REPRODUCTION BLOCK 11

19 August 2019
WEEK 1

Objectives Discipline
Describe the normal anatomy and physiology of the female genital tract. Anatomical Sciences
Physiology
Describe the development of the male and female genital organs and Anatomical Sciences
explain the development of gender identity.
Describe and explain the mechanisms of viral oncogenesis. Anatomical Pathology

Define menorrhagia and menometrorrhagia; state the WHO definition of Gynaecology

menorrhagia.
Explain how vaginal bleeding may come from sources other than a ‘normal’ Gynaecology/
endometrium; identify those sources of bleeding. Anatomical Pathology
Describe the nature of fibroids, discuss how they may be associated with Gynaecology/
menorrhagia/meno-metrorrhagia and explain what other symptoms they Anatomical Pathology
may create.
Explain how basic history taking, examination, and simple investigations Gynaecology
can establish the cause and extent of vaginal bleeding.
Describe the medical and surgical treatments for menorrhagia with or Gynaecology
without fibroids.
Explain the physiology of the menstrual cycle and the mechanism of Physiology/
menstruation. Gynaecology
Define the term sexually transmitted infections (STIs) as well as its scope. Clinical microbiology
Differentiate between STIs and non-sexually transmitted genital infections. Microbiology
Gynaecology
Describe four anatomical and/or physiological mechanisms that protect Physiology/Gynaecology
against STIs in the female. Anatomy
Classify STIs according to causative organisms Microbiology / Virology

Describe the pathophysiology of the following STIs: HIV infection, Microbiology

gonorrhoea, syphilis, chlamydia, lymphogranuloma venereum, hepatitis B,
Herpes simplex, Trichomona vaginitis, human papilloma virus, chancroi,
Gardnerella vaginalis vaginitis.
Explain how menorrhagia is assessed, investigated and managed Gynaecology
List common genitourinary symptoms of STIs in females and males and Gynaecology
explain the underlying pathophysiology of these, including the basis of
minimal or absent symptoms in some infected persons.
Describe the pathogenesis of the common sequelae of STIs, noting the Clinical microbiology
general ones as well as those unique to individual STIs. Gynaecology
Discuss the principles of diagnosis, laboratory investigation, management Gynaecology, Public
and prevention of STIs. health & Microbiology
Explain the causes, pathophysiology and investigations of amenorrhea. Gynaecology

Explain the basic care of the infertile couple based on an accurate Gynaecology
assessment of fertility in both partners; and when necessary, referral of the Public health
patients for further management
Demonstrate an approach to taking a focused gynecological history. Gynaecology
Clinical skills
Describe the burden of Reproductive Disorders, globally, regionally, and Public health
nationally
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 Discuss the determinants of Reproductive Disorders Public health
Identify the preventable causes of Reproductive Disorders Public health
Explain the levels of prevention of Reproductive Disorders Public health
Discuss issues of prejudice and labelling in professional dealings with Public health/ Bioethics
patients. Psychology
Discuss the complexities of delivering good health care in the best interests Public health/Bioethics
of the pregnant patient, taking into account the significance of her biological
role, social responsibilities, expectations, future health and survival.
Discuss ways in which sex and gender influence health and medicine in Public health/Bioethics
South Africa specifically with regards to the experience of being a patient
and issues of professionalization.
Discuss the legal, ethical and professional issues related to conducting Bioethics
intimate physical examination
Discuss the issues involved in patient confidentiality as they relate to the Bioethics
management and prevention of STIs.
List the various antifungal drugs available and describe their mechanisms of Pharmacology
action, adverse drug effects, drug interactions and current therapeutic
indications.

Learning Topics
LT 11.01.01. Normal Menstrual cycle
LT 11.01.02. Amenorrhea

LT 11.01.01. Normal Menstrual cycle

Aim
To study the physiology of the endometrial cycle with a focus on menstruation.

Delivery objectives

1. Describe the menstrual, proliferative and secretory phases of the endometrial cycle.

Content

Menstruation is the normal, periodic loss of blood, tissue fluid and endometrial cell debris from the
uterus. It is a cyclic event that commences approximately every 28 days (range 21 – 35 days) and
lasts for between 1 – 8 days. The ovarian steroids, oestrogens and progesterone control the monthly
growth and breakdown of the endometrium with menstruation representing one of the three major
phases of the endometrial cycle.

The menstrual phase

If fertilisation of the oocyte does not occur, hormonal support of the endometrial lining of the uterus
is withdrawn due to the demise of the corpus luteum. The vascular and glandular integrity of the
endometrium degenerates, the tissue breaks down and menstrual bleeding ensues.

The physiological mechanisms that result in bleeding include:

 Rhythmic spasm of spiral arteries resulting in ischaemia and stasis (it is thought that the
ischaemia is the underlying cause of the pain often associated with menstruation –
dysmenorrhea).
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  Influx of inflammatory white blood cells.
 Increased production of prostaglandins (especially of the E and F type) as a result of the
action of phospholipases liberated from lysosomes.

As a result of the removal of hormonal support and the above processes the endometrial cells begin
to die and eventually the tissue collapses and is shed from the uterine wall.

The average volume of menstrual blood loss is 30 ml (range: 10 – 80 ml) and the blood does not
clot due to the presence of fibrolysins released from necrotic endometrial cells.

After menstruation, all that remains on the inner surface of most of the uterus is a thin layer of
stromal cells and some remnant glands. However, epithelial cells remain in the lower uterine
segments, as well as regions close to the fallopian tubes.

The proliferative phase

After menstruation, the endometrium is restored within about five days and continues to increase
in thickness from about 0.5 mm to as much as 6 mm at ovulation. Proliferation and differentiation
of the endometrium are stimulated by oestrogens that are secreted by developing follicles. Levels
of oestrogens rise during the follicular phase and peak just before ovulation.

Oestrogens produce their effects on the endometrium through actions that include:

 Expression of proto-oncogenes that are involved in the expression of certain genes.

 Induction of the synthesis of growth factors such as insulin-like growth factor (IGF), tissue
growth factor (TGF) and epidermal growth factor (EGF).

The secretory phase

Following ovulation, the ovary secretes large amounts of progesterone (in addition to oestrogens),
which functions as an anti-oestrogen and therefore inhibits endometrial cell growth. Progesterone
also stimulates the glandular components of the endometrium and thus induces secretory changes
in the uterine lining, especially the secretion of glycogen-rich mucous. The stromal cells also become
larger and oedematous.
The secretory phase lasts for about 14 days, after which time the endometrium is engorged with
synthetic activity in anticipation of the arrival and implantation of the blastocyst.

At this stage the endometrium consists of three layers, namely:

 the outer zona compacta
 the middle zona spongiosa
 the inner zona basalis

that undergoes the cyclic

The outer and middle layers make up the so-called functional layer
proliferation/degeneration and which interacts with the embryo. The inner layer is
the layer left behind after menstruation (or parturition) and gives rise to the other
two layers at the beginning of the next endometrial cycle.

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 LT 11.01.02. Amenorrhea

Aim
To study the causes, pathophysiology and investigations of amenorrhea.

Delivery objectives
1. Define amenorrhea.
2. Discuss the causes of amenorrhea.
3. Describe the pathophysiology of the different causes of amenorrhea.
4. Describe the investigation of amenorrhea.

Content
Amenorrhea

 No period by age 14 in the absence of growth and development.

 No period by the age 16 regardless of the presence of normal growth and development with the
appearance of second-degree sexual characteristics.
 In a woman who has been menstruating, the absence of periods for a length of time equivalent
to a total of at least 3 of the previous cycle intervals or 6 months of amenorrhea.

Causes

Physiological

 Pregnancy – should be excluded in the initial investigation.

 Lactation – serum prolactin concentrations return to normal after about four to six weeks after
delivery.
 Perimenarche
Thirteen is the upper limit for menarche.
First cycles after menarche are often anovulatory.
Oligomenorrhea and amenorrhea are common.
 Perimenopause
Ovary becomes more insensitive to FSH and LH towards the end of reproductive life.
Anovulation and oligomenorrhea are common usually after the age of forty.

End-Organ Defects

Usually normal FSH and LH levels

 Asherman’s syndrome
o Secondary amenorrhea
o Overzealous post partum curettage resulting in the intrauterine scarification.
 Mullerian duct anomalies
o Cervical or vaginal atresia
o Present with the pelvic mass cryptonorrhea
 Mullerian duct agenesis
o Normal ovarian function
o Normal secondary sexual characteristics
o Absence or hyperplasia of vagina

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Gonadal Causes:

Increased FSH and LH

Primary ovarian failure

 Gonadal dysgenesis which may be

Turners- 45X Short stature
Web neck
Shield chest
 Mosaics i.e multiple cell lines of varying sex chromosome composition.
 46XX most common. Cause of dysfunction in these cases is not known.
Presentation varies – may present with absent menstrual periods and failure of secondary
sexual characteristics to a woman who has normal menses and later on premature menopause.
Functioning follicles undergo accelerated rate of atresia.

Premature ovarian failure

 Increased FSH and LH

 Turner’s syndrome: 45X
 Autoimmune destruction
 Destruction of follicles by infections e.g. mumps, oophoritis
 Physical insult such as irradiation or chemotherapy

Premature menopause

 Defined as amenorrhea before the age of forty with increased LH and FSH.

Gonadal dysfunction

 Polycystic ovary syndrome

 Presents with: menstrual abnormalities (amenorrhea, menorrhagia, oligomenorrhea)
o Hirsutism and acne
o Alopecia

Lectures
L 11.01.01. Introduction to Reproduction block
L 11.01.02. Public health introduction to Reproduction
L 11.01.03. Anatomy of the genital system
L 11.01.04. Normal menstrual cycle
L 11.01.05. Abnormal menstrual cycle
L 11.01.06. Pelvic Inflammatory Disease (PID)
L 11.01.07. Gynae HX and Exam
L 11.01.08. Professionalism and Intimate Examination
L 11.01.09. Introduction to Low Abdominal Pain
L 11.01.10. Benign Uterine Pathology
L 11.01.11. Syphilis
L 11.01.12. STI’s syndromic management
L 11.01.13. Viruses and cell cycle & the principle of viral oncogenesis
L 11.01.14. Viral STI’s
L 11.01.15. STI’s In Female Patients
L 11.01.16. STI’s In Male Patients
L 11.01.17. Pharmacology of Antifungal drugs
L 11.01.18. Pharmacology of treatment of sexual transmitted disease/infections antibiotic agents
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L 11.01.01. Introduction to Reproduction block

Aims
• To learn the normal aspects of the female reproductive cycle, from the reproductive years
to the postmenopausal period
• Also to learn about the common disorders in obstetrics and gynaecology

Delivery objectives:
• Management of the non-pregnant and pregnant patient
 History
 Examination
 Special investigations
• Bedside
• Laboratory
• Radiological
• Other
• Differential diagnosis
 Common disorders
 Life-threatening disorders
 Rare conditions
• Treatment
 Benefits vs. risks
• Important consideration during pregnancy

L 11.01.02. Public health introduction to Reproduction

Aims & delivery objectives:

 Describe the burden of Reproductive diseases, globally, regionally, and nationally

 Discuss the determinants of Reproductive diseases
 Identify the preventable causes of Reproductive diseases
 Explain the levels of prevention of Reproductive diseases

L 11.01.03. Anatomy of the genital system

Aim
To know the basic anatomy of the female genital system and the female pelvis.

Delivery objectives
1. Know the bones and ligaments of the pelvis.
2. Know the basic anatomy of the female external and internal genitalia.
3. Be familiar with the innervation and vascularization of the internal and external female
genitalia.
4. Know the definition and boundaries of the perineum; know the perineal pouches and their
major contents.
5. Know the boundaries of the anal and urogenital triangles.
6. Know the muscles of the pelvic floor.

Content
This lecture covers the anatomy of the female genital system. It includes the bones, muscles,
organs, blood vessels and nerve supply.

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L 11.01.04 & 05. Normal and Abnormal Menstrual Cycle

Aim
To study the assessment, investigation, and management of menorrhagia and to consider the need
to involve the patient and cater to the patient's individual needs.

Delivery objectives
1. Define menorrhagia
2. Explain how menorrhagia is assessed and investigated
3. Define abnormal uterine bleeding.
4. Describe treatment options (conservative medical and surgical)
5. Discuss counselling

Content
Please view PowerPoint presentation.

L 11.01.06. Pelvic Inflammatory Disease

Delivery objectives
1. Define PID
2. Describe pathophysiology
3. Discuss clinical presentation

Content
Please see PowerPoint Presentation

L 11.01.07. Gynae History and examination

Delivery objectives
1. Clinical history
2. Clinical examination
3. Describe the signs and symptoms of common gynaecological conditions

Content
Please see PowerPoint Presentation

L 11.01.08. Professionalism and the Intimate Examination

Aims
1. To draw attention to the importance of maintaining professional conduct in the context of
intimate examinations,
2. To discuss the need for chaperones both for the protection of the patient and the
practitioner; and
3. To stress that adequate communication is key to prevention of erroneous and false
allegations.

Delivery Objectives
1. Define sexual misconduct and sexual impropriety in the context of health care delivery
2. Understand the definition and the difficulties with the definition of the intimate examination
3. Explore the concept of trust in the context of sexual relationships between the practitioner
and patient
4. Understand the concept of chaperones being present during the intimate examination
5. Analyse the legal issues pertinent to the intimate examination
6. Avoid complaints of sexual impropriety from patients when in practice.
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Content: See resource
L 11.01.09. Introduction to Low Abdominal Pain

Aim
To understand pain as a subjective phenomenon influence by physical, social and psychological
factors.

Delivery objectives
1. To understand different aspects of pain such as onset, history and associated symptoms.
2. Acute and Chronic pain
3. Pregnancy and non-pregnancy associated pain and pain of non-gynecological origin.
4. Differential diagnosis, investigations and treatment.
5. The socio- economic impact of pain.

Content
See PowerPoint presentation

L 11.01.10. Benign Uterine Pathology

Aim
To study the causes of abnormal uterine bleeding, including the organic lesions identifiable
pathologically and the subtle functional abnormalities.

Delivery objectives
1. Explain the concept of abnormal vaginal bleeding and the terminology pertaining to this
(menorrhagia and metrorrhagia).
2. Explain the concept and causes of dysfunctional uterine bleeding.
3. Explain what is meant by ‘anovulatory cycle’.
4. Describe the causes of endometritis.
5. Discuss the pathology and complications of endometrial polyps.
6. Describe endometrial hyperplasia and discuss its consequences and significance.
7. Describe adenomyosis and discuss its complications.
8. Discuss the pathology and complications of leiomyomata.
9. Describe endometriosis.

Content
Please view PowerPoint presentation.

L 11.01.11. Syphilis

Aim
To enable students to understand the role of the laboratory to determine the epidemiology and
the diagnosis of sexually transmitted infections (STIs).

Delivery objectives
- Role of the laboratory in determining epidemiological trends, aetiology, and antibiotic resistance
profiles of microorganisms causing STIs.

- Discuss the laboratory diagnosis of different types of STIs (e.g. urethral discharges, vaginal
discharges, genital ulcerative diseases) in terms of causative organisms, specimen collection,
microscopy, culture and, where appropriate, antimicrobial susceptibility.

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- Discuss the importance of the laboratory in: the diagnosis of STIs in patients with mixed
infections and those who fail to respond to syndromic treatment; pelvic inflammatory disease
(PID); and inguinal bubos.
Content
Briefly discuss the principle of syndromic management of STIs in Southern Africa.

Discuss the role of the laboratory in elucidating epidemiology, aetiological causes, and
antimicrobial resistance trends of commonly-encountered STIs in the Southern African setting.

Discuss basic principles of collection and transport of specimens collected from the urogenital
tract.

List the common agents that are associated with urethritis, vaginal discharge, genital ulcer
disease, inguinal buboes, and pelvic inflammatory disease (PID) and brief description to identify
these.

L 11.01.12. STI’s Syndromic Management

Delivery objectives
 To define syndromic management of STIs
 To explain the rationale of syndromic management of STIs
 To discuss the pros and cons of syndromic management of STIs

Content
Please see PowerPoint Presentation

L 11.01.13. Viruses and cell cycle & the principle of viral oncogenesis

Aim
To study the role of the human papilloma virus in the causation of cervical cancer and its action at
the molecular level; to recognise the differing types of cervical cancer.

Delivery objectives
1. Explain the epidemiology of cervical cancer.
2. Explain the structure of the human papilloma virus.
3. Explain the role of HPV proteins in oncogenesis, particularly the E6 and E7 genes.
4. Describe the effects the E6 and E7 proteins have on the tumour suppressor genes RB and p53.
5. Classify the subtypes of HPV into high risk and low risk for oncogenesis.
6. Explain the difference between integration and episomal virus in terms of low and high risk
serotypes.
7. Classify the types of cervical carcinoma into histological subtypes.
8. Describe the mechanisms of detection of HPV.

Content
Please view PowerPoint presentation.

L 11.01.14. Viral STI

1. To understand the difference between viral and bacterial STIs

2. To understand the common viral STIs: HIV, HPV and Herpes

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L 11.01.15. STI’s In Female Patients

Delivery objectives
 To list STIs in females
 To describe common clinical manifestations of STIs in females
 To discuss laboratory diagnosis of female STIs
 To discuss approach to prevention and management of STIs in females

Content
Please see PowerPoint Presentation

L 11.01.16. STI’s In Male Patients

Delivery Objectives
 To list STIs in males
 To describe common clinical manifestations of STIs in males
 To discuss laboratory diagnosis of male STIs
 To discuss approach to prevention and management of STIs in males

Content
Please see PowerPoint Presentation

L 11.01.17. Pharmacology of Antifungal drugs

Aim
The study of several antifungal drugs; their mechanisms of action, adverse effects, interactions
and current therapeutic indications.

Delivery objectives
1. List the various classes of antifungal drugs.
2. List the antifungal drugs that are available for the treatment of systemic infections.
3. List the antifungal drugs that are available for the treatment of superficial infections.
4. Discuss the pharmacokinetic profile of each drug.
5. Discuss the adverse reactions of each drug and their management wherever appropriate.
6. Compare and contrast the mechanisms of action of the various antifungal drugs.
7. List the drugs used for the treatment of commonly seen fungal infections in
immunocompromised and non-immunocompromised patients.

Content:
PowerPoint

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L 11.01.18. Pharmacology of treatment of sexual transmitted disease/infections
antibiotic agents

Aim
This learning topic describes the treatment of sexually transmitted diseases/infections and is also
meant to be a revision of the pharmacology of some of the antimicrobial agents covered in the
PCMS block.

Delivery objectives
With reference to penicillins, 3rd generation cephalosporins, tetracyclines, macrolides,
fluoroquinolones and metronidazole define the following:
Susceptible organism
Mechanism of action
Contraindications
Safety during pregnancy / lactation
Adverse effects
Drug interactions
Precautions for use
Penicillins: beta-lactamase sensitivity
Resistance

Content
Please see notes

Theme Sessions
TS 11.01.01. Applied Anatomy of female genital system
TS 11.01.02. Counselling of STI patients
TS 11.01.03. Normal sexual responses

TS 11.01.01. Applied Anatomy of Female Genital System

Aim
To know the basic anatomy and histology of the female genital system. To know the basic
anatomy of the female pelvis.

Delivery objectives
1. Know the bones and ligaments of the pelvis and know the difference between the bony
pelvis of males and females.
2. Know the difference between the true and false pelvis; know the boundaries of the pelvic
inlet and outlet and the contents of the true female pelvis.
3. Know the basic anatomy and histology of the female external and internal genitalia.
4. Be familiar with the innervation and vascularization of the internal and external female
genitalia.
5. Know the definition and boundaries of the perineum; know the perineal pouches and their
major contents.
6. Know the boundaries of the anal and urogenital triangles.
7. Know the muscles of the pelvic floor.
8. Know the embryology of the female reproductive system.

Content
 This theme session covers the anatomy and histology of the female genital system.

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  The theme session investigates the structure and functions of the uterus and its
relationship to the urinary bladder, urethra and rectum.
 The theme session also investigates the anatomy and histology of the ovaries, uterine tube
and cervix.
 This theme session also includes the anatomy of the female pelvis, perineum and pelvic
floor.
 This theme session includes the embryology of the female reproductive, and associated
congenital abnormalities.

Please see worksheet

TS 11.01.02. Counseling of STI Patients

Aim
To describe an approach to counseling a patient with a STI during a primary care consultation

Delivery objectives
The Student will be able to:

1. Explain why counseling is necessary.

2. Describe a good doctor- patient relationship and explain respect, empathy, honesty and
tolerance.
3. Describe the consultation including history and examination, treatment of patient and
partner, options for safer sex, opportunistic counseling and testing for HIV.
4. Discuss several options for safer sex.

Content
The lecture will cover the need for counseling a patient with a STI, the importance of establishing
a good doctor-patient relationship, a practical approach to the consultation acknowledging the
constraints of time and the need for counseling on safer sex and HIV VCT. It will also present
practical advice on safer sex practices.

TS 11.01.03. Normal sexual responses

Aim
To explore the fundamentals of the normal sexual response and the importance of relationship
issues in the genesis of sexual problems

Delivery Objective

The students will be able to:

1. Describe the normal sexual response in adults.
2. Discuss the emotional and relationship issues contributing to the sexual response.
3. Describe an approach to dealing with sexual problems in adults.

Content
Please view PowerPoint presentation

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