Female Reproductive System

Medical and Surgical Nursing
Lecture Notes on Female Reproductive System System
Prepared By: Mark Fredderick R Abejo R.N, MAN
Medical and Surgical Nursing Abejo1
MEDICAL AND SURGICAL NURSING
Female Reproductive System
Lecturer: Mark Fredderick R. Abejo RN, MAN
Anatomy and Physiology of the Female Reproductive System

Internal Female Reproductive System
Vagina
Birth canal
Muscular tube (8 cm)
Connects cervix of the uterus to the exterior
Receives erect stimulus during sexual intercourse
Opens to outside
Cervix
Neck-like part
Entrance to uterus
Capable of very wide dilation during childbirth
Uterus (womb)
Virtually at a right angle to the vagina
Specialized to allow the embryo to become implanted in its
inner wall and to nourish the growing fetus from the
maternal blood
3 layers:
 Peritoneum (outer)
 Myometrium (middle) – labour, cramps
 Endometrium (inner) – sloughed off every 28 days
during menstrual cycle
Fallopian Tube (oviducts)
Found at the top of the uterus on each side
Function is to conduct ova (eggs) from the ovary to the
uterus
Not physically attached to the ovaries
 Fimbraie (finger-like projections) help draw the egg
into the fallopian tubes
 Right arm = fallopian tube, right hand = fimbraie,
left fist = ovary
Fertilization occurs near the ovarian end of the fallopian
tube (must take place within 24 hours of ovulation)
Movement of the egg down the fallopian tube is through
peristalsis
Ampulla: site for fertilization
Isthmus : site for tubal ligation
Ovaries (female gonads)
Main female reproduction organs
Produces egg cells which are nonmotile
Produces steroid hormones (estrogen and progesterone)
Held in place by ligaments
Each ovary contains numerous follicles (“shell”) each
containing an egg
Follicle serves as the endocrine gland
All immature eggs are produced before birth
30th
week of gestation – 7 million eggs
At birth – 2 million
Puberty – 300 000 – 400 000
300 to 400 mature eggs released in a life time
At puberty, 1 mature egg is released every 28 days
Will occur usually until the age of 45-50
When female has no more eggs to release she goes
into menopause
(physiological)
Fertilization must take place to complete meiosis II
As many as 20 follicles can begin development at
the beginning of the menstrual cycle
Older eggs have more chances of having problems
with the baby
External Female Reproductive Parts
Mons Pubis
Soft fatty tissue, lies directly over symphysis pubis &
becomes covered w/ hair just before puberty
It is where the pubic hair grows.
Labia Majora
W/ hair outside but smooth inside
fatty skin folds from MONS PUBIS to PERINEUM and
protects the labia minora , urinary meatus & vagina
Labia Minora
Thin, pink, smooth, hairless, extremely sensitive to
pressure, touch and temperature.
The glands of labia minora lubricate the vulva.
It is formed by the frenulum and the prepuce of the
clitoris which is also very sensitive
Clitoris
Composed of glans & shaft that is partially covered by
prepuce
GLANS is small and round and is filled w/ many nerve
endings and rich blood supply
SHAFT is a cord connecting the glans to the pubic bone;
w/in it is the major blood supply of clitoris
Urethral Meatus
Entrance of urethra, opens approximately 1cm below
clitoris
Skenes Gland
lubricates the external genitalia
Bartholins Gland
alkaline in ph, helps improve sperm survival
FEMALE REPRODUCTIVE DISORDER
OVARIAN CYSTS
 Cysts are nonneoplastic sacs that contain fluid or
semisolid material.
 Ovarian cysts are usually small and produce no
symptoms, ovarian cysts should be thoroughly
investigated as possible sites of malignant change.
 Common types include:
Follicular,cysts, which are usually very small,
semitransparent, and fluid-filled
Lutein cysts, including corpus luteum cysts, which
are functional, nonneoplastic enlargements of the
ovaries
Theca-lutein cysts, which are commonly bilateral
and filled with clear, straw-colored fluid
Polycystic (or sclerocystic) ovary disease is part of
the Stein-Leventhal syndrome.
 Ovarian cysts can develop any time between puberty and
menopause, including during pregnancy.
 Corpus luteum cysts occur infrequently, usually during
early pregnancy.

Cause / Risk Factors
Follicular cysts arise from follicles that over distend
instead of going through the atretic stage of the menstrual
cycle.
Corpus luteum cysts are caused by excessive
accumulation of blood during the hemorrhagic phase of
the menstrual cycle.
Theca-lutein cysts are commonly associated with
hydatidiform mole, choriocarcinoma, or hormone
therapy.
Polycystic ovary disease results from endocrine
abnormalities.
Clinical Manifestation
Usually small cysts produces no symptoms, unless
torsion or rupture causes signs of acute abdomen.
Low back pain
Mild pelvic discomfort
Dyspareunia ( difficult and or painful intercourse)
Abnormal uterine bleeding
Acute abdominal pain (similar to that of appendicitis) -in
ovarian cysts with torsion
In corpus luteum cysts appearing early in pregnancy, the
patient may develop unilateral pelvic discomfort and
(with rupture) massive intraperitoneal hemorrhage.
In polycystic ovary disease, the patient may develop
amenorrhea ( abnormal absence or stoppage of menses),
Oligomenorrhea (abnormally infrequent menstruation), or
infertility secondary to the disorder as well as bilaterally
enlarged ovaries.
Collaborative Management
Follicular cysts usually don't require treatment because
they tend to disappear spontaneously within 60 days.
 If they interfere with daily activities,
Clomiphene citrate P.O. for 5 days or
progesterone I.M. for 5 days, reestablishes the
ovarian hormonal cycle and induces ovulation.
Oral contraceptives may also accelerate involution of
functional cysts (including both types of lutein cysts and
follicular cysts).
Treatment for corpus luteum cysts that occur during
pregnancy is symptomatic because these cysts diminish
during the third trimester and rarely require surgery.
Theca-lutein cysts disappear spontaneously after
elimination of hydatidiform mole or choriocarcinoma, or
discontinuation of HCG or clomiphene citrate therapy.
Polycystic ovary disease treatment may include; drugs,
such as clomiphene citrate to induce ovulation or if drug
therapy fails to induce ovulation, surgical wedge
resection of one-half to one-third of the ovary.
Surgery may become necessary for both diagnosis and
treatment.
ENDOMETRIOSIS
 Endometrial tissue appears outside the lining of the
uterine cavity.
 This ectopic tissue usually remains in the pelvic area,
most commonly around the ovaries, uterovesical
peritoneum, uterosacral ligaments, and the cul-de-sac, but
it can appear anywhere in the body.
 Active endometriosis usually occurs between ages 30 and
40, more so in women who postpone child-bearing.
 Endometriosis usually becomes progressively severe
during the menstrual years, and subsides after
menopause.
 Infertility is the primary complication.
 Spontaneous abortion may also occur.
Trasportation---during menstruation, the fallopian tubes
expel endometrial fragments that implant of the ovaries
or pelvic peritoneum
Formation in situ--inflammation or a hormonal change
triggers metaplasia (differentiation of coelomic
epithelium to endometrial epithelium)
Induction--this is a combination of transportation and
formation in situ and is the most likely cause. The
endometrium chemically induces undifferentiated
mesenchyma to form endometrial epithelium
Dysmenorrhea (painful menstruation)-- Pain usually
begins 5 to 7 days before menses reaches its peak and last
for 2 to 3 days. It is less cramping and less concentrated
in the abdominal midline than primary dysmenorrheal
pain.
Lower abdominal pain and in the vagina --
Pain to posterior pelvis and back
Multiple tender nodules on uterosacral ligaments or in the
rectovaginal system. They enlarge and become more
tender during menses. Ovarian enlargement may also be
evident.
Other symptoms depend on the location of the ectopic
tissue:
Ovaries and oviducts--infertility and profuse menses
Ovaries or cul-de-sac--deep-thrust dyspareunia (painful
intercourse)
Bladder--suprapubic pain, dysuria (painful or difficulty
urinating), hematuria (Presence of blood in the urine)
Rectovaginal septum and colon--painful defecation,
rectal bleeding with menses, pain in the coccyx or sacrum
Small bowel and appendix--nausea and vomiting, which
worsen before menses, and abdominal cramps
Cervix, vagina, and perineum--bleeding from endometrial
deposits in these areas during menses
Diagnostic Test
Laparoscopy may confirm the diagnosis and determine
the stage of the disease
Barium enema rules out malignant or inflammatory
bowel disease.
For young women who want to have children
includes: androgens, such as danazol, which produce a
temporary remission in Stages I and II. Oral
contraceptives and progestins also relieve symptoms.
Stage III and IV (when ovarian masses are present), they
should be removed to rule out cancer.
The patient may undergo conservative surgery, but the
treatment of choice for women who don't want to bear
children or who have extensive disease (StageIII and IV)
is a total abdominal hysterectomy performed with
bilateral salpingo-oophorectomy.
UTERINE LEIOMYOMAS ( Myomas / Fibromyomas )
 These neoplasms (tumor; any new and abnormal growth)
art the most common benign tumors in women.
 They usually occur in the uterine corpus, although they
may appear on the cervix or on the round or broad
ligament.
Uterine Leiomyomas are usually multiple and usually
occur in women over age 35
They affect blacks three times more often than whites.
The cause is unknown, but excessive levels of estrogen
and human growth hormone (HGH) probably influence
tumor formation by stimulating susceptible fibromuscular
elements.
Large doses of estrogen and the later stages of pregnancy
increase both tumor size and HGH levels.

When estrogen production decreases, uterine leiomyomas
usually shrink or disappear (usually after menopause)
Pain
Submucosal hypermenorrhea (excessive menstrual
bleeding, but occurring at regular intervals and being of
usual duration)
Possibly other forms of abnormal endometrial bleeding
Dysmenorrhea (abnormally painful menses)
If tumor is large, the patient may develop a feeling of
heaviness in the abdomen;
Increasing pain
Intestinal obstruction
Constipation
Urinary frequency or urgency
Irregular uterine enlargement
Diagnostic Test
Blood studies/ anemia will support the diagnosis
D&C (dilatation and curettage)
Submucosal hysterosalpingoraphy - detects submucosal
leiomyomas
Laparoscopy - visualizes subserous leiomyomas on the
uterine surface
Treatment of choice for women who desire to have
children - A surgeon may remove small leiomyomas that
have caused problems in the past or that appear likely to
threaten a future pregnancy
Tumors that twist or grow large enough to cause
intestinal obstruction require a hysterectomy, with
preservation of the ovaries if possible
Pregnant patient: If a patient uterus no larger than a 6
month normal uterus by the 16th week of pregnancy, the
outcome for the pregnancy remains favorable, and
surgery is usually unnecessary. However if a pregnant
woman has a leiomyomatous uterus the size of a 5 to 6
month normal uterus by the 9th week of pregnancy,
spontaneous abortion will probably occur, especially with
a cervical leiomyoma. If surgery is necessary, a
hysterectomy is usually performed 5 to 6 months after
delivery (when involution is complete), with preservation
of the ovaries if possible
Appropriate intervention depends on the severity of
symptoms, the size and location of the tumors, and the
patient's age, parity, pregnancy status, desire to have
children, and general health.
Call your doctor immediately if there is any abnormal
bleeding or pelvic pain
PELVIC INFLAMMATORY DISEASE (PID)
 Recurrent, acute, subacute, or chronic infection of the
oviducts and ovaries, with adjacent tissue involvement.
 PID may refer to inflammation of the cervix, uterus,
fallopian tubes, and ovaries, which can extend to the
connective tissue lying between the broad ligaments
(parmetritis).
 Early diagnosis and treatment prevent damage to the
reproductive system.
 Complications of PID may include potentially fatal
septicemia, pulmonary emboli, shock and
infertility. Untreated PID may be fatal.
Clinical features vary with the affected area.
They may include profuse, purulent vaginal discharge
Low-grade fever
Malaise
Lower abdominal pain
Three Types of PID
Salpingo-oophoritis (fallopian tubes, and ovaries):
Acute: sudden onset of lower abdominal and pelvic pain,
usually after menses,
increased vaginal discharge
fever
malaise
lower abdominal pressure and tenderness
tachycardia
pelvic peritonitis
Chronic: recurring acute episodes
Cervicitis (inflammation of the cervix):
Acute- purulent, foul-smelling vaginal discharge;
Vulvovaginitis, with itching or burning
Red, edematous cervix
Pelvic discomfort
Sexual dysfunction
Metrorrhagia; infertility; spontaneous abortion
Chronic- cervical dystocia, laceration or eversion of the
cervix, ulcerative vesicular lesion (when cervicitis results
from herpes simplex virus type II)
Endometritis (inflammation of the uterus):
Acute- mucoopurulent or purulent vaginal discharge
oozing from cervix
Edematous, hyperemic endometrium, possible leading to
ulceration and necrosis
Lower abdominal pain and tenderness
Fever
Rebound pain
Abdominal muscle spasm
thrombophlebitis of uterine and pelvic vessels
Chronic- recurring acute episodes (more common from
multiple sexual partners and sexually transmitted
infections)
PID can result from infection with aerobic or anaerobic
organisms.
Any sexually transmitted infection
More than one sex partner
Conditions or procedures, such as cauterization of the
cervix, that alter or destroy cervical mucus, allowing
bacteria to ascend into the uterine cavity
Any procedure that risks transfer of contaminated
cervical mucus into the endometrial cavity by
instrumentation such as use of a biopsy curet
Infection during or after pregnancy
Infectious foci within the body, such as drainage from a
chronically infected fallopian tube
Treatment:
Effective management eradicates the infection, relieves
symptoms, and avoids damaging the reproductive system.
Aggressive therapy with multiple antibiotics begins
immediately after culture specimens are obtained.
Infection may become chronic if treated inadequately
Supplemental treatment of PID may include bed rest,
analgesics, and I.V. therapy
Narcotics may be needed, NSAID's are preferred for pain
relief.
Development of a pelvic abscess requires adequate
drainage. A ruptured pelvic abscess is a life-threatening
condition. If this complication develops, the patient may
need a total abdominal hysterectomy, with bilateral
salpingo-oophorectomy

VAGINAL PROBLEMS
Vaginitis Inflammation of the vagina
Most common:
Candida vaginitis (yeast infection): Studies shows approximately
75% of all women will have a yeast infection at least once in their
lifetime. Some will suffer form recurring yeast infections. Vaginal
yeast infections may cause pain during urination and or during
sexual intercourse.
Symptoms of yeast infection - itching, soreness and may have a
white, cottage-cheese-like discharge.
Bacterial vaginosis: For reasons unknown there may be a change
in the balance of naturally occurring bacteria in the vagina that
allows disease causing bacteria to dominate. It occurs commonly
during reproductive years.
Symptoms - Many women with this infection exhibit no symptoms,
but the predominate sign of this condition is a fishy smelling gray
discharge.
Trichomonas vaginitis: (produces a refractory vaginal discharge
and puritis) - causes itching and irritation of the vulva with
increased vaginal discharge that may be green and frothy.
Vaginismus: involuntary spastic constriction of the lower vaginal
muscles, usually from fear of vaginal penetration. If severe, this
disorder may prevent intercourse ( a common cause of
unconsummated marriages). Vaginismus affects females of all ages
and backgrounds. Patients usually experience muscle spasm with
constriction and pain on insertion of any object into the vagina,
such as a vaginal tampon, speculum or diaphragm. *Note -
Vaginismus usually has a psychological origins. It occurs usually
after sexual trauma such as rape or incest. Please seek counseling
and see your doctor.
Vaginal cancer: usually occurs primarily in women over the age of
50, vaginal cancer is very rare, studies shows approximately 2% of
all gynecological cancers. Once cancer appears on the vagina, it
may spread to surrounding tissues, including the bladder, rectum,
vulva and the pubic bone. Diagnosis is made by your doctor with
thorough examination with a colposcope and biopsy of any
suspicious-looking areas.
Vulvitis: Inflammation of the vulva. May cause itching, burning
and or pain. Pelvic examination and blood test or tests to check for
any STD ( sexually transmitted disease )
Symptoms:
Vaginitis: Increased vaginal discharge with an offensive odor,
burning, itching and pain
Vaginal Cancer: Abnormal discharge and bleeding, firm lesion on
any part of the vagina (possible cancer)
Vaginismus: muscle constriction, spasm and pain on insertion of
any object into the vagina
Vulvitis: if your vulva is inflamed and itches
Treatment:
Your doctor will determine the course of treatment. Treatment for
most vaginal disorders is aimed at maintaining proper bacterial
balance and treating your irritation and discomfort.
Bacterial vaginitis and trichomonas: Your doctor may prescribe a
topical cream and or oral medication
Vaginismus: Your doctor may want to refer you to a doctor who
specialize in psychology, and or one who specialize in sexual
therapy.
Candida vaginitis (yeast infection) topical cream .
PREMENSTRUAL SYNDROME: Also called PMS -The
effects of this disorder ranges from minimal discomfort to severe,
disruptive behavioral and somatic changes. Symptoms usually
appear 7 to 14 days before menses and usually subside with its
onset.
Cause: Direct cause unknown, PMS may result from a
progesterone deficiency in the luteal phase ot the menstrual cycle
or from an increased estrogen-progesterone ratio. Approximately
10% of patients with PMS have elevated prolactin levels
Symptoms:
Behavioral changes: Mild to severe personality
changes
Nervousness
Hostility
Irritability
Agitation
Sleep disturbance
Fatigue
Lethargy
Depression
Somatic changes :
Breast tenderness or swelling
Abdominal tenderness or bloating
Joint pain
Headache
Edema
Diarrhea or constipation
Patient may also experience exacerbations of skin
problems such as; ache - respiratory problems such
as asthma, and neurologic problems such as
seizures.
Treatment:
Treated symptomatically: treatment may include;
Antidepressants, NSAID's (nonsteroidal anti-
inflammatory drugs),
Vitamins
Tranquilizers
Sedatives
Progestins
Treatment may require; a diet that is low in simple
sugars, caffeine, and salt, with adequate amounts of
protein, high amounts of complex carbohydrates,
and possibly, vitamin supplements formulated for
PMS
There is also a self - help groups that exist for
women with PMS check in your local area.
MENOPAUSE: The mechanisms of menstruation cease to
function. Menopause results from a complex, long term syndrome
of physiologic changes, the climacteric-cause by declining ovarian
function.
Cause: Physiologic menopause, the normal decline in ovarian
function caused by aging, begins in most women between ages 40
and 50 and results in infrequent ovulation, decreased menstruation,
and eventually, cessation of menstruation ( usually ages 45 - 55)

Pathologic menopause (premature menopause), the gradual or
abrupt cessation of menstruation before age 40, cause unknown,
however certain disorders, especially severe infections and
reproductive tract tumors, may cause pathologic menopause by
seriously impairing ovarian function. Other factors that may incur
pathologic menopause include malnutrition, debilitation, extreme
emotional stress, excessive radiation exposure, and surgical
procedures that impair ovarian blood supply.
Artificial menopause is the cessation of ovarian function following
radiation therapy or surgical procedures.
Symptoms:
Declining ovarian function and decreased estrogen levels
accompanying all forms of menopause produce various
menstrual irregularities;
Decrease in the amount and duration of menstrual flow
Spotting
Episodes of amenorrhea (absence or abnormal stoppage
of menses) and polymenorrhea (abnormal frequent
menstruation) (possible with hypermenorrhea)-excessive
menstrual cycle
These irregularities may last only a few months or may
persist for several years before menstruation ceases
permanently.
Changes in the body's systems usually don't occur until
after the permanent cessation of menstruation
Reproductive system: changes may include; shrinkage of vulval
structures and loss of subcutaneous fat, possible leading to atrophic
vulvitis; atrophy of vaginal mucosa and flattening of vaginal rugae,
possibly causing bleeding after coitus or douching; vaginal itching
and discharge from bacterial invasion; and loss of capillaries in the
atrophying vaginal wall, causing the pink, rugose lining to become
smooth and white. Menopause may also produce excessive vaginal
dryness and dyspareunia due to decreased lubrication from the
vaginal walls, and decreased secretion from Bartholin's glands; a
reduction in the size of the ovaries and oviducts; and progressive
pelvic relaxation as the supporting structures of the reproductive
tract lose their tone from the absence of estrogen
Urinary system: Atrophic cystitis, resulting from the effects of
decreased estrogen levels on bladder mucosa and related structures,
may produce pus in the urine (pyuria), painful or difficulty
urinating (dysuria), and urgency, and incontinence. May have on
occasion have blood in the urine (hematuria)
Breasts: Menopause may cause reduced breast size
Integumentary system: Estrogen deprivation may lead to loss of
skin elasticity and turgor. The patient may have slight alopecia
(balding), and may experience loss of pubic and axillary hair.
Autonomic nervous system: Hot flashes and night sweats. Patient
may experience vertigo, syncope, tachycardia, dyspnea, tinnitus,
emotional disturbances such as irritability, nervousness, crying
spells, and fits of anger. Patients may also experience and
exacerbation of preexisting neurotic disorders such as; depression,
anxiety, and compulsive, manic, or schizoid behavior
Vascular and musculoskeletal systems: Menopause may also
induce atherosclerosis and osteoporosis.
Artificial menopause, without estrogen replacement, produces
symptoms within 2 to 5 years in 96% of women. Since
menstruation in both pathologic and artificial menopause often
ceases abruptly, severe vasomotor and emotional disturbances may
result.
Menstrual bleeding after 1 year of amenorrhea may indicate
organic disease
Treatment:
Since physiologic menopause is a normal process, it may
not require intervention.
Atypical or adenomatous hyperplasia requires drug
therapy
Cystic endometrial hyperplasia doesn't require treatment
If osteoporosis occurs, calcium is given
Estrogen therapy
Women who take estrogen must be monitored regularly
to detect possible cancer early. If the uterus remains
progestin is recommended in addition to estrogen.
FEMALE NFERTILITY: Infertility may be caused by any defect
or malfunction of the hypothalamic - pituitary - ovarian axis, such
as certain neurologic diseases. Other possible cause include:
Cervical factors, such as infection and possibly cervical antibodies
that immobilize sperm
Psychological problems
Ovarian factors
Tubal and peritoneal factors, such as tubal loss or impairment
secondary to ectopic pregnancy
Uterine abnormalities, such as; congenitally absent, double uterus;
leiomyomas or Asherman's syndrome, in which the anterior and
posterior uterine walls adhere because of scar tissue formation
Approximately 15% of all couples in the US cannot conceive after
regular intercourse for at least 1 year without contraception. 45 to
50% of all infertility is attributed to the female.
Symptoms:
Diagnosis requires a complete examination and health
history. Questions includes patient's reproductive and sexual
function, past diseases, mental state, previous surgery, types of
contraception used in the past, and family history
Treatment:
Intervention aims to correct the underlying abnormality
or dysfunction within the hypothalamic-pituitary-ovarian
complex.
Hormone therapy may be necessary in hyperactivity ;or
hypoactivity of the adrenal or thyroid gland
Progesterone replacement for progesterone deficiency
Anovulation requires treatment with clomiphene citrate
If mucus production decreases (an adverse effect of
clomiphene citrate), small doses of estrogen may be
given concomitantly to improve the quality of cervical
mucus
Surgical restoration may correct certain anatomic causes
of infertility, such as fallopian tube obstruction
Artificial insemination has proven to be an effective
alternative strategy for dealing with infertility problems
In vitro (test tube) fertilization has also been successful

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