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OBGYN BOARD > Female Reproductive Anatomy & Physiology > Flashcards

Female Reproductive Anatomy & Physiology Flashcards

1
Q

Where is the false pelvis located and what are its boundaries?

A

Located superior to the pelvic brim (linea terminalis)

Also known as the greater pelvis

Boundaries:

  • Abdominal wall (anterior & lateral)
  • Base of sacrum (posterior)
  • Flanged portions of Iliac bones (posterior)

**Contains loops of bowel

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2
Q

Where is the true pelvis located and what are its boundaries?

A

Located inferior to pelvic brim (linea terminalis)

Also known as the pelvic cavity/ lesser pelvis

Boundaries:

  • Symphysis Pubis and pubic rami (anterior)
  • Sacrum and coccyx (posterior)
  • Ilium and ischium (lateral)
  • Pelvic diaphragm

**Contains female reproductive system, bladder, distal ureters and bowel. In non-gravid pt. without pelvic masses, uterus, ovaries and adnexa are located here.

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3
Q

Cardinal ligament

A

Connects to the uterus at the level of cervix (isthmus portion) to provide support for the uterus and the cervix

Continuation of the broad ligament

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4
Q

Broad ligament

A

Extend from the lateral aspects of the uterus and attach to the lateral pelvic sidewall

Drapes of the fallopian tubes, uterus, ovaries, and blood vessels

Creates the retrouterine and vesicouterine pouches

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5
Q

Round ligament

A

Arises in the uterine cornua, anterior to the fallopian tubes and extends from the fundus of the uterus to the pelvic sidewalls

Contracts during labor

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6
Q

Ovarian ligament

A

Extends from the cornua of the uterus to the medial aspect of the ovary

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7
Q

Suspensory/ Infundibulopelvic ligament

A

Extends from the lateral portion of the ovary to the pelvic sidewall

Transmits the ovarian vessels and nerves

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8
Q

Psoas Major muscle

A

Arises from the thoracic and lumbar vertebrae and descends into the false pelvis. Below the level of the iliac crest, fibers begin to merge with fibers from the medial aspect of the iliacus muscle, forming the iliopsoas muscle

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9
Q

Iliopsoas muscle

A

Lateral landmark of the true pelvis

Formed by the psoas major and iliacus muscles

Course anterior and lateral through the false pelvis and descend until attaching to lesser trochanter of the femur

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10
Q

Iliacus muscle

A

Arises at the iliac crest and extends inferiorly until it merges with the psoas major muscle

Forms part of the lateral margins of the pelvic basin

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11
Q

Obturator internus muscle

A

Triangular sheet of muscle anchored along the brim of the true pelvis (lateral margins).

Extends posteriorly and medially along the side wall of the true pelvis.

Passes beneath the levator ani to exit through the lesser sciatic foramen and inserting on the greater trochanter.

Level of the vagina and lateral to the ovaries.

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12
Q

Piriformis muscles

A

FREQUENTLY MISTAKEN FOR OVARIES**

Located deeply posterior in the true pelvis

Arise from the sacrum, form part of the pelvic floor and course along the greater sciatic notch.

Posterior to the uterus, ovaries, vagina, and rectum. Anterior to the sacrum.

Course diagonally to obturator internus muscle.

Less routinely imaged due to deep location.

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13
Q

Levator Ani muscle group

A

1) Iliococcygeus muscle
2) Pubococcygeus muscle
3) Puborectalis muscle

Forms the anterior/ middle pelvic floor along with the piriformis or coccygeus muscle.

Located between the pubis and coccyx, posterior to the vagina and cervix.

Supports and positions the pelvic organs.

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14
Q

Vagina

A

7-10 cm in length

Collapsed muscular tube from vulva to cervix

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15
Q

Uterus

A

Pear-shaped, hollow retroperitoneal organ located between the bladder and the rectum

Parts of the uterus:

  • Fundus or dome= widest, most superior portion of the uterus which is in between the fallopian tubes
  • Body or corpus= main portion of uterus
  • Isthmus (LUS)= area between body and cervix, most flexible part and grow most rapidly during pregnancy
  • Cervix= acts as sphincter during pregnancy and provides alkaline secretion favorable for sperm penetration
    - internal os: opening from cervix into uterus
    - external os: opening from cervix into vagina
  • Endometrial cavity= thickness is dependent on hormone levels
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16
Q

Layers of the uterus

A

1) Perimetrium: serosal or external surface which is part of the visceral peritoneum
Not well visualized by ultrasound.
Most dependent recess in the body
-Anteriorly it forms vesicouterine pouch (anterior cul-de-sac)
-Posteriorly forms rectouterine pouch (Pouch of Douglas/ posterior cul-de-sac)
2) Myometrium: thickest layer, smooth muscle supported by connective tissue containing large blood vessels
-Composed of three layers of smooth muscle which contract during childbirth (parturition).
-Inner most layer is called the junctional zone
3) Endometrium: Mucous membrane lining the uterine cavity. Thickness is related to hormone levels. Composed of two layers…functional and basal.
-Functional layer: sheds with menses; superficial
-Basal layer: regenerates new endometrium; deep permanent layer

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17
Q

Uterine positions

A

Anteversion: most common uterine position, uterus bends slightly forward and creates 90 degree angle with the vagina

Anteflexion: Uterine fundus bends on the cervix, body of uterus bends forward

Retroversion: Tilting backward of the uterus at the cervix (oriented more linearly in relationship with the vagina)

Retroflexion: Bending backward of the uterus at the body

**Transvaginal imaging is best when looking at a retroverted or retroflexed uterus

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18
Q

Normal measurements of the uterus

A

Premenarche:

  • Length: 2-4 cm
  • Width: 1-2 cm
  • Height: 0.5-1 cm

Menarche:
-Length: 6-8.5 cm (not pregnant), 8-10.5 cm (pregnant)
-Width: 3-5 cm (not pregnant), 5-6 cm (pregnant)
Height: 3-5 cm (both)

Postmenopausal:

  • Length: 3.5-7.5 cm
  • Width: 4-6 cm
  • Height: 2-3 cm

Premenarche Uterus: 2/3 cervix and 1/3 body and fundus

Menarche/Postmenopausal uterus: 1/3 cervix and 2/3 body and fundus

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19
Q

Ovaries

A

Paired, almond-shaped endocrine glands located lateral to the uterus.

Composed of an outer cortex and a central medulla.

  • Cortex: consists of follicles and is covered with the tunica albuginea
  • Medulla: composed of connective tissue and contains nerves, blood, lymph vessels, and smooth muscle at the hilum
  • Tunica albuginea: outer layer that is surrounded by a thin layer of germinal epithelium.

Functions:

  • Produce ova
  • Produce hormones
    • Estrogen: secreted by the follicle
    • Progesterone: secreted by the corpus luteum
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20
Q

Ovary measurements

A

Menarche:

  • Length: 2.5-5 cm
  • Width: 1.5-3 cm
  • Height: 0.6-2.2 cm

ESP BOOK:
Premenopausal (varies with ovulatory stage):
-3.5 x 2.0 x 1.5 cm (V=/< 9.8 cm cubed)
Postmenopausal (varies with # of years since menopause):
-2.0 x 1.0 x 0.5 cm (V=/< 5.8 cm cubed)

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21
Q

Fallopian Tubes

A
  • Paired musculomembranous tubes
  • Extend laterally from uterine cornua
  • Function: Attract and transfer fertilized ova from the surface of the ovary to the endometrial cavity
  • Measure 7-14 cm in length, 8-10 mm in diameter
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22
Q

Sections of the fallopian tubes

A

Interstitial (intramural): narrow and relatively straight, located within uterine wall (cornua)

Isthmus: medial portion closest to the uterus, immediately adjacent to the uterine wall

Ampulla: longest portion, curves around ovary, thin walled and distendable, normally the site of fertilization. Most common area of ectopic pregnancies.

Infundibulum: outer, trumpet-shaped end, terminates at the fimbrial processes, opens into the peritoneal cavity adjacent to the ovary

Fimbriae: numerous finger-like projections which maintain a close relationship between the tube and the ovary. One fimbriae is attached to the ovary.

23
Q

Space of Retzius

A

Also known as the Retropubic space or Prevesical space

Located between the pubic bone and the anterior urinary bladder wall.

Rarely is fluid seen here but masses in this space will displace the bladder posteriorly.

24
Q

Vesicouterine Space

A

Also known as the anterior cul-de-sac

Located anterior to the uterus and posterior to the urinary bladder

This space is usually empty but may contain loops of bowel

25
Q

Recto/Retrouterine Space

A

Also known as the Pouch of Douglas or the posterior cul-de-sac

Located posterior to the uterine cervix and anterior to the rectum.

Most inferior or dependent recess in the body, therefore it is the most common site for free fluid to collect.

26
Q

Uterine Arteries

A
  • Ascend in a tortuous course lateral to the uterus within the broad ligament.
  • Course lateral and terminate at the confluence with the ovarian artery
  • Supply the cervix, vagina, uterus, ovaries, and fallopian tubes
27
Q

Arcuate Arteries

A
  • Branch off of the uterine artery

- Supply the outer 1/3 of the myometrium with blood

28
Q

Radial Arteries

A
  • Arise from the arcuate arteries

- Supply the deeper layers of the myometrium and endometrium.

29
Q

Spiral Arteries

A
  • Arise from the radial arteries and are found in the endometrium.
  • Blood from these arteries is shed during menses.
  • These lengthen during regeneration of the endometrium after menses to traverse to the endometrium and supply the zona functionalis.
30
Q

Ovarian Arteries

A
  • Arise from the lateral branches of the aorta, just below the level of the renal arteries.
  • Course medial within the suspensory ligaments
  • Join with the uterine arteries in the region of the uterine cornua.
  • Primary blood supply to the ovaries
31
Q

Ovarian Veins

A

Course within the suspensory ligaments

Right ovarian vein empties directly into the IVC, just below level of the right renal vein.

Left ovarian vein empties into the left renal vein

32
Q

Estradiol

A

This hormone reflects the activity of the ovaries.

Small amounts of this are present in the adrenal cortex and the arterial walls.

33
Q

Estrogen

A

Primary female sex hormone which is primarily produced by developing follicles and the placenta

Functions:

  • Promotes formation of female secondary sex characteristics
  • Accelerates growth in height and metabolism
  • Reduces muscle mass
  • Stimulates endometrial growth and proliferation
  • Increases uterine growth

FSH and LH stimulate the production of this in the ovaries.

The breasts, liver, and adrenal glands produce a small amount of this as well.

34
Q

Follicle-Stimulating Hormone (FSH)

A

Stimulates the growth and development of ovarian follicles

Secreted by the anterior pituitary gland

Levels decline in late follicular phase and demonstrate slight increase at end of the luteal phase

35
Q

Lutenizing Hormone (LH)

A

Secreted by anterior pituitary gland and is essential for both men and women for reproduction.

Stimulates maturation of follicle and is responsible for graafian follicular rupture causing ovulation.

Stimulates progesterone production which peaks after ovulation.

When fertilized ovum implants into endo, hCG production signals corpus luteum to continue secreting progesterone to prevent shedding of endometrial lining

When implantation does not occur, decreasing progesterone levels permit sloughing of uterine lining

Increasing estrogen levels stimulate LH production and a LH surge typically lasts only 48 hours.

36
Q

Progesterone

A

Produced in the adrenal glands, corpus luteum, brain and placenta

Increasing amounts of this are produced during pregnancy

Levels are low during preovulatory phase, increase after ovulation, and remain elevated during luteal phase

Functions:

  • Preparing endo for possible implantation
  • Starting next menstrual cycle
37
Q

Follicular phase of the ovary

A

Days 1-14 (begins at start of menstruation and ends at ovualtion)

FSH stimulates growth of primary follicles

  • several follicles develop each month
  • Dominant (Graafian) follicle may be seen about day 8 when it measures 10 mm ( >11 mm will most likely ovulate)
  • Dominant follicle will grow 2-3 mm/day
  • Estrogen levels increase

Sonographic findings:

  • Max diameter 15-30 mm
  • Line of decreased reflectivity around follicle suggests ovulation will occur within 24 hours
  • Presence of cumulus oophorus (mural nodule within follicle) suggests ovulation will occur within 36 hours
38
Q

Ovulation (Ovarian Phase)

A

Day 14

A surge of LH secretion causes rupture of follicular membrane (usually within 24-36 hours after surge)

Sonographic findings:

  • Sudden decrease in follicular size
  • Free fluid in posterior cul-de-sac
  • Irregular shaped cystic structure

Pelvic pain increases over the ovulatory ovary- this is called Mittelschmerz

39
Q

Luteal Phase of the ovary

A

Days 15-28 (Constant 14-day lifespan)

Crater left by expulsion of the ovum becomes filled with a fatty yellowish cell type, becoming the corpus luteum
-Corpus luteum manufactures and secretes progesterone (and smaller amounts of estrogen) to prepare and maintain the endo for implantation

In absence of hCG, the corpus luteum regresses and atrophies, becoming corpus albicans (small rounded hyperechoic area)

Sonographic findings:

  • Replacement of dominant cystic follicle with echogenic structure representing thrombus
  • Small irregular cystic mass with irregular thick borders and low-level echoes
  • Doppler findings of hypervascular corpus luteum with low resistance flow
40
Q

Menstrual Phase of the endometrium

A

Days 1-5

Functional layer undergoes necrosis from decrease in estrogen and progesterone levels

Menstrual bleeding patterns vary but typically:

  • Begin with 12-24 hours of heavy flow
  • Followed by 4-7 days of scanty flow

Sonographic findings:

  • Early phase: Hypoechoic central line during menstruation
  • Late phase: Thin, discrete, hyperechoic line postmenstruation measuring 2mm
41
Q

Proliferation Phase of the endometrium

A

Days 6-14 (overlaps postmenstruation phase and coincides with follicular phase of the ovary)

Regeneration and proliferation of the functional layer of the endo is stimulated by estrogen secreted by the developing follicles

Begins on the 4th or 5th day after menses and lasts about 10 days and ends at ovulation

Sonographic findings:

  • Early phase: Thin echogenic endo; hypoechoic area around prominent midline echo
  • Late phase: Thick hypoechoic functional layer and hyperechoic basal layer; tri-layered endo (three line sign)
42
Q

Secretory Phase of the endometrium

A

Days 15-28 (begins at ovulation)

Also known as postovulatory or premenstrual phase

Endo is preparing for possible implantation of a fertilized ovum

Under influence of progesterone, endo becomes thickened (reaching max thickness)
-In absence of fertilization, implantation and hCG production, the endometrial glands fragment and undergo autolysis, starting cycle again

Sonographic findings:

  • Hyperechoic endo with obscured midline echo, often with posterior acoustic enhancement
  • Max AP diameter up to 14-16 mm
43
Q

Premenarche

A

Time before onset of menses

Precocious Puberty (True)

  • Onset of secondary sexual characteristics prior to age 8
  • Resulting from an early but normal pattern of gonadotropin secretion from the pituitary
  • Elevated hormone levels indicate the possible presence of hypothalamus, gonad, or adrenal gland neoplasm
  • Early pubic hair, breast, or genital development

Precocious Pseudopuberty:

  • Caused by abnormal exposure to estrogen
  • Most often secondary to ovarian tumor
  • Early breast development, cervix is larger than fundus, normal ovaries without functional follicles
44
Q

Normal anatomy of premenarchal patient

A

Normal newborn female:

  • Cervix 2/3 and body 1/3 of total uterine size
  • Hyperechoic endo (due to maternal hormonal influence in utero)
  • Total length of uterus= 3 cm; AP= 0.5-1 cm
  • Ovaries may be found anywhere between lower poles of kidneys and true pelvis

After 2-3 months old (Maintained until age 7):

  • Cervix 1/2, body 1/2
  • Endo stripe not delineated
  • Small cysts may be seen in ovaries ( <9mm, may be as large as 17 mm)
45
Q

Postmenopausal Anatomy

A

Ovaries stop producing progesterone, estradiol, and significant levels of estrogen
-Ovaries atrophy and decrease in size with disappearance of follicles

Menses becomes irregular and generally ceases between 45-55 years of age

Endo, uterus and vagina gradually become atrophic (postmenopausal bleeding can be due to atrophic endo)

Sonographic features:

  • Myometrium may have calcified arcuate arteries
  • Small amount of fluid in the endometrial cavity (hydrometra) is considered normal
  • Normal endometrial stripe is less than 8 mm (4-5 mm if there is a history of bleeding)
  • Decreased estrogen levels= thinner endo stripe
  • Women on hormone replacement, the endo can resemble pre-menopausal cyclic endo, measuring up to 8 mm
46
Q

Postmenopausal vaginal bleeding

A

Any bleeding from the genital tract in an older woman that occurs more than 12 months after the last menstrual period

Causes:

  • Exogenous estrogen administration (most common)
  • Endometrial atrophy (most common cause without HRT)
  • Endometrial/ cervical carcinoma
  • Estrogen producing functional tumor of the ovary (rare)
47
Q

Tamoxifen

A

Nonsteriodal antiestrogen used as a chemotherapeutic agent in patients with certain types of breast cancer.

In some patients it may cause changes in the endo, increasing their risk for endometrial carcinoma

48
Q

Oral Contraception Pills (OCP’s)

A

Synthetic agents similar to natural female sex hormones that prevent contraception by inhibiting ovulation

Pills contain estrogen and progesterone and are usually taken every day for 20-21 days

Most patients on OCP’s will not develop a dominant follicle and ovulate and endometrial growth is suppressed, so normal cyclical endo changes will not occur

49
Q

Intrauterine Devices (IUD)

A

Foreign body is placed in the endometrial cavity at the level of the fundus and superior corpus
-Most have a lifespan of 5-10 years

Types of IUDs:

  • Copper-coated (Copper T, Paraguard)
  • Saf-T-Coli
  • Lippes Loop
  • Hormonal (Mirena, Progestasert, Skyla)

Risk factors:

  • Infection
  • Perforation (most common at time of insertion)
  • Attachment to the basal layer

Sono appearance:

  • Reflective (hyperechoic) to the endo- sometimes appears isoechoic
  • Posterior acoustic shadow or other artifact
  • Ovulation and formation of corpus luteum continues
50
Q

Infertility

A

The inability of a man and a woman to achieve pregnancy after at least 1 year of having regular sexual intercourse without any type of birth control.

This affects one in seven American couples

  • Approximately 40% are due to female factors
  • Approximately 40% due to male factors
  • 5-10% related to both partners
  • 5-10% unexplained

Female factors include:

  • Anovulation and abnormal ovulation
  • Tubal and transport factors (adhesions, hydrosalpinx)
  • Endometriosis
  • Uterine factors (myoma, congenital anomalies)
  • PCOS
  • Cervical factors
51
Q

Ovulation induction/ ovarian induction therapy

A

Medications are injected to stimulate follicular development. This stimulate the pituitary gland to increase secretion of FSH. Follicular growth monitored via US.

Medications used:
-Clomiphene Citrate (Clomid): comes in tablet form and is used for women who have infrequent/long periods

  • Gonadotropins: injectable medication that is used to induce the release of the egg once the follicles are developed and the eggs are mature.
  • Glucophage: Insulin lowering med, most commonly used in PCOS patients. It has been shown to reverse the endocrine abnormalities seen with PCOS within 2-3 months
  • hCG (Pregnyl, Novarel, Ovidrel, Profasi): used with other drugs to trigger ovulation
  • Parlodel and Dostinex: meds used to lower prolactin levels and will also reduce pituitary tumor size if one is present
52
Q

In Vitro Fertilization (IVF)

A

Consists of ovarian stimulation, needle aspiration of oocytes, incubation of oocytes with sperm, and catheter delivery of typically 2-4 embryos into the uterus

53
Q

Zygote Intrafallopian Tube Transfer (ZIFT)

A

Embryo (zygote) is placed into the fallopian tube, rather than into the uterus with IVF

54
Q

Gamete Intrafallopian Tube Transfer (GIFT)

A

Sperm and ova are placed into the fallopian tube

OBGYN BOARD (4 decks)

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