Female Reproductive

System
FUNCTIONS : Female Reproductive System
 Produce sex hormones
 Estrogen
 Progesterone
 Produce egg (ova)
 Support & protect developing embryo
 Give birth to new baby
 Major Organs
 Cervix
 Vagina
 Ovaries [gonads]
 Uterine tubes [Fallopian
tubes]
 Uterus

 Uterine and Ovarian

Ligaments
Cervix

 The lower portion or neck of the uterus.

 The cervix is lined with mucus, known as cervical
mucus

 Cervical mucus provides lubrication & sperm

transport during sexual intercourse
 During ovulation secretion of cervical mucus
increases in response to estrogen
 But when an egg is ready for fertilization, the mucus
then becomes thin and slippery, offering a “friendly
environment” to sperm
Cervix

At the end of pregnancy

The cervix acts as the passage

through which the baby exits the
uterus into the vagina.

The cervical canal expands to roughly

50 times its normal width for the
passage of the baby during birth
Vagina

 A muscular, ridged sheath

connecting the external
genitals to the uterus.

 Functions as a two-way street,

accepting the penis and sperm
during intercourse

 Serving as the avenue of birth

through which the new baby
enters the world
Vascular supply of the Vagina
Arteries
The arterial supply of the vagina is derived from the internal iliac arteries. The vaginal
arteries form two median longitudinal vessels, the azygos arteries of the vagina,
which descend anterior and posterior to the vagina. They descend on the vagina and
supply the mucous membrane. Branches are also sent to the vestibular bulb, fundus
of the bladder, and adjacent part of the rectum. The uterine, internal pudendal and
middle rectal branches of the internal iliac artery may also contribute to the blood
supply.

Veins
The vaginal veins, one on each side, form from lateral plexuses that connect with
uterine, vesical and rectal plexuses and drain to the internal iliac veins. The uterine
and vaginal plexuses may provide collateral venous drainage to the lower limb.
Lymphatics Drainage of Vagina
Vaginal lymphatic vessels link with those of the cervix, rectum and vulva. They form
three groups but the regions drained are not sharply demarcated. Upper vessels
accompany the uterine artery to the internal and external iliac nodes; intermediate
vessels accompany the vaginal artery to the internal iliac nodes; vessels draining the
vagina below the hymen, and from the vulva and perineal skin, pass to the superficial
inguinal nodes.
 Innervation of the Vagina

• The upper vagina is supplied by the • The lower vagina is supplied by the
splanchnic nerves (S2, S3 and pudendal nerve (S2, S3 and S4).
sometimes S4).
ANATOMY OF PUDENDAL NERVE

3 branches include the following:

1. Dorsal nerve of clitoris, which innervates the
clitoris
2. Perineal branch, which innervates the
muscles of the perineum, the skin of the
labia majora and labia minora, and the
vestibule
3. Inferior hemorrhoidal nerve, which
innervates the external anal sphincter and
the perianal skin
 External genitalia aka Vulva
 Vulva—which runs from the pubic area downward to the rectum.

 Labia majora or "greater lips" are the part around the vagina
containing two glands (Bartholin’s glands) which helps lubrication
during intercourse.

 Labia minora or "lesser lips" are the

thin hairless ridges at the entrance of
the vagina, which joins behind and in
front. In front they split to enclose the
clitoris

 The clitoris is a small pea-

shaped structure. It plays an
important part in sexual
excitement in females.
 VULVA

The female external genitalia or vulva include the mons pubis, labia majora, labia
minora, clitoris, vestibule, vestibular bulb and the greater vestibular glands
External genitalia aka Vulva
 The urethral orifice or external urinary
opening is below the clitoris on the upper
wall of the vagina and is the passage for
urine

 Opening of the vagina is separate from the

urinary opening and located below it.

 The hymen is a thin cresentic fold of tissue

which partially covers the opening of the
vagina; highly vascular. Medically it is no
longer considered to be a 100% proof of
female virginity.
VENOUS DRAINAGE OF THE VULVA
• Venous drainage of the vulval skin is via external pudendal veins to the long
saphenous vein.
• Venous drainage of the clitoris is via deep dorsal veins to the internal pudendal
vein and superficial dorsal veins to the external pudendal and long saphenous
veins
LYMPHATIC DRAINAGE OF THE VULVA
• 3-4 collecting trunks around the mons pubis which drain to superficial inguinal
nodes lying on the cribriform fascia covering the femoral artery and vein; these
nodes drain through the cribriform fascia to the deep inguinal nodes lying medial
to the femoral vein.
• The deep inguinal nodes drain via the femoral canal to the pelvic nodes.
• The last of the deep inguinal nodes lies under the inguinal ligament within the
femoral canal and is often called Cloquet’s node.
• Lymph vessels in the perineum and lower part of the labia majora drain to the
rectal lymphatic plexus.
• Lymph vessels from the clitoris and labia minora drain to deep inguinal nodes and
direct clitoral efferents may pass to the internal iliac nodes
Ovaries
 Also known as female gonads

 They produce eggs (also

called ova) every female is
born with a lifetime supply of
eggs

 They also produce hormones:

Estrogen & Progesterone
Fallopian tubes [uterine tubes]
 Stretch from the uterus to the ovaries and measure about 8
to 13 cm in length.

 The ends of the fallopian tubes lying next to the ovaries

feather into ends called fimbria

 Millions of tiny hair-like cilia line the fimbria and interior of

the fallopian tubes.

 The cilia beat in waves hundreds of times a second catching

the egg at ovulation and moving it through the tube to the
uterine cavity.

 Fertilization typically occurs in the fallopian tube

Uterus
• Pear-shaped muscular organ in the female reproductive tract.
• The fundus is the upper portion of the uterus where pregnancy occurs.
• The cervix is the lower portion of the uterus that connects with the vagina and
serves as a sphincter to keep the uterus closed during pregnancy until it is time
to deliver a baby.
• The uterus expands considerably during the reproductive process.
• The organ grows to from 10 to 20 times its normal size during pregnancy.
Uterus

 The main body consists

of a firm outer coat of
muscle (myometrium)
and an inner lining of
vascular, glandular
material (endometrium).

 The endometrium thickens during the menstrual cycle to

allow implantation of a fertilized egg.

 Pregnancy occurs when the fertilized egg implants

successfully into the endometrial lining.
Endometrium
 The endometrium is the innermost
layer as a lining for the uterus

 During the menstrual cycle, the

endometrium grows to a thick, blood
vessel-rich, glandular tissue layer.

 This represents an optimal

environment for the implantation of
a blastocyst upon its arrival in the
uterus.
Endometrium
• The endometrium is central, echogenic
(detectable using ultrasound scanners),
and has an average thickness of 6.7mm.
• During pregnancy, the blood vessels in the
endometrium further increase in size and
number, forming the placenta
• Placenta supplies oxygen and nutrition to
the embryo and fetus
Uterine and Ovarian Ligaments
Uterine and Ovarian
Ligaments cont.
Cardinal (transverse
cervical ligaments
• Extend from the
supravaginal cervix and
lateral parts of the
fornix of the vagina to
the lateral walls of the
pelvis
• Contains uterine
vessels
 Uterine and Ovarian Ligaments cont
• Uterosacral
Ligaments - pass
superiorly and
slightly posteriorly
from the sides of
the cervix to the
middle of the
sacrum; they are
palpable during a
rectal examination.
 Ligament of Ovaries :
Connect ovary to the
lateral wall of uterus
Suspensory
Ligament of
the Ovaries –
suspending the
ovaries to
lateral pelvic
wall; contains
the ovarian
arteries and
vein, lymphatic
vessels and
ovarian plexus.
INNERVATION OF FEMALE GENITALIA
INNERVATION OF
FEMALE GENITALIA
• NOTE : The sensory innervation of the
anterior and posterior parts of the
labium majora differ.
• The anterior third of the labium
majora is supplied by the
ilioinguinal nerve (L1)
• the posterior two-thirds are
supplied by the labial branches of
the perineal nerve (S3), and the
lateral aspect is also innervated by
the perineal branch of the posterior
cutaneous nerve of the thigh (S2)
MALE AND
FEMALE
HOMOLOGS
 Diseases and Disorders of the
31-37

Female Reproductive System

Disease/Disorder Description
Breast cancer Second leading cause of cancer deaths in
women; classified as stage 0 to 4

Cervical cancer Slow to develop; Pap smear detects

abnormal cervical cells
Cervicitis Inflammation of the cervix usually due to an
infection
Dysmenorrhea Condition with severe menstrual cramps
limiting normal activities
 31-38

Diseases and Disorders of the Female

Reproductive System (cont.)

Disease/Disorder Description
Endometriosis Tissues of uterine lining growing outside of
the uterus
Fibrocystic breast Abnormal cystic tissue in the breast; size
disease varies related to menstrual cycle; common in
60% of women between 30 and 50
Fibroids Benign tumors in the uterine wall; affect
25% of women in their 30s and 40s
Ovarian cancer Considered more deadly than other types;
detection difficult and often spreads before
detection
© 2009 The McGraw-Hill Companies, Inc.
 31-39

Diseases and Disorders of the

Female Reproductive System
(cont.)

Disease/Disorder Description
Premenstrual Collection of symptoms occurring just
syndrome (PMS) before a menstrual period

Vaginitis / Inflammation of the vagina / inflammation of

vulvovaginitis vagina and vulva; both associated with
abnormal vaginal discharge

Uterine (endometrial) Most common in post-menopausal women;

cancer causes about 6% of cancer deaths in women
CLINICAL CORRELATION : Pelvic
Inflammatory Disease (PID)
• Infectious condition of the pelvic cavity that may involve
infection of the fallopian tubes (salpingitis), ovaries
(oophoritis), and pelvic peritoneum (peritonitis)
• Often the result of untreated cervicitis – the organism
infecting the cervix ascends higher into the uterus, tubes,
ovaries & peritoneal cavity
• Chlamydia trachomatis and Neisseria gonorrhoeae
• are the most common causative organisms
• PID is the major cause of female infertility
• Silent PID can cause damage that cannot be reversed
 Risk Factors for PID
 Women at increased risk of chlamydial infections
- younger than 24 years
- multiple sex partners
 Clinical Manifestations of PID

 Lower abdominal pain – starts gradually

& is constant, intensity may vary from mild to
severe
 Pain associated with intercourse
 Spotting after intercourse
 Abnormal vaginal discharge
 Fever & chills
Complications of PID

 Septic shock
 Ectopic pregnancies
 Infertility
 Chronic pelvic pain
 CLINICAL CORRELATION :
ENDOMETRIOSIS
• Presence of endometrium-like glands and stroma
outside the uterus.
• Most commonly found in the ovaries, followed by
the anterior and posterior cul-de-sac / pouch of
Douglas, broad ligaments, uterosacral ligaments,
uterine wall, fallopian tubes, sigmoid colon and
appendix, and round ligaments.
• Complications of endometriosis consist of bowel
and ureteral obstruction resulting from pelvic
adhesions.
• Rarely, endometriosis is extra-peritoneal and
occurs in the lungs and central nervous system. The drawing illustrates the most
• Ectopic endometrial glandular tissue is influenced common sites for
by ovarian hormones and undergoes cyclic endometriosis.
 CLINICAL CORRELATION :
ENDOMETRIOSIS
• The earliest visible manifestations of
endometriosis are whitish peritoneal
plaques.
• The foci of endometrial tissue are small
subserosal nodules with a brown
appearance (termed "powder burns")
on gross examination; they are seen
on laparoscopic examination.
• Over time the repeated hemorrhaging
can produce extensive fibrosis
surrounding the endometrial tissue, • Risk factor for female
which can result in adhesions to infertility, ectopic pregnancy,
adnexal structures or to bowel and can secondary dysmenorrhea
obliterate the posterior pelvic cul-de-
ENDOMETRIOSIS : Clinical Manifestations

 Wide range of manifestations & severity

 Dysmenorrhoea
 Infertility
 Pelvic pain
 Dyspareunia
 Irregular bleeding
 Common Sites of
Endometriosis
The most common sites of endometriosis,
in decreasing order of frequency :
1. Ovaries
2. Anterior and posterior cul-de-sac
3. Posterior broad ligaments
4. Uterosacral ligaments
5. Uterus
6. Fallopian tubes
7. Sigmoid colon and appendix
8. Round ligaments
CLINICAL CORRELATION : PELVIC
ORGAN PROLAPSE (POP)
• Prolapse of the bladder (through the urethra) - CYSTOCELE
• Prolapse of the uterus and/or vagina (through the vaginal orifice) –
UTERINE PROLAPSE
• Prolapse of rectum – RECTOCELE
• Attenuation of the perineal body, associated with diastasis
(separation) of the puborectalis and pubococcygeus parts of the
levator ani  the formation of a cystocele, rectocele, and/or
enterocele, hernial protrusions of part of the bladder, rectum, or
rectovaginal pouch, respectively, into the vaginal wall
EXAMPLE OF POP – UTERINE
PROLAPSE
Uterine Prolapse
 Downward displacement of the uterus into the
vaginal canal
 Uterine Prolapse
 1st degree – Downward
displacement of the uterus into
the vaginal canal
 2nd degree - Downward
displacement of the uterus into
the vaginal canal with the cervix
at the vaginal opening
 3rd degree - Downward
displacement of the uterus into
the vaginal canal with the uterus
protruding through the introitus
Clinical Manifestations of Uterine Prolapse

 Vary with degree of prolapse

 Patient may describe a feeing of “something
coming down”
 Dyspareunia
 Dragging or heavy feeling in the pelvis
 Backache
 Bowel or bladder problems
CYSTOCELE AND
RECTOCELE
 Cystocele occurs when
support between the
vagina and bladder is
weakened
 Rectocele results from
weakening between the
vagina and rectum
 Woman may not be able
to empty bladder or bowel
CLINICAL CORRELATION : Ectopic Pregnancy
 The implantation of the fertilised ovum anywhere
outside the uterine cavity
 98% occur in the fallopian tube
 A life-threatening condition
 Risk factors include a history of PID, prior ectopic
pregnancy, use of IUD, in vitro fertilization procedures
Ectopic Pregnancy
Ruptured Tubal Pregnancy
Ectopic Pregnancy Sites
Clinical Manifestations Of Ectopic Pregnancy

 Abdominal or pelvic pain

 Missed menses
 Irregular vaginal bleeding
 Other symptoms of pregnancy
 With rupture the risk of haemorrhage
and hypovolaemic shock is present
 CLINICAL PROCEDURE :
CATHETERIZATION OF THE FEMALE
Because the female
urethra is shorter,
wider, and more
dilatable,
catheterization is
much easier than in
the male. Moreover,
the urethra is straight
and only minor
resistance is felt as
the catheter passes
through the urethral
sphincter.
ANATOMY OF FEMALE PELVIC FLOOR MUSCLE
The pelvic floor consists of three muscle layers:

1.Superficial perineal layer: innervated by the pudendal nerve

1. Bulbospongiosus
2. Ischiocavernosus
3. Superficial transverse perineal
4. External anal sphincter (EAS)

2.Deep urogenital diaphragm layer: innervated by pudendal nerve

1. Compressor urethra
2. Urethrovaginal sphincter
3. Deep transverse perineal

3.Pelvic diaphragm: innervated by sacral somatic nerve roots S3-S5

1. Levator ani: pubococcygeus (pubovaginalis, puborectalis), iliococcygeus
2. Coccygeus/ischiococcygeus
3. Piriformis
4. Obturator internus
bulbospongiosus
Urogenital Diaphragm
CLINICAL CORRELATION : PELVIC
FLOOR - REFERRED PAIN
Trigger Points in the muscles of the Pelvic Floor may refer pain in the
distribution of the pudendal nerve:

• Bulbocavernosus and Ischiocavernosus refer pain to the perineum

and adjoining urogenital structures
• External Anal Sphincter refers to posterior pelvic floor
• Levator ani and coccygeus refer to sacrococcygeal area
• Levator ani to vagina
• Obturator internus to vagina and anococcygeal area
 SURGICAL PROCEDURE : EPISIOTOMY
• The perineal body is the major
structure incised during a median
episiotomy
• A/w an increased incidence of severe
lacerations  an increased incidence
of long-term fecal incontinence, pelvic
prolapse, and anovaginal fistulae.

Mediolateral episiotomies - cuts

away from perineal body; appear to
result in a lower incidence of severe
Definition : Surgical incision of the perineum laceration and are less likely to be a/w
and inferoposterior vaginal wall - to enlarge
the vaginal orifice, w/ the intention of decreasing
damage to the anal sphincters and
excessive traumatic tearing of the perineum and canal.
uncontrolled jagged tears of the perineal muscles. AKA “5 o’clock episiotomy”
 Episiotomy : Indication
• When descent of the
fetus is arrested or
protracted
• When instrumentation
is necessary (e.g., use
of obstetrical forceps)
• To expedite delivery
when there are signs of
fetal distress
 CLINICAL CORRELATION :
FECAL INCONTINENCE
A 41-year-old previously healthy woman gives birth to a
term baby boy after a spontaneous vaginal delivery. The
delivery is complicated by a perineal tear that is repaired
at the bedside by the midwife. Hours after the birth, the
mother complains of soiling herself with stool in the bed.
Which of the following structures was most likely
damaged during delivery?
Fecal incontinence can result from damage to the anal sphincter during vaginal delivery. As
shown by the red circle in the image, the perineal body is the site of convergence of several
muscles of the urogenital diaphragm anterior to the anus: the bulbospongiosus, external anal
sphincter, and perineal muscles. A severe perineal laceration may result in damage to the anal
sphincter, leading to fecal incontinence. Perineal tears are common during vaginal deliveries,
particularly in the setting of prolonged labor, babies large for gestational age, and in older
mothers, as indicated in this vignette.
CLINICAL CORRELATION
: Speculum Examination, and
Pap Smear, Colposcopy

COLPOSCOPY IMAGE OF CERVIX

 Speculum Examination – Anatomy of Cervix
• Ectocervix: exterior/vaginal surface of
the cervix, seen upon visualization of
the cervix with the speculum
• Covered by plush, red columnar
epithelium (ectropion) surrounding
the os and a shiny pink squamous
epithelium continuous with the
vaginal lining
• Transformation zone:
squamocolumnar junction near the
os that is at risk for dysplasia and is
sampled by the pap smear
• Endocervix: interior cervical canal, walls
contain numerous folds and pilcae
• External os: a round, oval or slitlike
depression located in the center of the
cervix which marks the opening to the
endocervical canal
CLINICAL PROCEDURE : PUDENDAL
NERVE BLOCK
• Injection of local anesthetic is used for vaginal
deliveries and for minor surgeries of the vagina
and perineum.
• The sensory and motor innervation of the
perineum is derived from the pudendal nerve,
which is composed of the anterior primary
divisions of the S2,S3 and S4.

3 branches include the following:

1. Dorsal nerve of clitoris, which innervates the clitoris
2. Perineal branch, which innervates the muscles of the
perineum, the skin of the labia majora and labia minora, and
the vestibule
3. Inferior hemorrhoidal nerve, which innervates the external
anal sphincter and the perianal skin
CLINICAL PROCEDURE : PUDENDAL
NERVE BLOCK
A pudendal nerve block targets the pudendal nerve
trunk as it enters the lesser sciatic foramen, about
1 cm inferior and medial to the attachment of the
sacrospinous ligament to the ischial spine.

• Here, the nerve is medial to the internal

pudendal vessels. This nerve is accessed by 2
approaches, transvaginal and transcutaneous (or
perineal). The former approach is more reliable
and is used most often, except when an engaged
head makes vaginal palpation more difficult. The
anatomical basis for both approaches is to block
the nerve proximal to its terminal branches.
 REFRESH : INNERVATION OF THE VULVA

(Fig. 1.6).