Chapter 40 Disorders of the Female Genitourinary System

Female Reproductive Anatomy

Estrogens Sexual maturation Ovulation Development and maintenance of female accessory organs Cell division in breasts and endometrium Maintaining skin and blood vessels Decreasing bone resorption Increased HDL levels, decreased LDL, and cholesterol Moving fluid into tissues

Progesterones Maintaining pregnancy Breast and endometrium development Maturation of endometrium cells Increased body temperature Smooth muscle relaxation

Hypothalamus GnRH Anterior pituitary FSH LH The Menstrual Cycle Gonadotropin-releasing hormone (GnRH) from the hypothalamus begins the cycle It causes the anterior pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH) Hypothalamus GnRH Anterior pituitary FSH LH

The Menstrual Cycle (cont.) Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) make ovarian follicles begin to mature This is the follicular phase of the menstrual cycle anterior pituitary FSH LH ovarian follicles begin to mature

The Menstrual Cycle (cont.) The developing follicle produces estrogen Estrogen decreases FSH release Only the strongest follicles survive the drop in FSH anterior pituitary FSH LH negative feedback inhibits ovarian follicles FSH begin to mature release estrogen

The Menstrual Cycle (cont.) Only the strongest follicles survive the drop in FSH Follicles continue to make estrogen Estrogen now stimulates LH release from the anterior pituitary strongest follicle survives continued estrogen production stimulates LH release

The Menstrual Cycle (cont.) LH surge causes release of the egg Ovulation Follicle cells become corpus luteum, making progesterone This is called the luteal phase of the cycle LH surge follicle bursts open OVULATION oocyte released remaining follicle into fallopian cells become tube corpus luteum progesterone

The Menstrual Cycle (cont.) Progesterone prepares the body for pregnancy If pregnancy does not occur, the corpus luteum dies The drop in progesterone tells the hypothalamus to secrete GnRH and begin a new cycle LH surge follicle bursts open OVULATION oocyte released remaining follicle into fallopian cells become tube corpus luteum progesterone

Question Which hormone slows down the release of FSH? LH Estrogen Progesterone GnRH

Answer Estrogen Estrogen, produced by the developing follicle, decreased FSH release (which only the strongest follicles will be able to survive). The remaining follicles continue to produce estrogen, which will stimulate the pituitary gland to release LH.

Disorders of the External Genitalia Bartholin gland cyst and abscess Leukoplakia Lichen sclerosus Lichen simplex chronicus Vulvodynia Cyclic vulvodynia Vulvar dermatoses Vulvar dysesthesia

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

Vaginal Bacterial Flora Many different species of bacteria Dominated by species that produce lactic acid Vaginal pH 3.8–4.2 Protect against infections Normal flora can be disrupted by: Abnormal estrogen levels Increased glycogen availability Antibiotics

Cervical Epithelium Inside the cervix: columnar epithelium Exposed to acid in vagina: transforms to squamous epithelium Transforming cells are more likely to become cancerous

Cancers of the Cervix and Vagina Cervical cancer Related to human papillomavirus infection Vaginal cancer Related to prenatal exposure to diethylstilbestrol May also be caused by: Spread of cervical cancer Human papillomavirus infection Chronic local irritation

Question Tell whether the following statement is true or false: HPV is a contributing factor to both vulvular and cervical cancer.

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

Anatomic Abnormalities Disorders of pelvic support Cystocele Rectocele Uterine prolapse Variations of uterine position

Endometrial Disorders Endometritis Pelvic inflammatory disease Endometriosis Adenomyositis Endometrial cancer Leiomyomas

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

Endometriosis How did the tissue get there? Up through the fallopian tubes (retrograde menstruation) Activation of dormant cells that were always there The ectopic implants respond to hormones Go through menstrual cycle During menstrual period, tissue dies and bleeds Pain and adhesions result

Endometrial Cancer Endometrial cancer has sometimes been caused by administration of estrogen without progesterone Question Why would this make cancer more likely?

Ovarian Disorders Ovarian cysts Polycystic ovary syndrome Benign ovarian tumors Functioning ovarian tumors Estrogen secreting Androgen secreting Mixed estrogen and androgen secreting Ovarian cancer

Polycystic Ovary Syndrome ovarian follicles begin to mature Follicles develop But they do not ovulate after the LH surge The high LH levels continue LH stimulates androgen production This interferes with ovulation even more Ovaries contain many unovulated follicles strongest follicle survives decreased FSH levels continued estrogen production stimulates LH release LH surge follicle bursts open OVULATION

Benign and Functioning Ovarian Tumors Benign tumors Epithelial cell: cystadenomas Endometriomas or “chocolate cysts” Fibromas Cystic teratomas or dermoid cysts: develop from germ cells Functioning tumors: secrete hormones Estrogens: alter menstrual cycle Androgens: cause masculine characteristics

Ovarian Cancer Associated with family history of ovarian and breast cancer Causes vague GI symptoms Up to 75% of cases have metastasized by the time they are discovered No good screening tests available

Question Tell whether the following statement is true or false: Early detection through screening tests has improved the prognosis of ovarian cancer.

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

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

Scenario Ms. T is 63 and postmenopausal. She used hormone replacement therapy for 8 years after her menopause, but discontinued it on her doctor's advice 4 years ago She has come into the clinic to request birth control She says she has started to menstruate again and her breasts have “plumped out” Question What do you think is happening?

Menopause or Climacteric Decreased ovary function Low estrogen Osteoporosis risk Atherosclerosis risk Less inhibition of pituitary Increased FSH and LH Hot flashes anterior pituitary FSH LH negative feedback inhibits ovarian follicles FSH begin to mature release estrogen

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

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

Breast Anatomy Author: Add figure?

Disorders of the Breast Mastitis Ductal ectasia Fibrocystic changes Breast cancer

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 make cancer more likely In a cancer, cells continue dividing too fast Estrogen and other growth factors make breast cells divide Breast cells with too many estrogen or growth factor receptors are more likely to become cancerous