Chapter040

Chapter 40
Disorders of the Female
Genitourinary System
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Female Reproductive Anatomy

Estrogens
• Sexual maturation
• Ovulation
• Development and maintenance of female accessory
organs
• Cell division in breasts and endometrium
• Maintaining skin and blood vessels
• Decreasing bone resorption
• Increased HDL levels, decreased LDL, and
cholesterol
• Moving fluid into tissues

Progesterones
• Maintaining pregnancy
• Breast and endometrium development
• Maturation of endometrium cells
• Increased body temperature
• Smooth muscle relaxation

The Menstrual Cycle
• Gonadotropin-releasing
hormone (GnRH) from
the hypothalamus
begins the cycle
• It causes the anterior
pituitary to release
follicle-stimulating
hormone (FSH) and
luteinizing hormone
(LH)
Hypothalamus
GnRH
Anterior
pituitary
FSH LH

The Menstrual Cycle (cont.)
• Follicle-stimulating
hormone (FSH) and
luteinizing hormone
(LH) make ovarian
follicles begin to
mature
• This is the follicular
phase of the menstrual
cycle
anterior
pituitary
FSH LH
ovarian follicles
begin to mature

• The developing
follicle produces
estrogen
• Estrogen
decreases FSH
release
• Only the
strongest
follicles survive
the drop in FSH
negative
feedback
inhibits
FSH
release
anterior
pituitary
FSH LH
ovarian follicles
begin to mature
estrogen

• Only the
strongest follicles
survive the drop
in FSH
• Follicles continue
to make estrogen
• Estrogen now
stimulates LH
release from the
anterior pituitary
strongest follicle survives
continued estrogen
production
stimulates LH release

• LH surge causes
release of the
egg
• Ovulation
• Follicle cells
become corpus
luteum, making
progesterone
• This is called the
luteal phase of
the cycle
LH surge
follicle bursts open
OVULATION
oocyte released
into fallopian
tube
remaining follicle
cells become
corpus luteum
progesterone

• Progesterone
prepares the body
for pregnancy
• If pregnancy does
not occur, the
corpus luteum
dies
• The drop in
progesterone tells
the hypothalamus
to secrete GnRH
and begin a new
cycle
LH surge
OVULATION
oocyte released
into fallopian
tube
remaining follicle
cells become
corpus luteum
progesterone

Question
Which hormone slows down the release of FSH?
a. LH
b. Estrogen
c. Progesterone
d. GnRH

Answer
b. Estrogen
Estrogen, produced by the developing follicle, decreased
FSH release (which only the strongest follicles will be
able to survive). The remaining follicles continue to
produce estrogen, which will stimulate the pituitary
gland to release LH.

Disorders of the External Genitalia
• Bartholin gland cyst and abscess
• Leukoplakia
– Lichen sclerosus
– Lichen simplex chronicus
• Vulvodynia
– Cyclic vulvodynia
– Vulvar dermatoses
– Vulvar dysesthesia

Vulvar Carcinomas
• In younger women:
– Often preceded by vulvar intraepithelial neoplasia
– Related to human papillomavirus infection
• In older women
– Often preceded by non-neoplastic disorders
– Lesions cause itching and repeated injury
– Healing cells are more likely to mutate

Vaginal Bacterial Flora
• Many different species of bacteria
– Dominated by species that produce lactic acid
– Vaginal pH 3.8–4.2
– Protect against infections
• Normal flora can be disrupted by:
– Abnormal estrogen levels
– Increased glycogen availability
– Antibiotics

Cervical Epithelium
• Inside the cervix: columnar epithelium
• Exposed to acid in vagina: transforms to squamous
epithelium
• Transforming cells are more likely to become
cancerous

Cancers of the Cervix and Vagina
• Cervical cancer
– Related to human papillomavirus infection
• Vaginal cancer
– Related to prenatal exposure to diethylstilbestrol
– May also be caused by:
º Spread of cervical cancer
º Human papillomavirus infection
º Chronic local irritation

Question
Tell whether the following statement is true or false:
HPV is a contributing factor to both vulvular and cervical
cancer.

Answer
True
In young women, HPV has been linked to vulvular cancer;
it also causes 70% of cervical cancers.

Anatomic Abnormalities
• Disorders of pelvic support
– Cystocele
– Rectocele
– Uterine prolapse
• Variations of uterine position

Endometrial Disorders
• Endometritis
• Pelvic inflammatory disease
• Endometriosis
• Adenomyositis
• Endometrial cancer
• Leiomyomas

Pelvic Inflammatory Disease
• Infection ascends through uterus to fallopian
tubes and ovary
• Inflammation causes:
– Pain in lower abdomen and cervix
– Purulent discharge
– Increased WBC count
– Increased C-reactive protein

Endometriosis
• How did the tissue get there?
– Up through the fallopian tubes (retrograde
menstruation)
– Activation of dormant cells that were always there
• The ectopic implants respond to hormones
– Go through menstrual cycle
– During menstrual period, tissue dies and bleeds
– Pain and adhesions result

Endometrial Cancer
• Endometrial cancer has sometimes been caused
by administration of estrogen without
progesterone
Question
• Why would this make cancer more likely?

Ovarian Disorders
• Ovarian cysts
• Polycystic ovary syndrome
• Benign ovarian tumors
• Functioning ovarian tumors
– Estrogen secreting
– Androgen secreting
– Mixed estrogen and androgen secreting
• Ovarian cancer

Polycystic Ovary
Syndrome
• Follicles develop
• But they do not ovulate
after the LH surge
• The high LH levels
continue
• LH stimulates androgen
production
• This interferes with
ovulation even more
• Ovaries contain many
unovulated follicles
ovarian follicles
begin to mature
strongest follicle survives
decreased FSH levels
continued estrogen
production
stimulates LH release
LH surge
OVULATION

Benign and Functioning Ovarian Tumors
• Benign tumors
– Epithelial cell: cystadenomas
– Endometriomas or “chocolate cysts”
– Fibromas
– Cystic teratomas or dermoid cysts: develop from
germ cells
• Functioning tumors: secrete hormones
– Estrogens: alter menstrual cycle
– Androgens: cause masculine characteristics

Ovarian Cancer
• Associated with family history of ovarian and
breast cancer
• Causes vague GI symptoms
• Up to 75% of cases have metastasized by the
time they are discovered
• No good screening tests available

Question
Tell whether the following statement is true or false:
Early detection through screening tests has improved the
prognosis of ovarian cancer.

Answer
False
Because the signs and symptoms of ovarian cancer are so
vague, the majority of patients do not seek medical
attention until the disease is advanced (the cancer has
usually metastasized by then).
There are currently no good screening tests available to
detect ovarian cancer.

Menstrual Disorders
• Dysfunctional menstrual cycles
• Dysfunctional bleeding
• Amenorrhea
• Dysmenorrhea
• Premenstrual syndrome
• Menopause and aging changes

Scenario
• Ms. T is 63 and postmenopausal. She used hormone
replacement therapy for 8 years after her
menopause, but discontinued it on her doctor's
advice 4 years ago
• She has come into the clinic to request birth control
• She says she has started to menstruate again and
her breasts have “plumped out”
Question
• What do you think is happening?

Menopause or Climacteric
• Decreased ovary
function
• Low estrogen
– Osteoporosis
risk
– Atherosclerosis
risk
• Less inhibition of
pituitary
– Increased FSH
and LH
– Hot flashes
negative
feedback
inhibits
FSH
release
anterior
pituitary
FSH LH
ovarian follicles
begin to mature
estrogen

Question
Why are post-menopausal women at risk for osteoporosis?
a. Diminished function of the ovaries
b. Decreased progesterone levels
c. Decreased estrogen levels
d. Increased levels of FSH and LH

Answer
c. Decreased estrogen levels
Estrogen stimulates osteoblasts (bone cells that
build/synthesize bone tissue). Lower levels of estrogen
= less stimulation of osteoblasts = decreased bone
density = increased risk of osteoporosis (decreased
bone density, especially spongy bone).

Breast Anatomy

Disorders of the Breast
• Mastitis
• Ductal ectasia
• Fibrocystic changes
• Breast cancer

Breast Cancer
• Cancer develops when cells mutate and are not repaired
– BRCA1 and BRCA2 genes code for proteins that help
repair DNA after it has mutated
– Mutation of BRCA1 or BRCA2 make cancer more
likely
• In a cancer, cells continue dividing too fast
– Estrogen and other growth factors make breast cells
divide
– Breast cells with too many estrogen or growth factor
receptors are more likely to become cancerous

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