by Pedro R. Figueroa Casas
Anatomy and Physiology
The female reproductive system can be divided, from the anatomical, embryological and physiological point of view, into four organic units: the ovaries, the female gonaduct, the external genitalia and the sexual characteristics.
Ovaries They constitute the female gonad. This even organ is located deep in the pelvis, each one sitting on the posterior leaf of the respective broad ligament. The ovary measures, on average, 3.5 x 2 x 1 cm and, due to its shape and appearance, is compared to an almond; Due to its anteroinferior end, it joins the uterus through the utero-ovarian ligament, while through its posterior superior end, it joins the pelvis through the infundibulopelvian or suspensory ligament of the ovary.
In the section of the ovary a cortical zone and a medullary or central zone can be distinguished. Two types of tissues are found in the cortical zone: the stroma, a compact and specialized connective tissue that produces sexual asteroids, and the ovofollicular apparatus, made up of structures that contain female reproductive cells and that exhibit different modifications both in number and shape and size throughout a woman's life. The medullary zone of the ovary is made up of loose connective tissue and abundant vessels.
The ovary secretes three types of cholesterol-derived sex steroids: progesterone (C21), androgens (C19), and estrogens (08). The production of these ovarian hormones depends on the gonadotrophins (follicle-stimulating and luteinizing) originating in the pituitary, which, in turn, are regulated by the hypothalamic gonadotrophin-releasing factors or hormones (Gn-RH or LH-RH). The production of hypothalamic hormones is under double control: on the one hand, it depends on the plasma levels of ovarian steroids (feedback mechanism exerted, fundamentally, by estrogens and, to a lesser extent, by progesterone) and, on the other hand On the other hand, it depends on the neurotransmitters (norepinephrine, dopamine, acetylcholine) produced in various extrahypothalamic areas of the central nervous system.
The two most important phenomena in this whole system are 3rd ovulation and menstruation. Ovulation depends on a complex and highly specialized mechanism that will be described below. The beginning of the menstrual cycle (first day of menstruation) is characterized by a relatively high level of circulating FSH and LH (primarily the first). This increase in gonadotrophins has actually been occurring since the end of the preceding cycle and is due to the decrease in the negative feedback mechanism of progesterone and estradiol secreted by the corpus luteum, as its function declines. As a consequence of the relatively high circulating FSH and LH values, a new wave of ovarian follicles begins to mature. In non-human primates it has been shown that recruitment of this group of follicles reaching the growing follicle stage occurs between days 1 ~ 59 of the cycle. From day 6Q, one of them is selected and becomes the so-called dominant follicle, which will continue to grow until reaching the stage of mature follicle or preovulatory follicle and, subsequently, experience the rupture and elimination of the ovum. The rest of the follicles become involved and enter atresia. experience the rupture and removal of the egg. The rest of the follicles become involved and enter atresia. experience the rupture and removal of the egg. The rest of the follicles become involved and enter atresia.
This period between menstruation and ovulation usually lasts 14 days. Hormonally it is characterized by a progressive increase in plasma estradiol levels with a sharp increase (peak) between 32 and 68 hours before ovulation. About 16 to 20 hours after the estradiol peak, the LH peak occurs, which triggers, between 16 and 48 hours later, ovulation.
Once ovulation occurs, the luteal or secretory phase begins, which lasts between 12 and 16 days and ends when the next menstruation begins. This period is characterized by a rapid increase in progesterone levels and a moderate increase in estradiol. The final part of the luteal phase is distinguished by a rapid decline of ovarian steroids, which coincides with an incipient increase in FSH and LH levels that will give rise, as mentioned above, to a new growth cycle of ovarian follicles,
Female gonaduct. It is made up, from top to bottom, of the fallopian tubes, uterus, and vagina.
The tubes are musculomembrane ducts 11 to 12 cm long, whose function is to capture the egg and transport it to the uterus, with which it communicates through a tiny hole (tubal ostium).
The uterus or womb is a hollow organ located in the center of the pelvis, between the bladder in front and the rectum behind. It measures from 7 (nulliparous) to 9 (multiparous) cm in length; It has the shape of an inverted pear, weighs between 70 to 100 g and is divided into body (5-6.5 cm) and neck (2-2.5 cm). The uterine body has a thick layer of smooth muscle fiber covered, externally, by the peritoneal serosa, and internally by a mucosa (endometrium) whose primary function is to house the embryo during the nine months of gestation.
The endometrium is the fundamental "target" organ for estrogens and progesterone and is made up of a cubic lining epithelium, glands and stroma, which undergo various changes according to the phase of the menstrual cycle. In the proliferation phase (preovulatory), the endometrium, under the action of estrogens, shows straight glands with abundant mitosis; in the secretion phase (posovulatory) the glands become tortuous, with glycogen secretion inside, and ¿1 stroma becomes loose and edematous; These changes characteristic of the secretion phase prepare the endometrium to receive the egg. If the pregnancy does not take place, when the production of ovarian hormones declines, the endometrium breaks up a portion (no more than 2 mm) from its upper part and eliminates it to the outside.
The first menstruation (menarche) usually appears around the age of 12 and the last (menopause) occurs around the age of 50. The term menopause is defined as the definitive cessation of menstruation resulting from the loss of activity of the ovarian follicles. The term perimenopause or climacteric includes the period before menopause, of very variable duration, during which various alterations of the menstrual cycle appear, and it lasts up to a year after menopause.
Postmenopause is spoken of when more than a year has passed since the cessation of menstruation.
The cervix communicates through its upper end or isthmus with the body and through its lower end it causes a vaginal event. It has a muscular outer layer and an inner layer made up of mucus-producing cylindrical epithelium, which is another "target" organ for ovarian hormones; in fact, under the action of estrogens, the muco-secretory units of the endocervix produce abundant mucus (pre-ovulatory phase), which disappears when progesterone predominates (post-ovulatory phase). The cervical canal communicates through the internal hole with the uterine body and through the external hole with the vagina; This is pointed in the nulliparous and transverse in the pluriparous.
The vagina is a musculomembranous organ that connects the uterus to the outside. Its length is 9 to 10 cm. At the bottom it ends in the vulva or external genitalia and, from there, and with the woman in an erect position, it goes upwards and slightly backwards, forming an angle of approximately 70 "with the horizontal, to end up widening at its end superior and inserting around the cervix, 2 or 3 cm above the external cervical opening. This gives rise to four vaginal cul-de-sac (anterior, right and left lateral and posterior, the last of which corresponds to the lowest point of the peritoneal cavity, or Douglas cul-de-sac). The vagina is the organ of intercourse,
Female external genitalia (vulva). This third organic unit is made up of four medial structures: the mount of Venus, the clitoris and its hood, the urinary meatus and the vestibule, and three lateral ones: labia majora, labia minora, and Bartholino and perivulvar glands.
The mount of Venus is a structure that contains abundant adipose tissue covered by skin. The clitoris is a highly vascular, erectile, cylindrical organ that has abundant nerve endings and whose visible end on the vulva, the glans, is covered by a fold of the labia minora (hood). The vestibule is the area that is exposed when the labia minora are separated and is framed by their insertion into the vulva; The urinary meatus opens at its anterior end and the vaginal opening at its posterior end. The latter, in the virgin woman, is partially occluded by a connective tissue membrane, covered on both sides by a layered pavement epithelium called hymen;
The labia majora are two longitudinal folds of adipose tissue covered by skin that end at the front on the Mount of Venus and at the back join at the midline to form the hairpin. The labia minora are two pigmented skinfolds located inside and parallel to the labia majora. The perivestibular glands correspond to secretory glands whose holes are on both sides of the meatus (Skene's glands) and on both sides of the vaginal opening (Bartholino's glands).
Sexual characters. The fourth organic unit includes different characteristics of the female organism that respond to the secretion of sex steroids. They are the mammary glands, pubic and axillary hair, the voice, the characteristics of the hair, the distribution of fat, the pelvic girdle, the thickness of muscle tissue, etc.
All these sexual characters begin to develop when puberty begins. The most important and related to the semiology of the female reproductive system are three: the breasts, whose initial development —lark— and subsequent growth is carried out under the influence of estrogens and progesterone; pubic hair, whose initial development is called the pubarc and which is distributed in a triangular shape in women, while it is rhomboidal in men, and axillary hair. These last two characters grow under the influence of ovarian and adrenal androgens.
Interrogation. Symptoms and signs. Study methodology
Inexorably, four questions must appear in any medical history of a woman of reproductive age:
- Date of the last menstruation and menstrual type.
- Date of the last gynecological exam, including whether a Pap smear was performed.
- If you have sex, establish whether or not to use contraception (in which case, by what method).
- If you have been pregnant, number of pregnancies and their evolution: abortions (spontaneous or provoked) and deliveries.
If the patient is in postmenopause, another question replaces the last two: if she has received or is receiving replacement hormone therapy, usually consisting of estrogens and / or progesterone.
The first question is essential to rule out the possible existence of a pregnancy, sometimes not even suspected by the patient, and serves to establish the current menstrual rhythm. To this end, the patient will be asked, first, when her last menstruation began and that date is established. Then you will be asked how many days it usually lasts and what is the interval between the beginning of two periods. One way to record the menstrual rate in the medical record is to record, as a numerator, the duration of menstruation, and as a denominator the intermenstrual interval. Example: 3/28 or 4/30, etc.
The second question is intended, fundamentally, to advise and insist before women about the need to attend to the preventive aspects of their reproductive health; the third will evaluate both the possibilities of a pregnancy, according to the greater or lesser efficacy or absence of fertility regulating methods, as well as the possible contraindications and / or side effects of some of them; The fourth question is asked to establish their reproductive capacity together with possible sequelae of possible intrauterine maneuvers (scraping, manual removal of the placenta, etc.).
Finally, the question to the climacteric woman aims to record both a frequent potential cause of postmenopausal bleeding and eventual contraindications and side effects of replacement hormone therapy.
Next, other gynecological manifestations are mentioned about which to ask, along with examinations or complementary techniques to be performed in the presence of various symptoms and / or signs of the female reproductive system.
Menstrual delay and amenorrhea. Menstrual delay means the absence of menstruation for a period of less than 90 days; when this period is longer, it is defined as amenorrhea, which will be primitive if there was never spontaneous uterine bleeding (insist on this point in the questioning, since there are patients who have only had hormone-induced bleeding and are actually primitive amenorrhea) or secondary, if there were one or more periods before amenorrhea.
If one is in the presence of a primitive amenorrhea, its genetic origin must be ruled out first, resorting to the cytogenetic study (sexual chromatin and karyotype) and, secondly, the presence of malformations (gynecological examination and ultrasound). If amenorrhea is secondary, the first thing to rule out is a pregnancy, through the aforementioned questioning and the corresponding immunological tests; in the absence thereof, psychological factors (acute or chronic stress, neurosis, psychosis) or iatrogenic factors (psychotropic drugs and hormones), history of infectious or traumatic brain injuries or severe postpartum hemorrhage, that may compromise pituitary irrigation, or about the presence of symptoms of endocranial hypertension (tumor origin).
Hypermenorrhea and metrorrhagia. Before defining these two symptoms, it is necessary to establish what is understood by eumenorrhea or normal menstruation. It is considered as eumenorrhea to that menstruation that lasts between two and seven days, whose amount is median (this parameter is not easy to define clinically since it is widely subjective and depends largely on the sociocultural conditions of each woman; in general it is considered as a medium quantity in the absence of numerous clots or abundant liquid blood) and that does not cause pain or, if it exists, that does not require major analgesics or rest. Examples of eumenorrhea are these menstrual types: 4 / 28.2 / 22.6 / 34, etc.
Hypermenorrhea means the increase in the amount of blood expelled during menstruation. For metrotragia, all acyclic uterine bleeding.
In the presence of these symptoms, the questioning should be directed to rule out three main causes: organic (tumor or non-tumor), functional (due to hormonal imbalances) and iatrogenic. The first group is ruled out, in its first subgroup, by gynecological examination, hysterography and ultrasound; In the second subgroup, the use of intrauterine devices or the existence of hematological diseases should be investigated. For the second group, a history of previous disturbances of the menstrual cycle and psychological factors will be investigated. Data regarding the use of hormones (iatrogenic bleeding) should always be sought.
Hypomenorrhea This term is applied to all menstruation whose duration is less than two days. In the vast majority of cases this is not pathological and it is called essential hypomenorrhea. In other cases it may be due to partial destruction of the endometrium by recent or distant intrauterine maneuvers (usually abortive) on which the questioning must be directed.
Polymenorrhea. Oligomenorrhea. The first term is used when the interval interval is less than 21 days, and the second term when the interval is greater than 35 days. Also here this can be habitual and correspond to the particular menstrual type of the patient, without pathological implications. Consequently, the questioning must establish whether this is the patient's usual menstrual type, in which case it will not be relevant, or if it is of recent appearance. In this second possibility it may be due to hormonal imbalances and linked to sterility problems on which the questioning will be oriented.
Dysmenorrhea Strictly speaking, the term dysmenorrhea should be applied to all difficulties related to the expulsion of the menstrual product, the term algomenorrhea or painful dysmenorrhea being reserved exclusively for pain related to menstruation. However, the use has enshrined the term dysmenorrhea as a synonym for painful menstruation. Two types of dysmenorrhea must be distinguished: the essential or idiopathic, without apparent cause and which is the one that occurs in young women, generally from menarche, and the symptomatic one, which generally obeys some organic pathology and is acquired and of progressive intensity. In the interrogation it will be necessary to establish when the dysmenorrhea began,
Genital discharge. genital discharge is called the presence in the vagina and / or vulva of secretions -exudates or transudates- that do not exclusively contain blood and that can come from any part of the pelvic genital system.
The interrogation will be directed to establish if the symptom flow, so common in women, is. simply, a physiological fact constituted by the externalization of the mucus produced by the muco-secretory units of the endocervix, or if it is due to the action of microorganisms that act on the vagina or, more rarely, on the endocervix, the endometrium or the tube.
To differentiate both origins, the characteristics of the flow will be investigated. In the case of cervical mucus, it is a liquid, abundant, elastic secretion, which is compared to the "egg white"; it is not accompanied by vulvar itching, appears towards the end of the follicular phase and ceases a couple of days after ovulation. In the second case, and according to the acting microorganism, the flow almost always coexists with vulvar itching and may be white, in "milk curd", odorless (fungi of the Candida genus), or yellow, airy and fetid (for trichomonas), or greyish, airy and fetid (due to Gardnerella vaginatis), or without the characteristics described above (“nonspecific” flow), which can be due to various microorganisms: streptococci, staphylococci, proteus, etc.
Vulvar itching. It is the sensation of itching or burning in the external genitalia. Given this symptom, the first question will be directed to establish whether it is accompanied by flow, in which case it is very likely due to an inflammatory cause (vulvitis or vulvovaginitis). In the absence of flow, the questioning will be oriented to investigate the presence of extragenital causes that can produce itching (diabetes, jaundice, leukemia, etc.). Finally, inspection of the vulva and vagina will eliminate local causes such as inflammation of the periurethral glands (bartholinitis) or such as dystrophy or cancer of the vulva, or will confirm the existence of vulvitis or vulvovaginitis. In the absence of all these factors, itching is called essential and in these cases it is necessary to direct the questioning towards the psychic sphere.
Dyspareunia. Dyspareunia is understood as the presence of difficulties during intercourse (introduction of the erect penis into the vagina), the term algopareunia being reserved for when there is pain during intercourse. Usage has determined that both terms are used synonymously. During the first sexual acts dyspareunia can exist without this being abnormal. If the symptom is persistent and motivates the consultation, the questioning will be directed to establish if there are organic causes (flow, vulvar itching) or if it can be the product of psychic factors (personal and family history, level of previous sexual education, characteristics of the couple, fear of pregnancy, position regarding fertility regulation and use of contraceptive methods).
Frigidity. It is the impossibility, on the part of the woman, of achieving orgasm during intercourse. By the term anorgasmia it is defined to the absolute lack of libido, that is, of sexual desire. Both symptoms can coexist and, together or separately, they are generally due to psychic factors. The questioning will be similar to that mentioned above for dyspareunia. If it is also present, the anamnesis will be directed, in the first place, to discard the organic causes indicated above.
Sterility. It is the impossibility of achieving pregnancy. In Saxon countries it is used only for the absolute impossibility of having children, while the term infertility is used to designate sterility with the possibility of cure. In our environment, this term is reserved for those women who become pregnant but cannot carry pregnancies to term.
A basic concept that must be taken into account when addressing this issue is that this symptom is not unique to women; sterility is conjugal and not, at least "a priori", exclusively or preferably female; The fact that the woman consults more frequently, or first and alone, does not provide a basis for this erroneous and widespread preconception about the responsibility or the greater participation of the female factor in sterile couples.
The first thing to do in a case of infertility is to try to establish the duration of it, since it is less than 6 months for some, or one year for others, it does not require other investigations (the age of the woman —30 years or more) - or the disturbance or anxiety that the lack of pregnancies can cause can reverse this temporary notion). The second question will be directed to find out if the sterility in the couple is primitive (absence of previous pregnancies) or secondary (to one or more previous pregnancies). In the first case, the cause may be due to either the male factor or any of the most frequent female factors (ovarian, tubal or cervical). In the second case, the most frequent factor is the tubal, due to obstruction of the tubes after childbirth or abortions.
Although the in-depth study of the sterile couple is the heritage of the specialist, it is up to the general practitioner to establish the repercussion that this symptom produces on the psychosomatic sphere. Consequently, the couple will be asked about the attitude that each member assumes towards this symptom and about the existence of contemporary psychic or psychosomatic symptoms with sterility.
Mastalgia. It is the perceived pain in the mammary gland. In general terms, it can be mentioned that it is not a relevant symptom since it usually obeys benign breast processes; Cancer of this organ produces pain in advanced periods. Only in lactation does mastalgia demand rapid behavior since it can be linked to established or developing abscesses. When mastalgia appears during the menstrual period it is called mastodynia. The questioning regarding this symptom must establish, then, whether its appearance is premenstrual, extramenstrual or permanent, or whether it is linked to breastfeeding at the time of the consultation or recently terminated.
Spill through the nipple. In the presence of this symptom, the questioning must establish the type of spill. If it is reddish or blackish red, it is surely a galactorrhagia that may be due to malignant pathology that must be ruled out by breast examination, cytology of the effusion and diagnostic imaging methods. If the effusion is white (milk), the presence of cycle alterations will be investigated, especially amenorrhea; In these cases, a possible iatrogenic cause (use of psychotropic drugs or hormonal contraceptives) or tumor (hypophysephial adenoma) will be ruled out, which will be investigated using prolactin determinations and diagnosis by sella turcica. If the spill is white and without alterations of the cycle, or greenish chestnut, the existence of pregnancies and previous lactations will be investigated,
Breast tumor. The existence of a "hardness" in the breasts must set in motion a complete diagnostic methodology that exceeds the limits of this text. There are three guiding questions: the first will establish the age of the symptom; the second if there are changes in the size of the tumor related to the pre and postmenstrual periods; and the third if it coexists with heat and / b flushing of the breast. Prolonged time, premenstrual enlargement and the absence of inflammatory changes will generally guide benign processes.
Pelvian pains. Pelvic (or abdominopelvic) pain is a fairly frequent and nonspecific symptom in women. These characteristics determine that a thorough questioning is necessary to establish whether it actually originates in the reproductive system and, if so, in which organs and by which pathology.
First, the start date will be asked, whether it is acute or chronic and, in the latter case, its intensification with the passage of time. Next, your relationship to menstrual cycles will be established. If it appears before or during menstruation (dysmenorrhea) or if it is extramenstrual. Then the topography of the pain (in hypogastrium and / or iliac fossae) and its spread and eventual link with intercourse (dyspareunia) or with symptoms of other pelvic organs (bladder and intestine) will be investigated. It is also worth asking about the magnitude of the pain and, if it requires pain relievers, its type. An additional element to consider is if it is accompanied by other gynecological symptoms such as discharge or bleeding.