13 The female reproductive system

The obstetric history and examination is covered in Chapter 14.

The bony pelvis is composed of the two pelvic bones with the sacrum and coccyx posteriorly. The pelvic brim divides the ‘false pelvis’ above (part of the abdominal cavity) and the ‘true pelvis’ below.

The pelvic cavity contains the rectum, sigmoid colon, coils of the ileum, ureters, bladder, female reproductive organs, fascia, and peritoneum.

The vagina is a thin-walled distensible, fibromuscular tube that extends upwards and backwards from the vestibule of the vulva to the cervix. It is ~8cm long and lies posterior to the bladder and anterior to the rectum.

The vagina serves as an eliminatory passage for menstrual flow, forms part of the birth canal, and receives the penis during sexual intercourse.

This is the vaginal recess around the cervix and is divided into anterior, posterior, and lateral regions which, clinically, provide access points for examining the pelvic organs.

The uterus is a thick-walled, hollow, pear-shaped muscular organ consisting of the cervix, body, and fundus. In the nulliparous female, it is ~8cm long, ~5cm wide, and ~2.5cm deep. The uterus is covered with peritoneum forming an anterior uterovesical fold, a fold between the uterus and rectum termed the pouch of Douglas, and the broad ligaments laterally.

The uterus receives, retains, and nourishes the fertilized ovum.

In most females, the uterus lies in an anteverted and anteflexed position.

The Fallopian or ‘uterine’ tubes are paired tubular structures, ~10cm long. The Fallopian tubes extend laterally from the cornua of the uterine body, in the upper border of the broad ligament and open into the peritoneal cavity near the ovaries. The Fallopian tube is divided into four parts:

The main functions of the uterine tube are to receive the ovum from the ovary, provide a site where fertilization can take place (usually in the ampulla), and transport the ovum from the ampulla to the uterus. The tube also provides nourishment for the fertilized ovum.

The ovaries are whitish-grey, almond-shaped organs measuring ~4cm x 2cm which are responsible for the production of the female germ cells, the ova, and the sex hormones, oestrogen and progesterone.

They are suspended on the posterior layer of the broad ligament by a peritoneal extension (mesovarium) and supported by the suspensory ligament of the ovary (a lateral extension of the broad ligament and mesovarium) and the round ligament which stretches from the lateral wall of the uterus to the medial aspect of the ovary.

These are sometimes collectively known as the ‘vulva’. It consists of:

Menstruation is the shedding of the functional superficial 2/3 of the endometrium after sex hormone withdrawal. This process, which consists of three phases, is typically repeated ~300–400 times during a woman’s life. Coordination of the menstrual cycle depends on a complex interplay between the hypothalamus, the pituitary gland, the ovaries, and the uterine endometrium.

Cyclical changes in the endometrium prepare it for implantation in the event of fertilization and menstruation in the absence of fertilization. It should be noted that several other tissues are sensitive to these hormones and undergo cyclical change (e.g. the breasts and the lower part of the urinary tract).

The endometrial cycle can divided into three phases.

The first day of menses is considered to be day 1 of the menstrual cycle.

This begins at the end of the menstrual phase (usually day 4) and ends at ovulation (days 13–14). During this phase, the endometrium thickens and ovarian follicles mature.

The hypothalamus is the initiator of the follicular phase. Gonadotrophin-releasing hormone (GnRH) is released from the hypothalamus in a pulsatile fashion to the pituitary portal system surrounding the anterior pituitary gland. GnRH causes release of follicle stimulating hormone (FSH). FSH is secreted into the general circulation and interacts with the granulosa cells surrounding the dividing oocytes.

FSH enhances the development of 15–20 follicles each month and interacts with granulosa cells to enhance aromatization of androgens into oestrogen and oestradiol.

Only one follicle with the largest reservoir of oestrogen can withstand the declining FSH environment whilst the remaining follicles undergo atresia at the end of this phase.

Follicular oestrogen synthesis is essential for uterine priming, but is also part of the positive feedback that induces a dramatic preovulatory luteinizing hormone (LH) surge and subsequent ovulation.

The luteal phase starts at ovulation and lasts through to day 28 of the menstrual cycle.

The major effects of the LH surge are the conversion of granulosa cells from predominantly androgen-converting cells to predominantly progesterone-synthesizing cells. High progesterone levels exert negative feedback on GnRH which, in turn, reduces FSH/LH secretion.

At the beginning of the luteal phase, progesterone induces the endometrial glands to secrete glycogens, mucus, and other substances. These glands become tortuous and have large lumina due to increased secretory activity. Spiral arterioles extend into the superficial layer of the endometrium.

In the absence of fertilization by day 23 of the menstrual cycle, the superficial endometrium begins to degenerate and consequently ovarian hormone levels decrease. As oestrogen and progesterone levels fall, the endometrium undergoes involution.

If the corpus luteum is not rescued by human chorionic gonadotropin (hCG) hormone from the developing placenta, menstruation occurs 14 days after ovulation. If conception occurs, placental hCG maintains luteal function until placental production of progesterone is well established.

This phase sees the gradual withdrawal of ovarian sex steroids which causes slight shrinking of the endometrium, and therefore the blood flow of spiral vessels is reduced. This, together with spiral arteriolar spasms, leads to distal endometrial ischaemia and stasis. Extravasation of blood and endometrial tissue breakdown lead to onset of menstruation.

The menstrual phase begins as the spiral arteries rupture, releasing blood into the uterus and the apoptosing endometrium is sloughed off.

During this period, the functionalis layer of the endometrium is completely shed. Arteriolar and venous blood, remnants of endometrial stroma and glands, leukocytes and red blood cells are all present in the menstrual flow.

Shedding usually lasts ~4 days.

It is important to remember that many females can be embarrassed by having to discuss their gynaecological problems, so it is vital to appear confident, friendly, and relaxed.

Although there are parts particular to this history, most of it is the same as the basic outline described in Chapter 2 and we suggest that readers review that chapter before going on. We detail here those parts that may differ from the basic format.

More detailed questioning will depend on the nature of the presenting complaint. Ascertain:

It is essential to ask sexually active women of reproductive age about contraception, including methods used, duration of use and acceptance, current method, as well as future plans.

Document the specifics of each pregnancy:

Pay particular attention to any history of chronic lung or heart disease and make note of all previous surgical procedures.

Ask about all medication/drugs taken (prescribed, over-the-counter, and illicit drugs). Record dose and frequency, as well as any known drug allergies.

Make particular note to ask about the oral contraceptive pill (OCP) and hormone replacement therapy (HRT) if not done so already.

Note especially any history of genital tract cancer, breast cancer, and diabetes.

Take a standard SHx including living conditions and marital status.

This is also an extra chance to explore the impact of the presenting problem on the patient’s life—in terms of their social life, employment, home life, and sexual activity.

This is defined as >80ml of menstrual blood loss per period (normal = 20–60ml) and may be caused by a variety of local, systemic, or iatrogenic factors. Menorrhagia is hard to measure, but periods are considered ‘heavy’ if they lead to frequent changes of sanitary towels. See Box 13.1.

As well as the standard questions for any symptom, ask about:

This is pain associated with menstruation—thought to be caused by ? levels of endometrial prostaglandins during the luteal and menstrual phases of the cycle resulting in uterine contractions. The pain is typically cramping, localized to the lower abdomen and pelvic regions, and radiating to the thighs and back. See Box 13.2.

Dysmenorrhoea may be primary or secondary:

When taking a history of dysmenorrhoea, take a full pain history, a detailed menstrual history, and ask especially about the relationship of the pain to the menstrual cycle. Remember to ask about the functional consequences of the pain—how does it interfere with normal activities?

Intermenstrual bleeding is uterine bleeding which occurs between the menstrual periods. See Box 13.3 for causes.

As for all these symptoms, a full standard battery of questions should be asked, a full menstrual history, past medical and gynaecological histories, and sexual history.

Ask also about the association of the bleeding with hormonal therapy, contraceptive use, and previous cervical smears.

This is vaginal bleeding precipitated by sexual intercourse. It can be caused by similar conditions to intermenstrual bleeding. Take a full and detailed history as always.

See Box 13.4 for causes.

This is the absence of periods and may be ‘primary’ or ‘secondary’. See Box 13.5 for causes.

Amenorrhoea is a normal feature in prepubertal girls, pregnancy, during lactation, postmenopausal females, and in some women using hormonal contraception.

A full and detailed history should be taken. Ask especially about:

This is vaginal bleeding occurring >6 months after the menopause. It requires reassurance and prompt investigation as it could indicate the presence of malignancy. See Box 13.6 for some causes.

As well as all the points outlined under ‘amenorrhoea’, ask about:

Often present with profuse or continuous vaginal bleeding or with a bloodstained offensive discharge.

As with any type of pain, pelvic pain may be acute or chronic. Chronic pelvic pain is often associated with dyspareunia.

Dyspareunia is painful sexual intercourse and may be experienced superficially at the area of the vulva and introitus on penetration or deep within the pelvis. Dyspareunia can lead to failure to reach orgasm, the avoidance of sexual activity, and relationship problems.

When taking a history of pelvic pain or dyspareunia, you should obtain a detailed history as for any type of pain ( Chapter 2). Carefully differentiate from gastrointestinal pain (Box 13.7). Some causes of dyspareunia are shown in Box 13.8.

You also need to establish the relationship of the pain to the menstrual cycle. Ask also about:

Vaginal discharge is a common complaint during the child-bearing years. As well as the standard questions, ask about:

Physiological discharge is usually scanty, mucoid, and odourless. It occurs with the changing oestrogen levels during the menstrual cycle (discharge increases in quantity mid-cycle and is a physiological sign of ovulation) and pregnancy.

It may arise from vestibular gland secretions, vaginal transudate, cervical mucus, and residual menstrual fluid.

This usually represents infection (trichomonal or candidal vaginitis) and may be associated with pruritus or burning of the vulval area.

The main symptom to be aware of is itching or irritation of the vulva (pruritus vulvae). It can be debilitating and socially embarrassing. Embarrassment often delays the woman seeking advice. See Box 13.10 for some other vulval conditions.

Causes include infection, vulval dystrophy, neoplasia, and other dermatological conditions. Ask especially about:

This is an objectively demonstrable involuntary loss of urine that can be both a social and hygienic problem.

The two most common causes of urinary incontinence in females are genuine stress incontinence (GSI) and detrusor over-activity (DO). Other less commonly encountered causes include mixed GSI and DO, sensory urgency, chronic voiding problems, and fistulae.

When taking a history of urinary incontinence, ascertain under what circumstances they experience the symptom. Remember to ask about the functional consequences on the patient’s daily life.

Patients notice small amounts of urinary leakage with a cough, sneeze, or exercise. One third may also admit to symptoms of DO.

Ask about:

Urge incontinence, urgency, frequency, and nocturia. Ask about:

Voiding disorders can result in chronic retention leading to overflow incontinence and increased predisposition to infection. The patient may complain of hesitancy, straining, poor flow, and incomplete emptying in addition to urgency and frequency.

Suspect if incontinence is continuous during the day and night.

Genital prolapse is descent of the pelvic organs through the pelvic floor into the vaginal canal. In the female genital tract, the type of prolapse is named according to the pelvic organ involved. Some causes are outlined in 13.9. Some examples include:

Mild degrees of genital prolapse are often asymptomatic. More extensive prolapse may cause vaginal pressure or pain, introital bulging, a feeling of ‘something coming down’, as well as impaired sexual function.

Uterine descent often gives symptoms of backache especially in older patients.

There might be associated symptoms of incomplete bowel emptying (rectocoele) or urinary symptoms such as frequency or incomplete emptying (cystocoele or cysto-urethrocoele).

Explain to the patient that you would like to examine their genitalia and reproductive organs and reassure them that the procedure will be quick and gentle.

You should have a chaperone present, preferably female.

As always, ensure that the room is warm and well lit, preferably with a moveable light source and that you will not be disturbed.

The examination should follow an orderly routine. The authors’ suggestion is shown in Box 13.11. It is standard practice to start with the cardiovascular and respiratory systems—this not only gives a measure of the general health of the patient but establishes a ‘physical rapport’ before you examine more delicate or embarrassing areas.

Always begin with a general examination of the patient (as described in Chapter 3) including temperature, hydration, coloration, nutritional status, lymph nodes, and blood pressure. Note especially:

A full abdominal examination should be performed (see Chapter 7). Look especially in the periumbilical region for scars from previous laparoscopies and in the suprapubic region where transverse incisions from caesarean sections and most gynaecological operations are found.

The patient should be allowed to undress in privacy and, if necessary, to empty her bladder first.

Before starting the examination, always explain to the patient what will be involved. Ensure the abdomen is covered. Ensure good lighting and remember to wear disposable gloves.

Ask the patient to lie on her back on an examination couch with both knees bent up and let her knees fall apart—either with her heels together in the middle or separated.

The lithotomy position, in which both thighs are abducted and feet suspended from lithotomy stirrups is usually adopted when performing vaginal surgery.

Speculum examination is carried out to see further inside the vagina, to visualize the cervix, or take a cervical smear or swabs.

There are different types of vaginal specula (see Fig. 13.1) but the commonest is the Cusco’s or bivalve speculum. See Box 13.12.

Inspect the cervix which is usually pink, smooth, and regular.

This should be conducted with as much care as insertion. You should still be examining the vaginal walls as the speculum is withdrawn.

Digital examination helps identify the pelvic organs. Ideally the bladder should be emptied, if not already done so by this stage.

This examination is often known as per vaginam or simply ‘PV’.

It is often not possible to differentiate between adnexal and uterine masses. However, there are some general rules:

We describe the technique for obtaining a sample for ‘liquid-based cytology’ (LBC), now used by the majority of units in the UK.

It is easy to be seduced into thinking that the principal focus should be on very ‘medical’ diagnoses such as urinary tract infections, which contribute to significant morbidity (and mortality) in older people.

Continence issues are sadly overlooked in most clinical assessments. Large-scale surveys of prevalence have shown up to 20% of women over 40 reporting difficulties with continence; so whilst more common in older people, you should always be mindful of problems in younger adults too.

Although continence issues are one of the ‘Geriatric Giants’ of disease presentation, it is important to recall the physiology of the postmenopausal changes—such as vaginal atrophy (Box 13.13) and loss of secretions—which can complicate urinary tract infections, continence, and utero-vaginal prolapse in older patients.