Anatomy of the female genital organs. Labia in women: anatomical structure, indications for labiaplasty Labia in women: structure

The labia minora (labia minora pudendi, internal) are part of the female reproductive system and consist of two folds or “lips” - skin on the outside of the vagina, located longitudinally inward from the labia majora; they are the same color as their inner surface; with their free edges they can sometimes protrude from the genital slit.

The main role of these small folds is to protect the clitoris, urethra and vulva.

Anatomically, the base of the labia minora is separated from the external lips by an interlabial groove. The anterior section of each of the labia minora is divided into two legs - outer and inner. The inner, or lower, legs of both lips, connecting with each other and attaching from the back to the head of the clitoris, form the frenulum of the clitoris, and both outer, or upper, legs, connecting on the back of the clitoris, form the foreskin of the clitoris on the side of its upper surface.

Approximately in the middle of the inner surface of the outer lips, you can see how the small posterior lips gradually merge with them or connect with one another, forming a frenulum. In their thickness lie venous vessels resembling cavernous bodies, nerves, arteries, as well as elastic fibers and smooth muscle fibers; The skin contains sebaceous glands.

GENERAL INFORMATION

1. SIZES OF THE LAVA MIRA.

Until about 9-10 years of age, the inner labia are really very small. But the situation changes from the moment when nature begins to prepare the girl for the role of a woman. Now the influence of the hormone estrogen awakens to life everything that is intended for sex and reproduction. Starting from the age of 10-14, all girls, without exception, experience growth and enlargement of the labia minora to adult sizes, but in some this process occurs slowly and barely noticeably, in others it quickly and manifests itself more visibly.

The lips are often asymmetrical, which in practical terms means that they are usually slightly different sizes or lengths, and one side may hang lower than the other. In most cases, this does not indicate any problems and is in fact considered “normal” for most women. The only time this may indicate a problem is when one side suddenly swells and is accompanied by burning, itching or redness. This may indicate an infection or sexually transmitted disease.

2. WHAT DO THE LAVA MIRA LOOK LIKE?

Natural differences also appear in the appearance of the external genitalia, which in many ways resemble differences in the shape and size of developing breasts. In some, the genitals look almost the same as in childhood, in others, the small lips acquire a more expressive feminine appearance and become like wide petals of a bizarre shape. In 80% of girls under 10 years of age, the inner lips are hidden behind the outer lips, and in only 20% they are clearly visible before this age. In adult women, the appearance of the genitals changes noticeably. The external genitalia are clearly visible during external examination in more than half of women, and in about 30% of women, the inner lips are even larger in size than the outer ones.

3. COLOR OF THE LAVA MINOR

In healthy women, the inner labia have shades ranging from light to dark pink, sometimes brown or blackish-purple. A woman's overall skin tone does not always match the color of her labia, as some women who have dark brown complexions have light pink folds in their private parts, while some women with very fair complexions have vulvar skin organs are dark brown or gray in color. Almost any combination is considered normal, but if the area becomes blotchy or begins to change colors, it could indicate a skin disorder or rare skin cancer.

INFECTIONS AND INFLAMMATION OF THE LIPS MINARA

Infections often start in these areas due to their moisture, as well as their proximity to the urethra and vaginal opening. Initial symptoms of infections (itching, burning, swelling and discomfort) that occur on the skin of the labia minora then progress and spread to the vulva and vagina. Other complaints may include abdominal pain, burning sensation when urinating, and increased vaginal secretion. The most common causes of vulvaginal discomfort are thrush and bacterial vaginosis, and these can be successfully treated with medication. Sexually transmitted diseases, as causes of inflammation of the labia minora, also cause concern among gynecologists.

LABIA MINARA

In most cases, the size and shape of the labia minora do not matter to a woman. They can be almost invisible when viewed from the side or long enough to hang outward from the genital slit. Nature arranges it this way that they are rarely completely symmetrical. In some girls, one very large labia minora can constantly “pop out” (so-called “hypertrophy”). There is a special term - “Hottengot apron” - the intimate part of a woman with overdeveloped external genitalia, covering the entrance to the vagina and hanging far, far beyond the genital opening.

It happens that girls with overly developed genitals become the object of increased attention and even ridicule from friends in showers, saunas, locker rooms of fitness clubs, etc. places where you have to be naked. And, despite the fact that there is no generally accepted standard for their size, most women still prefer that they do not protrude too much outward, in other words, they do not look saggy, especially when looking at “that place” from behind.

Are your labia majora smaller than your labia minora?
(anonymous survey: answer and see how others are doing)

WHAT TO DO IF THE LAVA MINOR IS ENLARGEED?

Naturally, in intimate surgery there are operations to reduce their size. In order to achieve symmetry, the labia minora, which is larger in size, is resected, that is, partial removal of excess skin is carried out. This procedure is commonly known as labiaplasty surgery and is almost always performed for cosmetic reasons. In very rare cases, the folds can be so long that they actually interfere with sexual intercourse, maintaining hygiene in the area, or making it impossible to wear certain clothes - in this case the operation is performed for medical reasons.

External genitalia (genitalia externa, s.vulva), collectively called “vulva” or “pudendum”, are located below the pubic symphysis. These include pubis, labia majora and minora, clitoris and vestibule of the vagina . In the vestibule of the vagina, the external opening of the urethra (urethra) and the ducts of the large glands of the vestibule (Bartholin's glands) open.

Pubis – The border section of the abdominal wall is a rounded median eminence lying in front of the pubic symphysis and pubic bones. After puberty, it becomes covered with hair, and its subcutaneous base, as a result of intensive development, takes on the appearance of a fat pad.

Labia majora - wide longitudinal folds of skin containing a large amount of fatty tissue and fibrous ends of the round uterine ligaments. In front, the subcutaneous fatty tissue of the labia majora passes into the fatty pad on the pubis, and in the back it is connected to the ischiorectal fatty tissue. After reaching puberty, the skin on the outer surface of the labia majora becomes pigmented and covered with hair. The skin of the labia majora contains sweat and sebaceous glands. Their inner surface is smooth, not covered with hair and rich in sebaceous glands. The connection of the labia majora in front is called the anterior commissure, in the back - the commissure of the labia majora, or posterior commissure. The narrow space in front of the posterior commissure of the labia is called the navicular fossa.

Labia minora – Thick, smaller folds of skin called the labia minora are located medial to the labia majora. Unlike the labia majora, they are not covered with hair and do not contain subcutaneous fatty tissue. Between them is the vestibule of the vagina, which becomes visible only when the labia minora are separated. At the front, where the labia minora meet the clitoris, they divide into two small folds that merge around the clitoris. The superior folds join above the clitoris to form the clitoral foreskin; the lower folds meet on the underside of the clitoris and form the clitoral frenulum.

Clitoris – located between the anterior ends of the labia minora under the foreskin. It is a homologue of the corpora cavernosa of the male penis and is capable of erection. The body of the clitoris consists of two cavernous bodies enclosed in a fibrous membrane. Each corpus cavernosum begins with a pedicle attached to the medial edge of the corresponding ischiopubic branch. The clitoris is attached to the pubic symphysis by the suspensory ligament. At the free end of the body of the clitoris there is a small projection of erectile tissue called the glans.

Bulbs of the vestibule . Near the vestibule of the vagina, along the deep side of each labia minora, is an oval-shaped mass of erectile tissue called the vestibular bulb. It is represented by a dense plexus of veins and corresponds to the corpus spongiosum of the penis in men. Each bulb is attached to the inferior fascia of the urogenital diaphragm and is covered by the bulbospongiosus (bulbocavernous) muscle.

Vaginal vestibule located between the labia minora, where the vagina opens in the form of a vertical slit. The open vagina (the so-called opening) is framed by nodes of fibrous tissue of varying sizes (hymenal tubercles). In front of the vaginal opening, approximately 2 cm below the head of the clitoris in the midline, the external opening of the urethra is located in the form of a small vertical slit. The edges of the external opening of the urethra are usually raised and form folds. On each side of the external opening of the urethra there are miniature openings of the ducts of the glands of the urethra (ductus paraurethrales). The small space in the vestibule of the vagina, located behind the vaginal opening, is called the fossa of the vestibule of the vagina. Here, the ducts of the Bartholin glands (glandulaevestibulares majores) open on both sides. The glands are small lobular bodies the size of a pea and are located at the posterior edge of the vestibular bulb. These glands, along with numerous small vestibular glands, also open into the vestibule of the vagina.

Internal genital organs (genitalia interna). The internal genital organs include the vagina, uterus and its appendages - fallopian tubes and ovaries.

Vagina (vaginas.colpos) extends from the genital fissure to the uterus, passing upward with a posterior inclination through the urogenital and pelvic diaphragms. The length of the vagina is about 10 cm. It is located mainly in the pelvic cavity, where it ends, merging with the cervix. The anterior and posterior walls of the vagina are usually connected to each other at the bottom, having the shape of the letter H in cross section. The upper section is called the vaginal vault because the lumen forms pockets, or vaults, around the vaginal part of the cervix. Because the vagina is at a 90° angle to the uterus, the posterior wall is much longer than the anterior one, and the posterior fornix is ​​deeper than the anterior and lateral fornix. The lateral wall of the vagina is attached to the cardiac ligament of the uterus and to the pelvic diaphragm. The wall consists mainly of smooth muscle and dense connective tissue with many elastic fibers. The outer layer contains connective tissue with arteries, nerves and nerve plexuses. The mucous membrane has transverse and longitudinal folds. The anterior and posterior longitudinal folds are called fold columns. The stratified squamous epithelium of the surface undergoes cyclic changes that correspond to the menstrual cycle.

The anterior wall of the vagina is adjacent to the urethra and the base of the bladder, with the terminal part of the urethra protruding into its lower part. The thin layer of connective tissue that separates the anterior wall of the vagina from the bladder is called the vesicovaginal septum. At the front, the vagina is indirectly connected to the back of the pubic bone by fascial thickenings at the base of the bladder known as the pubovesical ligament. Posteriorly, the lower part of the vaginal wall is separated from the anal canal by the perineal body. The middle part is adjacent to the rectum, and the upper part is adjacent to the rectouterine cavity (Douglas pouch) of the peritoneal cavity, from which it is separated only by a thin layer of peritoneum.

Uterus (uterus) outside of pregnancy is located at or near the midline of the pelvis between the bladder in front and the rectum in back. The uterus has the shape of an inverted pear with dense muscular walls and a triangle-shaped lumen, narrow in the sagittal plane and wide in the frontal plane. The uterus is divided into body, fundus, cervix and isthmus. The vaginal insertion line divides the cervix into vaginal (vaginal) and supravaginal (supravaginal) segments. Outside of pregnancy, the curved fundus is directed anteriorly, with the body forming an obtuse angle with respect to the vagina (tilted forward) and bent anteriorly. The anterior surface of the uterine body is flat and adjacent to the apex of the bladder. The posterior surface is curved and faces above and behind the rectum.

The cervix is ​​directed downward and posteriorly and is in contact with the posterior wall of the vagina. The ureters approach the cervix directly laterally and are relatively close.

The body of the uterus, including its fundus, is covered with peritoneum. In front, at the level of the isthmus, the peritoneum bends and passes to the upper surface of the bladder, forming a shallow vesicouterine cavity. At the back, the peritoneum continues forward and upward, covering the isthmus, the supravaginal part of the cervix and the posterior vaginal fornix, and then passes to the anterior surface of the rectum, forming a deep rectouterine cavity. The length of the body of the uterus is on average 5 cm. The total length of the isthmus and cervix is ​​about 2.5 cm, their diameter is 2 cm. The ratio of the length of the body and cervix depends on age and number of births and is on average 2:1.

The wall of the uterus consists of a thin outer layer of peritoneum - the serous membrane (perimetry), a thick intermediate layer of smooth muscle and connective tissue - the muscular layer (myometrium) and the inner mucous membrane (endometrium). The body of the uterus contains many muscle fibers, the number of which decreases downwards as it approaches the cervix. The cervix consists of an equal amount of muscle and connective tissue. As a result of their development from the fused parts of the paramesonephric (Müllerian) ducts, the arrangement of muscle fibers in the uterine wall is complex. The outer layer of the myometrium contains mainly vertical fibers that run laterally in the upper body and connect to the outer longitudinal muscular layer of the fallopian tubes. The middle layer includes most of the uterine wall and consists of a network of spiral-shaped muscle fibers that are connected to the inner circular muscle layer of each tube. The bundles of smooth muscle fibers in the suspensory ligaments intertwine and merge with this layer. The inner layer consists of circular fibers that can act as a sphincter at the isthmus and at the openings of the fallopian tubes.

The uterine cavity outside of pregnancy is a narrow slit, with the anterior and posterior walls closely adjacent to each other. The cavity has the shape of an inverted triangle, the base of which is located at the top, where it is connected on both sides to the openings of the fallopian tubes; the apex is located below, where the uterine cavity passes into the cervical canal. The cervical canal in the isthmus region is compressed and has a length of 6-10 mm. The place where the cervical canal meets the uterine cavity is called the internal os. The cervical canal widens slightly in its middle part and opens into the vagina with an external opening.

Uterine appendages. The uterine appendages include the fallopian tubes and ovaries, and some authors include the ligamentous apparatus of the uterus.

The fallopian tubes (tubaeuterinae). On both sides of the uterine body laterally there are long, narrow fallopian tubes (fallopian tubes). The tubes occupy the superior portion of the broad ligament and arc laterally over the ovary before running downward over the posterior portion of the medial surface of the ovary. The lumen, or canal, of the tube runs from the upper corner of the uterine cavity to the ovary, gradually increasing in diameter laterally along its course. Outside of pregnancy, the stretched tube has a length of 10 cm. There are four sections: intramural area located inside the wall of the uterus and connected to the uterine cavity. Its lumen has the smallest diameter (Imm or less). The narrow section extending laterally from the outer border of the uterus is called isthmus(istmus); then the pipe expands and becomes tortuous, forming ampoule, and ends near the ovary in the form funnels. Along the periphery of the funnel there are fimbriae that surround the abdominal opening of the fallopian tube; one or two fimbriae are in contact with the ovary. The wall of the fallopian tube is formed by three layers: the outer layer, consisting mainly of the peritoneum (serous membrane), the intermediate smooth muscle layer (myosalpinx) and the mucous membrane (endosalpinx). The mucous membrane is represented by ciliated epithelium and has longitudinal folds.

Ovaries (ovarii). The female gonads are represented by oval or almond-shaped ovaries. The ovaries are located medial to the curved part of the fallopian tube and are slightly flattened. On average, their dimensions are: width 2 cm, length 4 cm and thickness 1 cm. The ovaries are usually grayish-pink in color with a wrinkled, uneven surface. The longitudinal axis of the ovaries is almost vertical, with the upper extreme point at the fallopian tube and the lower extreme point closer to the uterus. The posterior part of the ovaries is free, and the anterior part is fixed to the broad ligament of the uterus with the help of a two-layer fold of the peritoneum - the mesentery of the ovary (mesovarium). Vessels and nerves pass through it and reach the hilum of the ovaries. Attached to the upper pole of the ovaries are folds of the peritoneum - ligaments that suspend the ovaries (infundibulopelvic), which contain the ovarian vessels and nerves. The lower part of the ovaries is attached to the uterus by fibromuscular ligaments (proprietary ligaments of the ovaries). These ligaments connect to the lateral edges of the uterus at an angle just below where the fallopian tube meets the body of the uterus.

The ovaries are covered with germinal epithelium, under which there is a layer of connective tissue - the tunica albuginea. The ovary has an outer cortex and an inner medulla. Vessels and nerves pass through the connective tissue of the medulla. In the cortex, among the connective tissue, there are a large number of follicles at different stages of development.

Ligamentous apparatus of the internal female genital organs. The position in the pelvis of the uterus and ovaries, as well as the vagina and adjacent organs, depends mainly on the condition of the muscles and fascia of the pelvic floor, as well as on the condition of the ligamentous apparatus of the uterus. In a normal position, the uterus with fallopian tubes and ovaries are held suspensory apparatus (ligaments), anchoring apparatus (ligaments that fix the suspended uterus), supporting or supporting apparatus (pelvic floor). The suspensory apparatus of the internal genital organs includes the following ligaments:

Round ligaments of the uterus (ligg.teresuteri). They consist of smooth muscles and connective tissue, look like cords 10-12 cm long. These ligaments extend from the corners of the uterus, go under the anterior leaf of the broad ligament of the uterus to the internal openings of the inguinal canals. Having passed the inguinal canal, the round ligaments of the uterus fan out into the tissue of the pubis and labia majora. The round ligaments of the uterus pull the fundus of the uterus anteriorly (anterior tilt).

Broad ligaments of the uterus . This is a duplication of the peritoneum, extending from the ribs of the uterus to the side walls of the pelvis. The fallopian tubes pass through the upper parts of the broad ligaments of the uterus, the ovaries are located on the posterior layers, and fiber, vessels and nerves are located between the layers.

Own ovarian ligaments start from the fundus of the uterus behind and below the origin of the fallopian tubes and go to the ovaries.

Ligaments that suspend the ovaries , or infundibulopelvic ligaments, are a continuation of the wide uterine ligaments, running from the fallopian tube to the pelvic wall.

The anchoring apparatus of the uterus consists of connective tissue cords mixed with smooth muscle fibers that come from the lower part of the uterus;

b) posteriorly - to the rectum and sacrum (lig. sacrouterinum). They extend from the posterior surface of the uterus in the area of ​​​​the transition of the body to the cervix, cover the rectum on both sides and are attached to the anterior surface of the sacrum. These ligaments pull the cervix posteriorly.

Supporting or supporting apparatus make up the muscles and fascia of the pelvic floor. The pelvic floor is of great importance in maintaining the internal genital organs in a normal position. When intra-abdominal pressure increases, the cervix rests on the pelvic floor as if on a stand; The pelvic floor muscles prevent the genitals and viscera from descending. The pelvic floor is formed by the skin and mucous membrane of the perineum, as well as the muscular-fascial diaphragm. The perineum is the diamond-shaped area between the thighs and buttocks where the urethra, vagina and anus are located. In front, the perineum is limited by the pubic symphysis, in the back by the end of the coccyx, and the lateral ischial tuberosities. The skin limits the perineum from the outside and below, and the pelvic diaphragm (pelvic fascia), formed by the lower and superior fascia, limits the perineum deep above.

The pelvic floor, using an imaginary line connecting the two ischial tuberosities, is divided anatomically into two triangular regions: in front - the genitourinary region, in the back - the anal region. In the center of the perineum, between the anus and the entrance to the vagina, there is a fibromuscular formation called the tendinous center of the perineum. This tendon center is the site of attachment for several muscle groups and fascial layers.

Genitourinaryregion. In the genitourinary region, between the lower branches of the ischial and pubic bones, there is a muscular-fascial formation called the “urogenital diaphragm” (diaphragmaurogenitale). The vagina and urethra pass through this diaphragm. The diaphragm serves as the basis for fixing the external genitalia. From below, the urogenital diaphragm is limited by the surface of whitish collagen fibers, forming the lower fascia of the urogenital diaphragm, which divides the genitourinary region into two dense anatomical layers of important clinical significance - the superficial and deep sections, or perineal pockets.

Superficial part of the perineum. The superficial section is located above the lower fascia of the genitourinary diaphragm and contains on each side a large gland of the vestibule of the vagina, a clitoral stalk with an overlying ischiocavernosus muscle, a bulb of the vestibule with an overlying bulbospongiosus (bulbocavernosus) muscle and a small superficial transverse perineal muscle. The ischiocavernosus muscle covers the stalk of the clitoris and plays a significant role in maintaining its erection, as it presses the stalk against the ischiopubic branch, delaying the outflow of blood from the erectile tissue. The bulbospongiosus muscle originates from the tendinous center of the perineum and the external sphincter of the anus, then passes posteriorly around the lower part of the vagina, covering the bulb of the vestibule, and enters the perineal body. The muscle can act as a sphincter to tighten the lower part of the vagina. The poorly developed superficial transverse perineal muscle, which looks like a thin plate, starts from the inner surface of the ischium near the ischial buff and runs transversely, entering the perineal body. All muscles of the superficial section are covered by the deep fascia of the perineum.

Deep perineum. The deep part of the perineum is located between the lower fascia of the genitourinary diaphragm and the indistinct upper fascia of the genitourinary diaphragm. The urogenital diaphragm consists of two layers of muscles. The muscle fibers in the urogenital diaphragm are generally transverse, arising from the ischiopubic rami on each side and joining at the midline. This part of the urogenital diaphragm is called the deep transverse perineal muscle. Part of the fibers of the urethral sphincter rises in an arc above the urethra, while the other part is located circularly around it, forming the external urethral sphincter. The muscle fibers of the urethral sphincter also pass around the vagina, concentrating where the external opening of the urethra is located. The muscle plays an important role in restraining the process of urination when the bladder is full and is a voluntary compressor of the urethra. The deep transverse perineal muscle enters the perineal body behind the vagina. When contracted bilaterally, this muscle thus supports the perineum and the visceral structures passing through it.

Along the anterior edge of the urogenital diaphragm, its two fascia merge to form the transverse perineal ligament. In front of this fascial thickening is the arcuate pubic ligament, which runs along the lower edge of the pubic symphysis.

Anal (anal) area. The anal region includes the anus, the external anal sphincter, and the ischiorectal fossa. The anus is located on the surface of the perineum. The skin of the anus is pigmented and contains sebaceous and sweat glands. The anal sphincter consists of superficial and deep parts of striated muscle fibers. The subcutaneous part is the most superficial and surrounds the lower wall of the rectum, the deep part consists of circular fibers that merge with the levator ani muscle. The superficial part of the sphincter consists of muscle fibers running mainly along the anal canal and intersecting at right angles in front and behind the anus, which then enter the perineum in front, and behind - into a faint fibrous mass called the anal-coccygeal body, or anal-coccygeal body. coccygeal ligament. The anus is externally a longitudinal slit-like opening, which may be explained by the anteroposterior direction of many muscle fibers of the external anal sphincter.

The ischiorectal fossa is a wedge-shaped space filled with fat, which is externally limited by the skin. The skin forms the base of the wedge. The vertical lateral wall of the fossa is formed by the obturator internus muscle. The sloping supramedial wall contains the levator ani muscle. Ischiorectal fat allows the rectum and anal canal to expand during bowel movements. The fossa and the fatty tissue it contains are located anteriorly and deep upward to the urogenital diaphragm, but below the levator ani muscle. This area is called the front pocket. At the back, the fatty tissue in the fossa extends deep to the gluteus maximus muscle in the area of ​​the sacrotuberous ligament. Laterally, the fossa is bounded by the ischium and the obturator fascia, which covers the lower part of the obturator internus muscle.

Blood supply, lymphatic drainage and innervation of the genital organs. Blood supply external genitalia are mainly carried out by the internal genital (pudendal) artery and only partially by branches of the femoral artery.

Internal pudendal artery is the main artery of the perineum. It is one of the branches of the internal iliac artery. Leaving the pelvic cavity, it passes in the lower part of the greater sciatic foramen, then goes around the ischial spine and runs along the side wall of the ischiorectal fossa, transversely crossing the lesser sciatic foramen. Its first branch is the inferior rectal artery. Passing through the ischiorectal fossa, it supplies blood to the skin and muscles around the anus. The perineal branch supplies the structures of the superficial part of the perineum and continues in the form of posterior branches going to the labia majora and minora. The internal pudendal artery, entering the deep perineal section, branches into several fragments and supplies the bulb of the vestibule of the vagina, the large gland of the vestibule and the urethra. When it ends, it divides into the deep and dorsal arteries of the clitoris, which approach it near the pubic symphysis.

External (superficial) pudendal artery arises from the medial side of the femoral artery and supplies the anterior part of the labia majora. External (deep) pudendal artery also originates from the femoral artery, but more deeply and distally. After passing through the fascia lata on the medial side of the thigh, it enters the lateral part of the labia majora. Its branches pass into the anterior and posterior labial arteries.

The veins passing through the perineum are mainly branches of the internal iliac vein. For the most part they accompany the arteries. An exception is the deep dorsal clitoral vein, which drains blood from the erectile tissue of the clitoris through a fissure below the pubic symphysis into the venous plexus around the bladder neck. The external genital veins drain blood from the labia majora, passing laterally to enter the great saphenous vein of the leg.

Blood supply to the internal genital organs carried out mainly from the aorta (system of the common and internal iliac arteries).

The main blood supply to the uterus is provided uterine artery , which arises from the internal iliac (hypogastric) artery. In about half of the cases, the uterine artery arises independently from the internal iliac artery, but it can also arise from the umbilical, internal pudendal and superficial cystic arteries. The uterine artery goes down to the lateral pelvic wall, then passes forward and medially, located above the ureter, to which it can give an independent branch. At the base of the broad uterine ligament, it turns medially towards the cervix. In the parametrium, the artery is connected to the accompanying veins, nerves, ureter and cardinal ligament. The uterine artery approaches the cervix and supplies it with the help of several tortuous penetrating branches. The uterine artery then divides into one large, very tortuous ascending branch and one or more small descending branches supplying the upper part of the vagina and adjacent part of the bladder . The main ascending branch runs upward along the lateral edge of the uterus, sending arcuate branches to its body. These arcuate arteries surround the uterus under the serous layer. At certain intervals, radial branches depart from them, which penetrate into the intertwining muscle fibers of the myometrium. After childbirth, the muscle fibers contract and, acting as ligatures, compress the radial branches. The arcuate arteries quickly decrease in size along the midline, therefore, with midline incisions of the uterus, less bleeding is observed than with lateral ones. The ascending branch of the uterine artery approaches the fallopian tube, turning laterally in its upper part, and divides into tubal and ovarian branches. The tubal branch runs laterally in the mesentery of the fallopian tube (mesosalpinx). The ovarian branch goes to the mesentery of the ovary (mesovarium), where it anastomoses with the ovarian artery, which arises directly from the aorta

The ovaries are supplied with blood from the ovarian artery (a.ovarica), which arises from the abdominal aorta on the left, sometimes from the renal artery (a.renalis). Descending together with the ureter, the ovarian artery passes through the ligament that suspends the ovary to the upper part of the broad uterine ligament, giving off a branch to the ovary and tube; the terminal section of the ovarian artery anastomoses with the terminal section of the uterine artery.

In addition to the uterine and genital arteries, the branches of the inferior vesical and middle rectal arteries also participate in the blood supply to the vagina. The arteries of the genital organs are accompanied by corresponding veins. The venous system of the genital organs is very developed; the total length of the venous vessels significantly exceeds the length of the arteries due to the presence of venous plexuses that widely anastomose with each other. Venous plexuses are located in the clitoris, at the edges of the vestibule bulbs, around the bladder, between the uterus and ovaries.

Lymphatic system The genital organs consist of a dense network of tortuous lymphatic vessels, plexuses and many lymph nodes. Lymphatic pathways and nodes are located mainly along the blood vessels.

Lymphatic vessels that drain lymph from the external genitalia and the lower third of the vagina go to the inguinal lymph nodes. Lymphatic ducts extending from the middle upper third of the vagina and cervix go to the lymph nodes located along the hypogastric and iliac blood vessels. The intramural plexuses carry lymph from the endometrium and myometrium to the subserosal plexus, from which the lymph flows through efferent vessels. Lymph from the lower part of the uterus enters mainly the sacral, external iliac and common iliac lymph nodes; some also drains into the lower lumbar nodes along the abdominal aorta and into the superficial inguinal nodes. Most of the lymph from the upper part of the uterus drains laterally into the broad ligament of the uterus where it joins With lymph collecting from the fallopian tube and ovary. Next, through the ligament that suspends the ovary, along the ovarian vessels, lymph enters the lymph nodes along the lower abdominal aorta. From the ovaries, lymph is drained through vessels located along the ovarian artery and goes to the lymph nodes located on the aorta and inferior vena cava. Between these lymphatic plexuses there are connections - lymphatic anastomoses.

In innervation The female genital organs involve the sympathetic and parasympathetic parts of the autonomic nervous system, as well as the spinal nerves.

The fibers of the sympathetic part of the autonomic nervous system, innervating the genital organs, originate from the aortic and celiac (“solar”) plexuses, go down and form the superior hypogastric plexus at the level of the V lumbar vertebra. Fibers depart from it, forming the right and left lower hypogastric plexuses. Nerve fibers from these plexuses go to the powerful uterovaginal, or pelvic, plexus.

The uterovaginal plexuses are located in the parametrial tissue lateral and posterior to the uterus at the level of the internal os and cervical canal. The branches of the pelvic nerve (n.pelvicus), which belongs to the parasympathetic part of the autonomic nervous system, approach this plexus. Sympathetic and parasympathetic fibers extending from the uterovaginal plexus innervate the vagina, uterus, internal parts of the fallopian tubes, and bladder.

The ovaries are innervated by sympathetic and parasympathetic nerves from the ovarian plexus.

The external genitalia and pelvic floor are mainly innervated by the pudendal nerve.

Pelvic fiber. Blood vessels, nerves and lymphatic pathways of the pelvic organs pass through the tissue, which is located between the peritoneum and the fascia of the pelvic floor. Fiber surrounds all pelvic organs; in some areas it is loose, in others in the form of fibrous strands. The following fiber spaces are distinguished: peri-uterine, pre- and peri-vesical, peri-intestinal, vaginal. Pelvic tissue serves as a support for the internal genital organs, and all its sections are interconnected.

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are enzyme complexes usually associated with

membranes.

The mechanisms of energy transformation in biological structures are associated with conformational transformations of special macromolecular complexes, such as reaction centers of photosynthesis, H - ATPase of chloroplasts and mitochondria, bacteriorhodopsin. Of particular interest are the general characteristics of the efficiency of energy conversion in such macromolecular machines. Thermodynamics of biological processes is designed to answer these questions.

The female genital organs are divided into external and internal.

External genitalia.

The external genitalia in women include: the pubis, labia majora and minora, Bartholin glands, clitoris, vestibule of the vagina and the hymen, which is the boundary between the external and internal genitalia.

PUBIS - a triangular elevation covered with hair, located above the womb. The boundaries are: from above - the transverse skin groove; from the sides - inguinal folds.

In women, the upper border of the pubic hair looks like a horizontal line.

LABIA MAJORA - two folds of skin that limit the genital slit on the sides. In front they pass into the skin of the pubis, in the back they merge into the posterior commissure. The skin on the outer surface of the labia majora is covered with hair, contains sweat and sebaceous glands, under it there are vessels in the subcutaneous fatty tissue , nerves and fibrous fibers, and in the posterior third - large glands of the vestibule (Bartholin's glands) - round alveolar-tubular,

the size of a bean gland. Their excretory ducts open in the groove between the labia minora and the hymen, and their secretion is released during sexual arousal.

The space between the posterior commissure and the anal opening is called the inter-

ity. In an anatomical sense, the perineum is a muscular-fascial plate covered on the outside with skin. Its height is on average 3-4 cm.

LABIA MINARA - the second pair of longitudinal skin folds. They are located medially from the labia majora and are usually covered by the latter. In front, the labia minora bifurcate into two legs on each side, which, merging, form the foreskin of the clitoris and the frenulum of the clitoris. Posteriorly, the labia minora merge with large.Thanks to the

The labia minora are the organs of sexual sense due to the presence of blood vessels and nerve endings.

CLITORIS. Outwardly noticeable as a small tubercle in the anterior corner of the genital gap between the fused legs of the labia minora. The clitoris has a head, a body consisting of cavernous bodies and legs that are attached to the periosteum of the pubic and ischial bones. Abundant blood supply and innervation make it the main organ of sexual sensation women.

THE VAGINA VESTRUCTURAL is a space bounded in front by the clitoris, behind by the posterior commissure of the labia, on the sides by the inner surface of the labia minora, and above by the hymen. The external opening of the urethra and the excretory ducts of the Bartholin glands open here.

The hymen is a connective tissue membrane that covers the entrance to the vagina in virgins. Its connective tissue base contains muscle elements, blood vessels and nerves. There must be a hole in the hymen. It can be of any shape. After defloration, the hymenal papillae remain from the hymen, after childbirth - myrtle-shaped papillae.

Internal genital organs.

These include: the vagina, uterus, fallopian tubes and ovaries.

VAGINA is a well-stretchable, muscular-elastic tube. It runs from the front and bottom to the back and top. Starts from the hymen and ends at the place of attachment to the cervix. Average dimensions: length 7-8 cm (back wall 1.5-2 cm . longer), width 2-3 cm. Due to the fact that the front and back walls of the vagina are in contact, in cross section it has the shape of the letter H. Around the vaginal part of the cervix, which protrudes into the vagina, the walls of the vagina form a vaulted formation. It is customary to divide it on the anterior, posterior (deepest) and lateral fornix. The vaginal wall consists of three layers: mucous, muscle and surrounding tissue, in which vessels and nerves pass. The muscle layer consists of two layers: the outer longitudinal and the inner circular. The mucosa is covered with a multilayer flat epithelium containing glycogen. The process of glycogen formation is associated with the follicular hormone of the ovary. The vagina is very distensible due to the presence on the front and back walls of two longitudinal ridges, consisting of many transverse folds. There are no glands in the vaginal mucosa. The vaginal secretion is formed by soaking in fluid from the vessels. It has an acidic environment thanks to lactic acid formed from glycogen under the influence of enzymes and waste products of lactobacilli (Dederlein rods). Lactic acid contributes to the death of pathogenic microorganisms.

There are four degrees of purity of vaginal contents.

1st degree: the contents contain only lactobacilli and epithelial cells, the reaction is acidic.

2nd degree: fewer Dederlein rods, single leukocytes, bacteria, many epithelial cells, acidic reaction.

3rd degree: there are few lactobacilli, other types of bacteria predominate, there are many leukocytes, the reaction is slightly alkaline.

4th degree: no lactobacilli, a lot of bacteria and leukocytes, alkaline reaction.

1.2 degrees – a variant of the norm.

3.4 degrees indicate the presence of a pathological process.

The uterus is a smooth muscle hollow organ, pear-shaped, flattened in the anteroposterior direction.

Sections of the uterus: body, isthmus, cervix.

The dome-shaped part of the body above the lines of attachment of the tubes is called bottom of the uterus.

Isthmus- a part of the uterus 1 cm long, located between the body and the cervix. It is separated into a separate section, since the structure of the mucous membrane is similar to the body of the uterus, and the structure of the wall is similar to the cervix. The upper border of the isthmus is the place of dense attachment of the peritoneum to the anterior wall of the uterus. The lower the border is the level of the internal os of the cervical canal.

Neck- the lower part of the uterus, protruding into the vagina. There are two parts: vaginal and supravaginal. The cervix can be either cylindrical or conical (childhood, infantilism). Inside the cervix there is a narrow canal, spindle-shaped, limited internal and external pharynx. The external pharynx opens in the center of the vaginal part of the cervix. It has the shape of a slit in women who have given birth and a round shape in women who have not given birth.

The length of the entire uterus is 8 cm (2/3 of the length is on the body, 1/3 on the cervix), width 4-4.5 cm, wall thickness 1-2 cm. Weight 50-100 g. The uterine cavity has the shape of a triangle.

The wall of the uterus consists of 3 layers: mucous, muscular, serous. The mucous membrane of the uterus (endometrium) covered with a single-layer cylindrical ciliated epithelium containing tubular glands. The uterine mucosa is divided into two layers: superficial (functional), which is released during menstruation, and deep (basal), remaining in place.

Muscle layer (myometrium) richly supplied with vessels, consists of three powerful layers: outer longitudinal; middle circular; inner longitudinal.

Serous lining of the uterus (perimetry) is the peritoneum that covers the body and partly the cervix. From the bladder, the peritoneum passes to the anterior surface of the uterus, forming a vesicouterine cavity between these two organs. From the bottom of the uterus, the peritoneum descends along its posterior surface, lining the supravaginal part of the cervix and the posterior fornix of the vagina , and then passes to the anterior surface of the rectum, thus forming a deep pocket - the rectal-uterine recess (Douglas pouch).

The uterus is located in the center of the small pelvis, inclined anteriorly (anteversio uteri), its bottom is directed to the symphysis, the cervix is ​​posterior, the external cervical os is adjacent to the wall of the posterior vaginal fornix. Between the body and the cervix there is an obtuse angle, open anteriorly (anteflexio uteri).

The fallopian tubes start from the upper corners of the uterus, run along the upper edge of the broad ligament towards the side walls of the pelvis, ending in a funnel. Their length is 10-12 cm. There are three sections in the tube: 1) interstitial- the narrowest part passing through the thickness of the uterus; 2) isthmus (isthmus); 3) ampullary- an expanded part of the tube ending in a funnel with fimbriae. In this section of the tube, fertilization occurs - the fusion of the egg and sperm.

The wall of the pipes consists of three layers: mucous, muscular, serous.

The mucosa is covered with a single-layer cylindrical ciliated epithelium and has longitudinal folding.

The muscle layer consists of three layers: outer - longitudinal; middle - circular; inner - longitudinal.

The peritoneum covers the tube from above and from the sides. Fiber with vessels and nerves is adjacent to the lower section of the tube.

The movement of a fertilized egg through the tube towards the uterus is facilitated by peristaltic contractions of the muscles of the tube, flickering of the cilia of the epithelium directed towards the uterus and longitudinal folding of the mucous membrane of the tube. Along the fold, like a gutter, the egg slides towards the uterus.

OVARIES - paired female gonad, almond-shaped, measuring 3.5-4 x 2-2.5 x 1-1.5 cm, weighing 6-8 g.

The ovary is inserted at one edge into the posterior leaf of the broad ligament (ovarian hilum), the rest of it is not covered by the peritoneum. The ovary is held in a freely suspended state by the broad uterine ligament, the ovarian ligament proper, and the infundibulopelvic ligament.

In the ovary, there is a covering epithelium, a tunica albuginea, a cortical layer with follicles at different stages of development, and a medulla consisting of a connective tissue stroma in which blood vessels and nerves pass.

The ovaries produce sex hormones and eggs mature.

Ligamentous apparatus of the genital organs.

In a normal position, the uterus and appendages are held by the ligamentous apparatus (suspending and securing apparatus) and the pelvic floor muscles (supporting or supporting apparatus).

The hanging apparatus includes:

1. Round uterine ligaments - two cords 10-12 cm long. They extend from the uterine angles, and passing under the wide uterine ligament and through the inguinal canals, they fan out, attaching to the tissue of the pubis and labia majora.

2. The broad ligaments of the uterus are a duplicate of the peritoneum. They run from the ribs of the uterus to the side walls of the pelvis.

3. Uterosacral ligaments - extend from the posterior surface of the uterus in the area of ​​the isthmus, go

posteriorly, covering the rectum on both sides. Attached to the anterior surface of the sacrum.

4. The proper ovarian ligaments run from the fundus of the uterus (posteriorly and below the origin of the tubes) to the ovaries.

5. Infundibulopelvic ligaments are the outermost part of the broad uterine ligament, which passes into the peritoneum of the lateral wall of the pelvis.

The round ligaments keep the uterus in a state of anteversion, the broad ligaments tense when the uterus moves and thereby help keep the uterus in a physiological position, the ovarian ligaments proper and the infundibulopelvic ligaments help keep the uterus in the median position, the uterosacral ligaments pull the uterus posteriorly.

The anchoring apparatus of the uterus consists of connective tissue cords with a small number of muscle cells that extend from the lower part of the uterus: a) anteriorly to the bladder and further to the symphysis; b) to the lateral walls of the pelvis - the main ligaments; c) posteriorly, forming the connective tissue framework of the uterosacral ligaments.

The supporting apparatus consists of the muscles and fascia of the pelvic floor, which prevent the genitals and viscera from descending.

Blood supply to the genital organs.

The external genitalia are supplied with blood by the pudendal artery (a branch of the internal iliac artery).

The blood supply to the internal genital organs is provided by the uterine and ovarian arteries.

The paired uterine artery, departs from the internal iliac artery, goes to the uterus along the periuterine tissue, approaching the lateral surface of the uterus at the level of the internal os, gives off the cervicovaginal branch, supplying blood to the cervix and the upper part of the vagina. The main trunk rises along the rib of the uterus, giving off numerous branches that feed the wall of the uterus, and reaches the bottom of the uterus, where it gives off a branch going to the tube.

The ovarian artery is also paired, departs from the abdominal aorta, descends along with the ureter, passes through the infundibulopelvic ligament, giving branches to the ovary and tube. The terminal sections of the uterine and ovarian arteries anastomose with each other in the upper section of the broad uterine ligament.

Arteries are accompanied by veins of the same name.

Innervation of the genital organs.

The sympathetic and parasympathetic nervous systems (utero-vaginal and ovarian plexuses) take part in the innervation of the genital organs.

The external genitalia and pelvic floor are innervated by the pudendal nerve.

Physiology of female genital organs.

It is known that reproduction, or reproduction, is one of the most important functions

the female body. The reproductive function of women is carried out primarily due to the activity of the ovaries and the uterus, since the egg matures in the ovaries, and in the uterus, under the influence of hormones secreted by the ovaries, changes occur in preparation for the reception of a fertilized egg. The reproductive (childbearing) period continues from 17-18 to 45-50 years.

The childbearing period is preceded by the following stages of a woman’s life: intrauterine; newborns (up to 1 year); childhood (up to 8-10 years); prepubertal and pubertal age (up to 17-18 years). The reproductive period passes into menopause, in which premenopause, menopause (last menstruation) and postmenopause are distinguished.

The menstrual cycle is one of the manifestations of complex biological processes in a woman’s body. The menstrual cycle is characterized by cyclic changes in all parts of the reproductive system, the external manifestation of which is menstruation.

Each normal menstrual cycle is a preparation of a woman’s body for pregnancy. Conception and pregnancy usually occur in the middle of the menstrual cycle after ovulation (rupture of a mature follicle) and the release of an egg ready for fertilization from the ovary. If fertilization does not occur during this period, the unfertilized egg dies, and the prepared one to perceive it, the uterine mucosa is shed and menstrual bleeding begins. Thus, the appearance of menstruation indicates the end of complex cyclic changes in a woman’s body, aimed at preparing for the possible onset of pregnancy.

The first day of menstruation is conventionally taken as the first day of the menstrual cycle, and the duration of the cycle is determined from the beginning of one to the beginning of another (subsequent) menstruation. The normal duration of the menstrual cycle ranges from 21 to 35 days and for most women on average 28 days. Value blood loss on menstrual days is 50-100 ml. The duration of normal menstruation is from 2 to 7 days.

The first menstruation (menarhe) is observed at the age of 10-12 years, but for 1-1.5 years after this, menstruation may be irregular, then a regular menstrual cycle is established.

Regulation of menstrual function is carried out through a complex neurohumoral pathway with the participation of five links (levels): 1) cerebral cortex; 2) hypothalamus; 3) pituitary gland; 4) ovaries; 5) peripheral organs called target organs (fallopian tubes, uterus and vagina). Target organs, due to the presence of special hormonal receptors, most clearly respond to the action of sex hormones produced in the ovaries during the menstrual cycle.

The cyclic functional changes that occur in a woman’s body are conventionally combined into several groups. These are changes in the hypothalamic-pituitary system, the ovaries (ovarian cycle), the uterus and, first of all, in its mucous membrane (uterine cycle). Along with this, cyclic shifts occur in throughout a woman’s body, known as the menstrual wave. They are expressed in periodic changes in the activity of the central nervous system, metabolic processes, the function of the cardiovascular system, thermoregulation, etc.

The cerebral cortex exerts a regulating and corrective influence on processes associated with the development of menstrual function. Through the cerebral cortex, the external environment influences the underlying parts of the nervous system involved in the regulation of the menstrual cycle.

The hypothalamus is a section of the diencephalon and, through a number of nerve conductors (axons), is connected to various parts of the brain, due to which the central regulation of its activity is carried out. In addition, the hypothalamus contains receptors for all peripheral hormones, including ovarian (estrogens and progesterone). Thus, complex interactions take place in the hypothalamus between impulses entering the body from the environment through the central nervous system, on the one hand, and

influences of hormones of peripheral endocrine glands - on the other.

Under the control of the hypothalamus is the activity of the brain appendage - the pituitary gland, in the anterior lobe of which gonadotropic hormones are secreted, which affect the function of the ovaries.

The controlling effect of the hypothalamus on the anterior pituitary gland is carried out through the secretion of neurohormones.

Neurohormones that stimulate the release of tropic hormones from the pituitary gland are called releasing factors or liberins. Along with this, there are also neurohormones that inhibit the release of tropic neurohormones, called statins.

The anterior lobe of the pituitary gland secretes follicle-stimulating (FSH) and luteinizing (LT) gonadotropins, as well as prolactin.

FSH stimulates the development and maturation of the follicle in one of the ovaries. Under the combined influence of FSH and LH, the mature follicle ruptures, or ovulation. After ovulation, under the predominant influence of LH, the corpus luteum is formed from the elements of the follicle (the connective tissue membrane and the granulosa cells lining its inner surface). Prolactin promotes the production of the hormone progesterone by the corpus luteum.

In the ovaries, during the menstrual cycle, follicles grow and the egg matures, which eventually becomes ready for fertilization. At the same time, the ovaries produce sex hormones that ensure changes in the uterine mucosa, which is capable of receiving a fertilized egg.

Sex hormones synthesized by the ovaries affect target tissues and organs by interacting with the corresponding receptors. Target tissues and organs include the genitals, primarily the uterus, mammary glands, spongy bones, brain, endothelium and smooth muscle cells blood vessels, myocardium, skin and its appendages (hair follicles and sebaceous glands), etc.

Estrogen hormones contribute to the formation of genital organs and the development of secondary sexual characteristics during puberty. Androgens influence the appearance of pubic and axillary hair. Progesterone controls the secretory phase of the menstrual cycle and prepares the endometrium for implantation. Sex hormones play an important role in the development of pregnancy and childbirth

Cyclic changes in the ovaries include three main processes:

1) growth of follicles and formation of a dominant follicle (follicular phase);

2) ovulation;

3) formation, development and regression of the corpus luteum (luteal phase).

At the birth of a girl, there are 2 million follicles in the ovary, 99% of which undergo atresia throughout life. The process of atresia refers to the reverse development of follicles at one of the stages of its development. By the time of menarche, the ovary contains about 200-400 thousand follicles, of which mature to the ovulation stage of 300-400.

It is customary to distinguish the following main stages of follicle development: primordial follicle, preantral follicle, antral follicle, preovulatory (dominant) follicle. The dominant follicle is the largest (21 mm at the time of ovulation).

Ovulation is the rupture of the dominant follicle and the release of an egg. Thinning and rupture of the follicle wall occurs mainly under the influence of the enzyme collagenase.

After the release of the egg into the cavity of the follicle, the resulting capillaries quickly grow. Granulosa cells undergo luteinization: the volume of the cytoplasm increases in them and lipid inclusions are formed. LH, interacting with the protein receptors of granulosa cells, stimulates the process of their luteinization. This process leads to the formation of the corpus luteum.

The corpus luteum is a transient endocrine gland that functions for 14 days, regardless of the duration of the menstrual cycle. In the absence of pregnancy, the corpus luteum regresses.

The cyclic secretion of hormones in the ovary determines changes in the uterine mucosa. The endometrium consists of two layers: the basal layer, which is not shed during menstruation, and the functional layer, which undergoes cyclic changes during the menstrual cycle and is shed during menstruation.

The following phases of endometrial change during the cycle are distinguished:

1) proliferation phase; 3) menstruation;

2) secretion phase; 4) regeneration phase

Proliferation phase. As the secretion of estradiol by the growing ovarian follicles increases, the endometrium undergoes proliferative changes. The cells of the basal layer actively multiply. A new superficial loose layer with elongated tubular glands is formed. This layer quickly thickens 4-5 times. The tubular glands lined with cylindrical epithelium elongate.

Secretion phase. In the luteal phase of the ovarian cycle, under the influence of progesterone, the tortuosity of the glands increases, and their lumen gradually expands. The cells of the stroma, increasing in volume, come closer to each other. The secretion of the glands intensifies. They acquire a sawtooth shape. Increased vascularization of the stroma is noted.

Menstruation. This is the rejection of the functional layer of the endometrium. The endocrine basis for the onset of menstruation is a pronounced decrease in the levels of progesterone and estradiol due to regression of the corpus luteum.

Regeneration phase. Regeneration of the endometrium is observed from the very beginning of menstruation. By the end of the 24th hour of menstruation, 2/3 of the functional layer of the endometrium is rejected. The basal layer contains epithelial cells of the stroma, which are the basis for endometrial regeneration, which is usually completely completed by the 5th day of the cycle. In parallel, angiogenesis is completed with restoration of the integrity of ruptured arterioles, veins and capillaries.

In the regulation of menstrual function, the implementation of the principle of the so-called feedback between the hypothalamus, the anterior lobe of the pituitary gland and the ovaries is of great importance. It is customary to consider two types of feedback: negative and positive.

With a negative type of feedback, the production of central neurohormones (releasing factors) and gonadotropins of the adenohypophysis is suppressed by ovarian hormones produced in large quantities. With a positive type of feedback, the production of releasing factors in the hypothalamus and gonadotropins in the pituitary gland is stimulated by low levels of ovarian hormones in the blood. The implementation of the principle of negative and positive feedback underlies the self-regulation of the function of the hypothalamic-pituitary-ovarian system.

Female pelvis and pelvic floor.

The bony pelvis is of great importance in obstetrics. It is a container for the internal genital organs, rectum, bladder and surrounding tissues, and during childbirth it forms the birth canal through which the fetus moves.

The pelvis consists of four bones: two pelvic (nameless), sacrum and coccyx.

The pelvic bone consists of three bones: the ilium, the pubis and the ischium, connected to each other in the area of ​​the acetabulum.

There are two sections of the pelvis: large pelvis and small pelvis. The border between them runs anteriorly along the upper edge of the symphysis pubis, laterally along the innominate line, and posteriorly along the sacral promontory.

Big pelvis limited laterally by the wings of the ilium, posteriorly by the last lumbar vertebrae. In front it does not have a bony wall. Based on the size of the large pelvis, which is fairly easy to measure, one can judge the shape and size of the small pelvis.

Small pelvis is the bony part of the birth canal. The shape and size of the pelvis are of great importance during labor. With sharp degrees of narrowing of the pelvis and its deformations, childbirth through the natural birth canal becomes impossible, and the woman is delivered by cesarean section.

The posterior wall of the pelvis consists of the sacrum and coccyx, the lateral ones are formed by the ischial bones, and the anterior wall is formed by the pubic bones and the symphysis. The posterior wall of the pelvis is three times longer than the anterior one.

In the small pelvis there are the following sections: inlet, cavity and outlet. In the pelvic cavity there are a wide and a narrow part. In accordance with this, four planes of the small pelvis are considered: 1) the plane of the entrance to the small pelvis; 2) the plane of the wide part of the small pelvis; 3) the plane of the narrow part of the small pelvis; 4) the plane of the exit of the pelvis.

The plane of entry into the pelvis has the following boundaries: in front – the upper edge of the symphysis and pubic bones, on the sides – innominate lines, in the back – the sacral promontory. The entrance plane is kidney-shaped. In the entrance plane, the following dimensions are distinguished: straight, which is the true conjugate of the small pelvis (11 cm), transverse (13 cm) and two oblique (12 cm).

The plane of the wide part of the pelvic cavity limited in front by the middle of the inner surface of the symphysis, on the sides by the middle of the acetabulum, and behind by the junction of the II and III sacral vertebrae. In the wide part there are two sizes, straight (12.5 cm) and transverse (12.5 cm)

The plane of the narrow part of the pelvic cavity bounded in front by the lower edge of the symphysis, on the sides by the spines of the ischial bones, and behind by the sacrococcygeal joint. There are also two sizes: straight (11 cm) and transverse (10.5 cm).

Pelvic exit plane has the following boundaries: in front - the lower edge of the symphysis, on the sides - the ischial tuberosities, in the back - the coccyx. The exit plane of the pelvis consists of two triangular planes, the common base of which is the line connecting the ischial tuberosities. The direct size of the pelvic outlet is from the apex of the coccyx to the lower edge of the symphysis; due to the mobility of the coccyx during the passage of the fetus through the small pelvis, it increases by 1.5 - 2 cm (9.5-11.5 cm). The transverse size is 11 cm.

The line connecting the midpoints of the direct dimensions of all planes of the pelvis is called wired pelvic axis, since it is along this line that the fetus passes through the birth canal during childbirth. The wire axis is curved according to the concavity of the sacrum.

The intersection of the plane of the entrance to the pelvis with the horizon plane forms pelvic inclination angle equal to 50-55’.

Differences in the structure of the female and male pelvis begin to appear during puberty and become pronounced in adulthood. The bones of the female pelvis are thinner, smoother and less massive than the bones of the male pelvis. The plane of entrance to the pelvis in women has a transverse oval shape, while in men it has the shape of a card heart (due to the strong protrusion of the promontory).

Anatomically, the female pelvis is lower, wider and larger in volume. The pubic symphysis in the female pelvis is shorter than the male one. The sacrum in women is wider, the sacral cavity is moderately concave. The pelvic cavity in women is closer to a cylinder in outline, and in men it narrows funnel-shaped downwards. The pubic angle is wider (90-100’) than in men (70-75’). The tailbone protrudes anteriorly less than in the male pelvis. The ischial bones in the female pelvis are parallel to each other, and in the male pelvis they converge.

All of these features are very important in the process of birth.

Pelvic floor muscles.

The outlet of the pelvis is closed from below by a powerful muscular-fascial layer, which is called pelvic floor.

Two diaphragms take part in the formation of the pelvic floor - the pelvic and genitourinary.

Pelvic diaphragm occupies the back of the perineum and has the shape of a triangle, the apex of which faces the coccyx, and the corners face the ischial tuberosities.

Superficial layer of the muscles of the pelvic diaphragm represented by an unpaired muscle - the external sphincter of the anus (m.sphincter ani externus). The deep bundles of this muscle start from the apex of the coccyx, wrap around the anus and end in the tendon center of the perineum.

To the deep muscles of the pelvic diaphragm There are two muscles: the levator ani muscle (m.levator ani) and the coccygeus muscle (m. coccygeus).

The levator ani muscle is a paired, triangular-shaped muscle that forms a funnel with a similar muscle on the other side, the wide part facing upward and attached to the inner surface of the pelvic walls. The lower parts of both muscles, tapering, cover the rectum in the form of a loop. This muscle consists of the pubococcygeus (m. pubococcygeus) and iliococcygeus muscles (m.iliococcygeus).

The coccygeus muscle in the form of a triangular plate is located on the inner surface of the sacrospinous ligament. With a narrow apex it starts from the ischial spine, and with a wide base it is attached to the lateral edges of the lower sacral and coccygeal vertebrae.

Urogenital diaphragm–fascial – muscular plate located in the anterior part of the pelvic floor between the lower branches of the pubic and ischial bones.

The muscles of the urogenital diaphragm are divided into superficial and deep.

To the superficial include the superficial transverse perineal muscle, the ischiocavernosus muscle and the bulbospongiosus muscle.

The superficial transverse muscle of the perineum (m.transversus perinei superficialis) is paired, unstable, and can sometimes be absent on one or both sides. This muscle is a thin muscular plate located at the posterior edge of the urogenital diaphragm and running across the perineum. Its lateral end is attached to the ischium, and its medial part crosses along the midline with the muscle of the same name on the opposite side, partly intertwining with the bulbospongiosus muscle, partly with the external muscle that compresses the anus.

The ischiocavernosus muscle (m.ischiocavernosus) is a steam muscle that looks like a narrow muscle strip. It begins as a narrow tendon from the inner surface of the ischial tuberosity, bypasses the stalk of the clitoris and is woven into its tunica albuginea.

The bulbospongiosus muscle (m. bulbospongiosus) is a steam muscle, surrounds the entrance to the vagina, and has the shape of an elongated oval. This muscle starts from the tendinous center of the perineum and the external sphincter of the anus and is attached to the dorsal surface of the clitoris, intertwined with its tunica albuginea.

To the deep The muscles of the genitourinary diaphragm include the deep transverse perineal muscle and the urethral sphincter.

The deep transverse muscle of the perineum (m. transversus perinei profundus) is a paired, narrow muscle starting from the ischial tuberosities. It goes to the midline, where it connects with the muscle of the same name on the opposite side, participating in the formation of the tendon center of the perineum.

The sphincter of the urethra (m.sphincter urethrae) is a paired muscle that lies anterior to the previous one. Peripherally located bundles of this muscle are directed to the branches of the pubic bones and to the fascia of the genitourinary diaphragm. Bundles of this muscle surround the urethra. This muscle connects to the vagina.

Kelly. Fundamentals of modern sexology. Ed. Peter

Translated from English by A. Golubev, K. Isupova, S. Komarov, V. Misnik, S. Pankov, S. Rysev, E. Turutina

The anatomical structure of the male and female reproductive organs, also called genitals, has been known for many hundreds of years, but reliable information about their functioning has only recently become available. Male and female genitalia perform many functions and play an important role, participating in reproduction, and in receiving pleasure, and in the formation of trusting relationships in love.

Oddly enough, most popular sex education manuals traditionally consider the male genital organs primarily as a source of pleasant sexual sensations, and only then discuss their role in childbirth. When studying the female genital organs, the emphasis clearly shifts to the reproductive functions of the uterus, ovaries and fallopian tubes. The importance of the role of the vagina, clitoris and other external structures in sexual pleasure is often overlooked. In this and the next chapters, both the male and female genital organs are described as a potential source of intimacy in human relationships and sexual pleasure, as well as a potential source of the birth of children.

FEMALE GENITAL ORGANS

The female genital organs are not exclusively internal. Many of their important structures, located externally, play a large role in providing sexual arousal, while the internal parts of the female reproductive system are more significant in regulating hormonal cycles and reproductive processes.

The external female genitalia consists of the pubis, labia and clitoris. They are richly innervated and, due to this, sensitive to stimulation. The shape, size and pattern of pigmentation of the external genitalia vary greatly among women.

Vulva

The external female genitalia, located between the legs, below and in front of the pubic joint of the pelvic bones, is collectively called the vulva. The most noticeable of these organs is the pubis ( monsveneris)and labia majora (or labia majora) (labia majora). The pubis, sometimes called the pubic eminence or mount of Venus, is a rounded pad formed by subcutaneous fatty tissue and located above the rest of the external organs, just above the pubic bone. During puberty it becomes covered with hair. The pubis is fairly well innervated, and most women find that friction or pressure in this area can be sexually arousing. The vulva is generally considered the main erogenous zone in women, as it is generally very sensitive to sexual stimulation.

The labia majora are two folds of skin directed from the pubis down towards the perineum. They may be relatively flat and subtle in some women and thick and visible in others. During puberty, the skin of the labia majora darkens slightly, and hair begins to grow on their outer lateral surface. These outer folds of skin cover and protect the more sensitive female genitals located inside. The latter cannot be seen unless the large lips are parted, so a woman may need a mirror that needs to be positioned so as to see these organs.

When the labia majora are spread apart, you can see another, smaller pair of folds - the labia minora (or pudenda). They look like two asymmetrical petals of skin, pink, hairless and irregularly shaped, which connect at the top and form the skin of the clitoris, called the foreskin. Both the labia majora and minora are sensitive to sexual stimulation and play an important role in sexual arousal. On the inside of the labia minora are the exit openings of the ducts of the Bartholin's glands, sometimes called the vulvovaginal glands. At the moment of sexual arousal, a small amount of secretion is released from these glands, which may help moisturize the vaginal opening and, to some extent, the labia. These secretions, however, are of little importance for lubrication of the vagina during sexual arousal, and any other functions of these glands are unknown. Bartholin's glands sometimes become infected with bacteria from feces or other sources, and in such cases, treatment by a specialist may be required. Between the labia minora there are two openings. In order to see them, the labia minora often need to be spread apart. Almost just below the clitoris is a tiny opening called the urethra, or urethra, through which urine is removed from the body. Below is the larger vaginal opening, or entrance to the vagina. This hole is usually not open and can only be perceived as such if something is inserted into it. For many women, especially those in younger age groups, the entrance to the vagina is partially covered by membrane-like tissue - the hymen.

Human reproductive organs are important for both reproduction and pleasure. Historically, sexuality educators have focused on reproductive function and the internal genital organs, especially in women. In recent years, these specialists have also begun to pay attention to those aspects of sexual behavior that are associated with receiving pleasure, and to the external genitalia.

Clitoris

The clitoris, the most sensitive of the female genital organs, is located just below the superior fusion of the labia minora. This is the only organ whose function is only to provide sensitivity to sexual stimulation and to be a source of pleasure.

The clitoris is the most sensitive female reproductive organ. Some form of clitoral stimulation is usually necessary to achieve orgasm, although the most appropriate method varies from woman to woman. The most prominent part of the clitoris usually appears as a rounded projection protruding from under the foreskin, which is formed by the superior fusion of the labia minora. This outer, sensitive part of the clitoris is called the glans. For a long time, the clitoris has been likened to the male penis because it is sensitive to sexual stimulation and capable of erection. Sometimes they even incorrectly considered the clitoris to be an underdeveloped penis. In fact, the clitoris and its entire internal system of blood vessels, nerves and erectile tissue form a highly functional and important sexual organ (Ladas, 1989).

The body of the clitoris is located behind the glans under the foreskin. The glans is the only freely protruding part of the clitoris, and, as a rule, it is not particularly mobile. The part of the clitoris located behind the head is attached to the body along its entire length. The clitoris is formed by two columnar cavernous bodies and two bulbous corpora cavernosa, which are capable of filling with blood during sexual arousal, causing hardening, or erection, of the entire organ. The length of the non-erect clitoris rarely exceeds 2-3 cm, and in a non-excited state only its apex (head) is visible, but with erection it increases significantly, especially in diameter. As a rule, in the first stages of arousal, the clitoris begins to protrude more than in a non-aroused state, but as arousal increases, it retracts again.

The skin of the foreskin contains tiny glands that secrete a fatty substance, which, when mixed with the secretions of other glands, forms a substance called smegma. This substance accumulates around the body of the clitoris, sometimes leading to the development of a harmless infection that can cause pain or discomfort, especially during sexual activity. If smegma buildup becomes a problem, it can be removed by a doctor using a small probe inserted under the foreskin. Sometimes the foreskin is surgically incised slightly, further exposing the glans and body of the clitoris. This procedure, called circumcision in Western culture, is rarely performed on women, and doctors find little rational basis for it.

Vagina

The vagina is a tube with muscular walls and plays an important role as a female organ associated with childbirth and sexual pleasure. The muscular walls of the vagina are very elastic, and unless something is inserted into the vaginal cavity, they become compressed, so that the cavity is better described as a "potential" space. The length of the vagina is about 10 cm, although it can lengthen during sexual arousal. The inner surface of the vagina, elastic and soft, is covered with small ridge-like projections. The vagina is not particularly sensitive, except in areas immediately surrounding the opening or located deep from the opening to about one-third of the length of the vagina. This outer region, however, contains many nerve endings and its stimulation easily leads to sexual arousal.

The vaginal opening is surrounded by two muscle groups: the vaginal sphincter ( sphincter vaginae)and levator anus ( levator ani). Women are able to control these muscles to some extent, but tension, pain or fear can lead to involuntary contraction, which makes inserting objects into the vagina painful or impossible. These manifestations are called vaginismus. A woman can also regulate the tone of the internal pubococcygeus muscle, which, like the anal sphincter, can be contracted or relaxed. This muscle plays a certain role in the formation of orgasm, and its tone, like the tone of all voluntary contracting muscles, can be learned to be regulated with the help of special exercises.

It is important to note that the vagina cannot contract to such an extent that the penis will be held in it ( penis captivus),although it is possible that some have heard the opposite. In Africa, for example, there are many myths about people who become entangled during sex and have to go to hospital to be separated. Such myths appear to serve a social function of preventing adultery ( Ecker, 1994). When breeding dogs, the penis is erected in such a way that it is trapped in the vagina until the erection subsides, and this is necessary for successful mating. Nothing like this happens in people. During sexual arousal in women, a lubricant is released on the inner surface of the vaginal walls.

Douching

Over the years, women have developed a variety of methods for cleaning the vagina, sometimes called douching. It was believed to help prevent vaginal infections and eliminate bad odor. In a study of 8,450 women aged 15 to 44 years, it was found that 37% of them resorted to douching as part of their regular hygiene procedures (Aral , 1992). The practice is especially common among poor women and non-white minorities, for whom the rate can be as high as two-thirds. One National Black Women's Health Project participant ( Black Women's Health Project) speculated that douching may represent black women's response to negative sexual stereotypes. Meanwhile, research is providing growing evidence that douching, contrary to popular belief, can be dangerous. Thanks to it, pathogens can penetrate the uterine cavity, which increases the risk of uterine and vaginal infections. Women who douche more than three times a month are at four times higher risk of pelvic inflammatory disease than those who do not douche at all. The vagina has natural cleaning mechanisms that can be disrupted by douching. Unless specifically indicated for medical reasons, douching should be avoided.

Hymen

The hymen is a thin, delicate membrane that partially covers the entrance to the vagina. It can cross the vaginal opening, surround it, or have several openings of varying shapes and sizes. The physiological functions of the hymen are unknown, but historically it had psychological and cultural significance as a sign of virginity.

The hymen, present at the vaginal opening from birth, usually has one or more holes. There are many different shaped hymens that cover the vaginal opening to varying degrees. The most common type is the annular hymen. In this case, its tissue is located around the perimeter of the entrance to the vagina, and there is a hole in the center. Some types of hymen tissue extend to the opening of the vagina. The ethmoid hymen completely covers the opening of the vagina, but it itself has many small holes. The hymen is a single strip of tissue that divides the opening of the vagina into two clearly visible openings. Occasionally, girls are born with a closed hymen, that is, the latter completely covers the vaginal opening. This can only become clear with the onset of menstruation, when fluid accumulates in the vagina and causes discomfort. In such cases, the doctor must make a small hole in the hymen to allow the flow of menstrual fluid.

In most cases, the hymen has a hole large enough for a finger or tampon to fit through. Attempting to insert a larger object, such as an erect penis, usually results in rupture of the hymen. There are many other circumstances, unrelated to sexual activity, in which the hymen can become damaged. Although it is often claimed that some girls are born without a hymen, recent evidence casts doubt on whether this is actually the case. More recently, a group of pediatricians at the University of Washington examined 1,131 newborn girls and found that each had an intact hymen. From this it was concluded that the absence of a hymen at birth was very unlikely, if not impossible. It also follows that if the hymen is not found in a little girl, the cause is most likely some kind of trauma (Jenny, Huhns, & Arakawa, 1987).

Sometimes the hymen is stretchable enough to survive sexual intercourse. Therefore, the presence of a hymen is an unreliable indicator of virginity. Some peoples attach special importance to the presence of a hymen and establish special rituals for tearing a girl’s hymen before first copulation.

In the United States, between 1920 and 1950, some gynecologists performed special surgery for women who were getting married but did not want their husbands to know that they were not virgins. The operation, called the “lover's knot,” consisted of placing one or two sutures on the labia minora so that a thin closure appeared between them. During intercourse on the wedding night, the bow broke, causing some pain and bleeding (Janus & Janus, 1993). Many in Western society to this day believe that the presence of a hymen proves virginity, which is naive at best. In reality, the only way to physically determine whether copulation has taken place is to detect sperm in a vaginal smear using a chemical test or microscopic examination. This procedure must be performed within a few hours of sexual intercourse, and in cases of rape it is sometimes used to prove that penile-vaginal penetration has occurred.

A rupture of the hymen during sexual intercourse for the first time can cause discomfort or pain and possibly some bleeding when the hymen is torn. The pain can vary from mild to severe among women. If a woman is concerned that her first intercourse will be painless, she can use her fingers to widen the opening of the hymen in advance. The doctor may also remove the hymen or stretch the opening using dilators of increasing size. However, if your partner gently and carefully inserts the erect penis into the vagina, using adequate lubrication, there will usually be no problems. A woman can also guide her partner's penis herself, adjusting the speed and depth of its penetration.

Self-examination of the genital organs by a woman

After becoming familiar with the basics of their external anatomy, women are encouraged to examine their genitals monthly, paying attention to any unusual signs and symptoms. Using a mirror and appropriate lighting, you should examine the condition of the skin under the pubic hair. Then you should pull back the skin of the foreskin of the clitoris and spread the labia minora, which will allow you to better examine the area around the vaginal openings and urethra. Keep an eye out for any unusual swelling, abrasions, or rashes. They may be red or pale, but sometimes they are easier to detect not visually, but by touch. Do not forget to also examine the inner surface of the labia majora and minora. It is also advisable, knowing what your vaginal discharge looks like in normal condition, to pay attention to any changes in its color, smell or consistency. Although certain abnormalities can usually occur during the menstrual cycle, some diseases cause easily noticeable changes in vaginal discharge.

If you notice any unusual swelling or discharge, you should immediately consult a gynecologist. Often all these symptoms are completely harmless and do not require any treatment, but sometimes they signal the onset of an infectious process when medical attention is necessary. It is also important to tell your doctor about any pain or burning when urinating, bleeding between periods, pain in the pelvic area, and any itchy rashes around the vagina.

Uterus

The uterus is a hollow muscular organ in which the growth and nutrition of the fetus occurs until the very moment of birth. The walls of the uterus have different thicknesses in different places and consist of three layers: perimetry, myometrium and endometrium. To the right and left of the uterus there is one almond-shaped ovary. The two functions of the ovaries are the secretion of the hormones estrogen and progesterone and the production of eggs and their subsequent release from the ovary.

The cervix protrudes into the deepest part of the vagina. The uterus itself is a thick-walled muscular organ that provides a nutrient medium for the developing fetus during pregnancy. As a rule, it is pear-shaped, approximately 7-8 cm in length and about 5-7 cm in diameter at the top, tapering to 2-3 cm in diameter in the part that protrudes into the vagina. During pregnancy, it gradually increases to a much larger size. When a woman stands, her uterus is almost horizontal and at right angles to the vagina.

The two main parts of the uterus are the body and the cervix, connected by a narrower isthmus. The top of the wide part of the uterus is called its fundus. Although the cervix is ​​not particularly sensitive to superficial touch, it can sense pressure. The opening in the cervix is ​​called the os. The internal cavity of the uterus has different widths at different levels. The walls of the uterus consist of three layers: a thin outer layer - the perimeter, a thick intermediate layer of muscle tissue - the myometrium and an inner layer rich in blood vessels and glands - the endometrium. It is the endometrium that plays a key role in the menstrual cycle and in the nutrition of the developing fetus.

Internal gynecological examination

The uterus, especially the cervix, is one of the common sites for cancer in women. Because uterine cancer can remain asymptomatic for many years, it is particularly dangerous. Women should undergo periodic internal gynecological examinations and Pap smear tests from a qualified gynecologist. There is disagreement among experts about how often this examination should be done, but most recommend doing it annually. Thanks to the Pap smear, the death rate from cervical cancer was reduced by 70%. Approximately 5,000 women die in the United States from this form of cancer each year, 80% of whom have not had a Pap smear in the past 5 years or more.

During a gynecological examination, first of all, a vaginal speculum is carefully inserted into the vagina, which holds the vaginal walls in an expanded state. This allows direct examination of the cervix. To take the Pap smear (named after its developer, Dr. Papanicolaou), a thin spatula or stem-mounted swab is used to painlessly remove a number of cells from the cervix while the speculum remains in place. A smear is prepared from the collected material, which is fixed, stained and examined under a microscope, looking for any possible indications of changes in the structure of cells that may indicate the development of cancer or precancerous manifestations. In 1996, the Food and Drug Administration ( Food and Drug Administration) approved a new method for preparing a smear by the Pope, which eliminates the entry of excess mucus and blood into it, which makes it difficult to detect altered cells. This made the test even more effective and reliable than before. Recently, it has become possible to use another device, which, when attached to a vaginal speculum, illuminates the cervix with light specially selected for its spectral composition. Under such lighting, normal and abnormal cells differ from each other in color. This greatly facilitates and speeds up the identification of suspicious areas of the cervix that should be subjected to a more thorough examination.

After removing the speculum, a manual examination is performed. Using a rubber glove and lubricant, the doctor inserts two fingers into the vagina and presses them on the cervix. The other hand is placed on the stomach. In this way, the doctor is able to feel the overall shape and size of the uterus and surrounding structures.

If suspicious cells are detected in the Pap smear, more intensive diagnostic procedures are recommended. First of all, to determine the presence of malignant cells, you can resort to a biopsy. If an increase in the number of abnormal cells is shown, another procedure called dilatation and curettage (dilation and curettage) can be performed. The opening of the cervix widens, which allows you to insert a special instrument - a uterine curette - into the internal cavity of the uterus. A number of cells from the inner layer of the uterus are carefully scraped off and examined for the presence of malignant cells. Typically, dilation and curettage is used to clear the uterus of dead tissue after a miscarriage (involuntary abortion), and sometimes to terminate a pregnancy during an induced abortion.

Ovaries and fallopian tubes

On both sides of the uterus, two almond-shaped glands called ovaries are attached to it using the inguinal (pupart) ligaments. The two main functions of the ovaries are the secretion of female sex hormones (estrogen and progesterone) and the production of eggs necessary for reproduction. Each ovary is approximately 2-3 cm long and weighs about 7 grams. At birth, a woman's ovary contains tens of thousands of microscopic sacs called follicles, each of which contains a cell that can potentially develop into an egg. These cells are called oocytes. It is believed that by the time of puberty, only a few thousand follicles remain in the ovaries, and only a small fraction of these (400 to 500) will ever develop into mature eggs.

In a mature woman, the surface of the ovary is irregular in shape and covered with pits - marks left after the release of many eggs through the ovarian wall during the process of ovulation, described below. By examining the internal structure of the ovary, one can observe follicles at different stages of development. Two different zones are also distinguishable: the central medulla and a thick outer layer, cortex. A pair of fallopian, or fallopian, tubes lead from the edge of each ovary into the upper part of the uterus. The end of each fallopian tube, which opens next to the ovary, is covered with fringed projections - fimbriae, which are not attached to the ovary, but rather loosely encircle it. Following the fimbriae is the widest part of the tube - funnel. It leads into a narrow, irregularly shaped cavity stretching along the entire tube, which gradually narrows as it approaches the uterus.

The inner layer of the fallopian tube is covered with microscopic cilia. It is through the movement of these cilia that the egg travels from the ovary to the uterus. For conception to occur, a sperm must meet and penetrate the egg while it is in one of the fallopian tubes. In this case, the already fertilized egg is transported further into the uterus, where it attaches to its wall and begins to develop into an embryo.

CROSS-CULTURAL PERSPECTIVE

Mariam Razak was 15 when her family locked her in a room where five women held her struggling to escape while a sixth cut off her clitoris and labia.

The event left Mariam with a lingering feeling of being betrayed by the people she loved most: her parents and her boyfriend. Now, nine years later, she believes that the operation and the infection it caused robbed her of not only her ability to be sexually satisfied, but also her ability to have children.

It was love that led Mariam to this mutilation. She and her childhood friend, Idrissou Abdel Razak, say they had sex as teenagers and then he decided they should get married.

Without telling Mariam, he asked his father, Idrissa Seibu, to approach her family for permission to marry. His father offered a significant dowry, and Mariam's parents gave their consent, while she herself was told nothing.

“My son and I asked her parents to circumcise her,” says Idrissu Seibu. - Other girls, who were warned in advance, ran away. That's why we decided not to tell her what would be done."

On the day scheduled for the operation, Mariam's boyfriend, a 17-year-old taxi driver, was working in Sokode, a town north of Kpalime. Today he is ready to admit that he knew about the upcoming ceremony, but did not warn Mariam. Mariam herself now believes that together they could find a way to deceive her parents and convince them that she went through with the procedure, if only her boyfriend would support her.

When he returned, he learned that she had to be rushed to the hospital because the bleeding did not stop. She developed an infection in hospital and remained there for three weeks. But while her body was healing, she said, her feelings of bitterness intensified.

And she decided not to marry a man who failed to protect her. She borrowed $20 from a friend and took a cheap taxi to Nigeria, where she lived with friends. It took her parents nine months to find her and bring her home.

It took her boyfriend another six years to regain her trust. He bought her clothes, shoes and jewelry as gifts. He told her that he loved her and begged for forgiveness. Eventually her anger mellowed and they married in 1994. Since then they have lived in his father's house.

But Mariam Razak knows what she's lost. She and her now-husband made love in their youth, before she underwent FGM, and she said sex brought her great satisfaction. Now, they both say, she doesn't feel anything. She compares the permanent loss of sexual satisfaction to an incurable disease that stays with you until you die.

“When he goes into town, he buys drugs that he gives me before we have sex to make me feel pleasure. But it’s not the same,” says Mariam.

Her husband agrees: “Now that she's circumcised, there's something missing in that area. She doesn't feel anything there. I try to please her, but it doesn’t work very well.”

And their sorrows do not end there. They are also unable to conceive a child. They turned to doctors and traditional healers - all to no avail.

Idrissou Abdel Razak promises that he will not take another wife, even if Mariam does not become pregnant: “I have loved Mariam since we were children. We will continue to look for a way out."

And if they ever have daughters, he promises to send them away from the country to protect them from having their genitals cut off. Source : S. Dugger. The New York Times METRO, 11 September 1996

Female genital mutilation

Across cultures and historical periods, the clitoris and labia have been subjected to various types of surgical procedures that have resulted in female mutilation. Based on the widespread fear of masturbation since mid-2000s XIX century and until about 1935, doctors in Europe and the United States often circumcised women, that is, they removed, partially or completely, the clitoris - a surgical procedure called clitoridectomy. These measures were believed to "cure" masturbation and prevent insanity. In some African and East Asian cultures and religions, clitoridectomy, sometimes incorrectly called "female circumcision", is still practiced as part of the rites of passage into adulthood. The World Health Organization estimates that up to 120 million women worldwide have undergone some form of what is now called female genital mutilation. Until recently, almost all girls in countries such as Egypt, Somalia, Ethiopia and Sudan underwent this operation. Although it can sometimes take the form of traditional circumcision, which removes the tissue covering the clitoris, more often the glans of the clitoris is also removed. Sometimes an even more extensive clitoridectomy is performed, which involves removing the entire clitoris and a significant amount of surrounding labia tissue. As a rite of passage marking a girl's transition to adulthood, clitoridectomy signifies the removal of all traces of "male characteristics": since the clitoris in these cultures is traditionally seen as a miniature penis, its absence is recognized as the ultimate symbol of femininity. But in addition, clitoridectomy also reduces a woman's sexual satisfaction, which is important in those cultures where men are considered responsible for controlling women's sexuality. Various taboos are established to support this practice. In Nigeria, for example, some women believe that if the baby's head touches the clitoris during childbirth, the baby will develop a mental disorder ( Ecker, 1994). Some cultures also practice infibulation, in which the labia minora and sometimes the labia majora are removed and the edges of the outer part of the vagina are stitched or held together using plant thorns or natural adhesives, thus ensuring that the woman will not have intercourse before marriage. The bonding material is removed before marriage, although the procedure may be repeated if the husband intends to be away for a long time. This often results in the formation of rough scar tissue that can make urination, menstruation, copulation and childbirth more difficult and painful. Infibulation is common in cultures where virginity is highly valued in marriage. When women who undergo this operation are chosen as brides, they bring significant benefits to their families in the form of money, property and livestock (Eskeg, 1994).

These rites are often performed with crude instruments and without the use of anesthesia. Girls and women undergoing such procedures often become infected with serious illnesses, and the use of unsterile instruments can lead to AIDS. Girls sometimes die as a result of bleeding or infection caused by this operation. In addition, there is growing evidence that such ritual surgery can lead to serious psychological trauma, with lasting effects on women's sexuality, marital life and childbearing (Lightfoot - Klein, 1989; MacFarquhar, 1996). The influence of civilization has brought some improvements to traditional practices, so that in some places today aseptic methods are already used to reduce the risk of infection. For some time, Egyptian health authorities have encouraged this operation to be carried out in medical institutions to avoid possible complications, while simultaneously providing family counseling to end this custom. In 1996, the Egyptian Ministry of Health decided to ban all health workers in both public and private clinics from performing any type of female genital mutilation. However, it is believed that many families will continue to turn to local healers to carry out these ancient prescriptions.

There is growing condemnation of the practice, which is seen by some groups as barbaric and sexist. In the United States, the issue has come under greater scrutiny as it now becomes clear that some girls from immigrant families from more than 40 countries may have undergone the procedure in the United States. A woman named Fauzia Kasinga fled the African country of Togo in 1994 to avoid mutilation surgery and eventually came to the States illegally. She applied for asylum, but an immigration judge initially dismissed her case as unpersuasive. After she spent over one year in prison, the Board of Immigration Appeals ruled in 1996 that female genital mutilation did constitute an act of persecution and was a valid basis for granting asylum to women (Dugger , 1996). While such practices are sometimes seen as a cultural imperative that should be respected, this ruling and other developments in developed countries underscore the idea that such operations constitute a human rights violation that must be condemned and stopped ( Rosenthal, 1996).

Female genital mutilation often has deep roots in the entire lifestyle of a culture, reflecting a patriarchal tradition in which women are viewed as the property of men and female sexuality is subordinated to male sexuality. This custom can be regarded as a fundamental component of initiation rites, symbolizing the girl's acquisition of the status of an adult woman, and therefore serve as a source of pride. But with increasing attention to human rights around the world, including in developing countries, opposition to such practices is growing. There is fierce debate in those countries where these procedures continue to be used. Younger women more familiar with Western lifestyles - often with the support of their husbands - are calling for initiation rites to be made more symbolic in order to retain the positive cultural meaning of the traditional ritual but avoid painful and dangerous surgery. Feminists in the Western world have been particularly vocal on this issue, arguing that such procedures are not only dangerous to health, but are also an attempt to emphasize the dependent position of women. Such disputes represent a classic example of the clash between culture-specific customs and changing global views on sexuality and gender issues.

Definitions

CLITOR - organ sensitive to sexual stimulation located in the upper part of the vulva; When sexually aroused, it fills with blood.

HEAD OF THE CLITOR - the outer, sensitive part of the clitoris, located at the upper fusion of the labia minora.

BODY OF THE CLITORIUM - an elongated part of the clitoris containing tissue that can fill with blood.

VULVA - external female genitalia, including the pubis, labia majora and minora, clitoris and vaginal opening.

PUBIS - an elevation formed by adipose tissue and located above the woman’s pubic bone.

LABIA MAJOR - two outer folds of skin covering the labia minora, clitoris and openings of the urethra and vagina.

LAVIDA MIRA - two folds of skin within the space bounded by the large lips, joining above the clitoris and located on the sides of the openings of the urethra and vagina.

FORESKE - in women, the tissue at the top of the vulva covering the body of the clitoris.

BARTHOLINIY GLANDS - small glands, the secretion of which is released during sexual arousal through excretory ducts that open at the base of the labia minora.

OPENING OF THE URETHRAL CHANNEL - hole through which urine is removed from the body.

ENTRANCE TO THE VAGINA - external opening of the vagina.

VIRGIN HYMN - a connective tissue membrane that may partially cover the entrance to the vagina.

SMEGMA - a thick, oily substance that can accumulate under the foreskin of the clitoris or penis.

CIRCUMCISION - in women - a surgical operation that exposes the body of the clitoris, during which its foreskin is cut.

INFIBULATION is a surgical procedure used in some cultures in which the edges of the vaginal opening are sealed.

CLITORODECTOMY - surgical removal of the clitoris, a common procedure in some cultures.

VAGINISM - involuntary spasm of the muscles located at the entrance to the vagina, making penetration into it difficult or impossible.

pubococcygeal MUSCLE - part of the muscles that support the vagina, is involved in the formation of orgasm in women; women are able to control its tone to some extent.

VAGINA - a muscular canal in a woman’s body that is susceptible to sexual arousal and into which sperm must enter during sexual intercourse for conception to occur.

UTERUS - a muscular organ within the female reproductive system in which a fertilized egg is implanted.

CERVIX - the narrower part of the uterus that protrudes into the vagina.

ISTHmus - narrowing of the uterus directly above its cervix.

FUND (UTERUS) - wide upper part of the uterus.

ZEV - opening in the cervix leading into the uterine cavity.

PERIMETERIES - outer layer of the uterus.

MYOMETRIUM - middle, muscular layer of the uterus.

ENDOMETRIUM - the inner layer of the uterus lining its cavity.

SWAB DAD - microscopic examination of a preparation of cells taken by scraping from the surface of the cervix, carried out to detect any cellular abnormalities.

BARRIERS - a pair of female reproductive glands (gonads) located in the abdominal cavity and producing eggs and female sex hormones.

EGG - female reproductive cell formed in the ovary; fertilized by a sperm.

FOLLICLE - a conglomerate of cells surrounding a maturing egg.

OOCYTES - cells are the precursors of eggs.

FALLOPIAN TUBES - structures associated with the uterus that carry eggs from the ovaries to the uterine cavity.