Tabakman M.B. The Current State of Medico-Legal Examination of Menstrual Blood in Stains
The Department of Forensic Medicine (Head - Prof. V. M. Smolyaninov) II Moscow Medical Institute named after N.I. Pirogov
The current state of the forensic study of menstrual blood stains / Tabakman MB // Forensic-medical examination. - 1962. - №3. - pp. 55-58.
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Along with the determination of the presence, species and group affiliation of blood in a spot, an expert is often asked about the regional origin of blood. Expert practice shows that the establishment of menstrual blood stains is most often required. To resolve this issue, as well as for the diagnosis of nasal, pulmonary, gastric and other bleeding, forensic doctors have so far used the detection of impurities of various morphological elements in blood stains.
The difference between menstrual blood and “normal” (arterial, venous, or arterio-venous) was also long assumed only in its morphological composition. This refers to the period of a narrowly-localist understanding of menstrual function as a result of the activity of one organ, the uterus. Researchers [Baltazar, Döber, Gaussser, Gaist (Balchazard, Derobert, Hausser, Geist) and others] sought to find in the stains of menstrual blood and directly in her endometrial cells. This, of course, proves the menstrual origin of blood, but this kind of cells can be found in spots very rarely.
Subsequent recommendations included finding and clarifying the diagnostic value of finding a vaginal epithelium in the blood spot. However, it was found that the presence of these cells in the stain is not specific to menstrual blood, as they may be contained in vaginal secretions, with vaginal bleeding, etc. Morphologically, the epithelium of the vagina is almost the same as the epithelium of the skin, urethra, and any other squamous epithelium. The presence of glycogen in the cells of the vaginal epithelium was considered characteristic, but this again did not lead to an expert solution of the problem [V.K. Danelyants-Kocharova, Wigemann, Dierenfurt, Merkel (Wiegeman, Dyrenfuhrt. Merckel), etc.].
According to Smis (Smis), menstrual blood is characterized by a large number of bacteria - numerous cocci and bacilli, but they can be observed constantly in the study of rotting blood stains or in a number of diseases.
A.V. Khokhlov discovered a reduced red blood cell count in menstrual blood, Zondek (Zondek) and Stickel (Stickel) - an increase in the number of lymphocytes and a decrease in the number of neutrophils.
A number of authors [Tsondek, Richter, Zimske (Richter, Ziemke), and others] noted that there are no fibrin filaments in the menstrual blood. In the forensic medicine practice and in the spots of “normal” blood, which pervades the layers of tissue tissue, fibrin filaments are also not detected.
Merkel, Gajst, and other forensic doctors tried to use a combination of various of the above symptoms to diagnose menstrual blood in the spot. However, since different morphological elements change during drying of blood and subsequent processing for research, this way did not give practical results.
One of the latest cytological studies of menstrual blood is the work of Vaneva. The author describes the special cells found in menstrual blood and called menocytes. These data need further verification and research in order to find the menocytes in blood stains.
Forensic medical methods of proving the presence of menstrual blood stains were further proposed and improved in accordance with the development of physiology, gynecology and biochemistry.
Numerous studies are devoted to the toxicity of menstrual blood. Even in antiquity, its toxic properties were noted (Hippocrates, Avicenna). In 1920, Schick explained this by the presence of a special substance in the menstrual blood - “mentoxin”. Other authors explain the toxicity of a large amount of arsenic or choline, available in the menstrual blood [B.Ya. Sigal, M. Frank, Klaus, Macht, O. Smith, S. Smith (M. Frank, Klaus, Macht, O. Smith, S. Smith) and others]. A negative result in determining the toxicity of menstrual blood was obtained by PV Serebryannikov and Wiener (Wiener), who tried to apply this method to diagnose menstrual blood in forensic practice.
A distinctive feature of menstrual blood was searched for in its weak clotting. This was written by A.V. Khokhlov, N.S. Zvonitsky, Tsondek, Shtikel and others. Opinions about the reason for her liquid state were very different. For example, Burdach explained this with a large amount of carbon dioxide contained in menstrual blood and built a theory of menstruation based on the removal of excess carbon dioxide from the tissues. Horwitz (Horwitz) attached crucial importance to vaginal secretion, considering that it dissolves the convolutions of menstrual blood.
At the end of the XIX century S.S. Zhikharev and D.O. Ott found that the menstrual cycle is not a local process, but depends on the activity of the endocrine glands, in particular the ovaries. The next step in the understanding of menstrual function was the recognition of the participation of its three organs - the pituitary, ovaries and uterus.
This period includes the work of Frankl (Frankl), Halban (Halban) and Ashner (Aschner), explaining the liquid state of menstrual blood by the presence of a tryptic enzyme in it. Dienst found a large amount of antithrombin in it, and Schickele proved that antithrombin is septicified from the ovaries and accumulates in the premenstrual phase in the endometrium.
Zack (Sack), Gulardino (Gulardino), R. Frank (R. Frank) established the presence of various hormones in the menstrual blood, however, due to their instability in the stain, this fact has not found application in forensic practice.
Berg, Gulliford (Berg, Gulliford) for the purpose of forensic medical identification of menstrual blood in the spot proposed to determine its fibrinolytic activity by various methods and obtained positive results that need further refinement.
For the same purpose, Kamijo determined the presence of denatured protein, considering that its presence is characteristic of menstrual blood in the spot.
In all textbooks and manuals on forensic medicine, among the authors of which N.S. Bokariusa (1910), N.V. Popova (1938), Rhodes, Gordon and Turner (Rhodes, Gordon, Turner, 1945), Simonin (Simonin, 1947), Walcher (Walcher, 1950), Detling, Schönberg and Schwarz (Dettling, Schonberg, Schwarz, 1951), M .AND. Paradise (1953), M.I. Avdeeva (1959), V.M. Smolyaninova, K.I. Tatieva and V.F. Chervakova (1961), states that the only evidence that menstrual blood is found in the spot is endometrial cells. But, as we said above, they can only be found in isolated cases. “In the overwhelming majority of cases, forensic experts are unable to give any satisfactory answer to the judicial-investigative bodies” (MA Bronnikova).
To evaluate critically the possibilities of forensic research of menstrual blood in the spot, one must be familiar with modern views on the physiology of menstrual function and the biochemical composition of menstrual blood.
The menstrual cycle is a rhythmic change in a woman’s body. “Menstruation is not only a function of the uterus and its mucous membrane, not only a consequence of the influence of sex hormones on the functional activity of the genital organs, but also a complex process involving the central and peripheral nervous system, many endocrine glands” (EI Quater). In the light of this provision, the physical and biochemical properties of menstrual blood, which distinguish it from "normal", become clear.
The biochemical composition and properties of menstrual blood, according to modern data (VS Asatiani, Bussing, Beller, Graff, AI Pomaskina, H. F. Tolkachevskaya, and others), are as follows.
Physical properties. Menstrual blood has a brown color due to hemolysis occurring in it. The characteristic smell is given by numerous bacteria, including putrefactive ones. Its pH is 7.0, the water content is 88% (in venous blood 80%), viscosity - 2.4 (venous blood 1.8).
Organic properties. Menstrual blood contains significantly more than “normal” amino acids, glycogen, residual nitrogen, lactic acid and less protein, urea, fatty acids, cholesterol, hemoglobin (Table 1).
The greatest difference in the content of enzymes and hormones is the presence of fibrinolysin (plasmin) in menstrual blood (it is absent in “normal” blood), an increased amount of estrogen (in mental blood 80 γ%, in normal blood - 25 γ%), dehydrogenase, 17-ketosteroids, amylases and in a smaller amount - lipases.
Is it worth to sound the alarm if the monthly bright scarlet?
The color of the menstrual blood is an indicator of a woman’s health and the normal course of the cycle, so you need to know what color your menstruation should be. The statistical norm is dark, red-brown or burgundy color of blood, small blotches of mucus and clots - particles of dead uterine mucosa are possible. In the beginning, periods of a healthy woman may well be lighter in color: scarlet or red. Blood color is caused by its iron content, so in the first 1-2 days, when the process has just begun and fresh blood comes out, menstruation can be scarlet and not as thick as in the last days, when the blood and the rejected endometrial particles have already oxidized and collapsed. .
However, the process of oxidation and darkening of the blood is obligatory, and if the monthly go for 4–5 days, but their color does not change in the direction of brown, you should listen to your body. Scarlet secretions over several days or weeks may not be monthly, but uterine bleeding. Bleeding requires immediate medical attention, accurate diagnosis and treatment of hemostatic agents, along with treatment of their cause.
Dark menstrual blood is characteristic of the overwhelming majority of women, but the variants of the norm are both red monthly, and scarlet, and even pinkish, because often the color of blood depends on its chemical composition, which can differ even in one woman at different periods of her life and change over of the year. For those whose cycle is already established and stable, it will be easy to notice a change in the color of the discharge. If normally you always have lighter blood than almost black venous blood, it means that pink or orange blood will be a warning signal to you, or, on the contrary, it will be too dark discharge from the very first day. In this case, it should not be the blood of the scarlet color that is concerned, but the unusual color or consistency of the menses. A new shade of blood in combination with the scarcity of discharge or painful sensations is especially dangerous for you; if you note this set of symptoms, you should immediately go to an appointment with a gynecologist.
How to distinguish bleeding from menstruation?
- First appreciate the color, consistency and odor of discharge. their duration. Menstrual blood has a rather peculiar odor, whereas when bleeding there is almost odorless blood, more liquid, flowing, without mucus and pieces of the endometrium. On the other hand, an excessive amount of small clots also indicates problems.
- Intensity of discharge with monthly on average 20–50 ml per day, maximum 60 ml. Monthly out in portions, most often you can see the inclusion of solid tissue and clots. If the scarlet blood of yours goes continuously, in a steady stream, the richness of which is much higher than your usual monthly periods - see a doctor immediately! Even after 1 hour of bleeding a woman can lose a large volume of blood, fainting and weakness will occur. Soaking a tampon or pads in an hour or two should alert you.
- Cycle failure. Menstruation started a week earlier or later than you expected? Yes, and the blood is scarlet, the discharge is unusually scanty or too abundant. Probably, this is not a menstrual one at all, but a hormonal failure or even an ectopic pregnancy. You need to immediately undergo an ultrasound and visit a doctor. The same applies to the duration of the cycle, if the blood flow went up to 3 or more than 7 days, you have a reason to visit the doctor.
- Weakness, fatigue, pale skin of the face and hands, chills. You are not able to do your usual activities and lead your standard lifestyle, you instantly get tired and want to sleep, sleep and headache, coordination of movements is disturbed. All these symptoms speak of blood loss and the need for immediate medical attention.
Even minimal suspicion of bleeding that is not related to the natural menstrual cycle is a good reason for an urgent visit to the doctor!
When should you worry about bright scarlet menstruation?
There are a few more reasons why your monthly scarlet. Such discharge is possible in young girls in the period of formation of the menstrual cycle. Another age group for which such a feature is characteristic is women who will soon have menopause or the process of menopause has already begun. In both cases, the color of menstruation is affected by dramatic changes in hormonal levels. Most often, bright discharge is not the only difference from the usual course of menstruation, also varies the period of discharge, their intensity and nature. For women of reproductive age, such symptoms are unusual, and often signal problems in the field of gynecology.
More disturbing causes of light red or scarlet blood may be a decrease in the level of hemoglobin in the blood or other problems of the hematopoietic system. If you notice such a symptom for several months, it is necessary to pass a general blood test and seek advice not only to the gynecologist, but also to other specialists.
Crimson menstruation can be the result of various gynecological diseases or dysfunction of the reproductive system. Hypomenorrhea, the effects of chronic infections and inflammatory processes in the pelvic organs, ovulatory and anovulatory bleeding, the first signs of cancer, ectopic pregnancy - all this can affect the color of the blood. And in each of these cases, self-diagnosis and self-treatment are strictly contraindicated, and it is imperative and immediate to be examined and treated.
Characteristics of the normal menstrual cycle
Normal monthly - a topic relevant to every woman of reproductive age. The frequency of menstruation, the duration, the color of secretions are related to the state of the female body and indicate the absence or presence of pathologies. How many days are menstruation going on and how to count the cycle correctly? What are the implications of the cycle, and what symptoms speak of malfunctions in the body? Knowing the answers to these questions, it is easier to understand whether there are problems with women's health.
Knowing about the normal course of the monthly cycle, it is easier to notice problems with it.
The menstrual cycle - the monthly changes in the female body, repeated with a certain frequency and manifested bloody discharge.
Monthly discharge begins at adolescence, at the stage of puberty of girls, and ends with menopause. The menopausal age of 45-55 years is the norm in gynecology.
The cycle duration is taken into account from the first day of menstruation to the first day of the next menstruation. The result of calculations for each woman is individual, depending on the physiological characteristics of her body.
How much is the monthly cycle ideally? 28 days. But there are women whose duration varies from 21 to 35 days.
How much should monthly go? Normally - from 3 to 7 days. The process is accompanied by weakness, heaviness in the mammary glands, pain in the lower abdomen. If the duration of critical days is longer or shorter, it is recommended to consult a gynecologist. Deviations from the norm can be a symptom of inflammation or hormonal imbalance in the body.
The average menstrual cycle is 28 days
First menstrual cycle
In the language of medicine, it is called "menarche." Usually menstruation in girls begins by the age of 12, but may appear at another age - a period of 10-15 years will be the norm.
The cycle does not stabilize immediately: some people need 2-4 months to do this, some girls have a year to go by until it gets better. It’s difficult to talk about the periodicity of menstruation until the cycle stabilizes, because some girls may not have them at all.
How much the first menstruation lasts, not all teenagers know. Usually it lasts 3-5 days, it is characterized by scant brown discharge or a few blood drops. This is due to hormonal changes in the adolescent body and should not bother girls and parents.
The menstrual cycle is stabilized by the age of 14 - from now on, girls are advised to control its frequency. If the monthly go 1-2 days or more than a week, consult a doctor.
How much time should elapse after giving birth or “cesarean section” for women to recover their periods? The average period is 6 months, subject to breastfeeding.If the child is an artificialist, then the body recovers faster - the first menstruation can begin as early as 2-3 months.
The first menstruation after childbirth is often accompanied by copious bloody discharge - many women are worried about this condition, because the symptoms are similar to bleeding. Abundant discharge in this situation is normal, but if they have an unnatural smell and color, it is better to consult a doctor.
The recovery period of the cycle after a “cesarean section” is the same as after natural birth - closer to half a year. Sometimes surgery takes place with complications - then menstruation may begin later, because the uterus and ovaries take longer to recover, especially when stitches are applied.
Monthly after childbirth begins around the 6th month
How to count the duration of the cycle?
You already know that a normal menstrual cycle is 28 days with up or down tolerance. It is determined from the first day of menstruation to the next first day. The formula for counting for women is as follows: the date of the onset of menstruation in the current month - the date of the onset of menstruation last month + 1 day = cycle duration.
In practice, it looks like this. August 23 - July 26 +1 day = 28 days.
What caused cycle oscillations?
The menstrual period in women is interconnected with any changes occurring in the body. The cycle time may decrease or increase in the background:
- Increased workload at work.
- Viral and catarrhal diseases.
- Changes in the region, country of residence and climate.
- Unfavorable environmental conditions.
The autumn-spring off-season, when chronic diseases are exacerbated, can also cause cycle oscillations. 6-7-day deviations from the norm in the above cases are considered valid.
Bad ecology can disrupt the monthly cycle
What factors influence the number of critical days?
Menstrual flow can be twice a month or once in two months, lasts longer than a week, due to:
- Genetics. If one of the women in your family had monthly periods of 8 days, the likelihood of you repeating the situation is high. Genetic predisposition is not treated with medication, therefore, medical care is not required.
- Individual characteristics. Critical days can be long with poor blood clotting. Features of the structure of the uterus also affect the duration of menstruation.
- Diets and other eating disorders, a sharp weight loss are accompanied by hormonal changes. As a result, the menstrual cycle is disturbed - scanty or heavy discharge bothers women for more than a week, and sometimes stops altogether.
- Exhausting loads in the gym have an effect on the duration of menstruation.
- Oral contraception reduces the duration of menstruation, leads to its complete cessation.
- Malfunctions of the endocrine system are a common cause of disorders.
Doctors should establish the reason for deviations from the norm - treatment is prescribed only after an examination and an accurate diagnosis.
Sharp weight loss violates hormonal balance
Normal menstrual flow
Homogeneous bleeding during menstruation is the norm, they may be small blood clots, which is also normal. After all, during critical days, along with the secret of the vagina, the detached layer of the epidermis comes out.
At the beginning and at the end of the monthly allocation can be brown - there is nothing wrong with changing the color. There is little blood at these stages, it manages to clot under the influence of oxygen and vaginal microflora.
In the same period, the selection may be pink. This is explained by the fact that the process of cleansing the uterus from mucus and rejection of unnecessary epidermis has not yet begun or has already ended. The blood is excreted in small quantities - a few drops, therefore pink.
When the pink color should alert?
Monthly lasts several days, but instead of the characteristic bloody discharge on the pad pink mucus unpleasant smell and heterogeneous consistency. What is the reason and how much can it continue:
- Pink discharge may be due to hormonal disruptions, progesterone deficiency. This condition is treated with hormone therapy.
- In the postoperative period, pale pink mucus may appear in women instead of blood. As the body recovers, the cycle normalizes.
- Such color of menstruation occurs during cervical erosion, cyst, lipoma, pregnancy failure. In such cases, you should immediately be examined by a gynecologist. The period of treatment and restoration of the normal menstrual cycle is individual.
- Pink discharge in women, lasting for more than 10 days, is a symptom of infectious diseases, thyroid disorders, and other pathologies.
Bright discharge in the postoperative period is considered the norm.
What colors should alert?
How many symptoms of sexually transmitted diseases do you know? One of them - purulent or orange discharge during menstruation, often with gonorrhea. Often they are accompanied by itching, sharp pain during urination, have a specific fishy smell. Such menstrual flow is abundant, thick consistency. With vaginosis, there are also orange secretions.
Black menstruation in women occurs with inflammation of the appendages or the cervix, it is accompanied by nausea, dizziness, fever. No matter how much you delay the visit to the gynecologist, but this will have to be done - by itself it will not resolve.
Black color of blood sometimes happens after abortion, difficult childbirth, operations during the recovery period. The body is restored - the color of menstruation is normalized.
The green color of menstruation is an abnormality caused by an excess of white blood cells in the female body or severe inflammation of the genital organs.
You can solve the problem yourself if its cause is a change of climate, nervous strain or changes in diet. In other cases, without qualified medical assistance can not do.
We advise you to read on this topic.
Length (duration) of the menstrual cycle: how to calculate it
Features of the different phases of the menstrual cycle
What are the causes of menstrual failures
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2 Possible color variations
For the treatment and prevention of problems with the menstrual cycle (amenorrhea, dysmenorrhea, menorrhagia, Opsomenorrhea, etc.) and vaginal dysbacteriosis, our readers successfully use the simple advice of the chief gynecologist Leyla Adamova. Having carefully studied this method, we decided to offer it to your attention.
As noted earlier, the color of blood released during menstruation is a kind of indicator of health. It is for this reason that many of the weaker sex want to know what color should be the blood during menstruation. In practice, the blood released during menstruation does not undergo coagulation, and therefore its color is much darker than the color of blood circulating in the circulatory system. The color of the blood can be influenced by a lot of factors, for example, a significant weight loss in a short period of time, medication and age-related changes in the body. However, experts are generally recognized symptoms that indicate the development of various pathologies.
So, what does scarlet color of menstrual blood mean? A similar color of blood in the first 2 days of menstruation is ideal. This is evidence of the health and regularity of the processes occurring in the body. Such blood is characterized by the presence of the smell of iron.
If after 2 days the color of the menstruation remains unchanged, then this is not a very positive symptom. The situation is exacerbated, if at the same time the monthly ones are scanty. This situation can happen either in a teenage girl during the period of the formation of the cycle, or in a woman shortly before the menopause, which should occur no earlier than 50 years. If such symptoms are observed in women in reproductive age, then you should go through the necessary examinations by specialists, not doing self-diagnostics.
The scarlet color of blood throughout the days of discharge may be due to:
- taking oral contraceptives or entering the intrauterine device,
- complications after surgery gynecological nature,
- the formation of polyps in the uterus,
- infectious diseases,
- benign lesions in the pelvic organs,
- a recent abortion.
It is the presence of so many possible causes that necessitates a medical examination.
As you know, menstruation given out monthly should be 90% of blood, which allows you to get a red tint of discharge. If the blood content in the discharge decreases, then it is replaced by all sorts of mucus and endometrial particles, which is already a pathology. This situation develops with a decrease in the level of estrogen in a woman's body.
If menstruation acquires an orange color, then this can speak either of pathologies caused by impaired metabolic processes, or high blood pressure. Such color of the menstruation may also appear in case of insertion of the intrauterine device or incorrect curettage of the uterus cavity.
In medical practice, there are cases of black blood during menstruation. Of course, a change in the color of the blood may be quite common, but sometimes the black color of the blood may indicate the development of the following pathologies:
- stretching the muscles and ligaments of the uterus,
- narrowing of the lumen of the cervical canal,
- state of pregnancy
- the occurrence of benign neoplasms,
- endocrine system malfunction
- the growth of endometrial cells outside this layer, in other words, endometriosis.
If a woman has brown menstrual bleeding, this can be a sign of ectopic pregnancy.
Brown menstruation may also occur after unprotected sex. At the same time, brown discharge is characterized by a specific odor, pain and itching. This situation indicates the presence of genital infections in the body, for example, syphilis, chlamydia, gonorrhea, etc. Such infections must be identified and treated in a mandatory and urgent manner.
The brown color of the discharge during menstruation may indicate mismatched contraceptives. If this situation is repeated within 2 months after the start of taking such drugs, then you should stop taking them.
Thus, every woman should be attentive to her health and immediately seek medical help to rule out possible diseases. After all, every girl, girl, young woman is also the future mother. And the health of the future generation largely depends on it.
And a little about the secrets.
Have you ever suffered from problems with Menstrual cycle. Judging by the fact that you are reading this article - the victory was not on your side. And of course you do not know firsthand what it is:
- heavy or scanty clots
- chest and lower back pain
- pain during sex
- unpleasant smell
- urination discomfort
And now answer the question: does it suit you? Is it possible to endure problems? And how much money have you already “leaked” to ineffective treatment? That's right - it's time to stop with this! Do you agree? That is why we decided to publish an interview with the chief gynecologist of Russia Leyla Adamova. in which she revealed the simple secret of normalization of the menstrual cycle. Read the article ...
In women, menstruation usually occurs every month, but there are also non-standard periods of menstruation. Before puberty, during pregnancy and immediately after childbirth, there is no menstruation in menopause. The discharge immediately after childbirth is called lochia and continues for several weeks. Sometimes during breastfeeding, menstruation may be absent for a while, and in this absence of menstruation, such a method of preventing pregnancy as the lactational amenorrhea is built .
The first appearance of menstruation (menarche) in a woman occurs at the age of 12-14 years on average, (with a range of 9-11 years to 19-21 years). Menstruation in a hot climate shows between 11 and 15 years of life, in moderate - between 12 and 18 years and in cold - between 13 and 21 years of life. The age of menarche reveals certain racial differences: for example, in a number of studies it was shown that menarche occurs in Negroids earlier than in Europeans living in the same socio-economic conditions   .
After the first menstruation, the next one may be after 2 or 3 months. Over time, the menstrual cycle is established and lasts 28 days, but the duration of the cycle from 21 to 35 days is normal. Only 13% of all women have a cycle of exactly 28 days. Menstruation lasts about 2-8 days. All discharge comes from the vagina.
Premenstrual Syndrome Edit
Some women experience emotional changes associated with menstruation. Sometimes there is irritability, tiredness, tearfulness, depression. Such a range of emotional effects and mood shifts is also associated with pregnancy and can be explained by a lack of endorphins.  Estimates of the incidence of premenstrual syndrome range from 3%  to 30%.  In certain rare cases of people prone to psychotic disorders, menstruation can cause menstrual psychosis (English).
Age of menopause (cessation of menstruation): the norm is 40–57 years, most probably 50–52 years. In a temperate climate, menstruation lasts on average up to 50 years, after which menopause occurs, firstly the regula disappears for several months, then it appears and disappears again, etc. There are, however, women who preserve menstruation up to 70 years. From a medical point of view, menopause is considered to have come, if during the year menstruation was completely absent.
Menstrual Synchronization Edit
Since 1971, some studies have found indications that the menstrual cycles in women living together are gradually synchronized. Some anthropologists hypothesized that this has a definite evolutionary meaning: in ancient communities of hunters and gatherers, men went hunting when men at the same time began to have menstruation in adult women of the tribe (assuming that a woman during menstruation was not considered an acceptable object for sexual relations) [ 14] . However, at present, the very existence of the menstrual synchronization effect (English) is disputed. [sixteen]
Menstrual blood is called liquid vaginal discharge during menstruation. Strictly speaking, a more correct term is menstrual fluid, since its composition, besides the blood itself, includes the mucous secretion of the cervical glands, the secret of the vaginal glands and the tissue of the endometrium. The average volume of menstrual fluid released during one menstrual cycle is, according to the Great Medical Encyclopedia, about 50-100 milliliters. However, the individual variation ranges from 10 to 150 and even up to 250 milliliters. This range is considered normal, more abundant (or, conversely, scanty) discharge may be a symptom of the disease. Menstrual fluid has a reddish-brown color, slightly darker than venous blood. : p.381
The amount of iron lost with menstrual blood is relatively small for most women and cannot by itself cause the symptoms of anemia.  In one study, a group of women with symptoms of anemia were examined with an endoscope. It turned out that 86% of them actually suffered from various gastrointestinal diseases (such as gastritis or duodenal ulcers, which cause bleeding in the gastrointestinal tract), this diagnosis could not be made because of the erroneous attribution of iron deficiency to menstrual blood loss.  However, regular heavy menstrual bleeding in some cases can still lead to anemia.
General rules for menstrual hygiene Edit
For the maintenance of personal hygiene, adolescent girls and women use pads attached to their underwear and / or tampons inserted into the vagina. In both cases, the fabric of the pad or tampon absorbs menstrual flow. In European countries, the USA and Canada, menstrual cups are becoming increasingly popular as personal hygiene products.
When menstruation is especially necessary to observe the rules of hygiene.Due to the fact that bleeding menstrual flow is a favorable environment for the reproduction of bacteria, including pathogenic ones, medicine does not recommend bathing and bathing (both in fresh and in salty water), vaginal douching. It is recommended to wash the external genitals at least 2-3 times a day with warm water and soap (rinsing), and wash every day under the shower .
The woman’s performance during this period is generally maintained, but increased physical exertion, hypothermia, and overheating should be avoided . Alcohol and spicy foods are contraindicated, since the latter increase uterine bleeding due to the rush of blood to the abdominal organs.
Sexual intercourse during menstruation Edit
During menstruation, a woman may experience physical discomfort. In some cases, increased hormonal levels create emotional tension and irritation. The uterus during this period is very vulnerable to various kinds of infections , therefore it is recommended to completely stop having sex during menstruation  .
Menstruation disorders are quite frequent and boil down to:
Suspension of menstruation depends on various conditions. Conception stops normal bleeding and is a physiological cause. Menstruation can stop at any significant loss of blood in another part of the body, in this case, menstrual blood is delayed or removed in other ways [ which ones? ]. When you stop menstruation, you must keep in mind the reason that caused this abnormality. If after a cold, after emotional agitation, menstruation does not occur for a long time, then you need to go to a doctor. Of particular note is the mechanical delay of menstruation, it happens when the vagina is narrowed, when the vagina and the cervix itself are narrowed 
Sometimes bleeding occurs in any part removed from the uterus, from the latter the outflow can either be reduced or stopped, this phenomenon is called additional or rejected menstruation (vicarious menstruation) . In such cases, the outflow usually occurs in places devoid of skin, for example in wounds, ulcers, and also in the mucous membrane, for example of the mouth and nose. Generally speaking, there is not a single point on the surface of the body on which no additional menses would be observed. At the same time in the ovaries, there are phenomena common to menstruation [ source not specified 2038 days ] .
With menorrhagia outflow increased. This happens with diseases of the uterus or neighboring organs: with inflammation of the uterus, with erosion of the cervix, with blood of wide ligaments, etc., sometimes there are no disorders of the uterus, and increased outflow depends on the general deterioration of health [ source not specified 2038 days ] .
Dysmenorrhea called menstruation, accompanied by pain. When they often depart blood clots. During treatment, they pay attention to the cause that supports irregular menstruation, and try to eliminate it [ source not specified 2038 days ] .
Mayan mythology explains the origin of menstruation as a punishment for a woman’s violation of the social rules of a marriage union. According to Mayan beliefs, menstrual blood turns into snakes and insects used in black magic, until the moon goddess is revived by means of it .
In Abrahamic religions, menstrual blood is considered ritually impure, a ban on sex and participation in certain religious rituals during menstruation is set (ch. 15 of the book of Leviticus).
In the traditional cult of Nepal, there is a practice of honoring selected little girls as incarnations of the goddess Teledju, dating back to the time preceding the thirteenth century. According to legend, the goddess played dice with the ruler of Nepal, until he insulted her with her lustful looks. Offended Telaju has vowed since then never to return to the country, except in the guise of a young girl Kumari. From this time on, there is a cult of worshiping Kumari girls, Teledju's living incarnations, which are considered as such until the first menstruation, after which the goddess allegedly leaves the body. Severe illness, serious blood loss due to injury and even laughter are also regarded as the care of the goddess and are reasons for the girl to return to normal life .
In Southeast Asia, menstrual blood was considered to be associated with the female principle of yin and was used in traditional medicine practices. During the Japanese-Korean War of 1592–1598, the Korean General Gwak Cheu (Eng.) Wore red clothes painted with the menstrual blood of virgins . The general believed that the dark female energy of yin transformed his clothes into armor, inaccessible to Japanese firearms — the personification of the male energy of yang .
Menstruation, apart from humans, is also observed in females of some placental mammals. These include, first of all, many primates. Menstruation is common in species that are representatives of the infraorder monkey-shaped, to which a person belongs, apes, monkeys of the Old World (or monkeys) and monkeys of the New World (or broad-bearing monkeys) . Menstruation is rarely expressed in representatives of the more primitive semi-monkey sub-order: they were not found in the sub-squad of mock-carrying monkeys (which include lemurs and lori), but are sometimes observed in some species of long-tapers .
To other animals in which menstruation occurs, besides primates, include bats (bats) and jumpers (also known as elephant shrews)    . Interestingly, in the latter, malaria plasmodia are found in the blood, which is also evidence of their evolutionary closeness with lower primates (only primates, including humans, and tupaya suffer from malaria).
In females of other species of placental mammals, instead of the menstrual cycle, the estrus cycle occurs (estrus), during which the endometrium is not rejected, but completely reabsorbed in the body. It should be noted that in people with menstrual blood only one third of the volume of the endometrium is secreted, while the remaining two thirds is absorbed by the body.
The duration of the menstrual cycle in female orangutans, as in humans, averages 28 days, close to the length of the lunar month, 29.53 days, whereas, for example, in chimpanzee females the cycle duration is about 35 days. 
ADH - antidiuretic hormone
ACTH - Corticoliberin
ARG-Gn - releasing hormone agonist of gonadotropins
LH - luteinizing hormone
OP - oxyprogesterone
RG-Gn - releasing hormone gonadotropinov
STG - somatoliberin
VEGF - Vascular Endothelial Growth Factor
TSH - thyroid-stimulating hormone (thyroliberin)
FSH - follicle-stimulating hormone
FFR - fibroplastic growth factor
Normal menstrual cycle
Menses - This is a bleeding from the female genital tract, periodically resulting from the rejection of the functional layer of the endometrium at the end of a two-phase menstrual cycle.
The complex of cyclic processes that occur in the female body and externally manifest by menstruation is called the menstrual cycle. Menstruation begins as a reaction to changes in the level of steroids produced by the ovaries.
Clinical signs of a normal menstrual cycle
The duration of the menstrual cycle in the active reproductive period of a woman is on average 28 days. The cycle time from 21 to 35 days is considered normal. Large gaps are observed during puberty and menopause, which may be a manifestation of anovulation, which may occur at this time most often.
Typically, menstruation lasts from 3 to 7 days, the amount of blood lost is negligible. Shortening or lengthening of menstrual bleeding, as well as the appearance of scanty or heavy menstruation can be a manifestation of a number of gynecological diseases.
Characteristics of the normal menstrual cycle:
Duration: 28 ± 7 days
The duration of menstrual bleeding: 4 ± 2 days,
The amount of blood loss during menstruation: 20-60 ml*,
Average iron loss: 16 mg
*95 percent of healthy women with each menstruation lose less than 60 ml of blood. Blood loss of more than 60-80 ml is combined with a decrease in the level of hemoglobin, hematocrit and serum iron.
Physiology of menstrual bleeding:
Immediately before menstruation, a pronounced spasm of the spiral arterioles develops. After dilatation of the spiral arterioles, menstrual bleeding begins. Initially, the adhesion of platelets in the endometrial vessels is suppressed, but then, due to blood transudation, the damaged ends of the vessels are sealed with intravascular thrombus, consisting of platelets and fibrin. 20 hours after the onset of menstruation, when most of the endometrium has already been torn away, a pronounced spasm of the spiral arterioles develops, due to which hemo stasis is achieved. Regeneration of the endometrium begins 36 hours after the onset of menstruation, despite the fact that the endometrium rejection is not yet fully completed.
The regulation of the menstrual cycle is a complex neurohumoral mechanism, which is carried out with the participation of 5 main parts of the regulation. These include: the cerebral cortex, subcortical centers (hypothalamus), pituitary, gonads, peripheral organs and tissues (uterus, fallopian tubes, vagina, mammary glands, hair follicles, bones, adipose tissue). The latter are called target organs, due to the presence of receptors that are sensitive to the action of hormones that the ovary produces during the menstrual cycle. Cytozolreceptory - receptors of the cytoplasm, have strict specificity for estradiol, progesterone, testosterone, while nuclear receptors can be acceptors of molecules such as insulin, glucagon, aminopeptides.
Receptors for sex hormones are found in all structures of the reproductive system, as well as in the central nervous system, skin, adipose and bone tissue and the mammary gland. The free steroid hormone molecule is captured by a specific cytosolreceptor of a protein nature, the resulting complex is translocated into the cell nucleus. A new complex with a nuclear protein receptor appears in the nucleus; this complex binds to chromatin that regulates mRNA transcription, which is involved in the synthesis of a specific tissue protein. Intracellular mediator - cyclic adenosine monophosphoric acid (cAMP) regulates the metabolism in the cells of the target tissue in accordance with the needs of the body in response to the effects of hormones. The bulk of steroid hormones (about 80% is in the blood and transported in a bound form. Their transport is carried out by special proteins - steroid-binding globulins and non-specific transport systems (albumin and red blood cells). In a bound form, steroids are inactive, therefore globulins, albumin and erythrocytes can be considered as a kind of buffer system that controls the access of steroids to receptors of target cells.
Cyclic functional changes occurring in a woman's body can be divided into changes in the system of the hypothalamus-pituitary-ovaries (ovarian cycle) and the uterus, primarily in its mucous membrane (uterine cycle).
Along with this, as a rule, cyclic shifts occur in all organs and systems of a woman, in particular, in the central nervous system, cardiovascular system, thermoregulation system, metabolic processes, etc.
The hypothalamus is a part of the brain located above the optic chiasm and forming the bottom of the third ventricle. This is an old and stable component of the central nervous system, whose overall organization has changed little in the process of human evolution. Structurally and functionally, the hypothalamus is associated with the pituitary gland. Three hypothalamic areas are distinguished: anterior, posterior, and intermediate. Each region is formed by nuclei - clusters of bodies of neurons of a certain type.
In addition to the pituitary gland, the hypothalamus affects the limbic system (amygdala, hippocampus), thalamus, bridge. These departments also directly or indirectly affect the hypothalamus.
The hypothalamus secretes liberins and statins. This process is regulated by hormones that close the three feedback loops: long, short, and ultrashort. A long feedback loop is provided by circulating sex hormones that bind to the corresponding receptors in the hypothalamus, a short one: adenohypophysis hormones, ultrashort: liberins and statins. Liberin and statins regulate the activity of the adenohypophysis. Gonadoliberin stimulates the secretion of LH and FSH, corticoliberin - ACTH, somatoliberin (STH), thyroliberin (TSH). In addition to liberin and statins, antidiuretic hormone and oxytocin are synthesized in the hypothalamus. These hormones are transported to the neurohypophysis, from which they enter the blood.
Unlike the capillaries of other areas of the brain, the capillaries of the hypothalamic funnel are fenestrated. They form the primary capillary network of the portal system.
In the 70s-80s. A series of experimental work on monkeys was carried out, which allowed to reveal differences in the function of the neurosecretory structures of the hypothalamus of primates and rodents. In primates and humans, the arcuate nuclei of the mediobasal hypothalamus are the only place of formation and excretion of RH-LH responsible for the gonadotropic function of the pituitary gland. RG-LH secretion is genetically programmed and occurs in a certain pulsating rhythm with a frequency of approximately once per hour. This rhythm is called tsirkhoral (sentry). The region of arcuate nuclei of the hypothalamus is called arcuate oscillator. The circhoral nature of WG-LH secretion was confirmed by directly determining it in the blood of the portal system of the pituitary stalk and jugular vein in monkeys and in the blood of women with ovulatory cycles.
The releasing hormone LH is isolated, synthesized and described in detail. So far, it has not been possible to isolate and synthesize folliberin. RG-LH and its synthetic analogs have the ability to stimulate the release of LH and FSH from the anterior pituitary gland; therefore, one term for the hypothalamic gonadotropic liberins, the releasing hormone of gonadotropins (RH-Gn), is currently adopted.
Gnadoliberin stimulates the secretion of FSH and LH. It is a decapeptide secreted by neurons of the funnel nucleus. Gonadoliberin is not secreted continuously, but in a pulsed mode. It is very rapidly destroyed by proteases (half-destruction period is 2-4 minutes), so its impulses must be regular. The frequency and amplitude of emissions of GnRH vary throughout the menstrual cycle. The follicular phase is characterized by frequent fluctuations of a small amplitude of the serum level of gonadoliberin. By the end of the follicular phase, the frequency and amplitude of oscillations increase, and then decrease during the luteal phase.
In the pituitary gland, there are two lobes: the anterior - adenohypophysis and the posterior - neurohypophysis. The neurohypophysis has a neurogenic origin and represents the continuation of the funnel of the hypothalamus. The neurohypophysis is supplied with blood from the lower pituitary arteries. The adenohypophysis develops from the ectoderm of the pocket of Ratke, therefore it consists of glandular epithelium and has no direct connection with the hypothalamus. The liberins and statins synthesized in the hypothalamus enter the adenohypophysis through a special portal system. This is the main source of blood supply to the adenohypophysis. The blood in the portal system mainly enters through the upper pituitary arteries. In the region of the funnel of the hypothalamus, they form the primary capillary network of the portal system, the portal veins are formed from it, which enter the adenohypophysis and give rise to the secondary capillary network. Possible reverse flow of blood through the portal system. Features of the blood supply and the absence of the blood-brain barrier in the region of the funnel of the hypothalamus provide a two-way connection between the hypothalamus and the pituitary gland. Depending on the hematoxylin and eosin staining, the secretory cells of the adenohypophysis are divided into chromophilic (acidophilic) and basophilic (chromophobic). Acidophilic cells secrete growth hormone and prolactin, basophilic cells - FSH, LH, TSH, ACTH
In the adenohypophysis form STH, prolactin, FSH, LH, TSH and ACTH. FSH and LH regulate the secretion of sex hormones, TSH - the secretion of thyroid hormones, ACTH - the secretion of adrenal hormones. STG stimulates growth, has an anabolic effect. Prolactin stimulates the growth of the mammary glands during pregnancy and lactation after delivery.
LH and FSH are synthesized by gonadotropic cells of the adenohypophysis and play an important role in the development of ovarian follicles. By structure, they are referred to as glycoproteins. FSH stimulates follicle growth, the proliferation of granulosa cells, induces the formation of LH receptors on the surface of granulosa cells. Under the influence of FSH, the aromatase content in the maturing follicle increases. LH stimulates the formation of androgens (precursors of estrogen) in tech-cells, together with FSH promotes ovulation and stimulates progesterone synthesis in luteinized cells of ovulated follicle granulosis.
Секреция ЛГ и ФСГ непостоянна и модулируется яичниковыми гормонами, особенно эстрогенами и прогестероном.
Таким образом, низкий уровень эстрогенов оказывает подавляющий эффект на ЛГ, в то время как высокий стимулирует его производство гипофизом. In the late follicular phase, the level of serum estrogens is quite high, the positive feedback effect is tripled, which contributes to the formation of the preovulatory peak of PH. Conversely, during therapy with combined contraceptives, the level of estrogen in the blood serum is within the limits that determine negative feedback, which leads to a decrease in the content of gonadotropins.
The mechanism of positive feedback leads to an increase in receptors concentration and production of WG-H.
In contrast to the effect of estrogen, low progesterone levels have a positive feedback reaction to the secretion of LH and FSH by the pituitary gland. Such conditions exist immediately before ovulation and lead to the release of FSH. A high level of progesterone, which is noted in the luteal phase, reduces the pituitary production of gonadotropins. A small amount of progesterone stimulates the release of gonadotropins at the pituitary level. The negative effect of progesterone feedback is manifested by reducing the production of WG-H and reducing the sensitivity to WG-H at the level of the pituitary gland. The positive feedback effect of progesterone occurs on the pituitary gland and includes an increased sensitivity to WG-H. Estrogens and progesterone are not the only hormones that affect the secretion of gonadotropins by the pituitary gland. The same effect has the hormones inhibin and activin. Inhibin suppresses pituitary FSH secretion, activin stimulates it.
Prolactin Is a polypeptide consisting of 198 amino acid residues, synthesized by lactotropic cells of the adenohypophysis. Prolactin secretion is controlled by dopamine. It is synthesized in the hypothalamus and inhibits the secretion of prolactin. Prolactin has a diverse effect on the female body. Its main biological role is the growth of the mammary glands and the regulation of lactation. It also has a fat mobilizing effect and has a hypotensive effect. Increased secretion of prolactin is one of the common causes of infertility, since an increase in its level in the blood inhibits steroidogenesis in the ovaries and the development of follicles.
Oxytocin - peptide consisting of 9 amino acid residues. It is formed in the neurons of the macrocellular part of the hypothalamus paraventricular nuclei. The main targets of oxytocin in humans are smooth muscle fibers of the uterus and myoepithelial cells of the mammary glands.
Antidiuretic hormone (ADH) is a peptide consisting of 9 amino acid residues. It is synthesized in the neurons of the supraoptic nucleus of the hypothalamus. The main function of ADH - regulation of bcc, blood pressure, plasma osmolality.
The ovaries undergo three phases of the menstrual cycle:
- follicular phase
- luteal phase.
One of the highlights of the follicular phase of the menstrual cycle is the development of the egg. The woman's ovary is a complex organ consisting of many components, the result of the interaction of which is the secretion of sex steroid hormones and the egg is prepared for fertilization in response to the cyclic secretion of gonadotropins.
Hormonal activity from the preantral to peri-ovulatory follicle is described as a “two cell, two gonadotropin” theory. Steroidogenesis occurs in two cells of the follicle: in theca- and granulosa cells. In theca-cells, LH stimulates the production of androgens from cholesterol. In granulosa cells, FSH stimulates the conversion of the resulting androgens into estrogens (aromatization). In addition to the aromatization effect, FSH is also responsible for the proliferation of granulosa cells. Although other mediators are known in the development of ovarian follicles, this theory is fundamental for understanding the processes occurring in the ovarian follicle. It was found that for a normal cycle with a sufficient level of estrogen, both hormones are needed.
The production of androgens in the follicles can also regulate the development of the preanthral follicle. A low level of androgens enhances the process of aromatization, therefore, increases the production of estrogen, and vice versa, high - inhibits the process of aromatization and causes follicle atresia. The balance of FSH and LH is necessary for the early development of the follicle. The optimal condition for the initial stage of follicle development is low LH and high FSH, which occurs at the beginning of the menstrual cycle. If the LH level is high, the theca cells produce a large amount of androgens, causing atresia of the follicles.
Selection of a dominant follicle
Follicle growth is accompanied by secretion of sex steroid hormones under the influence of LH and FSH. These gonadotropins protect the preanthral follicle group from atresia. However, normally only one of these follicles develops to preovulatory, which is then released and becomes dominant.
The dominant follicle in the middle follicular phase is the largest and most developed in the ovary. Already in the first days of the menstrual cycle, it has a diameter of 2 mm and within 14 days by the time of ovulation it increases on average to 21 mm. During this time, a 100-fold increase in the volume of the follicular fluid occurs, the number of granulosa cells lining the basement membrane increases from 0.5x10 6 to 50x10 6. Such a follicle has the highest aromatizing activity and the highest concentration of FSH-induced receptors for LH, therefore the dominant follicle secretes the highest amount of estradiol and inhibin. Further, inhibin enhances the synthesis of androgens under the influence of LH, which is a substrate for the synthesis of estradiol.
In contrast to the FSH level, which decreases with increasing estradiol concentration, the LH level continues to rise (in low concentrations, estradiol inhibits LH secretion). It is the prolonged estrogenic stimulation that prepares the ovulatory peak of LH. At the same time, the dominant follicle is being prepared for ovulation: the number of LH receptors increases on the granular cells under the local action of estrogens and FSH. The release of LH leads to ovulation, the formation of yellow body and an increase in progesterone secretion. Ovulation occurs 10–12 hours after the peak of the LH or 32–35 hours after the start of raising its level. Usually only one follicle ovulates.
During follicle selection, FSH levels decrease in response to the negative effect of estrogens, therefore the dominant follicle is the only one that continues to develop with a falling level of FSH.
The ovarian-pituitary connection is decisive in the choice of the dominant follicle and in the development of atresia of the remaining follicles.
Inhibin and activin
The growth and development of the egg, the functioning of the corpus luteum occurs when the autocrine and paracrine mechanisms interact. It should be noted two follicular hormones that play a significant role in steroidogenesis, inhibin and activin.
Inhibin is a peptide hormone produced by granulosa cells of growing follicles, which reduces the production of FSH. It also affects the synthesis of androgens in the ovary. Inhibin affects folliculogenesis as follows: reducing FSH to a level at which only the dominant follicle develops.
Activin is a peptide hormone produced in the granulosa cells of the follicles and pituitary gland. According to some authors, activin is also produced by the placenta. Activin increases the production of FSH by the pituitary gland, enhances the process of binding FSH to granulosa cells.
Insulin-like growth factors
Insulin-like growth factors (IGF-1 and IGF-2) are synthesized in the liver under the influence of growth hormone and, possibly, in the granular cells of the follicles, act as paracrine regulators. Before ovulation, the content of IGF-1 and IGF-2 in the follicular fluid is increased by increasing the amount of fluid in the dominant follicle. IGF-1 is involved in the synthesis of estradiol. IGF-2 (epidermal) inhibits the synthesis of steroids in the ovaries.
The ovulatory peak of LH leads to an increase in prostaglandin concentration and protease activity in the follicle. The ovulation process itself is a rupture of the dominant follicle basement membrane and bleeding from the destroyed capillaries surrounding the theca cells. Changes in the wall of the preovulatory follicle, ensuring its thinning and rupture, occur under the influence of the enzyme collagenase, and prostaglandins contained in the follicular fluid, proteolytic enzymes formed in granular cells, oxytocin and relaxin also play a role. As a result, a small hole is formed in the wall of the follicle, through which the egg slowly leaves. Direct measurements have shown that the pressure inside the follicle does not increase during ovulation.
At the end of the follicular phase, FSH acts on LH receptors in granulosa cells. Estrogens are an essential cofactor in this effect. As the dominant follicle develops, estrogen production increases. As a result, the production of estrogen is enough to achieve secretion of the pituitary LH, which leads to an increase in its level. The increase occurs very slowly at the beginning (from the 8th to the 12th day of the cycle), then quickly (after the 12th day of the cycle). During this time, LH activates the luteinization of granulosa cells in the dominant follicle. Thus, progesterone is released. Further, progesterone enhances the effect of estrogen on the secretion of pituitary LH, leading to an increase in its level.
Ovulation occurs within 36 hours after the start of LH elevation. Determining the release of LH is one of the best methods, which determines ovulation and is carried out using the device "ovulation determinant".
The perovulatory peak of FSH probably occurs as a result of the positive effect of progesterone. In addition to increasing the levels of LH, FSH and estrogens, an increase in serum androgen levels is also noted during ovulation. These androgens are released as a result of the stimulatory effect of LH on tech-cells, especially in the non-dominant follicle.
An increase in the androgen content has an effect on libido enhancement, confirming that this period is the most fertile in women.
LH levels stimulate meiosis after the sperm enters the egg. When an oocyte is secreted from the ovary into ovulation, the wall of the follicle is destroyed. It is regulated by LH, FSH and progesterone, which stimulate the activity of proteolytic enzymes, such as plasminogen activators (which secrete plasmin, stimulating collagenase activity) and prostaglandins. Prostaglandins not only increase the activity of proteolytic enzymes, but also contribute to the appearance of an inflammatory-like reaction in the wall of the follicle and stimulate the activity of smooth muscles, which contributes to the release of the oocyte.
The importance of prostaglandins in the process of ovulation is proven by studies that determine that a decrease in the release of prostaglandin can lead to a delay in the release of the oocyte from the ovary during normal steroidogenesis (syndrome of underdeveloped luteinized follicle — SNLF). Since SNLF is often the cause of infertility, women wishing to become pregnant are advised to avoid taking prostaglandin synthesized synthesizers.
The structure of the yellow body
After the release of the egg from the ovary into the cavity of the follicle, capillaries are rapidly growing, granulose cells undergo luteinization: an increase in their cytoplasm and the formation of lipid inclusions. Granular cells and tektotsity form a yellow body - the main regulator of the luteal phase of the menstrual cycle. The cells that form the wall of the follicle accumulate lipids and yellow pigment lutein and begin to secrete progesterone, estradiol-2, inhibin. A powerful vascular network promotes the entry of yellow body hormones into the systemic circulation. A complete corpus luteum develops only in cases when an adequate number of granulosa cells with a high content of LH receptors is formed in the preovulatory follicle. An increase in the size of the corpus luteum after ovulation occurs mainly due to an increase in the size of granulosa cells, while their number does not increase due to the absence of mitoses. In humans, the corpus luteum secretes not only progesterone, but also estradiol and androgens. The mechanisms of regression of the corpus luteum are not well understood. It is known that prostaglandins have a luteolytic effect.
Fig. Ultrasound picture of the "blooming" yellow body during pregnancy 6 weeks. 4 days. Energy mapping mode.
Hormonal regulation of the luteal phase
If the pregnancy does not occur, the involution of the corpus luteum occurs. This process is regulated by a negative feedback mechanism: hormones (progesterone and estradiol) secreted by the corpus luteum act on the gonadotropic cells of the pituitary gland, inhibiting the secretion of FSH and LH. The secretion of FSH also inhibits inhibin. A decrease in FSH levels, as well as local action of progesterone, inhibits the development of a group of primordial follicles.
The existence of the corpus luteum depends on the level of LH secretion. When it decreases, usually 12-16 days after ovulation, the involution of the corpus luteum occurs. In its place a white body is formed. The mechanism of involution is unknown. Most likely, it is caused by paracrine influences. With the involution of the corpus luteum, the levels of estrogen and progesterone fall, which leads to an increase in the secretion of gonadotropic hormones. As the levels of FSH and LH increase, a new group of follicles begins to develop.
If fertilization has occurred, the existence of the corpus luteum and the secretion of progesterone support chorionic gonadotropin. Thus, the implantation of the embryo leads to hormonal changes that preserve the corpus luteum.
The duration of the luteal phase in most women is constant and is approximately 14 days.
The complex process of biosynthesis of steroids ends with the formation of estradiol, testosterone and progesterone. Steroid-producing tissues of the ovaries are granulosa cells lining the follicle cavity, cells of the internal teka and to a much lesser extent the stroma. Granulosa cells and tech-cells are synergistically involved in the synthesis of estrogens, the cells of the thecal membrane are the main source of androgens, which are also produced in small amounts in the stroma, progesterone is synthesized in the cells and granulosa cells.
In the ovary, 60-100 µg of estradiol (E2) are secreted into the early follicular phase of the menstrual cycle, 270 µg per luteal phase, at the time of ovulation, 400-900 µg per day. About 10% of E2 is aromatized in the ovary from testosterone. The amount of estrone formed in the early follicular phase is 60-100 mcg, by the time of ovulation its synthesis increases to 600 mcg per day. Only half the amount of estrone produced in the ovary. The second half is flavored in E2. Estriol is a low-active metabolite of estradiol and estrone.
Progesterone is formed in the ovary in the amount of 2 mg / day in the follicular phase and 25 mg / day in the luteal phase of the menstrual cycle. In the process of metabolism, progesterone in the ovary is converted to 20-dehydroprogesterone, which has a relatively low biological activity.
The following androgens are synthesized in the ovary: Androstenedione (testosterone precursor) in the amount of 1.5 mg / day (the same amount of androstenedione is formed in the adrenal glands). About 0.15 mg of testosterone is formed from androstenedione, approximately the same amount of it is formed in the adrenal glands.
A brief overview of the processes occurring in the ovaries
LH stimulates the production of androgens in theca cells.
FSH stimulates the production of estrogen in granulosa cells.
The most developed follicle in the middle of the follicular phase becomes dominant.
The increasing formation of estrogen and inhibin in the dominant follicle inhibits the secretion of FSH by the pituitary gland.
A decrease in the level of FSH causes atresia of all follicles except the dominant one.
FSH induces LH receptors.
Proteolytic enzymes in the follicle lead to the destruction of its wall and the release of the oocyte.
The corpus luteum is formed from granular and tech-cells that have survived after ovulation.
Progesterone secreted by the corpus luteum is the dominant hormone. In the absence of pregnancy, luteolysis occurs 14 days after ovulation.
Endometrium consists of two layers: functional and basal. The functional layer changes its structure under the action of sex hormones and, if the pregnancy has not occurred, is rejected during menstruation.
The beginning of the menstrual cycle is considered the 1st day of menstruation. At the end of menstruation, the thickness of the endometrium is 1-2 mm. Endometrium consists practically only of the basal layer. The glands are narrow, straight and short, lined with a low cylindrical epithelium, the cytoplasm of stromal cells is almost the same. As estradiol levels increase, a functional layer forms: the endometrium prepares for implantation of the embryo. The glands lengthen and become convoluted. The number of mitoses increases. По мере пролиферации высота эпителиальных клеток возрастает, а сам эпителий из однорядного становится многорядным к моменту овуляции. Строма отечна и разрыхлена, в ней увеличиваются ядра клеток и объем цитоплазмы. Сосуды умеренно извиты.
В норме овуляция происходит на 14-й день менструального цикла. The secretory phase is characterized by high levels of estrogen and progesterone. However, after ovulation, the number of estrogen receptors in endometrial cells is reduced. Endometrial proliferation is gradually inhibited, DNA synthesis decreases, the number of mitoses decreases. Thus, progesterone has a predominant effect on the endometrium during the secretory phase.
Glycogen-containing vacuoles appear in the glands of the endometrium, which are detected using the CHIC reaction. On the 16th day of the cycle, these vacuoles are rather large, are present in all cells and are under the nuclei. On the 17th day, the nuclei, pushed back by vacuoles, are located in the central part of the cell. On the 18th day, the vacuoles appear in the apical part, and the nuclei in the basal part of the cells, glycogen begins to be released into the lumen of the glands by apocrine secretion. The best conditions for implantation are created on the 6-7th day after ovulation, i.e. on the 20-21st day of the cycle, when the secretory activity of the glands is maximal.
On the 21st day of the cycle, the decidual endometrial stroma begins. The spiral arteries are sharply twisted, later due to a decrease in stromal edema, they are clearly visible. First, decidual cells appear that gradually form clusters. On the 24th day of the cycle, these clusters form perivascular eosinophilic couplings. On the 25th day, islands of decidual cells are formed. By the 26th day of the cycle, the number of neutrophils that migrate there from the blood becomes decidual. Neutrophil infiltration is replaced by necrosis of the endometrial functional layer.
If implantation has not occurred, the glands cease to produce a secret, and degenerative changes begin in the functional layer of the endometrium. The immediate cause of its rejection is a sharp drop in the content of estradiol and progesterone as a result of involution of the corpus luteum. In the endometrium, the venous outflow decreases and the vessels expand. Next, the arteries narrow, resulting in ischemia and tissue damage and functional loss of the endometrium. Then bleeding from arteriole fragments remaining in the basal layer of the endometrium occurs. Menstruation stops when the arteries are narrowed, the endometrium is restored. Thus, the cessation of bleeding in the endometrial vessels is different from hemostasis in other parts of the body.
As a rule, bleeding stops as a result of the accumulation of platelets and fibrin deposition, which leads to scarring. In the endometrium, scarring can lead to a loss of its functional activity (Asherman syndrome). To avoid these effects, an alternative hemostasis system is needed. Vascular contraction is a mechanism to stop bleeding in the endometrium. In this case, scarring is minimized by fibrinolysis, which destroys blood clots. Later restoration of the endometrium and the formation of new blood vessels (angiogenesis) leads to the completion of bleeding within 5-7 days from the start of the menstrual cycle.
The effect of estrogen and progesterone withdrawal on menstruation is well defined, but the role of paracrine mediators remains unclear. Vasoconstrictors: prostaglandin F2a, endothelium-1 and platelet-activating factor (TAF) can be produced within the endometrium and participate in the reduction of blood vessels. They also contribute to the beginning of menstruation and further control over it. These mediators can be regulated by exposure to vasodilating agents such as prostaglandin E2, prostacyclin, nitric oxide, which are produced by the endometrium. Prostaglandin F2a has a pronounced vasoconstrictor effect, increases arterial spasm and endometrial ischemia, causes contractions of the myometrium, which, on the one hand, reduces blood flow, and on the other, helps to remove the rejected endometrium.
Endometrial repair includes glandular and stromal regeneration and angiogenesis. Vascular endothelial growth factor (VEGF) and fibroplastic growth factor (PFR) are found in the endometrium and are potent angiogenic agents. It is revealed that estrogen-produced glandular and stromal regeneration is enhanced under the influence of epidermal growth factors (EGF). Growth factors such as transforming growth factor (TGF) and interleukins, especially interleukin-1 (IL-1), are of great importance.
A brief overview of the processes occurring in the endometrium
The main role at the beginning of menstruation is spasm of arterioles.
The functional layer of the endometrium (upper, constituting 75% of the thickness) is rejected.
Menstruation stops due to vasospasm and endometrial repair. Fibrinolysis prevents the formation of adhesions.
Characterized by estrogen-induced proliferation of glands and stroma.
Characterized by progesterone-induced secretion of glands.
Decidualization is induced in the late secretory phase.
Decidualization is an irreversible process. In the absence of pregnancy in the endometrium apoptosis occurs with the subsequent appearance of menstruation.
So, the reproductive system is a supersystem, the functional state of which is determined by the reverse afferentation of its constituent subsystems. Allocate: a long loop of feedback between the hormones of the ovary and the nuclei of the hypothalamus, between the hormones of the ovary and the pituitary gland, a short loop between the anterior lobe of the pituitary and the hypothalamus, ultrashort between the WG-LH and neurocytes (nerve cells) of the hypothalamus.
Feedback in a mature woman is both negative and positive. An example of a negative connection is the increased release of LH from the anterior pituitary in response to low estradiol levels in the early follicular phase of the cycle. An example of positive feedback is the release of LH and FSH in response to the ovulatory maximum of estradiol in the blood. The mechanism of negative feedback increases the formation of WG-LH with a decrease in the level of LH in the cells of the anterior pituitary gland.
Gonadoliberin is synthesized by neurons of the funnel nucleus, then enters the portal system of the pituitary gland and enters the adenohypophysis through it. Gonadoliberin secretion occurs impulsively.
The early stage of development of a group of primordial follicles does not depend on FSH.
With the involution of the corpus luteum, the secretion of progesterone and inhibin decreases and the level of FSH increases.
FSH stimulates the growth and development of a group of primordial follicles and their secretion of estrogen.
Estrogens prepare the uterus for implantation, stimulating the proliferation and differentiation of the functional layer of the endometrium and together with FSH contribute to the development of follicles.
According to the two-cell theory of the synthesis of sex hormones, LH stimulates the synthesis of androgens in techocytes, which are then transformed into estrogens in granulosa cells under the influence of FSH.
The increase in the concentration of estradiol on the mechanism of negative feedback, loop
which closes in the pituitary and hypothalamus, inhibits the secretion of FSH.
A follicle that will ovulate in a given menstrual cycle is called dominant. Unlike other follicles that have begun to grow, it carries a larger number of FSH receptors and synthesizes more estrogens. This allows it to develop, despite the decrease in the level of FSH.
Adequate estrogenic stimulation provides the ovulatory peak of LH. It, in turn, causes ovulation, the formation of the yellow body and the secretion of progesterone.
The functioning of the corpus luteum depends on the level of LH. When it decreases, the corpus luteum undergoes involution. This usually happens on the 12-16th day after ovulation.
If fertilization has occurred, the existence of the corpus luteum supports chorionic gonadotropin. The corpus luteum continues to secrete progesterone, which is necessary to preserve early pregnancy.
What is menstruation
Menstruation is part of the reproductive process. It begins in girls at puberty, but for each this process is different. Often, young girls worry about the fact that menstruation began too early, or, on the contrary, linger. Age limits in which the beginning of this process is considered normal, from 12 to 20 years, depending on various external (habitat, ecology) and internal (body structure, heredity) factors.
Despite the fact that most girls in the modern world know: sooner or later, they should have critical days, few people understand why there is blood during menstruation.
This process is directly related to the ovulation of the exit from the uterus of the egg, which was not fertilized. In a healthy female body, it occurs monthly. When the egg leaves the uterus, its endometrium mucosa is slightly injured. Small wounds are formed from which thick blood is drawn. With her, the uterus leaves the egg and exfoliated particles of the endometrium. Due to the fact that for the most part, the monthly blood consists of these mucous particles, it becomes thicker, but it does not clot.
Normally, the monthly should go no more than 7 days. The period from their first day in this month to the first day of the next day is called the menstrual cycle. It is believed that it can be from 21 to 35 days, but usually it is 28-30 days, therefore women consider that critical days come once a month.
In fact, blood during menstruation is a separate type of fluid that forms in a woman’s body. Therefore, it is important to understand not only where blood comes from, but also what gets into it on the way to exit from the vagina, in order to understand whether this is the norm or deviation.
Here are the main features of this fluid.
- Dark color is provided by secretions from the mucous membrane and endometrial particles, which are included in the initially scarlet blood. If the color remains bright, it indicates the presence of pathologies.
- Due to mucous secretion, it is thick blood, which has lost the ability to coagulate, and, therefore, there is no place to take the formation of a blood clot in the uterus.
- The first 2-3 days of selection are abundant, then gradually reduced.
- In the discharge should not be blotches of other colors and blood clots, but in the first days there are particles of the endometrium.
When the menstruation comes to an end, bloody strokes of a dark red or brown color may be observed for several days.
Some women worry that during menstruation an unpleasant odor can emanate from them. Normally, it is considered that the smell of discharge is similar to the smell of iron and should not be unpleasant. If the discharge smells harsh and unpleasant, this indicates a disease or hygiene. Here it will be useful to consult a gynecologist.
It is believed that during the critical days, the girl loses about 50 ml of blood, but do not panic, if this number reaches 80. At the same time, it is pure blood, you should not forget that there is a large amount of impurity of mucus in it.
Calculate how much liquid came out, in fact, is not so simple. There are suggestions that this can be calculated by the number of used gaskets (one gasket for 4-5 drops can absorb up to ml). But the amount of discharge and frequency, when a woman changes the means of hygiene is different for everyone.
The reason for worrying may be a situation in which the discharge is so strong that you have to change the gasket every 2-3 hours, and after 7 days they have not stopped.
Why menstruation is painful
Theoretically, menstruation should be painless. But in fact, a very small percentage of women do not experience discomfort these days. This is especially true for adolescents with a still unstable cycle, or when menopause approaches, during these periods hormonal changes are the cause of discomfort.
But in the majority of women of reproductive age, the first days of menstruation are accompanied by painful sensations. This is a natural process. Usually associated with the physiological characteristics of the female body, and when the egg comes out, the pain stops.
But sometimes painful critical days signal certain health problems. This can be as a result of stress, nervous or physical overstrain and lack of vitamins, as well as a serious illness. Therefore, if the discharge is accompanied by pain and deterioration of the general condition, it is necessary to consult a gynecologist and determine their nature. “Healing” a similar condition by taking painkillers or using folk remedies can lead to serious consequences.
Is it possible to have intercourse during menstruation?
Some believe that if the partner is not embarrassed by the blood during menstruation, then sexual intercourse is acceptable. And for some women, it is a kind of "anesthetic" during this period. If the partners can not deny yourself the pleasure, then you need to follow certain rules.
- Be sure to carry out hygiene procedures before and after - both partners.
- Use condoms or similar contraceptives.
- Avoid deep penetration, so as not to damage the female genitals that are particularly sensitive at this moment.
- Take care of the place where the act will take place, for example, spread a towel.
However, this is not a safe occupation. This process has a downside. Not everyone knows why it is impossible to make love during menstruation. The fact is that in this period of time the cervix is ajar, and various microbes can easily penetrate inside. The most common effects of sex during critical days are:
- endometritis (inflammation of the uterus mucosa),
- fungal diseases
- venereal diseases.
For health problems, intercourse is all the more worth giving up. By the way, some believe that it is impossible to get pregnant during this period, but this opinion is erroneous and pregnancy is quite possible, although with a lower probability.
Causes of hemoglobin increase
- Dehydration (reduced fluid intake, excessive sweating, impaired kidney function, diabetes mellitus, diabetes insipidus, profuse vomiting or diarrhea, use of diuretic drugs)
- Congenital heart or lung disease
- Pulmonary insufficiency or heart failure
- Kidney diseases (renal artery stenosis, benign kidney tumors)
- Diseases of the blood-forming organs (erythremia)
Causes of increased blood eosinophils
- Allergies (bronchial asthma, food allergies, pollen allergies and other airborne allergens, atopic dermatitis, allergic rhinitis, drug allergies)
- Parasitic diseases - intestinal parasites (giardiasis, ascariasis, enterobiasis, opisthorchiasis, echinococcosis)
- Infectious diseases (scarlet fever, tuberculosis, mononucleosis, venereal diseases)
- Cancer tumors
- Diseases of the hematopoietic system (leukemia, lymphoma, lymphogranulomatosis)
- Rheumatic diseases (rheumatoid arthritis, periarteritis nodosa, scleroderma)
Reasons for increasing monocytes (monocytosis)
- Infections caused by viruses, fungi (candidiasis), parasites and protozoa
- The recovery period after acute inflammation.
- Specific diseases: tuberculosis, syphilis, brucellosis, sarcoidosis, ulcerative colitis
- Rheumatic diseases - systemic lupus erythematosus, rheumatoid arthritis, periarteritis nodosa
- hematopoietic system diseases acute leukemia, myeloma, lymphogranulomatosis
- poisoning with phosphorus, tetrachloroethane.
Reasons for the increase in lymphocytes (lymphocytosis)
- Viral infections: infectious mononucleosis, viral hepatitis, cytomegalovirus infection, herpes infection, rubella
- Diseases of the blood system: acute lymphocytic leukemia, chronic lymphatic leukemia, lymphosarcoma, heavy chain disease - Franklin's disease,
- Poisoning with tetrachloroethane, lead, arsenic, carbon disulfide
- The use of drugs: levodopa, phenytoin, valproic acid, narcotic painkillers