15.1 Disorders of the Female Reproductive System

Menstrual disorders and gynecologic conditions can significantly impact women's health. From amenorrhea to endometriosis, these issues affect the menstrual cycle, fertility, and overall well-being. Understanding their causes and symptoms is crucial for early detection and treatment.

Gynecologic cancers pose serious health risks, with each type having unique risk factors and symptoms. Pelvic inflammatory disease, often caused by sexually transmitted infections, can lead to long-term complications if left untreated. Prompt diagnosis and appropriate management are essential for preserving reproductive health.

Menstrual Disorders and Gynecologic Conditions

Pathophysiology of menstrual disorders

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• Amenorrhea
  • Primary amenorrhea manifests as absence of menarche by age 16 signals potential developmental issues
  • Secondary amenorrhea occurs when menses cease for 3 consecutive cycles or 6 months indicates hormonal disruption
  • Hormonal imbalances disrupt normal menstrual cycle, structural abnormalities impede menstrual flow, genetic disorders affect reproductive development (Turner syndrome)
  • Absence of menstrual periods primary symptom, headaches and vision changes suggest pituitary involvement, excess facial hair growth indicates androgen excess
• Dysmenorrhea
  • Primary dysmenorrhea involves painful menstruation without underlying pathology common in young women
  • Secondary dysmenorrhea stems from underlying conditions (endometriosis, fibroids)
  • Excessive prostaglandin production triggers intense uterine contractions causing pain and associated symptoms
  • Cramping lower abdominal pain radiates to lower back, nausea and vomiting result from prostaglandin effects, diarrhea occurs due to intestinal smooth muscle contractions
• Menorrhagia
  • Abnormally heavy or prolonged menstrual bleeding exceeds 80 mL blood loss per cycle
  • Hormonal imbalances disrupt endometrial shedding, uterine fibroids increase bleeding surface area, coagulation disorders impair clotting
  • Bleeding lasting more than 7 days extends normal cycle length, large blood clots indicate heavy flow, anemia symptoms develop from chronic blood loss, frequent changing of menstrual products (every 1-2 hours) signifies excessive flow

Causes of endometriosis and PCOS

• Endometriosis
  • Retrograde menstruation deposits endometrial tissue outside uterus
  • Coelomic metaplasia transforms peritoneal cells into endometrial-like tissue
  • Lymphatic or vascular spread transports endometrial cells to distant sites
  • Family history increases risk by 7-10 times, early menarche or late menopause prolongs estrogen exposure, short menstrual cycles (< 27 days) increase tissue shedding, nulliparity associated with continuous menstruation
  • Chronic pelvic pain persists throughout menstrual cycle, infertility occurs in 30-50% of cases, adhesions and scar tissue formation distort pelvic anatomy, ovarian cancer risk increases 2-3 fold
• Polycystic Ovary Syndrome (PCOS)
  • Hormonal imbalances manifest as elevated androgens and insulin resistance disrupting ovulation
  • Genetic factors contribute to PCOS development (multiple genes involved)
  • Obesity exacerbates insulin resistance and hormonal imbalances, family history indicates genetic predisposition, insulin resistance leads to compensatory hyperinsulinemia
  • Infertility results from anovulation, type 2 diabetes risk increases 5-10 fold, cardiovascular disease risk elevates due to metabolic abnormalities, endometrial hyperplasia and cancer risk rises from chronic anovulation

Types of gynecologic cancers

• Cervical cancer
  • HPV infection primary risk factor (types 16 and 18), smoking increases risk 2-fold, multiple sexual partners elevate HPV exposure
  • Regular Pap smears and HPV testing detect precancerous changes, recommended every 3-5 years
  • Treatment options include surgery (conization, hysterectomy), radiation (external beam, brachytherapy), chemotherapy (cisplatin-based)
• Ovarian cancer
  • Age increases risk (peak incidence 60-64 years), family history elevates risk 3-fold, BRCA gene mutations increase lifetime risk to 40-60%
  • Early detection challenging due to vague symptoms (bloating, pelvic pain, urinary frequency)
  • Treatment involves debulking surgery and platinum-based chemotherapy
• Endometrial cancer
  • Obesity doubles risk for every 5-point increase in BMI, estrogen exposure without progesterone opposition increases risk, diabetes associated with 2-fold increased risk
  • Abnormal vaginal bleeding prompts endometrial biopsy for early detection
  • Treatment includes hysterectomy with bilateral salpingo-oophorectomy, radiation for advanced stages, hormone therapy for certain subtypes
• Vulvar cancer
  • HPV infection contributes to 40% of cases, chronic vulvar inflammation (lichen sclerosus) increases risk
  • Regular gynecological exams facilitate early detection of vulvar lesions
  • Treatment primarily surgical (wide local excision or vulvectomy), radiation for advanced cases
• Early detection and treatment importance
  • Improved survival rates (5-year survival for stage I cervical cancer > 90%)
  • Less aggressive treatment options preserve organ function
  • Fertility preservation possible with early-stage gynecologic cancers
  • Better quality of life outcomes with less extensive surgeries and treatments

Pelvic inflammatory disease management

• Pathophysiology of PID

  • Ascending infection from lower genital tract introduces bacteria to upper reproductive organs
  • Chlamydia trachomatis and Neisseria gonorrhoeae most common causative organisms (60-80% of cases)
  • Inflammation and scarring of fallopian tubes, ovaries, and uterus lead to long-term sequelae

• Diagnosis of PID

  • Clinical criteria include lower abdominal pain, cervical motion tenderness, adnexal tenderness (minimum 2 required)
  • Laboratory tests show elevated white blood cell count, positive cervical cultures for STIs
  • Imaging studies (transvaginal ultrasound, CT scan) detect tubo-ovarian abscesses or other complications

• Management of PID

  1. Initiate broad-spectrum antibiotic therapy (ceftriaxone + doxycycline + metronidazole)
  2. Provide pain management with NSAIDs or opioids if severe
  3. Treat sexual partners to prevent reinfection
  4. Consider hospitalization for severe cases, pregnancy, or treatment failure

• Potential long-term consequences of PID

  • Chronic pelvic pain affects 30% of women post-PID
  • Ectopic pregnancy risk increases 6-10 fold
  • Infertility occurs in 10-15% of cases due to tubal scarring
  • Increased risk of future PID episodes (15-20% recurrence rate)
  • Tubo-ovarian abscess formation complicates 15% of cases