W3: Female reproductive system

Question 1

Discuss ovaries with respect to peritoneum

Answer 1

Intra

Question 2

Ovarian ligaments

Answer 2

- proper ovarian ligament
(to the side wall of the uterus )
- suspensory ligament of the
ovary (to the pelvic wall).

Question 3

Structure of ovary

Answer 3

Central medulla
Peripheral cortex
Tunica albuginea - has a layer of germinal epithelial

Question 4

Ligaments of ovary

Answer 4

Each ovary is attached to the broad ligament of the uterus by the mesovarium and is suspended within the peritoneal cavity by the suspensory lig-ament of the ovary, which passes to the lateral abdominal wall. The suspensory ligament transmits the ovarian artery, vein and ovarian nerve plexus. The ovary is also attached to the side wall of the uterus via the utero-ovarian ligament.

3 ligaments

Question 5

Arterial supply of ovaries

Answer 5

Ovarian arteries (L2)

Question 6

Venous drainage of ovaries

Answer 6

➢Right ovarian vein: to IVC
➢Left ovarian vein: to left renal vein

Venous drainage is via the pampiniform venous plexus, which passes blood first to the ovarian vein, and then to the left renal vein on the left and inferior vena cava on the right.

Question 7

Structure of Fallopian tubes

Answer 7

Infundibulum – the funnel-shaped end of the oviduct which collects ovulated oocyte from the peritoneal cavity.

Ampulla – widest and longest part, responsible for the secretion of nutrients required by the ovulatedovum. This is the most common site of fertilisation.

Isthmus – passes to the uterine horn.

Uterine part – passes through the wall of the uterus to open into the uterine cavity at the uterine ostium.

Question 8

Where do the oviducts lie?

Answer 8

The oviducts lie within a mesentery called the mesosalpinx, which forms the superior edge of the broad ligament.

Question 9

Blood supply of oviducts

Answer 9

he ovi- ducts are supplied by both the ovarian and ascending uterine arteries.

Question 10

Structure of uterus

Answer 10

Portions:

• Body (corpus uteri)
• Fundus
• Horns
• Isthmus
• Cervix
  
  • Internal os
  • Cervical canal
  • External os

Question 11

Normal position of the cervix

Answer 11

The cervix is anteverted (angled anteriorly in respect to the vagina).

The body of the uterus is anteflexed (anterior position in
respect to the cervix).

Question 12

What is the external os surrounded by?

Answer 12

vaginal fornix

Question 13

Broad ligament

Answer 13

Broad ligament is a fold of the peritoneum in the coronal plane from the lateral pelvic wall to the uterus.

Divided into 3 portions:

• mesometrium - in relation to uterine wall
• mesosalpix - relation to tubes
• Mesovarium - relation to ovary

Question 14

Suspensory ligaments of the uterus and cervix

Answer 14

• Round ligament - enters inguinal canal and inserts to labia majora
• Pubocervical
• Transverse cervical (cardinal) - most important supporting structure
• Uterosacral (posterior) ligament

Question 15

Blood supply of the uterus

Answer 15

The uterus is supplied by the uterine artery, which arises from the internal iliac artery. The artery passes across the anterior aspect of the ureter, reaching the lateral walls of the uterus via the cardinal ligament. The uterus is drained by the uterine veins, which pass to the internal iliac veins through the cardinal ligaments.

Question 16

Vasculature of vagina

Answer 16

The superior part of the vagina is supplied by the uterine arteries, whilst the middle and inferior parts are supplied by the vaginal and internal pudendal arteries.

Vaginal artery comes from internal iliac (analogue to inferior vesicle)

Question 17

Lymphatic drainage of ovary, uterus, vagina

Answer 17

• Ovaries: to para-aorticlymph nodes.
• Fundus of uterus: to para-aortic, lumbarand superficial inguinal lymph nodes.
• Body and cervix of the uterus: to internal iliac lymph nodes.
• Vagina: to iliac and superficial inguinal lymph nodes.

Question 18

Ovarian Cancer

Answer 18

Ovarian cancer is the 5th leading cause of cancer-related deaths in women. Risk of ovarian cancer is increased by family history of ovarian cancer, early menarche, late menopause and nulliparity (lack of children). Most ovarian cancers originate from the epithelium of the ovaries. These cancers are usually diagnosed at a late stage due to the absence of symptoms at early stages and, depending on subtype, may metastasise to a number of locations including the para-aortic lymph nodes, liver, lungs and peritoneum. Symptoms, if present, include abdominal/pelvic masses, changes in bowel habits, unexplained abdominal pain and a sensation of bloating. Treatment is typically surgical removal of the uterus, oviducts and ovaries (bilateral salpingo-oophorectomy and hysterectomy) followed by postoperative chemotherapy.

Question 19

Uterine cancer

Answer 19

Endometrial (uterine) cancer is the 4th most common cancer in females and typically affects postmen- opausal women. Risk factors include unopposed oestrogen use (such as HRT use), obesity and diabetes. Endometrial cancer should be suspected in patients that report postmenopausal bleeding. Endometrial cancer may spread to the bladder, rectum, vagina, oviducts, ovaries and more distant structures. Treatment involves hysterectomy, bilateral salpingo-oophorectomy and, if malignant cells are found in the draining lymph nodes, a pelvic and para-aortic lymphadenectomy is required.

Question 20

Ovarian cysts

Answer 20

Two types of benign cyst may develop within the ovary: follicular cysts from the Graafian follicles and Corpus Luteum cysts. Most cysts are <2cm in diameter, usually asymptomatic and usually resolve without further treatment. Rupture of haemorrhagic corpus luteum cysts may cause sudden onset pain and signs of peritonitis. Pain from ovarian cyst rupture may occur in the lower abdomen, which is typically unilat- eral and sharp in character, due to irritation of the parietal peritoneum. Patients with polycystic ovary syndrome (PCOS) have multiple cysts within their ovaries, associated with obesity, abnormal menses and signs of excessive androgen production, including acne and abnormal hair growth. Treatment for PCOS is typically symptomatic.

Question 21

Uterine Retroversion & Retroflexion

Answer 21

A retroverted uterus is posteriorly tilted, which is seen in around 20% of females. A retroflexed uterus is where the fundus is pointing backwards (towards the rectum), creating a convex uterus anteriorly. This position may be caused by genetic factors and considered a normal variant, or may be indicative of pathol- ogy, such as adhesions, endometriosis or fibroids. The position of the uterus can be determined by a pelvic examination or ultrasound scan.

Question 22

Uterine Prolapse

Answer 22

Uterine prolapse refers to the descent of the uterus towards the external genitalia and may be graded on the extent of the descent. Symptoms may include a feeling of fullness or pressure within the pelvic region. Prolapse typically occurs in old age, particularly if the uterine components have been damaged during childbirth or the supportive ligaments and pelvic floor have become weakened. For moderate prolapses, patients may be treated with a pessary which structurally supports the uterus. For more severe prolapses, hysterectomy with surgical strengthening of the pelvic support structures may be required.