1. Chapter 40 Disorders of the Female Genitourinary System

2. Female Reproductive Anatomy

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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.

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

14. 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

15. 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

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

17. 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

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

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

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

21. Endometrial Disorders
Endometritis
Pelvic inflammatory disease
Endometriosis
Adenomyositis
Endometrial cancer
Leiomyomas

22. 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

23. 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

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

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

26. 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

27. 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

28. 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

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

30. 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.

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

32. 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?

33. 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

34. 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

35. 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).

36. Breast Anatomy
Author: Add figure?

37. Disorders of the Breast
Mastitis
Ductal ectasia
Fibrocystic changes
Breast cancer

38. 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