1. Anatomy & Physiology of the Female Reproductive Tract

4. External Genital Organs
mons pubis
labia majora
labia minora
prepuce (clitoral hood)
frenulum of the labia minora = fourchette
vestibule of the vagina
external urethral orifice
paraurethral glands (Skene’s glands) [prostate]
Bartholin's gland

6. Pubococcygeus Muscle main part of levator ani injuries
most likely muscle to be damaged during childbirth
supports the bladder, urethra, vagina, and rectum
injuries
cystocele
cystourethrocele or urethrocystocele
rectocele
urinary stress incontinence (weakening of pubovaginalis part of levator ani) => Kegel exercise

8. venous drainage: internal pudendal veins
vaginal orifice
hymen
greater vestibular glands
Bartholin’s glands [bulbourethral glands]
arterial supply
two external pudendal arteries
one internal pudendal artery
venous drainage: internal pudendal veins

11. Lymph Drainage
The external genitalia, anus, and anal canal drain to the superficial inguinal nodes.
The lower one third of the vagina drains to the sacral nodes and the internal and common iliac nodes.
The cervix drains to the external or internal iliac and sacral nodes

12. Lymph, cont’d The lower uterus drains to the external iliac nodes
The upper uterus drains into the ovarian lymphatics to the lumbar nodes. The lymphatics of the ovaries drain out of the pelvis to the lumbar nodes

14. Innervation ilioinguinal nerve
genital branch of the genitofemoral nerve
perineal branch of the femoral cutaneous nerve of thigh
perineal nerve

16. Pelvic Viscera Urogenital organs…
bladder, uterus, adnexa, and rectum
Also have…the sigmoid colon, cecum, and ileum are components of the pelvic anatomy.

17. Pelvic Viscera urinary organs rectum ureters urinary bladder
pass medial to origin of uterine artery and continues to level of ischial spine, where is crossed superiorly by the uterine artery. Then passes close to lateral portion of vaginal fornix and enters posterosuperior angle of bladder
urinary bladder
hollow viscus with strong muscular walls
trigone of bladder
urethra - about 4 cm long, anterior to vagina
rectum

18. Ligaments
round ligament of uterus - attaches anterior-inferiorly to uterotubal junctions
ligament of ovary - attached to uterus, posterior-inferior to uterotubal junctions
broad ligament - encloses body of uterus, freely moveable
transverse cervical ligaments - extend from cervix and lateral parts of vaginal fornix to lateral walls of pelvis
uterosacral ligaments - pass superiorly and slightly posteriorly from sides of cervix to middle of sacrum, can be palpated through rectum as pass posteriorly at sides of rectum. Hold cervix in normal relationship to sacrum.

20. Broad Ligament
Contains between its layers the fallopian tube; the ovary and the round ligament; the uterine and ovarian blood vessels, nerves, lymphatics, and fibromuscular tissue; and a portion of the ureter as it passes lateral to the uterosacral ligaments over the lateral angles of the vagina and into the base of the bladder

21. Internal Genital Organs
vagina
fornix
rectouterine pouch (pouch of Douglas)
sphincters of vagina
pubovaginalis muscle
urogenital diaphragm
bulbospongiosus muscle
lymphatic drainage
superior part into internal and external iliac lymph nodes
middle part into the internal iliac lymph nodes
vestibule into superficial inguinal lymph nodes

23. Uterus 7-8 cm long, 5-7 cm wide, 2-3 cm thick
projects superior-anteriorly over urinary bladder
two major parts
body (superior 2/3s)
fundus
cervix (inferior 1/3)
internal os
external os
anterior lip
posterior lip
lined with columnar, mucus-secreting epithelium
isthmus = a transitional zone between body and cervix

25. wall of uterus consists of 3 layers:
Perimetrium/serosa - outer serous coat, peritoneum supported by thin layer of connective tissue
myometrium mm smooth muscle, main branches of blood vessels and nerves of uterus are in this layer
endometrium - inner mucous coat

26. uterine tubes 10-12 cm long, 1 cm diameter
extend laterally from cornua of uterus
4 parts
infundibulum
distal end
abdominal ostium, about 2 mm in diameter
20-30 fimbriae
ovarian fimbria is attached to ovary
ampulla
tortuous part
widest and longest part, over 1/2 its length
fertilization occurs here
Most common site for ectopic

28. isthmus
short 2.5 cm, narrow, thick-walled part of tube that enters the uterine cornu
uterine part
short segment that passes through thick myometrium of uterus
uterine ostium (smaller than abdominal ostium)

30. Ovaries oval, almond-shaped, 3 cm long, 1.5 cm wide, 1 cm thick
ligaments
superior (tubal) end of ovary is connected to lateral wall of pelvis by suspensory ligament of the ovary
contains ovarian vessels and nerves
ligament of ovary - connects inferior (uterine) end of ovary to lateral angle of uterus
surface of ovary is not covered by peritoneum
oocyte expelled into peritoneal cavity

31. Pelvis The bony and ligamentous pelvic mechanism is designed to…
protect the pelvic viscera
support the vertebral column
facilitate locomotion
The pelvic girdle protects the viscera contained within its cavity from all ordinary trauma

32. Pelvis
The bony pelvis is formed anteriorly and laterally by the innominate bones and posteriorly by the sacrum and coccyx
The pelvic girdle is adapted for strength, support, and locomotion.
In the erect position, the pelvic girdle is inclined forward.

35. Man vs. Woman
The female pelvic inlet is oval; the male pelvic inlet is heart shaped.
The female pelvis has a more regular outline than the male pelvis, in which the sacral promontory is more prominent and the sacrum is longer and more curved.

36. Female Bony Pelvis
wider, shallower, and has larger superior and inferior pelvic apertures than male pelvis
hip bones farther apart
ischial tuberosities are farther apart because of wider pubic arch
sacrum is less curved, which increases the size of the inferior pelvic aperture and the diameter of the birth canal
obturator foramina is oval

37. Types of Bony Pelvis anthropoid = AP diameter > transverse diameter
23% females
platypelloid
uncommon
android = wide transverse diameter, posterior part of aperture is narrow
32% females
gynecoid = most spacious obstetrically
43% females

39. Superior Pelvic Aperture
AP diameter = measurement from the midpoint of the superior border of pubic symphysis to the midpoint of sacral promontory
transverse diameter = greatest width, measured from linea terminalis on one side to this line on opposite side

40. determine prominence of ischial spines
oblique diameter = measurement from one iliopubic eminence to the opposite sacroiliac joint
midplane diameter = interspinous diameter or distance between ischial spines and cannot be measured. Is estimated by palpating the scarospinous ligament through the vagina. The length of this ligament = about half the midplane diameter.
determine prominence of ischial spines
< 9.5 cm may prevent passage of fetus

41. Physiology Hypothalamus Anterior Pituitary Ovary
Endometrium & outflow tract

42. Hypothalamus
Release of GnRH (gonadotropin-releasing hormone), also called LHRH, into the pituitary portal circulation via the pituitary stalk
The menstrual cycle does not ‘begin’ here!! All are inter-related !

43. Hypothalamus What triggers the release of GnRH?
Unclear but in animal studies dopamine is inhibitory & norepinephrine is stimulatory
For normal gonadotropin release, GnRH must be released in pulses. The pulse frequency & amplitude are critical for normal menses
Decrease in pulse frequency will decrease LH release & increase FSH
Increase pulse frequency will increase LH & decrease FSH

44. Anterior Pituitary
Gonadotrophs respond to the GnRH by producing FSH (follicle stimulating hormone) & LH (Luteinizing hormone) into the general circulation
Release at this level is also controlled by circulating levels of estrogen & progesterone (gonadal steroids)…positive & negative feedback

45. Anterior Pituitary Stores & releases FSH & LH
Day 1-7, follicular phase: estrogen from the ovary will stimulate storage of FSH & LH(in the pituitary)…also inhibits secretion
Later in follicular phase with increasing estrogen levels (enlarging follicle) effect on gonadotrophs changes to stimulatory allowing for a secretion of LH which triggers ovulation

47. Under the influence of LH, the follicle begins to secrete progesterone shortly before ovulation
Low level of progesterone will induce the FSH surge that occurs immediately prior to ovulation

48. FSH Surge matures the oocyte (stimulates gametogenesis
produces proteolytic enzymes needed for follicle rupture
Increases the # of LH receptors(ovarian) required for optimal progesterone production in the luteal phase

49. LH surge
increase in intrafollicular proteolytic enzymes that destroy the basement membrane and allow follicular rupture
luteinization of the granulosa cells and theca, resulting in increased progesterone production
resumption of meiosis in the oocyte, thus preparing it for fertilization
an influx of blood vessels into the follicle, preparing it to become a corpus luteum.

51. After ovulation, the secretion of estrogen & progesterone in high concentrations from the corpus luteum inhibits both gonadotrophs & GnRH
As the corpus luteum dies off the hormone levels subside & FSH resumes the cycle

52. Ovary
By the fifth week of embryonic life, germ cells have formed the ovary
Maximum # of eggs the ovary is able to produce is at 20 weeks of gestation… 6-7 million!
1-2 million at birth
300,000 at the onset of puberty!

54. Ovary The functional unit is the FOLLICLE
Oocyte (frozen in the first stage of meiosis) surrounded by granulosa cells & adjacent stromal cells…Theca cells.
FSH will target the granulosa cells
LH will target the thecal & stromal cells

55. Ovary, cont’d
As the follicle matures, Antrum develops around the oocyte
A bunch of follicles will develop around day 7 of cycle…a dominant follicle will win!

57. Ovary cont’d
Rising estrogen levels from the maturing follicle itself will ‘prime’ the follicle for the LH surge.
When estrogen levels reach 200pg/ml or greater for longer than 48 hours, the LH surge occurs
The granulosa cells become luteinized just prior to ovulation & begin to produce progesterone

58. Progesterone rise is responsible for...
Facilitates the positive feedback action of estradiol in initiating the LH surge
LH surge occurs about 36 hours prior to ovulation
Responsible for the FSH peak

60. Ovary
An avascular area will develop on the wall of the follicle & with the help of proteolytic enzymes ovulation occurs.
The oocyte is picked up by the fimbriae of the tube
If not met by a sperm will degenerate in hours!

61. Ovary
After ovulation, luteinization will transform the ruptured follicle into a corpus luteum which produces estrogen & progesterone for the next days
If not aided by secretion of hCG, the corpus luteum will become the corpus albicans

62. Androgens
Androstenedione & testosterone are also secreted & can alter the ability of the ovary to respond to FSH & LH…may create atretic follicles early on

63. TWO CELL THEORY …of ovarian steroidogenesis
Theca cells produce androgens under the influence of LH
Granulosa cells convert the androgens to estrogen under the influence of FSH

64. Endometrium Contains receptors for both estradiol & progesterone
Estradiol causes the proliferation, steady increase in thickness of lining
When the corpus luteum starts producing progesterone; the proliferative effect of estradiol is neutralized & endometrial growth ceases

66. Endometrium
The lining now becomes SECRETORY with the endometrial vessels coiling & preparing to shed
If no baby… corpus luteum stops producing estrogen & progesterone. This withdrawal of steroid support from the endometrium causes endometrial breakdown

67. Why don’t women bleed to death every month??
Vascular spasm
Thrombosis
Resumption of endometrial proliferation under the influence of unopposed estrogen
Myometrial ischemia - dysmenorrhea