Chapter 40 Disorders of the Female Genitourinary System

Female Reproductive Anatomy

Estrogens Sexual maturation, skeletal growth, fat distribution Ovulation, implantation, pregnancy, parturition Development, maintenance of female accessory organs Cell division in the breasts and endometrium Maintain skin and blood vessels Decrease bone resorption Increase HDL, triglycerides; decrease LDL, cholesterol Sodium and water retention

Progesterones Maintain pregnancy Breast and endometrium development Decrease sodium reabsorption Increase body temperature Smooth muscle relaxation

The Menstrual Cycle Gonadotropin-releasing hormone (GnRH) from the hypothalamus begins the cycle. GnRH stimulates the anterior pituitary to release follicle- stimulating hormone (FSH) and luteinizing hormone (LH). FSH stimulates development of follicle cell layers. This is the follicular phase of the menstrual cycle.

The Menstrual Cycle (cont.) The developing follicle produces estrogen. Estrogen decreases FSH release; LH increases. Only the strongest follicles survive the drop in FSH. Follicles continue to make estrogen. Estrogen now stimulates LH release from the anterior pituitary. LH stimulates the mature follicle to burst.

The Menstrual Cycle (cont.) LH surge causes release of the egg = ovulation. Follicle cells become corpus luteum, producing progesterone. This is called the luteal phase of the cycle. Progesterone prepares the body for pregnancy. If pregnancy does not occur, the corpus luteum replaced by corpus albicans. The drop in progesterone tells the hypothalamus to secrete GnRH and begin a new cycle.

Disorders of the External Genitalia Bartholin gland cyst and abscess Leukoplakia Inflammatory dermatosis Nonneoplastic epithelial disorders Lichen sclerosus, lichen planus, lichen simplex chronicus Premalignant and malignant lesions Vulvodynia Localized, generalized

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

Cervical Epithelium Exocervix – stratified squamous epithelium Endocervix – columnar epithelium Hormones and acid in vagina – transforms columnar epithelium to squamous epithelium Transformation zone cells are more likely to become cancerous

Question True or false? HPV is a contributing factor to both vulvular and cervical cancer.

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

Uterine Disorders Endometritis Pelvic inflammatory disease Endometriosis Adenomyositis Endometrial cancer Uterine leiomyomas Disorders of uterine support

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

Endometriosis Endometrial tissue outside uterus Retrograde menstruation Metastasis through lymphatics or vascular system Activation of dormant cells that were always there Ectopic implants respond to hormones Go through menstrual cycle During menstrual period, tissue dies and bleeds Pain and adhesions result

Disorders of Pelvic Support Cystocele Rectocele Enterocele Uterine prolapse First, second, third degree

Ovarian Disorders Ovarian cysts Polycystic ovary syndrome Ovarian cancer

Polycystic Ovary Syndrome Chronic anovulation  Amenorrhea or irregular menses LH > FSH Stimulates androgen production Interferes with ovulation Ovaries contain many unovulated follicles Acne, hirsutism

Ovarian Cancer Ovulatory age – most significant risk factor BRCA1 and BRCA2 increase susceptibility High-fat diet and genital talc powders linked Causes vague GI symptoms No good screening tests available

Question True or false? Early detection through screening tests has improved the prognosis of ovarian cancer.

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

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

Menopause or Climacteric Decreased ovary function Low estrogen Osteoporosis risk Atherosclerosis risk Less inhibition of pituitary Increased FSH and LH Hot flashes

Question Why are postmenopausal women at risk for osteoporosis? Diminished function of the ovaries Decreased progesterone levels Decreased estrogen levels Increased levels of FSH and LH

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

Disorders of the Breast Inflammatory disorders Mastitis, ductal ectasia, fat necrosis Benign epithelial disorders Nonproliferative breast changes, proliferative breast disease without atypia, proliferative breast disease with atypia Breast cancer

Breast Anatomy

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