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Você está assistindo: Ciclo menstrual de 25 dias é normal

Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext . Sulista Dartmouth (MA): MDText.com, Inc.; 2000-.


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The normal Menstrual Cycle and the ao controle of Ovulation

Beverly G Reed, MD e Bruce R Carr, MD.

Author Information
Reproductive Endocrinology & Infertility Physician, IVFMD, 7501 Las colinas Blvd, Suite 200, Irving, texas 75039
Professor e Chairman, department of Obstetrics and Gynecology, university of texas Southwestern Medical center at Dallas, 5323 irmão Hines Blvd., J6-114, Dallas, texas 75390.

ABSTRACT

Menstruation is ns cyclic, orderly sloughing of a uterine lining, in solution to the interactions the hormones produced by the hypothalamus, pituitary, e ovaries. The menstrual cycle may be divided into dois phases: (1) follicular or proliferative phase, and (2) ns luteal or secretory phase. Ns length of naquela menstrual cycle is ns number of days between the first day of menstrual bleeding of one cycle to the onset of menses of a next cycle. A median expression of der menstrual bicycle is 28 days with most cycle lengths in between 25 come 30 dia (1-3. Patients quem experience menstrual cycles that occur at intervals less than 21 days ~ ~ termed polymenorrheic, when patients quem experience prolonged período cycles greater than 35 days, ~ ~ termed oligomenorrheic. Ns typical tonelada of blood perdido during menstruation is around 30 mL (4). Any kind of amount better than 80 mL is considered abnormal (4). The menstruação- cycle is commonly most irregular around the extremes of reproductive vida (menarche and menopause) as result of anovulation and inadequate follicular advance (5-7). Ns luteal step of a cycle is relatively consistent in tudo de women, with naquela duration the 14 days. Ns variability that cycle length is commonly derived from varying lengths of the follicular phase of a cycle, which have the right to range em ~ 10 to 16 days. Ao complete coverage of this and related topics, you re welcome visit www.endotext.org.


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Hormonal, Ovarian, endometrial, e basal body temperature changes and relations throughout the usualmente menstrual cycle.

(From Carr BR, Wilson JD. Disorders of a ovary and female reproductive tract. In: Braunwald E, Isselbacher KJ, Petersdorf RG, et al, eds. Harrison"s principles of internal Medicine. 11th ed. Novo York: McGraw-Hill, 1987: 1818-1837.


The follicular phase begins são de the primeiro day of menses until ovulation. Reduced temperatures on a basal corpo humano temperature chart, and more importantly, ns development that ovarian follicles, characterize this phase. Folliculogenesis starts during a last few days of a preceding fisiológico cycle until the release of ns mature follicle in ~ ovulation.

Declining steroid production by the corpus luteum and the dramatic outono of inhibin naquela allows for follicle stimulating hormone (FSH) to increase during the last few dia of the período cycle (Fig. 2) (8). One more influential coeficiente on the FSH level in the late luteal phase is associated to boost in GnRH pulsatile secretion second to naquela decline in both estradiol and progesterone level (9). This elevation in FSH allows para the recruitment of der cohort that ovarian follicles in every ovary, uma of which is destined to ovulate during ns next período cycle. Once menses ensues, FSH levels start to decrease due to a negative feedback the estrogen e the an adverse effects that inhibin b produced by ns developing follicle (Fig. 2) (8, 10-12). FSH activates the aromatase enzyme in granulosa cells, i m sorry converts androgens to estrogen. A decline in FSH levels leads to a production of der more androgenic microenvironment within surrounding follicles to ns growing dominant follicle. Also, ns granulosa cells of the growing follicle secrete a variety the peptides the may toque an autocrine/paracrine function in ns inhibition of breakthrough of ns adjacent follicles.


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Inhibin level transforms throughout the menstruação- cycle.

Inhibin b dominates ns follicular step of the cycle, if Inhibin der dominates ns luteal phase.


Development of a dominant follicle has been explained in 3 stages: (1) Recruitment, (2) Selection, and (3) dominance (Fig.3). The recruitment phase takes place during dia 1 v 4 the the menstruação- cycle. During this stage, FSH leads to recruitment of a cohort of follicles from the pool of non-proliferating follicles. Between cycle mim 5 and 7, selection of a follicle takes localização whereby only one follicle is selected são de the cohort that recruited follicles to ovulate, and the staying follicles will undergo atresia. Anti-Müllerian hormone (AMH), a product that granulosa cells, is believed to play der role in ns selection of a dominant follicle (13, 14). Through cycle job 8, 1 follicle exerts its supremacy by promoting its own growth e suppressing a maturation of a other ovarian follicles therefore becoming a dominant follicle.


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Time course for recruitment, selection, and ovulation of the dominant ovarian follicle (DF) with onset the atresia amongst other follicles of ns cohort (N-1).

(From Hodgen GD. The dominant ovarian follicle. Fertil Steril 1982; 38:281-300).


During ns follicular phase, serum estradiol levels rise in parallel to a growth of follicle size and also to the increasing variety of granulosa cells. FSH receptors exist specifically on a granulosa cabinet membranes. Increasing FSH levels throughout the atrasado luteal phase leader to rise in the number that FSH receptors and ultimately to an increase in estradiol cheap by granulosa cells. That is essential to keep in mind that the increase in FSH receptor numbers is early out to an increase in the population of granulosa cells and not early to an increase in a concentration the FSH receptors every granulosa cell. Each granulosa cabinet has approximately 1500 FSH receptors by a secondary phase of follicular development e FSH receptor number remains fairly constant for the remainder of breakthrough (15). Ns rise in estradiol secretion appears to increase the venenoso number the estradiol receptors on ns granulosa cells (16). In the presence of estradiol, FSH stimulates ns formation of LH receptors on granulosa cells allowing for the secretion of small quantities that progesterone and 17-hydroxyprogesterone (17-OHP) which may exert der positive feedback on a estrogen- primed pituitary come augment luteinizing hormone (LH) release (17). FSH also stimulates several steroidogenic enzymes including aromatase, and 3β-hydroxysteroid dehydrogenase (3β-HSD) (18, 19). In tabela 1, the production rates of sex steroids during ns follicular phase, luteal phase, e at ns time the ovulation are presented.


Table 1.


Production price of Sex Steroids in females at different Stages the the fisiológico Cycle


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DAILY manufacturing RATE
SEX STEROIDS*EarlyFollicularPreovulatoryMid-luteal
Progesterone (mg)1425
17α-Hydroxyprogesterone (mg)0.544
Dehydroepiandrosterone (mg)777
Androstenedione (mg)2.64.73.4
Testosterone (µg)144171126
Estrone (µg)50350250
Estradiol (µg)36380250

From Baird DT. Fraser IS. Blood production e ovarian secretion prices of esuadiol-17β e estrone in females throughout the menstruação- cycle. J Clin Endocrinol Metab 38: l009-1017. 1974.
the Endocrine Society.


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Values ~ ~ expressed in milligrams or micrograms per 24 hours.


In comparison to granulosa cells, LH receptors are located on theca cells during tudo stages the the período cycle. LH principally stimulates androstenedione production, and to der lesser level testosterone manufacturing in theca cells. In ns human, androstenedione is then transported to a granulosa cells whereby it is aromatized come estrone and finally converted to estradiol by 17-β-hydroxysteroid dehydrogenase type I. This is well-known as a two-cell, two-gonadotropin hypothesis of regulation the estrogen synthesis in the human ovary (Fig. 4).


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Two-cell, two-gonadotropin theory of regulation of estrogen synthesis in the human ovary.

Adapted by Carr, BR. Diseases of ns ovary and Reproductive Tract. In Wilson JD, Foster DW, Kronenberg HM, larsen PR, eds. Williams Textbook the Endocrinology 9th edition. WB Saunders, Philadelphia, p.751-817.


In a ovary, the primal follicles ser estar surrounded by a single class of granulosa cells e are arrested in a diplotene phase of the primeiro meiotic division. After ~ puberty, each primordial follicle enlarges e develops into naquela preantral follicle. A preantral follicle is now surrounded by number of layers that granulosa cells and by theca cells. A preantral follicle is the primeiro stage that FSH receptivity, as now the follicle has obtained FSH receptors. A preantral follicle then develops naquela cavity e is agora known together an antral follicle. Finally, that becomes der preovulatory follicle on its caminho towards ovulation. early out to a presence of 5α-reductase, preantral e early antral follicles produce much more androstenedione and testosterone in relationship to estrogens (20). 5α-reductase is the enzyme responsible for converting testosterone come dihydrotestosterone (DHT). E se testosterone has actually been 5α-reduced, DHT can not be aromatized. However, ns dominant follicle is able to secrete huge quantities that estrogen, generally estradiol, early out to high levels of CYP19 (aromatase). This shift from an androgenic come an estrogenic follicular microenvironment may toque an important function in choice of the dominant follicle são de those follicles the will come to be atretic.

As stated earlier, advance of a follicle to ns preantral phase is gonadotropin independent, e any follicular growth past this point will need gonadotropin interaction. Gonadotropin cheap is regulated by gonadotropin release hormone (GnRH), steroid hormones, e various peptides released by a dominant follicle. Also, as pointed out earlier, FSH is elevated during ns early follicular phase and then starts to decline until ovulation. In contrast, LH is low during a early follicular phase e begins to climb by a mid-follicular phase due to a positive feedback em ~ the rising estrogen levels. Para the hopeful feedback effect of LH release to occur, estradiol levels must be higher than 200 pg/mL para approximately 50 hours in expression (21). Gonadotropins estão normally secreted in der pulsatile moda from the anterior pituitary, e the frequency and amplitude of the pulses vary according to the phase the the período cycle (Table 2). During ns early follicular phase, LH secretion wake up at a pulse frequency the 60 come 90 minutes with relatively consistent pulse amplitude. Throughout the late follicular phase prior to ovulation, ns pulse frequency increases e the amplitude may start to increase. In most women, a LH pulse amplitude starts to rise after ovulation takes localização (22).


Mean (SEM) Luteinizing Hormone Secretory Burst characteristics During Phases that the menstruação- Cycle*


NUMBER (24 hr)PERODICITY (min)AMPLITUDE** (mlU/ml/min)HALF-DURATIONS (min)LH HALF-LIFE (min)TOTAL daily SECRETION (mlU/ml/24 hr)
Early follicular 175±1.4a80 ± 3a0.43 ± 0.02a6.5 ± 1.0a131 ± 13a49 ± 6a
Late follicular 26.9±1.6b53 ± 1b0.70 ± 0.03b3.5 ± 0.9b128 ± 12a56 ± 8a
Midluteal 10.1±1.0c177 ± 15#0.26 ± 0.02c#11.0 ± 1.1e103 ± 7a52 ± 4a
395 ± 37d#0.95 ± 0.05d#

Entries in every column figured out by a, b, c, d differ significantly (Duncan"s multiple-range test, p <.05). Periodicity is intersecretory explode interval. LH, Luteinizing hormone.**Duration of the deconvolution-resolved LH secretory burst at half-maximal amplitude.#Maximal price of LH cheap attained with a deconvolution-resolved LH secretory burst. Ns midluteal phase has been divided into small (less 보다 0.65 mIU/ml/min) e large (greater than 0.65 mIU/ml/min) secretory explode amplitudes.


Data em ~ Sollenberger MJ, Carlsen EC, Johnson ML, et al. Specific physiological regulation of LH secretory events throughout the human menstrual cycle. Novo insights into a pulsatile mode of gonadotropin release. J Neuroendocrinol 2:845, 1990.


There estão numerous substances uncovered in follicular fluid, such as steroids, pituitary hormones, plasma proteins, proteoglycans and non-steroidal ovarian factors, i m sorry regulate a microenvironment of a ovary e regulate steroidogenesis in granulosa cells. Growth determinants such as insulin-like growth fator 1 and 2 (IGF1, IGF2) and epidermal growth coeficiente (EGF) ser estar recognized as playing essential roles in oocyte development e maturation (23-25). A concentration of ovarian steroids is much greater in follicular liquid in compare to plasma concentrations. There ~ ~ 2 populations of antral follicles: (1) huge follicles, which estão greater than 8mm in diameter, e (2) little follicles, which are less than 8mm. In ns large follicles, a concentrations of FSH, estrogen, and progesterone ser estar high when prolactin concentration is low. In the small follicles, prolactin e androgen levels are higher compared to large antral follicles (26).


OVULATION

Ovulation occurs approximately 10-12 hrs after ns LH top (Fig. 5) (27). The LH ir para cima is initiated by der dramatic climb of estradiol produced by a preovulatory follicle (Fig. 6). To produce ns critical concentration of estradiol essential to initiate ns positive feedback, the dominant follicle is practically always >15mm in diameter ~ above ultrasound (28). A beginning of a LH ir para cima occurs about 34 to 36 hrs prior to ovulation e is naquela relatively an exact predictor porque o timing ovulation (Fig. 5) (29). Ns LH surge stimulates luteinization of ns granulosa cells e stimulates the synthesis of progesterone responsible para the midcycle FSH surge. Also, ns LH vir stimulates resumption the meiosis and the completion of reduction division in a oocyte with the release the the primeiro polar body. It has actually been prove in cultured granulosa cells that spontaneous luteinization can happen in a absence the LH. It is hypothesized that a inhibitory effects of factors such together oocyte mature inhibitor or luteinization inhibitor estão overcome in ~ ovulation (30).


The beginning of LH vir usually comes before ovulation by 36 hours. The peak, on a other hand preceded ovulation by 10-12 hours.


Changes in gonadotropins e ovarian steroids at midcycle, simply prior to ovulation. The initiation that LH vir is at time 0.

Abbreviations: E2, estrogen; P, progesterone (From Hoff JD, Quigley ME, Yen SCC. Hormonal dynamics at midcycle: naquela re-evaluation. J Clin Endocrinol Metab. 57:792, 1983.


Prostaglandins and proteolytic enzymes, such together collagenase and plasmin, ~ ~ increased in an answer to LH e progesterone. Although the precise device is no known, proteolytic enzymes e prostaglandins ser estar activated and digest collagen in ns follicular wall, bring about an explosive release of the oocyte-cumulus complex (31). Prostaglandin may also stimulate ovum relax by stimulation of smooth muscle within a ovary. Ns point of ns dominant follicle closest to the ovarian surface where this digestion wake up is called ns stigma. There is enquanto evidence to support a theory the follicular rupture occurs as a result of enhanced follicular pressure, although an accurate measurements precisely at rupture have not to be performed (32). In der recent report, laparoscopic image of human ovulation during an operative procedure foi ~ documented. The authors report visualizing naquela follicular area called a stigma which era protruding like a bleb a partir de the surface, include viscous yellow fluid evaginating into the peritoneal cavity (33). In humans, ovulation probably occurs randomly a partir de either ovary during any kind of given cycle. That interest, some studies have argued that ovulation occurs much more commonly são de the ideal ovary e right sided ovulation carries a higher potential ao pregnancy (34). A concentrations of prostaglandin E e F series and hydroxyeicosatetraenoic acid (HETE) reach der peak level in follicular fluid just before ovulation (35, 36). Prostaglandins may stimulate proteolytic enzyme while HETEs might stimulate angiogenesis e hyperemia (37). Patients cure with high dose prostaglandin synthetase inhibitors such as Indocin, can have a block in prostaglandin production and effectively block follicular rupture (38-40). This provides rise to what is well-known as ns luteinized, unruptured follicle syndrome and it gift in fertile e infertile patients same (41). Therefore, infertility patients ~ ~ advised to protect against taking prostaglandin synthetase inhibitors, as well as cyclo-oxygenase (COX) inhibitors, especially around ns time the ovulation (40). A schematic diagram illustrating the proposed mechanisms connected in follicular rupture is presented in figure 7.


Proposed mechanisms involved in follicular rupture.

From Tsafriri A, Chun S-Y. Ovulation. In: Adashi E, rock JA, Rosenwaks Z. Reproductive Endocrinology, Surgery and Technology. Philadelphia: Lippincott-Raven, 1996:236-249.


Estradiol levels outono dramatically immediately prior to a LH peak. This might be because of LH downregulation the its very own receptor or because of straight inhibition of estradiol synthetic by progesterone. Progesterone is likewise responsible para stimulating ns midcycle increase in FSH. Elevated FSH level at this time ~ ~ thought to free a oocyte from follicular attachments, stimulate plasminogen activator, and increase granulosa cabinet LH receptors. A mechanism causing the postovulatory fall in LH is unknown. The decline in LH might be due to ns loss of the positive feedback impact of estrogen, due to a increasing inhibitory feedback impact of progesterone, or early out to naquela depletion the LH contente of a pituitary são de downregulation of GnRH receptor (42).


LUTEAL PHASE

This phase is commonly 14 dia long in most women. After ovulation, a remaining granulosa cell that estão not released with the oocyte proceed to enlarge, come to be vacuolated in appearance, and begin come accumulate naquela yellow pigment referred to as lutein. A luteinized granulosa cells incorporate with ns newly created theca-lutein cells and surrounding stroma in a ovary to become what is known as a corpus luteum. The corpus luteum is a transient endocrine body organ that mostly secretes progesterone, and its primary role is to prepare a estrogen primed endometrium porque o implantation of a fertilized ovum. Ns basal lamina dissolves e capillaries attack into ns granulosa great of cells in an answer to secretion of angiogenic components by ns granulosa e thecal cells (43). Eight or nine mim after ovulation, about around a time of supposed implantation, optimal vascularization is achieved. Number 8 demonstrates a corpus luteum as watched on transvaginal ultrasound. Note a increased blood circulation seen surrounding ns corpus luteum as seen com Doppler evaluation. This time also corresponds to peak serum levels of progesterone e estradiol. The centro cavity of the corpus luteum may likewise accumulate with blood and become a hemorrhagic corpus luteum. The life span of ns corpus luteum depends upon ongoing LH support. Corpus luteum role declines through the fim of a luteal phase unless human chorionic gonadotropin is produced by naquela pregnancy. If pregnancy does no occur, ns corpus luteum undergoes luteolysis under a influence of estradiol and prostaglandins and forms der scar tissue called ns corpus albicans.


Corpus luteum as seen on transvaginal ultrasound. On ns right image, note ns Doppler flow indicating vaso sanguíneo flow surrounding the structure.


Estrogen levels rise and fall twice during the fisiológico cycle. Estrogen levels climb during a mid-follicular phase and then autumn precipitously after ~ ovulation. This is adhered to by der secondary increase in estrogen levels during the mid-luteal phase with der decrease in ~ the fim of the período cycle. The secondary rise in estradiol parallels the rise that serum progesterone e 17α-hydroxyprogesterone levels. Ovarian vein researches confirm that the corpus luteum is the terra of steroid production during the luteal phase (44).

The system by which the corpus luteum regulates steroid secretion is not fully understood. Regulation might be identified in component by LH secretory pattern and LH receptors or sport in ns levels of ns enzymes regulation steroid hormone production, such as 3β-HSD, CYP17, CYP19, or ao lado chain cleavage enzyme. The number the granulosa cells formed during a follicular phase e the amount of readily accessible LDL cholesterol may additionally play naquela role in steroid regulation by a corpus luteum. The luteal cell populace consists of in ~ least two cell types, a large e the little cells (45). Tiny cells estão thought to have actually been derived em ~ thecal cells while ns large cells from granulosa cells. Ns large cells are more energetic in steroidogenesis e are affected by miscellaneous autocrine/paracrine determinants such together inhibin, relaxin, and oxytocin (46, 47).

In researches looking into a mechanisms regulating the período cycle, LH era established as ns primary luteotropic agente in naquela cohort that hypophysectomized ladies (48). After ~ induction that ovulation, ns amount the progesterone secreted and the size of the luteal step is dependency on repeated LH injections. Administration of LH or HCG during ns luteal phase can extend corpus luteum function porque o an additional dois weeks (49).

The secretion of progesterone and estradiol during the luteal step is episodic, and correlates closely com pulses that LH cheap (Fig. 9) (50). The frequency and amplitude the LH secretion during the follicular step regulates subsequent luteal step function e is continuous with a regulatory role of LH during the luteal phase (51). Reduced levels of FSH during the follicular phase deserve to lead to der shortened luteal phase e the advance of der smaller body lutea (52). Also, the life span of the corpus luteum deserve to be lessened by constant LH management during ns follicular or luteal phase, diminished LH concentration, reduced LH pulse frequency, or lessened LH pulse amplitude (53-55). Ns role of other luteotropic determinants such together prolactin, oxytocin, inhibin e relaxin is quiet unclear (56, 57).


Episodic cheap of LH (top) e progesterone (bottom) during ns luteal phase of naquela woman.

Abbreviations: LH, luteinizing hormone: P, progesterone E2, estradiol; LH + 8, LH levante-se plus 8 days. (From Filicori M, butler JP, Crowley WF Jr. Neuroendocrine regulation of ns corpus luteum in a human. J Clin Invest. 73:1638 1984.


The body luteum role begins to decrease 9-11 dia after ovulation. Ns exact system of how the corpus luteum experience its death is unknown. Estrogen is thought to play der role in the luteolysis of a corpus luteum (58). Estradiol injected into ns ovary bearing a corpus luteum cause luteolysis while no effect is listed after estradiol injection of a contralateral ovary (56). However, ns absence the estrogen receptors in human luteal cells does not support ns role the endogenous estrogen in corpus luteum regression (59). Prostaglandin F2α shows up to it is in luteolytic in nonhuman primates e in research studies of women (60, 61). Prostaglandin F2α exerts its impacts via ns synthesis the endothelin-1, which inhibits steroidogenesis and stimulates ns release of a growth factor, tumor necrosis coeficiente alpha (TNFα), which induces cell apoptosis (62). Oxytocin e vasopressin exert their luteotropic effects pela an autocrine/paracrine system (63). Luteinizing hormone"s capacity to downregulate its own receptor may additionally play a role in termination of ns luteal phase. Finally, matrix metalloproteinases likewise appear come play der role in luteolysis (64).

Not tudo hormones undergo marked fluctuations during the normal menstrual cycle. Androgens, glucocorticoids, and pituitary hormones, not included LH and FSH, undergo só minimal fluctuation (65-68). Because of extra-adrenal 21-hyroxylation the progesterone, plasma levels of deoxycorticosterone are increased during a luteal phase (69, 70).


Endometrium

The results of differing concentrations the estrogen and progesterone throughout ns course the the menstrual cycle have actually characteristic impacts on a endometrium (Fig. 10) (71). The endometrial alters that happen can it is in visualized com sonography (Fig. 11). The characteristic endometrial changes likewise allow para histologic dating. Histologic dating is many accurately achieved by performing one endometrial biopsy 2-3 mim prior to expected menstruation. The proliferative step is more an overwhelming to date accurately in to compare to ns luteal phase. The glands during ns proliferative phase estão narrow, tubular, e some mitosis and pseudostratification is present. Ns endometrium thickness is usually between 0.5 and 5mm. In naquela classical 28-day menstrual cycle, ovulation wake up on day 14. On cycle job 16, the glands remover on a more pseudostratified appearance com glycogen accumulating at a basal section of the glandular epithelium and some nuclei ser estar displaced to a midportion of the cells. In der formalin addressed specimen, glycogen is solubilized resulting in a characteristic basal vacuolization at the base of a endometrial cells. This finding confirms a formation of der functional, progesterone producing, body luteum. In ns luteal phase, progesterone decreases ns biologic activity of estradiol on the endometrium by: (1) decreasing the concentration the estradiol receptors, (2) increasing a enzymatic task of 17β-hydroxysteroid dehydrogenase form II, the enzyme responsible for the conversion of estradiol come estrone, e (3) by increasing ns activity that estrone sulfotransferase (72, 73).


Dating of a Endometrium.

From Noyes RW, Hertig AW, rock J. Dating a endometrial biopsy. Férteis Steril 1950; 1:3.


On cycle day 17, the endometrial glands become an ext tortuous and dilated. Top top cycle day 18, a vacuoles in the epithelium diminish in size e are typically located following to a nuclei. Also, glycogen is agora found at the apex of the endometrial cells. By cycle work 19, a pseudostratification and vacuolation almost totally disappear e intraluminal secretions end up being present. On cycle work 21 or 22, the endometrial stroma starts to end up being edematous. Top top cycle work 23, stromal cell surrounding a spiral arterioles start to enlarge and stromal mitoses come to be apparent. On cycle job 24, predecidual cells show up around the spiral arterioles and stromal mitoses become an ext apparent. On cycle day 25, the predecidua begins to identify under the surface epithelium. Top top cycle work 27, over there is der marked lymphocytic infiltration e the top endometrial stroma appears as a solid sheet of well-developed decidua-like cells. On cycle work 28, menstruation begins.

In 2004, Chan et al., to be the o primeiro dia to confirm that stem cells were existing in human being endometrium (74). Subsequent pesquisar has affiliated characterization of ns different types of endometrial stem cells (75). Importantly, menstruação- fluid may be an easily easily accessible source ao certain varieties of endometrial stem cell (76). This may lead to advancements in ns treatment of numerous gynecologic disorders including endometriosis and Asherman syndrome and also non-gynecologic disorders such together neurologic and cardiac obstacle (75).


Cervix

The mucous secreting glands of the endocervix are affected by a changes in steroid hormone concentration. Automatically after menstruation, the cervicais mucous is scant and viscous. Throughout the late follicular phase, under ns influence of rising estradiol levels, the cervical mucous becomes clear, copious e elastic. A quantity of cervical mucous boosts 30 fold contrasted to the early follicular step (77). Ns stretchability or elasticity of the cervicais mucous deserve to be evaluated between dois glass slides and recorded as the spinnbarkeit. If check under the microscope, the cervicais mucous will display a characteristic ferning or palm-leaf arborization appearance. After ~ ovulation, as progesterone level rise, the cervical mucous once novamente becomes thick, viscous and opaque and the quantity created by the endocervical cells decreases.


Vagina

The alters in hormonal levels of estrogen and progesterone likewise have characteristic impacts on ns vaginal epithelium. During the early follicular phase, exfoliated vaginal epithelial cells have actually vesicular nuclei and are basophilic. During the tão tarde follicular phase, e the influence of ns rising estradiol level, a vaginal epithelial cells display screen pyknotic nuclei and are acidophilic (78). As progesterone rises during the luteal phase, the acidophilic cells decrease in number and are replaced by one increasing variety of leukocytes.


MENSTRUATION

In the absence of naquela pregnancy, steroid hormone levels begin to outono due to declining corpus luteum function. Progesterone withdrawal outcomes in raised coiling e constriction of a spiral arterioles. This eventually results in organization ischemia due to decreased blood flow to the superficialmente endometrial layers, the spongiosa e compacta. The endometrium releases prostaglandin that reason contractions of a uterine smooth muscle and sloughing of a degraded endometrial tissue. The release that prostaglandins might be due to decreased stability the lysosomal membrane in a endometrial cell (79). Infusions of prostaglandin F2α in women during the luteal phase has been displayed to induce endometrial necrosis e bleeding (80). Ns use of prostaglandin synthetase inhibitors decreases the amount of fisiológico bleeding e can be offered as therapy in women com excessive menstruação- bleeding or menorrhagia. Fisiológico fluid is created of desquamated endometrial tissue, vermelho blood cells, inflammation exudates, and proteolytic enzymes. Within two mim after the start of menstruation and while endometrial shedding is tho occurring, estrogen created by a growing follicles starts to stimulate a regeneration of the surface endometrial epithelium. The estrogen secreted by ns growing ovarian follicles, causes an extensive vasoconstriction enabling a formation of naquela clot over a denuded endometrial vessels (81). Also, the regeneration and remodeling of a uterine connective organization is regulated in component by ns matrix metalloproteinase (MMP) system (82).

The average duration of menstrual flow is between four to seis days, but the usualmente range in women have the right to be from as little as two dia up to eight days. As mentioned earlier, a average lot of menstruação- blood loss is 30 mL e greater 보다 80 mL is thought about abnormal <4>.


MENSTRUAL DISORDERS

Apart a partir de conditions the abnormal menstruation, particular disorders ser estar increased in ladies when compared to men. This conditions ~ ~ thought come be regarded hormone differences and hormone changes throughout the menstrual cycle. Enhanced autoimmune conditions, such together rheumatoid arthritis or systemic lupus erythematosus, estão believed to be concerned estrogen enhancement of humor immunity (83). Other researchers likewise describe higher vulnerability para drug abuse during phases that the menstruação- cycle once estradiol levels ser estar high (84).


SUMMARY

The size of naquela menstrual bicycle is ns number of mim between the primeiro day of menstrual bleeding of 1 cycle to a onset of menses of the next cycle. Ns median expression of naquela menstrual bike is 28 mim with most cycle lengths in between 25 to 30 days. The fisiológico cycle may be divided into two phases: (1) follicular or proliferative phase, e (2) ns luteal or secretory phase. A follicular step begins em ~ the o primeiro dia day the menses until ovulation. A development the ovarian follicles characterizes this phase. A LH ir para cima is initiated by der dramatic increase of estradiol developed by ns preovulatory follicle and results in succeeding ovulation. Ns LH surge stimulates luteinization of a granulosa cells e stimulates the synthesis of progesterone responsible para the midcycle FSH surge. Also, ns LH ir para cima stimulates resumption the meiosis e the completion of reduction division in ns oocyte with the release that the o primeiro dia polar body. Ns luteal step is 14 days long in most women. If a corpus luteum is no rescued by pregnancy, it will certainly undergo atresia. A resultant progesterone withdrawal results in menses. The average term of menstrual flow is in between four e six days, but the normal range in women deserve to be são de as tiny as two mim up come eight days. A average quantity of período blood is 30ml, e over 60 ml is taken into consideration abnormal.


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