Reproductive System

Functions
The male reproductive system is a grouping of organs that make up a man’s
reproductive and urinary systems. These organs have following functions:-
• They produce, maintain and transport sperm and semen (the protective fluid
around the sperm).
• They discharge sperm into the female reproductive tract.
• They produce and secrete male sex hormones
Penis
The penis is an external organ of the male reproductive system. It has two main
functions:
Sexual intercourse – During erotic stimulation, the penis undergoes erection,
becoming engorged with blood. Following emission, (mixing of the components
of semen in the prostatic urethra) ejaculation can occur, whereby semen moves
out of the urethra through the external urethral orifice. Finally, the penis
undergoes remission, returning to a flaccid state.
Micturition – The penis also has an important urinary role. It contains the
urethra, which carries urine from the bladder to the external urethral orifice,
where it is expelled from the body.
Structure of the Penis
• The penis can be anatomically divided into three parts:
Root – The most proximal, fixed part of the penis. It is located in the superficial
perineal pouch of the pelvic floor, and is not visible externally. The root contains
three erectile tissues (two crura and bulb of the penis), and two muscles
(ischiocavernosus and bulbospongiosus).
Body – The free part of the penis, located between the root and glans. It is
suspended from the pubic symphysis. It is composed of three cylinders of erectile
tissue – two corpora cavernosa, and 1 corpus spongiosum.
Glans – The most distal part of the of penis. It is conical in shape, and is formed
by the distal expansion of the corpus spongiosum. This contains the opening of
the urethra, termed the external urethral orifice.
Corpora cavernosa
• The corpora cavernosa are paired spongy cylinders that lie on the superior aspect of
the penis. They are enveloped by the tunica albuginea.
• The proximal ends of the corpora are separate structures anchored at the ischial
ramus.
• The corpora then fuse underneath the pubic ramus and share a common septum
distally towards the glans.
• Within the corpora, interconnected sinusoids are enveloped by trabeculae of smooth
muscle, collagen, and elastin.
• The sinusoidal smooth muscle is in intimate association with the cavernous nerves
and helicine arteries(branches of deep artery of penis) within the penis.
• The sinusoids are tonically constricted during the flaccid state.
• Arterial blood flow diffuses through larger central sinusoids to smaller peripheral
sinusoids.
During sexual stimulation, release of neurotransmitters causes the smooth
muscle around the sinusoids to relax.
This results in rapid influx of arterial blood, subsequent entrapment of blood
within these expanding sinusoids, and occlusion of veins traversing the tunica
albuginea.
Each of them terminates under cover of the glans penis in a blunt conical
extremity.
Corpus spongiosum
The corpus spongiosum is the forward continuation of the bulb of the penis. Its
terminal part is expanded to form a conical enlargement, called the glans penis.
Throughout its whole length, it is traversed by the urethra. Like the corpora, it is
also surrounded by a fibrous sheath.
The function of the corpus spongiosum in erection is to prevent the urethra from
pinching closed, thereby maintaining the urethra as a viable channel for
ejaculation.
To do this, the corpus spongiosum remains pliable during erection while the
corpora cavernosa penis become engorged with blood.
Glans Penis
At the distal end of penis there is an conical expanded mass, known as glans
penis, which is covered by a fold of skin called as prepuce/foreskin.
When the prepuce is retracted the base of the glans represent a raised margin the
corona glandis.
Just behind the glandis there is a circular sulcus called as neck of the penis.
The potential space between the glans and the prepuce is known as the preputial
sac.
Numerous sebaseous glands are present in the glandis which produces smegma.
Layers:-
• Skin
• Superficial fascia
• Buck’s fascia
• Tunica Albuginea
Ligaments of Penis
• Fundiform ligament
• Suspensory Ligament
Blood supply
The penis receives arterial supply from three sources:
• Dorsal arteries of the penis
• Deep arteries of the penis
• Bulbourethral artery
These arteries are all branches of the internal pudendal artery the branch of
anterior division of the internal iliac artery.
 Testis
• The testes (testicles) are male reproductive glands found in a saccular extension
of the anterior abdominal wall called the scrotum.
• It is suspended in the scrotal sac by spermatic cord.
• They are in ovoid shape and size is about four to six centimeters in length.
• Testes develop retroperitoneally on the posterior abdominal wall and descend to
scrotum before birth.
• After their descent, the testes remain connected with the abdomen by spermatic
cords, and attached to the scrotum by the testicular ligament.
• Testes in males are analogous to the female ovaries. They produce sex hormones
called androgens (primarily testosterone) in the process of steroidogenesis and
are the place of spermatogenesis, the production of sperm.
External Features
The testis lies obliquely so that their upper pole is tilted forward & medially. The
left testis is slightly lower than the right.
Testis is oval in shape & compressed from side to side. It is 3.75 cm long, 2.5 cm
broad & 1.8 cm thick approx. Weigh is about 10-15 gm.
It has-
• 2 poles
• 2 borders
• 2 surfaces
• The upper and lower poles are convex and smooth.
• The upper pole provides attachment to the spermatic cord.
• The anterior border is convex and smooth, and is fully covered by the tunica
vaginalis.
• The posterior border is straight, and is only partially covered by the tunica
vaginalis.
• The epididymis lies along the lateral part of the posterior border. The lateral part
of the epididymis is separated from the testis by an extension of the cavity of
the tunica vaginalis.
• This extension is called the sinus of epididymis.
• The medial and lateral surfaces are convex and smooth.
• Attached to the upper pole of the testis, there is a small oval body called the
appendix of the testis. Itis a remnant of the paramesonephric duct.
Coverings of the Testis
The testis is covered by three coats-
From outside inwards, these are;
• Tunica vaginalis,
• Tunica albuginea and
• Tunica vasculosa.
Coverings
Tunica vaginalis represents the lower persistent portion of the processus vaginalis.
It is invaginated by the testis from behind and, therefore, has a parietal and a
visceral layer with a cavity in between.
It covers the whole testis, except for its posterior border.
The tunica albuginea is a dense, white fibrous coat covering the testis all around.
It is covered by the visceral layer of the tunica vaginalis, except posteriorly where
the testicular vessels and nerves enter the gland.
Albuginea is thickened to form an incomplete vertical septum, called the
mediastinum testis, which is wider above than below. Numerous septa extend
from the mediastinum to the inner surface of the tunica albuginea. They
incompletely divide the testis into200 to 300 lobules.
The tunica vasculosa is the innermost, vascular coat of the testis lining its lobules.
The processus vaginalis (or vaginal process) is an embryonic developmental
outpouching of the peritoneum.
It is present from around the 12th week of gestation, and commences as a
peritoneal outpouching.
In males, it precedes the testis in their descent down within the gubernaculum,
and closes.
This closure (also called fusion) occurs at any point from a few weeks before
birth, to a few weeks after birth.
The remaining portion around the testes becomes the tunica vaginalis
Structure of the Testis
• The glandular part of the testis consists of 200 to300 lobules. Each lobule
contains two to three seminiferous tubules.
• Each tubule is highly coiled on itself.
• When stretched out, each tubule measures about 60 cm in length, and is about
0.2 mm in diameter.
• The tubules are lined by cells which represent stages in the formation of
spermatozoa. The seminiferous tubules join together at the apices of the lobules
to form 20 to 30 straight tubules which enter the mediastinum.
• Here they anastomose with each other to form a network of tubules, called the
rete testis.
• In its turn, the rete testis gives rise to 12 to 30 efferent ductules which emerge
near the upper pole of the testis and enter the epididymis.
Here each tubule becomes highly coiled and forms a lobe of the head of the
epididymis.
The tubules end in a single duct which is coiled on itself to form the body and tail
of the epididymis. Itis continuous with the ductus deferens.
Female Reproductive System
Introduction
Reproductive system ensures the continuation of species. Gonads are the primary
reproductive organs which produce the gametes (egg or ovum); a pair of testes
(singular = testis) produces sperms in males and a pair of ovaries produces ovum
in females. In some organisms like earthworms and snails, both sexes may be
present in the same organism and this condition is known as hermaphroditism.
In humans and most of the higher animals, reproduction occurs sexually, i.e. by
mating. However, there are some species like insects which can produce
offspring's without mating.
Reproductive organs include:
1. Primary sex organs
2. Accessory sex organs.
Mons Pubis
Mons pubis is a rounded eminence present in front of the pubic symphysis. It is
formed by accumulation of subcutaneous fat.
It is covered with pubic hair.
Labia Majora
Labia majora are two thick folds of skin enclosing fat. They form the lateral
boundaries of the pudendal cleft.
The outer surfaces are covered with hair, and the inner surfaces are studded with
large sebaceous glands. The larger anterior ends are connected to each other below
the mons pubis.
The skin of posterior ends of the labia is known as the posterior commissure. The
area between the posterior commissure and the anus which is about 2.5 cm long.
Labia Minora
Labia minora are two thin folds of skin, which lie within the pudendal cleft.
Anteriorly, each labium minus splits into two layers; the upper layer joins the
corresponding layer of the opposite side to form the prepuce of the clitoris.
Similarly, the lower layers of the two sides join to form the frenulum of the
clitoris.
Posteriorly, the two labia minora meet to form the frenulum of the labia minora.
The inner surface of the labia minora contains numerous sebaceous glands
Clitoris
The clitoris is an erectile organ, homologous with the penis. However, it is not
traversed by urethra. It lies in the anterior part of pudendal cleft(fissure between
the folds labia majora).
The body of clitoris is made up of two corpora cavernosa enclosed in a fibrous
sheath and partly separated by an incomplete pectiniform septum.
The corpus spongiosum is absent. Each corpus cavernosum is attached to the
ischiopubic rami.
The down-turned free end of clitoris is formed by a rounded tubercle, glans
clitoridis, which caps the free ends of corpora.
The glans is made up of erectile tissue continuous posteriorly with the
commissural venous plexus uniting right and left bulbs of vestibule called bulbar
commissure.
The surface of glans is highly sensitive and plays an important role in sexual
responses.
Vestibule of the Vagina
Vestibule of the vagina is space between two labia minora. Its features are as
follows.
Clitoris placed most anteriorly.
The urethral orifice lies about 2.5 cm behind the clitoris and just in front of the
vaginal orifice.
Most females (but not all) are born with a hymen, which is generally in the form of
an elliptical/oval-shaped membranous ring around the vaginal orifice (It is generally
perforated to some degree, most often in the center, kind of like a 'donut' shape).
The remnants of this membranous ring in adult females in known
as hymenal caruncles, which appear as small thin elevations of mucous membrane
around the vaginal opening. When the hymen completely covers the vaginal orifice,
it is known as an imperforate hymen.
An imperforate hymen may rupture naturally during various types of physical
activity
Orifices of the ducts of greater vestibular glands lie one on each side of vaginal
orifice, between the hymen and labium minus .
Numerous lesser vestibular or mucous glands open on the surface of vestibule.
The posterior part of vestibule between vaginal orifice and frenulum of labia
minora forms a shallow depression known as vestibular fossa.
Bulbs of the Vestibule
Bulbs of the vestibule are two oval bodies of erectile tissue that correspond to the two
halves of the bulb of the penis.
The bulbs lie on either side of the vaginal and urethral orifices, superficial to the
perineal membrane(thin triangular horizontal layer of dense tough fascia in
the perineum which divides the urogenital triangle into superficial (inferior) and deep
(superior) perineal pouches).
The tapering anterior ends of the bulbs are united in front of the urethra by a venous
plexus, called the bulbar commissure. The bulbs are overlaid by their
respective bulbospongiosus muscles.
The expanded posterior ends of the bulbs partly overlap the greater vestibular glands.
Greater Vestibular Glands of Bartholin
Greater vestibular glands are homologous with the bulbourethral glands of Cowper in
the male. These lie in the superficial perineal space. Each gland has a long duct about
2 cm long which opens at the side of the hymen, between the hymen and the labium
minus. The mucoid secretion helps in lubrication.
OVARIES
The ovaries are the female gonads.
Situation
Each ovary lies in the ovarian fossa on the lateral pelvic wall. The ovarian fossa is
bounded:
Anteriorly by the obliterated umbilical artery.
Posteriorly by the ureter and the internal iliac artery
Position
The position of the ovary is variable. In nulliparous women, its long axis is nearly
vertical, so that the ovary is usually described as having an upper pole and a lower
pole. However, in multiparous women, the long axis becomes horizontal; so that
the upper pole points laterally and the lower pole medially
External Features
In young girls, before the onset of ovulation, the ovaries have smooth surfaces
which are greyish-pink in colour.
After puberty, the surface becomes uneven and the colour changes from pink to
grey.
Each ovary has two poles or extremities—the upper or tubal pole, and the lower
or uterine pole; two borders— the anterior or mesovarian border, and the posterior
or free border; and two surfaces—lateral and medial
Microscopic Structure of Ovary
 Uterus
Uterus is a child-bearing organ in females, situated in the pelvis between bladder
and rectum.
Though hollow it is thick walled and firm, and can be palpated bimanually
during a PV (per vaginal) examination.
It is the organ which protects and provides nutrition to a fertilized ovum,
enabling it to grow into a fully formed fetus.
At the time of childbirth or parturition, contractions of muscle in the wall of the
organ result in expulsion of the fetus from the uterus
Size and Shape
The uterus is pyriform in shape.
It is about 7.5 cm long,5 cm broad, and 2.5 cm thick. It weighs 30 to 40 grams.
It is divisible into an upper expanded part called the body and a lower cylindrical
part called the cervix.
The junction of these two parts is marked by a circular constriction called the
isthmus. Part of uterus above the opening of fallopian tube is called the fundus.
The body forms the upper two-thirds of the organ, and the cervix forms the lower
one-third.
The superolateral angle of the body project outwards at the junction of body and
fundus and is called cornua of uterus.
The uterine tube, ligament of ovary and round ligament are attached to it on each
side.
Normal Position and Angulation
Normally, the long axis of the uterus forms an angle of about 90° with the long
axis of the vagina.
The angle is open forwards. The forward tilting of the uterus relative to the
vagina is called anteversion.
The backward tilting of the uterus relative to vagina is known as retroversion.
The uterus is also slightly flexed at the level of internal os of cervix; this is
referred to as anteflexion.
The angle of anteflexion is 125°
Parts of Uterus
The uterus comprises:
Fundus
Body with two surfaces, anterior or vesical and posterior or intestinal
2 lateral borders
Cervix.
The fundus is formed by the free upper end of the uterus. Fundus lies above the
openings of the uterine tubes. It is convex like a dome. It is covered with
peritoneum and is directed forward when the bladder is empty.
The fertilized oocyte is usually implanted in the posterior wall of the fundus or
upper part of body of uterus.
The anterior or vesical surface of the body is flat and related to the urinary
bladder. It is covered with peritoneum and forms the posterior or superior wall of
the uterovesical pouch.
The posterior or intestinal surface is convex and is related to coils of the
terminal ileum and to the sigmoid colon.
It is covered with peritoneum and forms the anterior wall of the rectouterine
pouch.
Each lateral border is rounded and convex.
It provides attachment to the broad ligament of the uterus which connects it to the
lateral pelvic wall. The uterine tube opens into the uterus at the upper end of this
border.
This end of the border gives attachment to the round ligament of the uterus,
antero-inferior to the tube; and to the ligament of the ovary postero-inferior to the
tube.
The uterine artery ascends along the lateral border of the uterus between the two
layers of the broad ligament.
Cervix of Uterus
The cervix is the lower, cylindrical part of the uterus. It is less mobile than
the body. It is about 2.5 cm long, and is slightly wider in the middle than at
either end.
The lower part of the cervix projects into the anterior wall of the vagina
which divides it into supravaginal and vaginal parts. The supravaginal part of
the cervix is related:
Anteriorly to the bladder.
Posteriorly to the rectouterine pouch, containing coils of intestine and to the
rectum .
On each side, to the ureter and to the uterine artery, embedded in
parametrium. The fibro fatty tissue between the two layers of the broad
ligament and below it, is called the parametrium.
The vaginal part of the cervix projects into the anterior wall of the vagina.
The spaces between it and the vaginal wall are called the vaginal fornices.
The cervical canal opens into the vagina by an opening called the external os. In a
nulliparous woman, i.e. a woman who has not borne children, the external os is
small and circular.
However, in multiparous women, the external os is bounded by anterior and
posterior lips, both of which are in contact with the posterior wall of the vagina.
The cervical canal, i.e. the cavity of the cervix, is fusiform in shape.
It communicates above with the cavity of the body of the uterus, through the
internal os, and below with the vaginal cavity through the external os.
The canal is flattened from before backwards so that it comes to have anterior and
posterior walls.
These walls show mucosal folds which resemble the branches of a tree called the
arbor vitae uteri. The folds in the anterior and posterior walls interlock with each
other and close the canal.
Contents of Broad ligament-
The uterine tube
The round ligament of the uterus
The ligament of the ovary
Uterine vessels near its attachment to the uterus
Ovarian vessels
The uterovaginal and ovarian nerve plexuses
Some lymph nodes and lymph vessels
Dense connective tissue or parametrium present on the sides of the uterus
Arterial Supply
The uterus is supplied chiefly by the two uterine arteries which are markedly
enlarged during pregnancy. Partly by the ovarian arteries.
Nerve Supply
The uterus is richly supplied by both sympathetic and parasympathetic nerves,
through the inferior hypogastric and ovarian plexuses.
Sympathetic nerves from T12, L1 segments of spinal cord produce uterine
contraction and vasoconstriction.
The parasympathetic nerves (S2–4) produce uterine inhibition and vasodilatation.
However, these effects are complicated by the pronounced effects of hormones on
the genital tract.
Pain sensations from the body of the uterus pass along the sympathetic nerves,
and from the cervix, along the parasympathetic nerves.
Supports of the Uterus
The uterus is a mobile organ which undergoes extensive changes in size and shape
during the reproductive period of life. It is supported and prevented from sagging down
by a number of factors which are chiefly muscular and fibromuscular.
Primary Supports
Muscular or active supports
1 Pelvic diaphragm
2 Perineal body
3 Distal urethral sphincter mechanism
Fibromuscular or mechanical supports
1 Uterine axis
2 Pubocervical ligaments
3 Transverse cervical ligaments of Mackenrodt
4 Uterosacral ligaments
Secondary Supports
These are of doubtful value and are formed by peritoneal ligaments.
Broad ligaments
Vesicouterine pouch and fold of peritoneum
Rectovaginal or rectouterine pouch and fold of peritoneum
Structure of uterus
Uterus is made up of three layers:
1. Serous or outer layer/Perimetrium
2. Myometrium or middle muscular layer
3. Endometrium or inner mucus layer.
Serous or outer layer is the covering of uterus derived from peritoneum.
Anteriorly, it covers the uterus completely, but posteriorly it covers only up to the
isthmus.
Myometrium or middle muscular layer
Myometrium is the thickest layer of uterus and it is made up of smooth muscle
fibers
Smooth muscle fibers of myometrium are arranged in three layers:
External myometrium with transversely arranged muscle fibres
Middle myometrium with muscle fibers arranged longitudinally, obliquely and
transversely
Internal myometrium with circular muscle fibers.
Muscular layer is interdisposed with blood vessels, nerve fibers, lymphatic vessels
and areolar tissues.
Endometrium or inner mucus layer
Endometrium is smooth and soft with pale red color. It is made up of ciliated
columnar epithelial cells. Surface of the endometrium has minute orifices, through
which tubular follicles of endometrium open.
Endometrium also contains connective tissue in which the uterine glands are
present.
Uterine glands are lined by ciliated columnar epithelial cells.
Microscopic Structure of Uterus
UTERINE TUBES/Fallopian Tube
The uterine tubes are also called fallopian tubes/salpinx.
Definition
They are tortuous ducts which convey oocyte from the ovary to the uterus.
Spermatozoa introduced into the vagina pass up into the uterus, and from there
into the uterine tubes. Fertilization usually takes place in the lateral part of the
tube.
Situation
These are situated in the free upper margin of the broad ligament of uterus.
Dimensions
Each uterine tube is about 10 cm long. At the lateral end, the uterine tube opens
into the peritoneal cavity through its abdominal ostium. This ostium is about 3
mm in diameter
Subdivisions
1 The lateral end of the uterine tube is shaped like a funnel and is, therefore, called
the infundibulum. It bears a number of finger-like processes called fimbriae and
is, therefore, called the fimbriated end. One of the fimbriae is longer than the
others and is attached to the tubal pole of the ovary. It is known as the ovarian
fimbria .
2 The part of the uterine tube medial to the infundibulum is called the ampulla. It
is thin-walled, dilated and tortuous, and forms approximately the lateral two-thirds
or 6 to 7 cm of the tube. It arches over the upper pole of the ovary. The ampulla is
about 4 mm in diameter. This is the site for fertilisation.
3 The isthmus succeeds the ampulla. It is narrow, rounded and cord-like. It forms
approximately the medial one-third or 2 to 3 cm of the tube.
4 The uterine or intramural or interstitial part of the tube is about 1 cm long and
lies within the wall of the uterus. It opens at the superior angle of the uterine
cavity by a narrow uterine ostium. This ostium is about 1 mm in diameter.
Structure of Vagina
Introduction
The vagina is a fibromuscular canal, forming the female copulatory organ. The
term ‘vagina’ means a sheath.
Extent and Situation
The vagina extends from the vulva to the uterus, and is situated behind the bladder
and the urethra, and in front of the rectum and anal canal.
Direction
In the erect posture, the vagina is directed upwards and backwards. Long axis of
uterus and cervix forms an angle of 90° with long axis of vagina
Size and Shape
The anterior wall of the vagina is about 8 cm long and the posterior wall about 10
cm long. The diameter of the vagina gradually increases from below upwards. The
upper end or vault is roughly 5 cm twice the size of the lower end (2.5 cm).
However, it is quite distensible and allows passage of the head of the foetus during
delivery.
The lumen is circular at the upper end because of the protrusion of the cervix into
it. Below the cervix, the anterior and posterior walls are in contact with each other,
so that the lumen is a transverse slit in the middle part, and is H-shaped in the
lower part.
In the virgin, the lower end of the vagina is partially closed by a thin annular fold
of mucous membrane called the hymen. In married women, the hymen is
represented by rounded elevations around the vaginal orifice, the caruncular
hymenales.
The vaginal fluid is acidic in nature because of the fermentation of glycogen (in
vaginal cells) by the Doderlein’s bacilli
Menstrual Cycle
Menstrual cycle is defined as cyclic events that take place in a rhythmic fashion
during the reproductive period of a woman’s life.
Menstrual cycle starts at the age of 12 to 15 years, which marks the onset of
puberty.
The commencement of menstrual cycle is called menarche. Menstrual cycle ceases
at the age of 45 to 50 years.
Permanent cessation of menstrual cycle in old age is called menopause.
DURATION OF MENSTRUAL CYCLE
Duration of menstrual cycle is usually 28 days. But, under physiological
conditions, it may vary between 20 and 40 days.
CHANGES DURING MENSTRUAL CYCLE
During each menstrual cycle, series of changes occur in ovary and accessory sex
organs.
These changes are divided into 4 groups:
1. Ovarian changes
2. Uterine changes
3. Vaginal changes
4. Changes in cervix
All these changes take place simultaneously
OVULATION
Ovulation is the process by which the graafian follicle ruptures with consequent
discharge of ovum into the abdominal cavity. It is influenced by LH. Ovulation
occurs on 14th day of menstrual cycle in a normal cycle of 28 days. The ovum
enters the fallopian tube.
UTERINE CHANGES DURING MENSTRUAL CYCLE
During each menstrual cycle, along with ovarian changes, uterine changes also
occur simultaneously . Uterine changes occur in three phases:
1. Menstrual phase
2. Proliferative phase
3. Secretory phase
MENSTRUAL PHASE
After ovulation, if pregnancy does not occur, the thickened endometrium is shed
or desquamated.
This desquamated endometrium is expelled out through vagina along with blood
and tissue fluid.
The process of shedding and exit of uterine lining along with blood and fluid is
called menstruation or menstrual bleeding. It lasts for about 4 to 5 days.
This period is called as menstrual phase or menstrual period.
The day when bleeding starts is considered as the first day of the menstrual cycle.
Two days before the onset of bleeding, that is on 26th or 27th day of the previous
cycle, there is a sudden reduction in the release of estrogen and progesterone from
ovary.
Decreased level of these two hormones is responsible for menstruation.
Changes in Endometrium
Menstrual Phase
Lack of estrogen and progesterone causes sudden involution(shrinkage) of
endometrium. It leads to reduction in the thickness of endometrium, up to 65% of
original thickness.
During the next 24 hours, the tortuous blood vessels in the endometrium undergo
severe constriction.
Endometrial vasoconstriction is because of three reasons:
a. Involution(shrinkage) of endometrium
b. Actions of vasoconstrictor substances like prostaglandin, released from tissues
of involuted endometrium
c. Sudden lack of estrogen and progesterone (which are vasodilators)
iv. Vasoconstriction leads to hypoxia, which results in necrosis of the
endometrium
Necrosis causes rupture of blood vessels and oozing of blood
Outer layer of the necrotic endometrium is separated and passes out along with
blood
This process is continued for about 24 to 36 hours
Within 48 hours after the reduction in the secretion of estrogen and progesterone,
the superficial layers of endometrium are completely desquamated
Desquamated tissues and the blood in the endometrial cavity initiate the
contraction of uterus
Uterine contractions expel the blood along with desquamated uterine tissues to
the exterior through vagina.
During normal menstruation, about 35 mL of blood along with 35 mL of serous
fluid is expelled. The blood clots as soon as it oozes into the uterine cavity.
Fibrinolysin causes lysis of clot in uterine cavity itself, so that the expelled
menstrual fluid does not clot.
However, in the pathological conditions involving uterus, the lysis of blood clot
does not occur. So the menstrual fluid comes out with blood clot.
Menstruation stops between 3rd and 7th day of menstrual cycle. At the end of
menstrual phase, the thickness of endometrium is only about 1 mm.
This is followed by proliferative phase.
PROLIFERATIVE PHASE
Proliferative phase extends usually from 5th to 14th day of menstruation, i.e.
between the day when menstruation stops and the day of ovulation. It corresponds to
the follicular phase of ovarian cycle. At the end of menstrual phase, only a thin layer
(1 mm) of endometrium remains, as most of the endometrial stroma is desquamated.
Endometrial cells proliferate rapidly
Epithelium reappears on the surface of endometrium within the first 4 to 7 days
Uterine glands start developing within the endometrial stroma
Blood vessels appear in the stroma
Proliferation of endometrial cells occurs continuously, so that the endometrium
reaches the thickness of 3 to 4 mm at the end of proliferative phase.
All these uterine changes during proliferative phase occur because of the influence
of estrogen released from ovary. On 14th day, ovulation occurs under the influence
of LH.
This is followed by secretory phase
SECRETORY PHASE
Secretory phase extends between 15th and 28th day of the menstrual cycle, i.e.
between the day of ovulation and the day when menstruation of next cycle
commences.
After ovulation, corpus luteum is developed in the ovary. It secretes a large
quantity of progesterone along with a small amount of estrogen.
Estrogen causes further proliferation of cells in uterus, so that the endometrium
becomes more thick.
Progesterone causes further enlargement of endometrial stroma and further growth
of glands.
Under the influence of progesterone, the endometrial glands commence their
secretory function.
Many changes occur in the endometrium before commencing the secretory
function.
Endometrial glands become more tortuous. Because of increase in size, the glands
become tortuous to get accommodated within the endometrium
Cytoplasm of stromal cells increases because of the deposition of glycogen and
lipids
Many new blood vessels appear within endometrial stroma. Blood vessels also
become tortuous
Blood supply to endometrium increases
Thickness of endometrium increases up to 6 mm
VAGINAL CHANGES DURING
MENSTRUAL CYCLE
Proliferative Phase
Epithelial cells of vagina are cornified(horn like). Estrogen is responsible for this.
Secretory Phase
Vaginal epithelium proliferates due to the actions of progesterone. It is also
infiltrated with leukocytes.
These two changes increase the resistance of vagina for infection.
HORMONES INVOLVED IN REGULATION
The regulatory system functions through the hormones of hypothalamo-pituitary-
ovarian axis.
Hormones involved in the regulation of menstrual
cycle are:
1. Hypothalamic hormone: GnRH
2. Anterior pituitary hormones: FSH and LH
3. Ovarian hormones: Estrogen and progesterone.
Luteinizing hormone (LH, also known as luteinising hormone, lutropin and
sometimes lutrophin) is a hormone produced by gonadotropic cells in the anterior
pituitary gland. The production of LH is regulated by gonadotropin-releasing
hormone (GnRH) from the hypothalamus.
In females, an acute rise of LH known as an LH surge, triggers ovulation and
development of the corpus luteum. In males, where LH had also been
called interstitial cell–stimulating hormone (ICSH), it stimulates Leydig
PREMENSTRUAL SYNDROME
Common Features
1. Mood swings
2. Anxiety
3. Irritability
4. Emotional instability
5. Headache
6. Depression
7. Constipation
8. Abdominal cramping
9. Bloating (abdominal swelling)
ABNORMAL MENSTRUATION
1. Amenorrhea: Absence of menstruation
2. Hypomenorrhea: Decreased menstrual bleeding
3. Menorrhagia: Excess menstrual bleeding
4. Oligomenorrhea: Decreased frequency of menstrual bleeding
5. Polymenorrhea: Increased frequency of menstruation
6. Dysmenorrhea: Menstruation with pain
ANOVULATORY CYCLE
Anovulatory cycle is the menstrual cycle in which ovulation does not occur. The
menstrual bleeding occurs but the release of ovum does not occur. It is common
during puberty and few years before menopause. When it occurs before
menopause, it is called perimenopause.
If it occurs very often during childbearing years, it leads to infertility.
Common Causes
1. Hormonal imbalance
2. Prolonged strenuous exercise program
3. Eating disorders
4. Hypothalamic dysfunctions
5. Tumors in pituitary gland, ovary or adrenal gland
6. Long-term use of drugs like steroidal oral contraceptives.
Clinical Anatomy of Uterus, Vagina & Ovary
Intrauterine contraceptive device is used to prevent implantation of fertilized
oocyte.
Uterus is common site of formation of fibroids
Perineal body(midline fibromuscular structure, with important muscular
attachments, which acts to stabilize the structures of the pelvis and perineum) is
one of the chief supports of pelvic organs.
Damage to the perineal body often leads to prolapse of the uterus and of other
pelvic organs.
An ovarian cyst is a fluid-filled sac that develops on an ovary. They're very
common and do not usually cause any symptoms.
Ovarian cysts are the common gynecological problems encountered by
gynecologists in their daily practice. They can occur in any age group in females.
They are broadly divided into two types, i.e., physiological and pathological.
Physiological cysts are mainly follicular and luteal cysts and need no treatment
unless the cysts are complicated.
Pathological cysts can be benign or malignant.
Benign tumors are more common in young females, while malignant ones are
common in elderly females.
Benign tumors generally are not harmful and will not lead to cancer, while the
malignant tumor is harmful and will become cancerous in the future; hence should
be treated immediately
Causes of Ovarian Cysts:
Hormonal Problems
Endometriosis: Endometriosis is a condition when the lining of the uterus grows
outside of the uterus.
Women with endometriosis can develop a type of ovarian cyst due to the growth
of uterus lining over the ovaries called an endometrioma. The endometriosis tissue
may attach to the ovary and can start growing.
This type of cysts can be painful during intercourse and during menstruation.
Pregnancy: An ovarian cyst generally develops in early pregnancy to support the
pregnancy until the placenta is formed. But in a few cases, the cyst stays on the
ovary until the later phase of the pregnancy and will have to be removed.
Severe Pelvic Infections
Polycystic ovarian syndrome (PCOS) This is a condition in which the ovaries
develop a large number of small cysts on the outer edge of the ovaries. It leads to
enlargement of the ovaries size, and if left untreated, PCOS can become a reason
for infertility. It may occur due to combination of genetic and environmental
factor, or due to imbalance of reproductive hormones thus it is known as
hormonal disorder also.
According to the World Health Organization (WHO) estimation revealed over 116
million women (3.4%) are affected by PCOS worldwide.
The risk factors include genetics, neuroendocrine, lifestyle/environment, obesity
that contributes to the development of PCOS.
The pathophysiological aspect of PCOS mainly focuses on hormonal dysfunction,
insulin resistance, and hyperandrogenism leading to impaired folliculogenesis
which arise the risk for associated comorbidities like endometrial cancer, type II
diabetes.
Complications of PCOS can include:
Infertility gestational diabetes or pregnancy involves high blood pressure.
Miscarriage or premature birth can happen.
Non-alcoholic steatohepatitis: An extreme liver inflammation that is caused by fat
accumulates in the liver.
Metabolic syndrome such as a cluster of conditions like high blood pressure, high
blood sugar, and abnormal cholesterol or triglyceride levels that significantly
increase your risk of cardiovascular disease.
Type 2 diabetes or prediabetes. Sleep asphyxia(breathing difficulty in sleep),
depression, anxiety and eating disorders.
Abnormal uterine bleeding, cancer of uterine lining (endometrial cancer)
Prolapse of the anterior wall of vagina drags the bladder (cystocoele) and urethra
(urethrocoele); the posterior wall drags the rectum (rectocoele).
Weakness of supports of uterus can give rise to different degrees of prolapse.
Similarly, trauma to the anterior and posterior walls of vagina can cause the
vesicovaginal, urethrovaginal and rectovaginal fistulae.
Neoplasms: Primary new growths of vagina, like the infections, are uncommon.
However, secondary involvement of vagina by the cancer cervix is very common.
Uterine fibroids, also known as leiomyomas, are the commonest uterine
neoplasms. Although benign, they can be associated with significant morbidity and
are the commonest indication for hysterectomy.
Clinical Anatomy of Uterine Tubes
The most common cause of sterility in the female is tubal blockage which may be
congenital, or caused by infection.
Patency of the tube can be investigated by: Insufflation test or Rubin’s test.
Normally, air pushed into the uterus passes through the tubes and leaks into the
peritoneal cavity.
This leakage produces a hissing or bubbling sound which can be auscultated over
the iliac fossae.
Hysterosalpingography(HSG) is a radiological technique by which the cavity of
the uterus and the lumina of the tubes can be visualized, after injecting a radio-
opaque oily dye into the uterus .
Tubal pregnancy: Sometimes the fertilized ovum instead of reaching the uterus
adheres to the walls of the uterine tube and starts developing there. This is known
as tubal pregnancy. The enlarging embryo may lead to rupture of tube.
SEXUAL LIFE IN FEMALES
Lifespan of a female is divided into three periods.
1st Period
First period extends from birth to puberty. During this period, primary and
accessory sex organs do not function. These organs remain quiescent. Puberty
occurs at the age of 12 to 15 years.
2nd PERIOD
Second period extends from onset of puberty to the onset of menopause. First
menstrual cycle is known as menarche. Permanent stoppage of the menstrual
cycle in old age is called menopause, which occurs at the age of about 45 to 50
years. During the period between menarche and menopause, women menstruate
and reproduce.
3rd PERIOD
Third period extends after menopause to the rest of the life.
Thank You
The Three Trimesters
Pregnancy has three trimesters, each of which is marked by specific fetal
developments. A pregnancy is considered full-term at 40 weeks; infants delivered
before the end of week 37 are considered premature. Premature infants may have
problems with their growth and development, as well as difficulties in breathing
and digesting.
First Trimester (0 to 13 Weeks)
The first trimester is the most crucial for development. During this period, your
feotus body structure and organ systems develop. Most miscarriages and birth
defects occur during this period.
Various changes during the first trimester in pregnant lady are- nausea, fatigue,
breast tenderness and frequent urination. Although these are common pregnancy
symptoms, every woman has a different experience. For example, while some
may experience an increased energy level during this period, others may feel very
tired and emotional.
Second Trimester (14 to 26 Weeks)
The second trimester of pregnancy is often called the "golden period" because
many of the unpleasant effects of early pregnancy disappear. During the second
trimester, pregnant lady likely to experience decreased nausea, better sleep
patterns and an increased energy level. However, there may be new set of
symptoms, such as back pain, abdominal pain, leg cramps, constipation and
heartburn.
Somewhere between 16 weeks and 20 weeks, baby's first fluttering movements
are felt.
Third Trimester (27 to 40 Weeks)
Some of the physical symptoms you may experience during this period include
shortness of breath, hemorrhoids, urinary incontinence, varicose veins and
sleeping problems. Many of these symptoms arise from the increase in the size of
the uterus, which expands from approximately 2 ounces before pregnancy to 2.5
pounds at the time of birth.