Ovaries

Today, I tackle a body part upon which I consider myself to be somewhat of an expert. Had my left ovary behaved years ago, I would not be typing this today–and I would still have both ovaries. Speaking with other women, it becomes obvious very quickly that we tend to know very little about our ovaries.  Hopefully, I will shed some light on this for you today!

Where are the ovaries?  It’s safe to say we know they’re in our pelvis, but where exactly?  A good estimate is to make a triangle with with your index fingers and thumbs and place that over your pelvis with the index fingers pointing downward.  In the upper corners is about where your ovaries are.  (They tend to be a bit lower and more centralized than most assume they are.)  The ovaries are held in place by a network of ligaments which also attach to the uterus and Fallopian tubes.  The ovaries are not connected directly to the Fallopian tubes.  Many diagrams shows the fimbriae (the leafy looking parts on the far left and right below) of the Fallopian tubes as been directly adjacent to the ovaries, which leads many to believe that the ovaries are directly attached to them.  They are not.  (Read more about the relationship between the ovaries and the Fallopian tubes in the section about Fallopian tubes.)


The ovaries are, ironically, shaped like eggs but are smaller than the chicken eggs that one typically purchases at the grocery.  The ovaries are about the size of a walnut, are slightly pearl colored, and have bumpy, soft surfaces.  The ovaries are responsible for producing a variety of sex hormones.  At birth, the ovaries of a healthy baby girl contain between one and two million eggs.  By the time puberty begins, most of these have wasted away leaving about 300,000 eggs–plenty for the reproductive lifespan.  Thus, a woman has a finite number of eggs, but men have a different mechanism that continually makes sperm.  This is why women have “childbearing” years, but men can father children throughout their adult lives.

The eggs have a complicated lifespan before they are even released for potential fertilization.  The term “egg” is generic and refers to a single cell’s journey through maturation.  Before maturation, the egg is referred to as an oocyte.  Once it finishes maturing (see diagram below), it becomes an ovum and three polar bodies.  The polar bodies are actually inside of the ovum and serve to “fuel” the egg once it is fertilized continuing cell division and replication before it implants in the uterine lining (where it forms a network of blood vessels that forms the placenta and umbilical cord).

Each month, the ovaries usually release one mature egg (not one from each).  The ovaries are covered in cells called follicles and within each follicle is a single egg.  Once an egg is matured, the process of ovulation can begin.  During this time, the follicle that houses the mature egg expands and eventually ruptures forcing the egg outward.  This rupturing is completely normal–it would be abnormal for ovarian follicles to never rupture, and in fact some women can actually feel a quick pain when the rupture occurs.  The diagram below is an illustration of the ovulation process, beginning in the upper-left hand corner and going clockwise.


Following a woman’s “childbearing” years, the ovaries continue to play an important role.  For years, many doctors prescribed a surgery called a hysterectomy to remove the ovaries (as well as the uterus and Fallopian tubes) once a woman was finished having children.  This was performed to prevent cancer from developing.  However, we now know that ovarian cancer can actually develop anyway after the ovaries have been removed.  This is because the ovaries share tissue with the internal cavity that remains following a hysterectomy.  Leaving the ovaries intact provides a number of hormonal benefits throughout menopause that are difficult to replace.  Thus, the benefits of leaving the ovaries intact often outweigh the drawbacks.  (This is something that should be discussed with a physician, because each individual has a different medical history that will affect any such decision.)

There is a lot more that could be said about ovaries, but let’s save that for another day.  Hopefully this gives you a better understanding of how the ovaries work!

The First Visit to the Gynecologist: A Guide (Part Two)

Finding Eve returns with Part Two of this first-timer’s guide.  (Click here for Part One.)

During your appointment:

  1. LISTEN!  You will be given a series of instructions throughout your appointment.  Things will generally be more comfortable for you if you follow them.  They may want the paper gown to open in the front or the back or the side.  They may want you sitting, standing, lying on your back.  Just pay attention and things will go much more smoothly.
  2. Be vocal.  Now that you’re getting into the stirrups and down to business, it’s up to you to make sure your doctor knows how you feel.  For example, if you have a bad back and lying a certain way hurts, let the doctor know she or he will usually be happy to accommodate.
  3. Remember your breasts.  Most, but not all, gynecologists will give your breasts a once-over to check for lumps, bumps, and irregularities.  So, be prepared for this.  This might be the most awkward you’ll feel since the doctor will be nearly face-to-face with you at this point.
  4. Be prepared for some unusual sensations.  No matter your level of comfort with your genitalia, your first appointment with the OB/GYN will be something new.  The doctor will need to insert a few things in your vagina.  It’s an unavoidably strange situation, but it doesn’t have to be a nightmare, so be prepared for the following:
  • The first thing in will generally be a speculum.  This is a device that goes in to spread the vaginal walls to allow the doctor to see in.  There will be bright lights focused on your vagina to aid in this.  While the doctor looks around, she or he will also use a swab to take a sample of cells from your cervix.  You’ll barely be able to feel the swab, so don’t be too worried about it.  The swab is then sent away for testing to see if you have (pre-)cancerous cells.  This is called a Pap smear.  REMEMBER, this only tests for one type of gynecologic cancer (cervical).  Keeping track of your periods and pelvic health is your best bet for detecting other types of cancer.
  • After the swab for the Pap smear has been collected the doctor will “manipulate” your pelvis.  That is to say, it’s time for the rough and tumble part of the exam.  Really, it is not as bad as it sounds or may look in the diagram below.  (Believe me, I have had several severe pelvic surgeries and I make it through the pelvic manipulation fine.)  This, to me, is the most important part of the exam.  The doctor is using her or his hands to “see” what’s inside you and to make sure all is well.  It’s normal to grimace.  It’s not the most normal feeling, but it will soon be over!
  • Ask questions!  Generally, after the manual exam, the doctor says you can sit up.  This is your invitation to ask questions.  Since this is your first time, you should ask as many questions as you want.  Many doctors’ offices will schedule first-timers with longer appointments because they expect the patients to have more questions.  Don’t be shy.  If there is any thing that you don’t understand or have reservations about below the belt, ASK!  The doctor will be able to help explain whatever it may be, and this will put your mind at ease.

    After your appointment:

  1. Follow through!  If the doctor recommends that you take care of yourself with some therapy, medicine, or change, do it.  If it is something drastic, feel free to go to another doctor for a second opinion.  It is your body, after all.
  2. If you are having testing for sexually transmitted diseases (STDs), you may be asked to make another appointment at a lab.  Larger doctors’ offices usually have their own lab, so you may be escorted across the hall to have blood taken.  If you’re afraid of having blood drawn, be prepared!  Drawing blood is crucial to many standard gynecological tests, so don’t be worried if you’re referred for blood work.
  3. Keep in touch.  You will most likely receive your test results (Pap smear, blood work, etc.) in the mail or over the phone in the subsequent two week.  If, after 2-4 weeks, you have not heard anything, call your doctor’s office!  You paid for those tests, so you have the right to know how they turned out.   Things can get lost in the mail or misplaced, so take the reins and find out.  The office staff won’t begrudge you at all.
  4. Remember to make an appointment for next year.  You should never go more than a year without a visit to the gynecologist’s.  Most insurance will only cover one visit in a 365 day period, so if you went on May 1st one year, you will have to wait until least May 1st of the next year.

Remember, this guide is intended as a rough guide to your first visit.  No two appointments will ever be identical.  It is important to do what is right for you.  Please feel free to add your comments and questions and thanks for reading!

The First Visit to the Gynecologist: A Guide (Part One)

A young woman’s first visit to the gynecologist can be daunting.  Women who have already been for a gynecological check-up generally report that it’s unpleasant.  So, naturally, this scares others and many avoid going until they have to.  BUT!  I’m here to help quell those fears and insist that all young women go for a check-up.  My first visit to the gynecologist was about as traumatic as possible, but I know that I might not be alive today if I had not gone.  So, it is of the utmost importance that you take your health seriously and face any fear you might have of going to the gynecologist.  Almost every young woman comes out after that first visit and says, “That wasn’t as bad as I thought it would be.”

Before your appointment:

  1. Do your research!  If you’re reading this blog, you’re off to a good start.  Continue on by finding a local gynecologist that you are comfortable visiting.  Many young women who nervous about their first appointment find it easier to visit a female physician.  It will serve you well to talk to friends about who they go to and why.  Also, look into insurance matters.  It can be really confusing, but ask the office staff of your doctor of choice to help you confirm what is or is not covered by insurance–they’re experts and can find out what you need to know.
  2. Monitor your period.  This is an important habit to keep up your whole life.  If you’ve never kept track of your periods before, start right now!  Keep a calendar record of when your periods begin and end and make notes about any irregularities (more pain, heavier flow, etc.).  You’ll be expected to know how regular (or irregular) your periods are at the doctor’s.
  3. Decide on a day and make the appointment.  Once you known when your “safe times”* are, call the doctor’s and make that appointment!  Just making the appointment is half the battle–the next half is keeping the appointment.  You can do it!

* Many gynecologists will not perform an exam when a woman is menstruating since the blood may obscure their view of the vaginal structures–they look for any abnormalities that are visible to the naked eye.

The day of your appointment:

  1. Shower!  Or bathe!  Just get clean somehow.  Doctors encounter enough unpleasantness throughout a working day–they will thank you for not adding to it.
  2. Try to stay as calm as possible.  Being nervous and jumpy will make the appointment even more lousy.  Take deep breaths, listen to calming music, think happy thoughts.  It might be a good idea to take a friend with you if you’re really nervous.
  3. Get to your appointment on time!  Most doctors’ offices will give a recommendation of how early you should arrive.  Follow it.  If you have a bit of time to spare, you might even show up earlier than that.
  4. Almost across the board, a gynecological appointment requires the patient to provide a urine sample.  So, about an hour or so before your appointment start sipping on water (or your beverage of choice).  They will collect the sample before your actual appointment with the doctor begins and you’ll want to have something in your bladder to give.
  5. Be prepared to answer questions!  Each doctor’s office will ask a different set of questions, but here are some of the most common ones:  When was the first day of your last period (menses/menstruation/etc.)?  What medications are you taking?  (Don’t forget non-prescriptions like vitamins!)  Have you been experiencing any problems, pain, or irregularities?  Do you have a family history of cancer . . . anything?  Are you sexually active?  (BE HONEST!  If you’re nervous about a parent finding out, don’t be.  Doctors, by law, have to respect your confidentiality.)
  6. Wear clothes that are easy to remove.  Wearing clothes with lots of buttons and buckles and so on are a rookie mistake.  You’ll be glad to have a shift dress or sweatpants or what-have-you when they only give you 90 seconds to disrobe!  You might have more time than this, but more often than not I have been given very little time to climb out of my clothes and into the paper clothes.  (Also, wear nice socks.  You’ll want something warm on your feet when you rest of you is clothed in paper.  Your feet will be in the doctor’s face for much of the appointment, so pick nice ones.


The is just the first half of the guide!  Part Two will be published soon.  As always, feel free to add any comments, recommendations, or questions.

(Here is Part Two.)

Teen Pregnancy and the Rhythm Method

I read in the news today about a report released a few days ago by the Centers for Disease Control (CDC).  The headline that emerged in numerous articles as a result of this report was that the use of the rhythm method to prevent pregnancy by teenagers rose from 11% in 2002 to 17% in 2010.  This is quite a jump.  The report was made to investigate why the teen pregnancy rate has risen markedly in recent years.  In fact, the United States has the highest teen pregnancy rate of any developed country in the world and one of the highest teen abortion rates.  So, I have decided it is time to tackle the issue of the rhythm method.

So, what is the rhythm method?  If there is such a great leap of teenagers responding that they have used it, it is pretty important for young women (you, the reader!) to understand what it is.  In general terms, the rhythm method is a means of birth control by which the female avoids sexual contact during the supposed window of fertility based on a calendric monitoring of her menstrual cycles.  In other words, if a young woman has a consistent 28 day menstrual cycle, she can estimate the days she will be fertile by following the “rhythm” of her menstrual cycle.  Here is an example of what a menstrual calendar would look like (with menstruating days in red and fertile days in green):

With perfect use, meaning that a young woman meticulously keeps track of her period without fail and strictly avoid sex on possibly fertile days, pregnancy still happens 9% of the time.  If you wanted to avoid pregnancy, would you really want to take a 1 in 10 chance?  But, keep in mind that virtually all forms of birth control are not used perfectly.  So, with typical use (a slip up here and there), the rhythm method results in pregnancy 25% of the time.  That is 1 in 4!  So, needless to say that the rhythm method is not a terribly effective means of preventing pregnancy.  Other factors make the rhythm method less reliable, especially for young women.  In particular, a woman’s period does not become regular (and therefore predictable) for quite some time after the first period, called menarche.  Hormones are in flux during adolescence and early adulthood, so the monthly time of fertility is particularly unpredictable for young women.  Other times in a woman’s life when the rhythm method is especially ineffective include just after giving birth (as hormones are again in flux), after discontinuing the use of a oral contraceptive (“the pill,” which manipulates hormones), and around the time of menopause when, yet again, hormones are in flux.  Hormones can be affected by a variety of factors including stress and emotions.  So, the rhythm method can never be 100% effective.

The rhythm method has generally been rejected as a useful means of birth control [page 375] (except, notably, by the Catholic Church) in the past few decades, so it is eyebrow raising that teenagers are suddenly reporting a significantly increased use of it.  The rhythm method was first proposed in the early twentieth century.  Before this time, the function of ovulation as the key to fertility was not yet understood.  When science could finally understand these processes, it was determined that in the normal menstrual cycle a woman ovulates once occurring about 14 days before the beginning of the next period.  When this was discovered, gynecologists promoted it to patients as a means to help promote pregnancy.  Some years later, in 1930, a Catholic physician in the Netherlands began to promote this as a means to help avoid pregnancy.  Catholic organizations in Europe and America also began to advocate this means of birth control throughout the 1930s.  By the 1960s, the popularity of the rhythm method as a means of birth control had begun to wane, especially with the introduction of the birth control pill in 1960.

Avoiding pregnancy is generally the point of using the rhythm method, but it extremely important to point out that the rhythm method in no way stops the spread of sexually transmitted diseases (and neither do birth control pills).  Condoms are the safest and most effective way to avoid spreading or getting a disease during sex.  Abstaining from sex altogether is the only 100% effective method of avoiding both disease and pregnancy.  So, if you are a young woman considering using the rhythm method, please keep all of this in mind.  If you have any comments or questions, I’d be glad to hear from you!

Fallopian Tubes

What springs to mind when Fallopian tubes are mentioned?  That they “connect” the ovaries to the uterus which leads finally to the vagina and the outside of the body?  Perhaps you think about ectopic pregnancies, as most ectopic pregnancies are indeed “tubal” pregnancies.  Whatever you may think of when Fallopian tubes are brought up, they are some of the least considered and understood parts of a woman’s reproductive tract.  Besides connecting the uterus and ovaries, do they do anything else?  Are they homologous to any part of the male anatomy?  Let’s try to answer some of the most common questions about Fallopian tubes.

First, where does the name “Fallopian” come from?  Unlike most parts of a woman’s reproductive system, this name does not come from Latin or Greek.  The Fallopian tubes are named for Gabriele Falloppio, a 16th-century Italian anatomist.  The canal through which the facial nerve runs after leaving the auditory cochlear nerve is also named after him–the aquaeductus Fallopii.

Back to the subject, why are the Fallopian tubes so often ignored?  Perhaps it has something to do with the lack of pathology or disease associated with the Fallopian tubes.  The most common maladies associated with the Fallopian tubes are, indeed, tubal (ectopic) pregnancy and pelvic inflammatory disease (PID).  (To read about two cases of rare ectopic pregnancies, click here.)  Ectopic  pregnancies are estimated to account for less than two of every one-hundred pregnancies.  PID is estimated to occur in nearly one in seven women in the United States.  PID accounts for a large number of all ectopic pregnancies, especially tubal.  Other disease are very rare in the Fallopian tubes.  Cancer, for example, is extremely rare and when it occurs it is often the result of adjacent cancer (such as ovarian).

So, what does a Fallopian tube look like?

The above sketch shows the different parts of the Fallopian tubes.  The fimbriae are the fringe-like extensions from the ostium of the Fallopian tube.   During ovulation, hormones stimulate the fimbriae to make a gentle sweeping motion against the ovaries to pull the released egg (or ovum) into the Fallopian tube.  The ovary and Fallopian are not actually connected to each other.  The ostium is where the fimbriae end and the Fallopian tube begins.  The infundibulum is the wider end of the Fallopian tube that narrows into the ampulla, which is the twisting portion of the tube in the above sketch.  It is where most fertilizations occur.  The ampulla continues into the isthmus, the shortest and most narrow portion of the Fallopian tube.  The pars uterina is the place where the uterus and Fallopian tube connects.

This sketch indicates better how the Fallopian tubes, uterus, and ovaries are all connected (or, in fact, not connected).  Most human Fallopian tubes are between seven and fourteen centimeters in length. Once an egg has entered the Fallopian tube, the mucosal cilia of the Fallopian tube move the egg towards the uterus.  The cilia are finger-like projects that sweep or push.  (Cilia are also found in the windpipe and sweep mucus and dust away from the lungs.)  Finally, Fallopian tubes are not homologous to any structure in the male body, thus they are completely unique to the female body.  (The ovaries, for example, are homologous to testes in males.)

Now, hopefully you and I both know a little more about the Fallopian tubes.  Want to know more or already know more and want to share it?  Please, don’t be shy!

Rare Ectopic Pregnancy, again

In the last blog entry I detailed the story of Zahra Aboutalib, a Moroccan woman with a rare complication of an ectopic pregnancy, a lithopedion.  The second incredibly rare complication of an ectopic pregnancy that I will cover happened to an English woman named Jane Ingram.  Jane was a 32 year old woman living in Suffolk, England, when she discovered in early 1999 that she was pregnant for the third time.  She and her husband Mark had a total of four children from previous marriages; this was their first child together.

Shortly into the pregnancy, a routine scan showed that she was carrying twins.  Continued abdominal pain led to further scans that showed eighteen weeks into pregnancy that Jane was indeed carrying triplets, the third baby had not implanted in the uterus as the other two had and had ruptured Jane’s fallopian tube.  This baby, the only boy of the pregnancy, had miraculously survived the rupture and continued to grow attaching his placenta to the outside of Jane’s uterus.  Jane had not been taking fertility drugs, a frequent cause of sets of multiple babies.

Immediately, the rarity of Jane’s case caught the attention of top doctors in the United Kingdom and leading obstetrician Davor Jurkovic at King’s College Hospital in London became the lead attending physician.  Jurkovic placed the odds of all three children and the mother surviving this situation were one in 60 million–if they did all survive it would be the first time in medical history.

Jane was closely monitored and at twenty-nine weeks, eleven weeks prematurely, it was decided that the cesarean section should go ahead.  A team of twenty-six medical professional assembled at King’s College Hospital on September 3, 1999 to assist in the two-hour long procedure.  The twin girls, Olivia (2lbs 10oz) and Mary (2lbs 4oz) were delivered first and the procedure went routinely.  The next challenge was to safely access the boy, who was in an awkward position.  Doctors decided to shift Jane’s intestines in order to reach him and successfully delivered Ronan (2lbs 4oz).

Amazingly, the triplets were born with no more complications than would be expected of any other triplets born at twenty-nine weeks.  Each was kept in the intensive care unit and placed on ventilators.  They only remained on the ventilators for about a week, Ronan being the first to grow strong enough to not need its assistance.  The worry remained that the pieces of Ronan’s placenta that could not be removed would cause complications for Jane.  No such complications arose and Jane was discharged from the hospital after about a week.

Today, the triplets are in fine health and not long ago celebrated their ninth birthdays.  The parents say that each has his or her own very distinct personality.  Doctors and newspapers have called Ronan a miracle baby.  Mark Ingram described himself shortly after the birth of the triplets as “the luckiest man on earth.”  With such amazing odds against them, many point to Jane’s optimistic though realistic attitude as the key to their survival.  So what do you think about Jane and her triplets?  Such a rare complication is not likely to be see again during our lifetimes.  Comments, questions, or otherwise?  You know what to do!

Rare Ectopic Pregnancy

Last night The Learning Channel replayed a program that I originally saw about a year ago entitled “Extraordinary Pregnancies.” It told the story of two women and their ‘extraordinary pregnancies’: Zahra in Morocco and Jane in England. The program is the repackaging of two other British programs that aired several years ago. Both women experienced rare complications from ectopic pregnancies. Each case is fascinating, to me at least, so let’s explore their cases a little more in depth–Zahra here, Jane in the next entry.

Zahra Aboutalib, a woman from just outside Casablanca, became pregnant at twenty-six years old and early in her pregnancy experienced excruciating abdominal pain. The pain eventually went away and in 1955 she went into labor. After laboring for more than two days, her family decided to take her to the closest hospital. In the hospital she saw other women undergo cesarean section and die because of the poor conditions in the hospital. Doctors told her she must have a c-section, too, and she decided she did not want to die too. She left the hospital still in pain and went home. Eventually the pain ceased and she remained pregnant. In Moroccan culture, there is a belief that babies can “sleep” inside of their mothers for indefinite periods of time. Assuming she had a sleeping baby, Zahra continued her life and adopted three children remaining pregnant for 46 years until terrible pain returned in her early 70s. Her children finally insisted she see a doctor. Doctors examined her and believed she had an ovarian tumor. After several rounds of testing and imaging, the doctors realized she was still carrying the child she conceived nearly five decades before.

When Zahra had become pregnant years before she had had an ectopic pregnancy in the fallopian tube. An ectopic pregnancy is any implantation of a fertilized egg outside of the uterus. As the fetus grew the fallopian tube expanded and finally burst, cause the pain early in her pregnancy. This occurrence can be quite dangerous for the mother and very often results in the death of the fetus. Amazingly, Zahra’s fetus continued to grow and attached itself through its placenta to Zahra’s internal organs. Because her fetus was outside of the uterus she could not vaginally deliver the child when she went into labor. C-section would have been the only way to extricate the child, though because of the dangerous circumstances she and her child may have perished. When the pain of labor subsided it was because her child has died inside of her. Her body could not absorb the child and, recognizing it as a foreign object, began to calcify the child resulting in what is called a lithopedion (stone child).

When the doctors decided to operate they faced a difficult challenge. The calcification of the baby Zahra bore had attached itself to many of her internal organs and her peritoneum (the lining of the abdominal cavity). The surgery was dangerous, but after hours of delicate maneuvering the surgeons were able to remove the whole, calcified child from Zahra’s stomach. The medical team dissected the lithopedion to study just how the calcification process works in cases like this. Zahra’s is one of the oldest lithopedions ever recorded. Zahra recovered fully from the procedure and returned to normal life.

Lithopedions are rare and are an extremely interesting occurrence. As the world moves towards a more Western model of medicine it is less likely that lithopedions will develop as most ectopic pregnancies can be surgically treated with less of a risk of to the mother and child. However, when other complications arise, that may change as we will see with the case of Jane in the next entry. Stay tuned! Comments, question? I’d love to hear from you.