External Genitalia

The external female genitalia, or vulva, extend from the mons pubis to the anal opening. The mons pubis is a fat pad that covers the symphysis pubis and protects it during coitus (sexual intercourse).

The labia majora are two vertical folds of adipose tissue that extend posteriorly from the mons pubis to the perineum. The size of the labia majora varies depending on the amount of fatty tissue present. The skin over the labia majora is usually darker than the surrounding skin and is highly vascular. It protects inner vulval structures and enhances sexual arousal.

The labia majora surround two thinner, vertical folds of reddish epithelium called the labia minora. The labia minora are highly vascular and have a rich nerve supply. Emotional or physical stimulation produces marked swelling and sensitivity. Numerous sebaceous glands in the labia minora lubricate the entrance to the vagina. The clitoris is a small, cylindric organ that is composed of erectile tissue with a high concentration of sensory nerve endings. During sexual arousal, the clitoris becomes larger and increases sexual sensation.

The vestibule is a longitudinal area between the labia minora, the clitoris, and the vagina that contains Bartholin glands and the openings of the urethra, Skene’s glands (paraurethral glands), and vagina. The two Bartholin glands, located deeply toward the back on both sides of the vaginal opening, secrete lubrication fluid during sexual excitement. Their ductal openings are usually not visible.

The area between the vaginal opening and the anus is the perineum. The skin of the perineum covers the muscles, fascia, and ligaments that support the pelvic structures.

Internal Genitalia

The internal female genitalia are shown in Fig. 72-1. The vagina is a hollow tube that extends from the vestibule to the uterus. In addition to being the channel for the passage of the menstrual flow, the vagina allows for insertion of the penis during intercourse and passage of the fetus during a vaginal birth. Reduced estrogen levels occurring during menopause cause the vaginal wall to become dry, thinner, and smoother. The vagina then atrophies and is prone to pathogenic growth, resulting in a variety of types of infections.

FIG. 72-1 Internal female genitalia.

The amounts of glycogen and lubricating fluid secreted by the vaginal cells are influenced by ovarian hormones. The normal vaginal bacteria (flora) interact with the secretions to produce lactic acid and maintain an acidic pH (3.5 to 5) in the vagina. This acidity helps prevent infection in the vagina.

At the upper end of the vagina, the uterine cervix projects into a cup-shaped vault of thin vaginal tissue. The recessed pockets around the cervix permit palpation of the internal pelvic organs. The posterior area provides access into the peritoneal cavity for diagnostic or surgical purposes.

The uterus (or “womb”) is a thick-walled, muscular organ attached to the upper end of the vagina. This inverted pear–shaped organ is located within the true pelvis, between the bladder and the rectum. The uterus is made up of the body and the cervix.

The upper segment of the uterine body, between the insertion sites of the fallopian tubes, is referred to as the fundus. Although the uterus is a hollow organ, its walls are in such close proximity in the nonpregnant state that its cavity is merely a slit.

The cervix is a short (1 inch [2.5 cm]), narrowed portion of the uterus and extends into the vagina. The surface of the cervix and the canal are the sites for Papanicolaou (Pap) testing. (See discussion on p. 1581.)

The fallopian tubes (uterine tubes) insert into the fundus of the uterus and extend laterally close to the ovaries. They provide a duct between the ovaries and the uterus for the passage of ova and sperm. In most cases, the ovum is fertilized in these tubes.

The ovaries are a pair of almond-shaped organs located near the lateral walls of the upper pelvic cavity. After menopause, they become smaller. These small organs develop and release ova and produce the sex steroid hormones (estrogen, progesterone, androgen, and relaxin). Adequate amounts of these hormones are needed for normal female growth and development and to maintain a pregnancy.

Breasts

The female breasts are a pair of mammary glands that develop in response to secretions from the hypothalamus, pituitary gland, and ovaries. The breasts are an accessory of the reproductive system that nourish the infant after birth.

Breast tissue is composed of a network of glandular and ductal tissue, fibrous tissue, and fat. The proportion of each component of breast tissue depends on genetic factors, nutrition, age, and obstetric history. The breasts are supported by ligaments that are attached to underlying muscles. They have abundant blood supply and lymph flow that drains from an extensive network toward the axilla (Fig. 72-2).

FIG. 72-2 Lymphatic drainage of the female breast.

Nutrition History

A nutrition history is often critical for an accurate assessment of reproductive system problems. For example, fatigue and low libido may occur with poor diet and anemia. Obesity raises the risk for uterine cancer. High-fat diets may increase the risk for cancer of the breast, ovary, and prostate gland (American Cancer Society [ACS], 2010). Ask the patient to recall his or her dietary intake for a recent 24-hour period to assess quality.

Assess the patient’s height, weight, and body mass index. The patient may be hesitant to discuss practices such as bingeing, purging, anorexic behaviors, or excessive exercise. However, these practices may affect the reproductive system. A certain level of body fat and weight is necessary for the onset of menses and the maintenance of regular menstrual cycles. Decreased body fat results in insufficient estrogen levels.

Women have special nutrition needs. Those who use oral contraceptives need increased sources of folic acid and vitamins B₆, B₁₂, and C. Heavy menstrual bleeding, particularly in women who have intrauterine devices, may require oral iron supplements. Teach all women of any age about their body’s need for calcium. Although adequate calcium intake throughout life is needed, it is especially important during and after menopause to help prevent osteoporosis due to decreased estrogen production (see Chapter 53).

Family History and Genetic Risk

The family history helps determine the patient’s risk for conditions that affect reproductive functioning. A delayed or early development of secondary sex characteristics may be a familial pattern.

The current age and health status of family members are important. Evidence of medical diseases or reproductive problems in family members (e.g., diabetes, endometriosis, reproductive cancer) allows better interpretation of the patient’s current symptoms. For example, daughters of women who were given diethylstilbestrol (DES) to control bleeding during pregnancy are at increased risk for infertility and reproductive tract cancer.

Specific BRCA1 and BRCA2 gene mutations increase the overall risk for breast or ovarian cancer (ACS, 2010). Men with first-degree relatives (e.g., father, brother) with prostate cancer are at greater risk for the disease than men in the general population. Testicular cancer can also be familial (ACS, 2010). More information about genetic risks is discussed with specific health problems in later chapters of this unit.