emotional, social, and intellectual responses throughout life.
Sexuality has always been a part of human life, but only in the past few decades has it been studied scientifically. One common finding of researchers has
been that feelings and attitudes about sex vary widely across cultures and individuals. Although the sexual experience is unique to each individual, sexual
physiology (how the body responds to sexual arousal) has common features (Resetkova & Rogers, 2015).
THE SEXUAL RESPONSE CYCLE
1. Excitement Phase
 occurs with physical and psychological stimulation (sight, sound, emotion, or thought) that causes parasympathetic nerve stimulation
o This leads to arterial dilation and venous constriction in the genital area. The resulting increased blood supply leads to vasocongestion and
increasing muscular tension.
 In women, this vasocongestion causes the clitoris to increase in size and mucoid fluid to appear on vaginal walls for lubrication. The vagina widens in
diameter and increases in length. Breast nipples become erect.
o Vaginal lubrication occurs, arterial dilation and venous constriction in the genital area, overall muscle tension increases
 In men, penile erection occurs as well as scrotal thickening and elevation of the testes. CR, RR, BP increases
  In both sexes, there is an increase in heart and respiratory rate and blood pressure.
2. Plateau Phase
 reached just before orgasm.
 In the woman, the clitoris is drawn forward and retracts under the clitoral prepuce, the lower part of the vagina becomes extremely congested
(formation of the orgasmic platform), and there is increased breast nipple elevation.
 In men, vasocongestion leads to distention of the penis. Flushing occurs, breathing becomes deeper, CR, RR and BP increase markedly. Heart rate
increases to 100 to 175 beats/min and respiratory rate to about 40 breaths/min.
3. Orgasmic Phase
 occurs when stimulation proceeds through the plateau stage to a point at which a vigorous contraction of muscles in the pelvic area expels or dissipates
blood and fluid from the area of congestion.
 The average number of contractions for the woman is 8 to 15 contractions at intervals of 1 every 0.8 seconds.
 In men, muscle contractions surrounding the seminal vessels and prostate project semen into the proximal urethra. These contractions are followed
immediately by three to seven propulsive ejaculatory contractions, occurring at the same time interval as in the woman, which force semen from the
penis.
 As the shortest stage in the sexual response cycle, orgasm is usually experienced as intense pleasure affecting the whole body, not just the pelvic area. It
is also a highly personal experience: Descriptions of orgasms vary greatly from person to person.
 Strong muscular contractions both voluntary and involuntary in many parts of the body. RR, CR doubles and BP increasing as much as 1/3 above
normal
4. Resolution Pgase
 The resolution is a 30-minute period during which the external and internal genital organs return to an unaroused state.
 For the male, a refractory period occurs during which further orgasm is impossible.
 Women do not go through this refractory period, so it is possible for women who are interested and properly stimulated to have additional orgasms
immediately after the first.
MASTURBATION
Masturbation is self-stimulation for erotic pleasure; it can also be a mutually enjoyable activity for sexual partners. It offers sexual release, which may be
interpreted by the person as overall tension or anxiety relief. Masters et al. (1998) reported women may find masturbation to orgasm the most satisfying sexual
expression and use it more commonly than men.
SEXUALITY AND SEXUAL INDENTIRY
Terms:
1. Biologic gender – chromosomal sex; XX for female, XY for male
2. Gender identity/sexual identity – inner sense of being a male or female
3. Gender role – male or female behavior a person exhibits
Development of Gender Identity
 Infancy
 Preschool
 School-age
 Adolescent
Sexual Orientation
1. Heterosexuality – opposite sex
2. Homosexuality – same sex
3. Bisexuality – both sex
4. Transsexuality – person of one biologic gender, feel as if he/she should be of the opposite gender
Sexual Expression
1. Celibacy – abstinence from sex
2. Masturbation – self stimulation for erotic pleasure
3. Erotic stimulation – use of visual materials for sexual arousal
4. Fetishism – sexual arousal from objects or situation
5. Transvestism – dresses to take on the role of the opposite sex
6. Voyeurism - peeping tom
7. Sadomasochism – sadism: inflicting pain; masochism: receiving pain
8. Others: exhibitionism, pedophilia
SEXUAL HARASSMENT AND VIOLENCE
Sexual gratification can be experienced in a number of ways. What is considered normal varies greatly among cultures, although general components of accepted
sexual activity are that it is an activity of adults with privacy, consent, and lack of force included.
 Sexual violence or violence in general occurs when one partner does not respect these boundaries.
 Sexual harassment is unwanted, repeated sexual advances, remarks, or behavior toward another that is offensive to the recipient or interferes with job or
school performance.
o It can involve actions as obvious as a job superior demanding sexual favors from an employee, or it could be a man or woman sending sexist
jokes by e-mail to another person in the department. In school, it can refer to bullying
Two types exist:
1. Quid pro quo (an equal exchange)
-an employer asks for something in return for sexual favors, such as a hiring or promotion preference.
2. Hostile work environment
-an employer creates an environment in which an employee feels uncomfortable and exploited (such as being addressed as “honey” or “babe,” asked to wear
revealing clothing, or working where walls are decorated with sexist posters).
sexual harassment may be so distressing that it can lead to short- or long-term psychosocial consequences for victims and their families such as emotional distress
(e.g., anxiety, depression, posttraumatic stress disorder, substance abuse), interpersonal conflict, and impaired intimacy and sexual functioning

DISORDER OF SEXUAL FUNCTIONING

1. Sexual Desire Disorder
-lack of desire for sexual relation
-inhibit sexual desire
2. Sexual Arousal Disorder
-failure to achieve orgasm
3. Orgasm Disorder
 Erectile dysfunction/impotence
-causes: aging, atherosclerosis, diabetes
-management: sildenafil(Viagra), tadalafil (cliasis)
 Premature ejaculation
4. Pain Disorder
 vaginismus – involuntary contraction
 dyspareunia/vestibulitis