L
27 The Male Reproductive System
Objectives
In this chapter we will study
· the common symptoms of disorders of the male reproductive system;
· diagnostic procedures for examining the male reproductive system;
· the causes and course of gynecomastia;
· the scrotal disorders hydrocele, varicocele, and spermatocele;
· several testicular disorders-ectopic testis, torsion of the testis, and testicular cancer; and
· prostatic disorders, specifically prostatitis, benign prostatic hyperplasia, and prostate cancer.
Assessment of the Male Reproductive
System
Because the male reproductive system is closely
related to the urinary system, many of the same
diagnostic procedures are used to evaluate both.
Additional physical evaluations and laboratory tests
are available for assessing the reproductive system
alone.
Pain is one of the most common symptoms of
male reproductive system disease. It may be diffuse
pain in the groin or pain localized to a specific area,
most often one of the testes. Since the penile urethra
is the passageway for both urine and semen, painful
urination may indicate either a urinary or a
reproductive system disorder. Males may also
experience discharge from the urethra. This is one of
the most frequent symptoms of a sexually transmitted
disease (STD), or it may arise from inflammation of
the epididymis (epididymitis) or the prostate gland
(prostatitis).
Testicular pain may indicate an STD, testicular
torsion, cancer, or cryptorchidism (failure of one or
both testes to descend into the scrotum). Pain in the
groin may be due to a muscle pull, an STD, or an
inguinal hernia. Men also seek medical attention for
infertility and erectile dysfunction.
Physical Examination
When obtaining a patient history in cases that involve
tbe reproductive system, the clinician inquires about
the patient’s sexual history and practices as well as
tb~ onset of the symptoms relative to the most recent
se.xual contact. Because these are such personal
questions, the clinician must assure the patient that
honest answers are essential to an accurate diagnosis
and that the information will remain confidential.
Examining the external genitalia and palpating
the prostate gland are routine. Because many STDs
produce characteristic lesions on the penis or
scrotum, these structures are inspected for vesicles,
chancres, or warts. The color and texture of the skin
are also noted. Excessive redness may indicate
inflammation, while dry, scaly skin may be a sign of
fungal infection (“jock itch”) or a nutrient imbalance.
If the man has not been circumcised, the foreskin
should be retracted and the glans examined.
Inflammation of the prepuce or adjacent tissues
prevents retraction of the foreskin, a condition called
phimosis.
Following visual inspection. the scrotum, testis,
epididymis, and ductus deferens are palpated on both
sides, and a digital rectal examination (DRE) is
conducted. Palpation allows the clinician to check for
inflammation, edema, masses, or other abnormalities
as well as to determine whether both testes are
present and in the proper location. A DRE involves
palpating the prostate and seminal vesicles through
the anterior rectal wall by inserting a gloved finger
into the rectum. The DRE is used to screen for
prostate disease and inflammation of the seminal
vesicles. If urethral discharge appears at any time
during the physical examination, it is cultured for
pathogenic microbes.
Laboratory Tests and Imaging Methods
If the patient history and physical examination
indicate that further tests are advisable, a variety of
diagnostic procedures are available. Blood samples
are examined for reproductive hormones
(testosterone, estradiol, luteinizing hormone, and
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follicle-stimulating hormone) and antibodies against
.organisms that cause STDs, such as Treponema
pallidum and HIV. A high level of prostate-specific
antigen (PSA) and alkaline phosphatase may suggest
prostate cancer, while a-fetoprotein and human
chorionic gonadotropin (HCG) point toward
testicular cancer.
Semen analysis includes measures of semen
volume and sperm count and assessment of sperm
motility and morphology. The composition of the
semen is also determined if abnormal function of one
or more of the accessory glands is suspected. Either
the semen or a urethral discharge may be cultured for
the presence of infectious agents that cause various
STDs. Finally, a biopsy may be done if cancer or
abnormal structure and function at the cellular level
is suspected.
X ray, CT, MRI, and sonography can be used to
help diagnose cancer and congenital abnormalities of
the reproductive organs. In sonography, the
ultrasound transducer is inserted into the rectum so
that the ultrasound waves travel only a short distance
to the prostate and back, and a clearer image is
produced. Sonography is also helpful in directing
biopsy needles to the appropriate location, since it
produces a real-time image of moving objects.
Gynecomastia
Gynecomastia, enlargement of the male breast,
affects upwards of 40% of men in the United States
and is seen most often in adolescents and men over
the age of 50. It occurs when the ratio between
testosterone and estrogen shifts in favor of estrogen,
a phenomenon that tends to happen in men during
puberty and aging. A variety of conditions can shift
the testosterone/estrogen ratio. Hypogonadism,
Klinefelter syndrome, cirrhosis and hepatitis,
hyperthyroidism, tuberculosis, and cancers of the
testicles, adrenal glands, and liver can cause
gynecomastia. It can also result from drugs such as
estrogen supplements, amphetamines, digitalis,
spironolactone, ergotamine, and certain
antidepressants.
Gynecomastia is readily diagnosed by physical
examination. The breast stroma shows hyperplasia,
producing a palpable mass (at least 2 em in diameter)
beneath the areola. Gynecomastia usually regresses
spontaneously-the pubertal form within 4 to 6
months and the senescent form within 6 to 12
months. If it does not, or if an underlying treatable
cause is known, that cause should be treated. Breast
regression then usually follows within 12 months. If
it does not, the man is instructed in breast selfexamination
since persistent gynecomastia can
develop into breast cancer. Breast cancer occurs in
about 1 male for every 275 female patients and
accounts for about 0.2% of cancer cases among
American males.
Scrotal Disorders
Some common noncancerous disorders of the
scrotum are hydrocele, varicocele, and spermatocele.
All can be detected by palpation.
Hydrocele, a collection of fluid in the tunica
vaginalis, is the most common cause of scrotal
swelling. It results from increased fluid production
(often due to inflammation) or decreased
reabsorption caused by either lymphatic or venous
blockage. The underlying cause is usually trauma or
infection of the testis or epididymis, but some cases
are idiopathic. Hydroceles vary from pea-sized to
bigger than a grapefruit. They can compress the
testicular artery and vein, thus reducing testicular
circulation and leading to atrophy. Hydrocele is
treated by aspirating the accumulated fluid. If it
recurs, a sclerosing drug is injected into the scrotum
to induce scarring of the tunica vaginalis in an
attempt to prevent recurrence. If this fails, the tunica
vaginalis is surgically removed.
Varicocele, abnormal dilation of veins in the
spermatic cord, typically occurs immediately after
puberty. It is said to feel “like a bag of worms.” This
disorder is caused by failure of the valves in the
spermatic veins to prevent the backflow of blood.
More than 95% of varicoceles occur on the left; the
presence of a unilateral right-side varicocele indicates
obstruction or compression of the inferior vena cava.
A varicocele reduces testicular blood flow, which can
lead to decreased spermatogenesis and infertility.
Surgical ligation or inducement of slight sclerosis of
the vein corrects the varicocele.
Spermatocele, a swollen aggregation of sperm in
the epididymis, is difficult to distinguish from a
hydrocele by palpation. Diagnosis is based on
aspiration of fluid from the mass. The fluid in a
hydrocele is clear, while the fluid in a spermatocele is
milky and contains sperm cells. Spermatoceles are
usually caused by inflammation and tend to resolve
spontaneously. Most are asymptomatic, and unless
discomfort or pain occurs, excision is not
recommended. -.
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Testicular Disorders
Disorders of the testis include ectopic testis,
cryptorchidism, testicular torsion, and testicular
cancer. Because the testes are the sites of
spermatogenesis and androgen production, these
disorders have potentially negative effects on both
fertility and secondary sex characteristics.
Cryptorchidism and Ectopic Testis
Cryptorchidism and ectopic testis are similar
congenital conditions in which descent of the testis is
incomplete (in the first case) or has taken an
abnormal route (in the second). In cryptorchidism,
the descending testis stops in the pelvic cavity,
inguinal canal, or upper end of the scrotum. An
ectopic testis ends up in the perineal or suprapubic
region or just beneath the skin of the thigh.
Cryptorchidism can result from adhesions along the
path of descent, an inguinal canal too naITOWfor the
testis to pass through, an absent or abnormal
gubernaculus, a too-short spermatic cord, and other
causes. Ectopic testis results from a gubernaculum
connected to the wrong site at its distal end, so that it
pulls the descending testis to an abnormal location.
Palpating the scrotum during the physical
examination reveals the absence of the testis.
Imaging techniques such as ultrasound, MR!, and CT
scans are used to locate testes that cannot be found by
palpation.
In both disorders, the testis is hormonally
functional but is too warm for spermatogenesis.
Fertility may be normal if only one testis is affected,
but in bilateral cases the patient is sterile. If the
condition is not cOITected,the risk of testicular cancer
is 35 to 50 times higher than normal. An ectopic
testis is normally removed to prevent cancer. The
surgical removal of a testis is called orchiectomy. In
cryptorchidism, an injection of human chorionic
gonadotropin can often stimulate completion of
descent. If this fails, the testis is surgically relocated
to the scrotum in young boys (a procedure called
orchiopexy), but because of the cancer risk,
orchiectomy is performed in boys over 10 years old
and in men.
Testicular Torsion
Testicular torsion, twisting of the testis on the
spermatic cord, may occur spontaneously or as a
result of trauma or strenuous exercise. It occurs most
often during puberty, but may happen at any time of
life. Twisting the testicular blood vessels causes
testicular ischemia, and if left untreated, necrosis of
the testis. Testicular torsion also produces scrotal
swelling that is not alleviated by rest or support of
the testis. The patient complains of severe pain and
nausea, and may vomit. Fever is common. Treatment
is aimed at alleviating the torsion by manually
rotating the affected testis or by surgery. Unless
cOITectedwithin 4 to 6 hours, damage to the testis
can permanently impair fertility.
Testicular Cancer
Testicular cancer is relatively rare, accounting for
less than 1% of all cancers in men. It is also one of
the most treatable cancers, with a cure rate exceeding
95%. Nevertheless, it causes about 350 deaths per
year in the United States, mostly because it is not
detected or treated in time to prevent metastasis. Up
to 10% of men with testicular cancer are
asymptomatic. Most victims are 15 to 34 years old.
White men have about four times the incidence of
testicular cancer that black men do, and within both
groups, men of higher economic status have higher
rates of testicular cancer. Some other risk factors for
testicular cancer are high androgen concentrations
and heredity. Brothers and especially identical twins
show higher shared incidence of testicular cancer.
The best defense against testicular cancer is testicular
self-examination (TSE). This is best done after a
shower because heat relaxes the scrotum. The testes
should be gently rolled between the thumb and
fingers, feeling for suspicious lumps. A slight
inequality in size is normal. TSE should be as routine
for men as breast self-examination (BSE) is for
women.
Most testicular tumors arise from germ cells. The
first sign of a tumor is an enlarged but often painless
testis. Its continued growth causes lower abdominal
aching or a feeling of testicular “heaviness.”
Epididymitis, gynecomastia, or hydrocele may
develop. Because up to 25% of cases are
misdiagnosed at first, testicular cancer often
metastasizes, especially to the lungs, lymph nodes,
and central nervous system. Metastasis to the lungs
causes cough, dyspnea, and hemoptysis. Neural
effects range from alterations in vision and mental
status to seizures.
Diagnosis is achieved by palpation, imaging, and
blood tests for such serum markers as a-fetoprotein,
HCG, and lactate dehydrogenase. The affected testis
is surgically removed. and metastasis is treated with
radiation and chemotherapy. The prognosis depends
on the tumor type and degree of metastasis. Most
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deaths occur within 2 years, and a disease-free
survival time of 3 years is considered a cure. As
evidence that men who survive testicular cancer can
live a normal life, consider Lance Armstrong, one of
the best professional cyclists in the world. After
diagnosis and treatment for testicular cancer,
Armstrong returned to training. In both 1999 and
2000, he won the Tour de France, a grueling 3-week,
2,300-mile cross-country bicycle race.
Prostatic Disorders
The most common disorders of the prostate are
prostatitis, benign prostatic hyPerplasia, and prostate
cancer.
Prostatitis
Prostatitis, or inflammation of the prostate, is seen in
up to 36% of males in the United States. It occurs in
bacterial and nonbacterial forms. Bacterial prostatitis
is usually caused by Escherichia coli, Pseudomonas,
and Streptococcus faecalis. Its signs and symptoms
are identical to those of a urinary tract infection,
including dysuria, frequent urination, nocturia, and a
weak urine stream. The patient may have a fever,
fatigue, and pain in the joints, muscles, lower back,
or rectum. The prostate is firm, swollen, tender, and
painful. Treatment employs broad-spectrum
antibiotics for up to 42 days, analgesics, bed rest, and
ample water intake.
Nonbacterial prostatitis is more common and has
an unknown cause. It, too, is characterized by
symptoms similar to those of a urinary tract infection,
along with pain in the infrapubic, suprapubic, scrotal,
penile, or inguinal regions and pain upon ejaculation.
Diagnosis is based on the absence of an infectious
agent in urine cultures or prostatic fluid and
inflammation of the prostate as confirmed by
examination. Treatment varies, but usually includes
bed rest, anti-inflammatory agents, and
anticholinergics.
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia (BPH), noncancerous
enlargement of the prostate gland, occurs mostly in
men over 50. Men of that age have a 25% to 30%
chance of requiring a prostatectomy (removal of the
prostate) at some time in their lives. The cause of
BPH is still unknown, but the amounts of
testosterone and other testicular steroids in the blood
are thought to be contributing factors. The onset of
BPH is slow. As the prostate increases in size,
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urethral compression causes the signs and symptoms
of urinary tract obstruction-decreased force of the
urine stream, increased frequency and urgency of
urination, and nocturia. Over time, the obstruction
worsens and the bladder cannot be fully emptied
upon urination. This leads to incontinence or urine
retention. Urine retention can cause elevated pressure
in the kidneys (hydronephrosis), which presents a
threat of renal failure.
BPH is diagnosed from these signs and
symptoms, palpation, and laboratory analysis. Upon
palpation, the prostate is found to be enlarged and to
have lost its distinctive lobular shape. In up to 50%
of patients, blood samples show an elevated level of
prostate-specific antigen (PSA). Since the
hyperplasia is not reversible, the only treatment in
severe cases is surgical removal of the hyperplastic
tissue or the entire prostate. In mild cases, treatment
with androgen antagonists (such as Proscar) can
reduce prostate size somewhat. Drugs that block (Xadrenergic
receptors and relax smooth muscle, such
as prozosin and terazosin, have also been successful.
Prostate Cancer
Prostate cancer is responsible for almost 7% of all
cancer deaths and is second only to lung cancer in
cancer-related deaths in men in the United States.
Although it accounts for 42% of all cancers in men,
over 80% of all cases are seen in men aged 65 and
over, and it rarely occurs before age 40. Diet and
family history appear to influence the risk of
developing prostate cancer. Androgens are not
thought to cause prostate cancer, but they may
promote tumor growth once the cancer has begun.
Most cases progress slowly and are
asymptomatic at first, making early detection
difficult. The initial signs and symptoms are those of
urinary tract obstruction. Prostate cancer metastasizes
to such sites as the pelvis, ribs, femur, vertebrae,
lymph nodes, lungs, liver, and adrenal glands.
Metastatic prostate cancer often produces bone pain
and pathological fractures. Other signs include
edema, hepatomegaly, and lymph node enlargement.
Diagnosis is through DRE, blood screening for PSA,
transrectal sonography, and biopsy. Sites of
suspected metastasis are examined by MR!, CT, and
biopsies.
Treatment depends on such factors as the stage of
the cancer, anticipated side effects, and the patient’s
age, health, and life expectancy. Older men who are
already in poor health may opt not to pursue
treatment, and men concerned about side effects such
as erectile dysfunction may also forgo treatment.
Treatment includes hormonal, chemical, or radiation
therapy, prostatectomy, or a combination. Side
effects include incontinence and erectile dysfunction.
The average 5-year survival rate for treated
prostate cancer is 78%; in cases without metastasis, it
rises to 95%. Because early detection is a key to
successful treatment, annual DRE and PSA screening
are recommended for men over 50; only DRE is
recommended for those between the ages of 40 and
50. However, men with a family history of prostate
cancer are encouraged to start screening earlier,
sometimes even in their 20s.
Case Study 27 The Athlete Who Ignored His Symptoms
‘r
Erik is a 21-year-old minor league hockey player
hoping for a spot in the National Hockey League
(NHL). In one game, Erik is involved in a fight and is
struck in the groin by an opponent’s stick. He falls to
the ice in extreme pain and is taken to the hospital. In
the emergency room, he is diagnosed with testicular
torsion and a developing hydrocele. The physician
relieves the torsion and aspirates a clear fluid from
the hydrocele. Erik is told to visit his regular
physician for further treatment if the swelling returns.
He returns to play after a few days and finishes the
season without incident. The following year, Erik is
drafted by an NHL team.
Three years later, Erik develops difficulty
breathing and a chronic cough that occasionally
produces bloody sputum. Fearful that he could lose
his place on the team, Erik downplays these
symptoms when questioned by the team physician.
But as the season progresses, the cough worsens and
Erik begins to experience frequent headaches,
dizziness, and blurred vision.
The team physician examines Erik and finds that
he has lymphadenopathy in addition to his other
symptoms. When questioned further, Erik mentions
that he is becoming fatigued more easily and has
been experiencing some abdominal pain.
During the physical examination, the team
physician notes that Erik has a mass in the right
testicle, but none in the scrotum. He asks Erik if the
testicle had been giving him any trouble. Erik says
that he’s noticed it seemed somewhat enlarged, but
he thought this was just because of the injury he
received back in the minor leagues. Suspecting a
testicular tumor, the doctor orders blood tests and a
CT scan. The blood analysis shows elevated
concentrations of lactate dehydrogenase and afetoprotein.
The CT scan reveals seven lung tumors
and a brain tumor. Erik is referred to an oncologist
and diagnosed with metastatic testicular cancer.
\’
“,
I
f
Erik’s oncologist tells him that in cases this
advanced, the chance of survival is about 50%. Erik
is determined to beat the cancer, however, and agrees
to an aggressive course of treatment.
He then undergoes orchiectomy and brain
surgery to remove the primary testicular tumor and
the metastatic brain tumor. He undergoes a successful
year-long course of chemotherapy for the lung
tumors. After remaining cancer-free for 2 years, Erik
is told that if he remains so for one more year, he will
be considered cured.
Based on this case study and other information in
this chapter, answer thefollowing questions.
1. If Erik’s testicular torsion were to go untreated,
what would happen to the testis?
2. Why is the swelling in his testis diagnosed as a
hydrocele rather than a spermatocele or a
varicocele?
3. Why does Erik’s cancer go undiagnosed long
enough to metastasize so widely?
4. Considering his occupation, what might happen
to Erik if the cancer metastasizes to his bones?
5. Why do you think Erik’s brain tumor is treated
surgically, instead of being treated with
chemotherapy like the lung tumors?
6. Angelo, a 55-year-old male, is diagnosed with
cirrhosis of the liver. Which of the following
disorders might he develop as a secondary effect?
a. prostatitis
b. testicular cancer
c. spermatocele
d. hydrocele
e. gynecomastia
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7. Terry is diagnosed at the age of 14 with an
ectopic testis located in the groin. The family
physician recommends orchiectomy rather than
surgically relocating the testis to the scrotum. His
parents, who would like to be grandparents one
day, protest and ask if it wouldn’t be better just
to relocate the testis. How would you expect the
doctor to advise them?
8. Why should men begin regular testicular selfexamination
(TSE) at an earlier age than they
start receiving digital rectal examinations
(DREs)?
9. Predict what a man might feel if he had
epididymitis and did a TSE.
10. In what way does varicocele resemble varicose
veins? (See chapter 20 of this manual.)
Selected Clinical Terms
benign prostatic hyperplasia (BPH) Noncancerous
growth of the prostate gland; leading to urethral
compression and impeded urine flow.
cryptorchidism The failure of one or both testes to
completely descend through the inguinal canal into
the scrotum.
digital rectal examination (DRE) Palpation of the
prostate and neighboring structures by means of a
gloved finger inserted into the rectum.
ectopic testis The descent of a testis to an abnormal
location such as the perineal, suprapubic, or femoral
region.
gynecomastia Abnormal enlargement of the male
breasts.
hydrocele An accumulation of serous fluid in the tunica
vaginalis of the scrotum.
orchiectomy Surgical removal of a testis.
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orchiopexy Surgical translocation of a testis to its
normal location in the scrotum.
phimosis The presence of a tight, nonretractable
foreskin; a risk factor for penile cancer.
prostate-specific antigen (PSA) An antigen secreted
by the prostate gland into the semen; elevated levels
in the blood serum indicate prostatic enlargement and
may be an early warning of prostate cancer.
prostatitis Inflammation of the prostate gland.
spermatocele A sperm-containing cyst in the
epididymis.
testicular torsion Twisting of a testis on the spermatic
cord, causing severe pain and testicular ischemia.
varicocele Abnormal dilation of veins in the spermatic
cord due to failure of the venous valves to prevent
backflow of blood.
.,
28 The Female Reproductive System
Objectives
In this chapter we will study
. common symptoms of female reproductive disorders;
. diagnostic procedures for examining the female reproductive system;
. two menstrual disorders-dysmenorrhea and amenorrhea;
. ovarian cysts and polycystic ovary;
· inflammatory diseases of the female reproductive system;
. endometriosis; and
. cervical, endometrial, and ovarian cancer.
Assessment of the Female
Reproductive System
up to 20% of women who visit a physician have
gynecological or obstetrical complaints. Menstrual
irregularity is often the chief complaint-abnormally
heavy or light flow, failure to menstruate, bleeding
between periods, or painful menstruation. Such
irregularities may be due to inflammation, sexually
transmitted diseases (STDs), improper nutrition, or
oral contraceptives. Pelvic pain and dysuria,
symptoms seen in male reproductive disorders,
routinely occur in females as well. Pelvic pain may
be due to inflammatory disease, an ovarian cyst, or a
tubal pregnancy. Dysuria and abnormal vaginal
discharge are most often the result of a microbial
infection. Women also seek medical attention for
infertility.
As with male reproductive disorders, a thorough
patient history, confidence in the physician, and strict
confidentiality regarding personal information are
vital to an accurate diagnosis and appropriate
treatment and counsel.
Physical Examination
After a routine check of height, weight, and vital
signs, a gynecological examination focuses on the
breasts, abdomen, and pelvic area. The examiner
palpates the breasts, reminds the patient to conduct
monthly breast self-examination (BSE), and may
recommend a mammogram. He or she also palpates
the abdomen.
In the pelvic examination, the external genitalia
are visually inspected for lesions, trauma, abnormal
masses, or swellings. Abnormal discharges from the
urethra or vagina are also noted, and samples are
taken for culture and identification of pathogens. The
walls of the vagina and the cervix are inspected by
using a speculum to spread the vagina and make the
mucosa more visible. Redness of the vaginal walls
indicates inflammation (vaginitis), a common sign of
infection. In nonpregnant patients, cyanosis of the
vaginal walls often indicates pelvic tumors.
(Cyanosis of the vaginal wall and cervix, called
Chadwick’s sign, is normal in pregnancy.) The cervix
is checked for lacerations, ulcerations, polyps, and
abnormal discharge. A small brush or spatula is used
to collect cells from the external os and prepare a Pap
smear for histological evaluation. Next, the clinician
conducts bimanual palpation by inserting two gloved
fingers into the vagina and using the other hand to
palpate the uterus and ovaries through the abdominal
wall. This yields information about the size, shape,
location, and tone of the uterus, the enlargement or
absence of an ovary, and the presence of any
abnormal pelvic masses.
The final component of the examination is a
rectovaginal examination, which is done by placing
the index finger into the vagina and the middle finger
into the rectum, and palpating the uterosacral
ligaments and the back of the uterus and cervix. The
examiner checks for abnormal masses and the proper
placement and tone of the ligaments. If a woman is
pregnant, care is taKen to minimize disrupting the
placenta or causing fetal trauma.
Laboratory and Imaging Tests
When warranted by the findings of the physical
examination, samples of blood, urine, and vaginal
and urethral discharge can be evaluated in the
]69
hiboratory. Blood is analyzed for levels of
reproductive hormones such as estradiol,
progesterone, luteinizing hormone, folliclestimulating
hormone, and prolactin. Urine is assayed
for estradiol and progesterone metabolites. If
pregnancy is suspected, the blood or urine sample
can be analyzed for the presence of HCG, which is
detectable only in pregnant women. Samples of blood
and vaginal or urethral discharge can be analyzed for
the presence of pathogens. The female reproductive
tract can also be examined by X ray, laparoscopy,
CT, MR!, and sonography. Mammography (X-ray
examination of the breasts) should be done
biannually in the 40s and annually after age 50.
Menstrual Alterations
Menstrual disorders include painful menstruation
(dysmenorrhea), lack of menstruation (amenorrhea),
and dysfunctional uterine bleeding, which means
abnormal duration, frequency, or timing of
menstruation. Only dysmenorrhea and amenorrhea
are discussed here.
Dysmenorrhea
Dysmenorrhea affects half to three-quarters of girls
and women from 15 to 25 years of age but declines
after the mid-20s. It often causes women to miss
work or school. Primary dysmenorrhea is painful
menstruation that cannot be traced to any underlying
pelvic disease. Secondary dysmenorrhea is traceable
to some other reproductive system pathology. In both
forms, the endometrium produces excessive amounts
of prostaglandin, which in turn causes constriction of
the uterine blood vessels, endometrial ischemia, and
painful contractions of the uterine muscle. The pain
begins in the pelvic region, radiates to the groin, and
is often accompanied by backache, anorexia,
vomiting, diarrhea, headache, and syncope.
Dysmenorrhea does not occur when a woman does
not ovulate, and is therefore relieved by oral
contraceptives. Exercise, a low-fat diet, heat and
massage, relaxation techniques, and orgasm also
relieve the symptoms.
Amenorrhea
Amenorrhea has a variety of causes and can be
broadly categorized according to the patient’s
menstrual history. Primary amenorrhea is a failure of
the menses to begin. A girl is considered amenorrheic
if she reaches the age of 14 without menarche or the
development of secondary sex characteristics, or if
170
she reaches 16 without menarche even if she does
develop the secondary sex characteristics. There are
numerous causes of primary amenorrhea, including
genetic disorders such as Turner syndrome,
congenital CNS defects such as hydrocephalus,
anatomical abnormalities such as lack of a uterus or
vagina, and CNS lesions. Secondary amenorrhea is
the cessation of menses in women who have
previously menstruated. It is considered to exist when
a women misses three consecutive periods. It can
result not only from a variety of diseases but also
from extreme weight loss, either through malnutrition
(as in people with anorexia nervosa) or through
exercise (as in dancers, gymnasts, and runners).
Secondary amenorrhea is also normal during
pregnancy, lactation, and menopause, and is common
in early adolescence.
Amenorrhea is diagnosed primarily from the
patient history, but the underlying cause may require
laboratory analyses such as blood hormone assays or
imaging methods to look for tumors. Menstruation
often resumes spontaneously (for example, when
breast-feeding is terminated), or it may require
weight gain or treatment of an underlying disease.
Menstruation can sometimes be restored by hormone
replacement therapy (HRT).
,’111
.,
Ovarian Cysts and Polycystic Ovary
Ovarian cysts usually occur in women between the
ages of puberty and menopause, but may appear
before or after those stages. They are benign cysts of
either follicular or luteal origin, arising from an
ovarian follicle that fails to ovulate or degenerate or
from an abnormally persistent corpus luteum. Both
types are hormonally active-follicular cysts produce
estrogen, and luteal cysts produce progesterone.
Ovarian cysts typically grow to 5 or 6 cm in
diameter, but sometimes up to 10 cm. They produce
abdominal and back pain, dyspareunia (pain during
intercourse), and irregular menstruation. Luteal cysts
are less common but cause more symptoms,
including pelvic pain, amenorrhea, or delayed but
heavy menstruation. They occasionally rupture,
causing excruciating pain and requiring emergency
surgery. Most ovarian cysts, however, require no
specific treatment and regress spontaneously within 2
months. ,
Polycystic ovary (PCO) affects women mainly
between the ages of 15 and 30. It results from
multiple follicles that develop but never ovulate, so
the ovaries accumulate numerous cysts about 2 to 6
mm in diameter. The underlying cause is a positive
1
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feedback cycle of abnonnal honnone secretion. FSH
level is low and LH level is high. The high LH level
causes the adrenal cortex and ovary to secrete an
abnonnally high level of androgens, which various
tissues convert to estrogen. The high estrogen level
inhibits FSH secretion and stimulates LH secretion,
thus completing the positive feedback loop. There is
enough FSH to cause more and more follicles to
begin developing, but not enough to cause them to
mature and ovulate. Thus, they turn into ovarian
cysts.
Women with PCO typically present with obesity,
excessive growth of body and facial hair (hirsutism),
and amenorrhea, although others lack hirsutism and
obesity and complain instead of irregular, heavy
uterine bleeding, an effect of the high estrogen level.
PCO is diagnosed from the patient history, physical
exam, and high levels of androgen and estrogen in
the blood. The treatment for PCO depends on
whether the woman wants to become pregnant and
other circumstances of individual cases. Options
include antiestrogenic drugs, progesterone, and lowdose
oral contraceptives. For hirsutism, bleaching of
the hair or hair-removal methods such as waxing or
electrolysis are recommended. If all else fails,
ovari~ surgery may be used to remove some or all of
the cysts.
Inflammation of the Female
Reproductive System
The female reproductive tract is subject to numerous
inflammatory disorders, caused by a variety of
infectious agents and irritants. These disorders
include inflammation of the vulva (vulvitis), vagina
(vaginitis), cervix (cen’icitis), uterine tubes
(salpingitis), ovaries (oophoritis), or a combination
of the uterus, uterine tubes, and sometimes the
ovaries (pelvic inflammatory disease). In many of
these diseases, any sexual partners should be treated
as well.
Vulvovaginitis is a combination of vulvitis and
vaginitis, often stemming from irritation by soap,
lotion, menstrual pads or tampons, feminine hygiene
sprays, or tight clothing. However, the main causes
are STDs and infection by Candida albicans (”yeast
infection”). The incidence of sexually transmitted
vulvovaginitis is greatest in women between the ages
of 10 and 24. Vulvovaginitis produces dysuria,
redness of the vulva, and a purulent, foul-smelling
vaginal discharge. The discharge can be cultured to
confirm the diagnosis and detennine what antibiotic,
if any, should be used in treatment. Medications for
vulvovaginitis also include agents to suppress
inflammation and acidify the vaginal pH. Patients are
counseled about hygiene and causative irritants. If the
condition is caused by an STD, the woman’s sexual
partner also must be treated.
Cervicitis usually results from an STD. The
cervix becomes red and edematous, and affected
women complain of dysuria, pelvic pain, and
bleeding. Some also report a mucopurulent (mucusand
pus-containing) discharge. Diagnosis is based on
these symptoms and identification of the causative
agent in the discharge. Treatment employs antibiotics
specific for the pathogen.
Pelvic inflammatory disease (PID) usually
stems from STDs in which the microbes have
migrated from the vagina to the uterus, uterine tubes,
and ovaries. Most cases of PID occur in sexually
active women under the age of 35 and are caused by
a mixed microbial infection. The scarring induced by
PID raises the risk of infertility or ectopic pregnancy.
Death is rare (8% to 9% of cases), but when it occurs
it is usually due to septic shock. Women may be
asymptomatic or show a wide range of signs and
symptoms, including extreme abdominal pain,
guarding or rebound tenderness (see chapter 25 of
this manual), and discomfort upon movement of the
cervix., Fever, vomiting, leukocytosis, and large
quantities of a purulent cervical discharge are also
present. Diagnosis is based on the patient history,
signs and symptoms, and identification of the
causative agent. Treatment includes bed rest,
antibiotics, and sexual abstinence during treatment.
Endometriosis
Endometriosis is the ectopic growth of endometrial
tissue. That is, endometrial tissue spreads beyond the
uterus and grows in the uterine tubes or on the
ovaries, uterine ligaments, and other sites. The
ectopic tissue is responsive to the reproductive
honnones and undergoes the same cyclic changes
that would be seen in the uterus (proliferation,
secretion, and bleeding). Endometriosis is thought to
occur in 3% to 10% of women of reproductive age,
but many of them are asymptomatic and the
endometriosis is discovered in the course of
examining some other condition. There is a genetic
predisposition to endometriosis, but otherwise the
cause is unknown.
The signs and symptoms include pelvic pain,
dysmenorrhea, constipation, dyspareunia, dyschezia
(painful defecation), abnonnal vaginal bleeding, and
infertility. Diagnosis is based on the symptoms,
171
family history, laparoscopy, and biopsy. Treatment is
aimed at alleviating pain, halting the progress of the
disease, and restoring fertility. Treatment strategies
depend on the patient’s age and desire to have
children in the future. Options include hormones such
as oral contraceptives to suppress growth of the
ectopic tissue, surgical removal of as much of the
ectopic tissue as possible, and surgical removal of the
uterus and ovaries followed by hormone replacement
therapy. Unfortunately, nearly half of the women
treated experience a recurrence of endometriosis
within 5 years.
Cancers of the Female Reproductive
System
Breast cancer strikes lout of every 8 or 9 women in
the United States and is a leading cause of female
mortality. Other cancers of the reproductive system
account for 1 in 8 cases of cancer and 1 in 10 cancerrelated
deaths in women of the United States. Here
we consider three of these: cervical, endometrial, and
ovanan cancer.
Cervical Cancer
Cervical cancer is the second most common cancer
of women worldwide and the fourth most common in
the U.S. It is now considered a sexually transmitted
disease because 75% to 90% of cases result ITom
infection with the human papillomavirus (HPV),
which is transmitted by intercourse. Risk factors for
cervical cancer include having first intercourse before
the age of 16, having multiple sexual partners or a
male partner who has had multiple partners, and
smoking.
The stages of cervical pathology are classified
according to histological changes. It begins as
cervical intraepithelial neoplasia rCIN; also known
as cervical dysplasia). The dysplasia is considered
mild, moderate, or severe according to the depth to
which it extends in the epithelium. CIN progresses to
cervical cancer in 10% to 75% of cases, taking 10 to
12 years to become malignant. CIN is asymptomatic
but can be recognized in a Pap smear, which
underscores the importance of regular Pap smears
and early detection.
Cervical carcinoma (cancer) produces vaginal
bleeding; a clear, pink, or yellowish vaginal
discharge; an abnormal, sometimes foul vaginal odor;
and abnormal menses. Diagnosis can be confirmed
by a Pap smear. Treatment depends on the stage and
size of the tumor. Precancerous lesions are often
172
ablated by cryosurgery or laser surgery. If the
lesion is cancerous, the treatment modalities are
radiation, chemotherapy, and hysterectomy. With
early detection, precancerous lesions have a cure rate
approaching 100%, while the overall 5-year survival
rate is 67%.
.,
Endometrial Cancer
Endometrial cancer accounts for 13% of all cancers
in women. It usually occurs after menopause, with
peak incidence between the ages of 58 and 60. At
greatest risk are women who are obese, anovulatory,
have a family history of breast or ovarian cancer, or
had an early menarche or late menopause. The most
common symptom is abnormal vaginal bleeding. In
fact, more than 30% of all postmenopausal women
with vaginal bleeding have endometrial cancer. Later
in the disease, pain and weight loss are also seen.
Screening and diagnosis are done through
endometrial biopsy. Additional imaging techniques,
such as CT, MRI, bone scans, ultrasound, and barium
enema, are used to locate the metastatic sites.
As with cervical cancer, early identification is the
key to achieving a cure, and treatment depends on the
stage of the disease. All tumors are removed through
either curettage or hysterectomy. Chemotherapy
and radiation therapy are also used. The prognosis
depends on the severity of the disease and the age
and health of the patient. Five-year survival rates
approach 65% for all cases.
Ovarian Cancer
Ovarian cancer has the highest incidence in
industrialized countries, accounting for 18% of all
reproductive cancers. Half of all women with ovarian
cancer are over 65 years of age, but it can strike at
any age. The causes of ovarian cancer are currently
unknown, but it is most common in women who have
never had children, who have had breast cancer, or
whose first-degree relatives (a mother, daughter, or
sister) have had ovarian cancer. Ovarian cancer can
arise from either the surface epithelium or the germ
cells of the ovary. Epithelial cancers affect mainly
women over 50.Germ cell tumors, on the other hand,
arise from the primitive germ cells of the fetal ovary
and occur mostly in children and adolescents.
The signs and symptoms vary considerably.
Unfortunately for most women, by the time
noticeable signs or symptoms appear, metastasis has
already occurred. The first symptoms are usually
abdominal pain and swelling. The patient may
“.
0.
experience dyspnea, vomiting, and inappropriate
vaginal bleeding. Unlike cervical and endometrial
cancer, screening tests for ovarian cancer do not
exist. Diagnosis is based on biopsy and imaging
techniques such as ultrasound, CT, and MRI.
Treatment involves surgery followed by
chemotherapy and radiation therapy. The 5-year
survival rate for all stages of ovarian cancer is 42%.
If detected early, survival rates exceed 90%, but
when metastasis has occurred, they decrease to
between 20% and 40%.
Case Study 28 The Woman with Abdominal Pain
Cathy, a 20-year-old college sophomore, visits the
student health center complaining of nausea,
vomiting, and extreme abdominal pain. She says the
pain came on suddenly after a meal, so she is
concerned about food poisoning. During the patient
history, Cathy discloses that she is sexually active
and has more than 10 sexual partners per year. She
uses oral contraceptives as her primary method of
birth control and does not rely on her partners to use
condoms. Cathy has a past history of vulvovaginitis,
cervicitis, and numerous STDs (chlamydia, syphilis,
and genital herpes). Recently she has noticed a
whitish vaginal discharge with a strong odor that has
increased in quantity over the past week. Cathy’s
vital signs are as follows:
Oral temperature =lO1.4°F(38.6°C)
Heart rate =78 beats/min
Respiratory rate = IS breaths/min
Blood pressure = 150/86mmHg
A gynecological examination is performed.
Palpation of the abdomen reveals abdominal
guarding, rebound tenderness, and an enlarged,
painful uterus. A surgical scar is also noted, and
Cathy explains that her appendix was removed when
she was a child. The external genitalia appear slightly
edematous but are otherwise normal. Both the vagina
and the cervix are slightly inflamed, and a purulent
discharge is noted. A sample of the discharge is taken
for culture, and a cell sample is taken from the
external os for a Pap smear. During the pelvic
examination, movement of the cervix creates
abdominal discomfort, and the rectovaginal
examination confirms the uterine enlargement noted
upon palpation,
Blood, fecal, and urethral samples are obtained.
Blood tests reveal leukocytosis but no HIV
antibodies. The Pap smear is negative, and the
cultures are positive for Chlamydia and Neisseria
gonorrhoeae. A pregnancy test (HCG assay) is
negative. Ultrasound imaging of the pelvic cavity
shows enlargement of the uterus and uterine tubes
without pregnancy. Based on these test results, Cathy
is diagnosed with pelvic inflammatory disease.
Cathy is prescribed a combination of antibiotics
and bed rest for 10 days. During this treatment
period, she is told to refrain from intercourse. She is
also advised to notifY her partners about her
condition and to encourage them to seek treatment. In
addition, Cathy is told to return for a follow-up
examination after completing her medication to
ensure that the infections have been controlled.
Finally, Cathy is encouraged to insist on condom use
to minimize her chances of contracting SIDs in the
future. Because of her history of numerous SID”s,she
is warned that she is at increased risk for infertility
due to uterine tube scarring as well as for uterine and
cervical cancer.
Based on this case study and other information in
this chapter, ans}<.’erthe following questions.
1. Which of Cathy’s signs and symptoms are
common to both pelvic inflammatory disease and
appendicitis? Why is it important to rule out
appendicitis?
2, What signs and symptoms support the diagnosis
of PID?
3. Suppose Cathy says that in spite of her
“wildness” in college, shejust wants to “get it all
out of my system, and then settle down and have
kids after I graduate.” As her physician, what
would you tell her about the relevance of her
present behavior to her family plans?
4. Why are a Pap smear and an HIV test conducted?
5. Why do Cathy’s signs and symptoms rule out
cervical, endometrial, and ovarian cancer?
173
6. Erica, a 17-year-old female, is a member of her
high school swim team. She visits her physician
because she has missed her last two menstrual
periods. Laboratory tests are negative for HCG.
Based on this limited information, speculate
about the cause of Erica’s amenorrhea. What
treatment, if any, would you recommend?
7. Twenty-eight-year-old Brenda visits her
gynecologist complaining of irregular
menstruation, back pain, and pain during
intercourse. Which of the following signs would
suggest that Brenda is suffering from polycystic
ovarydisease? .
a. elevated serum LH concentrations
b. elevated serum HCG concentration
c. mucopurulent discharge
d. rebound tenderness
e. dyschezia
8. Andrea, a 32-year-old female, visits her nurse
practitioner complaining of constipation, pelvic
pain, and dysmenorrhea. Within the last 6
months, Andrea’s sister has been diagnosed with
endometriosis. Laparoscopy reveals two regions
of ectopic endometrial tissue on Andrea’s
ovaries. Since Andrea does not intend to have
any children, she decides to take a GnRH agonist
in an attempt to treat the disorder without
resorting to surgery. Explain how this medication
would help alleviate the signs and symptoms of
this disorder.
9. Why is maintaining an acidic pH in the vagina
important in treating vaginitis?
10. A IS-year-old girl misses 3 days of school due to
severe menstrual cramps before her mother takes
her to a gynecologist. If you were the
gynecologist, what issues would you discuss with
the girl while taking her history? Suppose the
gynecologist tells the girl simply to use a heating
pad and analgesics, wait it out for another day or
two, and return to school when she feels better.
What do you think the diagnosis is?
Selected Clinical Terms
amenorrhea Absence of menstruation; classified as
primary if an adolescent girl never begins
menstruating and secondary if a previously
menstruating woman ceases to menstruate for three or
more consecutive cycles. –
cervicitis Inflammation of the cervix of the uterus.
cryosurgery An operation to destroy tissue by freezing
it with liquid nitrogen or liquid carbon dioxide.
curettage Scraping the intemallining of a hollow
organ, such as the uterus, to remove new growths or
to obtain tissue for biopsy.
dysmenorrhea Difficult or painful menstruation.
dyspareunia Pain experienced during sexual
intercourse.
endometriosis The growth of endometrial tissue in
ectopic sites such as the pelvic cavity or uterine tubes.
hysterectomy Surgical removal of the uterus.
laser surgery An operation to destroy unwanted tissue
or cauterize an organ by burning it with a laser beam.
174
ovarian cyst A cyst, often several centimeters in
diameter, that develops from an ovarian follicle or
corpus luteum.
pelvic examination Physical examination of the
external genitalia, vagina, cervix, and internal
reproductive organs by visual observation and
palpation, for purposes of health assessment or
diagnosis.
pelvic inflammatory disease (PID) Inflammation in
the pelvic cavity, usually caused by sexually
transmitted microbes that migrate up the uterus and
uterine tubes into the cavity.
polycystic ovary (PCO) The accumulation of
numerous ovarian cysts arising from follicles that
partially develop but fail to ovulate.
speculum Any instrument designed to be inserted into a
bodycavity or canal and used to spread it for easier
viewing; varieties exist for dilating the vagina,
rectum, eyelids, nostrils, and auditory canals.
vulvovaginitis Inflammation of the vulva and vagina.
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