Understanding Female
Reproductive Health

What is reproduction?

Reproduction is the process by which offspring are made, usually sexually.

In humans, this requires the fusion of two kinds of sex cells, called gametes. The male gamete, or sperm, and the female gamete, the egg or ovum, meet in the female’s reproductive system after intercourse. When a sperm cell meets and fuses with an ovum, this is called fertilisation. Fertilisation produces a zygote that then undergoes multiple rounds of cell division to become an embryo that later develops into a foetus during pregnancy.

The male and the female reproductive systems are both needed for reproduction.

Humans, like other organisms, pass some characteristics of themselves to the next generation through genes (the special chemical carriers of traits in living organisms). These genes come from the male’s sperm and the female’s egg, respectively.

What is the female reproductive system?

1. External genitalia:

• The outer part of the female reproductive organs is called the vulva, which means covering. Located between the legs, the vulva covers the opening to the vagina.
• The fleshy area located just above the top of the vaginal opening is called the mons pubis.
• Two pairs of skin flaps called the labia (which means lips) surround the vaginal opening. When girls undergo puberty, the outer labia and the mons pubis are covered by pubic hair.
• The clitoris is a small body of sensory nervous tissue located toward the front of the vulva where the folds of the labia meet.
• Between the labia are openings to the urethra (the urinary tract opening) and the vagina (the reproductive tract opening).

2. A female’s internal reproductive organs:

• The vagina is a muscular, hollow tube that extends from the vaginal opening externally to the opening of the uterus called the cervix. The muscularity of the vaginal walls allows the tract to become wider or narrower to accommodate a baby during birth. The vagina’s muscular walls are lined with mucous membranes, which keep it protected and moist.

The vagina serves three purposes:

1. It is where the penis is inserted during sexual intercourse
2. It serves as the birth canal
3. It is the route through which menstrual blood leaves the body during menstruation.

• The cervix is the opening (neck) of the uterus. It has strong, thick walls which can expand to allow a baby to pass during birth.
• The uterus (or womb) is the organ where a zygote implants if fertilisation has occurred and is where the embryo then foetus develops during pregnancy. It has a thick outer vascular lining and strong inner muscular walls — in fact, the uterus contains some of the strongest muscles in the female body! These muscles are able to expand and contract to push a baby out during the birth process. The outer vascular lining is shed monthly as menses (your period) if there has been no fertilisation.
• At the upper corners of the uterus, the ovarian ducts/fallopian tubes connect the uterus to the ovaries. There are two ovarian ducts/fallopian tubes, each attached to a side of the uterus.
• The ovaries are two oval-shaped organs that lie to the upper right and left of the uterus. These are the gonads of females (equivalent to the testes in males, as this is where the gametes are made). The ovaries produce, store and release ova/eggs into the ovarian duct in a process called ovulation.
  In ovulation, an ovum is released from an ovary and enters the fallopian tube. Once the egg is in the fallopian tube, tiny hairs in the tube’s lining help push it down the towards the uterus.

The ovaries are also part of the endocrine (hormone) system because they produce female sex hormones oestrogen and progesterone that are needed for good health and wellbeing.

A very thin piece of skin-like tissue called the hymen partly covers the opening of the vagina. The hymen differs from female to female.

How does the female reproductive system work?

When a women is born, her ovaries already contain hundreds of thousands of ova, which remain inactive until puberty begins. At puberty, the pituitary gland (a small gland in the central part of the brain) starts making hormones that stimulate the ovaries to make oestrogen. The secretion of these hormones causes a girl to develop into a sexually mature woman.

Toward the end of puberty, girls begin to release ova as part of a monthly period called the menstrual cycle. This onset of ovulation and menses (your period) is called menarche. From then on, about once a month, during ovulation, an ovary sends an ovum into one of the fallopian tubes.

Unless the egg is fertilised by a sperm while in the fallopian tube, the egg leaves the body about two weeks later through the uterus. This is menstruation (your period). Blood and tissues from the inner lining of the uterus are shed as well to form the menstrual flow, which in most girls typically lasts between three to five days.

It is common for women and girls to have some discomfort in the days leading to their periods.
This is known as Premenstrual Tension/Stress (PMS) and includes both physical and emotional symptoms that many girls and women get right before their periods, such as:

• Acne
• Bloating
• Tiredness
• Backaches
• Tender or sore breasts
• Headaches
• Constipation or diarrhoea
• Food cravings
• Depressed mood or irritability
• Difficulty concentrating or handling stress.

PMS is usually at its worst during the week before your period starts and disappears after it begins.

Many girls also have belly cramps during the first few days of their periods caused by prostaglandins, chemicals in the body that make the smooth muscle in the uterus contract. These involuntary contractions can be dull or sharp and intense. Abnormal and severe pain though is called dysmenorrhoea and should be discussed with your doctor or other healthcare provider.

It can take up to two years from menarche for a girl’s body to develop a regular menstrual cycle. During that time, her body is adjusting to the changing hormone levels. On average, the monthly cycle for an adult woman is 28 days, but the range is anywhere from 23 to 35 days.

After puberty, your menstrual cycle and period should be generally regular.
Abnormal bleeding can occur however, either outside of your period or that makes your period abnormally heavy. Talk to your healthcare provider if you are worried about heavy bleeding or bleeding outside of your period.

What happens during pregnancy?

If a female and male have sexual intercourse within a few days of the female’s ovulation, fertilisation can happen.
When the male ejaculates (when semen leaves the penis), a small amount of semen is deposited into the vagina containing millions of sperm cells are that “swim” up from the vagina through the cervix and uterus to meet the ovum in the fallopian tube. It takes only one sperm to fertilise an ovum.

The fertilised ovum, or zygote, will then travel down the fallopian tube and a few days later, it will burrow itself into the outer vascular lining of the uterus called the endometrium. This process is called implantation.

The hormone oestrogen causes the endometrium to become thick and rich with blood. Progesterone, another hormone released by the ovaries, keeps the endometrium thick with blood so that the fertilised ovum can attach to the uterus and absorb nutrients from it.

As cells in the fertilised ovum are nourished, another stage of development begins. In the embryonic stage, the fertilised ovum forms a developing embryo surrounded by the membranes of pregnancy (the amniotic and chronic membranes).

During the foetal stage, which lasts from nine weeks post fertilisation to birth, development continues as cells multiply. The foetus floats in amniotic fluid inside the amniotic sac. The foetus gets oxygen and nourishment from the mother’s blood supply via the placenta. This disk-like structure sticks to the inner lining of the uterus and connects to the foetus via the umbilical cord.

In humans, pregnancy lasts an average of 280 days, or about 9 months.

When the baby is ready for birth, its head presses the cervix, which begins to relax and widen. Mucous has also formed a plug in the cervix, which now loosens. This mucous plug and the amniotic fluid come out through the vagina when the mother’s water breaks.

When the contractions of labour begin, the walls of the uterus contract as they are stimulated by the pituitary hormone oxytocin. The contractions cause the cervix to widen and begin to open. After several hours of this widening, the cervix is dilated (opened) enough for the baby to come through. The baby is pushed out of the uterus, through the cervix, and along the vagina. The umbilical cord comes out with the baby.

The last stage of the birth process involves the delivery of the placenta, which at that point is called the afterbirth. After it has separated from the inner lining of the uterus, contractions of the uterus push it out, along with its membranes and fluids.

What is contraception?

Contraceptives are the medications and devices used to control the number and timing of pregnancies (family planning).

There are several different methods of contraception, and while most medically prescribed methods are highly effective, their reliability often depends on how closely you follow the instructions for use. Additionally, following instructions for some methods may be easier than for others. Oral contraceptives, for example, are very effective with perfect use; however, many women forget to take The Pill every day.
People tend to follow instructions more closely as they get used to using a certain method.

Besides reliability, each contraceptive method has individual advantages and disadvantages. For example, hormonal methods of contraception have certain side-effects that can help treat certain medical or reproductive system conditions.
Your choice of contraceptive method depends on your lifestyle, preferences and the degree of reliability you need.

If contraception fails, emergency contraception may help prevent an unintended pregnancy. Emergency contraception should not be used as a regular form of contraception and must be discussed with your healthcare provider before usage.

Understanding your menstrual cycle

The Pill

“The Pill” is a term for a number of different types of tablets that you need to take daily to avoid falling pregnant. It may also be called ‘hormonal contraception‘.

The combined pill contains both the hormones oestrogen and progesterone that stop the ovaries from releasing unfertilised eggs (ovulation). The combined pill also thickens the cervical mucus, preventing the sperm from getting to the egg.
The so-called “mini pill,” on the other hand, only contains the one hormone, progesterone for those women who cannot tolerate oestrogen.

Ask your healthcare provider whether the combined pill is a suitable method of contraception for you based on your medical history.

Getting started with The Pill

Making the decision to go onto an oral contraception should be discussed with your doctor. There are various types of contraception and The Pill is available in different formulations and strengths of hormones. Your doctor will help you identify the most suited product based on your needs and health history.

Other important topics to raise with your doctor:

• Your family health history
• Smoking
• When you want to change from one oral contraceptive to another as spotting may occur
• Always tell your doctor about the medicine you are using as medicines interact with one another (this includes complementary and traditional medicines).

Tablet-taking should usually start on the first day of your natural menstrual cycle (on the first day of menstrual bleeding). An additional barrier method – such as the use of a condom – is recommended for the first seven days of tablet taking during the first cycle.

How do you take The Pill properly?

Taking the pill is the same as taking most other medications that come in tablet form: you put one in your mouth and completely swallow it, preferably with water. This should be done consistently at the same time every day, regardless of whether you engage in sexual activity or not.

Forgetting or neglecting to take your pill means it won’t be as effective as it should be, and you could end up falling pregnant. Therefore, it is recommended that you pick a time to take your pill regularly and follow that routine to keep yourself from missing a pill.

On the off chance that you miss at least one pill, or start a pill pack past the point indicated on the packaging or instructions (various pills have various cycles), check the Patient Information Leaflet inside your pack.
If you are uncertain, talk to your healthcare provider or pharmacist.

Non-compliance: how to avoid contraceptive failure

Non-compliance is the main reason for contraceptive failure. Non-compliance can be attributed to:

• Forgetting to take the tablet
• Fear of weight gain
• Headache/migraines
• Bleeding irregularities.

Advice to make sure you never miss your pill:

• Always keep your tablets with you, especially if you are sleeping out.
• Take the tablets at the same time every day to create a routine.
• Nausea and vomiting may be helped by taking the pill in the evening or with food.
• It is not unusual to miss a period while taking the pill. Take a pregnancy test if you miss two or three periods in a row.
• Spotting can occur when taking the tablets to avoid menstruation or when switching from one contraceptive to another
• Study results confirm that favourable results are seen pertaining to body weight with the mean body weight remaining stable with the majority of women.

Precautions when accidently skipping tablets

Tablet-taking should never be stopped for longer than seven days. Uninterrupted tablet-taking for seven days is required to attain adequate suppression of the hormone cycle that controls fertility in women.

Additional contraceptive precautions:

If extra contraceptive precautions are required, patients must abstain from sex or be advised to use a cap plus spermicide or a condom.

The 7-day rule

Take extra contraceptive precautions during the next 7 days, but if these days run beyond the end of the yellow active tablets, the 7 white inactive tablets must not be taken (i.e. discard the current pack after taking the last yellow active tablet).
Start a new pack on the next day with the first yellow active tablet. You can continue to take your tablets as usual. Do not leave a gap between the packs.

Your menstrual period will occur after you have completed the second pack. If your period does not occur, consult your doctor before resuming the next pack.

When does the 7-day rule apply:

If you are more than 12 hours late taking a tablet, or if you have vomited, or if your doctor advises you to follow the 7-day rule because you are taking certain medicines.

What should you know about breast health?

The breasts are also part of the female reproductive system, and while also found in men, the mammary gland (milk production) function is usually only present in women.

The mammary glands (breast tissue that produces milk) serve the primary purpose of producing milk to nourish a newborn baby. The process of producing and secreting milk by nursing mothers is called lactation.

However, in non-pregnant women, the mammary tissue is largely undeveloped and instead consists of large amounts of dermal and subdermal (skin and below-skin) tissue, including adipose (fat) tissue.

The central area of the breast is usually more darkly pigmented and is called the areola. The areola in turn surrounds a central protruding nipple that can be stimulated by nerve cells to become erect with tactile touch, the cold and, sometimes, sexual arousal.
You may notice that your areola is slightly bumpy or that the skin appears slightly ruched? This is because large sebaceous glands are present and help to produce sebum, an oily secretion which helps prevent the skin of the nipple from chapping or cracking.

Women should always seek a doctor’s advice if they notice any abnormal changes in skin texture, puckering or leakage from the nipple, or if they note any irregular lumps that they can feel.
Breast cancer is the most common cancer in women globally.

Your risk of developing breast cancer is higher if you experienced menarche/puberty at a young age or if you have only experienced menopause later in life than expected. This is because many types of breast cancer are hormone-driven, meaning that oestrogen helps potentiate its development.

Other risk factors for breast cancer include:

• Physical inactivity
• Overweight and obesity
• Smoking
• Excessive alcohol consumption and,
• Sometimes, hormone treatment or hormonal contraceptives.

Additionally, you are at greater risk of developing breast cancer if you have a family history of ovarian and breast cancer (particularly a mother, aunt or sister). Genetic mutations to the BRCA genes are strongly associated with breast and ovarian cancer.

Breast examination should be scheduled routinely at doctor or clinic check-ups for women, as early detection of breast cancer is possible and results in better treatment outcomes.

Overview

An intrauterine device (IUD) is a birth control device that’s inserted into your uterus by a healthcare professional. An IUD is a long-acting reversible contraceptive that can last up to 6 years, depending on the brands available in South Africa. IUDs are considered one of the most effective forms of birth control, with an efficacy rate of over 99%.
The IUD can be removed at any time, and you can get pregnant as soon as it is taken out. IUDs don’t protect against sexually transmitted infections (STIs).

What is an IUD?

An IUD is a small, T-shaped device that is inserted into the uterus through the vagina. It works by reducing the ability of sperm to reach the egg for fertilisation.
It has a flexible, plastic frame that opens into the shape of a “T” inside the uterus. Strings attached to the bottom of the IUD extend into the vagina so that it can be removed when needed. Sizes of IUDs vary from 28 – 32mm across, and from 30 – 36 mm down, fitting women of all ages and regardless if they’ve had a baby before.

Types of IUDs and how they work

There are two types of IUDs:

1. Hormonal IUDs: These release the progestin hormone levonorgestrel, which flows through the stem of the IUD. Progestins (a synthetic version of progesterone) is the same hormone used in many birth control pills. Each IUD brand contains a different amount of the hormone, which determines how long the IUD can be used for.

   Hormonal IUDs work by thickening the cervical mucus – which stops the sperm from getting into the uterus and reaching an egg, thinning the lining of the uterus and partly stopping the release of an egg. They work within seven days of insertion.

2. Copper IUDs: These contain a thin copper wire which coils around the stem part of the “T.” It releases a small amount of copper, which creates a toxic environment for sperm. They work immediately after insertion.

They protect against pregnancy until its expiry date. IUDs can also be used as emergency contraception up to five days after unprotected intercourse.

Who can use an IUD?

Most healthy women can use an IUD. They’re suitable for those with one partner and who are at low risk of contracting a sexually transmitted disease (STD) as IUDs don’t protect against STDs.

Who shouldn’t use an IUD

IUDs should not be used if:

• You have an active STD or considered high-risk for contracting an STD.
• You currently have pelvic inflammatory disease or you have a history of pelvic infections.
• You have cervical cancer or uterine cancer.
• You have unexplained vaginal bleeding.
• You are pregnant.
• You have breast cancer or have had it.
• You have liver disease.
• You have a uterus that is not formed typically.
• You had an infection following an abortion or childbirth in the past 3 months.

Copper IUDs should not be used if you have an allergy to copper or have Wilson’s disease (a genetic condition that causes copper to build up in your body). Hormonal IUDs should not be used if you have breast cancer or if you are considered high risk for breast cancer.
Although rare, the size or shape of your uterus may make it difficult to place an IUD correctly.

How is an IUD inserted?

An IUD is inserted by a healthcare professional. An IUD can be placed at any time in your menstrual cycle, or at least 4 weeks post-partum, but it may be more comfortable to insert it when you’re having your period because the cervix is most open.

The actual insertion process only takes a few minutes. The healthcare profession will insert a speculum into your vagina to hold it open. The IUD will be placed into an applicator tube, then inserted through your cervix into your uterus. Once the IUD is in place, the IUD’s “arms” will open, and the applicator will be removed.

Many women find the insertion process more uncomfortable than painful, while others experience moderate to severe abdominal pain, cramping, and pressure during the procedure. You might break into a sweat, feel nauseous, or get lightheaded. These side effects should abate by the next day.

If you’re concerned about the pain, cramping or feeling anxious, your doctor can prescribe medication in advance, such as pain relievers, an anti-anxiety medication, or a medication to soften your cervix. Taking a nonsteroidal anti-inflammatory medicine, like ibuprofen, 1 to 2 hours before the procedure might help reduce cramping. You can also request local anaesthetic or nitrous oxide (laughing gas) for use during the procedure.

Preparing for your appointment

• Before you go, eat a light meal or snack so you don’t get dizzy.
• Drink water for a possible urine sample for a pregnancy test.
• For pain, take an over-the-counter (OTC) pain reliever before the procedure or the medications prescribed by your clinician. You can also bring a heating pad or hot water bottle.
• Bring panty liners or pads.
• Wear loose, comfortable clothing.

After IUD insertion

• It’s normal to experience mild cramps. It can last for as long as 3 – 6 months.
• Take an OTC pain reliever, like ibuprofen, and a heating pad or hot water bottle to ease any discomfort. If you have very painful cramps, call your doctor right away.
• Wear panty liners or pads for any spotting.
• For at least 24 hours after insertion:
  • Don’t insert a tampon or menstrual cup.
  • Avoid bathing and swimming.
  • Don’t having penetrative sex (unless your doctor recommends that you wait longer).

Removal and replacement

When you are ready to remove your IUD or when it has reached expiry, a healthcare provider needs to remove it for you. You can have a new IUD inserted at the same appointment.

How do IUDs affect you period?

Standard-dose hormonal IUDs can cause your period to stop, whereas lower-dose hormonal IUDs may cause lighter monthly bleeding. Women have fewer cramps with hormonal IUDs.

Women who use copper IUDs usually have a monthly period. For the first few months after insertion, your period may be heavier and longer than usual, and you might experience cramping, which should improve over time.

The IUD can be removed at any time. Doctors suggest that women wait for one normal period before trying to conceive so that the endometrium can return to normal before implantation.

Can my partner feel my IUD?

If your partner does feel the strings, it will only be minor contact and it shouldn’t cause any discomfort. The strings do soften the longer you have the IUD and can be trimmed shorter.

Side effects

Irregular bleeding and cramping are common side-effects and the main reasons why women remove their IUD.

Hormonal IUDs can cause:

• irregular bleeding (during the first several months after insertion)
• light bleeding
• stopping of periods altogether (depends on the type of IUD)
• headaches
• acne
• breast soreness
• cramping or pelvic pain

Copper IUDs can cause:

• longer and heavier periods
• cramping

Complications

IUDs can be safely used by most women, and complications from IUDs are rare. However, the following can happen:

• The IUD comes out of the womb by accident (expulsion). If it happens, the IUD won’t protect you against pregnancy and your healthcare provider will need to replace the device.
• The IUD moves through the uterine wall (uterine perforation). If this happens, it needs to be removed surgically.
• You pick up an infection. The IUD increases your risk for pelvic inflammatory disease (PID), an infection of the uterus, fallopian tubes, or ovaries. There is less than a 1% risk of infection within the first six months following insertion and if it does occur, it can be treated with antibiotics.
• You get an ovarian cyst. They’re usually go away on their own within 3 months. Some can cause bloating, swelling, and severe pain (if it ruptures). If you have these symptoms, seek medical attention immediately.

Complications are more likely for women who are pregnant or if they have a current pelvic infection. If you do fall pregnant (less than 1% chance), puts you at risk for an ectopic pregnancy (the fertilised egg implants outside of the uterus). It also increases your risk of infection, miscarriage, and early labour and delivery.

Living and managing

Check monthly if you can feel the strings. If they feel shorter or longer, it may have moved, and you need to consult your doctor.

When to see a doctor

If you experience any of the following, see your doctor:

• severe pain and cramping in your stomach or lower abdomen
• heavy bleeding
• abnormal vaginal discharge
• fever, chills, or have trouble breathing
• bloating and swelling with pain in the lower abdomen
• the IUD is expelled or feels like its coming out
• the IUD string feels shorter or longer than before
• penetrative sex becomes painful
• you bleed during or after sexual activity
• you think you might be pregnant