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 of the endometrial lining of the uterus. 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 the regulation of cyclic changes and the menstrual cycle (Greenspan , 1998).

Menstruation Cycle

1) Clinical menstrual

Most mid-aged women of reproductive, 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 up to ovulation – the 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).

Long menstrual bleeding also varies; in general the length of 4 to 6 days, but between 2 to 8 days can still be considered normal. Menstrual blood expenditure consists of fragments endrometrium mixed with the blood of many is not necessarily. Usually liquid blood, but if the blood flow velocity is too large, clots of various sizes are likely to be found. normal menstrual blood is caused by a system of local fibrinolitik active in the endometrium.

The average amount of blood loss in normal women during the menstrual period has been determined by several research groups, ie 25-60 ml. Normal Hb concentration of 14 g per dl and hemoglobin iron content of 3.4 mg per g, this blood volume containing 12-29 mg of iron and describe the same blood loss with 0.4 to 1.0 mg of iron for every day of the cycle, or 150 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 a synchronization, then it is possible the arrangement, coordination, called hormones. Hormones are chemical substances produced by endocrine glands, which flow directly in the bloodstream and affect specific organs called target organs. The hormones associated with the menstrual cycle is;

a) The hormones produced by the pituitary gonadotropin:

o 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 the peripheral tissue through the alteration of steroid precursors others; consequently, plasma levels of these hormones may not directly reflect the steroidogenic activity of ovaries.

3) Phases of the menstrual cycle

Each one menstrual cycle, there are 4 phases of change that occurs in the uterus. These phases is the result of highly coordinated cooperation between the anterior pituitary, ovaries, and uterus. These phases are:

a) menstrual phase or deskuamasi

During this phase, the endometrium regardless of the uterine wall with bleeding and an intact layer only stratum basale. This phase lasted for 3-4 days.

b) post-menstrual phase or phases of regeneration

This phase, wound healing occurs due to the loss of the endometrium. This condition started since the phase of menstruation occurred and lasted for ± 4 days.

c) phase or phases of proliferation intermenstum

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

Proliferative phase is divided into 3 phases, namely:

o early proliferative phase, occurred on day 4 to day 7. This phase can be identified from the thin surface epithelium and the regeneration of the epithelium.

o Phase associate proliferation, occurred on day 8 to day 10. This is a form of phase transition and can be recognized from the shape of the surface epithelium of high piston.

o the late proliferation phase, lasting between 11 days until day 14. This phase can be recognized from the uneven surfaces and found the number of mitosis.

d) Premenstrual phase or phases of secretion

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

Secretion phase is divided into 2 stages, namely:

o early phase secretion, in this phase of the endometrium is thinner than the previous phase due to loss of fluid.

o Phase secretion further, at this phase in the endometrial glands to grow and become more winding and secretion began to sap that contains glycogen and fat. The end of this period, endometrial stroma changed towards the cells; decidua, particularly surrounding arterial vessels. This situation allows the nidasi (Hanafi, 1997).

4) Mechanism of the menstrual cycle

During the period, the day is taken as the beginning of the first day of the new cycle. Will happen again an increase of FSH levels to reach 5 ng / ml (or the equivalent of 10 MUI / ml), under the synergistic influence of both gonadotropins, these developing follicles to produce oestradiol in significant amounts. Increased serum constantly in the late phase folikuler will suppress the pituitary FSH. Two days before ovulation, estradiol levels reached 150-400 pg / ml. These levels exceed the threshold value for the expenditure stimulated pre-ovulatory gonadotropin. As a result of FSH and LH in serum will increase and reach a peak one day before ovulation. As the same, estradiol levels will come back down. The maximum LH levels ranged between 8 and 35 ng / ml or equivalent to 30-40 MUI / ml, and FSH between 4-10 ng / ml or equivalent to 15-45 MUI / ml.

Occurrence of peak LH and FSH on day 14, then at this time the follicle will begin to break and one day later ovulation will occur. Along with this began the formation and maturation of the corpus luteum is accompanied by increased levels of progesterone, and gonadotropins began to fall again. Increased progesterone does not always make sense, that ovulation has taken place with both, because in some women ovulation does not occur remains found basal body temperature and endometrium according to the luteal phase.

The 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 are not experiencing atresia, also appear in the luteal phase with a higher concentration than during the early or middle phase folikuler. Estradiol and progesterone production of maximal encountered between days 20 and 23 (Jacoeb, 1994).