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 Big C: Cancer–The Disease in a Nutshell

Cancer is arguably the most feared disease in the Western world.  In America, cancer is the leading cause of death of people between 35-65 years of age.  Nearly 1 in 7 deaths worldwide in 2007 was due to cancer.  Cancer rates are exploding throughout the world as developing nations industrialize and eat diets that are less nutritious (think of pollution and McDonald’s).  Because of physiological and social reasons, gynecological cancers are some of the most lethal types of cancer in women.  To better understand gynecological cancers, let’s take a step back and get to grips with the basics of cancer.

Cancer is a disease affecting humans, and other animals, that is a result of abnormal cells growing out of control.  Cancer can happen in virtually any part of the body and there are more than 100 distinct types.  The cells in our bodies are continually regenerating.  There is a saying that our bodies completely regenerate every seven years.  (In fact, each type of cell–each part of the body– regenerates at a different pace.)  When our bodies dictate the script (DNA being the script) that causes cell reproduction, occasionally there is a typo.  Many different things (such as smoking) can cause a “typo.”  When this happens, the body has difficulty righting the mistake and it can grow out of control resulting in cancer as seen in this illustration:


The top half of the illustration is a process called apoptosis, by which a damaged cell is removed through programmed cell death.  (I jokingly think of apoptosis as telling a “bad cell” to “pop off.”)  A lack of apoptosis is when the damaged cells are not programmed out.  This is where cancer begins.

If this growth of abnormal cells is caught in an early stage, it usually can be treated easily by removing the growth.*  Stages are a means by which the cancerous growths can be classified by how far along it has progressed.  There are four main stages, and with specific types of cancers there are further subdivisions such as “Stage II-C.”  Usually by the time a cancerous growth has reached the fourth, most advanced stage it has undergone a process called metastasis.

Metastasis is when the cancer spreads from its primary site to other sites.  So, if you hear an official cancer diagnosis, it may sound something like, “metastatic breast cancer” or “metastatic cancer primary to the liver.”  This indicates where the cancer began and that it is present in other locations.  Metastasis usually occurs through the body’s lymphatic system.  That’s why one often hears about lymph nodes in relation to cancer.

There are innumerable ways in which cancer is diagnosed.  Once it is found and diagnosed, there is a great divergence between how cancer behaves and how it is best treated depending on the type of cancer, medical history, and other factors.  If you ever find yourself receiving a cancer diagnosis, you will need to create a very specific plan with your physicians–no two diagnoses are ever exactly identical.  Hopefully this brief overview of the Big C helps build your understanding of the disease if you ever find yourself in close contact with cancer.

*(In my case, I had a very slow-growing cancer.  So, even though it was not caught at all “early,” it was still in an early stage.)

The Uterus

Pound for pound, the uterus is the strongest muscle in the human body. The uterus weighs about 40 ounces (2.5 pounds; 1.1 kg) and is about the size of a pear when not pregnant. Yet, in the process of giving birth, the uterus can exert over 100 pounds of force (440 newtons). The uterus is responsible for protecting and nursing a growing fetus during a pregnancy, and also for pushing that fetus out when it’s time to give birth. Let’s further explore this great muscular feat of nature–the human uterus.

The word uterus comes from Latin meaning “womb” or “stomach.”  It is an organ particular to mammals.  The human uterus consists of two parts:  the main body, generally just called the uterus, and the narrow “neck” called the cervix (Latin for “neck”).  In humans, the uterus is labeled as simplex because it is generally a single (simple) compartment, but sometimes the uterus does not end up like this.  When a female fetus is developing in the womb, it starts out initially as an organ shaped like a V–as though the cervix has two horn-shaped compartments.  As the fetus develops, the horns will generally fused into one, “simplex” uterus.  About 6.7% of the time, though, this does not happen resulting in a malformed uterus.

The most common type of malformation is the bicornuate (or “two-horned”) uterus.   Other malformations include unicornuate (“one-horned”) uterus, double uterus (two whole, functioning uteruses), and absent uterus (where the uterus fails to develop at all).  Each of these malformations has its own set of issues, and a medical professional can help counsel a person with a malformed uterus.

The uterus consists of three main “layers,” much like the different layers of skin.  The innermost layer on the inside of the uterus is called the endometrium.  It is a temporary layer that builds up and jettisons away over the course of a menstrual cycle.  The middle layer is called the myometrium.  This is the main, muscular layer of the uterus and consists of smooth muscle mass.  The outermost layer is referred to as the perimetrium.  It is a thin membrane that secretes serous fluid.

Uterus IllustrationIn the reproductive cycle, the uterus receives the egg after it has been fertilized while traveling down the Fallopian tube (labeled here as the uterine tube).  Once the fertilized egg is in the uterus, it will usually implant in the endometrial lining of the uterus (that is normally shed when a woman has her period).  From this implantation, the uterus and the embryo form a network of blood vessels that exist only during the pregnancy.  This is called the placenta and is what the umbilical cord is attached to.

The uterus, besides being key to the reproductive cycle, is also important in the sexual response cycle.  It directs blood flow toward the pelvis and outer genitalia during sex. This directed flow of blood happens during arousal and allows for sex to be pleasurable to the woman.  The uterus is also involved in a somewhat rare type of orgasm called, of course, the uterine orgasm.

The uterus is, arguably, the most central organ to not only reproduction but also sexual response.  Take good care of your uterus and go to the gynecologist for your regular check-up!  Have questions or comments?  Let’s hear ’em.

Episiotomy

When I was younger I remember hearing the word episiotomy in relation to childbirth but never really knew what it meant.  As I got older, I heard the word less and less often.  That is until my senior year of college when I got to know the meaning of the word quite well without actually experiencing it myself.  In one of my seminar classes, a classmate (a midwife by day) was telling the class about the term paper she was writing.  It was about the birthing practices of rural Nicaragua.  She worked in a tandem network of midwives both here in the US and in Nicaragua.  She said that the practice of episiotomy in the US was almost completely extinct but that it was still commonly used in Latin America.

In a class of about 11 women and 1 man (poor guy!), we all wanted to know more about this “episiotomy.”  So, in the spirit of that midwife taking her time to explain this practice I hope to impart a better understanding of the practice on you.

I have heard an episiotomy rather brutally and frankly described as cutting the vagina to make it wider for a baby’s head to pass through more easily during birth.  This is basically true but is not necessarily as barbaric as it may sound.  The cut is actually a type of surgery and it is done under anesthesia.

Most Western countries (United States, Australia, and Europe in particular) have moved increasingly away from using the episiotomy because of the complications it can cause.  A birth may progress without any need for the vaginal opening to be wider or the perineum (skin at the back of the vagina) may tear on its own.  This, too, is not as gruesome as it may sound.  A natural “tear” is often much shallower than an episiotomy.  Thus an episiotomy may take longer to heal and cause more complications.

There are two main types of episiotomies:  one is basically a straight, lateral cut from the vagina backward–this is called midline.  The other kind is is called medio-lateral and is cut at more of an angle away from the anus.

While there is certainly a time and a place for an episiotomy (as there is for a Cesarean section), I believe that natural tearing is preferable to episiotomy if possible.  The midwife I mentioned earlier explained this in an example I will never forget.  She took a piece of notebook paper and cut it halfway through with scissors.  “This is an episiotomy,” she said.  She took another piece of paper and tore it half way.  She said, “This is a natural tear.”  The torn piece of paper had all sorts of fibers and extra edges to it that the cut piece of paper didn’t have.  These overlapping bits provide a better opportunity to heal.  (Imagine trying to glue the cut piece of paper back–you couldn’t!  But you could with the torn piece of paper.)

Some studies show episiotomies, especially midline, cause greater complications even after the healing has occurred.  For instance, a woman can have trouble with sexual intercourse–it can be painful due to scarring and her vaginal walls can have trouble becoming lubricated.

There are certain therapies (such as massage and perineal dilation) than can help give the vagina preparation for birth that will make it less likely that a doctor will perform an episiotomy.  In any event, it is yet another complicated decision that a mother must make in the birthing process.  Hopefully this sheds a bit more light on it.  Have questions or comments?  Don’t be shy–dive right in!

Vaginismus

My apologies for an absence! There were finals, work, a brief foray at an ivy league university, and two family emergencies–and my birthday was a week ago. Time marches on. Now I am back to talk about a subject I know quite a bit about–vaginismus.

Vaginismus is a disorder of the muscles in the vagina, specifically of the pubococcygeus muscle or PC muscle. The PC muscle controls urine flow in both women and men and is the muscle targeted by the popular Kegel exercise. The PC muscle is also very important to childbirth.  With vaginismus, the PC muscle reacts to stimulus by becoming spastic and wildly contracting, which the woman cannot control.  Stimulus that causes this reaction can include any sort of vaginal penetration from sexual contact to the insertion of a tampon to a gynecological exam.  These spasms are completely involuntary and are said to be like an eye blinking when an object comes too near it.

Vaginismus is most usually caused by trauma to the vagina or psychological trauma connected to the vagina.  For instance, an invasive and painful surgical procedure or childbirth could cause vaginismus.  Rape very often causes vaginismus because of the combined physical and psychological trauma.  Other, less personal forms of psychological trauma could cause vaginismus such as hearing that initial sexual activity is painful and therefore forming a fear (whether realized or not) of penetration.  Sometimes, vaginismus is a result of generalized trauma or stress that is unrelated to the vagina or sex.

The PC muscle reacts to this physical-psychological impetus by forming an automatic response to all contact.  This reaction makes sexual activity for a woman painful and oftentimes impossible.  Estimates of how many women suffer from vaginismus vary widely because so many women who have it are unaware of it what it is.  In any event, vaginismus is more common that most realize probably affecting 5% or more of the female population.

Treatment for vaginismus is most effective when it takes into account both psychological and physical factors.  In this treatment, the woman consults a therapist to work through feelings towards sexuality and vaginal penetration to remove the negative associations attached to them.  Additionally, the woman physically conditions her PC muscle to be less spastic.  These methods vary, though the most common is probably dilation therapy.  With dilation therapy, the vagina is slowly desensitized to penetration by inserting dilators that increase in size.  Dilators do not harm sexual sensitivity, but rather allow the PC muscle to build up a stimulus memory in which it does not spasm.  A relatively recent treatment for vaginismus is the use of Botox injections to relax the PC muscle to prevent spasms.  Studies have shown that it is highly effective against vaginismus but dilation therapy combined with psychological therapy is still the standard for most sufferers.

So, whether you have heard of vaginismus before or not, it is an important and under-discussed gynecological subject.  Please take the time to talk to your girlfriends and family members about what you have learned about vaginismus.  By spreading the word, more women will feel more confident about seeking treatment for this disorder that, if treated, is highly combatable.  Have any questions or something to add?  I’d love to hear from you!

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.