GYNEC

MED

The Female Reproductive

System
Lecturer: Dr. Diaz
Topic:

2018

Reference: Lecture #1

AMEC-BCCM

The Female Reproductive System

Unlike male, who are able to produce sperm cell, throughout their
reproductive lives, females produce a finite number of egg cells

During early fetal development germ cells migrate into the ovaries
and differentiate into oogonia

OOGONIA

divide by mitosis for the next few month and some differentiate
into PRIMARY OOCYTES
By fifth month there are about 7 million primary oocytes, but
most will degenerate during the next 2 months

Those that remain will be surrounded by a single layer of squamous

epithelial cells (follicle cells) called a Primordial follicle

Degeneration of primary oocytes continues

At birth = 2,4 million primordial follicles
At puberty = 400,000 remain in the ovary
Only 400-500 will reach maturity

The development of the genital organs is intimately involved with the

development of the renal system

The meiotic process begins as mitosis is ending in the fetal ovary

Components involved:

Meiosis is the mechanism by which diploid organisms reduce their

gametes to a haploid state so that they can recombine again during
fertilization to become diploid organisms

Two meiotic cell divisions are required to produce haploid

gametes
o
Reduction division, division I, or meiosis I occurs from fetal
life to menarche
o
usually one oocyte each month will complete meiosis I as a
function of ovulation
o
meiosis II if fertilization occurs, thus it is in fetal life that the
ovary makes all of the oocytes that the adult women will
have for reproduction

DEVELOPMENT OF THE GENITOURINARY SYSTEM

Gonads ovaries (XX) or

testes (XY)
Genital Duct System
mesonephric and
paramesonephric ducts
External Genitalia

Genetic sex is determined

at the time of conception

A Y chromosome is
necessary for the
development of the testes,
and the testes are
responsible for the
organization of the sexual
duct system into a male
configuration and for the
suppression of the
paramesonephric
(Mullerian) system

In the absence of a Y
chromosome or in the
absence of a gonand,
development will be
FEMALE in nature

Regression of Wolffian
ducts

OOCYTE MEIOSIS

Mesonephric (Wolffian) Duct System

gives rise in the male the epididyrnis, vas deferens, and seminal
vesicles

Remnant, of tite mesonephric duct system in the female remain as

parovarian cysts and the Gartner duct

FERTILIZATION AND EARLY CLEAVAGE

The earliest fetal epithelium to develop is the ectoderm, the

second is the endoderm, and the third is the mesoderm

HCG is secreted by the syncytiotrophoblast at about the time of

implantation. It doubles in quantity every 1.2 to 2 days until 7 to 9
weeks gestation

Angiogenesis is seen by day 15 or 16. Embryonic heart function

begins in the third week of gestation

Organogenesis is complete by postconception day 49

Paramesonephric (Mullerian) Duct System

Develops in the female to give rise to the fallopian tube. uterus,

and cervix

Remnants give rise to the hydatid of Morgagni at the end of the

fallopian tubes
THE FEMALE GENITAL FORMATION

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GYNECOLO

In the presence of ovaries or of gonadal agenesis, the

mesonephric ducts regress, and the paramesonephric
ducts develop into the female genital tract

This process begins at about 6 weeks and proceeds in a

cephalad to caudal fashion

while the inner medial surface is smooth. hairless and

contains sebaceous and sweat glands
3.

Labia Minora
2 thin folds of modified skin situated medial to the
labia majora

4.

HYMEN
A thin, usually perforated membrane at the entrance of
the vagina.
Demarcates the external from the internal genital
organs, and partially closes the vaginal orifice

5.

CLITORIS
Short, cylindrical, erectile organ at the superior portion
of the vestibule
The normal adult glans clitoris has a width less than
1cm, with an average length of 1.5 to 2cm.
The clitoris is the female homologue of the penis in the
male.

6.

BARTHOLIN GLANDS: (GREATER VESTIBULAR GLANDS)

Bilateral compound
racemose glands
Secrete mucus during sexual
excitement
Vulvovaginal glands that are
locates immediately beneath
the fascia at about 4 and 8 o
clock, respectively on the
posterolateral aspect of the
vaginal office

7.

VESTIBULE:
The area between the inner aspects of the labia minora
and the fourchette.
Structures that open in the vestibule are:
Urethra
Bartholin Glands ducts
Vagina

8.

VESTUBULAR BULBS:
Oblong masses of erectile tissue that lie on each side of
the vaginal introitus

9.

EXTERNAL URETHRAL MEATUS:

MALE and FEMALE DERIVATIVES of the UROGENITAL SINUS

ANATOMY OF THE FEMALE GENITAL SYSTEM

THE VULVA

"pudendum
collective term for the external genital organs that are
visible in the perineal area
The entire vulvar area is covered by keratinized, stratified
squamous epithelium. The skin becomes thicker, more
pigmented. and more keratinized as the distance from the
vagina increases

1.

Mons Veneres
A pad of overling the symphysis pubis covered by skin
& hairs

2.

Labia Majora
Two large, longitudinal, cutaneous folds of adipose and
fibrous tissue, and passing back from the mons veneris
to the perineum. The outer skin is covered by hairs

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The Female Reproductive System

2018

GYNECOLO

A triangular silt in the anterior part of the vestibule

below the clitoris in which the urethra opens.

10. SKENES DUCT:

2 blindly ending para urethral tubules which open in
the floor of the urethra, few millimetres from the
external urethral meatus.

Vaginal fascia

Connective tissue fascia that condenses anteriorly

forming the vesico vaginal fascia and posteriorly
forming the recto vaginal fascia.

Histology of the Vagina:

BLOOD SUPPLY:

Arterial Supply:
Internal pudendal artery
Branches form the femoral artery, supply the anterior
part.
Superficial and deep external pudendal arteries.
Venous Drainage:

The veins draining the vulva form a venous plexus from

which veins accompany their corresponding arteries.

The veins draining the clitoris join vaginal and vesical

venous plexuses.

AMEC-BCCM

The cut section of the vagina is H shaped with

approximation of the anterior to the posterior vaginal walls.
It is formed of three layers:
1.
Mucosa formed of squamous epithelium without
glands
2.
Muscularis with some fibres from the levator ani
inserted into it
3.
Adventitia connective tissue continuous with the
paracolpos.

Blood Supply:
Arterial supply:
Vaginal artery ( from the internal iliac artery)
Additional branches from:
Middle rectal artery (from the internal iliac artery)
Inferior rectal artery ( from the internal pudendal artery of
the internal iliac artery)
Venous drainage
A plexus around the vagina (the vaginal plexus), drain into
the internal iliac vein by the veins that accompany their
corresponding arteries.
LYMPHATICS & NERVE SUPPLY
Lymphatic drainage of the vagina:
Lower 1/3 drains to the inguinal lymph nodes
Upper 1/3 followrs lymphatic drainage of the cervix
Middle 1/3 drains in both upper and lower directions

LYMPHATICS AND NERVE SUPPLY

Lymphatic drainage of the vulva
From skin and appendages to the superficial inguinal lymph
nodes to the deep inguinal and femoral lymph nodes of
which the lymph nodes of Cloquet drains the clitoris
directly.
From the former superficial group, lymphatic channels pass
to the deep pelvic nodes including, the external iliac,
common iliac then para aortic lymph nodes.
Nerve Supply of the Vulva
The vulva is supplied mainly from the pudendal nerve (s2,
3 and 4)
Additional sensory nerves are supplied from the ilio
inguinal nerve (L1), the genital branch of the genito
femoral nerve (L1,2) and the posterior cutaneous nerve of
the thigh.
VAGINA

A fibromuscular tube from the vulva to the uterus forming

an angle of 60 with the horizontal plane.
Length:
Anterior wall 8 9cm
Posterior wall 10 11cm

Nerve supply of the vagina:

The pudendal nerve gives sensory fibres to the lower
vagina
APPLIED ANATOMY:
Vaginal Prolapse:
Weakness of the vaginal supports ( ligaments, fascia and
muscles) may lead to:
o
Descent of anterior vaginal wall (cystocele or
urethrocele)
o
Descent of posterior vaginal wall ( rectocele or
enterocele
o
Descent of the vaginal vault after hysterectomy
(vault prolapse)
Posterior fornix:
Offers a passage to the pouch of Douglas for performing
culdoscopy, culdocentesis and for drainage of a pelvic
abscess.
Lateral fornix:
The ureter lies 1 2 cm lateral to it so that it may be
inquired during clamping the angle of the vagina in
hysterectomy operation.
UTERUS

Vaginal Fornices
The cervix projects in the upper blind end of the vagina
that forms a pouch (vaginal pouch) around the cervix and
divided into four fornices: 2 lateral, anterior and posterior
(deeper) fornices.
Vaginal Supports
Ligaments attached to the upper vagina:

Pubocervical ligament anteriorly

Mackenrodts ligament laterally

Uterosacral ligament posteriorly

Levator ani muscles: pubo vaginalis part
Triangular ligament and the Perineal membrane

Pear shaped hollow muscular organ

Measuring around 7.5 x 4.0 x 2.5 cm in the longitudinal,
transverse and anteroposterior diameters.
Its slightly larger in the multipara than in the nullipara.

Divisions:
1.

Corpus Uteri:
a. Body that lies above the internal os.
b. Fundus lies above the insertion of the tubes
c. Cornu the area of insertion of the fallopian tubes:
3 structures are attached to the cornu:

Round ligament anteriorly

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GYNECOLO

2.

AMEC-BCCM

Fallopian tube centrally

Ovarian ligament posteriorly

Isthmus

An area 4 5 mm in length that lies between the

anatomical internal os above and the histological
internal os below. It is lined by low columnar epithelium
and few glands.

Expands during pregnancy forming the lower uterine

segment (10 cm) during the last trimester.

3. Cervix
The elongated lower part of the uterus
Measuring 2.5 3.0 cm
Divided by the vaginal attachment into

Supravaginal portion above

Vaginal portion ( portion vaginalis) below

The cervival canal is the cavity that communicates above with
the uterine cavity at the internal os and below with the vagina at
the external os.
The external os is round in nulliparas and slit shaped in
multiparas

Relations of the Body to the Uterus

Anteriorly: the bladder and vesicouterine pouch.

Posteriorly: the pouch of Douglas.
Laterally: the broad ligament on each side.

Histology of the Uterus

3 layers

1. Endometrium: mucosa
Lined by simple cuboidal or columnar epithelium
Contains tubular glands
Shows cyclic changes with the menstrual cycle under
the influence of ovarian hormones
2. Myometrium (muscular layer)

Three layers
a.
Outer longitudinal muscular layer
b.
Middle layer of interlacing criss cross muscle
fibers surrounding the blood vessels
c.
Inner circular muscular layer
3. Perimetrium or peritoneal covering

Anteriorly: firmly attached to the fundus and body

till the isthmus where it becomes loose and is
reflected on the superior surface of the urinary
bladder forming the vesicouterine pouch.

Posteriorly: firmly attached to the fundus, body,

cervix, and posterior vaginal fornix then is reflected
on the pelvic colon forming the Douglas Pouch.

Laterally: the anterior and posterior peritoneal

covering blend as the anterior and posterior layers of
the broad ligaments

Histology of the cervix:

Position

The uterus is kept in an anteverted anteflexed position

(AVF) with the external os lying ate the level of the ischial
spines by the support of the cervical ligaments, endopelvic
fascia and pelvic floor muscles (levator ani).
Anteversion : the uterus is inclined anteriorly to axis of
the vagina.
Anteflexion: the body of the uterus is bent forwars upon
the cervix.

1. Endocervix

Lined by simple columnar epithelium with compound

racemose glands or crypts that are liable to chronic
infection. It secretes alkaline cervical mucus.
2. Muscle layer

outer longitudinal and inner circular muscles ( 2

layers only)
3. Ectocervix

Formed by of stratified squamous epithelium

covering the outer portion of the cervix. The junction
b/w squamous and columnar epithelium at the
external os is either abrupt or it may form a
transitional zone 1 3 mm known as the
transformation zone

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The Female Reproductive System

GYNECOLO
BLOOD SUPPLY

Arterial supply:
THE UTERINE ARTERIES
o
Arise from the anterior division of internal iliac artery
o
In the base of the broad ligament, crossing above
the ureter an inch lateral to the supravaginal
cervix
2 branches :
o
An ascending
o
A descending branch
Venous drainage:
Starts as a plexus b/n the 2 layers of the broad ligament
(pampiniform plexus) that communicate w/ the vesical
plexus and
The veins of the pelvic organs accompany the arteries,
therefore, venous drainage from the :

Fundus goes to the ovarian

Corpus exits via the uterine veins into the

iliac veins
Lymphatic drainage:
The lymphatic drainage of the uterus is complex
The majority of lymphatics from the fundus and the body of
the uterus go to the aortic, lumbar, and pelvic nods
surrounding the internal iliac nodes
NERVE SUPPLY OF THE UTERUS

The cervix & body are relatively insensitive to touch,

cutting & burning
The cervix is sensitive to dilatation & the body is sensitive
to distension
Innervations

parasympathetic form S2,3,4

sympathetic from:

T5 & T6 (motor)

T10, T11, T12 & L1 (sensory)

Both reach the uterus through branches of inferior
hypogastric plexus

2018

Paired uterine tubes extending outwards from the

superolateral portion of the uterus & end by curling around
the ovary
The oviducts are also referred to using the prefix
salpingo, from the Greek salpinx, meaning a tube
b/n 10-14cm in length & slightly <1cm in external diameter
their lumen communicates b/n the uterine & the peritoneal
cavities

4 parts
1.

Interstitial (1cm)

Pierces the uterine wall &

surrounded by the
myometrium
2. Isthmus (4cm)

Very narrow

Has the most highly

developed musculature
3. Ampulla (5cm)

The widest, tortuous, thin

walled outer part
4. Infundibulum (2cm)

Trumpet shaped outer end opens into the peritoneal

cavity by the tubal ostium
o
The ostium is surrounded by fimbriae, one of
w/c is long & directed toward the ovary
(fimbria ovarica)
TUBAL FUNCTIONS

Ovum pick up, at the time of ovulation, by their free

fimbrial end
Transport of the ova through the tubal lumen, by their
peristaltic & ciliary movements

Production of secretions necessary for capacitation of

the sperm & nutrition of the ova during their journey

HISTOLOGY OF THE FALLOPIAN TUBES

Mucosa (endosalpnix) . Arranged into4-5 main

longitudinal ridges that give rise to subsidiary folds or
plicae. It is lined by columnar partially ciliated epithelium
Muscle layer. Outer longitudinal & inner circular
involuntary smooth muscles. It is thick at the isthmus &
thin at the ampulla.
Serosa (peritoneal covering). The exgtrauterine part is
covered by peritoneum in the upper margin of the broad
ligament

BLOOD SUPPLY & LYMPHATIC DRAINAGE

Arterial supply:
o
Branches from both the uterine artery, & the
ovarian artery
Venous drainage:
o
Right ovarian vein drains directly into the IVC
o
Left ovarian vein drains into the left renal
vein
Lymphatic drainage :
o
Para-aortic LNs directly via ovarian
lymphatics
Nerve supply
o
Sympathetic & parasympathetic fibers
Applied anatomy
o
Tubal pain is referred to the tubal points (on
the lower abdominal wall an inch above
the midinguinal points)

THE OVARY

THE FALLOPIAN TUBE

AMEC-BCCM

Almond shaped
Lying in the fossa ovarica on
the lateral pelvic wall
Measuring 3x2x1 cm
Not covered by peritoneum
Surfaces is pearly white &
corrugated by the effect of
the monthly ovulatory
activity

OVARIAN ATTACHMENTS
3 attachments :
1.

The MESOVARIUM: a peritoneal

fold that suspends the ovary
to the back of the broad
ligament
2.

The INFUNDIBULOPELVIC
LIGAMENT: suspends the
upper pole of the ovary to
the lateral pelvic wall &
carries the ovarian vessels,
nerves, & lymphatics

3.
The OVARIAN LIGAMENT:
attaches the lower pole to the
cornu of the uterus
ANATOMICAL RELATIONS

The ovary is bounded

Medially by the fallopian tube,

Laterally by the lateral pelvic wall

Superiorly & anteriorly it is surrounded by the

small intestine

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GYNECOLO

AMEC-BCCM

Inferiorly by the ovarian fossa where the ureter &

the internal iliac vessels pass

HISTOLOGY OF THE OVARY

The ovary is subdivided into: Cortex, Medulla, & Hilum
1. The Medulla: the central core of the ovary surrounded by
the cortex & continuous w/ the hilum. It is formed of
connective tissue
2. The Cortex: the outer active part of the ovary that
produces hormones & oocytes. Formed of:
a.
The surface epithelium: of cuboidal cells, called
the germinal epithelium, covering the free surface
of the ovary
b. CT stroma: composed of dense CT containing the
oocytes. It is condensed on the surface to form
the tunica albuginea
3. The Hilum: is the site of attachment of the mesovarium
that carries blood vessels, nerves & lymphatics entering &
leaving the ovary

1. Broad ligament
2. Round ligament
3. Ovarian ligament

THE BROAD LIGAMENT

BLOOD SUPPLY & LYMPHATIC DRAINAGE

Arterial Supply:
o
Ovarian artery: arises from the aorta at the
level L2 & passes through the
infundibulopelvic ligament
o
Ovarian branch from the uterine artery; w/c
anastomoses w/ the ovarian vessels at the
broad ligament

Venous Drainage:
o
The ovarian veins accompany the arterial
supply, & join w/ the pampiniform plexus of
veins & the uterine vein

Lymphatic Drainage:
o
To the para-aortic LNs via the ovarian vessels

Nerve Supply
o
Insensitive except to squeezing on P>V>
examination
o
Sympathetic & parasympathetic nerves (T10
& T11) through the preaortic plexus that
accompany the ovarian vessels
SUPPORT OF THE UTERUS

Double sheet of peritoneum that extends from the lateral

wall of the uterus to the lateral pelvic wall
Its outer part forms the infundibulopelvic ligament in w/c
the ovarian vessels traverse there way to the ovary

CONTENTS OF THE BROAD LIGAMNET

Round ligament
Ovarian vessels
Uterine vessels
Ureter
Parametrial pelvic cellular tissue & fascia
Sympathetic & parasympathetic nerves
Parametrial pelvic cellular tissue & fascia
Embryological remnants of the Wolffian ducts
Hydatid cyst of Morgagni
Koblets tubules
Epoophoron
Paroophoron Gartners duct
THE ROUND LIGAMENT

A fibromuscular ligament attached to the uterine cornu

Runs downwards & forwards in b/n the 2 leafs of the broad
ligament to enter the inguinal canal & inserts in the upper
part of the labium majus
It pulls the uterus forwards & help keeping it in an
anterverted position

THE OVARIAN LIGAMENT

A fibromuscular ligament that attaches

the inner lower pole of the ovary to the
cornu of the uterus

It plays no role in the pelvic support of

the uterus

THE CERVICAL LIGAMENTS

Condensed thickening of the pelvic cellular tissue, that lies

b/n the pelvic peritoneum above & the levators ani below &
radiates outwards from the cervix to reach the pelvic walls

They act as the chief support of the uterus & pelvic

structures

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GYNECOLO

AMEC-BCCM

3 PAIRS OF LIGAMENTS

1. Mackenrodts ligaments (the cardinal ligaments of the

cervix): spread out on either side from the lateral surface of
the cervix & vagina, in a fan-shaped manner, & are inserted
in the lateral pelvic wall
2. Utero-sacral ligaments: from the cervix & vagina,
backwards surrounding the rectum & below the utero-sacral
folds of peritoneum, to become inserted in the 3rd piece of
the sacrum

DIFFERENCE BETWEEN IMPERFORATE HYMEN AND

COMPLETE TRANSVERSE VAGINAL SEPTUM
COMPLETE
IMPERFORATE
TRANSVERSE
D HYMEN
VAGINAL
SEPTUM
Bulging bluish
Inspection
Shortened vagina
membrane

3. Pubo- cervical ligaments: extend from the anterior

surface of the cervix & vagina, forwards beneath the
bladder & surrounding the urethra, to the posterior surface
of the pubis

Rectal
exam/Transrectal
Ultrasound

Bulging mass
proximal to the
anus

Bulging mass few

cms beyond the
anus

Treatment

Hymenotomy/
Hymenectomy

Excision of
transverse vaginal
septum

MULLERIAN ANOMALIES

OUTFLOW TRACT OBSTRUCTION

CONGENITAL ANOMALIES OF THE FEMALE REPRODUCTIVE
SYSTEM
Are common
Can caused genetic errors or by teratogenic events during
embryonic development
Anomalies present at varying times in a womans life --- at
birth, before puberty, w/ the onset of menses, or during
pregnancy w/ adverse pregnancy outcomes

MULLERIAN ANOMALIES Classification:

1.

A. IMPERFORATE HYMEN

Occurs in 1-3% of women

Majority have no problem conceiving
but have higher rates of:
Spontaneous abortion
Premature delivery
Infertility
Abnormal fetal lie
Dystocia at delivery
Dysmenorrhea, endometriosis
Cervical Incompetence

The hymen opens normally during embryonic life to

establish a connection b/n the lumen of the vaginal canal &
the vestibule
If this perforation does not take place, the hymen is
imperforate
Incidence: 1 in 1000 live-born females
Many of which require surgical correction

DIAGNOSIS:
Primary amenorrhea is the major symptoms.
Occasionally in childhood a hydrocolpos or mucocolpos
may occur
o
Collection of secretions behind the hymen

At pubery, may have cyclic cramping but no menstrual flow

Over time the patient may develop hematocolpos and a

hematometrium

In more advanced cases the fallopian tubes may be

distended with menstrual flow

The flow may back up through the tubes

2.
3.

MAYER-ROKITANSKY-KUSTER-HAUSER SYNDROME

TREATMENT:

Hymenotomy - a cruciate incision into

extending to the 10,2,and 6 oclock position

the

hymen

B. COMPLETE TRANSVERSE VAGINAL SEPTUM

No canalization occurred b/w the sinovaginal bulb and

Mullerian tubercle if the ares of junction b/w these
structures is not completely
Septum is the junction b/w the upper third and lower two
thirds of the vagina
Incidence : 1 per 75,000 females

Agenesis of Uterus/ Vagina:

Mayer-Rokitansky-Kuster-Hauser Syndrome
Unilateral Development
Unicornuate Uterus
Lateral Fusion Defect (Obstructive or Non-Obstructive)

Vaginal Agenesis
Congenital absence of the vagina and uterus, but with
normal ovaries
Normal secondary development and external genitalia
Occurs in approx. 1 in 4,000 to 1 in 10,000 women
46,XX karyotype
15-30% renal, keletal, middle ear anomalies
Complete vaginal agenisis is discovered in 75% of patient
25% of patients have short vaginal pouch

Diagnosis
Expected menarch
No uterus on exam/UTZ/MRI
Differential Diagnosis
Imperforated Hymen
Treatment
Creation of a vagina when the patient wishes to become
sexually active

Surgical reconstruction of the vagina

Build a neovagina
UNICORNUATE UTERUS

Loss or absence of one side of the uterus

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LATERAL FUSION DEFECTS

Most common type of mullerian defects
Results from failure of the mullerian ducts or failure of the
absorption of the septum

AMEC-BCCM

3. BICORNUATE UTERUS
Fundus is indented
Partial fusion of mullerian ducts
37% of uterine abnormalities
HSG not diagnostic, needs laparoscopy
With unilateral pregnancy

1. UTERUS DIDELPHYS
double uterus
11% of uterine defect

2. SEPTATE UTERUS
A result of a defective resorption of the septum between the
fussed mullerian ducts
It may extend either partially down the uterus or the full
length of the cervix
28% of incomplete septum, 9% complete septum

Diagnosis
May be indicated by a history, physical examination and
confirmed with imaging
Several imaging modalities may be used including
sonohyterography, hysterosalpingoraphy, and
hysteroscopy
Ultrasound is a reasonable diagnostic procedure but should
not be considered diagnostic until supplementary studies
are performed
Magnetic resonance inaging is also appropriate
Treatment
For patients with unobstructed abnormalities, therapy may
not be needed - unicornuate and didelphic uteri
Septate uteri are often associated with miscarriage
problems, and correction may be necessary
o Metroplasty- removal of the septum by a wedge
incision and the reunification of the 2 cavities
during laparotomy

Partial vs. Complete

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