Anatomy and Phsio

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OT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
CHAPTER 5
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NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
Gynecologic Anatomy
and Physiology
© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION
Deana Hays
Nicole R. Clark
The editors acknowledge Nancy J. Hughes, Nancy M. Steele, and Suzanne M. Leclaire, who were the authors of the
Jones & Bartlett Learning,
previous editionLLC
of this chapter. © Jones & Bartlett Learning, LLC
The women’s health movement encourages (2) the sacrum, and (3) the coccyx. The innomi-
women to be ©knowledgeable
about their LLCbones consist of the pubis,©the
bodies, to nate Jones
ischium,& and
Bartlett Learning
appreciate theNOT FOR
unique formSALE OR DISTRIBUTION
and function of the fe- the ilium, all of which are fusedNOT FORatSALE
together the OR DISTRIB
male body, and to take responsibility for caring and acetabulum (Corton, 2012). The ilium comprises
making decisions about their bodies that will posi- the posterior and upper portion of the innominate
tively affect their health. This chapter reviews fe- bone, forming what is known as the iliac crest. It
male anatomy and physiology in terms of how they articulates with the sacroiliac joint posteriorly, and
directly affect gynecologic health and well-being. together with its ligaments is the major contributor
© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC
Female anatomy and physiology are often re- to pelvic stability. The pubic bones articulate anteri-
NOT ferred
FORtoSALE OR DISTRIBUTION NOT FOR
as reproductive anatomy and physiology. orly with the symphysis pubisSALE OR
and, with theirDISTRIBUTION
inferior
Gynecology is defined as the branch of medicine angles from the descending rami, form the impor-
dealing with the study of diseases and treatment tant bony landmark of the pubic arch (Figure 5-1).
of the female reproductive system. Regardless of The ischial spines are bony prominences that are
whether a woman is pregnant or ever intends to clinically important because they are used as land-
Jones & Bartlettreproduce,
Learning, LLC
her gynecologic © Jones
care has historically & Bartlett
marks when Learning,
performing LLC and in
pudendal blocks
focused on reproduction. This example of naming other medical procedures such as sacrospinous lig-
provides insight into why women often continue ament suspension (Anderson & Gendry, 2007). The
to be essentialized to reproductive functions by ischial spines are also used to assess progression of
clinicians. fetal descent during childbirth.
The authors of this chapter assume the reader The sacrum and the coccyx shape the posterior
has had basic human anatomy and physiology con- portion of the pelvis. The sacrum is formed by the
tent. Readers©requiring
Jonesa& Bartlett
more in-depthLearning, LLC of the five sacral vertebrae,
discussion fusion © Jones & Bartlett Learning
which includes
are referredNOT FORanatomy
to general SALE andORphysiology
DISTRIBUTION
the important bony landmark of NOT FORprom-
the sacral SALE OR DISTRIB
references. ontory, and joins the coccyx at the sacrococcygeal
symphysis. The coccyx is formed by the fusion of
four rudimentary vertebrae, is usually movable,
PELVIC ANATOMY and is itself a key bony landmark. The true pelvis
© Jones & Bartlett Learning,
Pelvic Bones and Pelvic Joints
LLC © Jones
constitutes the & Bartlett
bony passageway Learning,
through which LLC
the fetus must maneuver to be born vaginally.
NOT TheFOR SALE OR DISTRIBUTION
pelvis is composed of (1) two hip bones called
The best-known classification of the female
the innominate bones (also known as ox coxae), pelvis is the Caldwell–Moloy (1933) classification,
77
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9781284078916_CH05_077_094.indd 77 01/07/16 12:16 PM
78 Chapter 5: Gynecologic Anatomy and Physiology

FIGURE 5-1 Bones of the female pelvis.
Sacral promontory
Sacroiliac Ilium
synchondrosis
NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Linea
terminalis Sacrum

SacrococcygealLLC © Jones & Bartlett Learning, Sacrosciatic
LLC
OT FOR SALE OR DISTRIBUTION
symphysis NOT FOR SALE OR DISTRIBUTION notch
Coccyx
Ischial spine Pubis

Acetabulum
Iliopectineal
eminence Ischium
Symphysis pubis
Ischial tuberosity Obturator foramen
which includes four basic pelvic types: gynecoid, passing laterally through the greater sciatic fora-
android, anthropoid, and platypelloid (Figure 5-2). men and inserts in the upper border of the greater
Jones & BartlettEach
Learning,
pelvic typeLLC © Jones
is classified in accordance with & Bartlett
trochanter Learning,
of the femur. The origin ofLLC
the obturator
the characteristics of the posterior segment of the internus muscle includes the pelvic surfaces of the
inlet. The development of this classification re- ilium and ischium and the obturator membrane. It
sulted in the realization that most pelves are not exits the pelvis through the lesser sciatic foramen,
pure types but rather a mixture of types (Kolesova & where it attaches to the greater trochanter of the
Vetra, 2012). hip, enabling it to function in external hip rotation
(Anderson & Gendry, 2007; Corton, 2012).
Pelvic Support
© Jones & Bartlett Learning, LLC © Jones
The deep perineal space is a pouch that lies& Bartlett Learning
supe-
Pelvic support structures include not only the riorly to the perineal membrane NOT FOR SALE OR DISTRIB
(Figure 5 -3). This
muscles and connective tissue of the pelvic floor, deep space is continuous with the pelvic cavity and
but also the fibromuscular tissue of the vaginal contains the compressor urethrae and urethrovagi-
wall and endopelvic connective tissue (Richter & nal sphincter muscles, the external urethral sphinc-
Varner, 2007). The piriformis and obturator internus ter, parts of the urethra and vagina, branches of the
© Jones & Bartlett
muscles Learning,
and their fasciae form partLLC © Jones
of the walls of pudendal artery, and the & Bartlett
dorsal Learning,
nerve and vein of LLC
the pelvic cavity. The piriformis muscle originates the clitoris (Corton, 2012). The perineal membrane
NOT at FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
the front of the sacrum, near the third and fourth (also known as the urogenital diaphragm, although
sacral foramina. This muscle leaves the pelvis by this label is a misnomer) is a sheet made up of dense

9781284078916_CH05_077_094.indd 78 01/07/16 12:17 PM
Gynecologic Anatomy and Physiology 79

FIGURE 5-2 Caldwell–Moloy classification of pelves.
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Anthropoid

Gynecoid Android
Platypelloid
fibrous tissue that spans the opening of the anterior pubococcygeus is further divided into the pubovag-
pelvic outlet. The perineal membrane attaches to inalis, puboperinealis, and puboanalis.
the side walls of the vagina and provides support The levator ani and coccygeus muscles form the
to the distal vagina and urethra by attaching these pelvic floor, and the related fascia form a support-
structures to the bony pelvis (Corton, 2012). ive sling for the pelvic contents. The muscle fibers
The levator ani muscle is a critical component insert at various points in the bony pelvis and form
© Jones
of pelvic support; indeed,&it Bartlett Learning,
is often considered LLC
the functional © Jones
sphincters for the vagina, & and
rectum, Bartlett Learning
most important muscle of the pelvic floor (Corton, urethra. The origin of the NOT FOR SALE
levator ani muscle is the OR DISTRIB
2012). Normally this muscle is in a constant state pubic bone and the adjacent fascia of the obtura-
of contraction, providing support for all of the ab- tor internus muscle. Various portions of this mus-
dominopelvic contents against intra-abdominal cular sheet insert on the coccyx (the anococcygeal
pressures. The levator ani muscle is actually a rapine) and the perineal body, which is a fibrous
© Jones & Bartlett
complex Learning,
unit of several musclesLLC © Jones
with different band lying between & Bartlett
the vagina Learning,
and the rectum. The LLC
origins, insertions, and functions. The pubococ- different sections of the levator ani muscular sheet
NOT cygeus,
FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
puborectalis, and iliococcygeus are the are subdivided based on the exact origin and inser-
primary components making up this muscle. The tion of the fibers:

9781284078916_CH05_077_094.indd 79 01/07/16 12:17 PM

FIGURE 5-3 Superficial musculature of the perineum.
Clitoris
Sphincter– Urethra
membranous urethra © Jones
Perineal vestibule&Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION Vagina
Perineal membrane Bulbocavernosus
muscle
Deep transverse Ischiocavernosus
perineal muscle muscle
Superior fascia– NOT FOR SALE ORIschiopubic
DISTRIBUTION
ramus
urogenital diaphragm
Vestibular bulb
Levator ani–
pubococcygeus muscle Bartholin’s gland

Central tendinous point– Ischial tuberosity
NOTperineum
FOR
SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
Levator ani– Superficial transverse

iliococcygeus muscle perineal muscle
Gluteus maximus
NOT FOR SALEmuscleOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Rectum
External anal sphincter
Fat Anococcygeal body
Coccyx
• The levator prostatae or sphincter vaginae The fan-shaped coccygeus muscle lies anterior
fibers form the sling around the vagina and to the sacrospinous ligament, originates from the
originate from the posterior surface of the pu- ischial spine, inserts into the lower part of the sa-
bis; they insert in the perineal body. crum and coccyx, and works synergistically to aid
© Jones
• The puborectalis & Bartlett
fibers Learning,
are important LLC
in main- the © Jones
levator ani muscle. The transverse & are
perinei Bartlett Learning
taining NOT FOR SALE OR DISTRIBUTION
fecal continence; they originate from small straplike muscles that NOT FOR SALE OR DISTRIB
help support the pelvic
the posterior surface of the pubis and form a viscera. They originate from the ischial tuberosity,
sling around the rectum. pass by the genitalia, and insert in the central ten-
• The pubococcygeus fibers originate from the don at the midline. The bulbocavernosus muscles
posterior surface of the pubis and insert into aid in strengthening the pelvic diaphragm and
© Jones & anococcygeal
the Bartlett Learning,
rapine. LLC © the
in constricting Jones
urinary& and
Bartlett
vaginal Learning,
openings. LLC
• The iliococcygeus fibers originate from the Their muscle fibers originate in the perineal body
obturator internus fascia and the ischium and and surround the vaginal openings as the muscle
insert into the anococcygeal rapine. fibers pass forward to insert into the pubis. The

9781284078916_CH05_077_094.indd 80 01/07/16 12:18 PM

ischiocavernous muscle contracts to cause erec- This conception depicted a woman’s wholeness to
NOTduring
tion of the clitoris FORsexual
SALE OR Its
arousal. muscle be totally related to her genitals,NOT
DISTRIBUTION FOR
of which SALE OR DISTRIB
the most
fibers originate in the tuberosities of the ischium important was her uterus. Consequently, there was
and continue at an angle to insert next to the bul- little appreciation for female genitalia.
bocavernosus muscle (Anderson & Gendry, 2007; This section describes the multiple organs and
Corton, 2012). anatomic structures that constitute a woman’s
gynecologic anatomy, & Bartlett
which are shown Learning,
in a mid- LLC
NOT FEMALE
FOR SALE OR DISTRIBUTION
GENITALIA
sagittal view NOT FOR SALE OR DISTRIBUTION
in Figure 5-4 and Color Plate 1.
Equally important to the discussion of women’s
Dr. Nelson Soucasaux, a Brazilian gynecologist, gynecologic anatomy are the multiple nongeni-
has devoted much of her writing to the tradition- tal peripheral anatomic structures involved in fe-
ally typical and symbolic aspects of women’s sex- male sexual responses, such as salivary and sweat
ual organs, and the importance these views have in glands, cutaneous blood vessels, and breasts.
influencing our understanding of women’s nature.
According to Soucasaux (1993a, 1993b), historically External Genital Anatomy
it was believed that the key to understanding the Vulva
female psyche was having a deeper understanding The vulva is the externally visible outer genitalia
of woman’s genital functions. By tradition, a wom- (Figure 5-5 and Color Plate 2). It includes the
an’s uterus was considered “the fundamental or- mons pubis, labia minora, labia majora, clitoris,
gan” and was©synonymous
Jones & with Bartlett Learning,
her genital organs. LLC meatus, vaginal opening,
urinary © Jones & Bartlett
and corpusLearning
FIGURE 5-4 Midsagittal view of a woman’s pelvic organs.
Fallopian
tube
Ovary
Uterus
OT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Urinary
bladder
Pubic
bone
© Jones & Bartlett Learning, LLC Urethra

© Jones & Bartlett Learning
Cervix NOT FOR SALE OR DISTRIB
Clitoris
Rectum Labium
minora
Vagina
© Jones & Bartlett Learning, LLC © Jones & Bartlett Labium

Learning, LLC
majora
Sagittal section

9781284078916_CH05_077_094.indd 81 01/07/16 12:18 PM

FIGURE 5-5 Female external genitalia.
Mons pubis
Suspensory
Clitoris
ligament
Urethral opening
Labium minora
Labium majora Vaginal opening
OT FOR SALE OR DISTRIBUTION NOT FOR SALE
PerineumOR DISTRIBUTION
Anus

spongiosum erectile tissue (vestibular bulbs) of the size of the labia minora in women of reproductive
labia minora and perineum. The vestibule is inside age. The labia minora are usually more prominent
the labia minora and outside the hymen. On each in children and women who are postmenopausal
side of the vestibule is a Bartholin’s gland, which (Katz, 2012).
NOT secretes
lubricating mucus into the introitus during NOT FOR SALE OR DISTRIBUTION
sexual excitement. The mons pubis is the mound- Clitoris
like fatty tissue that covers and protects the sym- The clitoris is a sensitive organ that is typically de-
physis pubis. During puberty, genital hair growth scribed as the female homologue of the penis in the
covers this pad of tissue. male, particularly in terms of its erogenous func-
Jones & Bartlett Learning, LLC
The labia majora are fused anteriorly with the© Jones & Bartlett
tion (Puppo, Learning,
2013). During the earlyLLC
1800s, a re-
mons veneris, or anterior prominence of the sym- spected English gynecologist, Isaac Baker Brown,
physis pubis, and posteriorly with the perineal body theorized that habitual clitoral stimulation was the
or posterior commissure. They assist in keeping cause of the majority of women’s diseases because
the vaginal introitus closed, which in turn helps it caused an overexcitement of a woman’s nervous
prevent infection. The labia minora are surrounded system. As a result, clitorectomy came into favor
by the labia majora and are smaller, nonfatty folds as a means to rid women of ailments believed to
covered by © Jones & Bartlett
non-hair-bearing Learning,
skin laterally LLC
and by be caused by clitoral stimulation©(Duffy,
Jones 1963;&Hall,
Bartlett Learning
vaginal mucosaNOT FOR SALE OR DISTRIBUTION
on the medial aspect. The anterior 1998). Fortunately, this theory NOT FOR SALE
has long been re- OR DISTRIB
aspect of the labia minora forms the prepuce of the futed, and the practice of clitorectomy in the West-
clitoris and also assists in enclosing the opening of ern world is rare.
the urethra and the vagina. Anatomically, the clitoris is formed from the gen-
Women’s vulva vary in size, related to the ital tubercle (Bradshaw, 2012; Martini, Timmons, &
© Jones
amount & Bartlett
of adipose Learning, LLC
tissue, length, © Jones
and pigment Tallitsch, 2011). It is 1.5 to&2 Bartlett Learning,
cm in length, consists LLC
color of the labia minora or majora, which may be of two crura and two corpora cavernosa, and is
NOT light
pink, dark pink, shades of gray, peach, brown, covered by a sensitive rounded tubercle known as
or black. There is also considerable variation in the the glans (Anderson & Gendry, 2007; Katz, 2012).

9781284078916_CH05_077_094.indd 82 01/07/16 12:18 PM

The clitoris is a small, sensitive organ that consists Bartholin’s or Greater Vestibular Glands
of two pairedNOT FOR
erectile SALEand
chambers OR is DISTRIBUTION
located at The pea-sized Bartholin’s glands NOT areFOR
locatedSALE
at OR DISTRIB
the superior portion of the vestibule (Katz, 2012). about the 4 and 8 o’clock positions in the vulvo-
These chambers are composed of endothelial- vaginal area, just beneath the fascia. Each gland
lined lacunar spaces, trabecular smooth muscle, has an approximately 2-cm duct that opens into a
and trabecular connective tissue; they are sur- groove between the labia minora and hymen. The
© Jones
rounded& by
Bartlett
a fibrousLearning, LLCalbuginea. glands, which©are
sheath, the tunica Jones
made of&columnar
Bartlett Learning,
cells that se- LLC
The paired corpus spongiosum (bilateral vestibular crete clear NOT FOR SALE OR DISTRIBUTION
or whitish mucus, are stimulated dur-
bulbs) unite ventrally to the urethral orifice to form ing sexual arousal (Corton, 2012). If the Bartholin’s
a thin strand of spongiosus erectile tissue connec- ducts are blocked, infection can occur, resulting
tion (pars intermedia) that ends in the clitoris as the in cyst formation that can lead to the develop-
glans (Martini et al., 2011). The clitoris is capped ment of an abscess requiring surgical incision and
Jones & Bartlettexternally

Learning,by the glans, which is covered by a clito- drainage.
LLC
ral hood formed in part by the fusion of the upper
part of the two labia minora. NOTInternal
FOR SALE GenitalOR DISTRIBUTION
Anatomy
The clitoris has numerous nerve endings and Urethra
contains tissue that fills with blood when the The urethra is a short conduit, approximately 3 to
woman is sexually aroused. The blood supply to 5 cm long, extending from the base of the bladder
this organ includes the dorsal and clitoral caver- and exiting externally to the vestibule (Katz, 2012).
© which
nosal arteries, Jones & from
arise Bartlett Learning, The
the iliohypogastric LLC urethral mucosa is composed © ofJones
stratified&tran-
Bartlett Learning
pudendal bed.NOT TheFOR
autonomic
SALE efferent motor in- sitional epithelium near the urinary
OR DISTRIBUTION NOT bladder;
FOR SALE the OR DISTRIB
nervation occurs via the cavernosal nerve of the rest of this structure is lined by a stratified squa-
clitoris arising from the pelvic and hypogastric mous epithelium (Katz, 2012; Martini et al., 2011).
plexus (Bradshaw, 2012; Katz, 2012). In women, the urethra passes through the urogeni-
The labia minora, together with the clitoris, play tal diaphragm, which is a circular band of skeletal
a critical role in sexual activity. Because of their muscle that forms the sphincter urethrae, better
rich nerve and vascular supply, they are easily sen- known as the external urethral sphincter (Martini
NOT sitized
FOR and SALE become engorged with blood during et al., 2011). NOT
OR DISTRIBUTION FOR SALE OR DISTRIBUTION
For a woman to urinate, this sphinc-
sexual arousal. This vascular erectile tissue is ca- ter must be voluntarily relaxed—its typical state is
pable of becoming significantly enlarged and tense contraction.
during sexual excitement. In addition to the great
quantity of erectile tissue in the clitoris, erectile tis- Ovaries
Jones & BartlettsueLearning,
is found insideLLCthe labia majora and minora, © Jones & Bartlett
The paired Learning,
ovaries resemble a largeLLC almond in
around the vulvovaginal opening, and along the terms of their size and configuration; they are
lower third of the vagina. A very small quantity of located near the lateral walls of the pelvic cavity
this tissue can also be found in the vaginal walls (Katz, 2012; Martini et al., 2011) Each ovary mea-
and along the urethra. Age-associated female sex- sures approximately 1.5 cm × 2.5 cm × 4 cm and
ual dysfunction from decreased clitoral sensitivity weighs 3 to 6 gm (Katz).
may be associated with histologic changes in clito- The ovaries produce gametes (also known as
© erectile
ral cavernosal Jonestissue
& Bartlett Learning, ova)
(Katz, 2012). LLCand the sex hormones known © Jones & Bartlett Learning
as estrogen
NOT FOR SALE OR DISTRIBUTION and progesterone. The color NOT FORthese
and texture of SALE OR DISTRIB
Periurethral Glands organs change with a woman’s age and reproduc-
Two Skene’s (paraurethral) glands open directly tive stage. The ovaries in a nulliparous woman are
into the vulva and are adjacent to the distal urethra situated on a shallow depression called the ovarian
(Katz, 2012). The Skene’s glands, which release fossa, located on either side of the uterus in the
© Jones
mucus, & form
Bartlett Learning,
a triangular area of LLC
mucous mem- upper pelvic © Jones
cavity. & Bartlett
Several Learning,
ligaments support the LLC
brane surrounding the urethral meatus from the ovaries. The broad ligament is the principal sup-
NOT clitoral
glans to the vaginal upper rim or caruncle porting membrane of a woman’s internal genital
(Martini et al., 2011). organs, including the fallopian tubes and uterus.

9781284078916_CH05_077_094.indd 83 01/07/16 12:18 PM

The remaining ligaments include the mesovarium, the uterus, outward to their openings near the ova-
a posterior NOT FOR
extension SALE
of the broadOR DISTRIBUTION
ligament; the ries. Each fallopian tube includes NOT FOR SALE OR DISTRIB
four segments:
ovarian ligament, which is anchored to the uterus;
• The pars interstitialis (intramural portion) pen-
and a suspensory ligament, which is attached to
etrates the uterine wall. It contains the fewest
the pelvic wall. The outermost layer of the ovary is
mucosal folds, with the myometrium contrib-
composed of a thin layer of cuboidal epithelial cells
© Jones
called & theBartlett Learning,
germinal epithelium. LLC below • uting
Immediately
to its muscularis.
The isthmus, the narrow segment adjacent to
this epithelial layer is the tunica albuginea, which NOT
the uterine wall,FOR
containsSALE OR DISTRIBUTION
few mucosal folds.
is made up of collagenous tissue (Katz, 2012).
• The middle segment, known as the ampulla,
The ovaries comprise three parts:
is the widest and longest segment. It contains
• An outer cortical region (cortex), which con- extensive branched mucosal folds and is the
tains germinal epithelium with oogonia and most common site of fertilization.
Jones & Bartlett Learning, LLCthat number approximately
ovarian follicles © Jones
• The&infundibulum,
Bartlett Learning, LLC distal
the funnel-shaped
400,000 at the initiation of puberty (Halvorson, NOT FOR SALE
segment, ORnear
opens DISTRIBUTION
the ovary but is not at-
2012a) tached to it (Katz, 2012). Very fine fingerlike
• The medullary region (medulla), which con- fronds of its mucosal folds, known as fimbriae,
sists of connective tissue, myoid-like contrac- project from the opening toward the ovary to
tile cells, and interstitial cells help direct the oocyte into the lumen of the fal-
• A hilum, which is the point of entrance for all
© Jones & Bartlett Learning, LLClopian tube.
of the ovarian vessels and nerves (Halvorson,
© Jones & Bartlett Learning
NOT FOR SALE OR DISTRIBUTION The inner surface of each fallopian
NOT FOR tube is SALE
cov- OR DISTRIB
2012b; Katz, 2012)
ered by fine hairlike structures called cilia that help
Two ovarian arteries that arise from the aorta to move ova, when they are released from the
descend in the retroperitoneal space and cross in ovaries, along the tube and into the cavity of the
front of the psoas muscles and internal iliac ves- uterus. The fallopian tube extends medially and
sels (Katz, 2012). They enter the infundibulopelvic inferiorly from the infundibulum into the superior-
ligaments, finally reaching the mesovarium found lateral cavity of the uterine opening (Katz, 2012).
NOT in FOR SALE OR DISTRIBUTION
the broad ligament. The ovarian blood supply The wall NOT FOR SALE
of the fallopian tube isOR DISTRIBUTION
composed of
enters through the hilum, and venous return oc- three layers: mucosa, muscularis, and serosa. The
curs through a venous plexus, which collects blood internal mucosa includes the lamina propria and
from the adnexal region and drains into the vena ciliated columnar epithelium, which consists pri-
cava on the right and the renal vein on the left. marily of two main cell types. On the surface, the
Innervation ofLLC the ovaries is accomplished © by Jones
abundant & ciliated
Bartlett Learning,
columnar cells beatLLC
in waves to-
sympathetic and parasympathetic fibers of the ward the uterus, aiding in egg transport. Shorter,
ovarian plexus that descend along the ovarian mucus-secreting peg cells are interspersed among
vessels. These nerves supply the ovaries, broad the ciliated cells. These cilia propel the film they
ligaments, and uterine tube. The parasympathetic produce toward the uterus, help transport the
fibers in the ovarian plexus arise from the vagus ovum, and hinder bacterial access to the peritoneal
nerves. The nerve fibers to the ovaries innervate cavity. The muscularis—the middle layer of the
© Jones
only the vascular & Bartlett
networks, and not Learning, LLC tube wall—contains both
the stroma fallopian © Jones & Bartlett Learning
inner circular
(Katz, 2012).NOT FOR SALE OR DISTRIBUTION
Because the ovaries and surrounding and outer longitudinal smooth NOT FOR SALE
muscle layers. Its OR DISTRIB
peritoneum are sensitive to pain and pressure, it is wavelike contractions move the ovum toward the
important to take great care when examining the uterus. The outer covering of the fallopian tubes is
ovaries during the bimanual examination. the serosa; this lubricative layer is part of the vis-
ceral peritoneum (Corton, 2012; Katz, 2012).
Fallopian Tubes
The ovarian & Bartlett
and uterine Learning,
arteries supply blood LLC
The fallopian tubes (also known as the oviducts) to the fallopian tubes. The uterine veins, which
NOT are
paired narrow muscular tubes that extend ap- parallel the path of the arteries, provide the ve-
proximately 10 cm from each cornu of the body of nous drainage from this area. Sympathetic and

9781284078916_CH05_077_094.indd 84 01/07/16 12:19 PM

parasympathetic innervation to the fallopian tubes The nulliparous uterus is approximately 8 cm long,
NOT FOR
from the hypogastric SALE
plexus ORsplanchnic
and pelvic DISTRIBUTION
5 cm wide, and 2.5 cm thick, and NOT FOR
weighs SALE OR DISTRIB
approxi-
nerves regulates the activity of the smooth muscles mately 40 to 50 gm (Katz, 2012).
and blood vessels (Corton, 2012). The uterine wall of the fundus and body consists
of three layers: the endometrium, the myometrium,
Uterus and the serosa (also known as the adventitia). The
© Jones & Bartlett
The uterus Learning,
is a muscular, inverted,LLC
pear-shaped, uterine mucosa © Jones & Bartlett
layer consists of simple Learning,
columnar LLC
hollow, thick-walled organ that opens to the va- epithelium NOT FOR SALE OR DISTRIBUTION
supported by a lamina propria. Simple
gina at the cervix and then widens toward the top tubular glands extend from the luminal surface
where the uterine tubes enter. Its anatomic regions into the lamina propria. The stratum functionale
include the fundus, body, and cervix (Figure 5-6 is the temporary layer at the luminal surface that
and Color Plate 3). The fundus is the uppermost responds to ovarian hormones by undergoing cy-
Jones & Bartlettdome-shaped

Learning, extension of the uterine body, located clic thickening and shedding. The stratum basale is
LLC © Jones & Bartlett Learning, LLC
above the point of entry of the fallopian tubes. The the deeper, thinner, permanent layer that contains
body is the enlarged main portion. The cervix is theNOTtheFOR
basalSALE
portionsOR DISTRIBUTION
of the endometrial glands; this
downward constricted extension of the uterus that layer is retained during menstruation. The epithe-
opens into the vagina. lial cells lining these glands divide and cover the
The uterus is located anteriorly between the uri- raw surface of exposed endometrium that occurs
nary bladder and posteriorly between the sigmoid during menstruation.
colon and the© rectum.
JonesWhen& Bartlett Learning,
the bladder is empty, LLC The endometrium receives©aJones double & Bartlett Learning
blood
the uterus angles
NOTforward
FOR SALEover the OR
bladder. As the supply. In the middle of the myometrium,
DISTRIBUTION NOT FORa SALE pair OR DISTRIB
bladder fills, the uterus is lifted dorsally and may of uterine arteries branch to form the arcuate ar-
become retroflexed, pressing against the rectum. teries. These arteries then bifurcate into two sets
FIGURE
© Jones 5-6 Learning,
& Bartlett n anterior
A LLC © Jones
view of the female internal genital&anatomy
Bartlett Learning, LLC
showing the relationships of the ovaries,
NOT FOR SALE OR DISTRIBUTION fallopian
NOT FOR tubes,
SALE OR DISTRIBUTION
uterus, cervix, and vagina.
Body of uterus
Suspensatory Ampulla
Ovarian ligament Fundus of uterus
ligament
Jones & Bartlett Learning, LLC © Jones & Bartlett
Learning, LLC
Uterine cavity
Fallopian
tube
(oviduct)
Ovary Fimbriae
Egg cell
Round Follicle
©
ligament Jones & Bartlett Learning, LLC © Jones & Bartlett Learning
Endometrium
Myometrium
NOT
BroadFOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
Perimetrium
ligament
Cervical canal
Cervix
Vagina

9781284078916_CH05_077_094.indd 85 01/07/16 12:19 PM

of arteries: straight arteries to the stratum basale The vaginal walls can be easily separated because
NOT FOR
and coiled arteries SALE ORThe
to the functionalis. DISTRIBUTION
double their surfaces are normally moist, NOT FOR SALE
lubricated by a OR DISTRIB
blood supply to the endometrium is important in basal vaginal fluid.
the cyclic shedding of the functionalis; the straight The vaginal wall is composed of three layers:
arteries are retained during this process, while the mucosa, muscle, and adventitia. Vaginal epithe-
coiled arteries are lost (Anderson & Gendry, 2007). lium is stratified squamous epithelium supported
© Jones The&myometrium
Bartlett Learning,
is composed LLC of four poorly by a thick lamina © Jones
propria.& Bartlett
The Learning,
lamina propria has LLC
defined layers of smooth muscle that are thickest many NOT FOR SALE OR DISTRIBUTION
thin-walled blood vessels that contribute to
at the top of the uterus. The middle layers contain diffusion of vaginal fluid across the epithelium.
the abundant arcuate arteries. The outer layer of The lamina propria of the mucosa contains many
the uterus consists of two types of outer coverings: elastic fibers as well as a dense network of blood
A cap of serosa covers the fundus, and the body vessels, lymph nodes, and nerve supply. To a much
Jones & Bartlettis surrounded by an adventitia of loose connective lesser degree than seen in the skin, this epithelium
Learning, LLC
tissue (Anderson & Gendry, 2007).
undergoes hormone-related cyclic changes, in-
OT FOR SALE ORStructurally,
DISTRIBUTION NOT FOR
the cervix is made mostly of dense cluding slight SALE OR DISTRIBUTION
keratinization of the superficial cells
connective tissue, is usually 2.5 to 3 cm in length, during the menstrual cycle (Corton, 2012). The epi-
and is covered interiorly by a mucus-secreting cili- thelium has no glands, so it does not secrete mu-
ated epithelium at the upper regions and by strati- cus. Release of estrogen causes the epithelium to
fied squamous epithelium at the vaginal end. The thicken, differentiate, and accumulate glycogen.
opening of the© Jones
cervix into& the
Bartlett Learning,
vagina occurs LLC bacteria metabolize the©glycogen
at al- Vaginal Jonesto&lactic
Bartlett Learning
most a rightNOTangle FOR
to the SALE
long axisORof the vagina. acid, causing the typically lowNOT
DISTRIBUTION pH of FOR
the vaginal
SALE OR DISTRIB
Uterine blood supply is provided via the uterine environment.
and ovarian arteries, with venous return traveling Loose connective tissue containing many elastic
via the uterine veins. The hypogastric and ovarian fibers is found underneath the vaginal epithelium,
nerve plexuses supply sympathetic and parasym- which has a subdermal layer rich in capillaries.
pathetic fibers as well as carry uterine afferent sen- This rich vascular supply is the source for vaginal
sory fibers on their way to the spinal cord at T11 moisture during sexual stimulation (Soper, 2007).
NOT and FOR SALE OR DISTRIBUTION
T12 (Anderson & Gendry, 2007; Katz, 2012). Within theNOT FORlieSALE
epithelium OR DISTRIBUTION
the smooth muscles
of the muscularis, which are oriented longitudi-
Vagina nally on the outer layer and as circular bundles on
The vagina is a thin-walled tube extending from the inner layer. The outer layer—the adventitia—
the external vulva to the cervix. Its walls are nor- consists of dense connective tissue with many
Jones & Bartlettmally
Learning, LLC
in apposition and flattened, but can extend © Jones & Bartlett
elastic fibers, Learning,
which provides structuralLLCsupport for
(stretch) greatly, as observed during childbirth. The the vagina. It also contains an extensive nerve sup-
length of the vaginal walls varies greatly but on av- ply and venous capillaries. The adventitia is elastic
erage the anterior vaginal length is 6 to 9 cm and and rich in collagen, provides structural support to
the posterior vaginal length is 8 to 12 cm (Corton, the vagina, and allows for expansion of the vagina
2012; Katz, 2012). The upper portion of the vagina during intercourse and childbirth.
encircles the vaginal portion of the cervix. The va- The upper two-thirds of the vagina receives
gina touches©the Jones & Bartlett
empty bladder on the Learning, LLC innervation through ©theJones
ventral and efferent & Bartlett Learning
uterovaginal
superior surface. Inferiorly, it adheres to the poste- plexus, which contains both NOT FORpara-
sympathetic and SALE OR DISTRIB
rior wall of the urethra and opens adjacent to the sympathetic fibers. The pelvic splanchnic nerves
labia minora. provide the parasympathetic efferent input to the
The internal mucosal layer of the vagina con- uterovaginal plexus. The proximal two-thirds
tains traverse folds, known as rugae. This muscu- of the vagina is innervated via the uterovaginal
© Jones & Bartlett
lar canal Learning,
extends from the midpoint LLCof the cervix plexus. The © Jones
lower vagina&receives
Bartlett Learning,
autonomic ef- LLC
to its opening located between the urethra and the ferent innervation from the pudendal nerve. The
NOT rectum.
The mucous membrane lining the vagina distal one-third of the vagina has primarily so-
and musculature is continuous with the uterus. matic sensation; this innervation arises from the

9781284078916_CH05_077_094.indd 86 01/07/16 12:19 PM

pudendal nerve and is carried to the sacral spinal some size variation between a woman’s breasts is
cord (Katz, NOT
2012). FOR SALE OR DISTRIBUTION normal. The nipple and areola areNOT made FOR SALE OR DISTRIB
of smooth
muscle fibers and feature a thick network of nerve
endings.
BREAST ANATOMY AND PHYSIOLOGY The areola is populated by numerous oil-
In Western society, it often seems that a woman’s producing Montgomery’s glands. These glands may
© Jones
breasts&have
Bartlett Learning,
two functions or roles: LLC © Jones
one that is sex- form raised bumps and be & Bartlett
responsive to aLearning,
woman’s LLC
ual, and one that is maternal. The breasts are visible menstrual NOT FOR SALE OR DISTRIBUTION
cycle. They protect and lubricate the nip-
social sex symbols, and they are often a key source ple during lactation.
of a woman’s anxiety about her body. Breasts often The nipple usually protrudes out from the sur-
define women in both the public and private eye. face of the breast. Some nipples project inward or
The breasts—that is, the mammary glands—are are flat with the surface of the breast. Neither flat
large, modified sebaceous glands contained within nor inverted nipples appear to negatively affect a
Jones & BartletttheLearning, LLC © Jones & Bartlett Learning, LLC
superficial fascia of the chest wall located over woman’s ability to breastfeed.
the pectoral muscles (Katz & Dotters, 2012). Each NOT FOR SALEhormones
Reproductive OR DISTRIBUTION
are vital to the devel-
consists of a nipple, lobes, ducts, and fibrous and opment of the breast during puberty and lactation.
fatty tissue (Color Plate 4). Each breast is com- Prolactin (PRL) and growth hormone (GH) from the
posed of 12 to 20 lobes of glandular tissue. The anterior lobe of the pituitary stimulate mammary
number of lobes is not related to the size of the gland development. These hormones are aided
breast. The © Jones
lobes branch& to Bartlett
form 10 to Learning,
100 lobules byLLC human placental lactogen © fromJones & Bartlett Learning
the placenta,
per lobe, which
NOTareFOR in turn subdivided
SALE OR into many which stimulates the mammaryNOT
DISTRIBUTION gland ducts
FORtoSALE be- OR DISTRIB
secretory alveoli. These glands are connected to- come active during pregnancy. Estrogen promotes
gether by a series of ducts. The alveoli produce the growth of the gland and ducts, while progester-
milk and other substances during lactation. Each one stimulates the development of milk-producing
lobe empties into a single lactiferous duct that trav- cells. Prolactin, which is released from the anterior
els out through the nipple. As a result, there are 15 pituitary, stimulates milk production. Oxytocin,
to 20 passages through the nipple, resulting in just which is released from the posterior pituitary in re-
NOT as FOR SALE OR DISTRIBUTION
many openings in the nipple. NOT FOR
sponse to suckling, causes SALE OR from
milk ejection DISTRIBUTION
the
Fatty and connective tissues surround the lobes lactating breast.
of glandular tissue. The amount of fatty tissue de- The lymphatic system in the breast is abun-
pends on many factors, including age, the percent- dant and empties the breast tissue of excess fluid.
age of body fat relative to total body weight, and Lymph nodes along the pathway of drainage moni-
Jones & Bartlettheredity.
Learning,
Cooper’sLLC
ligaments connect the chest wall © Jones & Bartlett
tor for foreign bodies Learning,
such as bacteriaLLC or viruses.
to the skin of the breast, giving the breast its shape Although the main flow moves toward the axilla
and elasticity (Katz & Dotters, 2012). The size of and anterior axillary nodes, lymph drainage has
the nonpregnant breasts reflects the amount of been shown to pass in all directions from the breast
adipose tissue in the breast rather than the amount (Martini et al., 2011).
of glandular tissue. The secretory nature of the
breasts develops during pregnancy.
© and
The nipple Jonesareola&areBartlett Learning,
located near the cen-
MENSTRUAL
LLC CYCLE PHYSIOLOGY© Jones & Bartlett Learning
ter of each breast; the areola is the pigmented area The initiation of menstruation, NOT
calledFOR SALE OR DISTRIB
menarche,
surrounding the nipple. These areas usually have a usually happens between the ages of 12 and 15.
color and texture that differ from those of the ad- Menstrual cycles typically continue to age 45 to 55,
jacent skin. Notably, the color of the nipple–areolar when menopause occurs. Many women find them-
complex varies and darkens during pregnancy and selves reluctant to discuss the existence and nor-
© Jones & Bartlett
lactation. Learning,
The consistency LLC and are- mality of menstruation.
of the nipple © JonesThe & word
Bartlett Learning,
menstruation has LLC
ola may range from very smooth to wrinkled and been replaced by a variety of euphemisms, such as
NOT bumpy.
The size of the nipples and areolae also the curse, my period, my monthly, my friend, the red
varies a great deal from woman to woman, and flag, or on the rag.

9781284078916_CH05_077_094.indd 87 01/07/16 12:19 PM

Most women experience deviations from the menarche and just prior to menopause (Ferin &
NOT FOR
average menstrual SALE
cycle during OR
their DISTRIBUTION
reproductive Lobo, 2012; Fritz & Speroff, 2011). NOT FORcycles
Menstrual SALE OR DISTRIB
years. As a result, it is not uncommon for women that occur during the first 1 to 1.5 years after men-
to display certain preoccupations regarding their arche are frequently irregular due to the immaturity
menstrual bleeding, not only in relation to the reg- of the h ypothalamic–pituitary–ovarian axis (Fritz &
ularity of its occurrence, but also in regard to the Speroff, 2011).
© Jones & Bartlett
characteristics of theLearning,
flow, such asLLCvolume, dura- © Jones & Bartlett Learning, LLC
tion, and associated signs and symptoms. Unfor- The Hypothalamic–Pituitary–Ovarian
NOT FOR SALE OR DISTRIBUTION Axis
tunately, society has encouraged the notion that a
Hypothalamus
woman’s normalcy is based on her ability to bear
The hypothalamus controls anterior pituitary func-
children. This misperception has understandably
tions via the secretion of releasing and inhibiting
forced women to worry over the most miniscule
factors. Together with the pituitary, it manages the
Jones & Bartlettchanges
Learning,in their menstrual cycles. Indeed, changes
LLC
in menstruation are one of the most frequent rea-
© Jones & Bartlett
production of hormones Learning, LLC mes-
that serve as chemical
OT FOR SALE OR DISTRIBUTION NOT sengers
FOR for the regulation
SALE OR of the gynecologic system.
DISTRIBUTION
sons why women visit their clinician.
The hypothalamus initially releases gonadotropin-
Numerous patterns in the secretion of estrogens
releasing hormone (GnRH) in a pulsatile manner.
and progesterone are possible; in fact, it is difficult
On average, the frequency of GnRH secretion is
to find two cycles that are exactly the same. Studies
once per 60 to 100 minutes during the early follicu-
that include women of different ethnicities, occu-
lar phase, increases to once per 60 to 70 minutes
© Jones
pations, genetics, & Bartlett
nutritional status, andLearning,
age have LLC © Jones & Bartlett Learning
during the middle of the menstrual cycle, and then
demonstrated NOT that FOR
the length
SALEand duration of the
OR DISTRIBUTION NOT(McCartney
FOR SALE OR DISTRIB
decreases during the luteal phase &
menstrual cycle vary widely (Assadi, 2013; Johnson
Marshall, 2014). The release of GnRH stimulates
et al., 2013; Karapanou & Papadimitriou, 2010).
the pituitary gland to produce follicle-stimulating
Menarche is the most readily evident external
hormone (FSH) and luteinizing hormone (LH). Two
event that indicates the end of one developmental
other hormones necessary for gynecologic health,
stage and the beginning of a new one. It is now be-
lieved that body composition is critically important
estrogen and © Jones &are
progesterone, Bartlett Learning,
secreted by the ova- LLC
ries at the command of FSH and LH.
NOT in FOR SALE OR DISTRIBUTION
determining the onset of puberty and menstrua- NOT FOR SALE OR DISTRIBUTION
tion in young women (Ferin & Lobo, 2012). The
Pituitary Gland
ratio of total body weight to lean body weight is
The oval-shaped, pea-sized pituitary gland is
probably the most relevant factor, and individuals
located in a small depression in the sphenoid
who are moderately obese (i.e., 20–30% above their
bone of the skull. It is controlled by the hypo-
Jones & Bartlettideal
Learning,
body weight) LLC
tend to have an earlier onset © of Jones & Bartlett Learning, LLC
thalamus, which secretes releasing factors into
menarche (Johnson et al., 2013). Widely accepted
standards for distinguishing what are regular ver-
NOT a FOR
specialSALE OR DISTRIBUTION
blood vessel network (hypothalamic–
hypophyseal portal system) that feeds the pituicytes
sus irregular menses, or normal versus abnormal
McCartney &
( Marshall, 2014). These releasing
menses, are generally based on what is consid-
factors either stimulate or inhibit the release of
ered average and not necessarily typical for every
pituitary hormones that travel via the circulatory
woman. According to these standards, the normal
© Jones & Bartlett Learning,
menstrual cycle is 21 to 35 days with a menstrual LLC to target organs.
system © Jones & Bartlett Learning
The anterior pituitary synthesizes seven
flow lasting NOT FOR SALE OR DISTRIBUTION
4 to 6 days, although a flow for as few NOT FOR SALE OR DISTRIB
hormones:
as 2 days or as many as 8 days is still considered
normal (Ferin & Lobo, 2012). • Growth hormone (GH)
The amount of menstrual flow varies, with the • Thyroid-stimulating hormone (TSH)
average being 50 mL; nevertheless, this volume may • Adrenocorticotropin (ACTH)
be as little as 20 mL or as much as 80 mL. G
enerally, © Jones & Bartlett
• Melanocyte-stimulating Learning, LLC
hormone (MSH)
women are not aware that anovulatory cycles and • Prolactin (PRL)
NOT abnormal
uterine bleeding (changes in bleeding out-
• Follicle-stimulating hormone (FSH)
side of normal; see Chapter 24) are common after • Luteinizing hormone (LH)

9781284078916_CH05_077_094.indd 88 01/07/16 12:19 PM

FSH and LH (both gonadotropins) are respon- of the pulse, which varies throughout the cycle
NOT FOR
sible for regulating SALEorgan
gynecologic OR DISTRIBUTION
activities. (Fritz & Speroff, 2011); see ColorNOTPlateFOR5. SALE OR DISTRIB
FSH targets the ovaries, where it stimulates the As noted earlier, under normal physiologic con-
growth and development of the primary follicles ditions, GnRH pulses stimulate the release of FSH
and results in the production of estrogen and pro- and LH. As a result of this gonadotropic hormone
gesterone. The release of FSH from the pituitary is stimulation, the ovarian follicles develop and pro-
© Jones & Bartlett
governed Learning,
by a negative LLC
feedback mechanism induce estrogen.©AsJones & Bartlett
the amount of estrogenLearning,
in the cir- LLC
volving these steroids. In contrast, LH targets the culation NOT FOR SALE OR DISTRIBUTION
increases and reaches the pituitary gland,
developing follicle within the ovary; it is respon- it affects the amount of FSH and LH secreted, albeit
sible for ovulation, corpus luteum formation, and without significantly affecting the pulse frequency
hormone production in the ovaries. Prolactin is (negative feedback).
responsible for preparing the mammary gland for When the estrogen level becomes high enough,
lactation and brings about the synthesis of milk the negative feedback effect on the pituitary is re-
Jones & Bartlett(McCartney
Learning, LLC
& Marshall, 2014; Molitch, 2014).
versed. Now estrogen causes a midcycle positive
OT FOR SALE OR DISTRIBUTION NOTfeedback
FOR SALE effect onORthe DISTRIBUTION
pituitary, which results in
Ovaries and Uterus a surge of LH and FSH and causes ovulation. Un-
Complex changes occur in the ovaries and the en- der LH influence, the ruptured follicle becomes
dometrium as a result of the cyclic fluctuations of the corpus luteum and secretes progesterone. Al-
gonadotropic hormones. The endometrium emu- though the presence of progesterone reduces the
© Jones
lates the activities of the& ovaries;
Bartlett Learning,
thus LLC
whatever frequency of the hypothalamic©GnRH Jones & Bartlett
pulses, the Learning
happens in the uterus during the menstrual cycle amount of LH released from the pituitary is pro-
NOT FOR SALE OR DISTRIBUTION NOT
is precisely correlated with whatever is occurring portionally increased to sustain the corpus luteum
FOR SALE OR DISTRIB
in the ovaries. The objective of the ovarian cycle and the production of progesterone. In the absence
is to produce an ovum, while the objective of the of pregnancy, the corpus luteum degenerates, pro-
endometrial cycle is to prepare a site to nourish gesterone levels decline, and menstruation occurs.
and maintain the ovum if it becomes fertilized. The The GnRH pulses return to the frequency associ-
© Jones
ovarian&cycle
Bartlett Learning,
includes three distinctLLC
phases: the fol- ated with the© Jones & Bartlett Learning, LLC
beginning of the follicular phase and
NOT licular
FOR phase,
SALE OR DISTRIBUTION
ovulation, and the luteal phase. The a new cycle begins NOT (Ferin
FOR&SALE OR DISTRIBUTION
Lobo, 2012).
endometrial cycle can be divided into the prolifera-
tive phase, the secretory phase, and menstruation The Ovarian Cycle
(Fritz & Speroff, 2011).
The ovarian cycle comprises three phases: follicu-
lar, ovulatory, and luteal.
Hormonal Feedback System
The menstrual cycle is influenced by a complex in- Follicular Phase
teraction NOTThe
of hormones. In particular, the monthly FOR SALE
follicular OR
phase DISTRIBUTION
is characterized by the devel-
rhythmic functioning of the menstrual cycle de- opment of ovarian follicles and usually lasts from
pends on the changing concentrations of gonado- day 1 (first day of menses) to day 14 of the ovarian
tropic hormones. The release of LH and FSH from cycle. Folliculogenesis begins during the last few
the pituitary depends on the secretion of GnRH days of the previous menstrual cycle and continues
© Jones &which
from the hypothalamus, Bartlett Learning,
is modulated LLCthe release of the mature follicle
by until © Jones & Bartlett Learning
at ovulation.
the feedback NOT FOR SALE OR DISTRIBUTION
effects of estrogen and progesterone. The decrease in estrogen NOT FOR SALE OR DISTRIB
production by the corpus
The hormones LH and FSH, in turn, play impor- luteum and the dramatic fall of inhibin levels al-
tant roles in stimulating secretion of estrogen and low the FSH level to rise during the last few days
progesterone. of the menstrual cycle. During days 1 through 4 of
Almost all hormones are released in short pulses the menstrual cycle, a cohort of primary follicles is
at intervals of 60 to 90 minutes throughout most recruited from a pool of nonproliferating follicles
of the menstrual cycle, with these pulses decreas- in response to the increased concentration of FSH
NOT ing
FOR SALE OR
in frequency DISTRIBUTION
closer NOT
to menstruation. Steroid (Fritz & Speroff, FOR
2011). SALE
Follicles thatOR
haveDISTRIBUTION
enough
hormones modulate the frequency and amplitude granulosa cells will develop receptors for estrogen

9781284078916_CH05_077_094.indd 89 01/07/16 12:19 PM

and FSH on the cells of the granulosa layers, and continue to increase. At the end of the follicular
LH receptors NOTon theFOR
thecaSALE OR
cells. The DISTRIBUTION
primary role phase, estrogen reaches a blood NOTlevel FOR SALE OR DISTRIB
of approxi-
of FSH is to induce the development of increased mately 200 picograms per milliliter (pg/mL); this
receptors on the granulosa cells and thereby stim- concentration may be maintained for as long as
ulate estrogen production. The preliminary role of 50 hours (Fritz & Speroff, 2011; Halvorson, 2012b).
LH is to stimulate the cells’ production of androgen At this critical time, the high estrogen level initiates
© Jones & be
that will Bartlett
convertedLearning,
to estrogen byLLC © Jones
the granulosa a positive feedback of LH, & Bartlett
generating the Learning,
preovula- LLC
layers. tory LH NOT FOR SALE OR DISTRIBUTION
surge. The LH surge, which begins 34 to 36
Between cycle days 5 and 7, only one dominant hours prior to ovulation and provides a relatively
follicle from the cohort of recruited follicles is des- accurate predictor for timing ovulation, is respon-
tined to ovulate during the next menstrual cycle. sible for many changes in the follicle selected for
As menses progresses, FSH levels decline due to rupture.
Jones & Bartlettthe negative feedback of estrogen and the negative

Learning, LLC © JonesInitially the nuclear membrane around the
& Bartlett Learning, LLC
effects of the peptide hormone inhibin, which is se- oocyte breaks down, the chromosomes progress
OT FOR SALE OR DISTRIBUTION NOT
creted by the granulosa and theca cells of the de- through theFOR SALE OR
rest of the DISTRIBUTION
first meiotic division, and
veloping follicle (Fritz & Speroff, 2011; Halvorson, the egg moves on to the secondary stage. Meio-
2012b). The decrease in FSH level promotes a more sis ceases at this time and will be initiated again
androgenic microenvironment within the adjacent only if the ovum is fertilized. The LH surge stimu-
follicles. By the eighth day of the cycle, the domi- lates luteinization of the granulosa cells as well as
nant follicle©(Graafian
Jonesfollicle)
& Bartlett Learning,
is producing LLC of progesterone. Progesterone,
more synthesis © Jonesin&turn, Bartlett Learning
estrogen than NOT the FOR
total amount
SALEproduced by the enhances the positive feedbackNOT
OR DISTRIBUTION effect FOR
of estrogen
SALE OR DISTRIB
other developing follicles. In response to the domi- on the LH surge and is responsible for promoting
nant follicle’s combined production of estrogen enzyme activity in the follicular fluid capable of
and FSH, LH receptors develop on its outermost digesting the follicle wall. High levels of LH and
granulosa layers. The dominant follicle continues progesterone cause the synthesis of prostaglandins
to flourish and gradually moves toward the surface and proteolytic enzymes such as collagenase and
of the ovary (see Color Plate 6). The Graafian plasmin. Although the exact mechanism underly-
NOT follicle
FOR contains
SALE the ORovum
DISTRIBUTION
and is surrounded by a ing this process NOT FOR SALE
is unknown, OR DISTRIBUTION
the activated proteo-
layer of granulosa cells, which are themselves sur- lytic enzymes and prostaglandins digest collagen in
rounded by the specialized theca interna and theca the follicular wall, leading to an explosive release
externa cells. of the ovum (oocyte), along with the zona pellu-
An oocyte maturation inhibitor (OMI) in the fol- cida and corona radiate surrounding it. At ovula-
Jones & Bartlettlicular
Learning, LLC the final maturation of the
fluid suppresses © Jones
tion, the &ovum
Bartlett Learning,
is expelled and drawn LLC up by the
dominant follicle until the time of ovulation. The ciliated fimbriae of the fallopian tube to initiate its
OMI’s suppressive effects end hours before the LH migration through the oviduct (Ferin & Lobo, 2012;
surge that causes ovulation (Halvorson, 2012b). Fritz & Speroff, 2011).
New information about the timing of the LH
Ovulatory Phase surge and ovulation is available now because of
Ovulation is the process whereby the mature ovum the amount of data collected by many clinicians
is released © Jones
from & Bartlett
the follicle Learning,
(Halvorson, LLC in vitro fertilization. The LH
2012b). during © Jones
surge has & Bartlett Learning
a ten-
It occurs approximately 10 to 12 hours after the LH dency to occur around 3 a.m. NOT FOR SALE OR DISTRIB
in more than two-
peak—that is, when the highest level of LH is at- thirds of women, and ovulation has been found to
tained. Ovulation and the subsequent conversion occur primarily in the morning during the spring
of the follicle to the corpus luteum are dependent months and primarily during the evening during
on an increased level of estrogen and the LH surge, autumn and winter (Fritz & Speroff, 2011). In the
© Jones
which&marksBartlett Learning,
the beginning of theLLC © Jonesfrom
rapid rise of Northern Hemisphere, & Bartlett Learning,
July to February, ap- LLC
LH. During the mid-follicular phase, the dominant proximately 90% of women will ovulate between
NOT follicle’s
FSH levels diminish, but estrogen levels 4 and 7 p.m. During the spring, 50% of women will

9781284078916_CH05_077_094.indd 90 01/07/16 12:19 PM

ovulate between midnight and 11 a.m. (Fritz & 12 mm in height and increases eightfold in thick-
NOT
Speroff, 2011, FOR SALE OR DISTRIBUTION
p. 228). NOT of
ness in preparation for implantation FOR SALE
the fertil- OR DISTRIB
ized ovum (Ferin & Lobo, 2012).
Luteal Phase
Under the influence of LH, the follicle’s granulosa Secretory Phase
cells that are left in the ruptured follicle become en- The secretory phase begins at ovulation. When part
© Jones
larged,&undergo
Bartlett Learning,
luteinization, LLCthe corpus of a 28-day cycle,
and form © Jones & lasts
it usually Bartlett Learning,
from day 15 (the LLC
luteum. The corpus luteum continues to function day after ovulation—the exact cycle day will vary
for approximately 8 days after ovulation. It secretes with cycle length) to day 28. This phase does not
increased progesterone and some estrogen that take place if ovulation has not occurred. It tends to
start the negative feedback loop to the hypothala- be the most constant phase, in terms of time.
mus and pituitary gland, preventing further ovula- During the secretory phase, the glands of the
tion within the current cycle. In the absence of a endometrium become more tortuous and dilated
Jones & Bartlettfertilized
Learning, LLCcells degenerate, causing©a Jones
ovum, luteal & Bartlett Learning, LLC
and fill with secretions, primarily as a result of
OT FOR SALE OR decline in estrogen and progesterone levels, and increasedSALE
DISTRIBUTION NOT FOR OR DISTRIBUTION
progesterone production. The endome-
the corpus luteum regresses to become the corpus trium becomes thick, cushiony, and nutritive in
albicans. As a result of the regression of the corpus preparation for implantation of the fertilized ovum.
luteum, estrogen and progesterone levels decrease In the absence of implantation, the corpus luteum
rapidly, removing the negative feedback effect. FSH shrinks, and progesterone and estrogen levels
and LH then©beginJones & Bartlett
to increase Learning,
once again LLC
to initi- subsequently © Jones begins
decrease. The endometrium & Bartlett Learning
ate the next menstrual cycle (Ferin & Lobo, 2012; to regress toward the end of the secretory phase.
NOT
Fritz & Speroff, 2011).
FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
By days 25 to 26, progesterone and estrogen with-
drawal results in increased tortuous coiling and
The Endometrial Cycle constriction of the spiral arterioles in the thinning
The endometrial cycle has three phases: prolifera- layer.
tive, secretory, and menstrual. Until the last decade, it was believed that de-
creased blood flow to the superficial endometrial
NOT Proliferative
FOR SALE OR
Phase DISTRIBUTION NOT
layers resulted FORischemia
in tissue SALE OR DISTRIBUTION
and resulting
The proliferative phase is influenced by estrogen menses. The end of menses was believed to be
and entails the regrowth of endometrium after the caused “by longer and more intense waves of va-
menstrual bleed. It starts on about the fourth or fifth soconstriction, combined with coagulation mecha-
day of the cycle and usually lasts approximately nisms activated by vascular stasis and endometrial
Jones & Bartlett10Learning, LLCthe release of the ovum. The
days, ending with © Jones &aided
collapse, Bartlett Learning,
by rapid LLCmediated
re-epithelization
proliferative phase involves changes in the endo- by estrogen from the emerging new follicular co-
metrium, myometrium, and ovaries. These cyclic hort” (Fritz & Speroff, 2011, p. 595). Newer stud-
changes, which result from fluctuations in gonad- ies do not support the theory that menstruation
otropin and estrogen levels, are characterized by results from vascular events. Rather, the current
progressive mitotic growth of the deciduas functio- theory suggests that menstruation is initiated by
nalis in response to increasing levels of estrogen enzymatic autodigestion of the functional layer of
secreted by © theJones & Bartlett
ovary. They Learning, the
occur in preparation LLC © Jones
endometrium, which is triggered & Bartlett Learning
by estrogen–
for implantation of the fertilized ovum. progesterone withdrawal (FritzNOT FOR2011).
& Speroff, SALE OR DISTRIB
At the beginning of the proliferative phase, the As estrogen and progesterone levels fall during the
endometrium is relatively thin and the endome- days prior to menses, lysosomal membranes be-
trial glands are straight, narrow, and short. As the come destabilized, such that the enzymes within
phase progresses, the glands become long and tor- them are released into the cytoplasm of the epi-
© Jones
tuous.&TheBartlett Learning,
endometrium becomes LLC © Jones
thicker as a re- thelial, stromal, & Bartlett
and endothelial Learning,
cells and into the LLC
sult of the glandular hyperplasia and growth of the intercellular space. These enzymes are proteolytic:
NOT stroma.
The endometrium proliferates from 4 to They digest the cells surrounding them as well as

9781284078916_CH05_077_094.indd 91 01/07/16 12:19 PM

surface membranes. Their actions result in plate- After ovulation, when progesterone levels are
NOT
let deposition, FOR
release of SALE OR DISTRIBUTION
prostaglandins, vascular high, the cervical mucus once NOT againFOR SALE OR DISTRIB
becomes
thrombosis, extravasation of red blood cells, and thick, viscous, opaque, and decreased in amount.
tissue necrosis in the vascular endothelium (Ferin & This thick mucus is hostile and impenetrable to the
Lobo, 2012). Enzymatic action progressively de- sperm. The increased viscosity also reduces the
grades the endometrium and eventually disrupts risk of ascending infection at the time of possible
© Jones & Bartlett
the capillaries Learning,
and venous system LLC
just under the implantation.© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTIONhemor-
endometrial surface, causing interstitial Increased NOT FOR
estrogen levelsSALE
promoteOR DISTRIBUTION
stromal vas-
rhage and dissolution of the surface membrane cularization and edema and relax the myometrial
and allowing blood to escape into the endometrial fibers that supply the cervix. Activated collagenase
cavity (Fritz & Speroff, 2011). This degeneration causes the tightly bound collagen bundles to form a
continues and extends to the functional layer of the loose matrix, triggering the cervix to become softer
Jones & Bartlettendometrium,

Learning,where LLCrupture of the basal arterioles a few days prior to and at ovulation. The external
contributes to the bleeding. The concepts about cervical os everts prior to ovulation. Progesterone
OT FOR SALE OR DISTRIBUTION NOT
how the menstrual flow ceases remain unchanged. causes the FOR SALE
cervicalOR DISTRIBUTION
muscle to retract, the collagen
matrix to tighten, and the cervix to become firmer
Menstrual Phase (Fritz & Speroff, 2011; Halvorson, 2012b).
The menstrual phase begins with the initiation of
menses and lasts 4 to 6 days. Prostaglandins initi- Fallopian Tube Mobility
© Jones
ate contractions & Bartlett
of the uterine smooth Learning, LLC stimulates epithelial cell
muscle and Estrogen © Jones
activity, & Bartlett Learning
result-
sloughing ofNOT
the degraded endometrial tissue, leading in increased cilia movement and secretions in
FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
ing to menstruation. The composition of menstrual the uterine tubes. These special effects assist ovum
fluid comprises desquamated endometrial tissue, red mobility along the fallopian tube following ovula-
blood cells, inflammatory exudates, and proteolytic tion. Progesterone reverses these effects, thereby
enzymes. Because some of the clotting factors ordi- inhibiting the peristaltic activity of the fallopian
narily found in blood are lysed by lysosomal enzymes tube smooth muscle.
in the uterus, menstrual blood does not clot (Ferin &
NOT Lobo,
FOR2012;SALE Vagina
FritzOR DISTRIBUTION
& Speroff, 2011). For 3 to 5 days, NOT FOR SALE OR DISTRIBUTION
The changes in hormonal levels of estrogen and
20 to 80 mL (on average) of blood loss occurs. Ap-
progesterone have characteristic effects on the
proximately 2 days after the start of menstruation,
vaginal epithelium. This information becomes im-
estrogen stimulates the regeneration of the surface
portant when cervical cells are examined under
endometrial epithelium, while concurrent simulta-
the microscope, as their morphologic differences
Jones & Bartlettneous
Learning, LLC
endometrial shedding is occurring. ©Jones
can be & Bartlett
related Learning,
to specific LLC
stages of the menstrual
cycle. During the early follicular phase, exfoliated
Changes in Organs Due to Cyclic Changes vaginal epithelial cells have vesicular nuclei and
Cervix are basophilic. They appear flatter than the cor-
After menstruation, the cervical mucus is scant and responding cells in the later phases owing to the
viscous. During the late follicular phase, it becomes influence of progesterone, which causes them to
clear, copious, and elastic.
© Jones & The quantityLearning,
Bartlett of cervical become
LLC folded and clumped. The © pH of the vagina
Jones & Bartlett Learning
mucus increases 30-fold compared to the early fol- responds to cyclical changes as estrogen stimulates
licular phaseNOT FOR
and can SALE
stretch OR
to at least 6 cmDISTRIBUTION NOT FOR
(Ferin & the growth of lactobacilli. Lactobacilli SALE OR DISTRIB
metabolize
Lobo, 2012; Fritz & Speroff, 2011). The cervical glycogen from cervical secretions, producing lactic
mucus during this time is clear and stretchable acid that decreases the vaginal pH to a level that
(spinnbarkeit). It displays a characteristic ferning assists in protecting the gynecologic tract against
appearance during the ovulatory period if observed opportunistic pathogens (Fritz & Speroff, 2011;
© Jones
under& Bartlett Learning, LLC
a microscope. © Jones & Bartlett Learning, LLC
Halvorson, 2012b).

9781284078916_CH05_077_094.indd 92 01/07/16 12:19 PM

References
Anderson, J., & Gendry, R. (2007). Anatomy and embryology. In also influences peripubertal body mass index. American Journal
J. Berek (Ed.), Berek and Novak’s gynecology (14th ed., pp. 75–127). of Physical Anthropology, 150, 10–20.
Philadelphia, PA: Lippincott Williams & Wilkins. Karapanou, O., & Papadimitriou, A. (2010). Determinants of men-
Assadi, S. N. (2013). Is being a health-care worker a risk factor for arche. Reproductive Biology and Endocrinology, 5(1), 115–123.
women’s reproductive system. International Journal of Preventive © Jones & Bartlett Learning, LLC
Katz, V. (2012). Reproductive anatomy. In V. Katz, G. Lentz, R. Lobob, &
Medicine, 4(7), 852–857. D. Gershenson (Eds.), Comprehensive gynecology (6th ed., pp. 39–
NOT Bradshaw,
FOR SALE K. (2012).OR DISTRIBUTION
Anatomic disorders. In B. L. Hoffman, NOT FOR SALE OR DISTRIBUTION
65). Philadelphia, PA: Mosby Elsevier.
J. O. Schorge, J. I. Schaffer, L. M. Halvorson, K. D. Bradshaw,
Katz, V., & Dotters, D. (2012). Breast diseases. In V. Katz, G. Lentz,
F. G. Cunningham, & L. E. Calver (Eds.), Williams gynecology
R. Lobo, & D. Gershenson (Eds.), Comprehensive gynecology
(2nd ed., pp. 481–505). New York, NY: McGraw-Hill.
(6th ed., pp. 301–334). Philadelphia. {A: Mosby Elsevier.
Caldwell, W. E., & Moloy, H. C. (1933). Anatomical variations in fe-
Kolesova, O., & Vetra, J. (2012). Female pelvic types and age differ-
male pelvic bones and their effect on labor with a suggested
ences in their distribution. Papers on Anthropology, 21, 147–154.
classification. American Journal of Obstetrics & Gynecology, 26,
479–482. © Jones
Martini, F.,& Bartlett
Timmons, M. J., &Learning, LLC
Tallitsch, R. (2011). Human anatomy
(7th ed.). San Francisco, CA: Benjamin Cummings.
Corton, M. (2012). Anatomy. In B. NOTMcCartney,
L. Hoffman, J. O. Schorge, FOR SALE OR DISTRIBUTION
C. R., & Marshall, J. C. (2014). Neuroendocrinology of
J. I. Schaffer, L. M. Halvorson, K. D. Bradshaw, F. G. Cunningham, &
L. E. Calver (Eds.), Williams gynecology (2nd ed., pp. 918–947). reproduction. In J. F. Strauss & R. L. Barbien (Eds.), Reproductive
New York, NY: McGraw-Hill. endocrinology: physiology, pathophysiology, and clinical manage-
ment (7th ed., pp. 3–26.) Philadelphia, PA: Saunders.
Duffy, J. (1963). Masturbation and clitoridectomy. Journal of the
American Medical Association, 186(3), 246–248. doi:10.1001/ Molitch, M. (2014). Prolactin in human reproduction. In
jama.1963.63710030028012 J. F. Strauss & R. L. Barbien (Eds.), Reproductive endocrinology:
Ferin, M., & Lobo, R. (2012). Reproductive endocrinology. In © Jones & Bartlett Learning
physiology, pathophysiology, and clinical management (7th ed.,
G. Lentz, R. Lobo, D. Gershenson, & V. Katz (Eds.), Compre- pp. 45–65). Philadelphia, PA: Saunders.
NOT FOR SALE OR DISTRIBUTION Puppo, V. (2013). Anatomy and physiologyNOT
hensive gynecology (6th ed., pp. 67–95). Philadelphia, PA: Mosby FOR
of the clitoris, SALE OR DISTRIB
vestibular
Elsevier. bulbs, and labia minora with a review of the female orgasm and
Fritz, M., & Speroff, L. (2011). Clinical gynecologic endocrinology and the prevention of female dysfunction. Clinical Anatomy, 26(1),
infertility. Philadelphia, PA: Lippincott Williams & Wilkins. 134–152.
Hall, L. A. (1998). The other in the mirror: Sex, Victorians, and his- Richter, H., & Varner, R. (2007). Pelvic organ prolapse. In J. Berek
torians. Retrieved from http://www.lesleyahall.net/sexvict.htm (Ed.), Berek and Novak’s gynecology (14th ed., pp. 897–934).
© Jones
Halvorson, & L.Bartlett Learning,
M. (2012a). Amenorrhea. LLCJ. O. Schorge,
In B. L. Hoffman, © Jones & Bartlett Learning, LLC
Philadelphia, PA: Lippincott Williams & Wilkins.
Soper, D. (2007). Genitourinary infections and sexually transmitted
J. I. Schaffer, L. M. Halvorson, K. D. Bradshaw, F. G. Cunningham, &
L. E. Calver (Eds.), Williams gynecology (2nd ed., pp. 440–459). NOT FOR SALE OR DISTRIBUTION
diseases. In J. Berek (Ed.), Berek and Novak’s gynecology (14th ed.,
New York, NY: McGraw-Hill. pp. 541–559). Philadelphia, PA: Lippincott Williams & Wilkins.
Halvorson, L. M. (2012b). Reproductive endocrinology. In Soucasaux, N. (1993a). Archetypal aspects of the female genitals.
B. L. Hoffman, J. O. Schorge, J. I. Schaffer, L. M. Halvorson, Museum of Menstruation & Women’s Health. Retrieved from
K. D. Bradshaw, F. G. Cunningham, & L. E. Calver (Eds.), Williams http://www.mum.org/sougenit.htm
gynecology (2nd ed., pp. 400–439). New York, NY: McGraw-Hill. Soucasaux, N. (1993b). Psychosomatic and symbolic aspects of men-
Johnson, W., Choh, A., Curran, J., Czerwinski, S. A., Bellis, C., Dyer, struation. Museum of Menstruation & Women’s Health. Retrieved
T. D., & Demerath, E. (2013). Genetic risk for earlier menarche © Jones & Bartlett Learning, LLC
from http://www.mum.org/psychos.htm


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Ischial spine Pubis

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Levator ani– Superficial transverse

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FIGURE 5-4 Midsagittal view of a woman’s pelvic organs.

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Jones & Bartlettexternally

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Jones & Bartlettdome-shaped

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Jones & Bartlettthe negative feedback of estrogen and the negative

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning

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Jones & Bartlettendometrium,

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