Gametogenesis is the process of producing gametes, specialized reproductive cells. This process occurs through the cell cycle of meiosis and produces cells with a haploid number of chromosomes. The process of producing gametes in males is called spermatogenesis, and in females, it is called oogenesis. Spermatogenesis leads to the formation of sperm, while oogenesis results in the development of eggs (ova). These processes occur in the testes for males and the ovaries for females, respectively, and are essential for sexual reproduction.


Spermatogenesis occurs in the seminiferous tubules that form the bulk of each testis. The process begins at puberty, after which time sperm are produced constantly throughout the lifespan. One production cycle, from spermatogonia to formed sperm, takes approximately 64 days. A new cycle starts approximately every 16 days, although this timing is not synchronous across the seminiferous tubules. The total number of sperms a man produces slowly declines after age 35, and some studies suggest that smoking can lower sperm counts irrespective of age.


The process of spermatogenesis begins with mitosis of the diploid spermatogonia. Because these cells are diploid (2n), they each have a complete copy of the father’s genetic material, 46 chromosomes. However, mature gametes are haploid (1n), containing 23 chromosomes—meaning that daughter cells of spermatogonia must undergo a second cellular division through the process of meiosis.


The cycle starts at puberty, where the spermatogonium cell goes through mitosis. Two identical diploid cells result from spermatogonia mitosis. One of these cells remains a spermatogonium, and the other becomes a primary spermatocyte. The next stage is the process of spermatogenesis. As in mitosis, DNA is replicated in a primary spermatocyte before it undergoes a cell division called meiosis I. During meiosis I, each of the 23 pairs of chromosomes separates. This results in two cells, called secondary spermatocytes, each with only half the number of chromosomes. Then, a second round of cell division (meiosis II) occurs in both secondary spermatocytes. During meiosis II, each of the 23 replicated chromosomes divides, similar to what happens during mitosis. Thus, meiosis results in separating the chromosome pairs. This second meiotic division results in four cells with only half the number of chromosomes. Each of these new cells is a spermatid. Although haploid, early spermatids look very similar to cells in the earlier stages of spermatogenesis, with a round shape, central nucleus, and a large amount of cytoplasm. A process called spermiogenesis transforms these early spermatids, reducing the cytoplasm and beginning the formation of the parts of a true sperm. The fifth stage of germ cell formation—spermatozoa or formed sperm—is the end result of this process, which occurs in the portion of the tubule nearest the lumen. Eventually, the sperm are released into the lumen and are moved along a series of ducts in the testis toward a structure called the epididymis for the next step of sperm maturation.


Oogenesis process begins with the ovarian stem cells, or oogonia. Oogonia are formed during fetal development and divide via mitosis, much like spermatogonia in the testis. Unlike spermatogonia, however, oogonia forms primary oocytes in the fetal ovary prior to birth. These primary oocytes are then arrested in this stage of meiosis I, only to resume it years later, beginning at puberty and continuing until the woman is near menopause (the cessation of a woman’s reproductive functions). The number of primary oocytes present in the ovaries declines from one to two million in an infant, to approximately 400,000 at puberty, to zero by the end of menopause.


The initiation of ovulation—the release of an oocyte from the ovary—marks the transition from puberty into reproductive maturity in females. From then on, throughout the reproductive years, ovulation occurs approximately once every 28 days. Just prior to ovulation, a surge of luteinizing hormone triggers the resumption of meiosis in a primary oocyte. This initiates the transition from primary to secondary oocyte. However, as shown in the figure below, this cell division does not result in two identical cells. Instead, the cytoplasm is divided unequally, and one daughter cell is much larger than the other. This larger cell, the secondary oocyte, eventually leaves the ovary during ovulation. The smaller cell, called the first polar body, may or may not complete meiosis and produce second polar bodies; in either case, it eventually disintegrates. Therefore, although oogenesis produces up to four cells, only one survives.


How does the diploid secondary oocyte become an ovum—the haploid female gamete? Meiosis of a secondary oocyte is completed only if a sperm succeeds in penetrating its barriers. Meiosis II then resumes, producing one haploid ovum that, after fertilization by a (haploid) sperm, becomes the first diploid cell of the new offspring (a zygote). Thus, the ovum can be considered a brief, transitional, haploid stage between the diploid oocyte and diploid zygote.


The larger amount of cytoplasm contained in the female gamete is used to supply the developing zygote with nutrients between fertilization and implantation into the uterus. Interestingly, sperm contribute only DNA at fertilization—not cytoplasm. Therefore, the cytoplasm and all of the cytoplasmic organelles in the developing embryo are of maternal origin. This includes mitochondria, which contain their own DNA. Scientific research in the 1980s determined that mitochondrial DNA was maternally inherited, meaning that you can trace your mitochondrial DNA directly to your mother, her mother, and so on back through your female ancestors.


Perimenopause is the time just before and after menopause, around the age of 45-55 years. This time is considered a transition to menopause. It is associated with the early onset of symptoms like mood swings, vasomotor flushes, sleep disturbances, headaches, memory problems, decreased libido, urinary incontinence, and irregular cycles. It is accompanied by fluctuations in ovarian function, decreased number and maturation of the remaining follicles, and decreased sensitivity to gonadotropin.  Fertility rates are markedly reduced, but conception can occur, as exhaustion of all follicles is not complete yet.


During the transition from menses to menopause, there are some hormonal changes due to the decrease in ovarian cells’ sensitivity to gonadotropin stimulation, exhaustion of the supply of ovarian follicles, and loss of ovarian cells that secrete estrogen and progesterone. As a result, estrogen and inhibin levels are reduced. Decreased estrogen and inhibin remove the negative feedback on the higher centers. As the negative feedback is removed, gonadotropin, FSH, and LHs level are increased (Figure 1). A state of hypergonadotropic-amenorrhea develops among menopausal women.


The deficiency of estrogen can cause many physical complaints and changes in menopausal women, which include:


The most common complaint, and approximately 70% of symptoms presented in menopausal women, relate to vasomotor instability. This includes hot flashes due to inappropriate stimulation of the body’s heat-releasing mechanisms by the hypothalamus, and can last up to 2 years in women. Vasomotor instability can also cause vasodilation, redness, palpitations, and tachycardia. Vasomotor instability can be severe at night, during stress, or when eating hot or spicy foods.


Urogenital changes are marked by vaginal dryness, vaginal irritation, and itching. Loss of vaginal elasticity, size, vascularization, and decrease in vaginal acidity occur, leading to dyspareunia, or painful intercourse.


The atrophy of external genitalia occurs, the labia majora lose its fat, and the labia minora lose pigmentation and became pale. Weakness of the pelvic ligaments increases the tendency of uterine prolapse. Atrophy of the urethra and bladder mucosa occurs, leading to loss of urinary wall elasticity and urinary incontinence. Urogenital atrophy can cause recurrent genital and urinary tract infections.


Estrogen deficiency also increases the incidences of cardiovascular disease. In non-menopausal women, estrogen can stimulate coronary and cerebral blood flow and affect the lipid profile by increasing the HDL/LDL ratio and inhibiting plaque formation. As estrogen decreases in menopause, the HDL/LDL ratio decreases, and LDL levels rise, increasing the potential for heart attacks and strokes.


Other physical symptoms of postmenopausal women include an increase in facial hair due to a relative increase in androgens, atrophy of glandular tissue in the mammary glands and its replacement by fatty tissue, and the loss of collagen fibers in the dermis, leading to thin, dry skin with dark spots. Low estrogen at menopause could also decrease cognitive function and lead to mood instability.


There is a direct relationship between the lack of estrogen and osteoporosis. An individual experiencing menopause has a high chance to develop osteoporosis due to decreased estrogen levels. Osteoporosis is usually accelerated 5 to 7 years after menopause. An activation of osteoclast bone cells is increased, leading to a decrease in bone density and loss of bone matrix and minerals.


Menopausal women have a high tendency to have brittle bones and an increased risk of pathologic bone fractures and spinal deformities. Kyphosis may be developed. Osteoporosis can be prevented by increasing calcium and protein intake along with exercise. Estrogen hormones may be recommended in severe cases.


To reverse the effects of menopause, some women may be advised to partake in estrogen replacement therapy (ERT). ERT significantly improves vasomotor instability, night sweats, and hot flashes. It also relieves most urogenital symptoms, dryness, itching, and pain during sex. However, ERT does not relieve vaginal stenosis. ERT can also relieve depression, insomnia, and improve mood changes. Estrogen replacement plays a vital role in inhibiting osteoclast activity, preventing bone resorption and bone loss. Thus, estrogen replacement helps in reducing the incidence of wrist, hip, and vertebral fractures.


Estrogen replacement also increases the survival rate in menopausal women with a previous coronary stenosis or heart attack. It lowers blood cholesterol and increases coronary blood flow, causing a 50% reduction in cardiovascular danger and reducing the risk of stroke.


Correlating estrogen intake and cancer development is controversial. While estrogen replacement can reduce the risk of colon cancer, an over-intake of estrogen stimulates endometrial cell proliferation, leading to endometrial hypoplasia and endometrial cancer. Studies have also shown that the prolonged intake of estrogen more than 10 years could increase the risk for breast cancer development.


Menopause in men starts with the decrease in androgen, called andropause. Andropause does not occur as an abrupt and noticeable event like in women, but it occurs gradually. Androgen (Testosterone) levels begin to decline gradually around the age of 40, about 1% per year. That decline is not enough to account for any decrease in libido or erectile function. However, as testosterone level continues to decline with advanced age, facial hair growth may decrease, the penis and scrotum may shrink, a slight decrease in libido may occur, and erections may take a longer time to achieve.


Male aging may also be accompanied by some changes in adrenal function. Adrenal glands androgenic hormones may continue decreasing, leading to decreased vigor and muscular flexibility, and a decline in muscle mass and strength. The chance of osteoporosis in men also increases.


Research has suggested that the administration of the steroid DHEAS in middle-aged men can increase lean body mass. However, that may lead to a potential enlargement of the prostate, increase of testicular shrinkage, and limited sperm production. Its administration should be taken under extreme supervision.


The first changes begin around the age of eight or nine when the production of LH becomes detectable. The release of LH occurs primarily at night during sleep and precedes the physical changes of puberty by several years. In pre-pubertal children, the sensitivity of the negative feedback system in the hypothalamus and pituitary is very high. In other words, very low concentrations of androgens or estrogens will cause negative feedback onto the hypothalamus and pituitary, keeping the production of GnRH, LH, and FSH low.


As an individual approaches puberty, two changes in sensitivity occur. The first is a decrease of sensitivity in the hypothalamus and pituitary to negative feedback, meaning that it takes increasingly larger concentrations of sex steroid hormones to stop the production of LH and FSH. The second change in sensitivity is an increase in sensitivity of the gonads to the FSH and LH signals, meaning the gonads of adults are more responsive to gonadotropins than the gonads of children. As a result of these two changes, the levels of LH and FSH slowly increase and lead to the enlargement and maturation of the gonads, which in turn leads to the secretion of higher levels of sex hormones and the initiation of spermatogenesis and folliculogenesis.


In addition to age, multiple factors can affect the age of onset of puberty, including genetics, environment, and psychological stress. One of the more important influences may be nutrition; historical data demonstrate the effect of better and more consistent nutrition on the age of menarche in girls in the United States, which decreased from an average age of approximately 17 years of age in 1860 to the current age of approximately 12.75 years in 1960, as it remains today. Some studies indicate a link between puberty onset and the amount of stored fat in an individual. This effect is more pronounced in females but has been documented in both sexes. Body fat, corresponding with the secretion of the hormone leptin by adipose cells, appears to have a strong role in determining when menarche occurs. This may reflect, to some extent, the high metabolic costs of gestation and lactation. In individuals who are lean and highly active, such as gymnasts, there is often a delay in the onset of puberty.


Different sex steroid hormone concentrations between the sexes also contribute to the development and function of secondary sexual characteristics.


As a female reaches puberty, typically the first change that is visible is the development of the breast tissue due to the unopposed low dose estrogen stimulation for about two years before the first menses. This is followed by the growth of axillary and pubic hair. A growth spurt normally starts at approximately age 9 to 11, and may last two years or more. During this time, there is weight gain and an increase in body fat distribution, especially in the hips and thighs. Height can increase 3 inches a year.


Changes in the reproductive organs happen as the vagina lengthens and the labia majora and minora become thickened and rugated. These are followed by the start of menstruation and the first bleeding, menarche . Usually, menarche occurs two years after breast bud development due to fluctuating estrogen levels associated with follicle development. The age of menarche has currently declined to 12.2 years in the United States. Ovulation usually occurs within six months from the first episode of vaginal bleeding.


In males, the growth of the testes is typically the first physical sign of the beginning of puberty and begins at a mean age of 11.6. This is followed by growth and pigmentation of the scrotum and growth of the penis. The adult size and shape of the penis and scrotum is achieved between ages 12 and 17 with an average of about 15 years of age. Next, increased hair growth occurs, including in the armpit, pubic, chest, and facial hair. Pubic hair development is complete at 15 years of age. Testosterone stimulates the growth of the larynx and thickening and lengthening of the vocal folds, which causes the voice to drop in pitch, at an average age of 13.


Spontaneous erection and nocturnal emission may occur, which decrease gradually. The first fertile ejaculations typically appear at approximately 15 years of age, but this age can vary widely across individuals. Unlike the early growth spurt observed in females, the male growth spurt occurs toward the end of puberty, at approximately age 11 to 13.  The growth spurt continues over time, with 45% of the adult skeletal mass acquired between age 11 and age 18. A youth’s height can increase as much as 4 inches a year. In some males, development can continue through the early 20s.


Hormonal regulation of the male body is largely connected to the endocrine glands located in the brain and Hypothalamic-Pituitary axis. The hypothalamus initiates the synthesis and secretion of Gonadotropin Releasing Hormone (GnRH). GnRH stimulates the anterior pituitary and causes the secretion of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH and LH hormones circulate in the bloodstream and act at the testes to produce testosterone and stimulate the process of spermatogenesis.


LH positively affects the Leydig cells located within the interstitial spaces between the seminiferous tubules and stimulates the cells to produce testosterone. FSH acts at Sertoli cells located within the seminiferous tubules and stimulates the process of spermatogenesis. FSH does this by stimulating Sertoli cells to produce antigen binding protein (ABP), which leads to testosterone hormone uptake, increases its concentration within the seminiferous tubules, and initiating the production of sperms by the spermatogenic cells inside the tubules.


hormone uptake, increases its concentration within the seminiferous tubules, and initiating the production of sperms by the spermatogenic cells inside the tubules.


Testosterone also enters circulation and transport around the whole body, targeting many cells and organs. Once reaching skeletal muscle, testosterone increases protein synthesis and increases muscle growth. Testosterone also travels to the brain, where it boosts sexual desire and stimulates the synthesis and release of Growth Hormone (GH), supporting bone growth.


The surge in testosterone during adolescence explains why males often attain greater height than females. Along with making a taller, stronger body, testosterone plays a pivotal role in the initiation and maintenance of secondary sexual characteristics in males during puberty.


Lastly, testosterone influences male fetal development. It impacts Wolffian duct development and aids in the development of male reproduction structures during embryogenesis.


While testosterone has many initiative properties, its excess contributes to a negative feedback effect of the hypothalamus and anterior pituitary. The excess of testosterone causes a decrease in its synthesis and secretion either directly by suppressing pituitary gland production of LH, or indirectly by participating in negative feedback on GnRH at the hypothalamus higher center.


While testosterone has many initiative properties, its excess contributes to a negative feedback effect of the hypothalamus and anterior pituitary. The excess of testosterone


Another hormone produced by Sertoli cells is inhibin.  As Sertoli cells increase the production of inhibin hormone, it is not surprising that inhibin decreases the synthesis of sperms and inhibits spermatogenesis by suppressing the pituitary gland and inhibiting of LH production.


Some athletes use anabolic steroids to increase muscle mass and get stronger. These steroids act like natural male testosterone and could affect male reproductive organs and sperm production, as they cause hormonal imbalance and may suppress spermatogenesis by the negative hormonal effect at the higher center of the brain, hypothalamus, and pituitary glands.


could affect male reproductive organs and sperm production, as they cause hormonal imbalance and may suppress spermatogenesis by the negative hormonal effect at the higher center of the brain, hypothalamus, and pituitary glands.


could affect male reproductive organs and sperm production, as they cause hormonal imbalance and may suppress


Sperm are smaller than most cells in the body; in fact, the volume of a sperm cell is 85,000 times less than that of the female gamete. Approximately 100 to 300 million sperm are produced daily, whereas women typically ovulate only one oocyte per month.


Sperm have a distinctive head, mid-piece, and tail region (Figure 1).


The head of the sperm contains an extremely compact nucleus with a haploid number of chromosomes and very little cytoplasm. These contribute to the overall small size of the sperm (the head is only 5mm long). A structure called the acrosome covers the anterior 2/3 of the nucleus at the head of the sperm cell, the “Acrosomal cap”. This cap is filled with lysosomal and hydrolytic enzymes that participate and initiate acrosomal reactions at the time of fertilization. The acrosomal reaction helps sperm bind and burrow through the Zona Pellucida surrounding the egg and complete the process of fertilization.


The constriction between the head and the mid-piece called the neck.


The mid-piece of the sperm contains a tightly packed mitochondrion that provides the ATP and energy required for movement. The tail, which extends from the mid-piece, consists of a principal flagella structure around 45µm long that is highly mobile, and an end piece, a 5 µm long fibrous sheath of disorganized flagellum structure. Movement of the entire sperm cell occurs through the tail.


The attached portion of the penis at the perineum is called the Root, beginning directly below the bulbourethral glands. The elongated portion of the penis is known as the shaft. The shaft surrounds the urethra and comprises three column-like chambers of erectile tissue that span the length of the shaft. The two larger chambers, each called a corpus cavernosum (plural = corpora cavernosa), are located at the dorsolateral surface of the shaft and terminate at the distal shaft of the penis. Together, these make up the bulk of the penis.


The corpus spongiosum, which can be felt as a raised ridge on the erect penis, is a smaller chamber located at the inferior and middle of the penis. This surrounds the spongy (penile) urethra, and continues till the end of the penis within the glans.


The end of the penis, called the glans penis, has a high concentration of nerve endings, resulting in very sensitive skin that influences the likelihood of ejaculation. The skin from the shaft extends down over the glans and forms a collar called the prepuce (or foreskin). The foreskin also contains a dense concentration of nerve endings and lubricates and protects the sensitive skin of the glans penis.


A surgical procedure to remove the foreskin, prepuce, typically done within days of birth.  It is often performed for religious or social reasons. Circumcision is associated with lower risk of sexually transmitted infections, including HIV. It can also decrease the risk of penile cancer and cervical cancer in sexual partners.


Both erection and ejaculation are under the control of the autonomic nervous system stimulated at sexual arousal.


Sexual excitement causes parasympathetic division activation, causing erection.  Penile erections are the result of congestion, or engorgement of the tissues because of more arterial blood flowing into the penis than is leaving in the veins. During sexual arousal, nitric oxide (NO) is released from nerve endings near the blood vessels within the corpora cavernosa and spongiosum. Release of NO activates a signaling pathway that results in relaxation of the smooth muscles that surround the penile arteries, causing them to dilate. This dilation increases the amount of blood that can enter the penis and induces the endothelial cells in the penile arterial walls to also secrete NO and perpetuate the vasodilation. The rapid increase in blood volume fills the erectile chambers, and the increased pressure of the filled chambers compresses the thin-walled penile venules, preventing venous drainage of the penis. This increased blood flow to the penis and reduced blood return from the penis causes an erection. Depending on the flaccid dimensions of a penis, it can increase in size slightly or greatly during erection, with the average length of an erect penis measuring approximately 15 cm.


With continuous stimulation, the sympathetic nervous system gets activated, leading to emission and movement of semen into the urethra, followed my smooth muscle contraction of the penis, forcing semen out of the urethra and ejaculation to occur.


Viagra is the trade name for a medication known as sildenafil. These pills work by augmenting the effect of nitric oxide (NO) in the body, including the penis, and are commonly prescribed for managing erectile dysfunction (ED). It’s important to note that Viagra does not boost sexual desire; instead, it assists in the natural physiological process of attaining and sustaining an erection when stimulated sexually.


Paired seminal vesicles are located on the posterior surface of the urinary bladder, lateral to the ampulla of the ductus deferens. As sperm pass through the ampulla of the ductus deferens at ejaculation, they mix with fluid from the associated seminal vesicle (Figure 1).


The paired seminal vesicles are glands that contribute approximately 75% of semen by volume. Seminal vesicles secrete whitish yellow, thick and viscous fluid. The fluid contains large amounts of fructose for the sperms’ nourishment and prostaglandins, which are used by the sperms’ mitochondria to generate ATP to allow movement through the female reproductive tract. The secretion of seminal vesicles is under the influence of testosterone.


The seminal fluid contains both sperm and seminal vesicle secretions. This fluid moves into the associated ejaculatory duct, a short structure formed from the ampulla of the ductus deferens and the duct of the seminal vesicle. The paired ejaculatory ducts transport the seminal fluid into prostatic urethra which runs through the prostate gland.


The prostate gland is a centrally located gland that sits anterior to the rectum, inferior to the bladder, and surrounding the prostatic urethra (the portion of the urethra that runs within the prostate). The gland is the size of a walnut and is formed of both muscular and glandular tissues. The glandular tissue runs in three concentric layers of 30–50 tubuloalveolar glandular tissues.  The mucosal glands open directly into the urethra. The submucosal layer is larger than the mucosal and has short ducts that open into the urethra. The main mucosal glands have long ducts that open into the prostatic urethra. Prostatic secretion contributes to 20–30% of seminal fluid and is under the influence of testosterone. The prostate normally doubles in size during puberty. At approximately age 25, it gradually begins to enlarge again. This enlargement does not usually cause problems.


The prostatic secretion contains mucin and citric acid, providing nutrients for sperms. It is slightly acidic to partially neutralize the alkaline nature of seminal vesicle fluid. Prostatic secretion is rich in prostatic-specific antigen (PSA), an enzyme that helps liquify the viscosity of seminal fluid and achieve good sperm mobility. The final secreted fluid in the prostatic urethra is now called semen, which helps sperms pass farther into the female reproductive tract.


Abnormal growth of the prostate or benign prostatic hypertrophy (BPH) is usually caused by the enlargement of the mucosal and submucosal parts of the glands that lead to constriction of the urethra as it passes through the middle of the prostate gland. Prostatic hypertrophy can cause a number of lower urinary tract symptoms, such as a frequent and intense urge to urinate, a weak stream, and a sensation that the bladder has not emptied completely.  By age 60, approximately 40 percent of men have some degree of BPH. By age 80, the number of affected individuals has jumped to as many as 80 percent. Treatments for BPH attempt to relieve the pressure on the urethra so that urine can flow more normally. Mild to moderate symptoms are treated with medication, whereas severe enlargement of the prostate is treated by surgery in which a portion of the prostate tissue is removed.


Prostate cancer is the second most common cancer in men. Prostatic carcinoma usually arises from the largest and outer part of the glands, the prostatic bulk, that open via long ducts to the urethra. Some forms of prostate cancer grow very slowly and thus may not ever require treatment. In contrast, aggressive forms of prostate cancer can cause metastasis to vulnerable organs like the lungs and brain. There is no link between BPH and prostate cancer, but the symptoms are similar. Prostate cancer is detected by a medical history, a blood test, and a rectal exam that allows physicians to palpate the prostate and check for unusual nodular masses. If a mass is detected, the cancer diagnosis is confirmed by a biopsy of the cells.


The final addition to semen less than 5% is made by two bulbourethral glands (or Cowper’s glands), Located in the urogenital diaphragm on either side of the membranous urethra. The glands release a thick, salty fluid that lubricates the end of the spongy urethra and the vagina and helps to clean urine residues from the penile urethra. The fluid from these accessory glands is released after the male becomes sexually aroused and shortly before the release of the semen. It is sometimes called pre-ejaculate for this reason. It is important to note that, in addition to the lubricating proteins, bulbourethral fluid can pick up sperm already present in the urethra, and therefore it may be able to cause pregnancy.


within the seminiferous tubules then they transferred through the duct system, where they mature and exit the body during ejaculation. The duct system begins within the testes and ends with the urethra at the penis, where sperms are relased.


through the duct system, where they mature and exit the body during ejaculation. The duct system begins within the testes and ends with the


The Rete Testis is the first duct to receive sperm from the seminiferous tubules within the testis. They are small ducts located in the posterior portion of the testis, the mediastinum testis. From the rete testis, the sperm travels to the Efferent ducts, larger ducts which allow the sperms to travel from the rete testis to the Epididymis.


The Epididymis is a convoluted set of tubing consisting of a head, body, and tail. It is here that the storage, maturation, and leaking of sperm cells occurs. The sperm that is held for ejaculation is in the tail of the epididymis. This location is incredibly important when it comes to discussions of infertility. Often, the maturation of sperm does not properly occur here and thus sperm cells are left infertile.


When the sperm cells exit the epididymal tail, they enter the Ductus Deferens (vas deferens). This duct lies within the spermatic cord. When the ductus deferens reached the prostate, it enlarges, forming the ampulla. The ampulla lies at the proximal portion of the seminal vesicle, forming the ejaculatory duct.


The ejaculatory duct conducts sperm from the ductus deferens to the urethra.


The Urethra transports semen and sperms from the ejaculatory ducts to the outside of the body. There are three sections to the Urethra: the Prostatic urethra, Membranous urethra, and the Spongy (penile) urethra.


The scrotum is a skin-covered, highly-pigmented muscular sac containing the testes. The scrotum extends from the body behind the penis (Figure 1). This location is important in sperm production, which occurs within the testes and proceeds more efficiently when the testes are kept 2 to 4°C below core body temperature. The scrotum is homologous to the labia majora in the female during fetal development.


The scrotum is homologous to the labia majora in the female during fetal development.


The dartos muscle is a subcutaneous smooth muscle that makes up the wall of the scrotum. It continues internally to make up the scrotal septum that divides the scrotum into two compartments, each housing one testis. Descending from the internal oblique muscle of the abdominal wall are the two cremaster muscles, which cover each testis like a muscular net. By contracting simultaneously, the dartos and cremaster muscles can elevate the testes in cold weather (or water), moving the testes closer to the body and decreasing the surface area of the scrotum to retain heat. Alternatively, as the environmental temperature increases, the scrotum relaxes, moving the testes farther from the body’s core and increasing the scrotal surface area, which promotes heat loss. Externally, the scrotum has a raised medial thickening on the surface called the raphae defines the separation between the two scrotal sacs.


smooth muscle that makes up the wall of the scrotum. It continues internally to make up the scrotal septum that divides the scrotum into two compartments, each housing one testis. Descending from the internal oblique muscle of the abdominal wall are the two cremaster muscles, which cover each testis like a muscular net. By contracting simultaneously, the dartos and cremaster muscles can elevate the testes in cold weather (or water), moving the testes closer to the body and decreasing the surface area of the scrotum to retain heat.


Alternatively, as the environmental temperature increases, the scrotum relaxes, moving the testes farther from the body’s core and increasing the scrotal surface area, which promotes heat loss. Externally, the scrotum has a raised medial thickening on the surface called the raphae defines the separation between the two scrotal sacs.


The spermatic cord is a cord-like structure in the male reproductive system that communicates between the abdominal cavity and scrotum and transmits to the testes and genital ducts. It consists of several parts:


The testes (singular = testis) are the male gonads, the primary sex organ in the male reproductive system. They produce both sperms, in addition to the production and secretion of androgens and the male sex hormone, testosterone. Testes are active throughout the reproductive lifespan of the male.


The testes are paired oval structures, each approximately 4 to 5 cm in length and housed within the scrotum. During fetal development, the testes develop as abdominal organs. In the seventh month of the developmental period, each testis moves to descend into the scrotal cavity.  At birth, testes reach their final destination in the scrotal sacs. This process is called the “descent of the testis.”


During their migration to the scrotum, the testes are enclosed in part by the peritoneum membrane. As they descend into the scrotum, the anterior and lateral surfaces of each testis remain covered by the peritoneal membrane, the tunica vaginalis layer, a serous membrane that has both a parietal and a thin visceral layer of the peritoneum (Figure 2).


Cryptorchidism is a clinical term used when one or both of the testes fail to descend into the scrotum prior to birth. Undescended testes will lead to male infertility and inability to produce sperms, as the testes require a cooler environment for the manufacture of sperms. It may also be associated with testicular tumors. Usually, testes descend during the first year of life on their own; however, to reduce the risk, it is much better to be brought into the scrotum in infancy by a surgical procedure called orchiopexy.


Fluid accumulation between the two layers of tunica vaginalis leads to swelling of the scrotum, a condition known as hydrocele. It is a common condition in newborns and usually disappears without treatment by age 1.  Transillumination, through shining a light through the scrotum, will show clear fluid surrounding the testes.  A simple and easy diagnostic method to distinguish fluid accumulation from other causes of scrotum enlargement. Older boys and adult men can develop a hydrocele due to inflammation or injury within the scrotum.


Beneath the tunica vaginalis is the tunica albuginea, a tough, white, dense connective tissue layer covering the testis itself. Not only does the tunica albuginea cover the outside of the testis, but it also invaginates to form septa that divide the testis into lobes and lobules. Around 250 lobules are developed. Each lobule contains four convoluted seminiferous tubules, where sperms develop. In the posterior surface, Tunica albuginea projects deeper into the interior of the testis as the mediastinum testis, through which blood vessels, lymphatic vessels, and some nerves enter and leave the testis.


The seminiferous tubules are the tightly coiled tubules that form the bulk of each testis. They are composed of two types of cells: the sperm developing Spermatogenic cells and the supporting cells known as Sustentacular cells (Figure 3).


These are a population of dividing germ cells that continuously produce sperm beginning at puberty. Germ cells development progresses from the basement membrane at the perimeter of the seminiferous tubule toward its lumen.


The least mature cells, the spermatogonia (singular = spermatogonium), line the basement membrane inside the tubule. Spermatogonia are the stem cells of the testis, which means that they are still able to differentiate into a variety of different cell types throughout adulthood. Spermatogonia divide to produce primary and secondary spermatocytes, then spermatids, which produce formed sperm. The process that begins with spermatogonia and concludes with the production of sperm is called spermatogenesis.


The formed sperm are released into the duct system of the testis. Specifically, from the lumens of the seminiferous tubules to straight tubules (or tubuli recti), and from there into a fine meshwork of tubules called the rete testes. Sperms leave the rete testes, and the testis itself, through the 15 to 20 efferent ductules that cross the tunica albuginea.


The elongated, pyramid-shaped, non-dividing supportive cells that surround all stages of the developing sperm cells are called Sustentacular or Sertoli cells.  They extend physically around the germ cells from the peripheral basement membrane of the seminiferous tubules to the lumen.  They provide support and nourishment to spermatogenic cells, and phagocytose the degenerating cells during spermatogenesis.


The sustentacular cells are connected by tight, form-occluding junctions, creating a diffusion barrier called the blood–testis barrier. The barrier maintains a luminal environment favorable for sperm maturation. It keeps bloodborne substances from reaching the germ cells and, at the same time, keeps surface antigens on developing germ cells from escaping into the bloodstream and prompting an autoimmune response.


Under the influence of FSH, Sertoli cells also function to secrete androgen-binding protein (ABP) that increases the concentration of testosterone within the seminiferous tubules and facilitates the process of spermatogenesis.  They also secrete inhibin, a hormone that controls testosterone and sperm production at the higher brain centers.


Figure 3. Spermatogenic and Sertoli cells

Germinal epithelium of the testicle.

1. basal lamina

2. spermatogonia

3. primary (1st-order) spermatocyte

4. secondary (2nd-order) spermatocyte

5. developing spermatid

6. mature spermatid

7. Sertoli cell

8. tight junction (blood-testis barrier)


Between the seminiferous tubules, there is interstitial space and tissues. Within the interstitial tissue, interstitial cells, also known as Leydig cells, are located. Leydig cells, under the influence of LH hormones, get activated and secrete testosterone (androgenic hormone), the main male sex hormone. Testosterone circulates in the blood and, once reaches its target organs, stimulates puberty. It works on skeletal muscles, causing protein synthesis and muscle enlargement. It also stimulates Growth Hormone (GH) secretion, increasing bone growth in adolescence. Testosterone is responsible for the promotion and maintenance of secondary sex characteristics. In the brain, plasma testosterone increases the sex drive. Testosterone acts at Sertoli cells and stimulates spermatogenesis and sperms production. During fetal development, testosterone works at the Wolffian duct to promote the development of male reproductive structures.


The testes get nourishment and oxygenated blood through the testicular artery, a direct branch of the abdominal aorta, as they develop as abdominal organs. In the spermatic cord, the testicular artery is surrounded by a group of veins, Pampiniform plexus, that drain waste and return deoxygenated blood back to the testicular vein in the abdomen (Figure 4). This pampiniform plexus reduces the temperature around the testes and works as a countercurrent heat-exchange system to cool down the arterial blood before it enters the testis.


Varococoele are enlarged dilated pampiniform plexus veins that surround the testes. The veins feel like cords or worms within the scrotal sac and may be visible on the surface of scrotum. This may be caused by an upper venous drainage obstruction in the pelvis or abdomen, which leads to the stagnation of blood around the testes, impeding their heat-regulatory system and leaving the testes in a hot environment.  Varicoceles cause low sperm production and decreased sperm quality, and are a common cause of male infertility (Figure 5).


The normal ovulatory cycle pattern occurs every 24–32 days during reproductive years. The bleeding phase lasts approximately 3–7 days, with an average 30cc of blood lost. Nearly 80% of blood loss occurs in the first two days.


The chance of conception and occurrence of pregnancy is higher in polymenorrhea ovulatory cycles compared to oligomenorrhea ovulatory cycles due to multiple ovulations within a significant period.


Painful menses without evidence of an organic lesion or cause. Pain is usually brief, and worse on the first day of menstruation.  Primary dysmenorrhea is usually seen in ovulatory menstrual cycles, typically occurs within five years of menarche, and improves with age. Over 50% of all post-pubescent women are affected and 5% are affected for 1-3 days each month. Most theories about the cause of primary dysmenorrhea center around excess prostaglandin around the endometrium cells. Prostaglandin is a powerful vaso-constrictive hormone that stimulates smooth muscle contraction of the myometrium, resulting in powerful uterine muscle contraction.


Treatment is usually aimed at prostaglandin inhibition or the suppression of cycles to inhibit its release. Non-specific measures like heat, mild analgesics, and exercise should be encouraged, but narcotics are not used.


PMS is described as physical and emotional discomfort prior to menstruation, usually of unknown cause.


Symptoms include both emotional effects (depression, emotional liability) and physical effects (water retention, pain, breast tenderness). These symptoms are experienced in the luteal phase of the ovulatory cycle and become absent in the post-menstrual week.  Not all premenstrual changes are considered PMS. Symptoms should be severe enough to disrupt daily life and family interactions, and/or lead to alcohol or drug abuse, or suicidal thoughts.  Evaluation is usually made by carefully taken history.


Management of PMS depends on a responsive and cooperative patient who wants to get better. Sometimes exercise, vitamin B6, or antidepressants may be of value.


Abnormal uterine bleeding is bleeding that is considered excessive in frequency, duration, or amount by an individual who has previous normal menstrual pattern. The bleeding is different from a woman’s normal menstrual cycle, and unusual for her age. Abnormal uterine bleeding is one of the most common gynecological health issues and can have many causes.


The absence of a normal monthly period or menstrual cycle. There are two major types of amenorrhea:


When a young woman has not had her first period by age 16. Possible causes include:


Defined when a woman who was previously menstruating stopped having menstrual bleeding for three months or more. This is the most common type of amenorrhea, where the endometrial lining does not shed synchronously and could occur in normal or pathological conditions.


The hypothalamus stimulates the pulsatile release of GnRH, which stimulates LH and FSH release from anterior pituitary. FSH stimulates the development of egg cells, called ova, which develop in structures called follicles. Follicle cells produce estrogen and inhibin, which inhibits FSH production. LH also plays a role in the development of ova, the induction of ovulation, andthe  stimulation of estradiol and progesterone production by the ovaries. Progesterone inhibits LH production. The maturation of the hypothalamo-hyphophyseal axis typically occurs 2 years after puberty, and is associated with regular menstruation cycles.


Estrogens and progesterone are sex hormones (steroid hormones) derived from cholesterol and released from the developing ovarian follicles. Estrogen is the reproductive hormone in females that assists in endometrial regrowth, ovulation, and calcium absorption; it is also responsible for the secondary sexual characteristics of females. These include breast development, flaring of the hips, and a shorter period necessary for bone maturation. Progesterone assists in endometrial growth and complete endometrial layer maturation, and inhibition of FSH and LH release. Both estrogen and progesterone prepare the body for pregnancy and regulate the menstrual cycle.


The cycle consists of two parts, the ovarian and uterine cycles. The ovarian cycle governs the preparation of endocrine gonads and the release of eggs, while the uterine cycle governs the preparation and maintenance of the uterine lining. These two cycles occur concurrently and are coordinated over a 22–32-day cycle, with an average length of 28 days (Figure 1).


The follicular phase is the first phase of the ovarian cycle, preparing the egg for ovulation. The phase manifests by slowly rising levels of FSH and LH from the anterior pituitary. The release of FSH and LH causes the growth of follicles on the surface of the ovary. FSH is vital for the development and maturation of the follicles. FSH is required to synthetize theca cells at the periphery of the follicle to LH. LH then acts on the surrounding theca cells, stimulating androgen synthesis. FSH also acts on follicular granulosa cells and stimulates their uptake of androgen and the conversion of androgen into estrogen.


on the surrounding theca cells, stimulating androgen synthesis. FSH also acts on follicular granulosa cells and stimulates their uptake of androgen and the conversion of androgen into estrogen.


The continued rising of ovarian estrogen levels further increases FSH production and the growth of the follicles. Once estrogen reaches a peak and its threshold causes a negative effect at the pituitary and hypothalamus, the level of FSH drops and no more follicle maturation occurs. At the same time, the level of inhibin released from follicular cells increases, which inhibits the release of FSH from the anterior pituitary. The drop of FSH stops further maturation of the follicles.


The surge of estrogen secretion at this time is responsible for the mid-cycle surge of LH. A concentration of 200 pg/ml or more of estrogen is necessary to produce a positive feedback effect on LH release, and it should be sustained for about 50 hours. Ovulation occurs about 29 to 39 hours after the peak of LH. At this time, the mature follicle ruptures and releases its egg with its surrounding layers. The follicles that did not rupture degenerate, and their eggs are lost. The level of estrogen decreases when the extra follicles degenerate.


After ovulation, LH stimulates corpus luteum follicle formation, and the follicular cells produce estrogen and progesterone.  The increased level of progesterone drops LH at the pituitary and hypothalamic levels and prevents further ovulation, a negative feedback effect.  At the same time, the release of estrogen and progesterone out of the ovary influences the development of the endometrial lining of the uterus to support pregnancy. If fertilization and pregnancy do not occur, 14 days after ovulation, the corpus luteum degenerates. A fibrous tissue corpus albicans follicle develops and progesterone levels drop. With the decreased level of progesterone, the lining of the superficial endometrial layer is sloughed off.  This is the inception of menstrual bleeding, and the menstrual phase of the uterine cycle.


The uterine cycle consists of the menstrual, proliferative, and secretory phases. Figure 2 visually compares the ovarian and uterine cycles and Figure 1 shows the commensurate hormone levels in each.


High progesterone during the luteal phase stimulates the release of prostaglandin from endometrium cells.  Prostaglandins are a powerful vasoconstrictor of the smooth muscle of blood vessels. If there is no fertilization, prostaglandin causes the intermittent contraction of helical (spiral) arteries and decreases blood supply to the functionalis endometrial layer. The endometrial cells became anoxic, bacteria invades the dead endometrial layer, and the superficial layer dies (necrosis).


A sudden dilatation of the helical vessels follows as the vessels rupture. Hemorrhagic discharge, which includes blood associated with sloughed off dead functionalis layer and bacteria, is released through the vagina during menstruation, also referred to as menses. The first menses after puberty is called menarche. During this process, the basal endometrial cells remain intact.


This bleeding phase takes approximately 3-5 days. After that time, estrogen levels rise and the menstrual cycle enters the proliferative phase.


The proliferative phase starts with the end of the menstrual flow from day 4 to day 14 of the menstrual cycle. The released FSH and estrogen influence the reconstruction of the functionalis layer. The endometrium begins to regrow, replacing the blood vessels and glands that deteriorated during the end of the last cycle. Endometrial epithelial cells proliferate and reach about 2-3mm in length. Endometrial glands grow and straighten. Cells are active and start glycogen accumulation. Spiral arteries lengthen but do not reach the upper third of the endometrial layer. By day 14, the functionalis layer becomes fully restored and ovulation occurs. The ovarian cycle enters its luteal phase, and the uterine cycle enters its secretory phase.


The luteal phase starts on day 15-25 of the menstrual cycle. The secretory and luteal phases are under the influence of LH and progesterone. After ovulation, the cells in the follicle undergo physical changes and produce the corpus luteum. The corpus luteum produces estrogen and progesterone. Progesterone facilitates the complete construction and differentiation of the endometrial layer. Glands are hypertrophy, cells become convoluted, and glycogen and mucoid production increase within the glands. Spiral arteries elongate and extend into superficial layers. The endometrial lining reaches its full thickness of around 5mm. At this stage, the uterus is prepared to accept a fertilized egg (implantation).


Indeed, if an embryo implants, signals are sent to the corpus luteum to continue secreting progesterone to maintain the endometrium and the pregnancy. If an embryo does not implant, no signal is sent to the corpus luteum and it degrades, ceasing progesterone production and ending the luteal phase. Without progesterone, the endometrium thins and, under the influence of prostaglandins, the spiral arteries of the endometrium constrict and rupture as menstruation occurs (initiating the next menstrual cycle). The decrease in progesterone also allows the hypothalamus to send GnRH to the anterior pituitary, releasing FSH and LH and starting the cycles again.


Long-term use of high concentrations of estrogen and progesterone, as with oral contraceptive pills, can lead to pituitary suppression. High estrogen levels cause a negative feedback effect on FSH, halting maturation of the follicle, while high progesterone levels causes a negative feedback effect on LH, and inhibits ovulation.


As estrogen is responsible for endometrial layer growth and proliferation, the building hormone, it is considered a highly mitotic hormone. Conditions with high endogenous or exogenous levels of estrogen may lead to endometrial cell hyperplasia and cancer development.


Hormones are chemical substances secreted by cells within an organ, released directly to circulation and acting on a distant target (


. The human male and female reproductive cycles are controlled by the interaction of hormones from the hypothalamus and anterior pituitary with hormones from the reproductive tissues and organs of each sex. In both sexes, the hypothalamus monitors and causes the release of hormones from the pituitary gland.


When the reproductive hormone is required, the hypothalamus sends a gonadotropin-releasing hormone (GnRH) to the anterior pituitary. GnRH causes the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary into the blood and stimulates gonadal function. Note that the body must reach puberty for the adrenal glands to release the sex hormones that must be present for GnRH to be produced. Although FSH and LH are named after their functions in female reproduction, they are produced in both sexes and play important roles in controlling reproduction.


to the anterior pituitary. GnRH causes the release of


from the anterior pituitary into the blood and stimulates gonadal function. Note that the body must reach puberty for the adrenal glands to release the sex hormones that must be present for GnRH to be produced. Although FSH and LH are named after their functions in female reproduction, they are produced in both sexes and play important roles in controlling reproduction.


Other hormones released from the pituitary gland also have specific functions in the male and female reproductive systems. Prolactin hormones released from the anterior pituitary are used to measure sexual satisfaction in both sexes, with its main function focusing on mammary glands during pregnancy and lactation. Prolactin stimulates mammary gland development and milk production. Oxytocin hormones are released from the posterior pituitary and stimulate the smooth muscle contraction of reproductive organs.


Gynaecology  or  gynecology  (see  American and British English spelling differences ) is the area of  medicine  that involves the treatment of  women's diseases , especially those of the  female reproductive organs . It is often paired with the field of  obstetrics , which focuses on  pregnancy  and  childbirth , thereby forming the combined area of  obstetrics and gynaecology  (OB-GYN).


The term comes from Greek and means  ' the  science  of  women ' . [ 1 ] [ 2 ]  Its counterpart is  andrology , which deals with medical issues specific to the  male reproductive system . [ 3 ]


The word  gynaecology  comes from the  oblique stem  ( γυναικ- ) of the  Greek  word  γυνή  ( gyne ) meaning  ' woman ' , and  -logia  meaning  ' study ' . [ 4 ]


The  Kahun Gynaecological Papyrus , dated to about 1800 BC, deals with gynaecological diseases,  fertility , pregnancy,  contraception , etc. The text is divided into thirty-four sections, each section dealing with a specific problem and containing  diagnosis  and treatment; no  prognosis  is suggested. Treatments are non-surgical, comprising applying medicines to the affected body part or swallowing them. The womb is at times seen as the source of complaints manifesting themselves in other body parts. [ 5 ]


Ayurveda , an Indian traditional medical system, also provides details about concepts and techniques related to gynaecology. [ 6 ] [ 7 ]


The  Hippocratic Corpus  contains several gynaecological treatises dating to the 5th and 4th centuries BC.  Aristotle is another strong source for medical texts from the 4th century BC with his descriptions of biology primarily found in  History of Animals, Parts of Animals, Generation of Animals. [ 8 ]  The  gynaecological  treatise  Gynaikeia  by  Soranus of Ephesus  (1st/2nd century AD) is extant (together with a 6th-century  Latin  paraphrase by  Muscio , a physician of the same school). He was the chief representative of the school of physicians known as the " methodists ".


In the medical schools of the early nineteenth century, doctors did not study female reproductive anatomy, seen as repulsive, nor train in pregnancy and childbirth management. That women, because of their anatomy and the risks of the dangerous birthing process, had unique medical concerns and challenges, enough that a doctor might specialize in them, is an innovation widely credited to  J. Marion Sims  and to a lesser extent his trainee and partner  Nathan Bozeman , physicians from  Montgomery, Alabama . Sims is widely considered to be the father of modern gynaecology. [ 9 ]  While there have been isolated precedents for some of his innovations, he was the first to have published on the  Sims' position , the  Sims' speculum , the Sims sigmoid catheter, and on gynecological surgery, first on repair of  vesico-vaginal fistulas , a socially devastating consequence of protracted childbirth, at the time without treatment of any sort. He founded the first women's hospital in the country, first in his backyard in Montgomery, limited to Black enslaved women, then the  Woman's Hospital  of New York.


He was elected president of the  American Medical Association , and was the first American physician of whom a statue was erected.


Sims developed his new specialty using the bodies of enslaved women, who could not refuse the extended glance of any white male that cared to observe any part of their anatomy. They could not "consent" in the sense modern medical research requires.


At the time anesthesia was itself a research area, and the first experiments (in dentistry) were being published. Using early anesthesia (in 1845, say) was much more dangerous and difficult than it would be a century later. In addition, it was widely believed that Blacks did not feel pain as much as whites, and white women proved unable to endure the pain.


At the time, Sims was seen as a hero. Even his enemies, Bozeman chief among them, did not attack him for either experimenting on the enslaved, or for not using anesthesia. Abolitionists such as  William Lloyd Garrison  were quick to put in print any mistreatment of the enslaved; Garrison's influential  The Liberator  has been completely indexed, but it never mentions Sims. Nor does the digitized portion of the Black press mention him. When he left Alabama in 1853, a local newspaper called him "an honor to our state". [ 10 ]


In the late 20th century, Sims has come to be villainized. Now criticized for his practices, Sims developed some of his techniques and instruments by operating on slaves, many of whom were not given anesthesia. [ 11 ] [ 12 ]  Sims performed surgeries on 12 enslaved women in his homemade backyard hospital for four years. While performing these surgeries he invited eager physicians and students to watch invasive and painful procedures while the women were exposed. On one of the women, named  Anarcha , he performed 30 surgeries without anesthesia. [ 13 ]  Due to having so many enslaved women, he would rotate from one to another, continuously trying to perfect the repair of their fistulas. Physicians and students lost interest in assisting Sims over the course of his backyard practice, and he recruited other enslaved women, who were healing from their own surgeries, to assist him. In 1855, Sims went on to found the Woman's Hospital in New York, the first hospital specifically for female disorders. [ 14 ]


In some countries, women must first see a  general practitioner  (GP; also known as a family practitioner (FP)) prior to seeing a gynaecologist. If their condition requires training, knowledge, surgical procedure, or equipment unavailable to the GP, the patient is then referred to a gynaecologist. In other countries, laws may allow patients to see gynaecologists without a referral. Some gynaecologists provide  primary care  in addition to aspects of their own specialty. [ citation needed ]  With this option available, some women opt to see a gynaecological surgeon for non-gynaecological problems without another physician's referral.


As in all of medicine, the main tools of diagnosis are clinical history, examination and investigations. Gynaecological examination is quite intimate, more so than a routine physical exam. It also requires unique instrumentation such as the  speculum . The speculum consists of two hinged blades of concave metal or plastic which are used to retract the tissues of the vagina and permit examination of the  cervix , the lower part of the  uterus  located within the upper portion of the vagina. Gynaecologists typically do a bimanual examination (one hand on the abdomen and one or two fingers in the vagina) to palpate the cervix, uterus,  ovaries  and bony  pelvis . It is not uncommon to do a  rectovaginal examination  for a complete evaluation of the pelvis, particularly if any suspicious masses are appreciated. Male gynaecologists may have a female  chaperone  for their examination. An abdominal or vaginal  ultrasound  can be used to confirm any abnormalities appreciated with the bimanual examination or when indicated by the patient's history.


Examples of conditions dealt with by a gynaecologist are:


There is some crossover in these areas. For example, a woman with urinary incontinence may be referred to a  urologist .


As with all surgical specialties, gynaecologists may employ medical or surgical therapies (or many times, both), depending on the exact nature of the problem that they are treating. Pre- and post-operative medical management will often employ many standard drug therapies, such as  antibiotics ,  diuretics ,  antihypertensives , and  antiemetics . Additionally, gynaecologists make frequent use of specialized  hormone -modulating therapies (such as  Clomifene  citrate and  hormonal contraception ) to treat disorders of the female genital tract that are responsive to  pituitary  or  gonadal  signals.


Surgery , however, is the mainstay of gynaecological therapy. For historical and political reasons, gynaecologists were previously not considered "surgeons", although this point has always been the source of some controversy. Modern advancements in both general surgery and gynaecology, however, have blurred many of the once rigid lines of distinction. The rise of sub-specialties within gynaecology which are primarily surgical in nature (for example urogynaecology and gynaecological oncology) have strengthened the reputations of gynaecologists as surgical practitioners, and many surgeons and surgical societies have come to view gynaecologists as comrades of sorts. As proof of this changing attitude, gynaecologists are now eligible for fellowship in both the  American College of Surgeons  and  Royal Colleges of Surgeons , and many newer surgical textbooks include chapters on (at least basic) gynaecological surgery.


Some of the more common operations that gynaecologists perform include: [ 18 ]


In the UK the  Royal College of Obstetricians and Gynaecologists , based in London, encourages the study and advancement of both the science and practice of obstetrics and gynaecology. This is done through postgraduate medical education and training development, and the publication of clinical guidelines and reports on aspects of the specialty and service provision. The RCOG International Office works with other international organisations to help lower maternal morbidity and mortality in under-resourced countries.


Gynaecologic oncology  is a subspecialty of gynaecology, dealing with  gynaecology-related cancer .


Urogynaecology  is a subspecialty of gynaecology and urology dealing with urinary or fecal incontinence and pelvic organ prolapse.


Improved access to education and the professions in recent decades has seen women gynaecologists outnumber men in the once male-dominated medical field of gynaecology. [ 20 ]  In some gynaecological sub-specialties, where an over-representation of males persists, income discrepancies appear to show male practitioners earning higher averages. [ 21 ]


Speculations on the decreased numbers of male gynaecologist practitioners report a perceived lack of respect from within the medical profession, limited future employment opportunities and questions to the motivations and character of men who choose the medical field concerned with female sexual organs. [ 22 ] [ 23 ] [ 24 ] [ 25 ] [ 26 ]


Surveys of women's views on the issue of male doctors conducting intimate examinations show a large and consistent majority found it uncomfortable, were more likely to be embarrassed and less likely to talk openly or in detail about personal information, or discuss their sexual history with a man. The findings raised questions about the ability of male gynaecologists to offer quality care to patients. [ 27 ]  This, when coupled with more women choosing female physicians [ 28 ]  has decreased the employment opportunities for men choosing to become gynaecologists. [ 29 ]


In the  United States , it has been reported that four in five students choosing a residency in gynaecology are now female. [ 30 ]  In several places in  Sweden , to comply with discrimination laws, patients may not choose a doctor—regardless of specialty—based on factors such as ethnicity or gender and declining to see a doctor solely because of preference regarding e.g. the practitioner's skin color or gender may legally be viewed as refusing care. [ 31 ] [ 32 ]  In  Turkey , due to patient preference to be seen by another female, there are now few male gynaecologists working in the field. [ 33 ]


There have been a number of legal challenges in the US against healthcare providers who have started hiring based on the gender of physicians. Mircea Veleanu argued, in part, that his former employers discriminated against him by accommodating the wishes of female patients who had requested female doctors for intimate exams. [ 34 ]  A male nurse complained about an advert for an all-female obstetrics and gynaecology practice in  Columbia, Maryland , claiming this was a form of sexual discrimination. [ 35 ]  In 2000, David Garfinkel, a New Jersey-based OB-GYN, sued his former employer [ 36 ]  after being fired due to, as he claimed, "because I was male, I wasn't drawing as many patients as they'd expected". [ 34 ]


A  vestibulectomy  is a  gynecological  surgical procedure that can be used to treat  vulvar pain , specifically in cases of provoked  vestibulodynia .  Vestibulodynia  (vulvar vestibulitis) is a chronic pain syndrome that is a subtype of localized  vulvodynia [ 1 ]  where chronic pain and irritation is present in the  vulval vestibule , which is near the entrance of the vagina. [ 2 ]  Vestibulectomy may be partial or complete. [ 3 ]


Vulvar vestibulectomy is primarily supported as an intervention for people who suffer from provoked vestibulodynia, which causes sexual pain to women. [ 4 ]  It is not indicated as appropriate for people living with generalized vulvar pain disorders and non-provoked vestibulodynia. [ 1 ]


Vestibulectomy is not considered a first-line treatment option for provoked vestibulodynia, [ 5 ]  but it is considered an effective treatment for the long-run and has recorded high levels of satisfaction from the patients. [ 6 ]  One review found that significant pain relief was reported by 79% of patients. [ 7 ]


The surgery takes place below the urinary meatus, down to the border of the perineal area and includes the fourchette.  Incisions  are made on each side adjacent and parallel to the  labia minora . The structures removed are the  hymen ,  mucous membrane ,  Bartholin glands  ducts and minor vestibular glands. In some surgeries, the amount of tissue removed is not so extensive.  Vaginal mucosa  tissue remains attached and then is pulled downward to cover the area where tissue was removed. This surgery is also used to treat  lichen sclerosus . [ 8 ]  "The complete surgery removes the entire lateral hymenal tissues to the lateral vestibular walls at Hart’s line, and involves removal of the entire posterior fourchette from the posterior hymenal remnants down to the perineum" which barring complications, enables the entire procedure to be over within an hour. [ 9 ]


The procedure involves minimal bleeding and is usually done under spinal or general anesthesia. [ 10 ]  The amount of tissue removed during the surgery can vary with respect to the pain.


Complications related to vestibulectomy include bleeding and infection. Long-term complications can be weakness of the anal muscles, cosmetic changes, development of a  Bartholin's cyst , or a decline in vaginal lubrication. Reports of satisfaction with the outcome of the surgical procedure can be as high as 90%. [ 11 ]


The procedure has been known to be unsuccessful in rare cases, where the pain remained constant even after surgery. [ 12 ]  In such cases, alternative treatments like oral medicines or more surgeries may be considered, depending on the severity of the persisting pain. [ 13 ]


The recovery period is about 6–12 weeks, depending on the amount of vulvar tissues removed. Post-surgery, the patient might need further physical and possible mental therapy to avoid scarring and lead a regular sexual life. [ 12 ]


In a study done in 2006, it was discovered that 93% of patients who had undergone the surgery recommended it for vulvar pain. Only 11% of women continued to have issues in their sex lives post-surgery. [ 14 ]


AAGL  (originally named  American Association of Gynecologic Laparoscopists ) is a  professional association  of  laparoscopic surgeons  dedicated to the research and advancement of minimally invasive  gynecologic  procedures. AAGL was founded by Jordan M. Phillips, M.D., in 1971 as the American Association of Gynecologic Laparoscopists. It later switched to using just the acronym to reflect its international scope, and currently it has over 8,000 members spread over 110 countries. [ 1 ]  The laparoscope, a form of  endoscope , often allows  surgery  to be done with smaller  incisions  and faster  recovery  (that is, in a  minimally invasive  way) compared with older  open  techniques.


The society has held dialogues, discussed and shared views on minimally invasive procedures. [ 2 ]


AAGL provides a number of  Continuing Medical Education  (CME) events to its members throughout the year, including the AAGL Global Congress on Minimally Invasive Gynecology held each November.


AAGL publishes the advancements in  gynecologic   laparoscopy  and other conference proceedings in the Journal of Minimally Invasive Gynecology, a part of AAGL. [ 3 ]


AAGL has over 40 collaborations with sister societies around the world which include the North America, South America, European Union, Africa, Australasia & Asia. The society corroborates international relationship as a means to promote the art of training and free knowledge flow through partnership and collaboration. [ 4 ]


Advanced Life Support in Obstetrics  ( ALSO ) is a program that was developed by the  American Academy of Family Physicians  (AAFP). This course helps  physicians , certified  nurse midwives  (CNM),  registered nurses , and other health care providers involved in potential emergencies in the perinatal care of mothers. This course is important and even required in some hospitals for family practice physicians as well as a learning tool in most family practice  residency programs . [ 1 ]  ALSO was developed by Damos and Beasley, from the Department of  Family Medicine  at the  University of Wisconsin . [ 2 ]


ALSO aims to decrease  morbidity  and  mortality  for both the mother and baby.  ALSO does this by incorporating both  didactic  and practical hands on workstations with lifelike mannequins. [ 3 ]   Topics include assisted vaginal delivery,  Doppler fetal monitoring , fetal  dystocias ,  neonatal   resuscitation , management  premature labor , management of  postpartum hemorrhage , along with  forceps  and  vacuum -assisted delivery. Participants must pass a written test as well as a practical hands-on case management of a birth (mega-delivery) incorporating many elements learned throughout the course.


ALSO helps serve the same function as  advanced trauma life support  (ATLS) and  advanced cardiac life support  (ACLS) to help keep physicians who work with rural or underserved populations up to date on  evidence-based medicine  and curriculum. [ 2 ]


Although Canadian family physicians historically followed the ALSO course, the  College of Family Physicians of Canada  has also developed a similar program entitled  Advanced Labour and Risk Management  (ALARM), which serves the same purpose as the AAFP's ALSO.


Atypia  (from  Greek ,  a  +  typos , without type; a condition of being irregular or nonstandard) [ 1 ]  is a  histopathologic  term for a structural abnormality in a  cell , i.e. it is used to describe atypical cells.


Atypia can be caused by infection or irritation. If, for example it were diagnosed in a  Pap smear  in the  uterus  it is more likely to be precancerous.


The related concept of  dysplasia  refers to an abnormality of development, [ 2 ]  and includes abnormalities on larger,  histopathologic  scales.


Features that constitute atypia have different definitions for different diseases, but often include the following  nucleus  abnormalities: [ 3 ]


In  Barrett's esophagus , features that are classified as atypia but not as  dysplasia  are mainly: [ 5 ]


It may or may not be a  precancerous  indication associated with later  malignancy , but the level of appropriate concern is highly dependent on the context with which it is diagnosed.


For example, already differentiated, specialised cells such as epithelia displaying "cellular atypia" are far less likely to become problematic (cancerous/malignant) than are  myeloid progenitor cells  of the immune system. The 'further back' in an already specialised, differentiated cell's lineage, the more problematic cellular atypia is likely to be. This is due to the conferring of such atypia to progeny-cells further down the lineage of that cell type.


The  Ayre spatula  is a device used to collect  Pap smear . It is a wooden spatula with U-shaped openings on one side and a flat surface on another. [ 1 ]  The broad end is for vaginal sample collection and the narrow end is for cervical sample collection. It is rotated 360 degrees in the vagina to obtain the cells to be sent for Pap smear examination. Recent studies have shown that long-tipped spatulas ( Aylesbury device ) or a  cytobrush  along with an extended-tip spatula are better than an Ayre spatula in collecting  endocervical cells . [ 2 ]  However, the Ayre spatula continues to be used for cervical sample collection in lower-income countries. The Ayre spatula is introduced into the cervix after exposing the external os using a  speculum .  The  cytology  specimens are obtained by rotating the spatula firmly over the  ectocervix  and quickly transferring the cells to a slide or jar.


The Ayre spatula was invented by  James Ernest Ayre  and  Georgios Papanikolaou . Ayre was granted a patent for it in 1949 and donated the profits from sales of the spatula to the  American Cancer Society . [ 3 ]


Bacterial vaginosis  is caused by an imbalance of the  naturally occurring bacteria in the vagina . [ 1 ] [ 2 ]   The normally predominant species of  Lactobacilli  are markedly reduced. [ 3 ]  This is the list of organisms that are found in the vagina that are associated with  bacterial vaginosis , an infectious  disease  of the  vagina  caused by excessive growth of specific  bacteria . [ 4 ] [ 5 ]  The census and relationships among the microbiota are altered in BV, resulting in a complex bacterial milieu. Some species have relatively been identified recently. [ 6 ]  Having infections with the listed pathogens increases the risk of acquiring other  sexually transmitted infections  including  HIV/AIDS . [ 7 ] [ 8 ]


Bartholin gland carcinoma  is a type of  cancer of the vulva  arising in the  Bartholin gland . [ 2 ]  It typically presents with a painless mass at one side of the vaginal opening in a female of middle-age and older, and can appear similar to a  Bartholin cyst . [ 2 ]  The mass may be big or small, may be deep under skin or appear nearer the surface with overlying  ulceration . [ 2 ]  Average age at presentation is 53-years. [ 3 ]


The  tumor  can become large before a woman is aware of  symptoms . One of the first symptoms can be  painful sex . In other instances there may be a mass or ulcer in the vulva area. Many clinicians assume that an enlarged Bartholin gland is malignant in postmenopausal woman until proven otherwise. The growth of the tumor can spread to nearby areas such as the  ischiorectal fossa  and  inguinal lymph nodes . Approximately 50% of bartholin gland carcinomas originate from  squamous cell carcinomas . Another uncommon characteristic of Bartholin gland malignancies is that the growth of a lesion originates from the three types of epithelial tissue present in the gland:  mucinous ,  transitional , and  squamous . [ 4 ]


It is rare, accounts for less than 1% of all female genital tract cancer and less than 5% of all  vulva cancer . [ 2 ]


The cause is unknown. [ 2 ]


Bartholin gland can be differentiated by histology to determine whether the malignancy is due to squamous cell carcinoma, adenoid cystic carcinoma, or adenocarcinomas. [ 5 ]


Though Bartholin gland carcinoma is rare, along with other unusual Bartholin gland growths, it many not be the typical practice for clinicians to consider lesions malignant. Early diagnosis can help to prevent the cancer from the glands to surrounding. Though malignancies of the Bartholin gland are rare clinicians biopsy Bartholin gland lesions in older women or when the growth reoccurs or does not respond to original treatment. [ 4 ]


The prognosis is optimistic as long as the growth has not metastasized to the lymph nodes. [ 4 ]


Bartholin glands were described in cattle by Casper Barthlin in 1677. Their existence in humans was postulated at that time. [ 4 ]
Treatment can be a  vulvectomy  that results in the removal of the growth along with an extensive removal of adjacent tissue. An inguinal lymphadenectomy often accompanies the vulvectomy. The tissue that is removed sometimes includes sections of the  vagina  and  rectum . [ 6 ]


The  adenoid cystic carcinoma  of the Bartholin gland is another uncommon malignancy with symptoms that include local painful intermittent recurrences. The disease is slow to progress but it can result in lung cancer after a long time after the initial treatment. Treatment consists of surgical removal of the growth. Sometimes radiation and chemotherapy is performed. [ 7 ]


Basal body temperature  ( BBT  or  BTP ) is the lowest  body temperature  attained during rest (usually during sleep). It is usually estimated by a temperature measurement immediately after awakening and before any physical activity has been undertaken. This will lead to a somewhat higher value than the true BBT.


In women,  ovulation  causes a sustained increase of at least 0.2 °C (0.4 °F) in BBT.  Monitoring BBTs is one way of estimating the day of ovulation.  The tendency of a woman to have lower temperatures before ovulation, and higher temperatures afterwards, is known as a  biphasic  temperature pattern.  Charting this pattern may be used as a component of  fertility awareness . The BBT of men is comparable to the BBT of women in their  follicular phase . [ 2 ]


The higher levels of  estrogen  present during the pre-ovulatory (follicular) phase of the  menstrual cycle  lower BBTs.  The higher levels of  progesterone  released by the  corpus luteum  after ovulation raise BBTs. [ 3 ]   After ovulation, the temperature will be raised by at least 0.2 °C (0.4 °F), for at least 72 hours, compared to the previous six days. [ 3 ]


Charting of basal body temperatures is used in some methods of fertility awareness, such as the  sympto-thermal method , and may be used to determine the onset of post-ovulatory infertility. [ 4 ]   When BBT alone is used to avoid a pregnancy, it is sometimes called the Temperature Rhythm method. [ 4 ]


Basal body temperature alone is most effective at preventing pregnancy if the couple abstains from intercourse from the beginning of menstruation through the third day after the basal body temperature has risen. [ 5 ]   BBTs only show when ovulation has occurred; they do not predict ovulation.  Sperm typically lasts for at least three days and can survive as long as a week, [ 3 ]  making prediction of ovulation several days in advance necessary for avoiding pregnancy.


There is limited evidence about the effectiveness of  fertility awareness  family planning methods, some of which use basal body temperature as one component. [ 1 ]   About 24% of women who use any type of fertility awareness program become pregnant during the first year, compared to about 85% of sexually active women who are not trying to prevent a pregnancy. [ 6 ] [ 5 ]


The  World Health Organization  ranked fertility awareness methods, taken as a whole, as an "effective" method of preventing pregnancies. [ 5 ]  The WHO placed fertility awareness methods in the third tier of effectiveness, after "most effective" methods such as  IUDs  and "very effective" methods such as  combined oral contraceptive pills . [ 5 ] [ 7 ]


Couples that are trying to conceive can use BBT to determine when the opportunity for a pregnancy during this cycle has passed.


Infertility due to lack of ovulation is common.  BBT charts can be used to identify when and whether ovulation is taking place. [ 3 ]


Regular menstrual cycles are often taken as evidence that a woman is ovulating normally, and irregular cycles is evidence she is not.  However, many women with irregular cycles do ovulate normally, and some with regular cycles are actually  anovulatory  or have a  luteal phase defect .  Records of basal  body temperature  can be used to accurately determine if a woman is ovulating. [ 8 ]


Calculating the  expected due date  for a pregnancy based upon the self-reported  last menstrual period  is less accurate than calculating it based upon either BBT or ultrasound. [ 8 ]


Abdominal bloating  (or simply  bloating ) is a short-term disease that affects the  gastrointestinal tract . [ 1 ] [ 2 ]  Bloating is generally characterized by an excess buildup of gas, air or fluids in the  stomach . A person may have feelings of tightness, pressure or fullness in the stomach; it may or may not be accompanied by a visibly  distended abdomen . [ 3 ]  Bloating can affect anyone of any age range and is usually self-diagnosed, in most cases does not require serious medical attention or treatment. [ 4 ] [ 5 ]  Although this term is usually used interchangeably with abdominal distension, these symptoms probably have different pathophysiological processes, which are not fully understood. [ 6 ]


The first step for the management is to find a treatment for the underlying causes that produce it through a detailed medical history and a physical examination. The discomfort can be alleviated by the use of certain drugs and dietary modifications. [ 4 ]


Bloating can also be caused by  chronic conditions  and in rare cases can be a reoccurring life-threatening problem. [ 7 ]


The most common symptom associated with bloating is a sensation that the abdomen is full or distended. Rarely, bloating may be painful or cause shortness of breath. [ citation needed ]


Pains that are due to bloating will feel sharp and cause the stomach to  cramp . These pains may occur anywhere in the body and can change locations quickly. [ 8 ]  They are so painful that they are sometimes mistaken for heart pains when they develop on the upper left side of the chest. Pains on the right side are often confused with problems in the  appendix  or the  gallbladder .


One symptom of gas that is not normally associated with it is the  hiccup . Hiccups are harmless and will diminish on their own; they also help to release gas that is in the  digestive tract  before it moves down to the intestines and causes bloating. Important but uncommon causes of abdominal bloating include  ascites  and tumors. [ 9 ]


There are many causes of bloating, including: diet,  irritable bowel syndrome ,  lactose intolerance ,  reflux , and  constipation . [ 10 ] [ 11 ] [ 12 ] [ 13 ]
Specific medical conditions like  Crohn's disease  or bowel obstruction can also contribute to the amount of stomach bloating experienced.


Common causes of abdominal bloating are:


Important but uncommon causes of abdominal bloating include:


In animals, causes of abdominal bloating include:


All the factors mentioned contribute to bloated stomach abdominal pain.


Every person produces gases in their body during the digestion of food, such as methane, hydrogen, carbon dioxide, and nitrogen. And some of them are released outside the body, sometimes in small quantities that one does not notice and sometimes in larger quantities that may affect the normal course of life.


Most cases of stomach bloating are due to improper  diet . [ medical citation needed ]  Gas occurs because of the bacteria in the colon and is a by-product of soluble fiber digestion. Inadequate or irregular intake of fiber and water will cause a person to experience bloating or constipation. The most common natural sources of fiber include fruits and vegetables as well as wheat or oat bran. These fibers are most likely to cause  flatulence . [ 29 ]  Fiber is made by plants and is not easily digested by the  human gastrointestinal tract . There are two main types of  dietary fiber : soluble and insoluble fiber. Soluble fiber is  prebiotic  and readily fermented in the colon into gases, while insoluble fiber is metabolically inert and absorbs water as it moves through the digestive system, aiding in defecation. Most types of fiber (insoluble) are attached to  body water  in the  intestine  and increase the volume of stools. [ citation needed ]


Gas in the gastrointestinal tract has only two sources. It is either swallowed air or is produced by bacteria that normally inhabit the intestines, primarily the colon. [ 30 ]


Belching  or burping is a universal ability that works by removing gas from the stomach through the mouth. The stomach can become bloated when too much air is swallowed during eating and drinking too quickly. As the stomach swells, belching removes the gas and alleviates the pain associated with it. Burping can also be used as a form of relief from abdominal discomfort other than too much gas in the stomach. [ citation needed ]


Flatulence , or farting, provides relief of much the same kind as burping, but involves the passage of gas from the body via the  anus , not the mouth. Bacteria present in the intestinal tract cause gas that is expelled from the anus. They produce the gas as food is digested and moved from the  small intestine . This gas builds up and causes swelling or bloating in the abdominal area before it is released.


A common gastrointestinal problem is  constipation —infrequent bowel movements, hard stools, or strain during the movements—which causes serious cases of bloating. Since most cases of constipation are temporary, simple lifestyle changes, such as getting more exercise and increasing one's intake of fiber, can contribute to alleviating constipation. [ 31 ]  Some cases of constipation will continue to worsen and require unconventional methods to release the feces and reduce the amount of stomach bloating. Blood in the stool, intense pain in the abdomen, rectal pain, unexplained weight loss, and continued bloating and constipation not relieved by the above lifestyle changes should be reported to a doctor. Bloating consistently accompanies constipation, and they will not develop without an underlying cause. [ 22 ]


Painful burning sensations in the chest that are caused by gastroesophageal reflux is known as  heartburn . Reflux is the backflow of  gastric acid  juices from the stomach into the  oesophagus . [ 32 ]   Heartburn has different triggers, including certain foods, medications,  obesity , and stress. These triggers are different for each individual.  Gastroesophageal reflux disease  or GERD is a chronic condition that can lead to more serious complications like  esophageal cancer . [ 33 ]  Treatment options are available to treat the symptoms and the condition, but there is no cure for the disease. Symptoms include burping, abdominal and stomach bloating, along with pain and discomfort. Heavy meals, lying down or bending over after eating should be avoided to help prevent reflux from occurring. The stomach bloating experienced with reflux is intense and will remain until the food is digested all the way.


Postmortem bloating occurs in cadavers, due to the formation of gases by  bacterial  action and  putrefaction  of the internal tissues of the abdomen and the inside of the intestines. [ 34 ]


Conditions that are related to bloating include constipation, lactose intolerance, and  acid reflux  disease. [ 32 ]  All of these conditions share the same symptoms and can share the same causative agents. These causes include unhealthy diet, smoking, alcohol consumption, low amount of exercise, and overall health. Each of these conditions can be experienced as a symptom of the others and is also a cause for each of them. In most cases where one of the conditions is present, there is at least one if not two of the others. Treatment for each condition is performed using the same medications and recommended dietary changes like increased fiber intake and reduced fat intake. If the conditions develop into diseases such as gastroesophageal reflux disease or chronic constipation, additional medications will be required. Bloating and flatulence are sometimes related to constipation, and treating the underlying condition may be helpful. [ 35 ]


Promising evidence on the potential efficacy of the  low-FODMAP diet  in functional abdominal bloating is provided by the reduction of the bloating which has been observed in some studies on patients with  irritable bowel syndrome . Regarding the  gluten-free diet , there is insufficient scientific evidence to recommend it to reduce bloating and abdominal distension. [ 36 ]
As regards the  FODMAP  diet, this should be provided by experts in nutrition to reduce the risks associated with elimination diets. [ 37 ]


There are many  over-the-counter  (OTC) medications that can be used to treat bloating.
Food  enzymes  can be found in some products that will help break down the sugars found in grains, vegetables and  dairy products . They can be taken before food is consumed or added to the food that causes the gas and bloating. [ 38 ]  The most common treatment is  antacids . These medications have no effect on the gas that is present in the intestines but enable gas build-up to be belched away more easily, reducing the amount of bloating that develops.  Another treatment is  simethicone , an oral anti-foaming agent that helps the body to expel the gas more quickly.
Combinations of  prokinetics , such as  domperidone  +  metoclopramide  +  diphenhydramine  (the latter for the prevention of  extrapyramidal  reactions, especially acute  dystonic  reactions) +  proton pump inhibitors  (PPIs), have dramatic effects on bloaters and belchers especially. [ citation needed ]


Notes


Bibliography


Breast pain  is the symptom of discomfort in either one or both  breasts . [ 2 ]  Pain in both breasts is often described as  breast tenderness , is usually associated with the   menstrual period  and is not serious. [ 1 ] [ 3 ]  Pain that involves only one part of a breast is more concerning, [ 1 ]  particularly if a hard  mass  or  nipple discharge  is also present. [ 3 ]


Causes may be related to the  menstrual cycle ,  birth control pills ,  hormone therapy , or  psychiatric medication . [ 1 ]  Pain may also occur in those with large breasts, during  menopause , and in early  pregnancy . [ 1 ] [ 3 ]  In about 2% of cases breast pain is related to  breast cancer . [ 4 ]  Diagnosis involves  examination , with  medical imaging  if only a specific part of the breast hurts. [ 1 ]


In more than 75% of people the pain resolves without any specific treatment. [ 1 ]  Otherwise treatments may include  paracetamol  or  NSAIDs . [ 1 ]  A well fitting  bra  may also help. [ 3 ]  In those with severe pain  tamoxifen  or  danazol  may be used. [ 1 ]  About 70% of women have breast pain at some point in time. [ 2 ]  Breast pain is one of the most common breast symptoms, along with  breast masses  and nipple discharge. [ 1 ]


Breast pain linked to the menstrual cycle is called cyclic breast pain or cyclic mastalgia. Some degree of cyclical breast tenderness is normal in the menstrual cycle, and is usually associated with  menstruation  and/or  premenstrual syndrome  (PMS). [ 5 ]  Cyclic breast pain is often associated with  fibrocystic breast changes  or  duct ectasia  and thought to be caused by changes of prolactin response to  thyrotropin . [ 6 ] [ 7 ]


Breast pain that is not linked to a menstrual cycle is called noncyclic breast pain. Noncyclical breast pain has various causes and is harder to diagnose and frequently the root cause is outside the breast. Some degree of non-cyclical breast tenderness can normally be present due to hormonal changes in  puberty  (both in girls and boys), in  menopause  and during  pregnancy . [ 5 ]  After pregnancy, breast pain can be caused by  breastfeeding . [ 5 ]  Other causes of non-cyclical breast pain include  alcoholism  with liver damage (likely due to abnormal steroid metabolism),  mastitis  and medications such as  digitalis ,  methyldopa  (an  antihypertensive ),  spironolactone , certain  diuretics ,  oxymetholone  (an  anabolic steroid ), and  chlorpromazine  (a  typical antipsychotic ). [ 5 ]  Also,  shingles  can cause a painful blistering rash on the skin of the breasts. [ 5 ]


Some women who have pain in one or both breasts may fear  breast cancer . However, breast pain is not a common symptom of cancer. The great majority of breast cancer cases do not present with symptoms of pain, though breast pain in older women is more likely to be associated with cancer. [ 2 ] [ 8 ] [ 5 ]


Diagnosis involves  breast examination , with  medical imaging  if only a specific part of the breast hurts. [ 1 ]  Medical imaging by  ultrasound  is recommended for all ages, as well in those over 35 it is recommended together with  mammography . [ 1 ]


Ruling out the other possible causes of the pain is one way to differentiate the source of the pain. Breast pain can be due to:


Medications can be associated with breast pain and include:


Diagnostic testing can be useful. Typical tests used are  mammogram ,  excisional biopsy  for solid lumps,  fine-needle aspiration  and biopsy,  pregnancy test ,  ultrasonography , and  magnetic resonance imaging  (MRI). [ 8 ]


In more than 75% of people the pain resolves without any specific treatment. [ 1 ]  Otherwise treatments may include  paracetamol  or  NSAIDs . [ 1 ]  A well fitting  bra  may also help. [ 3 ]  In those with severe pain  tamoxifen  or  danazol  may be used. [ 1 ]


Bromocriptine  may be used as well. [ 14 ]


Spironolactone, low dose  oral contraceptives , and low-dose  estrogen  have helped to relieve pain. Topical anti-inflammatory medications can be used for localized pain.  Vitamin E  is not effective in relieving pain nor is  evening primrose oil .  Vitamin B 6  and  vitamin A  have not been consistently found to be beneficial.  Flaxseed  has shown some activity in the treatment of cyclic mastalgia. [ 8 ]


Pain may be relieved by the use of  nonsteroidal anti-inflammatory drugs  or, for more severe localized pain, by  local anaesthetic . [ 2 ] [ 5 ]  Pain may be relieved by reassurance that it does not signal a serious underlying problem, and an active life style can also effect an improvement. [ 2 ]


Information regarding how the pain is real but not necessarily caused by disease can help to understand the problem.  Counseling  can also be to describe changes that vary during the monthly cycle. Women on hormone replacement therapy may benefit from a dose adjustment. Another non-pharmacological measure to help relieve symptoms of pain may be to use good bra support. Breasts change during adolescence and menopause and refitting may be beneficial. Applying heat and/or ice can bring relief. Dietary changes may also help with the pain.  Methylxanthines  can be eliminated from the diet to see if a sensitivity is present. Some clinicians recommend a reduction in  salt , though no evidence supports this practice. [ 8 ]


Clitoral erection  (also known as  clitoral tumescence  or  female erection ) [ 1 ] [ 2 ]  is a physiological phenomenon where the  clitoris  becomes enlarged and firm.


Clitoral erection is the result of a complex interaction of psychological, neural, vascular, and endocrine factors, and is usually, though not exclusively, associated with  sexual arousal . Erections should eventually subside, and the prolonged state of clitoral erection even while not aroused is a condition that could become painful. [ 3 ]  This swelling and shrinking to a relaxed state seems linked to  nitric oxide 's effects on tissues in the clitoris, similar to its role in  penile erection . [ 4 ]


The clitoris is the  homolog  to the  penis  in the male. Similarly, the clitoris and its erection can subtly differ in size. [ 5 ]


The visible part of the clitoris, the  glans clitoris , varies in size from a few millimeters to one centimeter and is located at the front junction of the  labia minora  (inner lips), above the opening of the  urethra . It is covered by the  clitoral hood .


Any type of motion can increase  blood flow  to this organ and this results in increased  secretions which lubricate  the  vagina . There are many ways to stimulate the clitoris.