Chapter 40
Disorders of the Female
Genitourinary System
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Female Reproductive Anatomy
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Estrogens
• Sexual maturation
• Ovulation
• Development and maintenance of female accessory
organs
• Cell division in breasts and endometrium
• Maintaining skin and blood vessels
• Decreasing bone resorption
• Increased HDL levels, decreased LDL, and
cholesterol
• Moving fluid into tissues
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Progesterones
• Maintaining pregnancy
• Breast and endometrium development
• Maturation of endometrium cells
• Increased body temperature
• Smooth muscle relaxation
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The Menstrual Cycle
• Gonadotropin-releasing
hormone (GnRH) from
the hypothalamus
begins the cycle
Hypothalamus
GnRH
• It causes the anterior
pituitary to release
follicle-stimulating
hormone (FSH) and
luteinizing hormone
(LH)
Anterior
pituitary
FSH
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LH
The Menstrual Cycle (cont.)
• Follicle-stimulating
hormone (FSH) and
luteinizing hormone
(LH) make ovarian
follicles begin to
mature
• This is the follicular
phase of the menstrual
cycle
anterior
pituitary
FSH
LH
ovarian follicles
begin to mature
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The Menstrual Cycle (cont.)
• The developing
follicle produces
estrogen
anterior
pituitary
negative
feedback
inhibits
FSH
release
FSH
LH
ovarian follicles
begin to mature
• Estrogen
decreases FSH
release
• Only the
strongest
follicles survive
the drop in FSH
estrogen
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The Menstrual Cycle (cont.)
strongest follicle survives
continued estrogen
production
stimulates LH release
• Only the
strongest follicles
survive the drop
in FSH
• Follicles continue
to make estrogen
• Estrogen now
stimulates LH
release from the
anterior pituitary
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The Menstrual Cycle (cont.)
LH surge
follicle bursts open
OVULATION
oocyte released
into fallopian
tube
remaining follicle
cells become
corpus luteum
progesterone
• LH surge causes
release of the
egg
• Ovulation
• Follicle cells
become corpus
luteum, making
progesterone
• This is called the
luteal phase of
the cycle
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The Menstrual Cycle (cont.)
LH surge
• Progesterone
prepares the body
for pregnancy
follicle bursts open
OVULATION
• If pregnancy does
not occur, the
corpus luteum
dies
oocyte released
into fallopian
tube
remaining follicle
cells become
corpus luteum
progesterone
• The drop in
progesterone tells
the hypothalamus
to secrete GnRH
and begin a new
cycle
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Question
Which hormone slows down the release of FSH?
a. LH
b. Estrogen
c. Progesterone
d. GnRH
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Answer
b. Estrogen
Estrogen, produced by the developing follicle, decreased
FSH release (which only the strongest follicles will be
able to survive). The remaining follicles continue to
produce estrogen, which will stimulate the pituitary
gland to release LH.
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Disorders of the External Genitalia
• Bartholin gland cyst and abscess
• Leukoplakia
– Lichen sclerosus
– Lichen simplex chronicus
• Vulvodynia
– Cyclic vulvodynia
– Vulvar dermatoses
– Vulvar dysesthesia
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Vulvar Carcinomas
• In younger women:
– Often preceded by vulvar intraepithelial neoplasia
– Related to human papillomavirus infection
• In older women
– Often preceded by non-neoplastic disorders
– Lesions cause itching and repeated injury
– Healing cells are more likely to mutate
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Vaginal Bacterial Flora
• Many different species of bacteria
– Dominated by species that produce lactic acid
– Vaginal pH 3.8–4.2
– Protect against infections
• Normal flora can be disrupted by:
– Abnormal estrogen levels
– Increased glycogen availability
– Antibiotics
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Cervical Epithelium
• Inside the cervix: columnar epithelium
• Exposed to acid in vagina: transforms to squamous
epithelium
• Transforming cells are more likely to become
cancerous
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Cancers of the Cervix and Vagina
• Cervical cancer
– Related to human papillomavirus infection
• Vaginal cancer
– Related to prenatal exposure to diethylstilbestrol
– May also be caused by:
º Spread of cervical cancer
º Human papillomavirus infection
º Chronic local irritation
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Question
Tell whether the following statement is true or false:
HPV is a contributing factor to both vulvular and cervical
cancer.
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Answer
True
In young women, HPV has been linked to vulvular cancer;
it also causes 70% of cervical cancers.
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Anatomic Abnormalities
• Disorders of pelvic support
– Cystocele
– Rectocele
– Uterine prolapse
• Variations of uterine position
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Endometrial Disorders
• Endometritis
• Pelvic inflammatory disease
• Endometriosis
• Adenomyositis
• Endometrial cancer
• Leiomyomas
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Pelvic Inflammatory Disease
• Infection ascends through uterus to fallopian
tubes and ovary
• Inflammation causes:
– Pain in lower abdomen and cervix
– Purulent discharge
– Increased WBC count
– Increased C-reactive protein
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Endometriosis
• How did the tissue get there?
– Up through the fallopian tubes (retrograde
menstruation)
– Activation of dormant cells that were always there
• The ectopic implants respond to hormones
– Go through menstrual cycle
– During menstrual period, tissue dies and bleeds
– Pain and adhesions result
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Endometrial Cancer
• Endometrial cancer has sometimes been caused
by administration of estrogen without
progesterone
Question
• Why would this make cancer more likely?
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Ovarian Disorders
• Ovarian cysts
• Polycystic ovary syndrome
• Benign ovarian tumors
• Functioning ovarian tumors
– Estrogen secreting
– Androgen secreting
– Mixed estrogen and androgen secreting
• Ovarian cancer
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Polycystic Ovary
Syndrome
• Follicles develop
• But they do not ovulate
after the LH surge
• The high LH levels
continue
• LH stimulates androgen
production
• This interferes with
ovulation even more
• Ovaries contain many
unovulated follicles
ovarian follicles
begin to mature
strongest follicle survives
decreased FSH levels
continued estrogen
production
stimulates LH release
LH surge
follicle bursts open
OVULATION
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Benign and Functioning Ovarian Tumors
• Benign tumors
– Epithelial cell: cystadenomas
– Endometriomas or “chocolate cysts”
– Fibromas
– Cystic teratomas or dermoid cysts: develop from
germ cells
• Functioning tumors: secrete hormones
– Estrogens: alter menstrual cycle
– Androgens: cause masculine characteristics
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Ovarian Cancer
• Associated with family history of ovarian and
breast cancer
• Causes vague GI symptoms
• Up to 75% of cases have metastasized by the
time they are discovered
• No good screening tests available
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Question
Tell whether the following statement is true or false:
Early detection through screening tests has improved the
prognosis of ovarian cancer.
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Answer
False
Because the signs and symptoms of ovarian cancer are so
vague, the majority of patients do not seek medical
attention until the disease is advanced (the cancer has
usually metastasized by then).
There are currently no good screening tests available to
detect ovarian cancer.
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Menstrual Disorders
• Dysfunctional menstrual cycles
• Dysfunctional bleeding
• Amenorrhea
• Dysmenorrhea
• Premenstrual syndrome
• Menopause and aging changes
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Scenario
• Ms. T is 63 and postmenopausal. She used hormone
replacement therapy for 8 years after her
menopause, but discontinued it on her doctor's
advice 4 years ago
• She has come into the clinic to request birth control
• She says she has started to menstruate again and
her breasts have “plumped out”
Question
• What do you think is happening?
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Menopause or Climacteric
• Decreased ovary
function
anterior
pituitary
negative
feedback
inhibits
FSH
release
FSH
• Low estrogen
LH
– Osteoporosis
risk
– Atherosclerosis
risk
ovarian follicles
begin to mature
estrogen
• Less inhibition of
pituitary
– Increased FSH
and LH
– Hot flashes
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Question
Why are post-menopausal women at risk for osteoporosis?
a. Diminished function of the ovaries
b. Decreased progesterone levels
c. Decreased estrogen levels
d. Increased levels of FSH and LH
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Answer
c. Decreased estrogen levels
Estrogen stimulates osteoblasts (bone cells that
build/synthesize bone tissue). Lower levels of estrogen
= less stimulation of osteoblasts = decreased bone
density = increased risk of osteoporosis (decreased
bone density, especially spongy bone).
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Breast Anatomy
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Disorders of the Breast
• Mastitis
• Ductal ectasia
• Fibrocystic changes
• Breast cancer
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Breast Cancer
• Cancer develops when cells mutate and are not repaired
– BRCA1 and BRCA2 genes code for proteins that help
repair DNA after it has mutated
– Mutation of BRCA1 or BRCA2 make cancer more
likely
• In a cancer, cells continue dividing too fast
– Estrogen and other growth factors make breast cells
divide
– Breast cells with too many estrogen or growth factor
receptors are more likely to become cancerous
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