Section II: Answer the Following Questions

1. List and explain the 3 phases of the .

● Okay so you have the first phase of the menstrual cycle which is the . This is from day 1-14. The goal of this phase is to mature an oocyte. The oocyte matures into a secondary follicle, then into a graafian follicle. This all starts with pulsatile release of the gonadotropin-releasing hormone(GnRH) from the hypothalamus. This will stimulate cells (gonadotrophs) in the anterior pituitary (AP). The AP in response will secrete two hormones, the luteinizing hormone (LH) and the follicle-stimulating hormone (FSH). Through a very wordy process involving different cells and transactions, we get estrogen. And Estrogen is what turns the oocyte into a secondary follicle and then into a graafian follicle. Estrogen also causes endometrial growth. The remnant of the graafian follicle is what forms the corpus luteum, which is what produces progesterone. ● takes place on the 14th day On the 14th day with a LH surge, the graafian follicle will rupture and the oocyte will leave in hopes to become fertilized. ● The third phase is from day 14-28. This is known as the .The corpus luteum will form and will begin to secrete progesterone, this starts the luteal phase. Luteal phase never changes, it’s always 14 days. It is called luteal phase because it is under direct control of the secretion of the corpus luteum(which means yellow body lol cool). Progesterone has major effects on the endometrium. It causes the generation of spiral arteries in the endometrium, and stabilizes endometrium by opposing the effects of estrogen. It also relaxes the myometrial muscles, allowing them to expand giving room for the fetus to grow. Usually, you will have the corpus luteum continue to secrete progesterone for 7-8 days after ovulation. If fertilization does not occur, then the corpus luteum will degenerate into the corpus albicans. ● Awesome source. ​ 2. What is the average length of the menstrual cycle?

● 28 days

3. What is the average length of the menstrual flow?

● 3-5 days. Anywhere from 1-7 is normal.

4. Approximately how much blood is lost during the menstrual flow?

● “The usual amount of blood loss per period is 10 to 35 ml. Each soaked normal-sized or pad holds a teaspoon (5ml) of blood. That means it is normal to soak one to seven normal-sized pads or (“sanitary products”) in a whole period.” - See more at: http://www.cemcor.ubc.ca/resources/very-heavy-menstrual-flow#sthash.543PlWg5.dpuf ● Lol whatttttttttttttt. Dude my flow is super heavy if that’s the case, that seems ridiculously nothinggg.

5. How does cervical mucous change during the menstrual cycle? Why does this occur?

● Why: Basically, estrogen is what is changing your CM. When your estrogen is low, you’ll be dry because there’s no reason for your body to welcome sperm in basically because you’re not ovulating. When you ovulate, estrogen dramatically increases, as does your CM. It becomes thin and stretchy to welcome in sperm and support fertilization by providing nourishment for the sperm on their transportation. That’s freaking cool. ● Cycle: ○ Immediately following there is usually a dry vaginal sensation and there is little or no cervical fluid. ○ After a few days of dryness, there is normally a cervical fluid that is best described as "sticky" or "pasty" but not wet. While this kind of cervical fluid is not conducive to sperm survival these days may be considered as "possibly fertile" if found before ovulation. ○ Following these "sticky" days, most women generally notice a cervical fluid that is best described as "creamy". This fluid may be white, yellow or beige in color and has the look and feel of lotion or cream. At this point the vagina may feel wet and this indicates possible increased fertility. ○ The most fertile cervical fluid now follows. This most fertile fluid looks and feels like raw egg white. It is slippery and may be stretched several inches between your fingers. It is usually clear and may be very watery. The vagina feels wet and lubricated. These days are considered most fertile. This is the fluid that is the most friendly and receptive to sperm. It looks a lot like semen and, like semen, can act as a transport for sperm. ○ After ovulation, fertile fluid dries up very quickly and the vagina remains more or less dry until the next cycle. Some women may notice small amounts of fertile-looking fluid after ovulation as the corpus luteum produces small amounts of estrogen, but you are not at all fertile after ovulation has been confirmed. ● Source

6. What is ? ● Dysmenorrhea refers to pain during menstrual flow.

7. How is dysmenorrhea diagnosed?

● Primary dysmenorrhea is menstrual pain in the absence of pelvic pathology. Abnormal uterine bleeding, dyspareunia, noncyclic pain, changes in intensity and duration of pain, and abnormal pelvic examination findings suggest underlying pathology (secondary dysmenorrhea) and require further investigation. Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected. Endometriosis is the most common cause of secondary dysmenorrhea.

8. When is it considered primary? Secondary?

● I answered this above, but dysmenorrhea is considered primary in the absence of underlying pathology. Onset is typically six to 12 months after , with peak prevalence occurring in the late teens or early twenties. Secondary dysmenorrhea results from specific pelvic pathology.

9. Define .

● Mittelschmerz is usually one-sided, lower belly pain associated with normal ovulation.

10. Define .

● Premenstrual syndrome (PMS) is a group of a wide variety of symptoms, including mood swings, tender breasts, food cravings, fatigue, irritability, and depression.

11. How is PMS diagnosed?

There are no laboratory tests or unique physical findings to verify the diagnosis of PMS. The three key features are: ● The woman's chief complaint is one or more of the emotional symptoms associated with PMS (most typically irritability, tension, or unhappiness). The woman does not have PMS if she only has physical symptoms, such as cramps or bloating. ● Symptoms appear predictably during the luteal (premenstrual) phase, reduce or disappear predictably shortly before or during menstruation, and remain absent during the follicular (preovulatory) phase. ● The symptoms must be severe enough to interfere with the woman's everyday life. 12. What moods are associated with peri-menstrual cycle?

● The symptoms of PMS are cyclic in nature, generally beginning from 7 to 14 days before menstruation and ending within 24 hours after menstruation has begun. ● Moods range from irritability, lethargy, and rapid mood swings to hostility, confusion, aggression, and depression.

13. What physical changes are associated with peri-menstrual cycle?

● Physical symptoms may include headache, cramps, backache, bloating, constipation or diarrhea, and a number of related disorders.

14. What are natural and therapeutic remedies to control and or lessen the symptoms associated with PMS and the peri-menstrual cycle?

● The major method of treatment for most cases of PMS involves some combination of regular physical exercise, avoidance of stress, nonsteroidal anti-inflammatory drugs (NSAIDs), and hormone therapy. Restriction of sodium intake, avoidance of ​ ​ xanthines—found in coffee, tea, chocolate, and cola—and eating foods high in protein and complex carbohydrates are a few of the dietary measures that can be taken to reduce much of the physical discomfort. ● 15. Why are yeast infections more common during the menstrual cycle?

● In the premenstrual stage, estrogen levels dip, causing a change in the pH of the vagina and knocking down some of the good beneficial acidophilus bacteria. Fortunately, estrogen levels resort to normal values right after your period, which may cause the yeast symptoms to retreat - until the next month when the cycle begins once again. If you notice a pattern with these hormonal yeast infections, a little bit of preventative work may help you to maintain a healthy vaginal pH.

16. What are normal variations to the physical and emotional cycle of menses?

● Anything that does not interfere with day to day activities would be considered normal variations of the physical and emotional cycle of menses.

17. What are abnormal variations to the physical and emotional cycle of menses?

● Anything that interferes with day to day activities would be considered abnormal variations to the physical and emotional cycle of menses.

18. What would be considered abnormal uterine bleeding during menses?

● Bleeding or spotting between periods ● Bleeding or spotting after sex ● Heavy bleeding during menses ● Menstrual cycles that are longer than 38 days or shorter than 24 days ● “Irregular” periods in which cycle length varies by more than 7-9 days ● Bleeding after

19. Define dysfunctional uterine bleeding.

● Dysfunctional uterine bleeding (DUB) is irregular uterine bleeding that occurs in the absence of recognizable pelvic pathology, general medical disease, or pregnancy. It reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining. The bleeding is unpredictable in many ways. It may be excessively heavy or light and may be prolonged, frequent, or random.

20. What is the normal pattern of the menstrual cycle?

● A menstrual cycle normally lasts from 21 to 35 days, although teens and women in their forties may have longer, irregular cycles up to 45 days. If you are nearing menopause, you can expect that the time between your periods will probably get longer and eventually stop. ● A normal period usually lasts about three to five days; anything longer than seven days is considered prolonged bleeding. 21. Define the following:

Anovulation- is when the ovaries do not release an oocyte during a menstrual ​ cycle. Therefore, ovulation does not take place

Polymenorrhea- Polymenorrhea is the medical term for cycles with intervals of 21 days or ​ fewer.

Metrorrhagia- Metrorrhagia (metro = womb, -rrhagia = excessive flow) is uterine bleeding at ​ irregular intervals, particularly between the expected menstrual periods.

Oligomenorrhea- is a condition in which you have infrequent menstrual ​ periods. It occurs in women of childbearing age. Some variation in menstruation is normal, but a woman who regularly goes more than 35 days without menstruating may be diagnosed with oligomenorrhea.

Menorrhagia: Menorrhagia is the medical term for menstrual periods with abnormally heavy or ​ prolonged bleeding. Although is a common concern among premenopausal women, most women don't experience blood loss severe enough to be defined as menorrhagia.

Intermenstrual bleeding- (IMB) refers to (other than ​ postcoital) at any time during the menstrual cycle other than during normal menstruation. It can sometimes be difficult to differentiate true IMB bleeding from metrorrhagia (irregularly frequent periods).

22. Define :Amenorrhea is the absence of menstruation — one or more missed ​ menstrual periods.

23. What would you need to rule out with abnormal menstrual bleeding in a woman of childbearing age.

● Ummmmmmmmmmmmmmmmmm postcoital bleeding? Um, I feel like there’s many things. There’s all kinds of bleeding disorders, ectopic pregnancy, or miscarriage, PCOS..I don’t know fully I’m sorry.

24. When should you refer a woman with abnormal menses?

● I think after trying herbal remedies and proper nutrition and not being successful, it is appropriate to refer a woman to a specialist. It’s important to see if she’s just having slight abnormalities than can be corrected, or if it’s a full on imbalance that would be out of your scope.

25. Define polycystic ovarian syndrome (PCOS). ● The conventional medical way of diagnosing the problem when a woman has evidence of one of three problems: 1) androgen excess (usually hirsutism or ); 2) “funny periods” like amenorrhea, oligomenorrhea or irregular cycles, past or present ovulation disturbances (anovulatory or short luteal phase cycles); 3) many ovarian cysts in larger-than-normal ovaries. PCOS, like AAE is associated with both infertility and risk for insulin resistance and Diabetes Mellitus Type 2.

26. What other disease factors are associated with PCOS?

● Other disease factors associated with PCOS include: insulin resistance, high blood sugar, obesity, high cholesterol, and high blood pressure. Metabolic syndrome increases the risk for diabetes and heart disease. About one in three women with PCOS also has metabolic syndrome.

27. List the symptoms of PCOS.

● Symptoms of PCOS include menstrual irregularity, excess hair growth, acne, and obesity. ● Menstrual: abnormal menstruation, absence of menstruation, heavy menstruation, ​ irregular menstruation, short and light menstruation, or spotting ● Weight: obesity, overweight, or weight gain ​ ● Skin: acne or oily skin ​ ● Also common: infertility, depression, inappropriate male features, loss of scalp hair, or ​ unwanted hair

28. How do hormones affect PCOS?

● Androgen, sometimes called "male hormone," although all women make small amounts of androgens. Androgen controls the development of male traits, such as male-pattern baldness. Women with PCOS have more androgen than estrogen. Estrogen - also called "female hormone." Higher than normal androgen levels in women can prevent the ovaries from releasing an egg during each menstrual cycle, and can cause extra hair growth and acne, two signs of PCOS. ● High levels of insulin. Insulin is a hormone that controls how the food you eat is changed into energy. Insulin resistance is when the body's cells do not respond normally to insulin. As a result, your insulin blood levels become higher than normal. Many women with PCOS have insulin resistance, especially those who are overweight or obese, have unhealthy eating habits, do not get enough physical activity, and have a family history of diabetes (usually type 2 diabetes). 29. How might you educate a woman with PCOS? What lifestyle factors must be considered?

● There is no cure for PCOS but it is something that can be managed. Type 2 diabetes and PCOS have been linked, so good nutrition and exercise are key to helping her manage PCOS and prevent insulin resistance. Good nutrition and exercise can help lower the risks of heart disease as well. It is said that women with PCOS suffer with depression, that’s something that can be addressed and we could provide good counseling resources if needed. Pregnancy is possible with PCOS; however, it is just a bit harder to attain. Losing weight can help your chances of getting pregnant. Facial hair is common with women and PCOS, so if she wanted, talking to her about facial hair removal methods and providing resources if needed. Hormonal birth control has been used to treat this, so maybe we can walk alongside her and help her find natural remedies, instead of jumping to hormones right away.