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ANATOMY and PHYSIOLOGY (Female Reproductive System) Functions The female reproductive system is designed to carry out several

l functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next step for the fertilized egg is to implant into the walls of the uterus, beginning the initial stages of pregnancy. If fertilization and/or implantation does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. The female reproductive anatomy includes parts inside and outside the body.

The function of the external female reproductive structures (the genitals) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include: Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholin's glands: These glands are located beside the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the

foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect. The internal reproductive organs in the female include: Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall.

The Menstrual Cycle

Phases of the Menstrual Cycle There are four main phases to the menstrual cycle that are governed by your hormones. They are the follicular phase, the ovulatory phase, the luteal phase, and the menstrual phase. Each phase has a specific function and result. a.) The Follicular Phase The follicular phase occurs early in your cycle. During this phase the level of follicle stimulating hormone (FSH) is increasing, causing your ovaries to mature the eggs. About five to seven days into this phase a dominant follicle will appear, which has gotten more nourishment from your body than the other follicles. Your estrogen levels are on the rise. Your luteinizing hormone (LH) is low but rising, and your progesterone levels are low as well. This phase lasts about ten to eleven days for the average twenty-eight-day cycle. b.) The Ovulatory Phase The ovulatory phase occurs in the middle of your cycle. Your estrogen levels rise rapidly from about day 10 until day 15, at which point it decreases again. During this phase you will have a smaller surge of the FSH to begin ovulation, with a

large rapid surge of LH. Because it is no longer needed to house the oocyte, the dominant follicle begins to collapse during this phase, causing your body to produce more progesterone to help build and maintain the lining of your uterus should the egg fertilize. c.) The Secretory Phase It is during this secretory phase that your endometrium, or uterine lining, builds. This lining will be the home of your new baby until birth, should pregnancy occur. If you do not get pregnant during this cycle, the lining is sloughed off during your period as you go through progesterone withdrawal. This phase usually lasts about thirteen days. During the secretory phase, your ovaries are also going through the luteal phase. Your luteal phase finds your LH levels and FSH levels returning to normal. Your estrogen levels are not as high as they were at their peak, but are still above their baseline levels. However, your progesterone levels surge until the end of this phase. d.)The Menstrual Phase The menstrual phase is just what it sounds like. If pregnancy has not occurred, the spot on your ovary where the last egg was released, called the corpus luteum, begins to die and your menstrual cycle begins. If a pregnancy has occurred, the corpus luteum will produce hormones until the production of those hormones is taken over by the placenta, around twelve to fourteen weeks gestation. As your corpus luteum collapses, your progesterone levels fall and your body begins to cleanse itself of the uterine lining. Typically, menstrual bleeding will last four days, though it can last anywhere from two to eight days. The average length of your cycle will probably vary. The average cycle lasts twenty-eight days, but it is perfectly normal to have a cycle ranging anywhere from twenty-one to thirty-five days in length.

The Fertilization Process

The fertilization process is the meeting of the sperm of the male and the egg of the female during sexual intercourse. It is a vital process which occurs in humans and animals to ensure the continuation of life on the planet. Through the fertilization process, a new life is formed in the egg with characteristics much like the parents. After a certain period of development, the new organism is born. In humans, the fertilization process most often occurs when sexual intercourse takes place during a woman's fertile or ovulation period. A woman is usually fertile on about the 14th day of her menstrual cycle. Days before the woman ovulates, her cervix secretes mucus, which allows sperm to travel faster towards the uterus and into the fallopian tubes. During ovulation, a mature egg is released by the ovary to the fallopian tube. For about 12 to 24 hours, the mature egg is ready to be fertilized. Sperm released inside the vagina travel towards the uterus to the fallopian tube to seek out the egg. Hundreds of thousands of sperm may be released during ejaculation, but

only one gets to penetrate the egg and start the fertilization process. Sperm are capable of staying alive for 48 to 72 hours inside the female reproductive tract, and can fertilize the egg as soon as ovulation takes place. When sperm and egg meets, a zygote is formed.

THEORETICAL BACKGROUND A. Definition of the Disease An ectopic pregnancy (EP) is a condition in which a

fertilized egg settles and grows in any location other than the inner lining of the uterus. The vast majority of ectopic pregnancies are so-called tubal pregnancies and occur in the Fallopian tube (98%); however, they can occur in other locations, such as the ovary, cervix, and abdominal cavity. An ectopic pregnancy occurs in about one in 50 pregnancies. A molar differs from an ectopic in that it is usually a mass of tissue derived from an egg with incomplete genetic information that grows in the uterus in a grape-like mass that can cause symptoms to those of pregnancy. B. Signs and Symptoms The classic signs and symptoms of ectopic pregnancy include: abdominal pain, the absence of menstrual periods (amenorrhea), and vaginal bleeding or intermittent bleeding (spotting). The woman may not be aware that she is pregnant. These characteristic symptoms occur in ruptured ectopic pregnancies (those accompanied by severe internal bleeding) and nonruptured ectopic pregnancies. However, while these symptoms are typical for an ectopic pregnancy, they do not mean an ectopic pregnancy is necessarily present and could represent other conditions. In fact, these symptoms also occur with a threatened abortion (miscarriage) in nonectopic pregnancies. The signs and symptoms of an ectopic pregnancy typically occur six to eight weeks after the last normal menstrual period, but they may occur later if the ectopic pregnancy is not located in the Fallopian tube. Other symptoms of

pregnancy (for example, nausea and breast discomfort, etc.) may also be present in ectopic pregnancy.

C. Causes, Incidence and Risk Factors An ectopic pregnancy occurs when a pregnancy starts outside the womb (uterus). the The most to common site for an ectopic tube). pregnancy is within one of the tubes through which the egg passes from ovary the uterus (fallopian However, in rare cases, ectopic pregnancies can occur in the ovary, stomach area, or cervix. An ectopic pregnancy is often caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage in the tube by hormonal factors and by other factors, such as smoking. Most cases of scarring are caused by: Past ectopic pregnancy Past infection in the fallopian tubes Surgery of the fallopian tubes Up to 50% of women who have ectopic pregnancies have had swelling (inflammation) of the fallopian tubes (salpingitis) or pelvic inflammatory disease (PID). Some ectopic pregnancies can be due to: Birth defects of the fallopian tubes Complications of a ruptured appendix Endometriosis Scarring caused by previous pelvic surgery The following may also increase the risk of ectopic pregnancy: Age over 35

Having had many sexual partners In vitro fertilization In a few cases, the cause is unknown. Sometimes, a woman will become pregnant after having her tubes tied (tubal sterilization). Ectopic pregnancies are more likely to occur 2 or more years after the procedure, rather than right after it. In the first year after sterilization, only about 6% of pregnancies will be ectopic, but most pregnancies that occur 2 - 3 years after tubal sterilization will be ectopic. Ectopic pregnancy is also more likely in women who have: Had surgery to reverse tubal sterilization in order to become pregnant Had an intrauterine device (IUD) and became pregnant (very unlikely when IUDs are in place) Ectopic pregnancies occur in 1 in every 40 to 1 in every 100 pregnancies.

D. Diagnosis The health care provider will do a pelvic exam, which may show tenderness in the pelvic area. Tests that may be done include: Culdocentesis Hematocrit Pregnancy test Quantitative HCG blood test Serum progesterone level Transvaginal ultrasound or pregnancy ultrasound White blood count A rise in quantitative HCG levels may help tell a normal

(intrauterine) pregnancy from an ectopic pregnancy. Women with high levels should have a vaginal ultrasound to identify a normal pregnancy. Other tests may be used to confirm the diagnosis, such as: D and C Laparoscopy Laparotomy

E. Treatment Ectopic pregnancies cannot continue to birth (term). The

developing cells must be removed to save the mother's life. You will need emergency medical help if the area of the ectopic pregnancy breaks open (ruptures). Rupture can lead to shock, an emergency condition. Treatment for shock may include: Blood transfusion Fluids given through a vein Keeping warm Oxygen Raising the legs

MEDICAL TREATMENT Methotrexate, a folic acid antagonist, is a well-studied medical therapy. Methotrexate deactivates dihydrofolate reductase, which reduces tetrahydrofolate levels (a cofactor for deoxyribonucleic acid and ribonucleic acid synthesis), thereby disrupting rapidly-dividing trophoblastic cells. Other therapeutic agents include hyperosmolar glucose, prostaglandins, and mifepristone (Mifeprex).

SURGICAL TREATMENT Before the advent of laparoscopy, laparotomy with salpingectomy (removal of the fallopian tube through an abdominal incision) was the standard therapy for managing ectopic pregnancy. Laparoscopy with salpingostomy, without fallopian tube removal, has become the preferred method of surgical treatment. Laparoscopy has similar tubal patency and future fertility rates as medical treatment. Salpingostomy has an estimated 8 to 9 percent failure rate, which can be managed with methotrexate. If there is a rupture, surgery (laparotomy) is done to stop blood loss. This surgery is also done to: Confirm an ectopic pregnancy Remove the abnormal pregnancy Repair any tissue damage

Sources: Menstrual Cycle Biology of the Female Reproductive System;

Merck Manual; accessed 07/20/07 Copyright 2011 Yahoo!7 Inc. All Rights Reserved. qid=20070514161232AAaaSLb Richard E. Jones and Kristin H. Lopez, Human Reproductive Biology, Third Edition, Elsevier, 2006, page 238 Marieb, Elaine M. Human Anatomy and Physiology, 5th ed. pp. 1119-1122 (2001) Barnhart KT. Ectopic pregnancy. N Engl J Med. 2009;361:379387. [PubMed]

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