Clinical physiological features of female body

1. Clinical-physiological features of the
female body in different age periods
Done by: Askarova A.Zh. 412 GM
JSC “Astana Medical University”
Department of Obstetrics and Gynecology
Astana 2018

2. Plan
• Introduction
• Main body:
• - antenatal (intrauterine) period;
• - Newborn period;
• - the period of childhood ;
• - the period of puberty ;
• - the period of sexual maturity;
• - pre-menopausal period;
• - menopausal period
• Conclusion
• References
N!B! each part of main body
distinguished by colors on
the left upper corner.

3. Introduction
• The concept of the normal functioning of the
reproductive system of women is largely
determined by the age of the woman. Some
functional phenomena may be the absolute
norm in the adolescent period, but in post-
menopause is a serious pathology. This
difference is discussed by differences in the
anatomy and physiology of women in a
certain period of life and requires special
approaches in diagnosis and treatment.

4. Periods of life
• - antenatal (intrauterine) period;
• - Newborn period (up to 10 days after birth);
• - the period of childhood (up to 8 years);
• - the period of puberty (from 8 to 16 years);
• - the period of sexual maturity, or reproductive
(from 17 to 40 years);
• - pre-menopausal period (from 41 years to the
onset of menopause);
• - menopausal period (from the moment of
persistent termination of menstruation).

5. Antenatal Period
• In the first stage of gonadal development, it is impossible to distinguish
between the male and female gonad. Thus, it is known as the indifferent
stage.
• The gonads begin as genital ridges – a pair of longitudinal ridges derived
from intermediate mesorderm and overlying epithelium. They initially do
not contain any germ cells.
• In the fourth week, germ cells begin to migrate from the endoderm lining
of the yolk sac to the genital ridges, via the dorsal mesentary of the
hindgut. They reach the genital ridges in the sixth week.
• Simultaneously, the epithelium of the genital ridges proliferates and
penetrates the intermediate mesoderm to form the primitive sex cords.
The combination of germ cells and primitive sex cords forms the
indifferent gonad – from which development into the testes or ovaries can
occur.
Or a little trip into embryology

6. Ovaries
In a female embryo, the XX sex chromosomes are present. As there is no Y chromosome, there is no SRY gene to
influence development. Without it, the primitive sex cords degenerate and do not form the testis cords.
Instead, the epithelium of the gonad continues to proliferate, producing cortical cords. In the third month, these
cords break up into clusters, surrounding each oogonium (germ cell) with a layer of epithelial follicular cells, forming a
primordial follicle.

7. The Internal Genitalia
Indifferent Stage
• In the first weeks of urogenital development, all embryos have two pairs
of ducts, both ending at the cloaca. These are the:
• Mesonephric (Wolffian) ducts
• Paramesonephric (Mullerian) ducts
Female
• In the female, there are no Leydig cells to produce testosterone. In the
absence of this hormone, the mesonephric ducts degenerate, leaving
behind only a vestigial remnant – Gartner’s duct.
• Equally, the absence of anti-Mullerian hormone also allows for
development of the paramesonephric ducts. Initially, these ducts can be
described as having three parts:
• Cranial – becomes the Fallopian tubes
• Horizontal – becomes the Fallopian tubes
• Caudal – fuses to form the uterus, cervix and upper 1/3 of the vagina.
• The lower 2/3 of the vagina is formed by sinovaginal bulbs (derived from
the pelvic part of the urogenital sinus).

9. External Genitalia
Indifferent Stage
• The development of the external genitalia begins in the third week.
Mesenchymal cells from the primitive streak migrate to the cloacal
membrane to form a pair of cloacal folds.
• Cranially, these folds fuse to form the genital tubercle. Caudally, they
divide into the urethral folds (anterior) and anal folds (posterior).
• Genital swellings develop either side of the urethral folds.
Female
• Oestrogens in the female embryo are responsible for external genital
development. The genital tubercle only elongates slightly to form the
clitoris.
• The urethral folds and genital swellings do not fuse, but instead form the
labia minora and labia majora respectively.
• The urogenital groove therefore remains open, forming the vestibule into
which the urethra and vagina open.

10. Clinical feautures:
• In this period it is extremely important to
preserve the embryo from the harmful effects
of the environment: physical (radiation,
radiation), biological (infectious diseases of
various etiologies), chemical (from drugs to
the poisoning with vapors of chemicals). The
correct development of the reproductive
organs is the guarantee of further
reproductive health.

11. Newborn period
• By the end of pregnancy, the content of
estrogenic hormones in the mother-placenta-
fetus system is increasing. The girl is born with
a large content of estrogenic hormones, which
causes the presence of multilayered flat
epithelium of the mucus vagina (30-40 layers),
high glycogen content in the tissues of the
vaginal wall, acid reaction of the vaginal
contents, presence of Doderlein sticks.

12. Clinical feautures:
• In this period we can already find some congenital
defects.
• General examination should assess the gestational
maturity of the neonate and document any abnormal
findings such as:
• webbing of the neck, ectopia vesicae, congenital
ureteric fistula, imperforate anus, vaginal anus,
congenital adrenal hyperplasia, presence of inguinal
hernia, umbilical hernia or abdominal mass suggestive
of a genital tract abnormality, a bulging hymen
(mucocolpos), clitoromegaly, ambiguous external
genitalia, heterosexualityor true intersex.

14. Period of childhood
• It is characterized by low functional activity of the
reproductive system: the secretion of estradiol is
insignificant, the maturation of follicles to antral
is rare and unsystematic, receptor bonds
between subsystems are not developed, the
secretion of neurotransmitters is scant.
• In the young girl child, the vagina measures 4–5
cm, the cervix is twice the length of the uterus;
the ovaries are located high up at the pelvic brim.

15. Clinical feautures:
• Vulvovaginal infections and leucorrhoea
• Vaginal bleeding
• Ambiguous genitalia
• Abdominal neoplasms
• Sexual abuse

16. Vulvovaginal infections, pruritus and discharge:
Irritation or inflammation of the vulva may result from numerous
causes:
• Infections (molluscum contagiosum, condylomata acuminata,
herpes genitalis and gonorrhoea) may be transmitted through
sexual or nonsexual close contact with the child.
• Poor personal hygiene may lead to candidal vulvovaginitis,
• vulval irritation may follow worm infestation such as pin worms or
thread worms secondary to anorectal contamination.
• Poor sexual hygiene may lead to chronic nonspecific vulvovaginitis
and irritation leading to vulvitis causing labial adhesions.
• Exposure to chemicals (deodorants/antiseptics) may cause atopic
dermatitis leading to a chronic discharge, vulvar skin excoriation
and over time cause labial adhesions, or eczematoid changes.
Vaginal discharge: This is generally the result of infection caused by
nonspecific causes, generally resulting from poor hygiene or as a result
of specific infections.

17. How to treat vulvovaginal infections?
• If It Nonspecific vulvovaginitis:
• This is best treated by initially improving perineal hygiene such as
warm sitz baths, cleaning the perineal area with bland olive oil
followed by soap and water, keeping the parts dry, and the use of
clean cotton undergarments. Often these measures suffice.
• Vulvar medications should be prescribed sparingly as the skin of the
genital region is very sensitive in children. In case of unsatisfactory
response in 2–3 weeks, consider topical application of an
oestrogenic cream (Premarin/Dienesterol/Evalon). This brings about
a thickening of the vaginal mucosa, lowers the vaginal pH and
encourages growth of lactobacilli which in turn helps overcome
offending bacterial infection. Oestrogen also helps to improve the
vulvovaginal vascularity and produce rapid clinical improvement.
• If It Specific vulvovaginitis: The treatment determined by the
etiological agents. In this case should be done bacteriological test
with sensitivity to antibiotics and should be chosen appropriate
antibioticotherapy.

19. Vaginal bleeding:
• Common causes:
• Endocrine causes include transient neonatal vaginal bleeding as a result of
maternal circulating oestrogens in the newborn. Precocious puberty has
been reported as early as the age of 6 years; however, the presence of other
endocrine stigmata helps to resolve the diagnosis. Accidental ingestion of the
mother’s oral contraceptive pills resulting in bleeding has also been
reported.
• Trauma: This may be accidental, straddle-type injuries resulting from falling
astride a sharp object may result in minor injuries such as lacerations, or a
blunt injury may result in a vulval haematoma; the injuries caused by
penetrating objects may be serious and may result in peritoneal trauma
involving internal viscera requiring laparotomy.
• Prolapsed urethra may follow undue physical exertion when the child
complains of painful micturition, vulvar pain and bleeding.
• Condylomata acuminata. These warty or granular lesions may bleed at
times in a prepubertal child.
• Sarcoma botryoides also known as grape-like sarcoma is a rare and highly
malignant tumour of childhood carrying a serious prognosis.

20. Ambiguous genitalia:
• The recognition of genital abnormalities at an early age is
important to determine the sex of rearing of the infant, and to
chalk out plans for their correction, long-term management,
prognosis and parental counselling

21. Tumours of gynaecological origin in children:
• The role of the gynaecologist is to be aware of the possible
occurrence of tumours in childhood, and to be familiar
with the investigations to arrive at the proper diagnosis and
management plan. A large variety of swellings and tumours
of diverse origins have been recognized in infancy and
childhood. Many of these are not strictly of gynaecologic
origin but enter the domain of differential diagnosis or are
seen by the gynaecologist first, hence the need about their
awareness. These include sacrococcygeal tumour,
duplication cysts of the gastrointestinal tract (GI tract),
urachal cyst, umbilical hernia, Wilms’ tumour, single pelvic
kidney, lymphoma, haemangioma, chordoma,
neuroblastoma, meningioma and hamartoma.

22. Child sexual abuse:
• Two basic forms of sexual abuse are recognized.
• The first involves victimization by a stranger; it may involve
any form of sexual activity brought about by enticement,
coercion or force. Such acts are usually reported by the
child. This situation must be handled very tactfully.
Appropriate medical examination and tests performed,
counselling offered and efforts undertaken to bring the
offender to book. The second form of sexual abuse rampant
in society, and under reported is incest.
• Incest occurs frequently in families with social problems of
alcoholism, drug abuse, physical abuse, broken homes,
violence, delinquency, mental retardation and an
atmosphere of violence. Father-daughter relationships are
the commonest, but it may involve any close male relative.

23. Period of puberty
• During this period (from 8 to 16 years), not only the
maturation of the reproductive system occurs, but also
the physical development of the female body: the
body's growth in length, the ossification of the growth
zones of tubular bones, the physique and distribution
of fatty and muscle tissues are formed according to the
female type.
• At present, in accordance with the degree of maturity
of the hypothalamic structures, three periods of
maturation of the hypothalamic-pituitary-ovarian
system are distinguished.

24. • The first period - prepubertal (8-9 years) - is characterized by
increased secretion of gonadotropins in the form of separate acyclic
releases; the synthesis of estrogens is low. There is a "jump" in the
body's growth in length, the first signs of feminization of the physique
appear: the femurs are rounded up by increasing the amount and
redistribution of adipose tissue, the formation of the female pelvis
begins, the number of layers of the epithelium in the vagina increases
with the appearance of cells of intermediate type.
• The second period - the first phase of the puberty period (10-13
years) - is characterized by the formation of daily cyclicity and
increased secretion of GnRH, FSH and LH, under the influence of
which the synthesis of ovarian hormones increases. The mammary
gland enlargement begins, the pubic hair pubis, the flora of the
vagina changes - lactobacilli appear. This period ends with the
appearance of the first menstruation - menarche, which coincides in
time with the end of the rapid growth of the body in length.

26. • The third period - the second phase of the pubertal period (14-16
years) - is characterized by the establishment of a stable rhythm of
GnRH release, high (ovulatory) release of FSH and LH on the
background of their basal monotonic secretion. The development
of the mammary glands and sexual traction is completed, the body
is growing in length, the female pelvis is finally formed; the
menstrual cycle acquires an ovulatory nature.
• The first ovulation represents the culmination of the period of
puberty, but does not mean sexual maturity, which occurs by 16-17
years. By sexual maturity is understood the completion of the
formation not only of the reproductive system, but of the entire
body of a woman prepared for conception, pregnancy, delivery and
feeding a newborn

28. Genital Organs:
• Vulva—vulval skin under the influence of oestrogen becomes
keratinized and resistant to infection. Fat is deposited in the
labia majora.
• Vaginal mucosa becomes multilayered with the formation of
superficial layer containing glycogen and PH is maintained at
4.5 by Döderlein’s bacillus acting on glycogen.
• The uterus grows rapidly, and prepubertal ratio of uterus/
cervix of 1:1 changes to 2:1 or 3:1.
• n The ovaries start developing primordial follicles into
Graafian follicles. However, a dominant follicle with ovulation
occurs in 50% cases. Rest take 1–2 years for ovulatory cycles
to occur

29. Clinical feautures:
I. Primary amenorrhoea and delayed puberty
Aetiology of delayed puberty:
• Commonly, it is familial or idiopathic (60%).
• Hypothalamic and pituitary inadequacy. CT, MRI of sella turcica, FSH, LH
level confirm the diagnosis.
• Ovarian causes—Turner’s syndrome, Swyer syndrome, resistant ovary,
autoimmune disease, testicular feminizing syndrome, high FSH.
• Polycystic ovarian disease.
• Development of secondary sexual characters, but no menstruation—
absent uterus or cryptomenorrhoea, abstruction in the lower genital tract.
• Malnutrition, anorexia nervosa, childhood illness and vigorous exercise.
• Hypothyroidism.
Approach to diagnosis: All patients after the age of 14 years manifesting
absence of breast development and oestrogen effects need to be
investigated. Besides a detailed history and physical examination including
record of height in centimetres and weight in kilograms, the following
investigations are recommended:

30. II. Precocious puberty:
• This is defined as the appearance of any of the secondary sexual
characteristics before the age of 8 years or the occurrence of
menarche before the age of 10 years. It is not a common clinical
entity. Broadly speaking, precocious puberty can be divided into
two types.
1. The first variety (known as true, complete or isosexual
precocious puberty) results from the premature activation of
the endocrine pathway comprising the hypothalamic–pituitary–
ovarian axis. In such girls, the total growth spurt and potential
increase in height is not achieved, hence it is necessary to
identify the possibility early and advocate prompt treatment to
delay the maturation process to enable the child to achieve
increase in height.
2. In contrast, the second variety known as the pseudo or
incomplete precocious puberty is the result of sex steroid
stimulation independent of the above axis.

31. Aetiological classification of precocious puberty:

32. Period of sexual maturity
• Age from 17 to 40 years. The peculiarities of
this period are manifested in specific
morphofunctional transformations of the
reproductive system.

33. Anatomy

36. Physiology

40. Clinical Features:
• In this period woman usually starts sexual life,
become pregnance, use contraception, do
abortion and etc. Thus, may occur different
inflammation diseases, diseases transmitted
by sexual way, may be diseases during
pregnancy, diseases caused by contraception
pills. Morbidity in the reproductive period
highly depended on normal development of
the woman during childhood and puberty.

41. The Premenopausal Period
• The premenopausal period lasts from 41 years to
the onset of menopause, the last menstruation in
a woman's life, which occurs on average at the
age of 50. Fading of the sex glands. A distinctive
feature of this period is a change in the rhythm
and duration of menstruation, as well as the
amount of menstrual blood loss: menstruation
becomes less abundant (hypomenorrhea), their
duration is shortened (oligomenorrhea), and the
intervals between them increase (opsonomena).

42. The following phases of the premenopausal period are
conventionally distinguished:
• - Hypolutein - clinical symptoms are absent, there is a slight decrease in
secretion of adenohypophysis of lyutropin and ovaries - progesterone;
• - Hyperestrogenic - characterized by the absence of ovulation (anovulatory
menstrual cycle), cyclic secretion of FSH and LH, an increase in the content
of estrogens, which leads to a delay in menstruation for 2-3 months, often
with subsequent bleeding; the concentration of gestagens is minimal;
• - hypoestrogenic - there is amenorrhea, a significant decrease in the level
of estrogens - the follicle does not ripen and early atrophy;
• - ahormonic - the functional activity of the ovaries ceases, estrogens are
synthesized in small amounts only by the cortical substance of the
adrenals (compensatory hypertrophy of the cortex), the production of
gonadotropins is enhanced; is clinically characterized by persistent
amenorrhea.

43. Menopause
• Menopause is defined as the time of cessation of
ovarian function resulting in permanent amenorrhoea.
It takes 12 months of amenorrhoea to confirm that
menopause has set in, and therefore it is a
retrospective diagnosis.
• Climacteric is the phase of waning ovarian activity, and
may begin 2–3 years before menopause and continue
for 2–5 years after it. The climacteric is thus a phase of
adjustment between the active and inactive ovarian
function and occupies several years of a woman’s life,
and it involves physical, sexual and psychological
adjustments.

44. • There is 50% reduction in androgen
production and 66% reduction in
oestrogen at menopause. The oestrogen
level may remain low at 10–20 pg/mL.
Some oestrogen comes from the ovary,
but most of it is oestrone (E1) derived
from peripheral conversion of
androstenedione secreted by the ovary,
and its level varies between 30 and 70
pg/mL. The ovary also secretes a small
amount of testosterone which causes
mild hirsutism at menopause. The FSH
appears in high concentration in the
urine (more than 40 IU/l). E2/E1 ratio
maintained over 1 in the premenopausal
period is reduced to less than 1 in the
menopausal age, causing an oestrogen
deficiency state. Oestrogen level of over
40 pg/mL exerts bone and cardiotrophic
effect, but the level below 20 pg/mL may
predispose to osteoporosis and ischaemic
heart disease (Table 5.1). Low level of
growth hormone causes ovarian failure.
Hormone Levels

45. Anatomical Changes
• The genital organs undergo atrophy and retrogression. The ovaries shrink
and their surfaces become grooved and furrowed. The tunica albuginea
thickens. The menopausal ovary measures less than 2 3 1.5 3 1 cm in size (8
mL in volume) as seen on ultrasound.
• The uterus becomes smaller through atrophy of its plain muscle, so that the
connective tissues are more conspicuous. The endometrium is represented
by only the basal layer with its compact deeply stained stroma, and a few
simple tubular glands. The lymphoid tissue and the functional layer
disappear. The pre-existing fibromyoma gradually shrinks.
• The cervix becomes smaller and its vaginal portion is represented by a small
prominence at the vaginal vault. The cervical stenosis and pyometra are not
uncommon. The vaginal fornices gradually disappear as the cervix shrinks
after the menopause.
• The vagina becomes narrow and its epithelium becomes pale, thin and dry
and gets easily infected causing senile vaginitis (Figure 5.1). The vulva
atrophies and the vaginal orifice narrow and this can cause dyspareunia.
• The skin of the labia minora and vestibule becomes thin, pale and dry, and
there is considerable reduction in the amount of fat contained in the labia
majora. The pubic hair is reduced and becomes grey

46. Clinical feautures:
In this period more common non genital illnesses which start because of
hormone deficiency.
Menopausal women with chronic oestrogen deficiency are liable to develop
the following:
1. Arthritis, osteoporosis and fracture, backache
2. Cardiovascular accidents such as ischaemic heart disease, myocardial
infarction, atherosclerosis and hypertension
3. Stroke
4. Skin changes
5. Alzheimer’s disease
6. Ano-colonic cancer
7. Tooth decay
8. Prolapse genital tract, stress incontinence of urine and faecal
incontinence
9. Cataract, glaucoma and macular degeneration

47. Postmenopausal Bleeding
Aetiology
Several causes account for genital tract bleeding in a postmenopausal woman:
• 1. Vulva—trauma, vulvitis, benign and malignant lesions.
• 2. Vagina—foreign body such as ring pessary for prolapse, senile vaginitis, vaginal tumour
(benign as well as malignant) and postradiation vaginitis.
• 3. Cervix—cervical erosion, cervicitis, polyp, decubitus ulcer in prolapse and cervical
malignancy.
• 4. Uterus—senile endometritis, tubercular endometritis, endometrial hyperplasia (10%), polyp,
endometrial carcinoma and sarcoma and mixed mesodermal tumour.
• 5. Dysfunctional uterine bleeding, metropathia haemorrhagica, uterine polypi and endometrial
hyperplasia.
• 6. Fallopian tube malignancy.
• 7. Ovary—benign ovarian tumour such as Brenner tumour, granulosa and theca cell tumour and
malignant ovarian tumour.
• 8. Hypertension and blood dyscrasia.
• 9. Urinary tract—urethral caruncle, papilloma and carcinoma of the bladder may be mistaken
for genital tract bleeding.
• 10. Bowel—bleeding from haemorrhoid, anal fissures and rectal cancer may be misleading.
• 11. An important reason for postmenopausal bleeding is indiscriminate or prolonged use of
oestrogen unopposed by progestogens, and HRT when applied cyclically.

48. Conclusion
• In conclusion, it is worth noting that we need
this knowledge in order to put the right
diagnosis, to choose the appropriate
treatment. Each age category has its own
characteristics, even from the psychological
point of view, everyone needs to find their
own approach and be cut to achieve better
results in the treatment and management of
patients.

49. References
1. Shaw’s Textbook of Gynaecology, 16TH EDITION. Chapter 4.
Puberty, Paediatric and Adolescent Gynaecology, Page 51.
Chapter 5. Perimenopause, Menopause. Pagt 65.
2. Детская Гинекология. Э.Б.Яковлева. Репродоуктивная
система девочек-подростков. 87 стр.
3. Практическая гинекология Лихачев В.К. 2007 г.
4. DEVELOPMENT OF THE REPRODUCTIVE SYSTEM. Vicky
Theakston and Ayesha Khan from the educational web-site
http://teachmeanatomy.info/the-
basics/embryology/reproductive-system/