Female Reproductive

What are the major female genital organs?

• vulva

• vagina

• uterus

• fallopian tubes

• ovaries.

three layers of the uterus?

• Perimetrium – outer protective layer

• Myometrium – thick smooth muscle layer - contractions for childbirth

• Endometrium – inner mucosal lining

  • implantation of fertilized ovum

  • fetal develop

  • initiation of labour

  • menstruation

puberty and adolescence - common problems

• amenorrhea - absence of menstruation

• dysmenorrhea - cramping pain during menstruation

• HPV vaccination

reproductive age - common problems

• birth control

• pap smears

• pregnancy

• infertility

• sexually transmitted diseases

• pelvic inflammatory diseases

• dysfunctional uterine bleeding

• endometriosis

• polycystic ovary syndrome

45-55yrs - common problems

• dysfunctional uterine bleeding

• menopause

• benign tumour

• rare malignant tumours

55 yrs + - common problems

• cancer

• uterine prolapse

Define menarche.

first menstrual period experienced by a female.

Define amenorrhea.

absence of menstruation.

Define menorrhagia.

excessive menstrual bleeding.

Define metrorrhagia.

irregular uterine bleeding occurring between menstrual periods.

Define vaginal spotting.

small amount of vaginal bleeding that is not associated with a normal menstrual period.

Define dysmenorrhea.

Painful cramping during menstruation.

How long is the menstrual cycle?

What amount of bleeding is considered normal?

When does menarche occur?

When does menopause typically start?

What is Dysfunctional Uterine Bleeding (DUB)?

• abnormal vaginal bleeding that is NOT caused by a structural abnormality.

• results from hormonal dysregulation of the ovulatory cycle.

What causes Dysfunctional Uterine Bleeding?

hormonal regulation of ovulation is disrupted, leading to abnormal endometrial growth and unpredictable bleeding.

What conditions must be ruled out before diagnosing DUB?

• Nutritional causes

• Endocrine disorders

• Structural abnormalities

• Neoplastic (cancerous) causes

Describe the pathophysiology of Dysfunctional Uterine Bleeding.

• Failure to ovulate = no corpus luteum development = no progesterone

• estrogen continues stimulating endometrium = overgrowth

• endometrium outgrows blood supply = necrosis + heavy bleeding

Why does failure to ovulate cause DUB?

Failure to ovulate prevents formation of the corpus luteum, resulting in progesterone deficiency. Without progesterone, estrogen continuously stimulates the endometrium, leading to excessive growth and eventual heavy bleeding.

Why is progesterone important in the menstrual cycle?

stabilizes and prepares the endometrium after ovulation. Without progesterone, estrogen stimulation continues unchecked, resulting in abnormal endometrial proliferation and bleeding.

What clinical manifestations are associated with Dysfunctional Uterine Bleeding?

• Amenorrhea

• Menorrhagia - excessive menstrual bleeding

• Metrorrhagia - irregular bleeding from uterus between menses

• Iron-deficiency anemia

• Hemorrhagic shock

• Unpredictable menstrual cycles

• Infertility

Why can DUB cause infertility?

Persistent anovulation prevents normal ovulation and fertilization, reducing fertility.

What are common causes of Dysfunctional Uterine Bleeding?

• Anovulation (especially during adolescence and perimenopause)

• Hormonal imbalance

• Contraceptive medications

• Early pregnancy complications

Which populations are most likely to experience anovulatory DUB?

Adolescents and women in perimenopause commonly experience anovulatory dysfunctional uterine bleeding.

How is Dysfunctional Uterine Bleeding treated?

• Hormone therapy

• Oral contraceptives

• Hysterectomy (in severe or refractory cases)

What is primary dysmenorrhea?

Painful menstruation that is directly associated with ovulation and occurs without underlying pelvic disease.

What causes primary dysmenorrhea?

increased prostaglandin F2α production.

Describe the pathophysiology of primary dysmenorrhea.

• Increased prostaglandin F2α = increase myometrial contractions = contacts endometrial blood vessels = ischemia + PAIN

Besides pain, what symptoms are caused by prostaglandins during dysmenorrhea?

Prostaglandins may also produce:

• Nausea

• Diarrhea

• Headaches

Treatment for primary dysmenorrhea?

What is secondary dysmenorrhea?

painful menstruation caused by an underlying pelvic pathology rather than normal ovulation.

Define primary amenorrhea.

failure to achieve menarche.

When is primary amenorrhea diagnosed?

• No menstruation AND absent or poor secondary sexual characteristics by age 13

• OR

• No menstruation by age 15 regardless of secondary sexual characteristic development.

What are possible causes of primary amenorrhea?

• Congenital CNS defects

• Hypothalamic-pituitary-gonadal (HPG) axis abnormalities

• Acquired CNS lesions

• Anatomical abnormalities

• Genetic disorders = Turner’s syndrome

What is secondary amenorrhea?

absence of menstruation after menstrual cycles have previously been established.

dx secondary amenorrhea

• No menstruation for ≥ 3 months with no previous menstrual irregularities

• No menstruation for ≥ 6 months in women with previous menstrual irregularities

• The absence of menstruation within 5 yr of breast development

When is secondary amenorrhea considered physiologic (normal)?

• Early adolescence

• Pregnancy

• Lactation (breastfeeding)

• Perimenopausal period

other causes of secondary amenorrhea

What is Polyendocrine Metabolic Ovarian Syndrome (PMOS)?

previously called Polycystic Ovarian Syndrome (PCOS)

• hormonal and metabolic disorder

• characterized by

  • excess androgen production

  • ovulatory dysfunction

  • insulin resistance

  • polycystic ovaries.

Is PMOS hereditary?

inherited or associated with

• Adrenal dysfunction

• Thyroid dysfunction

• Androgen-producing ovarian tumors

• Hyperprolactinemia

• Insulin resistance

• Obesity

Patho of PMOS?

• excess androgens = inhibit ovulation by preventing normal follicular maturation

• impaired follicle maturation = no ovum = chronic anovulation

• excess androgen + estrogen = con’t stim endometrium

• dysfunctional uterine bleeding (DUB) + irregular menstrual cycle

• Insulin resistance further suppresses ovulation.

• Multiple enlarged cystic follicles remain on the ovary because ova are not released.

Why do ovarian cysts develop in PMOS?

Follicles mature incompletely and fail to rupture, allowing multiple enlarged cystic follicles to remain on the ovarian surface.

What are the diagnostic criteria for PMOS?

Diagnosis requires at least TWO of the following:

• Irregular menstrual periods

• Clinical or biochemical evidence of excess androgen (e.g., hirsutism)

• Polycystic ovaries on imaging

What are the clinical manifestations of PMOS?

• Amenorrhea or irregular menstrual cycles

• Hirsutism

• Infertility

• Insulin resistance

  • Increased risk of diabetes mellitus

PMOS treatment

What is perimenopause?

transition period before menopause that generally lasts 7–10 years

• characterized by fluctuating hormone levels.

What is menopause?

permanent cessation of menstruation caused by declining ovarian function and decreased production of female hormones.

• decrease in female hormones

• cessation of menstrual activity

• surgically induced - removal of ovaries

At what age does menopause usually occur?

45 and 55 years of age.

What hormonal changes occur during menopause?

There is a significant decline in estrogen and other female reproductive hormones, leading to permanent cessation of menstrual activity.

What are the clinical manifestations of menopause?

• Hot flashes

• Anxiety

• Insomnia

• Memory problems

• Mood changes

• Vaginal dryness

• Vaginal itching (pruritus)

• Pain during sexual intercourse (dyspareunia)

• Headaches

• Depression

Why does menopause cause vaginal dryness?

Reduced estrogen causes thinning and decreased lubrication of vaginal tissues, resulting in dryness, irritation, and discomfort during intercourse.

Why are mood changes common during menopause?

Declining estrogen affects neurotransmitters involved in mood regulation, increasing the risk of anxiety, depression, irritability, and emotional lability.

treatment - menopause

What is hormone therapy (HT)?

Hormone therapy replaces estrogen, with or without progesterone, to reduce menopausal symptoms.

What are the benefits of hormone therapy?

• Relief of menopausal symptoms

What short-term health benefits are associated with hormone therapy?

protects against

• Osteoporosis

• Colorectal cancer

What long-term benefits may hormone therapy provide?

• UTI prevention

• vaginal dryness

What are the risks associated with hormone therapy?

• Blood clots

• Small increase in breast cancer risk

• Endometrial cancer

• Heart disease

• Deep vein thrombosis (DVT) + Pulmonary thromboembolism (PTE/PT)

• Stroke

• Gallstones

Why do the dose and route of hormone therapy matter?

Different doses and routes (oral, transdermal, etc.) influence the balance between therapeutic benefits and adverse effects, affecting overall safety.

What is vulvitis?

inflammation of the skin of the vulva (external female genitalia).

What causes vulvitis?

• Irritating hygiene products

• Allergic reactions

• Spread of vaginal infections

How is vulvitis treated?

• Removing the irritant or allergen

• Sitz baths

• Topical cortisone cream

What is Bartholinitis?

inflammation of one or both Bartholin gland ducts.

Describe the pathophysiology of Bartholinitis.

Inflammation obstructs the Bartholin duct = secretions to accumulate = formation of a Bartholin cyst that may become infected and develop into an abscess.

What symptoms are associated with Bartholinitis?

Many patients are asymptomatic, but symptoms may include:

• fever

• swelling

• pain

• malaise

How is Bartholinitis treated?

• Sitz baths

• Surgical drainage

• Antibiotics

What is vaginitis?

inflammation of the vaginal mucosa.

What factors contribute to vaginitis?

• Altered vaginal pH (high pH) - local defence mech d/t

  • Antibiotic use

  • Poor overall health status

pH of vagina

• normal = 4-5

• low <4 = reduced infertility (acidic)

• high >5 = risk of infection (alkaline)

What is the most common cause of vaginitis?

sexually transmitted or infectious pathogens (trichomoniasis or Candida albicans (yeast infection)).

What are the clinical manifestations of trichomoniasis?

• frothy, malodorous, green/yellow discharge

• strawberry spots on cervix

What are the clinical manifestations of vaginal candidiasis?

• itching + pain

• discomfort with intercourse

• thick, white discharge (cottage cheese)

How is vaginitis diagnosed?

• hx + PE (physical exam)

• culture of vaginal discharge

How is trichomoniasis treated?

Metronidazole.

How is vaginal candidiasis treated?

Fluconazole.

What is cervicitis?

infection and inflammation of the cervix.

Which organisms most commonly cause cervicitis?

• Chlamydia trachomatis

• Neisseria gonorrhoeae

What does the cervix look like in cervicitis?

• Red

• Edematous (swollen)

• mucopurulent exudate (draining from external os)

How is chlamydial cervicitis treated?

Azithromycin.

How is gonococcal cervicitis treated?

Intramuscular Ceftriaxone plus Azithromycin.

Why is partner treatment important in cervicitis?

Treating sexual partners prevents reinfection and limits ongoing transmission of sexually transmitted infections.

Why are chlamydia and gonorrhea considered important public health diseases?

Both infections are reportable diseases because they can spread easily, cause serious reproductive complications, and require surveillance and partner notification by public health authorities.

What resource was referenced regarding reportable diseases?

Toronto Public Health Reportable Diseases of Public Health Significance document, which lists infections that must be reported to public health authorities.

What is Pelvic Inflammatory Disease (PID)?

Acute inflammation of 1+ organs in the upper female genital tract caused by ascending bacterial infection.

• oophoritis (ovaries)

• salpingitis (fallopian tubes)

• uterus also

• can affect entire peritoneal cavity

How does PID develop?

bacteria ascend from the vagina or cervix into the upper genital tract, causing infection and inflammation.

Describe the pathophysiology of PID.

• STI infects the cervix or vagina.

• Bacteria ascend into the uterus and fallopian tubes.

• Acute inflammation develops.

• Tissue damage and edema occur.

• Healing leads to fibrosis and scar tissue.

• Tubal obstruction and infertility may result.

What are the clinical manifestations of PID?

hard to dx

• Sudden severe abdominal pain

• Fever

• Dysuria

• Dyspareunia

• Mucopurulent vaginal discharge

• Abnormal vaginal bleeding

Why is PID difficult to diagnose?

Symptoms are often nonspecific and range from absent to severe, making diagnosis challenging.

What long-term complications occur in approximately 15–20% of PID cases?

• Infertility

• Ectopic pregnancy

• Chronic painful intercourse (dyspareunia)

• Pelvic adhesions

• Perihepatitis (Fitz-Hugh-Curtis syndrome)

• Tubo-ovarian abscesses

How is PID treated?

Treatment includes broad-spectrum antibiotics.

• Ceftriaxone

• Doxycycline

What are pelvic relaxation disorders?

result from progressive weakening of the pelvic support structures separating the vagina from surrounding organs.

What causes pelvic relaxation disorders?

• aging

• trauma

• childbirth

• surgery - pelvic

Which organs may become displaced in pelvic relaxation disorders?

• Bladder

• Urethra

• Rectum

• Uterus

What disorders are included under pelvic relaxation disorders?

• Cystocele - prolapsed bladder

• Rectocele - prolapsed rectum

• Uterine prolapse

How are pelvic relaxation disorders treated?

• Kegel exercises

• Pelvic floor physiotherapy

• Reducing heavy lifting

• Pessary placement - device inserted into vagina for support

• Surgical repair

cystocele

anterior wall prolapse - descent of bladder/anterior vaginal wall into vaginal canal

What are the clinical manifestations of a cystocele?

• Visible prolapse

• Pelvic pressure

• Urinary urgency

• Urinary frequency

• Urinary leakage (incontinence)

• Incomplete bladder emptying

What is a rectocele?

posterior vaginal wall prolapse in which the rectum bulges into the vaginal canal.