INTRODUCTION

THE GENITAL OR REPRODUCTIVE SYSTEM develops in close association with the urinary or excretory system.

Assignment 1

Normal embryogenesis of GU System

The embryology of urinary and genital systems is closely related. This is because the same mesoderm called the urogenital ridge gives rise to parts of urinary and genital systems.

The Urinary and genital systems develop from intermediate mesoderm along dorsal body wall of embryo on each side of aorta

The kidneys develop in the pelvis and migrate superiorly; gonads develop in the abdomen and migrate inferiorly

The part of urogenital ridge that gives rise to urinary system is the nephrogenic cord. The part that gives rise to genital system is the gonadal ridge.

The Urinary system consists of kidneys, ureters, urinary bladder and the urethra.

The development of kidneys passes through three stages:

Pronephros Mesonephros Metanephros

The first two developmental stages have a transitory character and the definitive kidneys develop from the metanephros stage.

The pronephros develop during the 4th week, beginning in the cranial part of the nephrogenic cord which atrophies during the 5th week. They are represented by few cell clusters in the neck region of the embryo. A pronephric duct runs caudally and opens into the cloaca.

The pronephric duct persists and is used by the next set of developing kidneys.

Mesonephros appear late in the fourth week, caudal to pronephroi.These function until the permanent kidneys develop. The mesonephroi consist of glomeruli and mesonephric tubules. The Tubules open into the mesonephric ducts (originally pronephric ducts). The mesonephroi degenerate towards the end of first trimester.

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Neural tubeNotochordAorta dorsalisDorsal mesenteryIntestinal tubeEctodermSomiteInferior cardinal veinMesonephric duct (Wolffian duct)Mesonephric tubuleUrogenital ridge

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Nephrogenic cordMesonephric duct (Wolff)MesonephrosIntestinal tubeCloacaAtrophying nephrotomes Yolk sac (umbilical vesicle)AllantoisOutflow of the mesonephric duct into the cloaca

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Nephrogenic cordMesonephric ductMesonephrosIntestineCloacaAtrophied nephrotomeYolk sac (umbilical vesicle)AllantoisOutflow of the mesonephric ductinto the cloacaUreter bud (anlage)

Transverse section along A (see previous figure).The urogenital ridge projects into the lumen of the coelom. With the S-shaped mesonephric tubules the mesonephric duct (Wolffian duct) forms a transitory precursor of the adult excretory system. The medial end of the mesonephric tubule is closed and forms a funnel (Bowman’s capsule) that surrounds a tuft of capillaries (the glomerulus). The capillaries come from lateral branches of the dorsal aorta and drain into the inferior cardinal vein. This functional unit is also termed the excretory unit of the mesonephros.

The mesonephros is the first excretory organs. The production of urine begins in the mesonephros during the 6th week.

Metanephroi is the primordial of the permanent kidneys which begins to develop early in the fifth week and starts to function about 4 weeks later. The definitive kidneys develop from: metanephric diverticulum (ureteric bud) and metanephric mass or (metanephric blastema). Both metanephroi are mesodermal origin.

Fig. 9 - Development of the metanephros: 5th week

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Pronephros (atrophying)Mesonephros (atrophying)Mesonephric duct(Wolffian duct)Nephrogenic cordUreter anlageMetanephric blastemaLiver anlageCloaca

Fig. 9 Sagittal section of a 5-week-old embryo - development of the metanephros. In the caudal region of the nephrogenic cord one observes the development of the metanephro-genic blastema that is in contact with the ureter anlage. In this stage the pronephros has disappeared almost completely. The mesonephros is also in the process of atrophying.

The metanephric diverticulum is an outgrowth from the mesonephric duct near its entrance into cloaca. It is the primordium of the ureter, renal pelvis, calyces and collecting tubules. The diverticulum penetrates the metanephrogenic mass (mass of cells that form the nephrons.).The stalk of the diverticulum becomes the ureter and its cranial end forms the renal pelvis. The mesonephric buds branch to form collecting tubules .The straight collecting tubules branches repeatedly and form successive generations of collecting tubules, the major and minor calyces.

Schematic cut through the kidney (sagittal section)

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UreterMajor calixMinor calixRenal pelvis Collecting ductMetanephric vesicle Kidney lobe

Fig. 11 - Enlargement of the inset in Fig. 10

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Distal tubuleProximal tubuleGlomerulusConnecting tubuleIntermediate tubule

The end of each arched collecting tubules induces clusters of mesenchymal cells in the metanephric mass. The clusters soon become metanephric vesicles. These vesicles elongate to become renal tubules. These tubules become part of the renal corpuscle. Its proximal end is invaginated by the glomeruli and constitutes a proximal convoluted tubule (loop of Henle) and distal convoluted tubule (has nephron).

The fetal kidneys are subdivided into lobes. The lobulation usually disappears during infancy as nephrons increase and grow. The nephron formation is complete at term. Functional maturation of kidneys occurs after birth.

Fig. 12 - Development of themetanephric outflow

 Legend

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CloacaUreter anlageMetanephric blastemaMetanephrosMesonephric duct (Wolffian duct)Nephrogenic cordMesonephros

Kidneys attain their adult position by ninth week. As abdomen grows, kidneys gradually come to lie in the abdomen and move further apart. As kidneys ascend they rotate medially almost 90 degrees .Initially kidneys receive blood supply from branches of common iliac arteries. Later the main supply is from abdominal aorta.

Fig. 16 - Migration of the kidneysStage 15 (ca. 36 days)

 Legend

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GonadMesonephrosAllantoisTuberculum genitaleCloacal membraneCloacaPosterior intestineMetanephrosMesonephric duct(Wolffian duct)Ureter anlage

Fig. 16Ascent of the kidney at the end of the 5th week. The kidneys still find themselves in the sacro-lumbar region. The mesonephros, which in this stage is still to be found under the undifferentiated gonads, is in the process of atrophying.

Fig. 17 - Migration of the kidneysStage 18 (ca. 44 days)

Fig. 18 - Migration of the kidneysStage 23 (ca. 56 days)

 Legend

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GonadBladder being formedGenital tubercleCloacal membraneRectumPosterior intestine MetanephrosMetanephrosMesonephric duct(Wolffian duct)

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GonadBladder being formedGenital tubercleRectumPosterior intestineMetanephrosMesonephric duct(Wolffian duct)UreterUrogenital orifice Anal orifice

Fig. 17Ascent of the kidneys at the end of the 7th week. At this point the ureter - independent of the mesonephric duct (Wolffian duct) - inserts into the bladder. The mesonephros has disappeared.

Fig. 18Ascent of the kidneys at the end of the 8th week. The kidneys find themselves at the upper lumbar level in their definitive position and are multilobular.

Urinary bladder

Initially the urinary bladder is continuous with the allantois .The allantois is situated ventrally in to the cloaca. The cloaca is the expanded terminal part of the hind gut.

The cloaca is divided into dorsal rectum and ventral urogenital sinus by urorectal septum that develops in the angle between the allantois and the hindgut.

The urogenital sinus is divided into three parts: a cranial vesicle part that forms most of the bladder and is continuous with the allantois; middle pelvic part that becomes the entire urethra in females; and caudal phallic part that grows toward the genital tubercle- primordium of clitoris.

By 12th week of development, the allantois constricts and becomes a thick fibrous cord- the urachus.In adults urachus is represented by median umbilical ligament.

As bladder enlarges distal parts of mesonephric ducts incorporate into its dorsal wall and contribute to the formation of the connective tissue in the trigone of the bladder. The epithelium of entire bladder is derived from endoderm of urogenital sinus. The other layers of bladder wall develop from adjacent splanchnic mesenchyme.

As the mesonephric ducts get absorbed into the dorsal wall, the ureters come to open separately into the bladder. Later the distal orifices of the ducts move close together and degenerate.

The epithelium of the entire female urethra is derived from endoderm of urogenital sinus.

The cortex of suprarenal glands develops from the mesenchyme lining of the posterior abdominal wall whereas the medulla differentiates and derives from the neural crest cells.

DEVELOPMENT OF GENITAL SYSTEM

The development of genital apparatus accompanies that of urinary system.the primordium gercells share in the formation of gonads.

The intermediate mesoblast is the origin of an elongated structure , the urogenital ridge which lies on both sides of the midline between the lateral mesoderm and the root of dorsal mesenterium of the embryo.it consists of two main components the nephrogenic cord out of which the urinary apparatus arises and the genital ridge as the origin of gonads.

The genital ridge extends from the upper thoracic region to the level of the cloaca. The true gonad analage though develops from only the middle area.

Fig. 3 - Sexually indifferent embryo:Migration of the primordial germ cells into the genital ridge

 Legend

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Coelomic epitheliumLocal mesenchyma (in proliferation)

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IntestineDorsal mesenteryGenital ridge

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Gonadal cordPrimordial germ cells (PGC)MesenchymaAllantoisOmphalomesenteric duct

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Nephrogenic cordMesonephric duct (Wolff)Mesonephric tubule Aorta

The initial period of genital development in the two sexes is similar and therefore is referred to as indifferent state of sexual development.

Development of Ovaries

The Xchromosome and an autosomal gene plays an important role in ovarian organogenesis

The ovaries are derived from three sources: mesodermal epithelium lining of the posterior abdominal wall, the underlying mesenchyme (embryonic connective tissue) and the primordial germ cell.

The gonadal cords extend into the medulla and form a rudimentary rete ovarii- this structure degenerates and disappears. The developing ovaries have the cortical cords extending from surface epithelium into underlying mesenchyme.As the cortical cords increase in size ,the primordium germ cells are incorporated into them.

At about 16weeks cortical cord begins to break into cell clusters called primordial follicles. Each follicle consists of an oogonium (derived from germ cell) . Active mitosis produces thousands of oogonia during fetal life. About 2 million enlarge to become primary oocytes and the rest degenerate before birth. The surface epithelium of the ovary is covered by a thin fibrous capsule called the tunica albuginea. As the ovary separates from regressing mesonephros, it gets suspended by mesentery called mesovarian.

Out of the upper, non-fused portion of the paramesonephric duct (Müller) arises the fallopian tube and its ampulla. The lower section fuses after it crosses medially on both sides of the inferior ovarian gubernaculum and forms the utero-vaginal canal. The medial septum in between disappears at the end of the 3rd month.

QuizQuiz 22

ReminderScheme showing the molecular factors involved in the development of the sexual apparatus

Fig. 42 - Differentiated female sex organs, ca. 4th month  Legend

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EpoöphoronParoöphoronOvarian ligament Atrophied mesonephric duct (Wolff) Cysts of GartnerHymenSuspensory ligament of ovaryFallopian tube (ampulla)Vesicular appendage (Morgani)UterusRound ligament of uterusVaginaInsertion of the round ligament of uterus at the genital swelling

Fig. 42Shown is the atrophied mesonephric duct (Wolff) that, however, leaves certain embryonic remnants behind. Out of the paramesonephric duct (Müller) arise on both sides the fallopian tubes and through fusion of both sides the uterus and the upper part of the vagina (blue). The lower part of the vagina (yellow) comes from the urogenital sinus (endoderm). To be noted is also the development of the ligaments and the hymen, the middle part of which usually disintegrates at around the time of birth.

Female embryos have two pairs of genital ducts: mesonephric ducts (wolffian ducts) and paramesonephric ducts (mullerian ducts).The mesonephric ducts completely disappear leaving only a few non-functional remnants. The paramesonephric ducts form most of the female genital tract.

The uterine tube develops from the unfused cranial parts of the paramesonephric ducts. The caudal fused portion forms the uterovaginal primordium, which gives rise to uterus and superior portion of vagina.

To be observed is the development of the ligaments. The ovarian gubernaculum

Fig. 43 - Formation of the uterus,       7th – 8th weeks

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gets attached on the developing utero-vaginal canal there where it goes over into the fallopian tube. Above it forms the ovarian ligament and below the round ligament of uterus, which goes through the inguinal canal and inserts in the female genital swelling (labia majora).If the separating wall beyond the fusion location of the two paramesonephric ducts is not resorbed, various utero-vaginal abnormalities result.

Fig. 43Up to the 7th week two canal systems on each side exist in both sexes. In the 8th week the paramesonephric ducts (Müller) fuse in the lower portion after they have crossed medially on both sides of the mesonephric duct (Wolff).

Fig. 44 - Formation of the uterusafter 8 weeks

Fig. 45 - Formation of the uterus      ca. 3rd month

 Legend

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Paramesonephric duct (Müller)Mesonephric duct (Wolff)Lower gubernaculumUtero-vaginal canalUrogenital sinus

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Fallopian tubeAtrophied mesonephric duct (Wolff)Ovarian ligament Round ligament of uterusUterusVagina

Fig. 44Formation of the utero-vaginal canal through fusion of the lower section of the two paramesonephric ducts (Müller). From the upper section - on both sides - arise the fallopian tubes with their ampullae.

Fig. 45At the end of the 3rd month the separating wall dissolves in the uterus and the vagina. The uterus lengthens in that the solid lower end of the paramesonephric duct stretches in a downward direction and is subsequently canalized. Out of the lower section arises the upper part of the vagina. It joins with the vaginal lamina, which arises from the urogenital sinus and forms the lower portion of the vagina.

Through atrophy of the mesonephros the upper gubernaculum connects the ovary directly with the upper rear body wall and becomes designated as the suspensory ligament of ovary. The lower gubernaculum has its origin in the bottom side of the ovary and forms the ovarian ligament and, further down, the round ligament of uterus that reaches the genital swelling (labia majora) through the inguinal canal.

The nephrogenic cord is originally vertical. The fallopian tube, which forms from the upper part of the paramesonephric duct (Müller), finally takes on a horizontal position in that it is drawn medially by the joining of the lower part of the paramesonephric duct (Müller) as the uterus is being formed.The ovary, which initially lies medially to the fallopian tube (paramesonephric duct) in front of the atrophying mesonephros, slides backwards as a result.

AnimationDisplacement of the ovary

More infoDevelopment of the ligaments

The peritoneal mesos passively follow these movements. Finally the broad

Fig. 31 - Formation of the broadligament of uterus, ca. 8 weeks

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ligament of uterus forms with three sections:

1. Upper section: mesosalpinx with the fallopian tube

2. Ventral section: mesometrium with the round ligament of uterus

3. Dorsal section: mesovarium with the ovarian ligament.

Fig. 31 Transverse section through an embryo: The two paramesonephric ducts (Müller) approach in the middle. The mesonephric duct (Wolff) and the mesonephros are still clearly visible at this stage.

Fig. 32 - Formation of the broad ligament of uterus, ca. end of the 8th week

Fig. 33 - Formation of the broad ligament of uterus, ca. 10 weeks

 Legend

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Paramesonephric duct (Müller)Mesonephric duct (Wolff)OvaryIntestineNeural tubeNotochord

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AortaMesenchymaCoelomic cavityUmbilical artery Urinary bladder Broad ligament or mesometrium

Fig. 32Transverse section somewhat later and more caudal. Observe how the mesonephros has atrophied (across from the ovary). The paramesonephric ducts are almost fused.

Fig. 33Transverse section showing the fusion of the paramesonephric ducts to form the utero-vaginal canal. The mesonephric duct has atrophied and the broad ligament of ovary subdivides the pelvic space in the 10th week.

The endometrium stroma and myometrium are derived from splanchnic mesenchyme.The fusion of paramesonephric ducts also bring together peritoneal fold that form the right and left broad ligament and the peritoneal compartments :recto-uterine pouch and the vesicouterine pouch.

The vagina epithelium is derived from endoderm of urogenital sinus. The fibromuscular wall of vagina develops from surrounding mesenchyme.

The contact of uterovaginal primordium with urogenital sinus induces paired endodermal outgrowths called sinovaginal bulbs.these bulbs fuse to form vaginal plate.

The central vaginal cells break down forming thelumen of vagina. Until late fetal life , the lumen of vagina is separated from cavity of urogenital sinus by a membrane called hymenthat persists at the inferior end

Through canalization of the vaginal plate the utero-vaginal canal opens itself towards the outside. The upper 3/4 of the vagina comes from the mesoderm and the lower fourth from the endoderm. The fibromuscular walling forms from the neighboring mesenchyma. The vagina is separated from the SUG by the hymen. Its origin is not entirely clear. Discussed is a passive invagination of the back wall of the SUG.

Fig. 48 - Female sex organsca. 3rd month

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Fig. 48The canalization of the vaginal plate begins in the 3rd month.

Fig. 49 - Female sex organsca. 5th month

Fig. 50 - Female sex organsca. 9th month

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Vaginal vestibule Uterine cavity Uterine cervix (neck) Vagina: The lower fourth out ofendodermVagina: The upper 3/4 out ofmesodermHymen

Fig. 49In the 5th month the vaginal canal is completely canalized, but the lumen is separated from the SUG by the hymen.

Fig. 50Normally, the hymen tears open at the time of birth. The uterus and the vagina then have a connection to the vaginal vestibule.

AnimationDifferentiation of the female sex organs

The external genitalia of females – phallus growth ceases and it becomes the clitoris

urogenital folds do not fuse except for small portion that forms the frenulum of the labia minora

unfused urogenital folds become labia minora

labioscrotal folds fuse and form poster. labial commissure posteriorly, anter.labial commisure and mons pubis anteriorly

middle portion of the folds remains unfused and forms labia majora

The ovaries also descend from posterior abdominal wall to the pelvis , just inferior to the pelvic brim. The gurbenucumum is attached to the uterus near the attchmemmt of the uterine tube. The cranial part of gurbenuculum becomes the ovarian ligmanet and the caudal part foems the round lig of the uterus.the round lig passes through inguinal canal and terminate into labia majora.

before we are born

http://d3jonline.tripod.com/24-Reproduction/Development_of_the_Urogenital_System.htm

The most common anomalies of the internal genitaliaresults from defect in fusionof paired structures that form the uterus, cervix and vagina.

Chromosomal congenital anomalies

The chromosal sex is determined at fertilization depending on the sex chromosome complex (XX) or (XY).The embryos can have abnormal sex chromosome complexes such as XXX or XXY. The number of X chromosome appears to be unimportant in sex determination. If a normal Y chromosome is present, the embryo develops as a male. If Y chromosome is not present, female development occurs.

The loss of an X chromosome doesn’t interfere with the migration of the primordial germ cells to gonadal ridges. However an incomplete set of X (fetal gonad of 45) develops Turners syndrome and have incomplete ovarian development. Females with Turners syndrome typically experience dysfunctioning ovaries which results in amenorrhea (absence of menstrual cycle) and sterility.

Various types of uterine duplication and vaginal anomalies result from developmetal arrest of the uterovaginal primordium during the 8th week of development:

These developmental anomalies may include:

Incomplete fusion of the paramesonephric ducts Incomplete development of one or both paramesonephric ducts Failure of parts of one or both paramesonephricducts to develop Incomplete canalization of vaginal plate that forms the vagina.

A double uterus (uterus didelphys)results from failure of fusion of inferior parts of the paramesonephric ducts.It may be associated with a double or single vagina.

In some cases the uterus is divided internally by a thin septum.if the duplication only involves the superior part of the body of uterus, the condition ios called bicornuate uterus.

If growth of one paramesonephric is retarded and the duct doesnot fuse with theother one , a bicornuate uterus with a rudimentary horn develops .the rudimnaary horn may not communicate with the cavity of the uterus.

A unicornuate uterus develops when one paramesonephric does not develop. This results ina uterus with one uterine tube .

In many of these cases the individuals are fertile ,but may have an increased incidence of premature delivery.

A disturbed fusion of the lower section of the paramesonephric duct (Müller) can lead to a variety of abnormalities in the utero-vaginal region. Such abnormalities in the genital region are almost always associated with such of the urinary tract, since these two systems are closely connected with each other.

Utero-vaginal abnormalities

As we saw earlier, the absence of AMH leads without fail to a further development of the paramesonephric duct. Three phases can be distinguished:

The spread of the paramesonephric duct down to the urogenital sinus. The fusion on both sides of the lower third of the paramesonephric duct out of

which the uterus and the upper 3/4 of the vagina arise The resorption of the dividing wall of the paramesonephric duct on both sides

after fusion (end of the 3rd month)

An absent or incomplete migration of the paramesonephric duct in the direction

Fig. 75 - Unilateral atresia, leading to a uterus unicornis unicollis

of the SUG is responsible for an atresia and/or complete or incomplete aplasia of the uterus, which is usually associated with renal abnormalities. This syndrome is called the Maye Rokitansky Kuster Hauser syndrome.

A partial or complete failure of the lower parts of the two paramesonephric ducts (Müller) to fuse or an incomplete development (atresia) of one of two paramesonephric ducts is responsible for the formation of a uterus bicornis uni- or bicollis with or without doubling of the vagina. The uterus bicornis unicollis is encountered the most frequently.

Fig. 76 - Uterus didelphys bicollis

Fig. 77 - Uterus bicornis bicollis Fig. 78 - Uterus bicornis unicollis

The absent resorption of the median Fig. 79 - Uterus septus

dividing wall of the two paramesonephric ducts (Müller) leads to a septated uterus:

Uterus septus (from the body to the uterine cervix)

Uterus subseptus (only in the body region)

Uterus subseptus (only in the cervical region)

When no vaginal plate develops, this leads to a vaginal aplasia that, though, only very rarely occurs in isolation. Due to their partly common origin uterine abnormalities are mostly associated with those of the vagina.

Fig. 80 - Uterus septus subtotalis unicollis Fig. 81 - Uterus septus unicornis bicollis

incomplete fusion of the Mullerian or paramesonephric ducts results in the most common types of uterine malformation:

Complete failure results in uterus didelphys. This extremely rare condition is characterised by:

double vagina double cervix entirely double uterus ie. two single-horned uteruses

A variant of this is the uterus bicornis bicollis which is characterised by:

double or single vagina double cervix two single-horned uteruses which show partial fusing of their muscular walls

More extensive fusion of the Mullerian ducts results in the uterus bicornis unicollis which is characterised by:

single vagina single cervix double, single-horned uteruses which are partially fused

Other abnormalities include:

uterus subseptae - uterus has midline septum

uterus arcuatus - uterus slightly indented in the middle uterus unicornis - with a second blind-ending rudimentary horn

A septate vagina or a double vagina may occur in isolation if canalisation of the most caudal part of the fused Mullerian duct is incomplete.

Agenesis of vagina results from failure of sinovaginal bulbs to developand form the vaginal plate.when the vagina is absent , the uterus is usually absent also (because the developing uterus induces formation of sinovaginal bulb which fuse to from the vaginal plate.

Failure of cacnalization of vaginal plate resukts in blockage of vagina.

Failure of the inferior end of the vaginal plate to perforate results in an imperforate hymen.

Absent perforation of the hymen

Missing hymen perforations are rare. During organogenesis a layer of endodermal tissue divides the vagina from the urogenital sinus (future vaginal vestibule). This tissue layer degenerates during the 5th month and leaves only the hymen behind. If this degeneration fails to occur, the hymen perforation does not occur and mucus from the cervical glands, stimulated by the (maternal) estrogen, collects above the hymen. This can lead to a hydrometrocolpos. Sometimes this abnormality manifests itself only in adolescence by a painful amenorrhoea with a hematometrocolpos.

Congenital Adrenal Hyperplasia and FertilityFemales and menstruationMost girls who have CAH will get their periods. However, theirbleeding may be irregular. For girls who take their medicine, theaverage age for a first period is 13. This is just a little later than theaverage age for girls who don’t have CAH.The delayedThe delayed period and irregular cycles result from high androgenlevels. If not treated, high androgen can lead to polycystic ovariansyndrome (PCOS).

PCOS is a common cause of infertility and lack of menstruation.PCOS means that both the adrenal glands and the ovaries areproducing too much androgen. Symptoms of PCOS includeirregular bleeding, cycles without ovulation, excess body hair andenlarged ovaries with many small cysts.If you are taking steroid medicine to suppress androgen productionand it does not correct the symptoms of PCOS, your doctor may

Fertility in womenCAH may make it harder for women to have children, especiallyif they do not take their medicines as prescribed. But with good

medical care and the support of their medical team, most womenwith CAH are able to conceive and bear children.http://region4genetics.org/region4/_docs/endocrine_project/CAHLivingwithFinal.pdf

Endometriosis

In endometriosis one finds ectopic endometrial tissue outside the uterus, either on the ovaries, the fallopian tube, the uterine ligaments, the recto-vaginal septum, the pelvic peritoneum or possibly in a scar following a laparotomy. Just like the uterine endometrium, this tissue takes part in the menstrual cycle. There are various theories concerning the origin of this tissue:

· The metaplasia theory maintains that the coelomic epithelium, out of which the paramesonephric duct through invagination has arisen, and formed the fallopian tube, the uterus and parts of the vagina, retained its ability to differentiate and become endometrium.

The reflux theory holds that scaly endometrial material gets into the abdominal cavity retrogradely and primarily grows into the small pelvic area and only secondarily into the peritoneum.

The implantation theory says that possibly through an inadvertant transplantation during a surgical intervention endometrial tissue gets outside the uterus and starts to grow there.

In the engendering of endometriosis genetic, immunologic and hereditary factors probably also play a role. This explains why not all women in whom endometrial cells get into the abdominal cavity are susceptible to the same extent for the formation of an endometriosis.

IllustrationTypical localizations of endometriosis sites

Possible localizations of an endometriosis Sagittal section at the level of the abdomen and pelvis

By: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-959447005

http://www.icd10data.com/ICD10CM/Codes

http://www.embryology.ch/genericpages/moduleorganoen.html

Congenital defectsCongenital defects such as cervical stenosis, the lack of opening in the hymen or other congenital abnormalities causing menstrual blood retention in the uterus or retrograde menstruation that allows endometrial cells to implant in the abdominal region.

Hydrocolpos or hydrometrocolpos o Accumulation of fluid due to congenital vaginal obstruction is the cause of

hydrocolpos (ie, distension of the vagina) and hydrometrocolpos (ie, distention of the vagina and uterus). The obstruction is frequently caused by imperforate hymen or, less commonly, to transverse vaginal septum. Obstructing genital anomalies may present at birth with mucocolpos, but the obstructive anomaly is often asymptomatic and escapes detection. An imperforate hymen is often difficult to diagnose perinatally because of the small size of the genitalia and the influence of maternal estrogens, which cause thickening and enlargement of the labia minora. The neonate with hydrocolpos related to congenital vaginal obstruction can present with a bulging interlabial cyst, as shown below, associated with a mass in the lower abdominal quadrants, often inducing urinary tract obstruction.

If no abdominal mass is present at birth, congenital vaginal obstruction becomes evident only at menarche, when the child presents with the features of puberty, primary amenorrhea, and intermittent or chronic lower abdominal pain, which is probably caused by accumulation of menstrual blood (ie, hematocolpos). The vagina can accommodate a considerable volume of blood, but a small amount may collect in the uterus (ie, hematometra). Physical signs are similar to those of hydrocolpos and include lower abdominal mass and a bulging membrane at introitus (bluish in this case, as shown below). Treatment consists of a cruciate incision in the membrane with excision of

the excess tags; usually, no further procedure is necessary.

Vaginal abnormalities

Vaginal agenesis: o Usually occurs with absent uterus but ovaries present.

Vaginal atresia: o The lower portion of the vagina consists of fibrous tissue with a well-

differentiated uterus. Müllerian aplasia:

o Nearly all of the vagina and most of the uterus are absent.2

o Accounts for most cases of absence of vagina with normal external genitalia.

o Can be associated with other anomalies including fused cervical vertebrae and middle-ear defects.

Transverse vaginal septa: o Can be present as single or multiple in the upper or lower segments and

may be patent or perforated, and can be the cause of haematometra or other fluid collections.

o Longitudinal vaginal septa have also been reported.3

Associated anomalies: o The urethra can open into the vaginal wall or the vagina can open into a

persistent urogenital sinus. Associated rectal abnormalities include vaginorectal fistula, vulvovaginal anus, rectosigmoidal fistula.

Abnormalities of the hymen

Imperforate hymen is not uncommon and is either congenital or acquired from inflammatory occlusion after perforation.

This may first present with obstruction of menstrual flow after puberty.

I. Segmental Mullerian agenesis or hypoplasia

1. Vaginal 2. Cervical 3. Fundal 4. Combined

II. Unicornuate uterus

1. With rudimentary horn o With endometrial cavity

Communicating Non-communicating

o Without endometrial cavity 2. Without a rudimentary horn

III. Uterine didelphys

IV. Bicornuate uterus

1. Complete (division to the internal os) 2. Partial 3. Arcuate

V. Septate

1. Complete (septum to the intrnal os) 2. Partial

VI. Diethylstilbestrol

 

 The authors stressed that vaginal anomalies may exist alone or in association with other Mullerian anomalies , but vaginal anomalies were not classified because they were not associated with fetal loss. Vaginal anomalies using their scheme were most often associated with classes III and IV.  

Tubal : Shortening , narrowing and absence of fimbriae .

http://eradiology.bidmc.harvard.edu/LearningLab/genito/Epps.pdf

Adenomyosis

Nabothian cysts

Gartners cyst

Ovarian factors(cystic ovarioan disease- PCO

Endometriosis

Normal pelvic anatomy

The functions of the pelvis include protection of the viscera, composition of the girdle by which the lower limb is attached to the axial skeleton, and an attachment site for the external genitalia

The pelvis, is a bony ring, interposed between the movable vertebral column which it supports, and the lower limbs upon which it rests; Thepelvis is composed of four bones: the two hip bones laterally andanteriorly and the sacrum and coccyx posteriorly.the hip bones consist of three parts:ilium ,ischium and the pubis.

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  The pelvis is divided by an oblique plane passing through the prominence of the sacrum, the arcuate and pectineal lines, and the upper margin of the symphysis pubis, into the greate(pelvis major) and the lesser pelvis(pelvis minor). The circumference of this plane is termed the pelvic brim.

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1.

1.

The pelvis major

The false pelvis lies superior to the pelvic brim.Its cavity is part of the abdominal cVITY.It contains abdominal viscera e.g sigmoid colon.

The pelvis minor

The true pelvis lies to superior pelvic apertureand pelvic brim.it is limited inferorly by pelvic outlet wchich is closed by the pelvic diaphragm and thats closed mainly by leavtor ani mm.its inferior boundarycorresponds to a line joining the tip of coccyx to the inferior border of pubic symphysis.

This is the pelvic cavity and coantins pelvicIt contains, in the fresh subject, the pelvic colon, rectum, bladder, and some of the organs of generation. The rectum is placed at the back of the pelvis, in

the curve of the sacrum and coccyx; the bladder is in front, behind the pubic symphysis. In the female the uterus and vagina occupy the interval between these viscera

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 The pelvic cavity shortad curved forms basinlike partof abdominopelvic cavity.it is tilted anteroinferiorly when it is in the anatomical position.

The posterior wall of pelvis minor is formed by concave pelvic surface of tghe sacrum and coccyx which is longer than its anterior wall.the anterior wall is formed by pubic symphsis, the body of pubis and pubic rami.the lateral walls are formed byt he pelvic aspects of ilium amd ischium.

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FIG. 239– Diameters of inferior aperture of lesser pelvis (female). (See enlarged image)

 

  The superior pelvic aperture or pelvic inlet is variable in shape and contour by gender,race and also by nutritional differences.the periphery of the aperture if fromed bythe pelvic brim and is indicated by the iliopectineal line.

The inferior pelvic aperture or the pelvic outletdoesnot have a smooyh contour because it is bounded posteriorly by sacrum and coccyx, anteriorly by pubic symphsisand laterally by ischial tuberosites.

ligments

The parts of bony pelvis are bound by dense ligs.The iliolumbar ligconnects tips of trtansverse process of l5to iliac crest posteriorly. The inferior fibres of this lig are attached to lateral parts of the sacrum. The sacrotuberous ligpasses from scarum to ischial tuberosities. It has a wide attachment to the dorsal surfaces of the sacrumand coccyx and the posterior superior iliac spine.the sacrospinouos lig-is a thin triangular lig extends from the lateral marginof the sacrum and coccyx to ischial spine.the sacroiliac lig-these ligs hold the wedge shaped sacrum inbetween the iliac ones froming sacroiliac joints.

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The joints of the bony pelvis

 The lumbosacracl joint fromed by articulation of l5 and s1.

The sacrococcycegeal jointis a cartilaginous joint in which fibrocartilage and ligments join the articulating bones, the apex of sacrum and base of coccyx.

The sacroiliac joints are synivial jointsbetween articular surfaces of sacrum and ilium

The pubic symphysis is a median secondary cartilaginous joint between the bodies of two pubic bones. Each articular surface is covered by a thin layer of hyaline cartilage

MM

The walls of pelvic cavity is composed of :superficial mm, hip bonesand their associated ligs , deep mm, blood vessels ,nerves ,,lymphatics and peritoneum..

The anterior pelvic wall of tge pelvis is formed on each side by bodies of pubisc bones and its superior and inferior ramiwchich terminate laterlallly in the body of isschium and obtruator internus mmand its facsia. Tghe pubic symphysis also froms part of the anterior pelvic wall.

Lateral pelvic walls is covered mostly by obtraor internus mm. Medial tyto this mm on each side are obturaros nerves, vessels and other branches of internal iliac artery.. the obrturair inernus passes from the pelvis through the lesser scatic foramen adn its fibres converge to form a tendon that is attached to greater trochanter of the femur.

Posrerior pelvic wall is fromed by sacrum , adjacent parts of the ilium and the sacroiliac joints and their ligs.the piriformis mm lines the posterior wall laterally .these pear shaped mm occupy a key position in the glueteal region .each pirifromis mm leaves the pelvic minor thru greater s ciatic foramen. Medial to these mm are scaral plexus and internal iliac vessels and its subsidiaries.

Floor of the pelvis is fromed by funnel shaped pelvic diaphragm.it is compsed of two levator ani and two coccygeus mm.this diaphragm closed the pelvic outlet. Except for a gap in the pelvic floor beween the anterior edges of the levator ani mm.this gap is filled with loose facsiaareound the vagina and is closed by urogenital diaphragm . te pelvic doapghram also separates the pelvic cavity from the perineum.the rectum and urethra an dthe vagina penetrate te pelvic diaphragm to reach the exterior.

 Levatro ani mm are the largest and most mporatnt mm in the pelvic floor the mm is divided into three principal parts: puborecatlis, pubococygeus and iliococygeus.these mm supports the pelvic visera and resists the inferior tnrust tht accompanies increase in traabdominal pressure. The parts of these mm that inserts into the perineal body support the posterior wall of vagina

The coccygeus mm are triangular sheet s of mm that lie against posreior part of the iliococcygeal mm with wchich it is continous.these along with levator ani from sthe pelvic diaphragm.

The pelvic fascia surrounds the pelvic viscera by loose connective tissue . the fascia is thickened laterally to from the uterosacraland transverse cervical ligs . these ligs passing from the side of the uterine cervix to the posterior wall of the pelvis are a major source of support for the uterus.

Arteries of the pelvis

The internal iliac artery- thses large vessels are paird temial branches of common iliac arety.it supplies most of the blood to the pelvic viscera .the internal iliacs begins at at level between l5 and s1 wghere it is crossed by the ureter.it passes posreromedially into the pelvis minor medial to the extreernla iliac vien.it ends at the superior end of the great sciatic foamen by didving into anterior and posterior divisions. The branches of anterior dividion aree mainly viscerla i.e to bladder, rectum and reproductive organs.the bbranches of IIA whcihc commonly arise are:

Umbilical artery:these vessels run anteroinfriorly between the urinary bladder and the lateral wall of the pelvis

The vaginal artery runs aneriorly and passes along the side of the vagina wehre it dividesinto numerousbranches athat supp;y the anterior and posterior surface of the vagina., posterionfrior parts of the urinary baldder and the pelvic prt of tthe urethra.

The uterine artey arises separtarly from IIA, but may arise from umbilical artery.it deccsends on the latrla wall of the pelvis , anterior to the IIA and enters the root of the broadlig where it passed superior to the lateral portion of the fronix of vagina to reach the lateral margin of the uterus.

The ovarian arety:arises from the abdominal aorta inferior to the rena aretrybut superior to inferior mesenrtic artery.as it passes inferiorly it adhers to the parietal peritoneumand runs anterior to the ureter on the posterior abdominal wall. As it enters the pelvis minor it crosses the proximal ends of the external iliac vessels . it then runs medially in thesuspensory lig of the ovary snd uterinr tubes . the ovarian arerty anastomoses with the uterine aertey.

VENOUS Drainage of pelvis

The pelvis is drained maily by internal iliac veins and their tributaries.

The IIV joins the EIV to form the common iliac vein. These unite with its partners to form the IVC.

The pelvic viscera

Contains rectum , urinary bladder and female genitalia.

The urinary organs

These consist of kidneys that produce urine which is conveyed to the urinary bladdr via uretes before expelling to the exterior through uretehra.kidneys are located int he abdomen.

The Ureter is abdominal part and pelvic part. As ureter leaves the abdomen and enter the pelvis minro tey pass over the pelvic brim, anterior to the origins of EIA.the ureter decsne don the lateral wall of the pelvis minor , where it froms the posterior boundary of the ovarian fossa . it then passes close to the lateral porion of the fornix of the vagina , especially on the left side and enters the posterosuperior angle of the bladder.

Arterial supply and venous drainage:

The most constant arteries supplying the pelvic parts of the ureters in females are branches of uterine areties

Lymphatic drainage of ureters are into aortic, common iliac, external iliacand ionternal lymph nodes.

The urinary bladder

Is a hollow mmuscular vesicle for storing urine.inadults it lies in the pelvis monor.the peritoneum is reflected from the superior surface of the bladder near its posterior border and onto the anterior wall of the uterus at the junction of its body and cervix . the vesicouterine pouch extends between the baldder and the uterus.

The wall of baldder is composed of smooth mm called detrusa mm.its mm fibres run in many directions and at theneck of the bladder these fibres form the invoulunatry internal sphincter.these mm fibres ae continous with the mm in the wall of the urethra.the uretetic orifices and the internal uretehral orifce are located at the angles of the trigone.

Arterial supply:branches of internal iliac areries.the superior vesicle arerty, brsnsnches of umbilical arteries, supply anterosuperior parts of the bladder . the vagina arteries send branches to poseroinferior parts of the baldder. The obtrurartr and inferior gluteal arteries also supply parts of bladder.

Venouos drainage-veins of bladder correspond to te arteiries and are tributeries of internal iliac veins.

Lymphatic drainage of bladder –lymph vessels from superior partof bladder pass to the external

iliac lymph nodesand those from the inferior part pass to internal iliac lymph nodes

Urethra- female urethra is a short mm tube wchich is lined by mucous membrane. It passes anteroinferiorly from urinary bladder,posterior and inferior to pubic symphysis. The external urethral orifice is located inthe vestibule of vagina. It is located anterior to the vagina.it passes with the vagina through pelvic and urogenital diaphragms and the perineal membrane.

The blood supply is from the internal pudendal and aginal arteries. The veins correspons to the aretieries.

Most lymph vessels from urtehra pass to the scaral and internal iliac lymph nodes.

Midsagittal View of Longitudinal Section

Describe:

1. the gross and histological structure of the uterine tube. List their functions.

UTERUS- of a nonpregnant woman is a holoow , thick walled , pear shaped muscular organ located between the baldder an dthe rectum. It is 7-8 cm long and 5-7cm wide and 2-3 cm thick.the uerus normally projects superoanteriolry over the urinary bladder.the uers consist of two major parts: the bodyis the expanede superior twothirdsand cylindrical inferior third called cervix. A slight constriction called isthmus marksthe junction between the body and the cervix.the fundus of

uterus is the rounded superior part of the body wchich is locatedsuperior to the line joining points of entrance of uterine tube.. te region of body where the uterine tube enters are called the cornua.

The uetrrus can be bent anterioelry called anteverted or bent posteriorly called retroverted.

Walls of uterus consists of 3 layers:

Perimetium –the ourer serouos coat consist of peritoneum supported by a thin layer of connective tissue.

Myometrium-middle muscular coat. Main branches of blood vessels an nerves are located in this layer.

Endomertiuim-the inner mucous coat frmly adherent to myometroum.

The endometiurm is partly sloughed offeach month during menstruation

endometrium - The inner glandular mucous membrane lined by a simple cuboidal epithelium and supported by a complex vascular supply, which lines the uterus; it consists of two layers, an deeper permanent stratum basalis and a variable superficial stratum functionalis; the stratum functionalis is sloughed off at the end of each menstrual cycle as a blood tinged discharge, but then grows again, under the influence of changing levels of estrogens and progesterone from the corpus luteum of the ovary; it is the tissue layer in which the early embryo (blastocyst stage) implants and develops; it elaborates a supportive structure, the placenta, in conjunction with the embryo, to provide close connections between fetal and maternal circulation for the purpose of exchanging nutrients, respiratory gases, wastes, and various regulatory substances.

endometrial glands - The complex branched tubular mucous glands of the inner mucosal lining of the uterus which fluctuate in length as a part of the uterine cycle of growth and degeneration of the endometrium of the uterus.

stratum functionalis - The superficial thicker (~2/3 of total) variable layer of the endometrium which arises from stem cells in the deeper stratum basalis layer, whose vessels and glands repeatedly gives rise to this layer in accord with the uterine cycle; the tissues of this layer are responsive to the reproductive hormone changes; this layer is sloughed off at the end of each menstrual cycle as a blood tinged discharge, but then grows again, under the influence of changing levels of estrogens and progesterone from the corpus luteum of the ovary.

The middle coat of cervix mainly cocnsist of fibrous tissue.the cervix is more firm and rigid then the bbody of uterus.

The body of uterus is enclosed between the layers of broad ligs and is freely movable.the cervix is not mobile because it is held in position by several ligs.

The transverse cervical ligs extend from the cervix and lateral parts of the vagina; fornix to the lateral walls of the pelvis.

The principal spport of uterus is the pelvic floor.the mm important in supporting the uterus are:2 levator ani mm,2 coccygues mm,and mm of urogenital diaphragm.

Peritoneum covers the uerus anteriorly and superiorly except for the vagina part of the cervix.

The broad lig is a double layered sheet that etxends from the sides of the uterus to te lateral walls and the floor of the pelvis.the broad lig holds the urteus in its normal position. The layers of broad lig are continous with each other at the fee edge, which is directed anteriolry and superiory to surround the uterine tube.the ovarian lig lies posterosuperiorly and the round lig of the ueterus lies anteroinferiory within the broad lig.the broad lig gives attachement to the ovaries through mesoovarium.

The relationships of the uterus: anteroirly the body of uterus is separated from the urinary baldder by the vesicouterine pouch.this pouch is empty when uterus is inits normal position, but it usually c onatians a loop of bowel when its retroverted.

Posteriorly the body of uterus and supravagina part of the cervix are separated from the sigmoid colon by a layer of peritoneum and peritoneal cavity.the uterus is sperated from the rectum byrectouterine pouch( pouch of douglas).. the inferior part of this pouch is closely related to the posterior part of the fornix of vagina.

laterally the ureters is crossed supriorly by the uterine arteies at the side of the cervix.

Arterial supply of the uterus:the blood supply of uterus is manily derived from the uterine arteries , ewhich are braches of internal iliacs areteries.they enter the broad lig beside the lateral parts of the fornix of the vagina.

Uterus is also supplied bythe ovarian arteries, which are branches of arota.the uterine arteries pass along the sides of the uterus withn the broad lig and then turm laterally at the entrance to the uterine tubes , where they ananstomose with the ovarian arteries.

Venaous drainage : uterine veins enter the broad ligmentswith the uterine arteries.. they form venous plexus on each side of the c ervix and its tribuatatries drain into internal iliac veins.

Lymphatic d rainage;:the lymph vessels of the uterus follow thre main routes: lymph vessels vrom the fundus pass with the ovarian vessels to the aortic lymph nodes.some pass to external iliac lymph nodes and to the superficial inguinal lymph nodes.

Lymph vessels from body pass to the ei lymph nodes.

From the cervix pass to the internal iliacs and scacral lymph nodes.

cervical mucus - The thick secretion of the cervical glands which fills the cervical canal and covers the external opening ("os") of the cervix to prevent microbial contamination of the uterus by the adjacent normal flora of the vaginal canal; spermatozoa must penetrate this cervical mucus in order to traverse the uterus and uterine tubes = oviducts to locate and fertilize the egg = ovum; to facillitate penetration by spermatozoa, the secretions become less viscous after the midcycle pulse of LH and FSH from the anterior pituitary; failure of this hormonally regulated change in viscosity can be a cause of infertility.

The uterine tubes

Also called fallopiam tubes , 10-12 cm long and 1 cm in diamterer, extend lateraaly from the cornua of tge uerus .the uerine tubes carru oocytes from the ovariesand sperms from the uerus to the fertilization site in the ampulla of the uterine tube.. it also converys the dividing zygote to the uterine cavuty.each tube opens at its proximal into the cornua or the hron of the uerus .and its distal end into the peritoneal cavity near the ovary.consequently the uterine tubes allow communication between the peritoneal cavty and the exterior of the body.

The uerine tube is divided into 4 parts:infundibilum-is funnel shaped lateral or distal end of the uterine tube , whci is closely related to tthe ovary . iys opening into the peritonaeal cavity id called the abdomainl ostium. About 2 mm in diamtere, the ostium lies at the bottom of the infundilulm.its meargins have 20-30 fimpbrae. Thiese fingerlike processes spread over the surface of the ovary and a large one , the ovarian fimbia,is attached to the ovary.during ovulation the fimbriae trap the oocyte and sweep it thruuohg the abdominal ostium into the ampulla.

The ampulla of the uterine tube begins at the medial end of the infundibulum.the amulla is the widest and the longest part of the uterine tube , making up over half of its length.

The isthmus of the uterine tube is the shaort narrow, thickwalled part of the uerien tube that enters the cornau of the uterus.

The uteruen part or intramural portion is the short segment that passess thruioght the thick myometrium of the uterusan dopens via the uterine ostium into the uterine cavity.

The uterine tube s lie in the free edge of the broad ligs of the uterus.the part of the broad lig attached to the uterine tube is called the mesentry of the tube or mesosalpinx.the tubes extend posterolaterallyto the laterall walls of the pelvis wher they ascend and arch over the ovaries.

Arterial supply: the arteies to the tubes are derived from the uetrien and ovarian artries.

Venous Drainage:the veins of the tube are arranged similarly to the arteriesand drain into the uterine and ovarian veins.

Lymphatic drainage: the lymph vessels of the uterine tubes follow tgose of fundus of the uterusand

ovary and ascend with ovarian veins to the aortic lymph nodse in the lumbar region.

Gross Structure of the Uterine Tube

The vagina – is the female organ of copulation , is a muscloumembranoues tube 7-9cm in length. It forms the inferior portion of the female genital tract and birth canal.it extends from the ccervix to the vestibule of vagina.tghe vagina descends anteroinferiorly.its anterior and posterior walls are normally in apposition, except ts superior end where cervix of uterus enters its cavity.

It is located posterior to the urinary baldder and anterior to the rectum and passes between the medial margins of the levator ani mm.it piecres the urogenital diaphragm with the shpincetr urethra mm. The vagina recess around the cervix is called the fornix.. the posterior part of the fornix ids the deepest and is related to the rectouterine pouch.its anterior wall is in contact with the cervix, the fundus of the bladder, the terminal parts of the ureters and the urethra.

Atreial supply of the vagina: the vagina artery is branch of the uterine artery, which may RISE FROM internal iliac artery.the internal pudendal artery and vaginal branches of the middle rectal artery also supplies vagina.( branches of IIA)internl iliac artery.

Venous drainage of :the vaginal veins from vaginal venous plexus along the sides of the vagina and within its mucosa. They drain into the internal iliac vein and communicate with the vesice,uterine and rectal venous plexus.

The lymphatic drainage:the s uperior part accompany the uterine artery and drain intointernal and external lymph nodes. The middle part accompany the vaginal artery and drain into the internal iliac lymph nodes. Those from vestibule drain mainly into the superficial inguinal lymph nodes.

The ovaries are almond shaped , oval, pinkish white glands about 3cm long, 1.5cm wide and 1 cm thick. Before pubebrty the surface of ovaries are smooth.thereafter it becomes progressively scarred and distrorted owing to repeated ovulation, unless ovulation has been inhibited by brith control pills.the ovaries are located on each side , close to the lateral wall of pelvis minor in a recess called ovarian fossa.the fossa is bouneded anterior; by umbilical lig and posteriorly by

ureter and internal iliac artery.the anterior border of the ovary is atthatcehd to the posterior border of the broad lig y peritoneal fold called the mesovarian.the ampulla of uterine tube curves over the lateral end of the ovaries and the infundibulum engulfs the ovary so that it can trapthe oocyte at ovulation.

The superior or tubal end of ovary is connected to the lateral wall of the pelcvis by the suspensroy lig of the ovary. This lig is a fold of the posterior layer of the broad lig.the suspensry lig conatins the ovarian vessels and the nerves. Which pass to the hilum of the ovary.each ovary is alos attached to the uterus by a band if fibreous tissue, the ligment of the ovary.it connects the inferior or uterine end of the ovary to the lateral angle of the uterus.the surface of ovary is not covered by peritoneum therefore during ovulation the oocyte is expelled nto the peritoneal cavity. Its intraperitoneal life is short because it is trappe byt he fimbrae of the uterine tube and carried to the ampulla.

Atreial supply of the ovary- the ovarian arteies arise from the abdominal arotaand decsnd along the posterior abdominal wall. On reaching the pelvic brim, the retires cross over the external iliac vessels and enter the suspensry lig.the ovarian atrey sends branches through the mesooavriums to the ovary and continues medially in the broad ligto supply the uerine tube. It ananstomoses with the uterine artery.

The ovarian veins leave hilum of the ovary and form a vine like network of vessels called pampinifom plexus in the broad lig near the ovary and uterine tube.the rught ovarian vein ascend sto the IVC wheras the left ovarian vein drains into the left renal vein.

The lymph vessels follow the ovarian blood vessels and joins those fromthe uterine tubes and fundus of the uterus as they ascend to aortic lymph nodes in the lumber region.

a chart illustrating the histological changes in the female uterine cycle.    9

Normal ovarian cycle

FSH and LH produce cyclic changes in the ovaries. This developls the ovarian follicle, ovulation and formation of corpus luteum. During each cycle fsh promotes growth of several primary follicles however only one of them usually develop into mature follicleand ruptures.

Development of ovrian follicles is characterized by : growth an differentiation of primary oocyte, proliferation of follicular cells, formation of zona pellucid, development of connective tissue capsulesurrounding the follicle-theca folliculi.

The theca folliculi differentiate into 2 layers: internal vascular and glandular layer called theca interna and capsule like layer called theca externa.theca cells are believed to produce an angigenic factor that promotes growth of blood vessels in the theca interna, these vessels provide nutritive supportfor follicular development.

Ovulation

The follicular cells divide actively producing stratified layer around the oocyte. Subsequently fliud filed spaces appear around the follicular cells which coalesce to form a single cavity, the antrum containing follicular fliud . after the antrum forms the ovarian follicle is called the secondary follicle. The primary oocyte is surrounded by mound of follicular cellsknown as cumulus oophorus which projects into the enlared antrum. The follicle continues to enlearge and soon forms a bulge on the surface of the ovary . a small oval avascular spot, the stigma soon appears on this bulge..

Before ovulation the secondry oocyte and some cells of cumulus oophorus , detach from the interior of the istennded follicle . ovulation follows within 24hrs of a surge of lh production.this surge elicited by high estrogen level in the blood appears to cause the stigma to rupture., expelling secondary oocyte with follicular fluid .

The expelled secondary oocyte is surrounded by the zona pellucida and one or more layers of the follicular cells which are radilaly arranged to form the corona radiate and the cumulus oophorus.

Corpus luteum

Shortly after ovulation, the ovarian follicle collapses.under the influence of LH, the walls of the follicle develop into a glandular structure called corpus luteum which secretes primariy progesterone but some oestrogen.. if the oocyte is fertilizrd the CL enlarges to form a CL of pregnancy and increases its hormones production.degeneratoin of CL is prevented by hcg.. if the oocyte is ot fertilized the CL begins to degenerate aprox 10-12 days after ovulation. Which is then called CL of menstruation.. The CL is subsequently transformed into white scar tissue in the ovary, forming the corpus albicans(degenerated CL).

Menstrual cycle

The menstrual or endometrial cycle is the period during which the oocyte matures , is ovulated and enters the uterine tube, the hormones produces by ovarian follicles ad corpus luteum( estrogen and progesterone )produce cyclic changes in the endometrium of te uterus.theses monthly changes in the uterine lining constitute the endometrial , or mmenstrual cycle or period. The average menstrual cycle is 28

days , wit day 1 cycle corresponding to the day on which mesntruaation begins. Mensus cycle may normally vary in length by several days in normal women.

Phases:

Menstrual cycle can be divied in to 3 main phases, however these are continuos processes with each phase gradually passing in the next one.

Mensntrual phase - the 1std ay of the menstruation is the beginning of the menstrual cycle. The functional alyer of uterine wall is sloughed off and discarded with memstrual flow which usually lasts 4-5 days,. The menstrual flow discharged througg the vagina consists of varying amounts of blood combne dwith small pieces of endometrial tissue.. after menstrualtion eroded endometrium is thin.

Proliferative phase-lasts upto 9 days, coincides with the growth of the ovarian follicles and is controlled by estrogen secreted by thse follicles . this is a 2-3 fold incresase in the thickness o fthe endometrium during this time. Early during this phase , the surface epithelium of the endometrium regenerates..the glands increase in number and length and spiral arteries elongate.

Luteal phase-or the secretory phase lasts approx 13 days coincides with the formation , function aand growth of CL. Te progesterone produced by the CL stimulates the glandular epithelium to secrete glycogen –rich, mucoid material. The glands become wide , tortouos and saccular and the endometrium thickens bcoz of the influence of progesterone and estrogen from CL and increase in the fliud in the c onnective tissue.:

If fertilization doesnot occur : CL degenerates,estrogen and progestwrone levels decrase and endometrium enters an ischeamic phase during the alst day of luteal phase. , mesnstrauation occurs.

Ischemia of spiral arteriesoccur by constriction resulting from decrease in the secretion of progesterone. Hormone withdrawl also results in the stoppage of the glandular secretion , a loss of interstitial fluid and a marked shrinking of the endometruim . toward the end of the ischemic phase the spiral areteies become constricted for longer periods . . this results in venous statsis and patchy ischemic necrosus in suoerficial tissues. Small pools of blood formand break thrugh the endometrial suface resulting in bleeding in uterine ,lumen and subsequent drainage into the vagina..

As small pieces of endometium detach and pass into the uterine cavity , the torn ends of arteries bleed into uterine cavuty, resulting in aloss of 20-80 ks of blood . eventually over 3-5 days , the entire compact layer and most of the spongy layer of the endometrium are discarded . remnets of spongy layers and basal layers soon undergo regeneration during the subsequent proofeartive phase of the endomertium..

During prefnancy menstrual cycle ceasese and endometrium passes into pregnancy phase.

Causes of Menstrual Abnormalities

It is important to understand that abnormalities of menstruation are a symptom, not a disease. If at all possible, an underlying cause should be searched for and treatment should be directed at the cause.

When a woman has abnormal menstrual cycles, the cause can lie either within the uterus, within the ovary, within the hypothalamic pituitary system, or because of some other illness or hormonal disturbance. Androgen (male hormone) disorders are very common in women with a life-long history of irregular periods. This is covered in another pamphlet and will be given to you if appropriate.

The most common cause of irregular menstrual periods is the failure of ovulation to occur - either on a regular basis in which case the woman has completely irregular or on a temporary basis which may only disrupt the cycle for a short time. Organic causes within the uterus are usually fairly easy to diagnose using a combination of SONOHYSTEROGRAPHY and Hysteroscopy. Treatment then depends on what problem is found.

Even though failure of ovulation is the cause of DUB in most women, the ovary itself is rarely the primary offending organ. The ovary is not working properly to produce an egg each month either because it is not being properly instructed to do so by the pituitary hormones or because other problems are interfering with the ovary's ability to respond to the controlling pituitary hormones. PolyCystic Ovary Syndrome (PCOS), the most common endocrine disorder in women of reproductive age, is a classic example of this type of problem.

The one major exception is the presence of any persistent cyst or tumor (even benign) within the ovary. Any "foreign object" within the ovary will disrupt normal ovarian function and may lead to irregular bleeding.

One of the most common causes of DUB and anovulation in women is the increased production of androgen - male hormone. All women produce some androgen as all men produce some estrogen. However, when a woman produces excessive amounts of androgen, the ability of the ovary to respond to its controlling hormones is impaired and the ovary either ovulates abnormally or fails to ovulate at all.

Women who produce excess amounts of androgen are usually easy to recognize. They are often overweight and almost always have either acne or facial hair or both.

Women who have such a syndrome of irregular menstrual periods (or no menstrual periods at all) in association with obesity and facial hair and/or acne have been given several terms including Stein-Leventhal Syndrome and Polycystic Ovary Syndrome (PCOS) . I do not like these terms, particularly the latter, because they are inaccurate and because they convey the impression that the problem is mainly ovarian whereas in reality, the problem involves the pituitary, the adrenal, the ovary, and your metabolic "system" as well. Nonetheless, PCOS is the term everyone uses and as bad as it may be, we are stuck with it.

Newer information indicates that PCOS is really a total body disorder involving not only abnormalities in the ovary and adrenal but in the pancreas and insulin secretion as well. PCOS usually begins at puberty. If a teenage girl begins to develop symptoms of PCOS, prompt diagnosis and treatment may prevent the full-blown syndrome from developing. Unfortunately, many of these girls are simply put on oral contraceptive pills to "regulate" their cycle. This is does nothing to address the underlying cause and only delays proper diagnosis and treatment.

Another common cause of menstrual irregularity is a major change in body weight. Women who lose a great deal of weight for whatever reason will frequently develop some abnormality of menstruation. It is well established that the ratio between your body fat to lean body mass (muscles, ligaments, bones, etc.) is a major regulator of menstrual function. Women who maintain a very low ratio frequently stop menstruating. This is typically seen in women athletes, particularly marathon runners, and it is extremely common in dancers. For instance, the term "ballerina amenorrhea" has been coined because of the frequency with which this problem occurs in these women.

Women who are overweight commonly have irregular periods and these women commonly produce increased amounts of androgen solely as a function of their body weight. They are also producing increased amounts of estrogen. This occurs in the fat where androgen is converted to estrogen.

Although true anorexia nervosa is a fairly uncommon problem, eating disorders in teenage girls is not rare. In an attempt to control their weight, or as a result of various emotional stresses, many teenage girls will become anorexic or they may resort to purging or they may become bulimic. Any of these problems can disrupt their menstrual cycle.

One of the most common causes of menstrual irregularity is emotional stress. Usually the precipitating factor is easily recognized and unless the problem is significant, no specific therapy of menstrual disturbance is necessary. It has been often stated that a woman's menstrual cycle mirrors her emotions and my clinical experience has more than justified this conclusion.

Further complicating the problem of the woman who is under emotional stress is the fact that, when they either see their family physician or sometimes a psychiatrist, they will be frequently placed on Prozac or drugs similar to Prozac. Any of the "psychiatric" drugs, but especially anti-depressants, may cause elevations in the hormone prolactin.

The "major tranquilizers" - drugs that are used to treat serious mental disturbances - very frequently cause an elevated prolactin level. Drugs of this category include Thorazine, Haldol and other similar medications. Women on these drugs frequently stop menstruating completely.

When a woman is on such a drug and is found to have an elevated prolactin, the question then becomes whether it was the emotional stress that caused her menstrual irregularity or whether it was a secondary effect of the medication that was being used to treat her emotional distress.

While most people are familiar with syndromes of anorexia nervosa and other situations in which severe emotional stress and/or weight loss produce complete amenorrhea, many people

are not aware that abnormalities in the menstrual cycle other than amenorrhea may also be due to emotional factors.

Another fairly common cause of menstrual irregularity is an elevation in the serum Prolactin- even in women not taking a psychiatric drug. Prolactin is a hormone produced by the pituitary and it is well known that it is necessary for breast development during pregnancy to permit breast feeding. No one yet knows what Prolactin does in non-pregnant women or in men. What is known, however, is that elevation in the Prolactin level will create menstrual abnormalities.

In some women, the elevated Prolactin is due to a small tumor of the pituitary gland. At one time, it was feared that most women with an elevated Prolactin had one of the these small tumors and it was further feared that many women would require surgery to remove them.

We now recognize that while elevated Prolactin levels are not uncommon, in the majority of instances, a tumor does not appear to be present and even when the tumor is present, surgical therapy is not necessary. The elevated Prolactin can be easily controlled with medication and even when there is a tumor present, the medication will often, at the very least, prevent the tumor from enlarging and in many instances will actually make it shrink.

Thyroid disease has long been popularly mentioned as a cause of menstrual abnormality. In fact, at least in my experience (which is rather extensive), thyroid disease is a very uncommon cause of menstrual abnormalities and 99% of women that I treat with DUB have absolutely nothing wrong with their thyroid at all.

With modern laboratory tests, it is very easy to determine with a high degree of accuracy whether or not a woman has an abnormality of her thyroid. If she has an abnormality of her thyroid function, treatment is usually simple and highly effective. If a woman does not have an abnormality of her thyroid gland, there is no justification for the use of thyroid hormone therapy.

There are many other causes of menstrual abnormalities which are beyond the scope of this discussion but the ones I have mentioned here are the most common and most important ones.

 

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Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries. Most cysts are harmless, but some may cause problems such as rupturing, bleeding, or pain; and surgery may be required to remove the cyst(s). It is important to understand the function of the ovaries and how these cysts may form.

Women normally have two ovaries that store and release eggs. Each ovary is about the size of a walnut, and one ovary is located on each side of the uterus. One ovary produces one egg each

month, and this process starts a woman's monthly menstrual cycle. The egg is enclosed in a sac called a follicle. An egg grows inside the ovary until estrogen (a hormone), signals the uterus to prepare itself for the egg. In turn, the lining of the uterus begins to thicken and prepare for implantation of a fertilized egg resulting in pregnancy. This cycle occurs each month and usually ends when the egg is not fertilized. All contents of the uterus are then expelled if the egg is not fertilized. This is called a menstrual period.

In an ultrasound image, ovarian cysts resemble bubbles. The cyst contains only fluid and is surrounded by a very thin wall. This kind of cyst is also called a functional cyst, or simple cyst. If a follicle fails to rupture and release the egg, the fluid remains and can form a cyst in the ovary. This usually affects one of the ovaries. Small cysts (smaller than one-half inch) may be present in a normal ovary while follicles are being formed.

Ovarian cysts affect women of all ages. The vast majority of ovarian cysts are considered functional (or physiologic). This means they occur normally and are not part of a disease process. Most ovarian cysts are benign, meaning they are not cancerous, and many disappear on their own in a matter of weeks without treatment. While cysts may be found in ovarian cancer, ovarian cysts typically represent a harmless (benign) condition or a normal process. Ovarian cysts occur most often during a woman's childbearing years.

The most common types of ovarian cysts are the following:

Follicular cyst: This type of simple cyst can form when ovulation does not occur or when a mature follicle involutes (collapses on itself). A follicular cyst  usually forms at the time of ovulation and can grow to about 2.3 inches in diameter. The rupture of this type of cyst can create sharp severe pain on the side of the ovary on which the cyst appears. This sharp pain (sometimes called mittelschmerz) occurs in the middle of the menstrual cycle, during ovulation. About one-fourth of women with this type of cyst experience pain. Usually, these cysts produce no symptoms and disappear by themselves within a few months.

Corpus luteum cyst: This type of functional ovarian cyst occurs after an egg has been released from a follicle. After this happens, the follicle becomes what is known as a corpus luteum. If a pregnancy doesn't occur, the corpus luteum usually breaks down and disappears. It may, however, fill with fluid or blood and persist on the ovary. Usually, this cyst is found on only one side and produces no symptoms.

Hemorrhagic cyst: This type of functional cyst occurs when bleeding occurs within a cyst. Symptoms such as abdominal pain on one side of the body may be present with this type of cyst.

Dermoid cyst: This is a type of benign tumor sometimes referred to as mature cystic teratoma. It is an abnormal cyst that usually affects younger women and may grow to 6 inches in diameter. A dermoid cyst can contain other types of growths of body tissues such as fat and occasionally bone, hair, and cartilage.

o The ultrasound image of this cyst type can vary because of the spectrum of contents, but a CT scan and magnetic resonance imaging (MRI) can show the presence of fat and dense calcifications.

o These cysts can become inflamed. They can also twist around (a condition known as ovarian torsion), compromising their blood supply and causing severe abdominal pain.

Endometriomas or endometrioid cysts: Part of the condition known as endometriosis, this type of cyst is formed when endometrial tissue (the lining tissue of the uterus) is present on the ovaries. It affects women during the reproductive years and may cause chronic pelvic pain associated with menstruation.

o Endometriosis is the presence of endometrial glands and tissue outside the uterus.

o Women with endometriosis may have problems with fertility.

o Endometrioid cysts, often filled with dark, reddish-brown blood, may range in size from 0.75-8 inches.

Polycystic-appearing ovary: Polycystic-appearing ovary is diagnosed based on its enlarged size - usually twice that of normal - with small cysts present around the outside of the ovary. This condition can be found in healthy women and in women with hormonal (endocrine) disorders. An ultrasound is used to view the ovary in diagnosing this condition.

o Polycystic-appearing ovary is different from the polycystic ovarian syndrome (PCOS), which includes other symptoms and physiological abnormalities in addition to the presence of ovarian cysts. Polycystic ovarian syndrome involves metabolic and cardiovascular risks linked to insulin resistance. These risks include increased glucose tolerance, type 2 diabetes, and high blood pressure.

Polycystic ovarian syndrome is associated with infertility, abnormal bleeding, increased incidences of miscarriage, and pregnancy-related complications.

Polycystic ovarian syndrome is extremely common and is thought to occur in 4%-7% of women of reproductive age and is associated with an increased risk for endometrial cancer.

The tests other than an ultrasound alone are required to diagnose polycystic ovarian syndrome.

Cystadenoma: A cystadenoma is a type of benign tumor that develops from ovarian tissue. They may be filled with a mucous-type fluid material. Cystadenomas can become very large and may measure 12 inches or more in diameter.

http://www.emedicinehealth.com/ovarian_cysts/article_em.htm

pathologies that affect fertility and that can be demonstrated by ultrasound: