C h a p t e r 4 0
Disorders of the Female Genitourinary System
1041
androstenedione. This instability may give rise to “hot
flashes,” palpitations, dizziness, and headaches as the
blood vessels dilate. Despite the association with these
biochemical changes, the underlying cause of hot flashes
is unknown. Tremendous variation exists in the onset,
frequency, severity, and length of time that women
experience hot flashes. When they occur at night and
are accompanied by significant perspiration, they are
referred to as
night sweats
. Insomnia as well as frequent
awakening because of vasomotor symptoms can lead to
sleep deprivation. A woman may experience irritability,
anxiety, and depression as a result of these uncontrol-
lable and unpredictable events.
Consequences of long-term estrogen deprivation
include osteoporosis due to an imbalance in bone
remodeling (see Chapter 44), and an increased risk
for cardiovascular disease, which is the leading cause
of death for women after menopause. With perimeno-
pause, changes occur in the cardiovascular lipid profile:
total cholesterol increases, HDL cholesterol decreases,
and LDL cholesterol increases.
Menopausal hormonal therapy has come under
scrutiny with the publication of the Women’s Health
Initiative.
54,55
Since the publication of these trials,
there has been great interest in developing alternative
doses, delivery systems, and medications for hormone
therapy. Many products are now available, including
transdermal delivery systems and lower-dose tradi-
tional hormone therapy. Vaginal estrogen preparations
are available to treat symptoms related to vaginal atro-
phy. Selective estrogen receptor modulators (SERMs)
may be used in place of estrogen to alleviate vulvovagi-
nal atrophy and prevent osteoporosis.
Disorders of the Breast
Although anatomically separate, the breasts are func-
tionally related to the female reproductive system in
that they respond to the cyclic changes in sex hormones
and produce milk for infant nourishment. The breasts
are composed of specialized epithelium and stroma that
may give rise to both benign and malignant lesions.
Breast Structures
The breasts, or mammary glands, are located between
the third and seventh ribs of the anterior chest wall
and are supported by the pectoral muscles and super-
ficial fascia. They are specialized glandular structures
that have an abundant shared nervous, vascular, and
lymphatic supply
1,2
(Fig. 40-17). Structurally the breast
consists of fat, fibrous connective tissue, and glandu-
lar tissue. The superficial fibrous connective tissue is
attached to the skin, a fact that is important in the
visual observation of skin movement over the breast
during breast self-examination. A nipple is located near
the tip of the breast at about the level of the fourth
intercostal space and is surrounded by an area of pig-
mented skin called the
areola
(Fig. 40-18). The areola
contains sebaceous glands and modified sweat glands
(glands of Montgomery). These glands have a structure
intermediate between sweat glands and true mammary
glands, and produce small elevations at the surface of
the areola.
The breast mass is supported by the fascia of the
pectoralis major and minor muscles and by the fibrous
connective tissue of the breast. Fibrous tissue ligaments,
called
Cooper ligaments
, extend from the outer boundar-
ies of the breast to the nipple area in a radial manner, like
the spokes on a wheel (see Fig. 40-17). These ligaments
further support the breast and form septa that divide the
breast into 15 to 20 lobes. Each lobe consists of grape-
like clusters of glands (alveolar glands) and a duct (lac-
tiferous duct) that lead to the nipple and opens to the
outside (see Fig. 40-18). Two epithelial cell types line the
SUMMARY CONCEPTS
■■
Dysfunctional menstrual cycles, including
amenorrhea (absence of menstruation),
hypomenorrhea (scanty menstruation),
oligomenorrhea (infrequent menstruation),
and polymenorrhea (excessive menstruation)
are most often due to a lack of ovulation and
disturbances in the pattern of ovarian hormone
secretion
■■
Dysmenorrhea, or pain or discomfort during
menses, can occur as a primary disorder due to
intense uterine contractions caused by excess
prostaglandin secretion or as a secondary
disorder due to structural abnormalities or
disease processes such as endometriosis, pelvic
adhesions, or pelvic inflammatory disease.
■■
The terms premenstrual syndrome and
premenstrual dysphoric disorder represent an
array of predictable physical, cognitive, affective,
and behavioral symptoms that occur during the
luteal phase of the menstrual cycle and that
are resolved by menstruation or within a few
days of onset. Although the etiology of these
disorders is currently unknown, it is probably
the result of an interaction between the sex
hormones and central neurotransmitters,
particularly serotonin.
■■
Menopause is the cessation of ovarian function
and menstrual cycles. It is accompanied by a
decline in secondary sexual characteristics,
vasomotor instability, and long-term
consequences, including increased risk of
osteoporosis and heart disease.
