The mons pubis (also known as mons veneris) is a fatty layer of tissue over the pubic symphysis (joint of

the pubic bones). During puberty the mons pubis becomes covered with pubic hair, and its sebaceous and
sweat glands become more active. Estrogen causes fat to be deposited under the skin, giving the mons pubis
a moundlike shape. This cushion of tissue protects the pubic symphysis during sexual intercourse.

The labia majora (singular, labium majus) are two folds of skin that arise at the mons pubis and extend
back to the fourchette, forming a cleft. Like the mons pubis, the labia majora undergo changes at puberty:
the amount of fatty tissue increases, pubic hair grows on the lateral surfaces, and sebaceous glands on the
hairless medial surfaces begin to secrete lubricants. Because of an extensive network of nerve endings,
the labia majora are highly sensitive to temperature, touch, pressure, and pain and are homologous to the
male scrotum (see Figure 22-2 and Figure 22-13). The principal function of the labia majora is to protect the
inner structures of the vulva.

The labia minora (singular, labium minus), two smaller, thinner folds of skin, lie within the labia majora.
Anteriorly they form the clitoral hood, or prepuce, and frenulum, then split to enclose the vestibule, and
converge near the anus, forming the fourchette. The labia minora are hairless, pink, and moist and are well
supplied with nerves, blood vessels, and sebaceous glands. These glands secrete a bactericidal fluid that has
a distinctive odor and that lubricates and waterproofs the vulvar skin. During sexual arousal the labia minora
become swollen with blood.

The clitoris is a richly innervated, erectile organ that lies anterior, between the labia minora. It is a small,
cylindrical structure having a glans that is visible and a shaft that lies beneath the skin (see Figure 22-4). The
clitoris is homologous to the male penis. Like the penis, the clitoris is a major site of sexual stimulation and
orgasm. With sexual arousal, erectile tissues in the clitoris fill with blood, causing it to enlarge somewhat.
Similar to other vulvar glands, the clitoris secretes a fluid, called smegma, which has a unique odor and may
be erotically stimulating to the male.

The vestibule is the area protected by the labia minora and contains the external opening of the vagina,
which is called the introitus, or vaginal orifice. A thin, perforated membrane called the hymen may cover
the introitus. The vestibule also contains the opening of the urethra, or urinary meatus (orifice).
These structures are lubricated by two pairs of glands: Skene glands and Bartholin glands. The ducts of
Skene glands (also called the lesser vestibular or paraurethral glands) open on both sides of the urinary
meatus. The ducts of Bartholin glands (greater vestibular or vulvovaginal glands) open on either side of
the introitus. In response to sexual stimulation, Bartholin glands secrete mucus that lubricates the inner
labial surfaces, as well as enhances the viability and motility of sperm. Skene glands help lubricate the
urinary meatus and the vestibule. Secretions from both sets of glands facilitate coitus. Also, in response to
sexual excitement, the highly vascular tissue just beneath the vestibule fills with blood and becomes
engorged.
The less hairy skin and the subcutaneous tissue that lie between the vaginal orifice and the anus are referred
to as the perineum. Unlike the rest of the vulva, this area has little subcutaneous fat so that the skin is close
to the underlying muscles. The perineum covers the muscular perineal body, a fibrous structure that
comprises elastic fiber, connective tissue, and the common attachment of the bulbocavernosus, the external
anal sphincter, and the levator ani muscles (see Figure 22-4). The perineum varies in length from 2 to 5 cm
or more and stretches remarkably. The length of the perineum and the elasticity of the perineal body
influence tissue resistance and injury during childbirth.

Vagina
The vagina is an elastic fibromuscular canal, 9 to 10 cm long in a reproductive-aged female, which extends
up and back from the introitus to the lower portion of the uterus. As Figure 22-5 shows, it lies between the
urethra (and part of the bladder) and the rectum. Mucosal secretions from the upper genital organs,
menstrual fluids, and products of conception leave the body through the vagina, which also receives the
penis during coitus. During sexual excitement the vagina lengthens and widens and the anterior third
becomes congested with blood.
The vaginal wall is composed of four layers:
1. Its lining is a mucous membrane of squamous epithelial cells. (Types of epithelium are described and
illustrated in Chapter 1, Table 1-7.) This layer thickens and thins in response to hormones, particularly
estrogen.
The squamous epithelial membrane is continuous with the membrane that covers the lower part of the
uterus.
In women of reproductive age, the mucosal layer is arranged in transverse wrinkles, or folds, called rugae
(singular, ruga) that permit stretching during coitus and childbirth.
2. Fibrous connective tissue containing numerous blood and lymphatic vessels.
3. Smooth muscle.
4. Connective tissue and a rich network of blood vessels.
The upper part of the vagina surrounds the cervix, the lower end of the uterus (see Figure 22-5). The
recessed space around the cervix is called the fornix of the vagina. The posterior fornix is deeper than the
anterior fornix because of the angle at which the cervix meets the vaginal canal. In most women this angle is
about 90 degrees. A pouch called the culde- sac separates the posterior fornix and the rectum. Its elasticity
and relatively sparse nerve supply enhance the vaginas function as the birth canal. During sexual arousal
the vaginal wall becomes engorged with blood, like the labia minora and clitoris. Engorgement pushes some
fluid to the surface of the mucosa, enhancing lubrication. The vaginal wall does not contain mucus-secreting
glands; rather, secretions drain into the vagina from the endocervical glands or enter from the vestibule,
from the Bartholin and Skene glands.
Two factors help maintain the self-cleansing action of the vagina and defend it from infection, particularly
during the reproductive years: (1) an acid-base balance that discourages the proliferation of most pathogenic
bacteria and (2) the thickness of the vaginal epithelium. Before puberty, vaginal pH is about 7 (neutral) and
the vaginal epithelium is thin. At puberty, the pH becomes more acidic (4 to 5) and the squamous epithelial
lining thickens. These changes are maintained until menopause (cessation of menstruation), at which time
the pH rises again to more alkaline levels and the epithelium thins out. Therefore, protection from infection
is greatest during the years when a woman is most likely to be sexually active.
Between puberty and menopause, vulnerability to infection varies somewhat with cyclic changes in pH and
epithelial thickness. Both defenses are greatest when estrogen levels are high and the vagina contains a
normal population of Lactobacillus acidophilus, a harmless resident bacterium that helps maintain pH at
acidic levels. Any condition that causes vaginal pH to rise, such as douching or use of vaginal sprays or
deodorants, low estrogen levels, or destruction of L. acidophilus by antibiotics, lowers vaginal defenses
against infection.

Uterus
The uterus is a hollow pear-shaped organ whose lower end opens into the vagina. The functions of the
uterus are to anchor and protect a fertilized ovum, provide an optimal environment while it develops, and
push the fetus out at birth.
In addition, the uterus plays an important role in sexual response and conception. During sexual excitement
the opening of the uterus (the cervix) dilates slightly. At the same time, the uterus increases in size and
moves upward and backward, creating a tenting effect in the midvagina that results in the cervix sitting in
a pool of semen. During orgasm, rhythmic contractions facilitate movement of sperm through the cervical os
while also enhancing physical pleasure.
At puberty the uterus attains its adult size and proportions and descends from the abdomen to the lower
pelvis, between the bladder and the rectum (see Figure 22-5). The uterus of a mature, nonpregnant female is
approximately 7 to 9 cm long and 6.5 cm wide, with muscular walls 3.5 cm thick. It is held loosely in
position by ligaments, peritoneal tissue folds, and pressure of adjacent organs, especially the urinary bladder,
sigmoid colon, and rectum. In most women the uterus is anteverted; that is, it is tipped forward so that it
rests on the urinary bladder. However, it may be retroverted, or tipped backward.
Various degrees of flexion are normal (Figure 22-6).
Figure 22-7 shows a cross section of the uterus. The uterus has two major parts: the body, or corpus, and the
cervix. The top of the corpus, above the insertion of the fallopian tubes, is called the fundus. The diameter
of the uterine cavity is widest at the fundus and narrowest at the isthmus, which is the narrowed part of the
corpus just above the cervix. The cervix, or neck of the uterus, extends from the isthmus to the vagina.
The passageway between the cervixs upper opening (the internal os) and its lower opening (the external os)
is called the endocervical canal. The entire uterus, like the upper vagina, is innervated exclusively by motor
and sensory fibers of the autonomic nervous system.
The uterine wall is composed of three layers: the perimetrium, the myometrium, and the endometrium (see
Figure 22-7). The perimetrium (parietal peritoneum) is the outer serous membrane that covers the uterus.
The myometrium is the thick muscular middle layer. The myometrium is thickest at the fundus, apparently
to facilitate birth. The endometrium, or uterine lining, is composed of a functional layer (superficial
compact layer and spongy middle layer) and a basal layer. The functional layer of the endometrium is
responsive to sex hormones.
Between puberty and menopause this layer proliferates and sloughs off monthly. The basal layer, which is
attached to the myometrium, regenerates the functional layer after it sloughs (menstruation).
The endocervical canal does not have an endometrial layer.
Rather, it is lined with columnar epithelial cells (see Table 1-7). The endocervical lining is continuous with
that of the outer cervix and vagina, but it is not made up of the same type of epithelial cells. The point at
which the columnar epithelium of the cervix meets the squamous epithelium of the vagina is called the
transformation zone, or the squamous-columnar junction. The transformation zone is especially
susceptible to the oncogenic human papillomavirus (HPV), which leads to cervical dysplasia and, ultimately,
cervical cancer; these are the cells sampled during a Papanicolaou test (Pap test).10 The cervix acts as a
mechanical barrier to infectious microorganisms that may be present in the vagina. The external cervical
os is a very small opening that contains thick, sticky mucus (the mucous plug) during the luteal phase of the
menstrual cycle and all of pregnancy. During ovulation, the mucus changes under the influence of estrogen
and forms watery strands, or spinnbarkeit mucus, to facilitate the transport of sperm into the uterus. In
addition, the downward flow of cervical secretions moves microorganisms away from the cervix and uterus.
In women of reproductive age, the pH of these secretions is inhospitable to most bacteria. Further, mucosal
secretions contain enzymes and antibodies (mostly immunoglobulin A) of the secretory immune system.
(The secretory immune system is discussed in Chapter 7.) These defenses do not always prevent infection,
even if they are intact. Besides infection, uterine pathophysiology includes displacement of the uterus within
the pelvis, benign growths (fibroids) of the uterine wall, hyperplasia of the endometrium, endometriosis, and
cancer.

Fallopian Tubes
The two fallopian tubes (oviducts, uterine tubes) enter the uterus bilaterally just beneath the fundus (see
Figure 22-7).
Their function is to conduct the ova from the spaces around the ovaries to the uterus. From the uterus the
fallopian tubes curve up and over the two ovaries. Each tube is 8 to 12 cm long and about 1 cm in diameter,
except at its ovarian end, which flares out like the bell of a trumpet. This widened end, called the
infundibulum, is fringed or fimbriated. The fimbriae (singular, fimbria) (fringes) move, creating a current
that draws the ovum into the infundibulum. Once the ovum has entered the fallopian tube, cilia and
peristalsis (muscle contractions) keep it moving toward the uterus.
The ampulla, or distal third, of the fallopian tube is the usual site of fertilization (see Figure 22-7). Sperm
released into the vagina travel upward through the endocervical canal and uterine cavity and enter the
fallopian tubes. If an ovum is present in either tube, fertilization can occur. Whether or not the ovum
encounters sperm, it continues to travel through the fallopian tube to the uterus. If fertilized, the ovum (then
called a blastocyst) implants itself in the endometrial layer of the uterine wall. If not fertilized, the ovum
breaks down within 12 to 24 hours.
Disorders that affect the fallopian tubes can block the path of sperm and ovum and cause infertility or
ectopic (tubal) pregnancy. Such disorders include congenital malformations, infection, and inflammation.

Ovaries
The ovaries, or the female gonads, are the primary female reproductive organs. They have two main
functions: secretion of female sex hormones and development and release of female gametes, or ova.
The almond-shaped ovaries are located on both sides of the uterus and are suspended and supported by the
mesovarian portions of the broad ligament, ovarian ligaments, and suspensory ligaments (see Figure 22-7).
The ovaries are smaller than their male homologs, the testes. In women of reproductive age, each ovary is 3
to 5 cm long, 2.5 cm wide, and 2 cm thick and weighs 4 to 8 g. Size and weight vary somewhat from phase
to phase of the menstrual cycle (see p. 792).
Figure 22-8 shows a cross section of an ovary. The central part, or medulla, is composed of connective
tissue and contains many small arteries, veins, and lymphatics that enter at the hilum. Surrounding the
medulla is the cortex. At birth the cortex of each ovary contains approximately 2 million ova within
immature ovarian follicles. Follicles grow and undergo atresia continuously and irrevocably during a
womans life. By puberty the number ranges between 300,000 and 500,000 ova.
During puberty some of the follicles and the ova within them begin to mature. Between puberty and
menopause the ovarian cortex always contains follicles and ova in various stages of development. Once
every menstrual cycle (about every 28 days), usually only one of the follicles reaches maturation and
discharges its ovum through the ovarys outer covering, the germinal epithelium. During the reproductive
years, 400 to 500 ovarian follicles mature completely and release an ovum, an event termed ovulation. The
rest either fail to develop at all or degenerate without maturing completely.1
Having ejected a mature ovum, the follicle develops into another structure, the corpus luteum (see Figure
22-8). The immediate fate of the corpus luteum depends on whether the ejected ovum is fertilized. If
fertilization occurs, the corpus luteum enlarges and begins to secrete hormones that maintain and support
pregnancy. If fertilization does not occur, the corpus luteum secretes these hormones for approximately 14
days and then degenerates, which triggers the maturation of another follicle. The ovarian cyclethe process
of follicular maturation, ovulation, corpus luteum development, and corpus luteum degenerationis
continuous from puberty to menopause, except during pregnancy or hormonal contraceptive use. At
menopause, this process ceases and the ovaries atrophy to the point that they cannot be felt during pelvic
examination.
Four types of cells within the ovarian cortex secrete sex hormones: cells of the stroma, or tissue matrix; two
types of cells in the ovarian follicle, granulosa cells and theca cells, and cells of the corpus luteum (Figure
22-9). These cells all contain receptors for the gonadotropins (LH and FSH) or for the sex hormones, which
are discussed in the next section. Because gonadotropins and hormones regulate ovarian function, any
disorder that disrupts this process, such as abnormal pituitary or thyroid function, or reception by target cells
can cause ovarian dysfunction and infertility. Benign or malignant growths, cysts, infection, or inflammation
also can cause ovarian pathologic conditions.1
Hormone cycles in the menstrual period:

Phase of cycle LH FSH Progesterone Estradiol

Follicular phase low High low low

Late follicular phase High low lower limit high

Mid cycle Peak raised increasing low

Luteal phase raised raised high high

Start of Next cycle low rsing rising rising