Porth's Essentials of Pathophysiology, 4e

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Disorders of the Female Genitourinary System

C h a p t e r 4 0

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. ■■ 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 SUMMARY CONCEPTS

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 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.