ANATOMY AND PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM

The internal reproductive organs

1) Vagina - a 3-4 inch long dilatable canal located between the bladder and the rectum; contains rugea (which permit considerable stretching without tearing); organ of copulation; passageway of menstrual discharges and fetus.2) The uterus - is a hollow, thick walled muscular organ - lies in the lesser pelvis normally with its body lying on top of urinary bladder and its neck between the urinary bladder and rectum. It is about 3 inches (7.5cm) long and 2 inches (5cm) broad and one inch (2.5cm) thick weighing 50-60 grams in non –pregnant woman.

3) Fallopian tubes - 4 inch long from each side of the fundus; widest part called ampulla spread into finger like projections called fimbriae.

-responsible for transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half.4) Ovaries - almond-shaped, dull white sex glands near the fimbriae, kept in place by ligaments. Produce mature and expel ova and manufacture estrogen and progesterone.

Normally the long axis of the uterus forms as angle of 90 degrees with the long axis of the vagina - This forward bending of uterus relative to the Vagina is called anteversion. The uterine body is slightly bend anteriorly relative to the cervix, this is called anteflexion. The angle of anteflexion is about 120 degrees. The position of the uterus changes with the degree of fullness of the bladder and rectum. During pregnancy uterus enlarges greatly to accommodate the fetus.

Layers of the UterusThe uterus is made up of three special layered linings of tissue and muscle.

The innermost layer is called the endometrium. After the onset of puberty, the endometrium lines the main body of the uterus and is where a fertilized ovum implants at the earliest moment of pregnancy. It provides a nesting place with immediate nutrition for the fertilized egg. If a woman is not pregnant, this lining is not needed, so it separates from the uterus and leaves the body as the menstrual flow during the menstrual period. This process is repeated monthly. Immediately a new lining begins to form in case a pregnancy occurs during the woman's next cycle. Except during a pregnancy or some

abnormal circumstances, this series of events continues uninterrupted from puberty to menopause.

The second layer is called the myometrium. This gives the uterus its great strength and elasticity. The myometrium contracts during the birth process and forces the fetus out of the uterus into the birth canal.

The third layer is called the perimetrium. It is a thin external covering for the other two layers. The uterus is held loosely in place in the pelvic cavity by several sets of ligaments: the broad ligament, the round ligament and the uterosacral ligament.

The Uterus and MenopauseDuring and after menopause, the reduced supply of estrogen causes the uterus to shrink in size. It no longer enlarges in response to sexual stimulation as it once did, but the feelings of sexual excitation, orgasm and fulfillment remain, and a woman can enjoy intercourse as much as she did before menopause.

Parts of uterusThe uterus is divisible into 2 main parts.1) The body2) The cervix

1. BODY Fundus Isthmus

2. CERVIX OF THE UTERUSIs the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. During menstruation the cervix stretches open slightly to allow the endometrium to be shed.

ABNORMAL POSITION OF UTERUS

a) ProlapseProlapse is a common complaint and severe degrees are most often seen in women of menopausal age who have borne children. In prolapse straining causes protrusion of the vaginal wall, while in severe cases the cervix may be pushed down to the level of the vulva. In extreme cases the whole uterus and both vaginal walls may be extruded. This produces micturition symptoms, low mild sacral backache, and sense of weakness and insecurity in the region of perineum. Most common cause is atomicity and asthenia that follow menopause. It may also occur after difficult labor.

b) RetroversionRetroversion means the position where the uterus is not anteverted. There can be mobile and fixed retroversion. Fixed retroversion means that the uterus is bound by adhesions or tumours. Retroversion may cause dysmenorrhoea, menorrhagia, pressure, backache, dyspareunia, inferlity or abortion.

c) Inversion of the uterusIn inversion uterus becomes turned inside out. At first fundus is pushed down into cavity of the uterus leaving a cupshaped depression on the peritoneal surface.

THE PHASES OF MENSTRUAL CYCLE

1) First phase (proliferative) - immediately after the menstrual flow (which occurs during the first 4-5 days of a cycle), the endometrium, or lining of the uterus, is very thin, approximately one cell layer in depth. As ovary begins to produce estrogen (in the follicular fluid, under the direction of the pituitary FSH), the endometrium begins to proliferate. This growth is very rapid and increases the thickness of the endometrium approximately eightfold. This increase continues for the first half of the menstrual cycle (from approximately day 5 to day 14).this half of a menstrual cycle is term interchangeably the proliferative, estrogenic, follicular, or postmenstrual phase.

2) Second phase (secretory) - after ovulation, the formation of progesterone in the corpus luteum (under the direction of LH) causes the glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen (an elementary sugar) and mucin (a protein).the capillaries of the endometrium increases in amount until the lining takes in the appearance of rich, spongy velvet. This second phase of menstrual cycle is termed the progestational, luteal, premenstrual, or secretory phase.

3) Third phase (ischemic) - if fertilization does not occur, the corpus luteum in the ovary begins to regress after 8-10 days. As it regresses, the production of estrogen and progesterone decreases. With the withdrawal of progesterone stimulation, the endometrium of the uterus begins to degenerate (at approximately 24 or 25 day cycle).the capillaries rupture, with minute hemorrhages, and the endometrium sloughs off.

4) Final phase (menses) - the following products are discharges from the uterus as menstrual flow or menses:

a. blood from the ruptured capillaries.

b. mucin from the glands.

c. fragments of endometrial tissue.

d. the microscopic , atrophied, and unfertilized ovum.

Hormones

1) Estrogen

Structural promote formation of female secondary sex characteristics decelerate height growth[14] accelerate metabolism (burn fat) reduce muscle mass stimulate endometrial growth increase uterine growth increase vaginal lubrication thicken the vaginal wall maintenance of vessel and skin reduce bone resorption, increase bone formation morphic change (endomorphic -> mesomorphic -> ectomorphic)

Protein synthesis increase hepatic production of binding proteins

Coagulation increase circulating level of factors 2, 7, 9, 10, plasminogen decrease antithrombin III increase platelet adhesiveness

Lipid increase HDL, triglyceride decrease LDL, fat deposition

Fluid balance salt (sodium) and water retention increase cortisol, SHBG

Gastrointestinal tract reduce bowel motility increase cholesterol in bile

Lung function promotes lung function by supporting alveoli (in rodents but probably in humans).

2) Progesterone Inhibits production of leutenizing hormone. Increases endometrial tortuosity. Increases endometrial secretions. Inhibits uterine motility. Decreases muscle tone of gastrointestinal and urinary tracts. Increases musculoskeletal motility. Facilitates transport of the fertilized ovum through the fallopian tubes . Decreases renal threshold of lactose and dextrose. Increases fibrinogen levels;decreases hemoglobin and hemtocrit. Increase body temperature after ovulation.

KINDS OF FIBROIDS/ MYOMA DEPENDS ON THEIR ORIENTATION IN THE UTERINE WALL

Ultrasound Report June 1, 2010

TRANSVAGINAL ULTRASOUND

Uterus is anteverted enlarged with irregular outline and inhomogenous echo pattern. Uterine body measure 8.13 x 6.82 x 6.37cm. Cervix measure 1.98 x 1.33 cm. Endometrium measure 1.56cm.

Multiple hypoechoic structure is anterior and posterior walls measuring 1.99 x 1.55cm. 1.60 x 1.78cm. 2.20 x 1.47cm.

Left ovary measures 1.68 x 1.14cmRight ovary is not visualized

No posterior cul de sac fluid

Impression:Enlarged uterus with multiple intramural myomasThick endometriumUnremarkable left ovary and adnexia