Basic Anatomy Review

You have these parts for life, why not get to know them?  First, structure creates function.  Knowing how things are built together can tell you how they work together.  Leonardo Da Vinci was a brilliant man, as he discovered how the human form renders its function.  As an artist, he did most of his work with the external muscle and skeletal form, but the same concept surfaces here.  You need to know what your parts look like and then it is easier to understand how everything works. 

 The female system is comprised of the ovaries, tubes, uterus, cervix, vagina, and bladder.  I will also include information about the rectum.  Note the physical relationship between the organs from the front views and side views.  (Figure 1-front view and Figure 2-side view)  Let’s start at the “bottom”.  The opening of the vagina is called the vestibule while the length of the vagina is called the vault.  The vagina is essentially a cylinder-like shape and at the top it is connected to the cervix.  The vagina is made of a muscular wall and blood vessels.  The lining, or mucosa, faces the inside.  The muscle is what allows it to maintain its shape and to help support the bladder above it and keep the rectum back.  It also can stretch wider for childbirth. 

The cervix is at the top of the vagina and is contiguous with the uterus.  (Figure 3)  Visually trace the uterus from its top most area and then downward where it becomes the cervix.  The cervix has an inside and an outside.  The type of cells and function of the cells changes as the transition from the cervix to uterus happens.  The outside of the cervix (where it contacts the vagina) is the ectocervix.  The part of the cervix that is at the bottom of the uterus is the endocervix.  Pap smears are done by brushing the outside and the inside for samples.  A whole chapter is dedicated to that can of worms topic. 

The tubes are small with trumpet shaped openings near the ovaries.  The width of them is similar to a pencil.  Tubes have microscopic hairs inside them to help sweep bacteria out and sweep sperm, eggs, and embryos (all the good stuff) along.  They are very fragile.  Ovaries are a complex surprise.  They have millions of eggs in all stages of development and a stroma, or tissue, where hormone interactions occur.  The eggs “rest” in the stroma.  Picture if you will eggs sitting in a bird nest, which the concept and imagery are strikingly similar.  Did you know that we are born with all of the eggs we will ever have?  Men just keep making their swimmers, but we get the finite pool of eggs.  I’ll get to that later. 

The uterus is lodged in between the cervix and tubes.  Going from inside to outside, several layers are stacked.  The inside lining, or endometrium, is closest to the inside cavity and it “sheds” off with menstruation.  Muscle layers lie beneath the lining and they make the wall of the uterus.  The muscle wall of the uterus is not like the muscles we use to move our limbs.  They are smooth muscle and respond to hormones.  Position of the uterus varies between women, with the most common being slightly tilted forward, like in Figure 2.  The majority of women have some tilt.  The old phrase “you have a tilted uterus” is meant to refer to the women where there is a slight backwards tilt.  Tilt does not mean anything about fertility, pap smears, periods, etc.  It is not abnormal, only a variation of possibilities.  A rare percentage of women can have a “double” uterus.  It is weird but true.  I have delivered ladies like this before.  The first time was while I was a resident and my attending kept saying, “You got yourself a uterus like a dog.”  I thought he was just being crass until I went home and looked it up on the internet.  True.

Bladders are unique, and can be troublesome for women.  Look very carefully at how it is positioned in relation to the vagina and uterus in Figure 2.  Simply, it is for storage of urine and it is made of stretchable muscle with a thin lining on the inside.  It is supported by the strong muscle wall of the vagina which is underneath it.  The urethra is the tube that urine travels down to get out.  It has got to cross your mind: how does urine not just constantly leak out if it is like an upside down bottle with no plug?  There is a ring of muscle at the base of the bladder before the urethra starts.  It is called the sphincter.  We have control over this sphincter, like controlling a garage door opener.  Our body tells it to remain shut in its natural state.  That is why we do not walk around with urine coming out like a leaky faucet.  Normally, the sphincter remains tightened or closed while the muscle of the bladder is told to relax.  This allows the bladder to store urine without leaking out.  When the bladder gets to a certain volume, nerves are triggered that tell our brain “you need to urinate”.  We then go to the toilet and control the opening of the sphincter.  The bladder muscle then contracts, which pushes out the urine. 

On the back side of the vagina is the rectum mainly for evacuation of the bowels.  The rectum is also held back from falling into the vagina by the strong muscular wall of the vagina.  Another sphincter, or ring of muscle, is at the bottom edge of the rectum.  Like the bladder sphincter, it normally is closed which would make sense so stool does not constantly fall out.  Thank heavens for sphincters, or we would all be wearing diapers.  The same mechanism that I described in the bladder happens when the rectum fills with stool.  Nerves send a message to the brain to tell you about the bowel movement, and then the sphincter is voluntarily relaxed, which opens it.  Gosh, thank heaven for sphincters.

Do you know your vagina?  Take a look at it.  Don’t be afraid, it will not bite you.  I promise.  I have a hand mirror for patients to use in every exam room so women can see what I see instead of trying to describe in words where I see something or where they think they see something.  The visual impact holds in the memory better that saying, “It is a little to the left and downwards but in the middle of that space you have between your vaginal opening and rectum.”  Wouldn’t you rather have a mirror and be shown? 

Lie down on the bed or stand with one leg on a chair and take a mirror and look.  (Figure 4)  Find your urethra, pubic bone, perineum (space between vagina and rectum).  Be familiar with your labia major and minor.  Check it out, it is good for you.  The female labia are very sensitive to touch and stimulation.  Size does not matter and everyone’s labia look different.  The labia minor can be long, protrude, dangle, and be smooth, darker or lighter in color.  Just like sweat glands elsewhere in the body, the labia and vagina area have these also, which contributes to lubrication for sex.

The clitoris is the female counterpart to the penis, funny as that may seem.  After sex or when aroused, it can be enlarged and swollen, sound familiar?  So from top to bottom, you will see:  clitoris, urethra, vaginal opening, and then rectal opening. 

You need to know where things are and how they work together.  Some things can go in there and other things do not belong in there at all, like kielbasas.  The particular way the female pelvic organs are placed and work together in space and form is fascinating.  Structure creates function.  Your body is what makes you a woman.  Know it.  Love it.  Protect it and treat it well.  Next, venture forward to unearth the mystery of the menstrual cycle.  Keep going through the chapters and you will find more than you ever thought you could know, want to know, or even things you didn’t know that you should know.  It will all become clear.

Allyn G. Schaub M.D.

Your Girlfriend Gynecologist^TM

Your Girlfriend is in Town

Your body, and in particular your uterus and ovaries are your best friend.  It is a love/hate relationship that you need to know.  Girlfriends do not always see eye to eye on everything, so appreciate how sometimes she may not cooperate.  She may arrive early or unexpectedly when you have just gotten out of the shower, when you are in the middle of a work day, or when you decided to wear those fabulous white pants that look so hot on you.  Sometimes, she trots in with other friends (aka acne, painful breasts, and bloating).  If you understand what makes her tick, you will be fabulous friends for life.

The most important thing for you to understand about your body is the basic menstrual cycle.  It is the amazing cream of the crop of physiology.  It is complex, driven by many different hormones in precise patterns, that, if any are out of synchronization, the system will not work.  Keep an eye on the chart and follow along.  When the hormones are mentioned, refer back to it, and reread it.  Getting this down now will enhance your ability to understand the other topics and not leave you feeling like you need to flip back constantly. 

The chart reads left to right, with the beginning of your cycle at the left.  The synchrony of events happens vertically.  To be precise, all of the events lining up vertically are happening at the same time.  Look at the days of the cycle on the bottom of the chart and note that the first day is ‘Day 1’.  Also, Day 1 represents the first day of your period.  This chart represents an average cycle of twenty eight days.  It is normal for cycles to vary from twenty four to thirty five days in the majority of women.  A few women have longer time frames between periods while others experience shorter ones.  This is fine, since we are not all the same.  A common misconception is that the cycle ends with menstruation.  Understanding that this event comes first is important as you will see time and again in the coming chapters.

You are born with all of the eggs you will ever have, which is about twenty million.  That seems ludicrous to me because the average male has double that number of sperm in each ejaculation.  Men also seem to have that never-ending supply of swimmers.  Back on base, these “birth right” eggs are only partially developed.   Puberty triggers the final development of them.  One at a time, as directed by the brain, each egg will be hormonally driven to develop and ovulate.  They are also called follicles. 

The menstrual cycle is broken into two main phases.  You might hear at your doctor’s office the words follicular phase and luteal phase.  Follicular phase refers to the development of the follicle/egg before ovulation of it, while the luteal phase is the development of the corpus luteum after ovulation of the follicle/egg (described below).

Four hormones are seen on the graph.  Lutenizing Hormone (now will be referred to as LH) and Follicle Stimulating Hormone (now will be referred to as FSH) are made in the brain and they tell the ovary what to do.   The two main hormones produced by the ovary areestrogen and progesterone.  Estrogen and progesterone control the growth of the lining of the uterus.  In general, estrogen thickens the lining of the uterus, while progesterone prepares the lining to shed off. 

The female body operates on hormone signals.  Each organ or part of your body will make a hormone to tell the other part what it is “thinking”.  Basic communication is essential and the SIGNALS are very well defined.  

Let’s look again.  In the beginning of the cycle, the lining is shedding off because there are no hormones to stabilize it. The estrogen is low and progesterone is low in the body.  The brain hormones (LH and FSH) are low also. This is the FIRST SIGNAL to the brain.  When this “void” or lack of hormones from the ovaries is detected by the brain, your brain begins to make LH again.  LH tells the ovaries to start making a new egg, or “follicle”.  (The words egg and follicle are interchangeable.)  See how the egg starts small, and as days go by, it gets larger.  As it gets larger, it secretes estrogen.  Watch the graph showing your estrogen level in your blood go up as the egg grows.  Subsequently, estrogen will cause the uterus lining to thicken.  As the egg approaches its maturity, or optimal size, it will produce a high enough estrogen level to set the SECOND SIGNAL into motion. 

The second signal is complex.  Two things happen in the second signal.  The estrogen must 1) peak and2) the brain must respond to it.  There is a certain attainable blood estrogen level at which the brain will then respond by producing a surge of LH and FSH.  It is like mama bear’s bed.  It needs to be just right.  Note that the peak in estrogen precedes the peaks of LH and FSH.  This subsequent peak in LH and FSH alters the follicle and tells it to release the egg inside. 

The release of the egg happens approximately fourteen to fifteen days after the firstday of your period.  Therefore, these are your most fertile days.  If you are hankering to be pregnant, you would want to have the most frequent sex around these days.  If not, then run the other way.  After ovulation, the egg has finished developing, and the estrogen level is never that high again during the rest of your cycle.  It begins to slowly decline. 

Now that the egg is released, the “casing”, or shell that the egg was in, which remains in the ovary, is still of prime importance.  Now it is called the corpus luteum and it primarily makes progesterone.  The body now enters the luteal phase.  Progesterone alters the blood vessels in the lining of the uterus.  When it declines in your blood as shown in the second half of the graph, the lining of the uterus will shed. 

Nearing day twenty seven and twenty eight, the estrogen and progesterone levels drop, as do the levels of LH and FSH.  The lining has no hormone support, and it sheds: your girlfriend has arrived.  Hormone levels remain low for several days.  The brain senses the low hormones levels, and the cycle starts all over again. 

To summarize in all of this pomp and circumstance:  Brain tells ovary to make egg.  Egg makes estrogen.  Estrogen thickens lining of uterus.  Brain tells ovary to release egg.  Estrogen goes down.  Corpus luteum makes progesterone.  Progesterone gets lining of uterus ready to shed.  Lining sheds.  Voila!  Let’s go have a cocktail. 

Allyn G. Schaub M.D.

Your Girlfriend Gynecologist^TM

How to Use My Blog

Major catastrophes do not happen all day and every day.  My day was generally filled with happy women who are having problems.  But they are worried and need information.  It is not simple either.  My days were about educating, helping, and doing for others.  Also as a proficient listener, I found the common thread between us women:  we want to know why, how, and what are our options.  We as women want to make decisions based on good solid information.  Who wouldn’t?  But we can not be comfortable with the decisions that we make with our bodies unless we really understand our specialized female system.  So came along my blog (was a book-wanna-be, but never happened with no time).  This blog is intended to fill an information void for you, the woman.  There is not super-sci-fi information in here, but simply the basics to understanding female medicine and your body. 

When I began this project in my mind, which happened long before I laid a finger on a keyboard, I dreamt of a massive encyclopedia of information that women would have dreams of owning, maybe as a coffee table book.  However, something of that proportion as a centerpiece in the living room could scream “I have vaginal issues” and it could scare away neighbors, husbands, or potential boyfriends, so I down-graded.  Usually I am an “I’ll take-the-upgrade-of-anything kind of girl”, always choosing triple fudge over milk chocolate, but then I thought my encyclopedia adventure might be totally indigestible.  I mentally shredded my encyclopedia dream book to focus on what I felt women really needed.  I went back to my source of inspiration:  my patients.  Discovering the common denominator among all of us, I started writing.  We want to be talked with, not talked to.  We want someone to recognize that need, fulfill it, and help us. 

Information in this blog is organized into a straight forward format.  The basics of anatomy and female hormones are posted to give you a good solid starting ground.  Then I will get to my “housekeeping agenda” with contraception, pap smears, and infections.  After that, the most common problems are discussed in detail:  abnormal bleeding, ovarian cysts, infertility, and pelvic pain.  Lastly, I review the common surgical and office procedures that any woman might encounter. 

I feel that if you do not have a good knowledge base before you walk into the gynecologist’s office, you miss an opportunity to ask questions and participate more fully in your healthcare.  I commonly saw women for second opinions about a treatment that has been recommended for them.  I review old records, do the exam, and take a careful history.  At the end, I usually did not change the treatment recommended by the other physician, but I offer something special:  a detailed explanation of how, why, other options, and when to follow-up.  That’s all.   So take this blog and use it for reference and review.  I do not want you to try to self-diagnose major problems or propose your own surgery.  It is written to be relaxed and easy to understand as if you are having a conversation with your girlfriend.  But please do NOT replace your own doctor’s evaluation, recommendations, or advice with my blog.  It is a supplementary explanation blog for you, not a replacement for proper individualized medical care.  So, tag it, flag it, share my site to friends. Images and all written content are trademarked and not for reproduction.

Allyn G. Schaub M.D.

Your Girlfriend Gynecologist^TM