Menstrual Cycle (SONO 123 Week 1)

How many follicles will be released at mid cycle?

1 mature follicle

Each egg contains how many oocytes that have already entered the maturation cycle and is arrested in the prophase of the first maturation division?

1 oocyte

Indications for using IUCDs

1. Contraception 2. Treatment for endometrial hyperplasia 3. Hormone therapy replacement regimen 4. Treatment for excessive bleeding

Contraceptive barriers

1. Diaphragm 2. Cervical cap 3. Condoms 4. Hysterectomy 5. Elective abortion

3 types of IUCDs

1. Inert 2. Copper-bearing 3. Hormone-containing

Inert IUCDs

1. Plastic polyethylene - Lippes Loop - older women (not often used anymore) - Saf-T-Coild - Dalkon shield (problematic) 2. Stainless steel ring - widely used in China and not as effective as those used in US

Phases of the ovarian cycle?

1. Preovulatory (days 6-13) 2. Follicular (days 1-14) 3. Luteal (days 14-28)

bicornuate uterus

2 completely separate uterine cavities and 1 cervix

Follicles grow at the daily rate of

2-3 mm up to ovulation

Ovulation occurs how long after the onset of LH surge?

24-36 hours

How much blood is lost during menstrual cycle?

4 Tbsp - 1 cup (60-250 mL)

On the first day of each menstrual cycle, how many follicles begin to grow?

4-5

Approximately _____ of pregnancies abort on extraction of the IUCD

50% - always seen external to fetal sac

How many eggs do the ovaries contain and birth?

500,000

A postmenopausal patient not undergoing HRT should have their endometrium measure no more than ______

5mm

What's responsible for the maturation of the graffian/dominant follicle?

FSH

Under the influence of ____ there is a proliferation of the ______ cells of the follicle with the production of ______ and a mature ______

FSH granulosa estrogen follicle

FSH & LH are released when...

FSHRF & LHRF stimulate the pituitary gland

T/F Formation of eggs can occur after birth

False

Under the influence of ______ release, the FSHRF & LHRF are released by hypothalamus

GnRH

Gonadotropin releasing hormones are produced where?

Hypothalamus

At mid cycle, there is a surge of ____, which is produced throughout the ovarian cycle by the pituitary gland

LH

What is responsible for inducing ovulation?

LH

Hormone containing IUCDs

Mirena (most likely) and Progestasert - lasts for 5 years - highly echogenic - enlarged follicles ---> 12% of women using mirean - also treats hyperplasia, menorrhagia, and hormone replacement therapy

Post-coital hormonal contraception (PCC)

Morning-After pill - administered 72 hours after unprotected sex and stops the embryo from attaching to the uterine wall

Most commonly Copper-bearing IUCDs seen

Paraguard (T-shaped, effective for 10 years) Copper-7

T/F The corpus luteum secretes both estrogen and progesterone

True

How to measure a uterine congenital anomaly?

WFC: W - measurement of uterine width F - fundal distortion C - length of unaffected uterine cavity

Menometrorrhagia

a condition in which prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal

The oocyte is surrounded by

a single layer of granulosa cells

Secondary Amenorrhea

a woman who has previously menstruated misses 3 or more periods in a row

Menorrhagia/Hypermenorrhea

abnormally heavy and prolonged menstrual period at regular intervals

Hypomenorrhea

abnormally small or scanty blood flow

unicornuate uterus

agenesis or hypoplasia of 1 of the Mullerian ducts

Primary Amenorrhea

an adolescent female that has not yet begun menstruation by 16 y.o.

FSH is produced by _____ pituitary gland

anterior

If perforation of an IUCD occurs, when would it?

at time of IUCD insertion

When is the follicular phase?

begins first day of menses and continues until the follicle matures and ovulation occurs

Hematocolpos

blood filled dilated vagina but without any accompanying blood (menstrual) within uterine cavity

Hematometrocolpos

blood filled distended uterus and vagina

What does LH do?

brings the follicle to maturity, eventually causing it to rupture and release the ovum

After ovulation, the wall of the follicle becomes convoluted and fills with blood and lymph to form

corpus hemorrhagicum

Progesterone is secreted by

corpus luteum

When is menses? What happens during menses?

days 1-5 endometrium is shed

When and what is the early secretory stage?

days 15-20 - ruptured follicle fills with luteum - corpus luteum secretes progesterone and estrogen - endometrium becomes thicker - if fertilization occurs, it occurs 24-36 hours after ovulation

When does the secretory phase occur?

days 15-28

When and what is the mid secretory cycle?

days 22-25 - increased estrogen and progesterone levels - endometrium lining thickens - max thickness seen for endometrium

When and what is the late secretory cycle?

days 26-28 - no fertilization = progesterone and estrogen levels decrease - menses begins - endometrium sheds - if pregnancy occurs, endometrium is supported by progesterone produced by corpus luteum

The most well known drug to cause a congenital anomaly is

diethylstibestrol

Hydrometra

distended uterus filled with clear non-infected fluid

didelphys uterus

double uterus, double cervix, double vagina

If fertilized, hCG levels are

doubled every 48 hours until 8-10 weeks gestation

Sizes of endometrium at different phases/stages

early pro phase: 2mm early sec phase: 6-8mm mid sec phase: 10-12mm late sec phase: 8-12mm

What generally regulates the hypothalamus and pituitary activity?

estrogen

hCG maintains

estrogen and progesterone activity of the corpus luteum

What determines the cyclic pattern of the FSH and LH in the normal menstrual cycle by providing a negative feedback mechanism?

estrogen production

Hydrocolpos

expanded fluid filled vaginal cavity associated with distention of uterine cavity

Hydrometrocolpos

expanded fluid filled vaginal cavity with associated distention of the uterine cavity

What happens at the onset of menopause?

follicular maturation and ovulation become less frequent and eventually stops completely

Proliferative phase corresponds to

follicular phase of the ovarian cycle

Can ovulation be seen on US?

has been detected in 90% of cases

Progesterone

hormone mostly responsible for premenstrual symptoms and symptoms of early pregnancy

Increasingly postmenopausal women are being treated with..

hormone replacement therapy to relieve postmenopausal vasomotor symptoms and to prevent: - urogenital atrophy - osteoporosis - cardiovascular disease

Polymenorrhea

increased frequency of periods with less than 21 days between each

When happens with the negative feedback?

increasing estrogen production effects a decline in FSH, which helps induce atresia in all but 1 of the maturing follicles

Pyometra

infection of the endometrial cavity with resulting expansion due to accumulated pus

Diethylstilbestrol (DES)

known to create a T-shaped uterus if a female fetus is exposed to it during utero

When does the endometrium demonstrate a triple-layer appearance?

late proliferative phase

What triggers the secretion of FSHRF & LHRF?

low estrogen levels during the first few days of the menstrual cycle

What phase is the corpus luteum formed?

luteal phase

Secretory phase correlates to

luteal phase of ovarian cycle

What happens during days 12-13?

mature follicle develops and thin homogeneous endometrium is seen

The maturation of follicles falls under

neuroendocrine control

The ovary functions in the periodic release of...

oocytes, which is associated with release of estrogen and progesterone

What phase does ovulation occur?

ovulatory phase @ end of proliferative phase

The uterus originates from

paired Mullerian ducts

hCG is eventually produced by

placental tissue (trophoblasts)

hCG in a fertilized ovum prevents

regression of the corpus luteum

Ovulation

release of an egg (ova) from the ruptured mature follicle

septate uterus

result of absent or incomplete resorption of the intervening uterovaginal septum following fusion of the Mullerian ducts

Corpus luteum

ruptured follicle begins to fill with luteum

vaginal atresia

segmental Mullerian agenesis or incomplete vaginal canalization

What's the most common congenital uterine anomaly?

septate uteri

Most common form of hormone replacement therapy in the US

sequential estrogen and progesterone - premarin - 1st 1/2 of month - provera - 2nd 1/2 of month

What does FSH do?

stimulates the growth of the follicles

Amenorrhea

the absence of menstrual flow in a woman of reproductive age

FSHRF & LHRF both are released into...

the blood to reach the pituitary gland

A premenopausal women ~ day 14 will display

the classic periovulatory tri-laminar appearance

If fertilization and implantation occur, what happens?

the corpus luteum continues to secrete progesterone and estrogen for 3 months until placenta takes over

What happens with the activation of the hypothalamic-pituitary-ovarian endocrine functions?

the cyclic pattern continues throughout the reproductive lifetime of a female only being interrupted with pregnancy

What is the menstrual cycle dependent upon?

the cyclic release of estrogen and progesterone that's produced in ovaries

Estrogen is secreted by

the follicles

The menstrual cycle is regulated by...

the hypothalamus

The cyclic changes of the uterus throughout the menstrual cycle correlate with

the interactions of hormones from the ovaries and the pituitary gland

Arcuate uterus

the near-complete resorption of the uterovaginal septum

Puberty is noted by

the onset of the release of gonadotropin releasing hormone from the hypothalamus

FSHRF & LHRF both trigger...

the pituitary gland to produce hormones

What helps support the pregnancy?

the progesterone being secreted by the corpus luteum

The increase of circulating estrogen triggers..

the release of LH

The endometrium thickens during

the secretory phase in anticipation of fertilization and implantation of the ovum

What happens during the follicular phase?

under the influence of FSH, a variable # of follicles undergo further development with the initiation of estrogen production by the granulosa cells

How does the endometrium look sonographically in the late secretory phase?

uniformly echogenic thickens to 7-14mm

Hematometra

uterus fills with menstrual blood

How do Copper-bearing IUCDs work?

via a local increase in copper levels which leads to decreased sperm mobility and endometrial irritation

When does ovulation occur?

~ day 14

When does 1 follicle typically become dominant?

~ day 9

What happens when the follicle ruptures with the presumed release of the ovum?

- Sudden decrease in follicle size - Escape of fluid into posterior cul de sac

Oral contraception

- contains estrogen and progesterone used to inhibit ovulation - creates changes to the endometrial lining and cervical mucus

Sonographic findings for normal uterus

- contour of fundus is straight or convexed - external contour of the uterus is convex or straight with an indentation < 10mm

If fertilization does not occur, what degenerates?

- corpus luteum - now call albican and stops producing progesterone

When and what is the early proliferative stage?

- days 6-7 - end of menses and beginning of ova development - estrogen begins to increase *when endometrium is at its thinnest*

Oligomenorrhea

- decreased frequency of periods with more than 35 days between periods - only 4-9 periods in a year

Mittleschmertz

- describes mid-cycle pain associated with pelvic inflammation at time of ovulation - caused by changes in estrogen levels

What happens to the granulosa cells in the luteal phase?

- enlarge - accumulate lipid & yellow pigment called luteum

The hypothalamus produces...

- follicle stimulating hormone releasing factor (FSHRF) - lutenizing hormone releasing factor (LHRF)

Functional ovarian cysts

- follicular - corpus albican - corpus lutein of pregnancy - theca-lutein

A properly placed IUCD should be seen where?

- in endometrium - high in fundus of uterus

Risks associated with IUCDs

- increased chance of ectopic pregnancy developing - PID - perforation of the IUCD - lost IUCD

Depot-medroxyprogesterone Acetate (DMPA)

- injected every 3 months - used to inhibit ovulation - creates changes in the cervical mucus

Fibroids

- lobulations of the myometrial tissue in the uterus - overgrowth of uterine smooth muscle that forms a benign tumor

When the luteinization of the granulosa cells is induced, it initiates...

- progesterone production - rupture of the follicle - expulsion of the egg - subsequent formation of a corpus luteum with continued progesterone production

When and what is the late proliferative stage?

- surge in LH, which causes ovulation - endometrium grows and becomes thicker - endometrium considered to be periovulatory

Dalkon Shield IUCD

- taken off market many years ago - associated with PIDs - appears as echogenic foci with shadowing SAG and TRV

uterine aplasia

- the arrested development of the Mullerian ducts - uterus doesn't fuly develop, instead 2 tubes are present

The surge of LH causes

- the follicle to rupture and release the ovum - ovaries produce estrogen and progesterone which helps the maturation of the endometrium

Levonorgesterel Implants

- thin capsules inserted under skin of upper arm - inhibits ovulation for ~ 5 years - thickens cervical mucus

Lippes Loop

- trademark serpentine shape - appears as 2-5 echogeinc dots with shadowing in SAG and 1 line in TRV - composed of polyethylene material