REPRODUCTIVE BIOLOGY
Content

Female Reproductive system
- External genitalia (vulva).
- Internal reproductive organs.
- Blood supply for the pelvic organs.

Reproductive function.
- Menstruation.
- Cervical mucus changes.

Female genital mutilation.

Family planning.

Reproductive health.

Male reproductive system
- External genitalia.
- Internal reproductive organs.

Sexual response cycle.

Sexual dysfunction.
Key terms:
- Climacteric.
- Corpus luteum.
- Endometrium.
- Epididymis.
- Gametes.
- Menarche.
- Mons pubis.
- Myometrium.
- Ovulation.
- Prepuce.
- Seminiferous tubules. - Spermatogensis
- Vas deferens.
- Vestibule.
1
- Vulva.
Introduction
The obstetric nurse is called upon to counsel prospective parents
before and throughout pregnancy and childbirth. To accomplish this task,
the nurse must have a working knowledge of reproductive anatomy and
physiology and the menstrual cycle. This knowledge guides the nurse in
choosing appropriate interventions for the childbearing woman and her
family.
The main purpose of the male and female reproductive systems is
to produce offspring. Male testes produce and female ovaries gametes or
sex cells, spermatozoa (sperm) in the male and ova (eggs) in the female.
Each gamete contains one half of the genetic material needed to produce
a human baby. However, as you will see some of the structures in the
reproductive tract serve dual purposes. Most often these alternate
functions have to do with urinary elimination because the urinary system
is connected closely with reproductive system.
You will notice the most structures in the reproductive tract are
paired (e.g., testes, ovaries, labia majora, labia minora) and that male and
female reproductive systems are complementary; for example, male testes
and female ovaries; male scrotum and female labia majora; and male
glans penis and female clitoris. It is important to know that the pituitary
gland governs reproductive hormone production and function.
2
Female reproductive system
OBJECTIVES:
General objective:
At the end of this lecture the postgraduate student should be able to
upgrade a comprehensive knowledge about anatomy and physiology of
female genital tract.
Specific objective:
At the end of this lecture the postgraduate student should be able to:
1. Identify component of external genitalia
2. Identify component of internal genitalia
3. Discuss Blood supply, nerve supply and lymphatic drainage of
External genitalia.
4. Identify perineal body and perineal muscles.
5. Discuss Component of internal genital tract.
6. Explain Structure and function of internal genital tract.
7. Discuss Blood supply, nerve supply, lymphatic drainage of internal
genital tract.
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Female Genital Tract:
- The external genitalia, or vulva,
and internal reproductive organs
compose the female reproductive
tract
- The purposes of the female
reproductive tract is to allowfor
sexual intimacy and fulfillment
and to produce children through
the process
of
conception,
pregnancy; and child birth.
- Each part of the female
reproductive tract contributes in
some way to these purposes.
- The mammary glands and bony
pelvis are also part of female
reproductive anatomy.
(1) Externa femalel genitalia
(Vulva):
4
The term of vulva applies to the
external genital organs.
It consists of the following
structures:
 Monos pubis.
 Labia majora.
 Labia minora.
 Clitoris.
 Vestibule.
 The uretheral orifice & skine's
ducts.
 Vaginal orifice & bartholin’s
glands.
 Perineal body.
* Monos Pubis:
- It's called "mons veneris" is the
fatty pad that lies over the
symphysis pubis. It is covered with
pubic hair from the time of
5
puberty.it is triangular in shape; the
base of the triangle is toward the
symphysis pubis and the apex
toward the labia majora and thighs.
- The function of mons pubis is to
protect the pelvic bones, especially
during sexual intercourse.
*Labia Majora (greater lips):
 These are two rounded, fleshy
folds of fat and areolar tissue that
extend from the mons pubis to
the perineum, they have slightly
deeper
pigmentation
than
surrounding skin and are covered
with pubic hair.
 Labia majora are covered by
stratified squamaus epithelium
containing hair follicles and
sebaceous glands
6
 The chief function of is to protect
the structure lying between them.
 They are 7-8 cm in length and 23cm in width.
*Labia Minora (l esser lips):
These are paired of erectile
tissue folds lying between the labia
majora. It extends anteriorly from
the clitoris and then joins posteriorly
to the fourchette.
- The labia minora are thinner than
the labia majora, are hairless,
contain oil glands that lubricant &
water proof the vulvar skin and
provide bactericidal secretions &it
rich in blood supply and nerve
ending.
* Clitoris:
- At the apex of labia minora is
ahooded body composed of
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erectile tissue called clitoris. It is
similar to the glans penis.
- It is 5 to 3mm long and 6 to 8
mm across.the hooded structure
over the clitoris is called the
prepuce.
- It is very rich in blood and nerve
supplies and allows the women to
experience sexual pleasure &
orgasm
during
sexual
stimulation.
* The vestibule:
- this is the area enclosed by the
labia minora in which are situated
the openings of the urethera,
parauretheral (skene's ) glands,
vaginal opening or introitus and
bartholin's glands. It is boat shape.
*The Urethral orifice:
8
- This orifice lies 2.5cm posterior
to the clitoris. Its long is 4 cm
- On either side lie the openings of
skene’s ducts, two small blindended tubules 0.5 c.m long
running within the uretheral wall.
Their secretions lubricate the
vaginal vestibule to facilitate
sexual intercourse.
*The vaginal orifice:
- This is also known as introitus
of the vagina and occupies the
posterior two thirds of the
vestibule.
- The orifice is partially closed
by the hymen, a thin elastic
membrane that tears during sexual
intercourse or during the birth of
the first child. However, the
hymen can be torn in ways other
9
than sexual intercourse, such as
during heavy physical exertion or
with use of the tempons.
- The hymen is a vascular & it
varies in shape from woman to
woman.
*
Bartholin’s
glands
(vulvovaginal glands):
- There are two small glands that
open on the either side of the
vaginal orifice and lies in the
posterior part of the labia majora.
- These glands secrete mucus that
is clear and thick mucus with an
alkaline pH that enhances the
viability and motility of the
sperm deposited in the vaginal
vestibule. These glands ducts can
harbor (Neisseria gonorrhea) and
other bacteria, which can cause
10
pus formation and Barthotin's
gland abscess.
The vulval Blood supply:
- Mainly from the internal &
external pudendal arteries
- The veins of the vulva from
venous plexus.
Lymphatic drainage:
- This is mainly via the inguinal
glands.
Nerve supply:
- This is derived from branches of
the pudendal nerve. The vaginal
nerves supply the erectile tissue
of the vestibular bulbs and
clitoris and their parasympathetic
fibers have a vasodilator effect.
Pelvic floor:-
11
The pelvic floor is formed by the
soft tissues that fill the outlet of the
pelvis. The most important of these
is the strong diaphragm of muscle
slung like a hammock from the wall
of the pelvis. Through it pass the
urethera, the vagina and the anal
canal.
Function:
- It supports the weight of the
abdominal & pelvic organs.
- Its muscles are responsible for
the
voluntary
control
of
micturation and defication &
play an important part of the
sexual intercourse.
- During childbirth it influences
the passive movements of the
fetus through the birth canal and
12
relaxes to allow the exit of the
fetus from the pelvis.
Muscles Layers:
The superficial layer is composed of
five muscles:
- The external anal sphincter
surrounding the anus and
attached behind by a few fibres
to the coccyx.
- The transverse perineal muscles
pass from the ischial tuberosities
to the center of the perineum.
- The bulbocavernosus muscles
pass from the perineum forwards
around the vagina to the corpora
cavernosa of the clitoris just
under the pubic arch.
- The ischiocavernosus muscles
pass from the ischial tuberosities
13
along the pubic arch to the
corpora cavernosa.
- The membranous sphincter of the
urethra is composed of muscle
fibrous passing above and below
the urethra and attached to the
pubic bones. It is not a true
sphincter.
The deep layer is composed of
three Paris of muscles which
together are known as the levator ani
muscles. They are so called because
they lift or elevate the anus. Each
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levator ani muscle (left and right)
consists of the following:
- The
pubococcygeus
muscle
passes from the pubis to the
coccyx, with a few fibres
crossing over in the perineal
body to form its deepest part.
- The iliococcygeus muscle passes
from the fascia covering the
obturator internus muscle (the
white line of pelvic fascia) to the
coccyx.
- The
isciococcygeus
muscle
passes from the ischial spine to
the coccyx, in front of the
sacrospinous ligament
Perineal body:
- This is the pyramid of muscle
and fibrous tissue situated
between the vagina and the anus.
15
The perineal body measures 4
c.m in each direction.
- Several site of the superficial &
deep muscle groups meet at the
perineum to provide support for
pelvic structures.
- The perineum & muscles of the
pelvic floor are capable of great
expansion during child birth to
allow for delivery of the fetus.
The perineum is the site in which
the episiotomy is sometimes
done.uncontrolled tearing and
laceration can also occur.if these
are not properly repaired, or if
they do not heal appropriately,
the woman may experience stress
incontinence or prolapse of
pelvic organs later in life.
Internal female Genitalia
16
It includes the vagina, cervix,
uterus, fallopian tubes, and the
ovaries
*The vagina:
- The vagina or birth canal is a
muscular tube that leads from the
vulva to the uterus.
Functions:
- The vagina is a passage which
allows the escape of the
menstrual flow.
- The inner folds, or rugae, allow
the vagina to stretch during birth
to accommodate a full-term
infant.
- In additionally, normally, the
vagina maintains an acidic pH of
4 to 5, which protect the vagina
from infection.
17
- It receives the penis and the
ejected sperm during sexual
intercourse and provides an exit
for the fetus during delivery.
Position:
It is a canal running from the
vestibule to the cervix, passing
upwards and backwards into the
pelvis along a line approximately
parallel to the plane of the pelvic
brim.
Relations:
Anterior: In front lie the bladder and
the urethra, which are closely
18
connected to the anterior
vaginal wall.
Posterior: Behind, the pouch of
Douglas, the rectum and the
perineal body each occupy approximately one-third of the
posterior vaginal wall.
Lateral: Beside the upper two-thirds
are the pelvic fascia and the
ureters which pass beside the
cervix, while beside the lower
third are the muscles of the
pelvic floor.
Superior: Above the vagina lies the
uterus.
Inferior: Below the vagina lie the
external genitalia.
Structure:
- The posterior wall is 10cm long
while the anterior wall is only 7.5
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cm in length because the cervix
projects at a right angle into its
upper part.
- The upper end of the vagina is
known as the vault. Where the
cervix projects into it, the vault
forms a circular recess which is
described as four arches or fornices.
- The posterior fornix is the largest
of these because the vagina is
attached to the uterus at a higher
level behind than in front.
- The anterior fornix lies in front
of the cervix and the lateral fornices
lie on either side. The vaginal walls
are pink in appearance and thrown
into small folds known as rugae.
- These allow the vaginal walls to
stretch during intercourse and
childbirth.
20
Layers:
- The lining is made of squamous
epithelium.
- Beneath the epithelium lies a
layer of vascular connective
tissue.
- The muscle layer is divided into
a weak inner coat of circular
fibres and a stronger outer coat of
longitudinal fibres.
- Pelvic fascia surrounds the
vagina, forming a layer of
connective tissue.
Contents:
- There are no glands in the
vagina.
- It is. However, moistened by
mucus from the cervix and a
transudate which seeps out from
21
the blood vessels of the vaginal
wall.
- In spite of the alkaline mucus, the
vaginal fluid is strongly acid (pH
4.5) due to the presence of lactic
acid formed by the action of
Doderlein's bacilli on glycogen
found
in
the
squamous
epithelium of the lining.
- These lactobacilli are normal
inhabitants of the vagina.
- The acid deters the growth of
pathogenic bacteria.
Blood Supply:
This comes from branches of the
internal iliac artery and includes the
vaginal artery and a descending
branch of the uterine artery. The
blood drains through corresponding
veins.
22
Lymphatic drainage:
This is via the inguinal, the internal
iliac and the sacral glands.
Nerve supply:
This is derived from the pelvic
plexus. The vaginal nerves follow
the vaginal arteries to supply the
vaginal walls and also the erctile
tissue of the vulva.
*The uterus:
Position:
It lies in the true pelvis in an
anteverted and ante flexed position.
1. Shape:
It’s similar to that of English
pear.
2. Size:
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7.5 long, 5cm wide, 2.5cm thick
and weight about 60gms.
3. Structure:
- The cervix: Froms the lower third
of the uterus.
- The isthmus: Is the narrowed
construction about 7mm thick
lying between body of uterus and
cervix.
- The corpus or body: Forms the
upper two thirds of the uterus and
is that portion of organ lying above
the cervix.
- The cornua: Are the areas of uterus
where fallopian tubes are inserted
the lumen of this tubes opens into
the uterine cavity.
- The fundus: It’s the portion lies
above and between the cornuae.
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- The cavity: Is a triongular hollow
shape in the center of the uterus.
The wall of the uterus normally lie
in opposition.
4. Layers of uterus:
There are 3 layers:
1- Perimetruim:
It’s the outer pertoneal layer of
double serous membrane that covers
most of the uterus.
Laterally the perimetruim is
continuos with the broad ligaments
on sides of the uterus.
2- Myometruim:
- Is the middle layer of thick muscle.
- Most of the muscle fibres are
connected in the upper part of the
25
uterus and progressively diminish
toward the cervix.
- These are three layers of muscles
each has a function in childbirth.
A-Longitudinal:
Are found mostly in the fundus
and are designed to expel the fetus
effectively toward the pelvic outlet
during birth.
B- Interlacing figure 8:
They make up the middle layer.
These fibers contract after birth to
impress blood vessels that pass
between them to limit blood loss.
C-Circular fibers:
They prevent reflux of menstrual
blood and tissue into the fallopian
tubes, they form a constriction
where the fallopian tubes enter the
uterus.
26
Promote normal implantation of
the fertilized ovum by controlling its
into the uterus, and retain the fetus
till the appropriate time of birth.
3- Endometrium:
Forms a lining of epithelium
(mucous membrane) on abase of
connective tissue in uterine cavity
this endometrium is changing in
thickness throughout the menstrual
cycle it contain two layers.
A-The basal layer:
It doesn’t alter but provides the
foundation from which the upper
layer regenerate.
B- The functional layer:
- Lies above the basal layer and
contains the endometrial arteries,
veins and glands.
27
- This gland secrete alkaline
mucous.
- The epithelial cells are tall and
columnar in shape.
- The cervical endometrium is
thinner them that of the body and
is folded into a pattern known as
the arbor vitae this is thought to
assist the passage of the sperm.
- This layer is shed during each
menstrual period and after child
birth in form of lochia.
5. Blood supply:
Ovarian arteries on the right and
left from the abdominal aorta supply
the fundus of the uterus.
They pass downward to meet the
uterine artery of the corresponding
side.
28
Uterine arteries on the right and
left reach the uterus at the level of
the internal Os, and send branches to
supply the body of the uterus as well
as cervix and vagina.
Venous drainage is into the
ovarian veins, which drain into the
inferior a cava on the right hand
side, and into the renal vein on the
left.
6. Lymphatic drainage:
Symphatic drainage is into the
internal iliac and the sacral glands.
7. Nerve supply:
Nerve supply is via sympathetic
and parasympathetic nerves from the
Lee-Frankenhauser (sacral) plexus.
8. Supports:
The round ligaments:
29
Composed largely of fibrous
tissue, maintain the uterus in its
position
of
anteversion
and
anteflexion.
They extend from the cornua at
each side, pass downwards and
insert into the tissues of the labia
majora. However, they allow enough
movement for the uterus to rise
when the bladder is distended.
The broad ligaments:
Are not true ligaments but folds
of peritoneum extending laterally
between the uterus and sidewalls of
the pelvis.
The
cardinal
ligament,
pubocervical
ligaments
and
uterosacral gaments:
Although described as supporting
ligaments of the cervix, are piously
30
also
uterine
supports.
Over
stretching of these ligaments will
result in prolapse of the uterus. They
are composed of thickened bands of
pelvic fascia, connective tissue and
muscle fibres from the pelvic floor
and uterus. In particular, the
pubocervical
ligaments
are
especially concerned maintaining
the angle between the cervix and the
horizontal plane.
9. Function:
- To keep the uterus in anteverted,
anteflexed position.
- To prevent genital prolapse.
10. Relations:
Anterior: As for the cervix. The
intestines lie above the bladder
and in front of the body of the
uterus.
31
Posterior: Relation of the cervix and
the uterosacral ligament.
Laterally: Relations of the cervix,
the fallopian tubes, ovaries and
round ligaments.
Inferior: The vagina.
Superior: The intestines.
I- The cervix:
1. Position:
It forms the lower third of the
uterus and is the area below the
isthmus which includes the internal
and external Os. It enters the vagina
at aright angle and some times called
the neck of the uterus.
2. Size:
In adult female is 2.5cm long and
forms one third of the total length of
the uterus.
32
3. Shape:
The cervix as a whole tends to be
barrel shaped.
4. Structure:
The cervix protrudes into vagina
approximately 1 to 3cm. The cervix
has an opening or Os leading
connection with the isthmus of
uterus
and
external
opening
(external OS) is a small round
opening at the lower and of cervix
the cervical canal lies between these
2 or a this canal is shaped like a
spindle, narrow at each end and
wider in the middle. After vaginal
childbirth appears as slit like but
before birth it appear as a small dot.
5. Content:
- Consists mostly of connective
tissue and has few muscle cells, it
33
lined by secretory epithelium
which include many glands
(cervical glands).
- The cervical canal is lined with
mucous membrane that secrete
alkaline mucous.
6. Blood supply:
Uterine arteries, and venous
drainage through the uterine veins.
7. Lymphatic drainage:
It’s into the internal iliac and
sacral gland.
8. Nerve supply:
Sympathetic
and
parasympathetic.
9. Supports:
- Transverse cervical ligments:
Extend from the cervix to the
lateral wall of cervix.
34
- Pubocervical
ligments:
Run
forward from cervix to the pubic
bone.
- Uterosacral ligments: Extends
from the cervix and pass back
words to the sacral.
10. Function:
- Prevent ascending infection.
- Role in vaginal delivery through
dilatation and effacement.
11. Relation:
Anterior: Utero vesical pouch of
peritoneum and the bladder.
Posterior: Douglas pouch and
rectum.
Laterally: The broad ligment and the
uterus which are crossed by
the uterine arteries.
II- The fallopian tubes:
35
1. Situation:
- Each tube extends from the cornua
of the uterus, travels towards the
sidewalls of the pelvis, then turns
downwards and backwards before
reaching it.
- The tubes lie within the broad
ligament.
2. Shape:
They are tubular, as their name
implies. The lumen of each tube
communicates with the cavity of the
uterus, at its proximal end and the
peritoneal cavity at its distal end.
3. Size:
The length of each tube is
approximately 10cm. The diameter
varies in each part of the tube:
- Interstitial portion 1mm.
- Isthmus 2.5mm.
36
- Ampulla and infundibulum each
6mm.
4. Structure:
- The interstitial portion: Lies within
the wall of the uterus and is 2.5cm
in length.
- The isthmus: Is also 2.5cm in
length. It is the narrowest portion
of the tube and acts as reservoir for
spermatozoa
because
the
temperature is lower there than in
the rest of the tube. The lumen of
the isthmus is under hormonal
control and is contracted or dilated
according to stimulating hormones
which also affect the condition of
the uterine endometrium.
- The ampulla: Is the widened
lateral area of the tube where
37
fertilization normally occurs. It is
5cm in length.
- The infundibulum or fimbriated
end: Is the terminal and distal
portion of the tube which turns
backwards and downwards and
ends in finger-like projection
(fimbriae) which surround the
orifice of the tube. One fimbria lies
in closer proximity to the ovary
than the others.
5. Blood supply:
- The blood supply comes from the
uterine and ovarian arteries,
venous return is by corresponding
veins.
- The
infundibulum
has
a
particularly rich supply and blood
vessels, and muscle fibres. At the
time of ovulation, the blood
38
vessels become engorged and give
the fimbriae increased power of
movement so that they can range
over the ovary and waft the ovum
into the lumen.
6. Lymphatic drainage:
The lymphatic drainage is into
the lumbar glands.
7. Nerve supply:
The nerve supply is from the
ovarian plexus.
8. Supports:
This is provided by the
infundibulopelvic ligaments, these
are formed from folds of the broad
ligament and run from the
infundibulum of the tube to the
sidewalls of the pelvis.
9. Function:
39
The tube forms a canal through
which the ovum and sperm can pass
and unite, where the fertilized ovum
can commence early development.
10. Relations:
- Anterior: The peritoneal cavity
and the intestines.
- Posterior: The peritoneal cavity
and the intestines.
- Superior: The peritoneal cavity
and the intestines.
- Inferior: The broad ligament and
the ovaries.
- Laterally:
Infundibulopelvic
ligaments and round ligaments.
- Medial: The uterus.
III- The ovaries:
1. Situation:
40
The two ovaries lie within the
peritoneal cavity in a small
depression of the posterior wall of
the broad ligament. They are
situated at the fimbriated end of the
fallopian tube, at about the level of
the pelvic brim.
2. Shape:
The ovaries are small, almoundlike organs, dull white in colour and
with a corrugated surface.
3. Size:
3cm x 2cm x 1cm. Weight 5-8g.
4. Structure:
- Germinal epithelium: Is another
name for the peritoneum which
encloses the ovary.
- Tunica albuginea: Is the tough
fibrous outer coat.
41
- Cortex: Consists mostly of
vascular fibrous tissue, stroma in
which graafian follicles are
embedded. These follicles each
contain an ovum and can be found
at varying degrees of development.
The corpus luteum is the scar
tissue which forms after a follicle
has burst. The cortex is, therefore
the working part, of the ovary.
- Medulla: Is the central portion and
point of entry for blood vessels,
lymphatics and nerves. It consists
chiefly of fibrous and elastic.
5. Blood supply:
The blood is supplied from the
ovarian arteries, venous drainage is
into the ovarian veins.
6. Lymphatic drainage:
42
The blood is supplied from the
ovarian arteries, venous drainage is
into the ovarian veins.
7. Nerve supply:
The nerve supply is from the
ovarian plexus.
8. Supports:
- The fossa in which the ovary lies.
Where it is attached to the broad
ligament is called the mesovarium.
- The broad ligament which extends
between the fallopian tubes and the
ovary
is
known
as
the
mesosalpinx.
9. Function:
- To produce ova for fertilization.
- Hormonal production of estrogen
and progesterone.
10. Relations:
43
- Anterior: The broad ligament.
- Lateral: Fallopian tube.
I-
The cervix:
1.
Position:
It forms the lower third of the uterus and is the area below
the isthmus which includes the internal and external Os. It
enters the vagina at aright angle and some times called the neck
of the uterus.
2.
Size:
In
adult female is 2.5cm long and
forms one third of the total length of
the uterus.
3. Shape:
The cervix as a whole tends to
be barrel shaped.
4. Structure:
44
The cervix protrudes into vagina
Menstrual cycle
Hypothalamus pituitary ovarian
axis
- Toward the end of the normal
menstrual cycle, blood levels of
estrogen
and
progesterone
decrease.
- Low blood levels of these
ovarian hormones stimulate the
hypothalamus
to
secrete
gonadotropin-releasing hormone
(GnRH).
- In turn, GnRH stimulates anterior
pituitary secretion of folliclestimulating hormone (FSH).
45
- FSH stimulates development of
ovarian graafian follicles and
their production of estrogen.
- Estrogen
levels
begin
to
decrease, and hypothalamic
GnRH triggers the anterior
pituitary to release luteinizing
hormone (LH).
- A marked surge of LH and a
smaller peak of estrogen (day 12)
precede the expulsion of the
ovum from the graffian follicle
by about 24 to 36 hours.
- LH peaks at about day 13 or 14
of a 28-day cycle.
- If fertilization and implantation
of the ovum have not occurred by
this time, regression of the
corpus luteum follows.
46
- Levels of progesterone and
estrogen decline, menstruation
occurs, and the hypothalamus is
once again stimulated to secrete
GnRH.
- This process is called the
hypothalamic-pituitary cycle.
Menstrual cycle
Introduction:
There are two main components
of the menstrual cycle, the changes
that happen in the ovaries in
response to pituitary hormones, the
ovarian cycle, and the variations that
take place in the uterus, the uterine
cycle.
It is important to remember that
both
cycles
work
together
simultaneously to produce the
menstrual cycle.
47
Changes in cervical mucus also
take place during the course of the
menstrual cycle.
Ovarian cycle
Cyclical changes in the ovaries
occur in response two anterior
pituitary
hormones:
folliclestimulating hormone (FSH) and
lutenizing hormone (LH). Each of
the three phases of the ovarian cycle
is named for the hormone that has
the most control over that particular
phase.
The
follicular
phase,
controlled by FSH, encompasses
days 1 to 14 of a 28-days. LH
controls the luteal phase, which
includes days 15 to 28.
Follicular phase
- At the beginning of each
menstrual cycle, a follicle on one
48
of the ovaries begins to develop
in response to rising levels of
FSH.
- The follicle produces estrogen,
which causes the ovum contained
within the follicle to mature.
- As the follicle grows, it fills with
estrogen-rich fluid and begins to
resemble a tiny blister on the
surface of the ovary.
Ovulatory phase
- When the pituitary gland detects
high levels of estrogen from the
mature follicle, it releases a surge
of LH.
- This sudden increase in LH
causes the follicle to burst open,
releasing the mature ovum into
the abdominal cavity, a process
called ovulation.
49
- Ovulation occurs on day 14 of a
28-day cycle.
- As the ovum floats along the
surface of the ovary, the gentle
beating of the fimbriae draws it
toward the fallopian tube.
Luteal phase
- After, ovulation, LH levels
remain elevated and cause the
remnants of the follicle to
develop into a yellow body called
the corpus luteum.
- In
addition
to
producing
estrogen, the corpus luteum
secretes a hormone called
progesterone.
- If fertilization does not take
place, the corpus luteum begins
50
to degenerate, and estrogen and
progesterone levels fall.
- This process leads back to day 1
of the cycle, and the follicular
phase begins a new.
Uterine cycle
Menstrual phase
- Shedding of the functional layer
of the endometrium is initiated
by periodic vasoconstriction in
the upper layers of the
endometrium.
- The basal layer is always retained
and regeneration begins near the
end of the cycle from cells
derived from the remaining
glandular remnants or stromal
cells in this layer.
Proliferative phase
51
- When estrogen levels are high
enough, the endometrium begins
to regenerate.
- Estrogen stimulates blood vessels
to develop.
- The blood vessels in turn
nutrients and oxygen to the
uterine lining, and it begins to
grow and become thicker.
- The proliferative phase ends with
ovulation on day 14.
Secretory phase:
- After ovulation, the corpus
luteum begins to produce
progesterone.
- This hormone causes the uterine
lining to become rich in nutrients
in preparation for pregnancy.
- Estrogen levels also remain high
so that the lining is maintained.
52
- If pregnancy does not transpire,
the corpus luteum gradually
degenerates, and the woman
enters the ischemic phase of the
menstrual cycle.
Ischemic phase:
- On days 27 and 28, estrogen and
progesterone levels fall because
the corpus luteum is no longer
producing them.
- Without these hormones to
maintain the blood vessel
network, the uterine lining
becomes ischemic.
- When the lining starts to slough,
the woman has come full cycle
and is once again at day 1 of the
menstrual cycle.
Cervical mucus changes
53
- Changes in cervical mucus take
place over the course of the
menstrual cycle.
- Some
women
use
these
characteristics to help determine
when ovulation is likely to
happen.
- During the menstrual phase the
cervix does not produce mucus.
- Gradually, as hormonal changes
transpire and the proliferative
phase begins, the cervix begins to
produce a tacky, crumby type of
mucus that is yellow or white.
- As the time of ovulation draws
near, the mucus becomes
progressively clear, thin, and
lubricative, with the properties of
raw egg white.
54
- At the peak of fertility (i.e.,
during ovulation), the mucus has
a distensible, stretchable quality
called spinnbarkheit.
- After ovulation the mucus again
becomes scanty, thick, and
opaque.
Nursing role during menstrual
cycle:
Nurse must provide health
teaching about the following items:
Sanitary pads and tampons:
- Wash hands before and after
giving self perineal care.
- Washing or wiping the perineum
should be always done from front
to back.
55
- Reduce use of tampons by
substitute sanitary pads part of
the time especially at night.
- Apply perineal pad snugly
enough so it won't slide back and
forth with her movements.
- Do not touch the side of the
perineal pad that will come in
contact with the perineum.
- Frequently take warm bath to
maintain personal hygiene.
Diet:
- Decrease intake of caffeine (tea,
coffee, coals, chocolate) to
reduce anxiety.
- Decrease intake of simple sugars.
- Decrease intake of salty food to
reduce fluid retention.
- Eat six small meals a day to
prevent hypoglycemia.
56
- Increase fluid intake.
- Avoid alcohol which aggravates
depression.
Nutritional self-care:
- Vitamin B complex neutralizes
the excessive amounts of
estrogen produced by the ovaries
thus reduce nervousness that
sometimes occur premenstrually.
It is present in lean meats, whole
grains,
dark
green
leafy
vegetables.
- Vitamin B6 can relive the heavy
bloated puffy feeling that is often
experienced before the period.
- Vitamin E is a mild prostaglandin
inhibitor similar to aspirin but
without the side effects. It
improve
circulation,
reduce
muscular spasm and pain by
57
reducing the uterus need for O2.
It is present the yeast, wheat
germ.
- Iron is needed to prevent
depletion of the female iron
stores.
- Calcium may also provide relief
from menstrual symptoms, it is
present in yogurt and cheese.
Exercise:
- Daily exercise can prevent
cramps, relieves constipation.
- Deep breathing brings more O2 to
the blood which relaxes the
uterus.
- Aerobic activities as jogging or
walking alleviate irritability and
tension.
Heat and massage
58
- Using any form of hot
application such as hot tub,
heating pads may be beneficial
during painful periods.
- Massage can also sooth aching
muscles, promote relaxation and
blood flow.
Female Genital Mutilation
General objectives
At the end of this lecture each student should be able to acquire a
comprehensive knowledge and attitude toward Female genital mutilation.
Specific objectives
59
At the end of this lecture each student will be able to:
- Define Female genital mutilation.
- Determine the incidence of Female genital mutilation.
- Describe types of female genital mutilation.
- Enumerate short term & long term complications of female genital
mutilation.
- Explain nursing care of complications of female genital mutilation.
Introduction
Through history customs harmful to women health have been
practiced in order to make women seem more attractive or likely to
marry . Female circumcision is one of these customs
60
It is practiced in many communities of Africa and some
communities in Middle East and a small number of communities in south
east Asia. it involves cutting part of girls or woman's genitals .female
circumcision is practiced for a variety of reasons most of them based on
culture and tradition .
Definition
Female genital mutilation constitutes all procedures which involve
partial or total removal of the external female genitalia or injury to the
female genital organs whether for cultural or any other non Therapeutic
reasons
Incidence
The incidence is higher in rural areas and it declines in high
sociocultural classes. The estimated prevalence is well over 80 % in such
countries as (WHO 1998): (Djibouti - Egypt - Eritrea - Ethiopia – Sierra
Leone – Somalia - Sudan)
Egypt → 97 % equal 27,905, 990 woman (WHO 1998)
Age incidence
The age of girls at time of operation is usually about 10 years , but
the range is from 3 to 12 years.
Types of FGM
Type 1 traditional
Excision of prepuce with or without excision of part or the clitoris
Type 2
Excision of the prepuce and clitoris together with partial or total
excision of the labia minora
Type 3 Infibulations
Excision of part or all of the external genitalia and stitching /
narrowing of the vaginal opening
61
Type 4
Unclassified:
- Pricking, piercing or incision of the clitoris and or labia
- Stretching of the clitoris and or labia.
- Cauterization by burning of the clitoris and surounding tissue.
- Scraping (angurya cuts) of the vaginal orifice or cutting (gishiri
cuts) of the vagina.
- Introduction of the corrosive substances into the vagina. To cause
bleeding or herbs into the vagina with the aim of tightening or
narrowing the vagina.
Short term complications
 Pain
 Injury
 Haemorrhage
 Shock
 Death
 Acute urine retention
 Urinary tract Infection
 Fracture or dislocation
 Infection
 Failure to heal
62
Long term complications
 Problems with micturition.
 Recurrent urinary tract infections.
 Pelvic infections
 Keloid scar
 Abscess
 Cysts and abscess on thevulva
 End-stage renal failure(from chronic urinary tract infection).
 Menstrual problems.
 Increased risk of vesicovaginal fistula.
 Sexual dysfunction.
 Calculus formation.
 Infertility.
 Psychological damage.
Pregnancy and childbirth possible complications arising from FGM:
 Difficulty in fetal monitoring and assessing progress of labour.
 Obstructed labour due to scar tissue.
 Severe perineal tears.
 More caesarian sections.
 FGM doubles the risk of mother death in childbirth(WHO1993).
 FGM increases the risk of the baby being born dead.
Nursing care for immediate Health Effects Of FGM
- Infection, Failure, of healing, tetanous and also septicemia may occur
as a result of the operation being performed under unhygienic
63
conditions with instruments wich are not sterile and by attendants who
are unskilled. Mortality may be high as 50.60% because of tetanous
infection.
- Pain and shock often from no analgesia and the young girl experiences
great pain wich can cause her to get in shock.
- Hemorrhage
can result from injury to the vulva from cutting of ablood vessels in
the area and can cause the young girl to go into shock.
- Urine retention is very common in the first Two to Four days after
excision and infibulation because of the pain resulting from the wring
to mching wound. Which may lead to UTI
Working For Change
What you can do:
If you don’t agree with this practice, there are many ways you can
help girls in your community:
 If you are a mother, help your daughters feel valued and loved,
whether they are circumcised or not.
 Encourage your daughters to continue with their education and to
learn enough to make their own decisions.
 Share the information about the health problems caused by
female circumcision with other women and men in your
community. Work with them for change.
 Find out what women's organizations in your community or
region are doing.
Nursing care of complications of female genital mutilation
1- Heavy bleeding and shock
64
Heavy bleeding from a deep cut or tear can happen quickly
And is very dangerous if a girl loses too much blood. She can go into
shock and die
Warning sings of shock (one or more of the following)
 Sever thirst.
 Pale, cold and damp skin.
 Week and fast pulse (more than 110b/m).
 Fast breathing (more than 30 breaths /m).
 Confusion or loss of consciousness (fainting).
what to do
 Get help immediately .shock is an emergency.
 Press firmly on the bleeding site .keep her lying down while you
take her to medical help.
 Help her drink as much as she can.
 If she is unconscious and you live far from health services you may
need to give her rectal fluids before taking to help.
2-Infection
If the cutting tool is not cleaned properly (disinfected) before and after
each use .germs can cause a wound infection, tetanus, HIVIAIDS or
hepatitis.
Signs:
 Fever, swelling in the genitals, pus or a bad smell from the wound,
pain that gets worse.
 Of tetanus: tight jaw, stiff neck and body muscles, difficulty
swallowing and convulsions.
 Signs of shock.
 Sepsis.
65
What to do
 Give an antibiotic.
 Keep watching for worning signs of tetanus ,sepsis and shock.
 Give tetanus vaccine for girls who have not had.
 Give medication for pain.

Keep genitals very clean.
3- Urine problems
Since circumcision often causes sever pain when a girl passes
urine .some girls try to hold their urine back. This can cause infection and
damage to the urine tubes and forms stones in the bladder.
What to do
 Watch for signs of bladder and kidney infection.
 Run clean over the genitals when passing urine .
 Drinking more liquid will help.
 Pour water .the sound of the running water sometimes helps the
person start to pass urine.
 Apply a damp towel soaked in worm water to the genitals to
relieve the pain
4- Problem with monthly bleeding
If the vaginal hole that is left after infibulation is to small or blocked
by scarring inside the body. The flow of a girls monthly bleeding can be
blocked .this can cause:
 Very painful monthly bleeding.
 Long monthly bleeding, lasting 10 to 15 days.
 No monthly bleeding because the vaginal opening is blocked and
the blood cannot get out.
66
 Trapped blood that can lead to serious pelvic inflammatory disease
and infertility.
What to do
 Apply a towel soaked in hot water to the lower abdomen.
 It may help to walk around and do a light work or exercise.
 If the problem are sever, the vaginal opening may need to be
larger.
5- Problems with sexual relations and sexual health
If a circumcised woman has none of the health problems described
above she may be able to enjoy sex. But many woman who have been
circumcised, especially those who have been infibulated find sex
difficult.
If woman have sex before the wound has healed, sex will be very
painful and dangerous and the wound may take longer to heal
During sex a women may find it difficult to become aroused since
the clitoris has been cut off.
What to do for problems with sex:
A woman can talk with her partner about finding ways to become
more sexually aroused and explain that she may need more time to feel
aroused. She can also talk about to make sex less painful, having enough
wetness can make sex safer and hurtless.
6- Problems with ChildBirth
With some types of circumcision, there is a greater risk that the
baby will have difficulty getting out of the vagina (blocked birth). If the
hole left after infibulation is very small, It must be opened so the baby’s
head can pass through. This is called “deifibution”.
What to do:
67
Plan in advance for childbirth. During the second half of pregnancy, a
pregnant woman should try to see a trained midwife or other health
worker trained in helping circumcised women give birth. The midwife
can tell her if there is a risk of complications, or if the vaginal opening
should be made larger, if there are risks, a woman can make plans for
getting medical care ahead of time.
7-Infertility
Infection can cause scarring of the womb and tubes, which make it
difficult for woman to get pregnant.
8- Leaking urine and stool
During a blocked birth the lining of the vagina. Bladder or rectum can
tear, causing urine or stool to leak out of the vagina. If a couple has anal
sex because the woman's vaginal opening is too small, the anus may
become stretched or torn. Stool may leak out of the anus.
Leaking urine and stool are terrible problems to live with. Many young
women have been rejected by their partners because of the smell and
because they cannot control the leaking. Seek medical help as soon as the
problem is discovered
9- Mental health problems
A girl who has been circumcised can become overwhelmed with fear,
worry (anxiety), or sadness. When circumcision is done in front of
women that a girl knows and trusts to protect her from harm .she may feel
that she can no longer trust anyone. It's worse if the girl did not wish to be
circumcised. Chronic pain and suffering can cause other lasting mental
health problems, such as deep sadness (depression), and feelings of
helplessness and worthlessness. Sexual problems can also cause severe
strain between a woman and her parther. A woman may feel she is unable
to please him because the pain makes her afraid of sex.
What to do:
68
 Encourage her to talk about her feelings.
 If she seems withdrawn, distant, and unable to do dialy activities
10- Effects of excision and infibulation on marriage and childbirth
1. Problems with the Consummation of Marriage
A woman who has undergone infibulation often has a very tiny
vaginal opening because of the stitching together of the vulva. Tight
scarring of the vaginal opining and narrowing of the vaginal opening
make the concummation of marriage painful and difficult, or sometimes
impossible. The woman may need to have the vaginal opening enlarged
by cutting. If this surgery is necessary, she then faces all the health risks
and complications she did when she was first circumcised. These
complications are shock from pain or hemorrhage, infection, tetanus,
septicemia.
The emotional impact is tremendous on the woman and reflects on
her relationship with her spouse. Among the psychiatric disturbances
associated with female circumcision, especially in the event of physical
complication such as fistula and dermoid cysts, are anxiety reaction,
chronic irritability, episodes of depression, and even frank psychosis
anxiety.
69
FAMILY PLANNING
Introduction
It is estimated that around 500.000 women die each year due to
causes related to pregnancy & childbirth most of that death occur to
women in developing countries. In Egypt maternal mortality is
174.100.000 live birth according to the national maternal mortality survey
by ministry of health.
So, family planning is the proper solution to the problem of
maternal mortality in developing countries. It improve the health of
women by helping them to avoid high risk pregnancy, effective methods
of contraception prevent women's from performing dangerous, illegal
abortion with it's consequences of post abortion infection, bleeding and
death.
Studies conducted in Egypt indicated that neonatal, infant & child
mortality rates all decline as the birth interval increase. For example birth
occurring at less than 2 years intervals associated with high infant
mortality rate 194/1000 compared to those occurring at four years or
more intervals 52/1000.
Definition:
Family planning refers to practice that help individuals or couples
to attain certain objectives:
- Avoid unwanted birth, illegal abortion.
- Regulate the intervals between pregnancies.
- Control time at which births occur in relation to the age of parents.
Hormonal contraception:
1. Oral contraceptive pills:
Types:
70
- Combined pills "estrogen & progesterone" 28 pills or 21 pills.
- Sequential pill estrogen for 14 days then followed by combined for
7 days.
- Minipills progestin only.
Effectiveness: 99%.
Mechanism of action
- Inhibition of ovulation.
- Acceleration of ovum transport.
- Luteolysis decrease progesterone level & interfere with normal
implantation.
- Thickening of cervical mucous that interfere with the sperm ability
to penetrate cervical mucous.
Advantages:
- Decrease premenstrual syndromes & endomertiosis.
- Little or no menstrual cramping or pain.
- Does not interrupt intercourse.
- Decrease incidence of ovarian cysts.
- Diminished fibrocystic breast disease and fibroadenomass.
- Improve anemia and rheumatoid arthritis.
- Decrease incidence of endometrium and ovarian cancer.
Disadvantages:
- Systemic medical risks associated with use.
- Remembering to take the pill daily.
- Weight gain for some women.
Indications:
71
- Women who has desires to use a highly effective methods of
contraception.
- Women who has anemia from heavy menstrual bleeding.
- Women who have severe menstrual cramping.
- Women who has benign ovarian cysts.
- Women who has history of ectopic pregnancy.
- Women who has strong family history of ovarian cancer.
Contraindications:
Absolute:
- Women who has known or suspected pregnancy.
- Women who has unexplained abnormal vaginal bleeding.
- Women has benign or malignant liver tumors.
- Thrombophilebitis or thromboembolic disorders.
Relative:
- Women who has hypertension.
- Women who has DM.
- Women who has epilepsy.
- Women who has depression.
- Women who has more than 40 years and smoker.
Client instruction
- The first pills should be taken on the fifth day of menses.
- A pill should be taken every day at the same time of day.
- The last 7 pills "of 28 days pills" contain iron supplements rather
than hormones, they should be taken last. Withdrawals bleeding
usually occur at this time.
72
- After taken the last pill of the first cycle, start a new pack of pills
the very next day and continue to the arrows. If pills contain only
21 pills wait one week before starting the next pack.
- Missed pills:
1) If forget one pills, should take as soon as possible and next pill take
at the regular time.
2) If forget two pills, should take two pills as soon as possible and
two the next day, use back up method finish the pack.
3) If forget three pills, should take two pills for 3 days and use back
up method "barrier method" till the end of the cycle before starting
new pack.
- Return to the clinic immediately if any of the following warning
signs occurs, that remembered by ward ACHES:
2. Injectable method:
Types:
- Depomedrexy progesterone acetate "DMPA": Depoprovera, IM
contain 150 mg every 3 months.
- Norethiserone enanthate "NET-EN" contain 100 mg every 2
months.
- Progesterone-estrogen combination once monthly injection.
Effectiveness: 99.5%.
Mechanism of action:
- Increase viscosity of cervical mucous inhibit sperm transport.
- Inhibition of ovulation.
- Decrease tubal motility.
- Atrophic change in endometrium inhibit implantation.
Advantages:
- Extremely effective.
73
- Simple delivery.
- Independent on coitus.
- Contraceptive privacy.
- Can use by older women.
- Can use by women with sickle cell disease.
Disadvantages:
- Irregular menstrual patterns.
- Amenorrhea.
- Delay return for fertility after discontinuation.
- Weight gain or weight loss.
Contraindications:
Absolute:
- Women who has known or suspected pregnancy.
- Breast cancer or unexplained breast pathology.
- Unexplained uterine or vaginal bleeding.
- All types of genital cancer.
Relative:
- Nulliparity.
- DM.
- History of liver disease or jaundice.
- Allergy to injectable method.
- Thrombophilebitis or thromboembolic disorders.
Side effects:
- Amenorrhea.
- Increase menstrual bleeding.
- Delayed return for fertility.
- Depression.
74
- Headache, dizziness, visual problems.
- Weight gain or loss.
Client instructions:
- The first injection should be given between first and seventh day
after menses begins.
- Client should return to take another injection every 3 months for
Depo-Provera and every 2 months for noristerat.
- Injection may cause amenorrhea or heavy bleeding.
- Return to fertility 2-3 months after injection is stooped.
- Warning signs that require return to clinic immediately as:
* Bleeding between periods for more than 7 days.
* Menstrual period twice as longer or twice as often as usual.
3. Implant:
Effectiveness: 99%.
Mode of action:
- Increase viscosity and decrease amount of cervical mucous inhibit
sperm transport.
- Inhibit implantation.
- Inhibit ovulation.
Advantages:
-
Highly effective.
- No estrogen side effect.
- Long lasting "continuous for 5 years".
- One decision method.
- Help to prevent anemia.
Disadvantages:
75
-
Change in bleeding patterns.
- Visible.
- Initially more expensive.
- Must inserted and removed by health professional.
Indications:
- Women who desire a method that do not need to be remembered
daily.
- Women who desire long acting contraceptive method.
- Women who desire method not related to intercourse.
- Women who do not tolerate IUD or pills.
Contraindications:
Absolute:
- Women who has known or suspected pregnancy.
- Undiagnosed vaginal bleeding.
- Cancer of breast or genital tract.
Relative:
- Nulliparity.
- DM.
- Breast feeding less than 6 weeks.
- Liver disease or jaundice.
- Thromboembolic or heart disease.
Side effects:
- Irregular menstruation
amenorrhea".
"prolonged
- Local infection at site of insertion.
- Ectopic pregnancy.
- Expulsion of implant.
76
menses
or
spotting,
- Weight gain or loss.
- Headache.
Client instructions:
- Inserted during first week of menstrual cycle.
- Avoid trauma to area of insertion and keep it dry and clean for 4
days.
- Return to clinic after 1 month, 3 months, 6 months, 1 year, then
annually for check up.
- Norplant capsules should be replaced after 5 years.
- Irregular bleeding or amenorrhea may occur at 1st year.
- Warning signs that require return to clinic immediately as:
* Sever abdominal pain.
* Arm pain.
* Heavy vaginal bleeding.
* Expulsion of norplant.
* Pus or bleeding at site of insertion.
* Delayed menstruation after regular patterns.
* Migraine headache.
Mechanical methods
1. Intrauterine device "IUD":
Mechanism of action:
- Inhibition of implantation by local production prostaglandin.
- Increase viscosity of cervical mucous prevent sperm transport.
- Accelerate tubal motility.
- Decrease estrogen level at 1st half of cycle degeneration of corpus
luteium.
77
Advantages:
- Inexpensive.
- Easy insertion and removal.
- Once in place it remain effective for years.
- Not interrupt coitus.
- Not interfere with breast-feeding.
- Not delay return for fertility.
Side effects and complications:
- Prolonged heavy menstruation and intermenstrual spotting may
occur.
- Pain and cramps after insertion and at time of menstruation.
- Expulsion.
- Missing IUD.
- Ectopic pregnancy.
- Perforation.
- PID.
Indication:
- Breast feeding women.
- Women who have difficulty using other method.
- Women to whom other method are contraindication.
Contraindications:
Absolute:
- Known or suspect pregnancy.
- Known or suspect cervical or uterine malignancy.
- Acute or chronic pelvic infection.
Relative:
78
- Nulliparity.
- Dysmenorrhea.
- Anemia.
- Vulvular heart disease.
- Abnormalities of uterine shape size and position.
Client instructions:
- Some increase in bleeding and cramping is normal.
- Check strings at midcycle and after period.
- If strings are missed use another contraceptive method and contact
health care provider.
- Return for follow up schedule every 3 months in first year then
every one-year.
- Warning signs that require immediate return for clinic as
"remembered by ward PAINS".
* Period late.
* Abdominal pain.
* Infection.
* Not feeling well, fever, chills.
* Strings misses.
2. Vaginal diaphragm:
Definition: is shallow dome shaped rubber cup with flexible rim.
Effectiveness: 85-98%.
Advantages:
- Inexpensive.
- No health hazard.
- Some protect against STD.
79
- Prevent cancer cervix.
Disadvantages:
-
Difficult in apply and removal.
- Require special training for use.
- Left in vagina at least 8 hours after intercourse.
- Require supplies spermicids.
Indications:
- Contraindication of other contraceptive method.
- Back up for other method.
- Has sex only once in while.
Contraindications:
- Allergy.
- Urinary tract infection.
- Uterine prolapse, sever cystocele.
- History of toxic shock syndrome "TSS".
- RVF, vaginal septum.
Side effects:
- Allergy.
- TSS.
- Cystitis or urethritis.
- Discomfort and pain due to pressure on bladder or rectum.
Client instructions:
- Use diaphragm with every time of intercourse.
- First empty your bladder and wash your hands.
- Check diaphragm for holes by pressing it or fill it with water.
80
- Put spermicids at center of diaphragm and around the rim then
squeeze the rim together.
- Use the following position for insertion:
* Raise one foot up on chair and spread the lips of vagina apart.
* Hold the diaphragm after squeeze the rim between two fingers,
insert it in the vagina and push the front rim behind pubic bone,
then put your finger in vagina and fell cervix to ensure it is
covered.
* Leave it one place 6-8 hours after intercourse.
* To remove it place your finger between it and pubic bone to break
suction and pull it out.
* After use clean with soap and water, dry it and dust with powder
before out in container.
3. Condom:
Definition: is sheath made of latex or sheep's intestine to collect semen
and prevent its passage into vagina.
Effectiveness: 85- 95%.
Advantages:
- Inexpensive.
- No side effects.
- Protect from STD.
- Not require medical prescription or examination.
Disadvantages:
-
Interrupt sex.
- Require stock.
- Rupture during intercourse.
- Require one for each intercourse.
81
- Decrease sensation during sex.
Indications:
- Newly married couple.
- Have sex only once in while.
- Immuno-infertility.
- Treatment of premature ejaculation in male.
- Space children.
- Contraindication of other method.
Contraindications:
- Allergy.
- Unreliable use.
Client instructions:
- Put condom before any genital contact.
- Put it on erect penis.
- Be sure to leave half inch of latex material at the end of erected
penis for collection of semen.
- Compress tip between finger and thumb to exclude air during apply
it.
- Do not use any material for lubrication.
- Withdraw when penis still erected and hold the ring of condom
firmly at the bases of penis to prevent slip off.
- Use it for once and discard.
4. Cervical cap:
Definition: it is similar to diaphragm but smaller and applied direct to
cervix suction.
Effectiveness: 85-95%.
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Advantages:
- No health hazards.
- Inexpensive.
- No pressure against bladder.
- Remain in vagina for long time 48 hour.
Disadvantages:
- Difficult in applying and removal.
- Limited size.
- Can be dislodged during intercourse.
- Cervical laceration with prolonged use.
Indications:
- Contraindications of other methods.
- Has healthy cervix.
- Has erected cervix is RVF.
- Has sex only once in while.
Contraindications:
- History of TSS.
- Allergy.
- Abnormal pap smear.
- Recent delivery.
- Acute cervicitis or PID.
Side effects:
- Increase risk of cervicitis.
- Trauma to cervix and vagina.
- Infection.
Chemical method
83
Types:
- Suppositories, cream, jell, foams, tablet.
Effectiveness:
- 80-90% if use alone and may reach 98% if use with male condom.
Advantages:
- No systemic side effects.
- No medical prescription.
- Not require examination.
- Serves as lubrication.
Disadvantages:
- Some fell burning and irritation on their genitals.
- May be messy to use.
- Increase failure rate may reach to 15%.
Indications:
- Contraindications of other methods.
- Newly married couple.
- Have sex only once in while.
- Want to space children for limited time.
- Perimenopausal women.
- Back up when other methods interrupted.
Contraindications:
- Allergy to spermicids.
- Woman who need a highly effective method.
- Physical disability that cause difficult in use.
- Inability to remember to use consistently.
Side effects:
84
- Allergic reaction.
- Uncomfortable heat sensation.
Client instructions:
1. Foam tablets:
- Shake container 20-30 times before uses it.
- Place container in up right position and fill it with foam.
- Lying down and insert applicator into vagina near cervix and push
plunger to release foams.
- Foam should be place in vagina before intercourse by 10 minute.
- Couple waits 30 minute after insertion and make intercourse.
- Vaginal douche should done after 6-8hour of intercourse.
- Each intercourse requires new tablet.
- Tablet can dip in water to facilitate its insertion.
2. Creams and jell:
- Squeeze cream or jell to full into applicator.
- Insert applicator into vagina near cervix and push plunger to
release creams or jells.
- Use it 20-30 minute before intercourse and make sex immediately.
- Clean applicator with soap and warm water before store.
Surgical methods "sterilization"
1. Tubal ligation:
Definition: Surgical procedure in which female is sterilized by occluding
or cutting fallopian tubes.
Indications:
- Woman has more than 4 children or over 45 years.
- Recurrent ectopic pregnancy.
- RVF.
- Recurrent toxemia with pregnancy.
85
- Woman has uncontrolled DM or HIM.
- Congenital abnormalities.
Effectiveness: 99%.
Advantages:
- Highly effective, permanent, very private.
- No thing to buy or remember.
- Not interrupt sex.
Disadvantages:
- No protection against STD, HIV.
- Require surgical and aseptic technique.
- Permanent, reversibility difficult.
Complications:
- Infection.
- Hemorrhage.
- Hematoma.
- Perforation of uterus.
- Bladder or bowel injury.
2. Vasectomy:
Definition: surgical procedure for interruption or ligation of vas
deference to prevent passage of sperm.
Effectiveness: 99.5%.
Advantages:
- Permanent, very safe.
- Quickly performed.
- Highly effective, inexpensive on long time.
- Relieve female of contraceptive burden.
Disadvantages:
- Permanent.
- Expensive on short time.
86
- No protection against STD, HIV.
- Require surgical and aseptic technique.
Complications:
- Inflammation.
- Pain.
- Epididymitis.
- Hematoma.
- Infection.
Natural method
1. Safe period through:
Calendar method:
- Ovulation occurs at 14 days before onset of next menses.
- Sperm can survive for 3 days after intercourse and still fertilize for
ovum.
- Ovum can be fertilizing for no more than 24 hours following
ovulation.
- Menstrual cycle are charted for 6-12 months, 18 days are
subtracted from the shortest cycle to determine the first day of
fertile phase and 11 days are substracted from the longest cycle to
determine the last day of fertile phase.
Basal body temperature "BBT":
- One to two days after a woman ovulate, her basal body temperature
raise 0.2-0.3 degree as result of a raise in the level of progesterone
in her body. The BBT use this signal to make the end of fertile
period.
- A woman records her BBT after at least 6 hours of uninterrupted
sleep, through the cycle. A usual body temp thermometer is used.
87
Which has an expanded scale compared to the fever thermometer.
Intercourse is not permitted until 3 days after rise in temperature.
Cervical mucus:
- AT the time of ovulation cervical mucus becomes transparent,
slippery and capable of considerable, so it become stretching
between finger and thumb. This fertile mucus looks like raw egg
white. Fertile phase begins when mucus is first noticed and ends 4
days after the last day of fertile mucus.
2. Breast feeding "prolonged lactation"
- This method mentions in lecture of breast-feeding and has great
failure rate.
3. Coitus interruption:
- This involves with drawl of penis prior to ejaculation and
necessitates tremendous self-control. This method has a high
failure rate as semen leakage can occur prior to ejaculation.
Definition of counseling:
- It is face to face communication to help the client to make free,
informed and voluntary choice abut family planning method and
reproductive health.
Element of counseling:
Is summarized in ward "GATHER"
G Greets client in friendly and helpful way.
Great client:
- As soon as you meet client, give them your full attention.
- Ask how you can help.
- Tell client that you will not tell other what she says.
- Conduct counseling where no one else can hear.
88
Ask client about her self and her needs:
- Help client talk about her needs, wants and any doubts, concerns or
question she has about family planning.
- If client is new obtain complete history: (demographic, medical,
surgical, obstetric and gynecological, ……).
- Explain that you are asking for this information to help to her to
choose the best method.
- If client is not new ask her if any thing has changed since the last
visit.
Tell client abut family planning method:
- Tell your new client which methods are available and where.
- Ask your client which method interest to her.
- Ask your client what she knows about her interest method.
- Briefly describe each method that client want to hear about it, talk
about: (how it work, advantages, disadvantages, side effects,….).
Help client choose a method:
- Ask the client about her needs and her family situation, if uncertain
about the future start with present.
- Ask client what her husband want, what method he wants her to
use?
- Ask client if there is any thing she did not understand, repeat
information if necessary.
- Some method is not safe for some client, when method unsafe tells
the client and explains clearly, then help to choose another method.
- Check whether client made a clear decision specially ask "what
method have you decided to use?"
Explain how to use method:
- After the client chooses the method give her supplies.
89
- If the method can not given immediately, tell the client how, when
and where it will provide.
- Explain how to use the method.
- Ask the client to repeat instruction to make sure understanding.
- Describe possible side effects and warning signs.
- Tell the client when come back for follow up.
Return for follow up:
At the follow up visit:
- Ask client if still using the method.
- If yes, ask client if has any problem with use.
- Ask client if has any side effects then find out how sever they are,
reassurance of client with minor side effects and explain what she
can do to relieve them, if side effect is sever refer to treatment.
- Ask the client how she/he use the method to ensure correct use.
- Ask if the client has any questions.
90
Reproductive Health
Introduction:
Every year, at least 585.000 women die from complications of
pregnancy, childbirth, and postpartum period. About 99% of these
women die in the reproductive age (19-44 years) in developing countries.
In Egypt, 84 women die per 100.000 every year. In addition, the causes of
maternal death often have some of their roots in the woman's life before
pregnancy. They may start from infancy, or even before her birth.
The woman is source of the nation and a basic unit of the society.
Hence, the reproductive health of women should be supported and
protected, and considered a crucial part of general health. Not only it is a
key element of health during adolescence period, but also it set the pace
for health beyond reproductive years, and has an effect on generations.
Definition:
Reproductive health is a status of complete physical, mental and
social wellbeing and not merely the absence of disease or disability in all
matters relating to the reproductive system and to its function and
processes.
Benefits of reproductive health interventions
-
Improving adolescent reproductive health reduces unwanted
pregnancies and the risk of contracting HIV and other sexually
transmitted infections. It improves the chances of girls continuing
school and expands their life options.
-
Providing life coping skills including RH education for boys and
girls.
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-
Prevention and management of sexual transmitted infections
(STLs) prevents sexual spread of HIV.
-
Integrating HIV prevention activities in mother and child health
(MCH) and family planning (FP) programs addresses missed
opportunities to curb the HIV epidemic.
-
Being able to choose when to get pregnant, apart from being health
issue, greatly influences population growth, and environmental
conditions.
-
Increasing contraceptive choices and access leads to fewer unsafe
abortions-arguably the most easily avoidable cause of maternal
death.
-
Life-saving care for complications from abortion is an excellent
opportunity to provide contraception, avoiding another unwanted
pregnancy.
-
Reducing pregnancy-related deaths and illness in mothers
increases newborn and child survival, and improves productivity.
-
Reducing maternal deaths depends on a functioning death system.
Strengthening the system to improve maternal health benefits in
many other areas of death.
Factors affecting reproductive health and women's right:
-
Economic circumstance.
-
Education.
-
Employment.
-
Living conditions.
-
Family environment.
-
Social and gender relationships and the traditional and legal
structures within which they live.
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-
Sexual and reproductive behaviors are governed by complex
biological, cultural and psychosocial factors.
Basic elements of reproductive health:
-
Employment of women.
-
Woman's nutrition.
-
Care of adolescent.
-
Safe sexual behavior.
-
Safe motherhood.
-
Widely available family planning services.
-
Elimination of unsafe abortion.
-
Prevention of unwanted pregnancy.
-
Prevention and management of infertility.
-
Male involvement.
-
Prevention and treatment of malignancies and post menopausal
care.
Women's and men's reproductive health needs:
Women's reproductive health need are:
-
A continuum from sexual health.
-
Prevention and management of infertility.
-
Fertility by choice, not by chance.
-
Pre-conceptional care.
-
Keeping labour normal.
-
Pregnancy and child birth, post natal care.
-
In addition, it covers menopausal and postmenopausal health care.
Men's reproductive health needs include:
93
-
Sexuality.
-
Protection against sexually transmitted infectious.
-
Infertility prevention and management and fertility regulation.
-
Protection against prostatic hypertrophy and prostatic cancer is
another concern.
Reproductive health index:
It included the following:
-
Maternal mortality ration.
-
Birth attended by trained personnel.
-
Percentage of women receiving antenatal care.
-
Percentage of pregnancy women with anemia.
-
Contraceptive prevalence.
-
Availability of safe abortion services.
-
Prevalence of infertility.
-
Level of HIV and aids in women.
Reproductive health rights:
-
Right to be free from all forms of discrimination.
-
Right to life, liberty and security.
-
Right to marry and found a family.
-
Right to education and information.
-
Right to benefit from scientific progress.
-
The right of sexual equality.
-
Right to health and health care.
-
The Egyptian women work law.
-
Right of adolescents to meet their needs.
94
Strategies for improving reproductive health and assuring
women's rights:
-
Efforts to delay early marriage and/or childbearing through good
reproductive health education.
-
Effective prenatal care and safe management of routine deliveries.
-
Access to emergency medical care and dealing with complications
of childbirth.
-
Access to high quality of family planning services and a choice of
contraceptive methods.
-
Emergency care for complications that accompany unsafe
abortion.
-
Public education and counseling to prevent the spread of AIDs and
STDs.
-
Diagnosis and treatment of STDs and reproductive cancers, where
resources and circumstances permit.
-
Effective and accessible infertility treatment.
-
Efforts to educate local communities about harmful cultural
practices that influence the health as female circumcision.
-
Elimination of all forms of violence against women, female youth
and children.
-
Improvement of women's status and enhancement of quality.
-
Applying human rights in national constitutions and international
conventions to advance safe motherhood (e.g. by requiring states
to take effective preventive and curative measures to reduce
mortality and to treat women with respect and dignity).
-
Reducing inequalities in social and economic policies.
95
-
Protecting and promoting women's rights, choices and autonomy
are critical to reduce maternal deaths and ill health.
Male Reproductive System
Objectives
- Discuss structure and function of external male genitalia.
- Identify structure and function of internal male genitalia.
- Determine the location and function of accessory a glands.
- Trace the pathway of the sperm from the tests to the outside of the
body.
- Describe the composition of semen.
Introduction:
The male reproductive anatomy consists of external reproductive
organs & internal reproductive organs. The purposes of male reproductive
tract are to allow for sexual intimacy and reproduction of offspring, and
to provide a conduit for urinary elimination.
External Genitalia:
The external genitalia consists of the penis and scrotum
*The Penis
Functions:
1- The penis serves a dual role as the male organ of reproduction.
2- During sexual excitement it stiffens (an erection) in order to
penetrate the vagina and deposit sperms near the woman’s cervix.
3- It carries the urethera, which is Passage for urine & semen.
Position:
96
The roots lies in the perineum, where it passes forward below the
symphysis pubis, the lower two- thirds are outside the body in front of the
scrotum.
Structure:
It is an elongated cylindrical structure consisting of the body (shaft) and
the glans.
The glans:
- It is the most sensitive area on the penis because this is where the
greatest concentration of nerve endings is found.
- This part of the penis is analogous to the clitoris in the female. At
birth a layer of tissue, prepuce, or foreskin, covers the glans, it is
the part removed during circumcision.
The shaf:
- It is composed of three column of sponge like erectile tissue, two
corpora cavernosum & one corpus spongiosum. The cavernous
bodies are parallel, and the spongy body lies atop theme in the
midline. The spongy body is cradled in the channel created where
the cavernous bodies meet.each column is encased in a thick sheat
called the tunica albuginea.
Support system:
The suspensory ligament is the main support for the penis extended from
the symphysis pubis and merges with the deep fascia of the penis.
Nerve Supply :
- The penis innervated by pudendal nerve.
- Sympathetic fibers from hypo gastric & pelvic plexus, while
parasympathetic fibres from third sacral nerve.
- When the parasympathetic fibers are stimulated the ischiocavernous
muscle contracts, preventing the return of venous blood from the
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cavernous sinuses , the blood vessels of the penis engorge causing
erection and it elongates , thickens & stiffens & if stimulation is intense
enough , the forceful & sudden expulsion of semen occur through the
rhythmic contraction of the penile muscles (ejaculation).
*Scrotum
The scrotum is an external sac that houses the testes in two internal
compartments.
Functions
- The main functions of the scrotum are to protect the testes from
trauma & to regulate the temperature within the testes, a process
that important to the production of healthy male gametes.
Structure
-It is formed of pigmented skin and has two compartment, one for each
testis.
Internal Genitalia :
Male internal reproductive organs include the testes and the system of
glands & ducts that are involved in the formation of nutrient plasma and
the transport of semen out of the man's body.
*The testes ( or testicles )
- The testes are a pair of oval organ housed in the scrotum.
Functions:
- The testes are the male gonads and produce spermatozoa .
- Secrete male hormones androgens (Testosterone).
- Testosterone is responsible for the development of the secondary
sex characteristics together with follicle stimulating hormone
( FSH ), it also promote the production of the sperm
Position
98
The testes are situated in the scrotum. In order to achieve their proper
function, they must be kept below the body temperature, and this is why
they are situated outside the body.
Structure:
- The testes are oval structure , with in color , about 4 cm long , 2.5
cm wide, & 3 cm thick .They each weigh between 10 to 14 gm.
- The testes are enclosed in a protective fibrous capsule, the tunica
albuginea, and covered by a serous membrane, the tuinca vaginalis
which enables each testis to move freely within its scrotal cavity.
Layers of testes:
Tunica vasculosa: This is the inner layer of connective tissue containing
a fine net warke of capillaries.
Tunica albiginia:
This is fibrous covering in growths of with divide the testes into 250-400
lobules
Tunica vaginalis:
This is the outer layer which is made of peritoneum brought down which
the descending testes when it migrate from the lumber region in fetal life.
*The seminiferous tubules
These are where spermatogenesis or production of the sper take place.
There are three of them in each lobule. Between the tubules are interstial
cells that secrete testosterone. The tubules join to form a system of
channels that lead to the epididymis.
Epididymis
Function
99
- The epididymis provides a reservoir where spermatozoa can
survive for long period. Spermatozoa are immobile and incapable
of fertilizing an ovum. Spermatozoa remain in the epididymis for 2
– 10 days and become motile and fertile.
Position
It lies behind each testis, it arises from the top of the testis, extends down
ward and then passes upward, where it becomes the vas deferens.
Structure:
- These are fine convoluted tubules, each about 6 ml in length which
connect the testes & the vasa deference
- The tubules have ciliated bithelial lining which helps the sperm to
migrate to the vas deferens.
*Vas deferense
 It is the muscular tube in which the sperm begin their journey out
of the man's body
 It connects the epididymis with the ejaculatory duct.
 The vas deferense is sheathed in the spermatic cord, which also
contains the blood vessels, nerves, and lymphatic that serve the
testes.
 The left spermatic cord is usually longer than the right so that the
left testis hangs lower than the right.
*The spermatic cord
Function
● The spermatic cord transmits deferent duct or vas deferens up into
the body, along with other structures.
100
● the function of the deferent duct is to carry the sperm to the
ejaculatory duct.
Position
- The cord passes upwards through the inguinal canal, where the
different structures diverge.
- The deferent duct then continues upwards over the symphysis
pubis and arches backwards besides the bladder.
- Behind the bladder it merges with the duct from the seminal
vesicle and passes through the prostate gland as the ejaculatory
duct.
Structure
- The spermatic cord consists of the deferent duct, the testicular
blood vessels, lymph vessels, and nerves.
Blood supply
- The testicular artery, a branch of the abdominal aorta, supplies the
testis, scrotum, and attachments & testicular veins.
Lymphatic drainage
- This is to lymph nodes round the aorta.
Nerve supply
- This is from the 10th and 11th thoracic nerves.
*The ejaculatory duct
 These small muscular ducts carry the spermatozoa and the seminal
fluid to the urethera.
 Each duct is formed by the union of the vas deferens and the
seminal duct.
 The ejaculatory ducts are approximately 2.5 cm long. They pass
through the prostate gland & join the urethra .They connect the
vast deferens and urethra.
101
*The urethera
- The male urethera is a passage way for urin and semen. The urethera
begins in the bladder and passer through the prostate gland, where is
called the prostatic urethera.
- The urethera emerges from the prostate gland to becom the
membranous urethera.
- It terminate in the penis where it is called the penile uretheral, in
the penile uretheral goblet secretory cells are present and smooth
muscle is replaced by erectile tissue.
Accessory glands
Seminal vesicles glands:
Function
- The function of the seminal vesicles is production of a viscous
secretion to keep the sperm alive and motile.
Position
- The seminal vesicles are two pouches situated posterior to the
bladder.
Structure
- The seminal vesicles are 5 cm long and pyramid shaped. they are
composed of columnar epithelium, muscle tissue and fibrous
tissue.
Prostate gland
Function
- The prostate gland produces a thin lubricating fluid that enters the
urethera through ducts.
Position
102
- It surrounds the urethera at the base of the bladder, lying between the
rectum and the symphysis pubis.
Structure
- It is 4 cm transversely, 3 cm in its vertical diameter and 2 cm deep.
It composed of columnar epithelium, muscle tissue and fibrous
tissue.
Bulbo – Urethral (Cowper’s) gland
 These are two small glands about the size of pee, yellowish color
lying just below the prostate gland, their ducts about 3 cm long
open into the urethra & its secretions are added to the seminal
fluid.
 The bulbo – urethral glands release a small amount of fluid prior to
ejaculation & this lubricates the penis & facilitating its entry into
the vagina.
N.B:
The alkaline fluids secreted by these glands are nutrient plasma with
several functions, including:
● Enhancement of sperm motility.
● Nourishment of the sperm (i.e, provides a ready source of energy
with the simple sugar Fructose).
● Protection of the sperm (i.e, sperm are maintained in an alkaline
environment to protect them from the acidic environment of the
vagina).
Seminal Fluid:
 This fluid in which the spermatozoon as suspended .It nourishes
them & aids their motility.
103
 The prostatic secretion is the largest component of it. But
secretions of seminal vesicles & Cowper’s glands all help to
nourish as will as provide mean of transport for the sperm
Normal semen analysis:
 Average amount: of ejaculate is 3.5 ml but the normal range lies
between 2 and 6 ml.
 Average density: is 60-150 000 000 sperm per milliliter of seminal
fluid of these 75% are mobile and 20- 25 % will be malformed.
Rate of movement: a speed of 2, 3 mm per minute but reach to 0.5
mm per minute in acidic vaginal secretion.
Semen:
- Semen is a thick, whitish fluid ejaculated by the man during
orgasm It contains spermatozoa and fructose rich nutrients.
- During ejaculation, semen receives contributions of fluid from the
seminal vesicles and the prostate gland.
- Combined semen is alkaline (average pH, 7.5).
- The average mount of semen released during is ejaculation is 2.5 to
3.5 ml.
- About 60-120 millions spermatozoa per ml.
- If the sperm count less than 20 millions male is considered infertile
Composition of Semen
Origin
Testes and
Epididymis
Seminal
vesicles
Component
Some fluid.
Sperm (hundred of
million).
Fructose.
Thick mucus.
Prostaglandin.
Functions
Fertilization of ova.
Energy source.
Increase motility of
uterus.
104
Percent
of
ejaculate
Under
5%
30 %
Nutrition for the
sperm.
Prostate
gland
Bulbourethra
l gland
Alkaline fluid.
Thin mucus.
Fibrinolysin.
Citrate – zinc.
Magnesium-acid
phosp .
Piprinolysin
Alkaline fluid.
Support sperm
motility.
Liquefies semen 10
min.
After ejaculation to
release sperm.
Assist the prostate
gland in its function.
60 %
5%
The male hormones:
- The control of the male gonads is similar to that in the female, but it is
not cyclical.
- The hypothalamus produces gonadotrophin- releasing factors. These
stimulate the anterior pituitary gland to produce FSH and luteinising
hormone (LH).
- FSH acts on the seminiferous tubulesto bring about the production of
yhe sperm, whereas LH acts on the intrestetial cells that produce
testosterone.
- Testosterone. This hormone is responsible for the secondary sex
characteristics – namely depending on the voice, growth of genitalia
and growth of hair on the chest, pubis, and axilla and face.
Spermatogenesis process :
 Full Spermatogenesis is achieved in most male by their 16 th years
and then continues throughout life.
 Spermatogenesis takes place in the seminiferous tubules under the
effect of FSH and testosterone. As the spermatozoa develop, they
take about 10 days to be mature.
- Spermotogonia: are the primitive structure and reproduce by
mitosis then they nourish by sertoli cell and develop into.
105
- Primary spermatocytes: containing diploid number of
chromosomes in their nuclei & undergo meiosis (reduction
division ) one spermatocytes produces two daughter cells.
- Secondary spermatocytes: which has haploid number, undergo a
second meiotic division in order to make further re arrangement of
genetic material.
- Spermatids: are the celsls produced by the second meitic division
the largest part of the spermatid the nucleus become the head of
mature spermatozoon.
Mature spermatozoon:
 Four mature spermatozoa have developed from one original
spermatogonia.
Amature sperm consists of:
1- Head: containing the nucleus & covered by acrosome, which
contains hyaluronidase enzyme, which facilitates fertilization of
ovuim.
2- Neck: Which units the head to the body.
3- Body: Which is concerned with the production of energy required
for motility?
4- Tail: it is specialized for motility.
Sperm store in genital system 42 days in male genitalia & can live
only 2 or 3 days in the female genital tract.
Sperm Production & Transportation
Passage of sperm through the male reproductive system
Organ
Function
106
Testes
- Produce spermatogenic cells.
- Produce testosterone .
Seminiferous
Trubules
Epididymis
- Divide spermatocytes by meiosis .
- Stores mature spermatozoa .
- Moves sperm along tract by smooth
muscle action.
- Contributes secretions to seminal fluid .
Ductus deferens
- Stores spermatozoa and tubal fluid in its
Ampulla .
- Carries spermatozoa to duct of seminal
vesicle by muscular contraction .
- Contribute nutrient – laden secretion and
prostaglandins to semen .
Seminal vesicles
- Join ducts deferens to become ejaculatory
duct .
- Extends from junction of ducts deferens
and seminal vesicles through prostate
gland to prostatic urethra, carrying sperm.
Ejaculatory duct
- Secrete viscid alkaline fluid, contributing
to semen and deacidifying vaginal
environment.
Bulbourethral
Glands
- Counteracts acidity of semen by addition
of alkaline secretions to increase sperm
motility.
(Cowper’s glands)
- Allows excretion of ejaculate to exterior .
Prostatc urethra
- Permits exit of semen .
Pentile urethra
107
(Corpus
Spongiosum)
External urethral
Orifice
Function of the male reproductive system:
 As in the female, the male reproductive organs are stimulated by
the gonadotrophic hormones from the anterior lobe of the pituitary
gland .
 The follicle stimulating hormone stimulates the seminiferous
tubules of the tubules of the testes to produce the male germ cell
the spermatozoa (Fig . 15:20 ).
 The spermatozoa then pass through the epididymis, the urethra
coitus and consists of :
1- Spermatozoa
2- A viscid fluid which helps to nourish the spermatozoa , secreted by
the seminal vesicles
3- A thin lubricating fluid produced by the prostate gland
4- Mucus secreted by glands in the lining membrane of the urethra.
Puberty in the Male:
This occurs between the ages of 13 and 16 years. Luteinising hormone
or , as it called in the male , the interstitial cell stimulating hormone
(ICSH) from the anterior lobe of the pituitary gland stimulates the
interstitial cells of the testes to produce the hormone testosterone .
This hormone influences the development of the body to sexual maturity.
The changes which occur at puberty are:
1- Growth of muscle and bone and a marked increase in height.
2- The voice ‘breaks’ due to enlargement of the axillae, the prostste
gland.
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3- Growth of hair on the face, on the axillae, the chest, the abdomen
and the pubis.
4- Enlargement of the penis, the scrotum and the prostate gland.
5- Maturation of the seminiferous tubules and the production of
spermatozoa.
In the male fertility and sexual ability tend to decline gradually with
ageing. There is no period comparable to the menopause in the female.
SEXUAL HEALTH
Outline:
- Objectives.
- Introduction.
- Definition of sexual health.
- Source of sexual arousal.
- Sexual responses cycles.
- Factors affecting sexual function.
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SEXUAL HEALTH
Objectives:
General objectives:
At the end of this lecture each student should be able to acquire
complete scientific knowledge about sexual health.
Specific objectives:
At the end of this lecture each student should be able to:
- Define sexual health.
- Enumerate source of sexual arousal.
- Explain sexual response cycles.
- List factors affecting sexual function.
110
Sexual Health
Introduction:
Human sexuality response is complicated: Biopsycho-social
phenomena in which internal and external stimuli are modulated by brain
through central and peripheral nervous system, it result in cascade of
biochemical hormone and circulatory changes that lend to cognitive and
physical sexual arousal.
Sexual self-concept:
How individuals perceive themselves in terms of gender,
masculinity or feminity, and their adoption of effectives sex-role
behaviors has an effect on their relationship with peers, adult, and
members of the opposite sex.
Gender:
Is a biologic concept that refers simply to an individual's sex, male
or female. Children's idea of their gender is usually fixed by 3 years of
age. Biological differences between males and females include: primarily
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chromosomal and anatomic differences and physiologic differences in
the endocrine and genitourinary systems.
Non biologic concepts also are important for an understanding of
sexuality.
Masculinity and femininity:
Are culturally prescribed, reinforced characteristics of the sexes
that are independent of gender.
Sex-role behaviors:
Are behaviors commonly assigned to men and women; these are
more likely to change in response to situational demands.
Definition of sexual function:
The physiological response to sexual stimulation follows the same
pattern in the male and female, a four stage.
Normal sexual intercourse:
Defined as anything erotic which gives pleasure to both partner,
who are consenting adults, and doesn't hurt anyone.
Masturbation:
The response follows the same pattern regardless of the source of
stimulation and orgasm achieved by hetro-or hemo-sexual coitus.
Definition of sexual health:
The World Health Organization defines sexual health as "the
positive integration of somatic, emotional, intellectual, and social aspects
of sexual being in ways that are positively enriching and that enhance
personality, communication, and love".
Woods suggests that sexual health function sexual self-concept,
and sexual relationship, which are interrelated over the life span.
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Sexual health ahs always been apart of human life and is a complex
phenomena that involve physical, psychological, cultural, and social
aspects.
Source of sexual arousal:
Some stimuli may lead to sexual arousal without any prior
experience or learning called (primary erotic stimuli) as light touch on
any body surface and particularly on the genitalia (secondary erotic
stimuli) are learned as kissing by all types or mouth to mouth stimulation
touching.
The arousal lead to sexual excitation when stimulation the genitals
in male and female, breasts are the most obvious example but erogenous
zones can be found all-over the body.
Many people the lips, neck, and inner thighs are erogenous zones.
And inner surface of the forearm, ears, armpit, clitoral stimulation is often
more intense than vaginal stimulation and is more likely to induce
multiple orgasm.
Sexual response cycles:
The human sexual response cycle, or how the human body
responds to sexual arousal, is composed of four distinct phases:
1. Excitement phase:
a. In women, the following occur:
- Vaginal lubrication increases.
- The inner two-thirds of the vagina begins to lengthen and distend,
the outer one-third undergoes slight thickening, and the body pf the
uterus is pulled upward. The vaginal walls become congested with
blood and darken in color, and the clitoris increases in diameter,
possibly with slightly increased tumescence of the glans clitoris.
- The labia minora become engorged with blood and increase in size.
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- The libia majora flatten somewhat and retract away from the
middle of the vulva.
- The nipples become erect, and breast size increases.
- Flushing occurs in approximately 75% of women.
b. In men, the following occur:
- Penile erection beginning.
- Scrotal skin becomes congested and thick.
- Testes elevate into the scrotal sac.
- Some nipple erection may occur.
- Flushing may occur.
- Heart rate and blood pressure begin to.
- Generalized muscle tension increase increases, with a tendency
toward involuntary muscle contractions.
2. Plateau phase:
a. In women, the following occur:
- The walls of the outer one-third of the vagina become further
engorged with blood, decreasing the internal vaginal diameter.
- The labia minora become further engorged with blood and darken
and swell.
- The clitoris retracts and is covered by the clitoral hood; the clitoral
body decreases in size by about 50%.
- The nipple become further engorged.
- Flushing may spread to the abdomen, thigh, and back.
- Muscle tension increases. Breathing becomes deeper; heart rate and
blood pressure increase markedly as tension rises toward orgasm.
b. In men, the following occur:
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- The penis further enlarges sometimes undergoing color changes,
corresponding to reddening of the female labia.
- Preorgasmia emission may from cowper glands.
- The testes continue to be elevated, enlarge, and rotate
(approximately 30% degrees).
- Heart rate, blood pressure, and respiratory rate continue to
increase.
- Muscle tension increases.
3. Orgasmic phase:
a. In women, the following occur:
- Strong muscular contractions occur in the outer one-third of the
vagina, and the inner two-thirds expands.
- The uterine muscles contract.
- No observable changes occur in the labia majora, labia minora,
clitoris, or breasts.
- Flushing reaches a peak of color intensity and distribution.
- Possibly strong muscular contractions, both voluntary and
involuntary, may occur in many parts of the body, including the
rectal sphincter muscle.
- Respiratory rate may reach a peak of two to three times normal,
heart rate may double, and blood pressure may increase as much as
one-third above normal.
b. In men, the following occur:
- Rhythmic contractions expel semen from the epididymis through
the vas deferens, seminal vesicles, prostate gland, urethra, and
urethral meatus.
- Testes are at maximum elevation, size and rotation.
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- Flushing reaches its peak.
- Heart and respiratory rates also peak.
- A general loss of voluntary control occurs.
- A refractory period being as the final contractions of the urethral
walls occur.
4. Resolution phase:
a. In women, the following occur:
- Blood engorging the walls of the outer one-third of the vagina
disperses rapidly.
- The inner two-thirds of the vagina gradually shrinks, and color
returns to pre-excitement shade.
- The uterus descends, and the cervix dips into the seminal pool.
- The libia minora and majora return to unstimulated thickness and
close toward the midline.
- The clitoris protrude from under the clitoral hood, and eventually
returns to pre-stimulated size.
- Flushing disappears.
- Muscles relax quickly.
- Heart rate and blood pressure return to normal.
b. In men, the following occur:
- More than 50% of the erection is lost rapidly in the first stage of
resolution, with the penis gradually returning to its unstimulated
size during the second stage.
- The scrotum gradually loses its congested and thick status.
- The testes descend and return to normal size.
- Nipple erection subsides.
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- Flushing disappears.
- Heart rate, blood pressure, and respiratory rate return to normal.
- General muscle relaxation occurs.
Factors affecting sexual function:
1. Child hood experience:
This affects adult sexuality and is linked with unconscious
motivation and the Oedipus-Electra conflict.
2. Partner rejection:
An unsuitable relationship with partner rejection and failure to
communicate is clearly unlikely to be associated with good sexual
function.
3. Ignorance and inadequate techniques:
Satisfactory sexual function depends on both partners receiving
adequate stimulation and being free to respond to this. Ignorance may
lead to sexual anxiety and fears of failure. In the male this may cause
premature ejaculation which enhances the fear of failure and may lead to
impotence; in the female such fears, often allied to inadequate
understanding of the clitoral stimulation and communication about this in
a partnership, cause a dry vagina, dyspareunia and eventually frigidity.
4. Disease:
General ill health and chronic pain decrease libido in both sexes
long standing uncontrolled diabetes mellitus may be associated with
partial impotence; vaginal or pelvic pathology may cause dyspareunia,
and the pain experienced during intercourse leads to fear and rejection of
coitus. Many other disorders alter sexual function, from the rigid limbs of
the spastic to the problems following ileostomy. Chronic and progressive
disease such as multiple sclerosis poses a special problem because genital
117
sensation disappears in the female. A couple may be helped to understand
the pleasure of oral sex and so prolong a happy sexual relationship.
5. Drugs:
Drugs usually diminish rather than enhance sexual pleasure, and
most aphrodisiacs are pharmacologically inactive. If they do enhance
erotic behavior it is by placebo effects. Small doses of alcohol,
barbiturates and amphetamines may release inhibitions and apparently
enhance sexuality, but chronic abuse of all of them causes sexual
depression. Impotence is a frequent complication of methylodopa, and
many other drugs also depress sexual function.
6. Pregnancy:
- During pregnancy, the woman's desire for sex may be altered
owing to fatigue, nausea, and discomforts of pregnancy.
- Breasts may be painful to touch, especially during the first
trimester. Some men may find the normal increase in the amount
and odor of vaginal discharge during pregnancy "a turn of", others
do not.
- Other sexual concerns during pregnancy include dyspareunia and
male erectile dysfunction.
- Some women and couple need "permission" to be sexuality active
during pregnancy, long with reassurance that female orgasm will
not harm the fetus.
- For a couple who cannot have or who choose not to have
intercourse during pregnancy, kissing, hugging, and oral or manual
genital stimulation can be satisfying expressions of closeness and
intimacy.
7. Menstruation:
118
During the second half of the menstrual cycle, the luteal phase
there is increased fluid retention and vaso congestion in the woman's
lower pelvic, because some vaso congestion is already present at the
beginning of the excitement stage of the sexual response, women appear
to reach the plateau stage more quickly and achieve orgasm more readily
during this time women also seen to be more interested in initiating
sexual relation at this time.
8. Cultural factors:
Cross-cultural studies have supported the existence of sex
differences in the areas of aggressiveness and dominance.
SEXUAL DYSFUNCTION
Objectives:
General Objective:
At the end of this lecture the student should be able to acquire
complete knowledge about sexual dysfunction.
Specific objectives:
- Define of sexual dysfunction.
- Explain the causes of sexual dysfunction.
- Recognize the classification of sexual dysfunction.
- Explain the types of sexual dysfunction.
- Enumerate the sexual activity with aging.
119
SEXUAL DYSFUNCTION
Outlines:

Introduction.

Definition of sexual dysfunction.

Incidence.

Etiology.

Classification.
- Primary sexual dysfunction.
- Secondary sexual dysfunction.
- Situational sexual dysfunction.

Types of sexual dysfunction.
Female sexual dysfunction.
A. Sexual desire disorder.
- Hypoactive sexual desire.
120
- Sexual aversion.
B. Sexual arousal disorder.
- Frigidity.
C.
Orgasmic disorder.
- Life long an orgasmia (primary).
- Intermittent an orgasmia.
D. Sexual satisfaction disorder.
- Dyspareunia.
- Vaginismus.
Male sexual dysfunction.
A. Sexual desire disorder.
B. Sexual arousal disorder.
- Impotence.
C. Orgasmic disorder.
- Premature ejaculation.
Sexual Dysfunction
Introduction:
The human sexual response is a complex process that is made up of
leamed responses based on cultural, religious and socioeconomic factors,
it may be affected by organic diseases, pharmacological agents, or by
situational and psychological factors of the individual's life. Women had
been so inhibited by their culture that some had lived through courtship
marriage, child bearing, and men's pause without ever experiencing their
bodies in sexual arousal, orgasm or a sense of sexual freedom.
Definition of sexual dysfunction:
Is the decreased, disturbed or absence of sexual interest or sexual
responses to adequate stimulation.
Incidence:
121
There is insufficient data to determine the incidence or prevalence
of sexual dysfunction according to age group. It can be range of 18-73
years as follows:
- Lack of sexual desire (33% - 38%).
- Lack of excitement (lubrication) – (14%-18%).
- Lack of orgasm (an orgasmia) – (15% - 24%).
- Lack of pleasure (16% - 21%).
Etiology:
The cause of sexual dysfunction are un known, but there are
multifactors:
- Health (physical & emotional).
- Life style.
- Sociocultural characteristics.
- Sexual experience.
Risk predictors for sexual dysfunction in women:
- Decrease in household income.
- Emotional problems or stress (ex. mastectomy).
- Sexual forced by man.
- Sexually touched as a child (ex. rape).
- History of STDs.
- Urinary tract symptoms.
- Poor to fair health.
- Previous abortion.
Classification:
Sexual dysfunction can be classified as follows:
122
- Primary sexual dysfunction: has sexual dysfunction with the first
time sexual intercourse.
- Secondary sexual dysfunction: has sexual dysfunctions after
successful times of previous sexual intercourse.
- Situational sexual dysfunction: the functions of sexual responses
are present in some situations but not in others.
Female sexual dysfunction:
A. Sexual desire (libido) disorder:
Traumatic head injury, temporal lobe epilepsy, acromegaly and
back injury decrease libido, sexual desire can be categorized as follow:

Hypoactive sexual desire: Is characterized by a persistent or
recurrent insufficient or absence of sexual fantasies or desire for
sexual activity.
This form can be affected by woman's general physical and
psychological health, hormonal abnormalities, medication (ex.
antidepressant).

Sexual aversion: Is recurrent or persistent avoidance of coitus.
This form can be associated with the following:
- History of physical; or sexual abuse.
- Vaginismus.
- Dyspareunia (superficial or deep dyspareunia).
- Extensive negative feeling about relationship.
- Aversion of semen (a phobic form of disorder and is very difficult
to treat).

Sexual desire disorder: can also be categorized as:
- Primary inhibited sexual desire.
- Secondary inhibited sexual desire.
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B. Sexual arousal disorder:
Is defined as the absence or partial lack of physical signs of arousal
during the excitement phase of the sexual response cycle, with other
phases being intact.

Frigidity:
Lack
or
insufficient
lubrication
during
sexual
intercourse.
Pathophysiology: Oestrogen deficiency compromises blood flow
within the vaginal mucosa and results in decreases lubrication.
Causes: Related to physical as (vaginal stenosis, scarring,
infection…), emotional as (lack of stimulation, poor partner
relationship, stress …..).
C. Orgasmic disorders:
Is defined as the persistent or chronic recurrent inability to reach
orgasm (an orgasmia).
This condition can be classified as follows:
- Life long an orgasmia or primary an orgasmia (the woman never
reaches orgasm during sexual intercourse) affect about 10% of
women.
- Intermittent an orgasmia (situational an orgasmia) is reported in
approximately 50% of women.
The causes of female anorgasmia:
- Traumatic sexual experiences (rape).
- Psychotropic medications (thioridazine, fluphenazine or major
tranquilizers and anti depressants).
- Alcohol consumption and recreational drugs.
124
- Environmental contact with pesticides lead.
- Physical origin (pelvic surgery, spinal cord injury or surgical
intervention).
- Emotional disorders or poor partner relationship.
D. Sexual satisfaction disorder:
Causes: Psycho-social interpersonal, environmental, cultural, general
health,
current
and
past
medication,
religious
and
family
characteristics.
Dyspareunia: Is chronic recurrent genital pain generated before,
during or after sexual intercourse.
It is disorder which leads to depression, anxiety and sexual
dysfunction.
Causes: Post delivery or post surgical scarring, vaginal stenosis, PID,
or endometriosis.
Dyspareunia is sub classified as follow:
-
Superficial dyspareunia: Is pain during pineal insertion and is
usually caused by vulvo-vestibular or vaginal disorder.
- Deep dyspareunia: Occurs upon deep pineal penetration and is
frequently
experienced
after
surgery,
PID
and
pelvic
endometriosis.
- Diffuse dyspareunia: Is the presence of superficial and deep
penetration pain. Long-lasting diffuse dyspareunia is highly
refractory to treatment.

Vaginismus: Is recurrent chronic involuntary contraction of the
distal third of the vagina and makes pineal penetration of the
vagina difficult.
Causes: Unpleasant sexual experience, rape. Un expressed negative
feeling toward a sex partner, fear of pain, fear of pregnancy.
125
Male sexual dysfunction:
Normal male coital function requires arousal through mental,
visual or tactile stimulation, erection (parasympathetic), penetration,
ejaculation (sympathetic) and resolution.
Causes
of
male
sexual
dysfunction
are
related
to
organic,
pharmacological or psychological.
A. Sexual desire disorder:
Causes: Physical or organic as (illness, surgery).
Psychological as anxiety, fear of woman poor partner relationship,
mental illness.
B. Sexual arousal disorder:

Importance: is defined as absence or inability of maintain erection
for the end of the sexual intercourse.
Causes:
- Congenital anomalies such as spina bifida or acquire neurological
problems as tumours or trauma in spinal cord.
- Psychological problem as anxiety, depression or stress.
- Medical disorders as DM, liver failure, myxoedema or hyper
prolactinemia.
- Drugs as hypotensive, psychotropic, alcohol.
- Infection in urogenital tract.
C. Orgasmic disorder:
Premature ejaculation.
Causes:
- Congenital abnormalities such as hypospadias.
126
- Drugs which affect neurological control.
- Psychological problems as stress, anxiety.
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