Why do women menstruate? Historical and evolutionary review

Theories regarding the significance of menstruation from the time of Aristotle to the present are reviewed, followed by a brief description of the evolutionary changes in the uterus. A specific duct for the transport of ova first appears in jawed fishes. Its important role in the evolution of internal fertilisation and the protection and nourishment of the embryo is followed through the vertebrate orders, amphibia, reptiles and mammals. The problems associated with the presence of a gamete or zygote of different genetic make up inside the maternal tract is stressed, and the mechanisms to overcome or modify the maternal inflammation reaction discussed. In egg laying reptiles and birds, the secretion of coverings around the embryo presumably shields the foreignness of the tissue, while in viviparous animals, the secretion of progesterone plays a major role in controlling the inflammatory reaction. In some mammals, for example the mouse, the invasiveness of the trophoblast is such that the blastocyst penetrates inside the wall of the endometrium. The stroma responds under the influence of progesterone, to undergo an implantation/decidual reaction which bears considerable resemblance to an inflammatory/granulation tissue reaction. A similar reaction occurs in women during the luteal phase in anticipation of a very invasive blastocyst. When there is no fertilisation the progesterone drops and the differentiated stromal tissue is shed with bleeding; menstruation.