ANATOMY OF FEMALE

REPRODUCTIVE SYSTEM
(Goa Hung)
Organs of Female Reproductive System
 Ovaries
–Almond in shape
– Located along lateral wall of uterus in
a region ovarian fossa and it is an
intra-peritoneal organ.
•In nulliparous adult – It lies in the
ovarian fossa below the pelvic brim.
•In newborn – It lies above the pelvic
brim.
•In multiparous females – May be
prolapsed in the recto-uterine pouch.
Ligaments
Suspensory ligament of ovary (infundibulum ligament) -superior (tubal) end
of ovary is connected to lateral wall of pelvis, contains ovarian vessels &
nerves
Ligament of ovary (round ligament)- connects inferior end of ovary to lateral
angle of uterus
- remains of the upper part of the gubernaculum
Mesovarium: attach to the postero-anterior layer of the broad ligament,
connected with suspensory ligament
Fallopian Tube
Uterus
Uterus axis
Uterus
Support
 Vagina

•Thin-walled tube lying

between the bladder and the rectum, extending from the cervix
to the exterior of the body
•Wall consists of three coats: fibroelastic adventitia, smooth
muscle muscularis, and a stratified squamous mucosa
•Mucosa near the vaginal orifice forms an incomplete partition
called the hymen
•Vaginal fornix: upper end of the vagina surrounding the cervix
•
Female External Genitalia
MENSTRUAL CYCLE
(Faiz)
OVARIAN CYCLE
UTERINE CYCLE
CONCEPTION
(KAVINEIL)
Conception
- Is the start of ovulation and when the sperm successfully fuses with the ovum to produce an embryo

Stages:

1. Gametogenesis
2. Ovulation
3. Approximation of gametes
4. Penetration of barriers of the ovum
5. Fusion of pronucleus of gametes
6. Embryo
DIFFERENTIAL DIAGNOSIS
(Issam)
MULTIPLE UTERINE LEIOMYOMA
Definition?
Benign tumour that arise from the
smooth muscle cells in the
myometrium.
ETIOLOGY & RISK FACTORS
(Haninah)
 Etiology

● Genetic changes - chromosomal abnormalities

● Hormones - oestrogen & progesterone
● Other growth factors - insulin-like growth factor
 Risk Factors
● Reproductive age - 30-50 years old
● Hereditary
● Race - African-Caribbean origin
● Environmental factors
○ Onset of menstruation at an early age
○ Use of birth control
○ Overweight or obese
○ Vitamin D deficiency
○ Diet higher in red meat and lower in green vegetables & fruits
○ Alcohol
PATHOPHYSIOLOGY &
COMPLICATIONS
(Kavinniyaa)
CLINICAL FEATURES
(Kenny/Wei Fang)
Menorrhagia
Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding.

Signs and symptoms of menorrhagia may include:

Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
Needing to use double sanitary protection to control your menstrual flow
Needing to wake up to change sanitary protection during the night
Bleeding for longer than a week
Passing blood clots larger than a quarter
Restricting daily activities due to heavy menstrual flow
Symptoms of anemia, such as tiredness, fatigue or shortness of breath
Etiology
Hormone imbalance. In a normal menstrual cycle, a balance between the hormones estrogen and
progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during
menstruation. If a hormone imbalance occurs, the endometrium develops in excess and eventually sheds by
way of heavy menstrual bleeding.

A number of conditions can cause hormone imbalances, including polycystic ovary syndrome (PCOS), obesity,
insulin resistance and thyroid problems.
Dysfunction of the ovaries. If your ovaries don't release an egg (ovulate) during a menstrual cycle (anovulation), your
body doesn't produce the hormone progesterone, as it would during a normal menstrual cycle. This leads to hormone
imbalance and may result in menorrhagia.
Uterine fibroids. These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine
fibroids may cause heavier than normal or prolonged menstrual bleeding.
Polyps. Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual
bleeding.
Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle,
often causing heavy bleeding and painful periods.
Intrauterine device (IUD). Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for
birth control. Your doctor will help you plan for alternative management options.
Pregnancy complications. A single, heavy, late period may be due to a miscarriage. Another cause of heavy bleeding
during pregnancy includes an unusual location of the placenta, such as a low-lying placenta or placenta previa.
Cancer. Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are
postmenopausal or have had an abnormal Pap test in the past.
Inherited bleeding disorders. Some bleeding disorders — such as von Willebrand's disease, a condition in which an
important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.
Medications. Certain medications, including anti-inflammatory medications, hormonal medications such as estrogen
and progestins, and anticoagulants such as warfarin (Coumadin, Jantoven) or enoxaparin (Lovenox), can contribute to
heavy or prolonged menstrual bleeding.
Risk factors
In a normal cycle, the release of an egg from the ovaries stimulates the body's production of progesterone,
the female hormone most responsible for keeping periods regular. When no egg is released, insufficient
progesterone can cause heavy menstrual bleeding.

Menorrhagia in adolescent girls is typically due to anovulation. Adolescent girls are especially prone to
anovulatory cycles in the first year after their first menstrual period (menarche).

Menorrhagia in older reproductive-age women is typically due to uterine pathology, including fibroids, polyps
and adenomyosis. However, other problems, such as uterine cancer, bleeding disorders, medication side
effects and liver or kidney disease must be ruled out.
Complications
Anemia. Menorrhagia can cause blood loss anemia by reducing the number of circulating red blood cells. The
number of circulating red blood cells is measured by hemoglobin, a protein that enables red blood cells to
carry oxygen to tissues.

Iron deficiency anemia occurs as your body attempts to make up for the lost red blood cells by using your iron
stores to make more hemoglobin, which can then carry oxygen on red blood cells. Menorrhagia may decrease
iron levels enough to increase the risk of iron deficiency anemia.

Signs and symptoms include pale skin, weakness and fatigue. Although diet plays a role in iron deficiency
anemia, the problem is complicated by heavy menstrual periods.

Severe pain. Along with heavy menstrual bleeding, you might have painful menstrual cramps
(dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to require medical
evaluation.
Menstrual cramps (dysmenorrhea)

throbbing or cramping pains in the lower abdomen. Many women have menstrual cramps just before and
during their menstrual periods.

Conditions such as endometriosis or uterine fibroids can cause menstrual cramps.

Symptoms
Symptoms of menstrual cramps include:

Throbbing or cramping pain in your lower abdomen that can be intense

Pain that starts 1 to 3 days before your period, peaks 24 hours after the onset of your period and subsides in
2 to 3 days
Dull, continuous ache
Pain that radiates to your lower back and thighs

Some women also have:

Nausea
Loose stools
Headache
Dizziness
Etiology
Endometriosis. The tissue that lines your uterus becomes implanted outside your uterus, most commonly on
your fallopian tubes, ovaries or the tissue lining your pelvis.
Uterine fibroids. These noncancerous growths in the wall of the uterus can cause pain.
Adenomyosis. The tissue that lines your uterus begins to grow into the muscular walls of the uterus.
Pelvic inflammatory disease. This infection of the female reproductive organs is usually caused by sexually
transmitted bacteria.
Cervical stenosis. In some women, the opening of the cervix is small enough to impede menstrual flow,
causing a painful increase of pressure within the uterus.
Risk factors
You might be at risk of menstrual cramps if:

You're younger than age 30

You started puberty early, at age 11 or younger
You bleed heavily during periods (menorrhagia)
You have irregular menstrual bleeding (metrorrhagia)
You have a family history of menstrual cramps (dysmenorrhea)
You smoke
Complications
Menstrual cramps don't cause other medical complications, but they can interfere with school, work and
social activities.

Certain conditions associated with menstrual cramps can have complications, though. For example,
endometriosis can cause fertility problems. Pelvic inflammatory disease can scar your fallopian tubes,
increasing the risk of a fertilized egg implanting outside of your uterus (ectopic pregnancy).

By Mayo Clinic Staff

Weak & Lethargy
Causes: -dehydration (d/t loss of fluid and blood that occur during period.)

-decrease in oestrogen levels

-iron-deficiency anemia (d/t significant amount of blood loss

Treatment: -stay hydrated (drink plenty of fluids)

-proper diet (to prevent hypoglycemia)

-iron supplements

-increase intake of iron-rich food

Other Clinical Features
● Pelvic pressure or pain
● Frequent urination
● Difficulty emptying the bladder
● Constipation
● Backache or leg pains
 MORPHOLOGY
(Kenny/Wei Fang)
Gross
● Firm-gray white masses
● Whorled appearance on cut section
● Typically sharply circumscribed
● Single but mostly multiple tumors ( scattered within the uterus )
● Ranging from small nodules to large tumors
● Embedded within intramural/submucosal/subserosal
● May extend and attached to surrounding organs, from which they may
develop a blood supply (parasitic leiomyomas)
Histology

Normal myometrium is at the left,

and the neoplasm is well-
differentiated so that the leiomyoma
at the right hardly appears different.
Histology
● Tumor cells resemble normal cells (uniform,elongated,spindle-shaped) and
form bundles with different directions (whirled)
● Foci of fibrosis,calcification
● Degenerative softening may be present.
EXAMINATIONS &
INVESTIGATIONS
(Kavineil & Kayen)
Non invasive Examination
● Bimanual examination
● Ultrasonography
● MRI
Bimanual Examination
- Palpation of the cervix, vagina and uterus

Normal (uterus):

1. Inverted pear shaped

2. Anteverted & anteflexed
3. Smooth surface but firm when felt
4. Not tender

Leiomyoma (uterus):

5. Large
6. Immobile
7. irregular
Ultrasonography
- Using soundwaves to produce an image
of the uterus

Equipment:

1. Ultrasound scanner
2. Lubricants
3. Condom
Saline infusion sonohysterography (SIS)
- Using saline fluid to produce an image with an ultrasound
scanner
- Endometrium lining is shown
 Hysteroscopy

- Inside of uterus is examined

through a thin telescope
(hysteroscope) that is inserted
through the cervix
- Electrolyte-containing solution:
normal saline, lactated Ringer’s
solution
Multiple fibroids
Laparoscopy

- A surgical procedure
- Allows surgeon to access
inside of the abdomen and
pelvis
Fibroids
Endometrial biopsy

- Take a tissue
sample from
endometrium
MRI (Magnetic resonance imaging)
- Not generally used for
diagnosis, but it the most
accurate modality
- Especially good in
distinguishing between
fibroids and adenomyosis
Cross section view
<< Fibroid
Biochemical

- Complete blood count (CBC)

- Pregnancy test
- Hormonal test (FSH, LH, estrogen)
TREATMENT &
MANAGEMENT
(Betty)
 Non-surgical Procedures Surgical
Procedures
Non-invasive Minimally invasive

● MRI-guided focused ● Myolysis ● Abdominal

ultrasound surgery ● Uterine artery myomectomy
embolisation ● Hysterectomy
● Radiofrequency ablation
● Non invasive
● Performed while you’re inside an MRI
scanner equipped with a high-energy
ultrasound transducer for treatment.
● Minimally invasive
● Small particles (embolic
agents) are injected
into the arteries
supplying the uterus.

● Minimally invasive
● This treatment,
performed with a
specialized instrument
inserted into your
uterus.

● Minimally invasive
● The procedure of
delivering energy to
myomas in an attempt
to disrupt their blood
supply.
● Hysterectomy
● Option if the fibroids are contained inside the
uterus (submucosal).
● Access and remove fibroids using instruments
inserted through vagina and cervix into uterus.
References

1) https://www.mayoclinic.org/
2) https://www.nhs.uk/conditions/fibroids/
3) http://fibroidcenter.ucsf.edu/fibroid-diagnosis-how-do-i-know-i-have-fibroids