Chapter040

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 40

Disorders of the Female Genitourinary System

Chapter 40

Disorders of the Female Genitourinary System


Female Reproductive AnatomyFemale Reproductive Anatomy


EstrogensEstrogens• 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


ProgesteronesProgesterones

• Maintaining pregnancy

• Breast and endometrium development

• Maturation of endometrium cells

• Increased body temperature

• Smooth muscle relaxation


The Menstrual CycleThe 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.)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


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 openOVULATION

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


oocyte released into fallopian

tube

remaining follicle cells become corpus luteum

progesterone



Question Question

Which hormone slows down the release of FSH?

a. LH

b. Estrogen

c. Progesterone

d. GnRH


Answer 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 GenitaliaDisorders of the External Genitalia

• Bartholin gland cyst and abscess

• Leukoplakia

– Lichen sclerosus

– Lichen simplex chronicus

• Vulvodynia

– Cyclic vulvodynia

– Vulvar dermatoses

– Vulvar dysesthesia


Vulvar CarcinomasVulvar 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 FloraVaginal 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 EpitheliumCervical 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 VaginaCancers 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 Question

Tell whether the following statement is true or false:

HPV is a contributing factor to both vulvular and cervical cancer.


Answer Answer

True

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


Anatomic AbnormalitiesAnatomic Abnormalities

• Disorders of pelvic support

– Cystocele

– Rectocele

– Uterine prolapse

• Variations of uterine position


Endometrial DisordersEndometrial Disorders

• Endometritis

• Pelvic inflammatory disease

• Endometriosis

• Adenomyositis

• Endometrial cancer

• Leiomyomas


Pelvic Inflammatory DiseasePelvic 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


EndometriosisEndometriosis

• 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 CancerEndometrial Cancer

• Endometrial cancer has sometimes been caused by administration of estrogen without progesterone

Question

• Why would this make cancer more likely?


Ovarian DisordersOvarian 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 SyndromePolycystic 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


strongest follicle survives decreased FSH levels

continued estrogen production

stimulates LH release

LH surge



Benign and Functioning Ovarian TumorsBenign 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 CancerOvarian 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 Question

Tell whether the following statement is true or false:

Early detection through screening tests has improved the prognosis of ovarian cancer.


Answer 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 DisordersMenstrual Disorders

• Dysfunctional menstrual cycles

• Dysfunctional bleeding

• Amenorrhea

• Dysmenorrhea

• Premenstrual syndrome

• Menopause and aging changes


ScenarioScenario

• 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 ClimactericMenopause 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


estrogen


Question 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 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 AnatomyBreast Anatomy


Disorders of the BreastDisorders of the Breast

• Mastitis

• Ductal ectasia

• Fibrocystic changes

• Breast cancer


Breast CancerBreast 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

Chapter040

Documents

release of fsh

vagina cervical cancer

cervical epithelium

cervical cancers

vulvar carcinomas

toproduce estrogen

developing follicle

pregnancy doesnot