Chapter 39: Normal Anatomy and Physiology of the Female Pelvis

ovulation normally occurs on about day____for a 28 day cycle

14

This phase begins the first day of menstrual bleeding and continues until ovulation on day 14?

Follicular

Describe the exact location of the following muscles: psoas, iliacus, piriformis, obturator internus, coccygeus and levator ani.

Muscles: Psoas major: lumbar spine to anterior side wall Iliacus: forms pelvic side wall Piriformis: Sacrum to posterior pelvis Obturator internus: Forms pelvic floor (diaphragm) Coccygeus: forms pelvic floor (diaphragm) Levator ani: forms the anterior part of the diaphragm

the greatest quantity of free fluid in the cul de sac normally occurs immediately following________when the mature follicle ruptures

Ovulation

Describe the ovarian cycle.

Proliferative phase: Days 1 to 14 (follicular) Menstruation days 1 to 4: thin endometrium, estrogen level increased, multiple follicles developOvulation on day 14 Secretory phase: Day 15 to 28 (luteal): corpus luteum secretes progesterone, endometrium thickens, decrease in estrogen and progesterone. Menses day 28

oocyte

an incompletely developed or immature ovum

space of Retzius

located between the anterior bladder wall and the pubic symphysis; contains extraperitoneal fat

The secretory phase corresponds ot the ____phase of the ovarian cycle

luteal

coccygeus muscles

one of two muscles in the pelvic diaphragm; located on the posterior pelvic floor, where it supports the coccyx

levator ani

one of two muscles of the pelvic diaphragm that stretch across the floor of the pelvic cavity like a hammock, supporting the pelvic organs and surrounding the urethra, vagina, and rectum; a broad, thin muscle that consists of the pubococcygeus, iliococcygeus, and puborectalis

dysmenorrhea

pain associated with menstruation

ovarian ligament

paired ligament that extends from the inferior/medial pole of the ovary to the uterine cornua; also called the utero-ovarian ligament

striations

parallel longitudinal lines commonly seen in muscle tissue when imaged sonographically; appear as hyperechoic parallel lines running in the long axis of the hypoechoic muscle tissue

true pelvis

pelvic cavity found below the brim of the pelvis; also called the minor or lesser pelvis

amenorrhea

the absence of menstruation

menarche

the onset of menstruation and the commencement of cyclic menstrual function; usually occurs between 11 and 13 years of age

menses

the periodic flow of blood and cellular debris that occurs during menstruation

mesovarium

the posterior portion of the broad ligament that is drawn out to enclose and hold the ovary in place

The retropubic space is also called?

the space of Retizius

mesosalpinx

the upper portion of the broad ligament that encloses the fallopian tubes

the___is located anterior to the fundus of the uterus btwn the bladder and uterus

vesicouterine pouch

the endometrial phase after ovulation is referred to as the____phase and extense from day 15 to menses.

Secretory

List the female reproductive organs.

The internal organs of the female pelvis consist of two ovaries and fallopian tubes, a uterus and vagina. The external genitalia include the mons pubis, labia majora, labia minora, clitoris, bulb of the vestibule, greater vestibular glands, and the vestibule of the vagina.

What are the functions of the ovary?

The ovaries produce the reproductive cell, the ovum, and two known hormones: estrogen, secreted by the follicles, and progesterone, secreted by the corpus luteum. These hormones are responsible for producing and maintaining secondary gender characteristics, preparing the uterus for implantation of the fertilized ovum, and developing the mammary glands.

What are the two regions of the ovary?

The ovary consists of the outer region or cortex, which surrounds the central medulla, and the cortex consists primarily of follicles in varying stages of development. It is covered by a layer of dense connective tissue, the tunica albuginea, and a thin single layer of cells, the germinal epithelium. The central medulla is composed of connective tissue containing blood, nerves, lymphatic vessels, and some smooth muscle at the region of the hilum.

What is the course of the ureter as it relates to the iliac vessels?

Ureter: Crosses pelvic inlet anterior to bifurcation of common iliac artery Runs anterior to internal iliac artery and posterior to the ovary Runs anterior and medially under the base of the broad ligament, where it is crossed by the uterine artery Runs anterior and lateral to the vagina to enter the bladder

iliacus muscles

paired triangular, flat muscles that cover the inner curved surface of the iliac fossae; they arise from the iliac fossae and join the psoas major muscles to form the lateral walls of the pelvis

false pelvis

portion of the pelvis found above the brim; that portion of the abdominal cavity cradled by the iliac fossae; also called the greater or major pelvis

retroverted

position of the uterus when the entire uterus is tipped posteriorly so that the angle formed between the cervix and the vaginal canal is greater than 90 degrees

retroflexed

position of the uterus when the uterine fundus bends posteriorly upon the cervix

What are the three anatomic areas of the fallopian tubes?

Fallopian tubes: Infundibulum: funnel-shaped lateral tube that projects beyond the broad ligament to overlie the ovaries; the "free edge" of the funnel has fimbriae—fingerlike projectors draped over the ovary Ampulla: widest part of the tube where fertilization occurs Isthmus: hardest part and lies just lateral to the uterus

Cells in the lining of the ruptured ovarian follical begin to multiply and create the corpus luteum, or yellow body during the______phase

Luteal

Describe the layers of the uterus.

The uterus is composed of the asternal layer or serous coat, the middle layer or muscular coat, and the internal mucous layer. The external layer, the peritoneum, surrounds the uterus except where the bladder lays against it at the cervical-vaginal connection. The middle layer, the myometrium, comprises the majority of the uterus. It is primarily a smooth muscle that is longitudinal and circular. The inner layer, the endometrium, is lined by a thin, smooth mucous membrane. This membrane is contiguous with the lining of the vagina. The inner lining of the body of the uterus varies in appearance and histologic structure, depending on the period of life in which it is studied.

follicle-stimulating hormone (FSH)

a hormone secreted by the anterior pituitary gland that stimulates the growth and maturation of graafian follicles in the ovary

gonadotropin-releasing hormone (GnRH)

a hormone secreted by the hypothalamus that stimulates the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) by the anterior pituitary gland

progesterone

a steroidal hormone produced by the corpus luteum that helps prepare and maintain the endometrium for the arrival and implantation of an embryo

menorrhagia

abnormally heavy or long periods

psoas major muscle

paired muscles that originate at the transverse process of the lumbar vertebrae and extend inferiorly through the false pelvis on the pelvic sidewall, where they unite with the iliacus muscle to form the iliopsoas muscle before inserting into the lesser trochanter of the femur; serves to flex the thigh toward the pelvis

anteverted

position of the uterus when the uterus is tipped slightly forward so that the cervix forms a 90-degree or smaller angle with the vaginal canal; most common uterine position

cardinal ligament

wide band of fibromuscular tissue arising from the lateral aspects of the cervix and inserting along the lateral pelvic floor; a continuation of the broad ligament that provides rigid support for the cervix; also called the transverse cervical ligaments

estrogen

a steroidal hormone secreted by the theca interna and granulosa cells of the ovarian follicle that stimulates the development of female reproductive structures and secondary sexual characteristics; promotes the growth of endometrial tissue during the proliferative phase of the menstrual cycle

Describe the bony landmarks of the pelvis.

Anatomically, the pelvis is divided by an oblique line that separates the greater (false) and lesser (true) pelvis. This pelvic brim passes through the prominence of the sacrum to the superior margin of the pubic symphysis. The greater pelvis is cephalic to this brim and communicates with the abdomen cephalically and with the lesser pelvis caudally. The lesser pelvis represents the area caudal to the pelvic brim.

What are the normal uterine positions?

The body of the uterus is normally "bent" forward, or anteflexed, to make a slight angle with the cervix; and the cervix makes a similar angle with the vagina, also called anteverted. In some females, the uterus tips backward rather than forward to become "retroverted" and/or retroflexed. The broad ligaments and round ligaments help somewhat to hold the uterus in position.

Describe the location and relationship of surrounding structures of the fallopian tubes.

The normal fallopian tube is about 12 cm in length and 1 to 4 mm in diameter. It is difficult to distinguish from the surrounding ligaments and vessels. The tubes lie above the uteroovarian ligaments, round ligaments, and tuboovarian vessels. They are contained in a special fold of the broad ligament called the mesosalpinx that is attached to the part of the ligament near the ovary. Doppler may help distinguish vessels from tubes. The fallopian tube has three anatomic parts—the infundibulum (distal), and ampulla (mid), and isthmus (proximal).

What is the best landmark for the ovary?

The ovaries usually lie near the cornu of the uterus, along the side wall of the pelvis, suspended from the back of the broad ligament of the uterus in a fold of peritoneum called the mesovarium. The ovaries are usually medial to the external iliac vessels and anterior to the ureter.

How is the ovary measured and the volume calculated?

The ovary is measured in three planes: length, width, and anteroposterior dimension. Multiplying these three numbers together grant the volume.

Discuss the anatomic landmarks of the pelvic cavity

The pelvic cavity is that part of the abdominal cavity found below the pelvic brim. The posterior wall is formed by the sacrum and coccyx. The piriformis and coccygeus muscles overlie the sacrum and coccyx. Along the lateral margins of the pelvic cavity lie the hip bones, which are covered by the obturator internus muscles. The lower margin of the pelvic floor is formed by the levator ani and coccygeus muscles. The region above the pelvic diaphragm is the pelvic cavity; the smaller area below the pelvic floor is the perineum. The lowest part of the peritoneal cavity is the rectouterine pouch (pouch of Douglas).

What vessels are routinely evaluated in the female pelvis using Doppler?

The uterine artery and ovarian artery are evaluated with Doppler.

Discuss the function of the broad and round ligaments of the uterus.

The uterus is supported in its midline position by paired broad ligaments, round ligaments, and uterosacral ligaments, as well as other lesser ligaments. The broad ligaments are a double fold of peritoneum and provide bilateral support for the uterus. They attach to the lateral walls of the pelvis, surrounding the fallopian tubes, round ligaments, ovary, parovarium, connective tissue, unstriped muscular fiber, blood vessels, and nerves. The upper edge of the broad ligament encloses the fallopian tube as it extends from the cornua of the uterus. The round ligaments occupy space between the layers of broad ligament and occur in front of and below the fallopian tube. These two cords commence on each side of the superior aspect of the uterus and course upward and lateral to the inguinal canal and labia majora.

iliopectineal line

a bony ridge on the inner surface of the ilium and pubic bones that divides the true and false pelvis; also called the pelvic brim or linea terminalis

broad ligament

a broad fold of peritoneum draped over the fallopian tubes, uterus, and ovaries; extends from the sides of the uterus to the sidewalls of the pelvis, dividing the pelvis from side to side and creating the vesicouterine pouch anterior to the uterus and the rectouterine pouch posteriorly; it is divided into the mesometrium, mesosalpinx, and mesovarium

piriformis muscle

a flat, pyramidal muscle arising from the anterior sacrum, passing through the greater sciatic notch to insert into the superior aspect of the greater trochanter of the femur; serves to rotate and abduct the thigh

gonadotropin

a hormonal substance that stimulates the function of the testes and the ovaries; in the female, FSH and LH are gonadotropins

luteinizing hormone (LH)

a hormone secreted by the anterior pituitary gland that stimulates ovulation and then induces luteinization of the ruptured follicle to form the corpus luteum

perimetrium

a serous membrane enveloping the uterus; also called the serosa

obturator internus muscle

a triangular sheet of muscle that arises from the anterolateral pelvic wall and surrounds the obturator foramen, passes through the lesser sciatic foramen and inserts into the medial aspect of the greater trochanter of the femur, and serves to rotate and abduct the thigh

oligomenorrhea

abnormally light menstrual periods

polymenorrhea

an abnormally frequent recurrence of the menstrual cycle; a menstrual cycle of less than 21 days

corpus luteum

an anatomic structure on the surface of the ovary, consisting of a spheroid of yellowish tissue that grows within the ruptured ovarian follicle after ovulation; acts as a short-lived endocrine organ that secretes progesterone to maintain the decidual layer of the endometrium should conception occur

rectouterine recess (pouch)

area in the pelvic cavity between the rectum and the uterus that is likely to accumulate free fluid; also known as the posterior cul-de-sac and the pouch of Douglas

vesicouterine recess (pouch)

area in the pelvic cavity between the urinary bladder and the uterus; also known as the anterior cul-de-sac

suspensory (infundibulopelvic) ligament

paired ligaments that extend from the infundibulum of the fallopian tube and the lateral aspect of the ovary to the lateral pelvic wall; also called the infundibulopelvic ligament

round ligaments

paired ligaments that originate at the uterine cornua, anterior to the fallopian tubes, and course anterolaterally within the broad ligament to insert into the fascia of the labia majora; hold the uterus forward in its anteverted position

anteflexed

position of the uterus when the uterine fundus bends forward toward the cervix

uterosacral ligaments

posterior portion of the cardinal ligament that extends from the cervix to the sacrum

What is the significance of the rectouterine recess and bowel?

It is normal to observe an accumulation of free fluid throughout the menstrual cycle in the rectouterine recess and cul-de-sac. This region is the most posterior and dependent region of the peritoneal cavity. The greatest quantity of free fluid in the cul-de-sac occurs after the mature follicle ruptures. This does not always indicate ovulation. Accumulated fluid may be clear, contain blood or pus, which may suggest pathology, such as a ruptured cyst, ascitic fluid, a ruptured corpus luteum cyst, ectopic pregnancy, pelvic inflammatory disease, or viscous fluid.

the phase of endometrial regeration is called the ________phase and will last until luteinization of the graafian follicle around ovulation

proliferative