Chapter 23
Alterations of the Reproductive
Systems
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Overview
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Delayed sexual development
Suboptimal sexual performance
Structural and functional abnormalities
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Alterations of Sexual Maturation
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Delayed puberty
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Secondary sex characteristics have not appeared in
girls by age 13
• Breast development age decreasing
 Secondary sex characteristics have not appeared in
boys by age 14
 95% of cases are physiologic (hormonal- or
hypothalamic-pituitary-gonadal axis delay)
 5% are caused by some type of disruption of the
hypothalamic-pituitary-gonadal axis
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Alterations of Sexual Maturation
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Precocious puberty (rare)
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Sexual maturation before age 6 in black girls and
age 7 in white girls
Sexual maturation before age 9 in boys
Forms
• Isosexual precocious puberty
• Heterosexual precocious puberty
• Incomplete precocious puberty
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Precocious Puberty
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Central (GnRH dependent)
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Hypothalamic-pituitary-gonadal axis is working
normally but prematurely
Failure of central inhibition of the GnRH
Peripheral (GnRH independent)
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Sex hormones produced by mechanism other than
stimulation by the gonadotropins
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Disorders of the Female
Reproductive System
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Hormonal and menstrual alterations
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Primary dysmenorrhea 50%–90% of young
women
• Painful menstruation associated with prostaglandin
release in ovulatory cycles
• Related to duration and amount of menstrual flow
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Secondary dysmenorrhea
• Painful menstruation related to pelvic pathology
• Can occur at any time in the menstrual cycle
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Hormonal and
Menstrual Alterations
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Primary amenorrhea
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Failure of menarche and the absence of
menstruation by age 14 years without the
development of secondary sex characteristics or
by age 16 years regardless of the presence of
secondary sex characteristics
Secondary amenorrhea
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Absence of menstruation for a time equivalent to
three or more cycles or 6 months in women who
have previously menstruated
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Hormonal and
Menstrual Alterations
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Secondary amenorrhea
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Causes
• Pregnancy
• Dramatic weight loss
• Malnutrition or excessive exercise
• Hypothyroidism
• Polycystic ovary syndrome
• Common during early adolescence, perimenopause,
pregnancy, and lactation
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Anovulation
 Hyperprolactinemia
 Clinical manifestations
• Infertility, vasomotor flushes, vaginal atrophy, acne,
osteopenia, hirsutism
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Hormonal and
Menstrual Alterations
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Abnormal uterine bleeding
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Menstrual irregularity
• Anovulatory cycles
• Other: tumors, polyps, cysts
Dysfunctional uterine bleeding
• Heavy or irregular bleeding without disease

Perimenopause
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Hormonal and
Menstrual Alterations
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Polycystic ovary syndrome
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Oligo-ovulation or anovulation
Elevated levels of androgens or clinical signs of
hyperandrogenism and polycystic ovaries
Leading cause of infertility in United States
Multifactorial
• Hyperinsulinism
Dysfunction of follicle development
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Hormonal and
Menstrual Alterations
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Premenstrual syndrome (PMS) and
premenstrual dysphoric disorder (PMDD)
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Cyclic physical, psychologic, or behavioral changes
that impair interpersonal relationships or interfere with
usual activities
Occurs in the luteal (postovulatory) phase
Abnormal nervous, immunologic, vascular, and GI
tissue response to the normal menstrual cycle (>200
symptoms)
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Infection and Inflammation
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Pelvic inflammatory disease (PID)
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Acute inflammation caused by infection
May involve any organ of reproductive tract
• Salpingitis
• Oophoritis
Sexually transmitted diseases migrate from the
vagina to the upper genital tract
Polymicrobial infection
• Microbes ascend from infected cervix to endometrial tissue;
infect uterus and adnexae
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Pelvic Inflammatory Disease (PID)
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Infection and Inflammation
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Vaginitis
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Infection of the vagina
Sexually transmitted pathogens and Candida
albicans
Acidic nature of vagina provides some protection
• Maintained by cervical secretions, normal flora
Cervicitis
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Inflammation or infection of the cervix
Mucopurulent cervicitis (MPC)
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Infection and Inflammation
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Vulvitis
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Inflammation of the female external genitalia
Causes
• Contact with soaps, detergents, lotions, hygienic sprays,
shaving, menstrual pads, perfumed toilet paper, or
nonabsorbing or tight-fitting clothing
• Vaginal infections that spread to the labia
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Infection and Inflammation
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Bartholinitis
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Inflammation of one or both ducts that lead from
the vaginal opening to Bartholin glands
 Caused by microorganisms that infect the lower
female reproductive tract
 Inflammation narrows the distal portion of the
ducts
 Leads to obstruction and stasis of glandular
secretions
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Pelvic Organ Prolapse
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The bladder, urethra, and rectum are
supported by the endopelvic fascia and
perineal muscles
The muscular and fascia tissue loses tone
and strength with aging
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Pelvic Organ Prolapse
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Uterine prolapse
Cystocele and rectocele
Vaginal prolapse
Urethrocele
Cystourethrocele
Enterocele
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Pelvic Organ Prolapse
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Benign Growths and
Proliferative Conditions
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Benign ovarian cysts (common)
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Unilateral
Produced when a follicle or number of follicles are
stimulated but no dominant follicle develops and
reaches maturity
Follicular cysts
Corpus luteum cysts
Dermoid cysts
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Benign Growths and
Proliferative Conditions
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Endometrial polyps
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Benign mass of endometrial tissue
Common cause of intermenstrual or excessive
menstrual bleeding
Malignancy is rare
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Benign Growths and
Proliferative Conditions
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Leiomyomas
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Commonly called uterine fibroids
Benign tumors of smooth muscle cells in the
myometrium
Cause abnormal uterine bleeding, pain, and
symptoms related to pressure on nearby
structures
Adenomyosis
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Islands of endometrial glands surrounded by
benign endometrial stroma within the myometrium
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Leiomyomas
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Benign Growths and
Proliferative Conditions
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Endometriosis
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Functioning endometrial tissue or implants outside
the uterus
 Responds to hormone fluctuations of the
menstrual cycle
 Possible causes
• Retrograde menstruation, spread through vascular or
lymphatic systems, stimulation of multipotential epithelial
cells on reproductive organs, or depressed Tc cells
tolerate ectopic tissue
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Endometriosis
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Female Reproductive Cancer
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Cervical cancer
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Cervical dysplasia
 Cervical carcinoma in situ
• Generally a precursor of invasive carcinoma of the cervix
 Invasive carcinoma of the cervix
 Almost exclusively caused by cervical human
papillomavirus (HPV) infection
 With early detection and treatment, prognosis is
excellent
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Cervical Cancer
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Female Reproductive Cancer
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Vaginal cancer
Vulvar cancer
Endometrial cancer
Uterine sarcoma
Ovarian cancer
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Frequently diagnosed after metastases have
occurred
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Sexual Dysfunction
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Disorders of desire (inhibited sexual desire,
decreased libido)
Vaginismus
Anorgasmia (orgasmic dysfunction)
Rapid orgasm
Dyspareunia (painful intercourse)
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Impaired Fertility
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Infertility
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Inability to conceive after 1 year of unprotected
intercourse with same partner
Fertility can be impaired by factors in the man,
woman, or both
Fertility tests
• Structural
• Hormonal
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Disorders of the Male
Reproductive System
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Disorders of the urethra
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Urethritis
• Inflammation of the urethra usually but not always
caused by a STD
• Nonsexual origins can be due to urologic procedures,
insertion of foreign objects, anatomic abnormalities, or
trauma
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Urethral strictures
• Fibrotic narrowing of urethra caused by scarring
• Commonly due to trauma or untreated or severe urethral
infections
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Disorders of the Male
Reproductive System
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Disorders of the penis
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Penile foreskin (prepuce) is “too tight”
Phimosis
• Inability to retract foreskin from the glans of the penis
(distal to proximal)
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Paraphimosis
• Inability to replace or cover the glans with the foreskin
(proximal to distal)
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Frequently caused by poor hygiene or chronic
infections
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Disorders of the Male
Reproductive System
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Disorders of the penis
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Peyronie disease
• “Bent nail” syndrome
• Slow development of fibrous plaques (thickening) in the
erectile tissue of the corpus cavernosa, causing lateral
curvature of penis during erection
• Occurs in middle-aged men and causes painful erections
and intercourse
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Disorders of the Male
Reproductive System
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Disorders of the penis
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Priapism
• Condition of prolonged penile erection
Balanitis
• Inflammation of the glans penis
• Usually associated with foreskin inflammation (posthitis)

Accumulation under the foreskin (smegma) causes
irritation of the glans
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Disorders of the Male
Reproductive System
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Disorders of the penis
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Penile cancer
• Carcinoma of the penis is rare
• Mostly squamous cell carcinomas
• HPV, smoking
• Often diagnosed in men older than age 55
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Disorders of the Scrotum,
Testis, and Epididymis
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Disorders of the scrotum
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Varicocele
• Inflammation/dilation of veins in spermatic cord
• Cause: inadequate or absent valves in the spermatic
veins
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Hydrocele
• Scrotal swelling due to collection of fluid within the tunica
vaginalis
• Imbalance between fluid secretion and reabsorption
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Disorders of the Scrotum,
Testis, and Epididymis
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Disorders of the scrotum
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Spermatocele
• Painless diverticulum of the epididymis located between
head of the epididymis and the testis
• Contains milky fluid that contains sperm and does not
cover the entire anterior scrotal surface
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Disorders of the Scrotum
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Disorders of the Scrotum,
Testis, and Epididymis
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Disorders of the testis
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Cryptorchidism
• Failure of one or more of the testes to descend from the
abdominal cavity into the scrotum
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Ectopic testis
• Testis that has strayed from the normal pathway of
descent
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Disorders of the Scrotum,
Testis, and Epididymis
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Disorders of the testis
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Torsion of the testis
• Rotation of the testis
• The rotation causes the twisting of the blood vessels in
the spermatic cord
• Painful and swollen testis
• Condition may be spontaneous or follow physical
exertion or trauma
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Disorders of the Scrotum,
Testis, and Epididymis
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Disorders of the testis
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Orchitis
• Acute inflammation of the testis
• Complication of a systemic disease or related to
epididymitis
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Cancer of the testis
• Among the most curable of cancers
• Common in men between ages 15 and 35
• Causes painless testicular enlargement
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Disorders of the Scrotum,
Testis, and Epididymis
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Disorders of the epididymis
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Epididymitis
• Inflammation of the epididymis
• Common in sexually active young men
• The pathogenic microorganism reaches the epididymis
by ascending the vas deferens from an already infected
bladder or urethra
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Disorders of the Prostate Gland
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Benign prostatic hyperplasia
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Enlargement of the prostate gland
Symptoms associated with urethral compression
Relationship to aging
Evaluation
• Digital rectal exams
• Prostate-specific antigen (PSA) monitoring
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Disorders of the Prostate Gland
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Prostatitis
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Inflammation of the prostate
Normal protective barriers
• Urethral length, micturition, and ejaculation
Similar symptoms to BPH
• Acute bacterial
• Chronic bacterial
• Nonbacterial
Prostatodynia
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Disorders of the Prostate Gland
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Cancer of the prostate
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95% of prostate neoplasms are adenocarcinomas
and demonstrate peripheral zone growth
Prostatic cancer is asymptomatic until its
advanced stages
Symptoms are similar to BPH
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Disorders of the Prostate Gland
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Cancer of the prostate
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Dietary factors
Hormones
• Male equivalent of the female uterus
Vasectomy
Familial factors
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Male Sexual Dysfunction
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Vascular, endocrine, and neurologic disorders
Chronic diseases
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Renal failure and diabetes mellitus
Penile diseases and penile trauma
Iatrogenic factors
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Surgery and pharmaceuticals
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Impairment of Sperm Production
and Quality
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Hormone and growth factors
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FSH, LH, and testosterone
Androgen-binding protein, inhibin B, other
peptides
Adequate spermatogonia
Sperm count >20 million/ml
Sperm motility
Antisperm antibodies
Drugs and toxins in the semen
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Disorders of the Breast
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Galactorrhea
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Persistent and sometimes excessive secretion of
milky fluid from the breasts of a woman who is not
pregnant or nursing
Galactorrhea can also occur in men
Nonpuerperal hyperprolactinemia
Women with galactorrhea also experience
menstrual abnormalities
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Benign Breast Lesions
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Nonproliferative breast lesions
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Fibrocystic changes
Proliferative breast lesions without atypia
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Epithelial hyperplasia
Florid hyperplasia
Sclerosing adenosis
Complex sclerosing lesion
Papillomas
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Benign Breast Lesions
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Proliferative breast lesions with atypia
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Atypical hyperplasia
Ductal hyperplasia
Lobar hyperplasia
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Breast Cancer
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Most common cancer in American women
Leading cause of death from ages 40 to 44
Second most common killer after lung cancer
Ductal carcinoma in situ
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Controversy on whether lesions progress to
infiltrative malignancy
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Breast Cancer
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Reproductive factors
Hormonal factors
Environmental factors and lifestyle
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Radiation
Diet
Chemicals
Physical activity
Familial factors and tumor-related genes
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Disorders of the Male Breast
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Gynecomastia
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Overdevelopment of the breast tissue in a man
Results from hormone alterations
• Idiopathic and system disorders, drugs, or neoplasms
Male breast cancer

Most commonly seen after age 60
 Tumors resemble carcinomas of the breast in
women
 Crusting and nipple discharge are common clinical
manifestations
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