S2) The Woman

Question 1

Identify the following structures in the female reproductive system:

Answer 1

Question 2

Describe the clinical basis for a sharp pain at ovulation

Answer 2

• Mittelschmerz pain is pelvic/lower abdominal pain felt during ovulation
• Exact cause is unknown

Question 3

Why do nuns tend to get ovarian cancer?

Answer 3

They have the maximum number of follicular ruptures, thus get repeated healing/scarring which predisposes them to cancer

Question 4

What are ovarian cysts?

Answer 4

Ovarian cysts are large fluid filled lesions on the ovary

Question 5

How might a patient with an ovarian cyst present?

Answer 5

• Lower abdominal pain (stretching of perineum, rupture / torsion of ovary)
• Bloating
• Back pain

Question 6

Identify the following structures on the uterus:

• Uterine tube
• Fundus
• Vagina
• Cervix
• Body

Answer 6

Question 7

What sort of structure is the cervix?

Fibrous or muscular?

Answer 7

Fibrous structure

Question 8

Distinguish between the external Os of a cervix that has had a baby passed through and one that hasn’t

Answer 8

Question 9

Why do pregnant women experience the following symptoms:

• Acid reflux
• Constipation
• Polyuria

Answer 9

• Acid reflux: uterus pushes on stomach from below
• Constipation: uterus pushes backwards onto large intestine
• Polyuria: uterus pushes downwards onto bladder

Question 10

In terms of fertilisation, what is the clinical significance of the uterine tubes?

Answer 10

Site of fertilisation

Question 11

What is notable about the ampulla region of the fallopian tube?

Answer 11

Most common site for ectopic pregnancies

• normally places that aren’t in the uterus wall

Question 12

What is the most important investigation in women of reproductive age with abdominal pain?

Answer 12

Pregnancy test

Question 13

Identify the peritoneal ligaments

Answer 13

• Broad ligament
• Round ligament
• Ovarian ligament
• Suspensory ligament of the ovary

Question 14

Describe the structure of the broad ligament

Answer 14

Broad ligament – peritoneal fold, covers uterus, fallopian tube and ovary like a vacuum

Question 15

Describe the structure of the suspensory ligament of the ovary

Answer 15

Suspensory ligament of the ovary – neurovascular pathway bulging into peritoneum supplies the ovaries

Question 16

Describe the origins of the round ligament and the ligament of ovary

Answer 16

Round ligament and ligament of ovary – remnants of the gubernaculum, helps keep uterus anteverted and anti flexed

Question 17

What is the mesovarium?

Answer 17

Mesovarium is the portion of the broad ligament of the uterus that suspends the ovaries

Question 18

What is the mesosalpinx?

Answer 18

Mesosalpinx is the portion of the broad ligament that stretches from the ovary to the level of the uterine tube

Question 19

What is the mesometrium?

Answer 19

Mesometrium is the mesentery of the uterus, composing most of the broad ligament of the uterus, excluding only the mesosalpinx and the mesovarium

Question 20

How does the uterus get its blood supply?

Answer 20

• Uterine artery
• Ovarian artery

Question 21

What is significant about the axis of cervix?

Answer 21

• Axis of cervix to axis of vagina < 180^o = cervix is anteverted (most common)
• Axis of cervix to axis of vagina >180^o = cervix is retroverted

Question 22

What is significant about the axis of uterine body?

Answer 22

• Axis of uterine body to axis of vagina < 180^o = uterus is anteflexed (most common)
• Axis of uterine body to axis of vagina > 180^o = uterus is retroflexed

Question 23

How is anteversion/anteflexion maintained?

Answer 23

Peritoneal ligaments

Question 24

Describe the three different types of vaginal mutilation

Answer 24

• Removal of clitoris
• Removal of all except urethra and vagina
• Everything is removed, sewn up and leaving a tiny opening for urine

Question 25

What is the origin of the blood supply to the ovary?

Answer 25

The ovarian artery arises from the **abdominal aorta**

Question 26

Describe the venous drainage of the left and right ovaries

Answer 26

- Left ovarian vein (LOV) drains into **left renal vein** - Right ovarian vein (ROV) drains into the **inferior vena cava**

Question 27

To which lymph nodes does the ovary drain?

Answer 27

Para-aortic lymph nodes

Question 28

Identify the following areas in the fallopian tube: - Fimbriae - Ampulla - Isthmus

Answer 28

* fimbriae transport the egg from the ovary to the Fallopian tube

Question 29

How might infection spread to the peritoneum from the female reproductive tract?

Answer 29

Via the fimbrae, there is a gap in the abdomen where potential infection could spread to

Question 30

Describe how the tissue structure of the Fallopian tube facilitates the transport of the ovum towards the uterus

Answer 30

- **Peristalsis:** muscular tube moves ovum in peristaltic waves - **Cilliary sweeps:** unidirectional movement of ovum

Question 31

What may be the consequence of infection in the uterine tubes?

Answer 31

- Scarring - Ectopic pregnancy - Infection could spread to peritoneum (peritonitis)

Question 32

Where would pain be felt with an ectopic pregnancy implanted in the ampulla of the uterine tubes?

Answer 32

Iliac fossa

Question 33

Why is shoulder tip pain associated with the rupture of an ectopic pregnancy?

Answer 33

Blood runs up **paracolic recesses** (spaces between abdominal wall and colon) which compresses the phrenic nerve

Question 34

Describe the arterial supply to the uterine tubes

Answer 34

- Uterine arteries - Ovarian arteries

Question 35

Be able to identify the following structures: - Ovarian artery - Uterine artery - Vagina artery - Internal pudendal artery

Answer 35

Question 36

Why is the ureter at risk of being damaged during a hysterectomy?

Answer 36

- When removing the uterus, the uterine artery is clamped - The ureter is closely associated to the uterine artery (water under the bridge) * can feel the difference between the ureter and artery because ureter will undergo peristalsis and you can feel it

Question 37

What are the posterior anatomical relations of the vagina?

Answer 37

- Rectum - Anus

Question 38

What are the anterior anatomical relations of the vagina?

Answer 38

- Bladder - Urethra

Question 39

What are the lateral anatomical relations of the vagina?

Answer 39

- Ureter - Uterine artery

Question 40

In terms of lymphatic drainage, identify the structures below:

Answer 40

Question 41

In terms of the vulva, label the following structures: - Mons pubis - Labia majora & minora - Clitoris - Vestibule of the vagina - External urethral orifice - Anus

Answer 41

Question 42

Describe the structure of the recto-uterine pouch

Answer 42

- Aka **pouch of Douglas** - It is an extension of peritoneum between the posterior wall of uterus and the rectum in females

Question 43

Describe the structure of the vesico-uterine pouch

Answer 43

**Vesico-uterine pouch** is a second but shallower pouch formed from the peritoneum over the uterus and bladder

Question 44

In a bimanual/pelvic examination, which structure can be palpated anteriorly from the fornix?

Answer 44

Vesico-uterine pouch

Question 45

In a bimanual / pelvic examination, what structures can be palpated from the posterior fornix?

Answer 45

Recto-uterine pouch

Question 46

peg cells

Answer 46

* found in the ampulla * secrete nutrients and supportive factors for sperm to gain more energy to reach the egg cells

Question 47

pouch of Douglas relevance

Answer 47

* lowest part of the abdomen * fluid can collect containing infections

Question 48

which lymph nodes do the lymphs of the uterus drain

Answer 48

internal iliac

Question 49

which lymph nodes does the lower third of the vagina drain

Answer 49

superficial inguinal

Question 50

which tissue do the gonads develop

Answer 50

intermediate mesoderm in the abdomen

Question 51

what structure does the uterus develop

Answer 51

paramesonephric duct