Disorders of the Female and Male Reproductive Tract Disorders of the Female Reproductive Tract OVERVIEW DISORDERS - OF FEMALE REPRODUCTIVE TRACT - - - - DISORDERS OF THE UTERUS, FALLOPIAN TUBES, & VAGINA Because normal menstrual bleeding is most directly a function of the growth state of the uterine endometrium, disorders of the uterus, including hormonal dysfunction, myomas (fibroids, benign tumors of the underlying myometrium), and cancer of the endometrium itself, often present with abnormal vaginal bleeding. - Any change in the precise rate or amplitude of GnRH secretion by the hypothalamus can result in altered pituitary responsiveness (eg, down regulation of GnRH receptors or altered gonadotropin secretion). Pelvic infections can produce adhesions and scarring of the endometrium or fallopian tubes that may result in infertility. - This altered pituitary function, in turn, results in disordered ovarian function (eg, inadequate steroidogenesis with or without an ovulation) and altered target tissue response (eg, endometrial atrophy and menstrual abnormalities). The initial presentation typically includes abdominal and pelvic (cervical and adnexal) pain and with fever, an elevated white blood cell count, or a positive endocervical culture. Common infectious agents include gonorrhea, anaerobic bacteria, and Chlamydia. - Multiple organisms are usually involved, - Pelvic infections can develop into tubo-ovarian abscesses requiring surgical drainage. Many female reproductive disorders can be traced to a particular level of the neuroendocrine feedback axis and thus can be categorized as resulting from central (pituitary, hypothalamus, or other brain centers which influence the hypothalamus), ovarian or endorgan (target tissue, eg. uterine) dysfunction. Many central (eg. psychic stress) and peripheral (eg. body fat content) inputs affecting pulsatile GnRH release are integrated in the hypothalamus. Thus, altered GnRH release from the hypothalamus is a common cause of amenorrhea (eg. in athletic young women). DISORDERS OF THE OVARY - PCOS is manifested by an ovulation, hirsutism, infertility, dyslipidemia, and either abnormal uterine bleeding or amenorrhea. - DISORDERS OF CENTRAL HYPOTHALAMIC PITUITARY FUNCTION - - Proper ovarian function involves responsiveness to gonadotropins, intrinsic viability of follicles, and a host of paracrine interactions within and between individual follicles. Polycystic ovary syndrome (PCOS) is an example of ovarian dysfunction resulting from a selfperpetuating cycle of altered feedback relationships (see later discussion). DISORDERS OF PREGNANCY - - - - The normal events of pregnancy potentially set the stage for a wide array of localized and systemic disorders. Abnormalities in the process of implantation, for example, appear to predispose to recurrent miscarriage and preeclampsia-eclampsia. In addition, genetic predisposition to diseases that might otherwise remain latent for decades may be manifested first—often transiently— during pregnancy. A good example of the latter is the genetic predisposition to development of diabetes mellitus Disorders of the MaleReproductive Tract - MALE INFERTILITY - - However, aging and hormonal factors are both clearly important. Age-related increases in prostate size are evident at autopsy, and the development of symptoms is age-related. Data from autopsy studies show pathologic evidence of benign prostatic hyperplasia in less than 10% of men in their 30s, in 40% of men in their 50s, in more than 70% of men in their 60s,and in almost 90% of men in their 80s. Clinical symptoms of bladder outlet obstruction are seldom found in men younger than 40 years but are found in about one-third of men older than 65 years and in up to three-fourths of men at age 80 years.Prostatic androgen levels, particularly DHT levels, play an important role in development of the disorder. Pathology - - - BENIGN PROSTATIC HYPERPLASIA - - Benign prostatic hyperplasia is nonmalignant growth of the prostate stroma and epithelial glands that causes enlargement of the prostate gland. Growing slowly over decades, the gland can eventually reach up to 10 times the normal adult prostatesize in severe cases. Benign prostatic hyperplasia is a common agerelated disorder. Most men are asymptomatic, but clinical symptoms and signs occur in up to one-third of men older than 65 years, and each year more than 500,000 men in the United States undergo TURP. Etiology - The cause of benign prostatic hyperplasia is unknown. The normal prostate is composed of both stromal (smooth muscle) and epithelial (glandular) elements. Growth of each of these elements—alone or in combination—can result in hyperplastic nodules and ultimately the symptoms of benign prostatic hyperplasia. Pathologically, the hyperplastic gland is enlarged, with a firm, rubbery consistency. Although small nodules are often present throughout the gland, benign prostatic hyperplasia arises most commonly in the periurethral and transition zones.
