Week 7

• Sex


  Biological process of human reproduction via sexual intercourse
• Gender


  Socially constructed roles, behaviours, expressions and identities of girls, women, boys, men and gender diverse people
• Intersex


  • A general term for a person born with reproductive or sexual anatomy that doesn't fit the boxes of female or male
  • It is a naturally occurring variation in humans - it is not a medical problem (i.e. surgical interventions or hormone therapy aren't medically necessary)
  • Some intersex people have genitals or internal organs that fall outside the male/female categories
  • Other intersex people have combinations of chromosomes that are different to what we usually consider "normal", i.e. combinations other than XY and XX
  • Some people are born with external genitals that fall into the typical male/female categories, but their internal organs or hormones don't
  • The six biological karyotype sexes (that don't result in death to the foetus) are:
• Hermaphrodite


  An organism that has both kinds of reproductive organs and can produce both gametes associated with male and female sexes
• The term hermaphrodite is not applied to humans; there are no identified cases of a human reproducing as both male and female
• Eunuch


  In contemporary practise, this refers to biological males who have undergone voluntary castration (i.e. have had their testicles and/or penis removed) for reasons other than male to female transition (e.g. traumatic mutilation due to accident)
• Legally, these individuals are still considered male. However, when castration is performed in pre-pubescent boys, castration alters their sexual development; it leads to a higher than typical pitch, the growth of breasts, wider hips, and a lack of facial hair. The removal or mutilation of testes of adult males results in infertility but has a smaller influence on their appearance
• Trans or transgender


  Refers to a person who has changed or is in the process of changing, their biological sex by undergoing medical treatment such as hormone replacement therapy (HRT) and optionally sex reassignment surgery (SRS), or rarely only SRS
• Sex


  Biological attributes, when someone is classified as male or female, noting there is variation in the biological attributes that comprise sex and how those attributes are expressed
• Gender


  The socially constructed roles, behaviours, expressions and identities of girls, women, boys, men and gender diverse people
• Traditionally the terms men/man and woman/women have been used in relation to gender (as opposed to 'male' and 'female')
• Gender is increasingly understood as not binary but on a spectrum
• Transgender


  An umbrella term for people whose gender identity is different from the sex assigned at birth
• Importance of sex and gender in pharmacy practice

  • Communication - Traditionally, respectful communication between health professionals and patients has required the use of prefixes such as Mrs or Mr and reference to gendered pronouns. It is important to confirm a persons preferences at the start of your consultation - if in doubt simply ask if they'd prefer to be referred to by their first name. In written correspondence, "they/them/their" are appropriate non-gendered terms.
  • Clinically - For guidelines where there are separate recommendations for male versus females, it is important to be aware of any differences in biological sex characteristics. This is even more important for individuals who are transitioning, where there are ongoing physiological changes over time.
• Female reproductive anatomy


  • The ovaries contain all of the primordial and developing follicles
  • The fallopian tubes carry the released ovum to the uterus
  • The uterus consists of three layers of tissues: Perimetrium is the outer smooth muscle layer that contracts during the menstrual period to allow shedding of the endometrium, Myometrium is the middle smooth muscle layer that contracts during childbirth in response to oxytocin from the posterior pituitary to help expel the foetus from the uterus, Endometrium is the inner, highly vascularised layer that build up over the course of the menstrual cycle to allow implantation of a fertilised ovum, and then sheds during menstruation if the oocyte is not fertilised
  • The cervix forms a barrier or doorway between the uterus and the outside of the body to exclude pathogens from the vagina and allow sperm to enter the uterus. It is also responsible for producing cervical mucus that assists sperm movement
  • The vagina is the entry point to the uterus, where sperm is deposited. It also contains a collection of bacteria, some of which have protective roles, such as preventing urinary tract infections
• Hormonal regulation of the female reproductive system

  • The length of the menstrual cycle is typically 28 days
  • The initial stages of the 28 day cycle, from the day menstruation starts (day 1) to the say ovulation occurs (day 14) is called the follicle phase. This phase is called that because it is the period over which follicles are recruited and matured in the ovaries. The follicle phase is under the control of the FSH
  • The final stages of the 28 day cycle (from the day of ovulation to the start of the next menstrual period) is called the luteal phase. This phase gets its name from the fact that what remains of the mature follicle after the oocyte is released forms the 'corpus luteum', a cellular structure that produces large amounts of estrogen and progesterone to build the endometrium lining to allow implantation of a fertilised ovum. If fertilisation does not occur, the corpus luteum degrades to form the corpus albicans, which does not produce estrogen and progesterone. As a result, hormone concentrations fall, triggering the start of menstruation
  • Before ovulation, estrogens are the primary ovarian hormones. After ovulation, both progesterone and estrogens are secreted by the corpus luteum
• Feedback mechanisms that control female hormone production

  1. In the menstrual phase, GnRH released from the hypothalamus stimulates the release of FSH and LH from the anterior pituitary. FSH stimulates the initial development of ovarian follicles

  2. In the preovulatory stage a dominant follicle secretes estrogen and inhibin, causing a decrease in FSH via a negative feedback mechanism which stops other less developed follicles from growing. High levels of estrogen from the almost mature follicle exert positive feedback on the hypothalamus and anterior pituitary. This causes the release of more GnRH, LH and FSH, the LH surge brings about ovulation

  3. In the postovulatory phase the corpus luteum forms under the influence of LH. LH stimulates the corpus lumen to secrete progesterone, estrogen, relaxin and inhibin. If the oocyte is not fertilised the levels of these hormones decreases, resulting in positive feedback on the hypothalamus and anterior pituitary to release GnRH, FSH and LH and a new cycle begins. The withdrawal of progesterone and estrogen if an oocyte is not fertilised is what causes menstruation
• The average length of a menstrual cycle is 28 to 29 days, but every woman's cycle is different. For example teenagers might have cycles that last 45 days, whereas women in their 20's and 30's might have cycles that last 21 to 38 days
• The first period is called menarche. In western countries the average age for a first period is 12 to 13, but is can start as early as 9 and as late as 16
• The last period is called menopause. In Australia, the average age for women to reach menopause is 51 to 52. some women might reach menopause as late as 60
• Menstrual disorders


  • Normal physiological processes that present distressing signs and symptoms for which a female may seek treatment, such as menopause and period pain
  • Health disorders that involve irregularities/changes to normal biology and physiology, that require treatment, such as heavy menstrual bleeding (menorrhagia) and bleeding disorders, amenorrhoea (the absence of a menstrual period in a woman if reproductive age), and dysmenorrhoea (excessively painful periods that can affect functioning for several days per cycle)
• Individualised assessment and management

  • Important for health and quality of life
• Health disorders


  • Irregularities/changes to normal biology and physiology, that require treatment
• These disorders may impact fertility (and, often, are diagnosed when there are problems with fertility)
• Common health issues relating to menstruation


  • Heavy menstrual bleeding (menorrhagia) and bleeding disorders
  • Amenorrhoea
  • Dysmenorrhoea
  • Premenstrual cycle
• Amenorrhoea


  The absence of a menstrual period in a woman if reproductive age
• Types of amenorrhoea


  • Primary amenorrhoea - menstruation never begins at puberty
  • Secondary amenorrhoea - menstruation ceases following previously normal menstruation
• There are several possible causes for amenorrhoea including pregnancy, breastfeeding, eating or thyroid disorders, excessive exercise or menopause
• Dysmenorrhoea


  Excessively painful periods that can affect functioning for several days per month
• Dysmenorrhoea can occur without an underlying problem or may be due to an underlying condition such as endometriosis or uterine fibroids
• Premenstrual syndrome (PMS)


  A group of varied symptoms that occur in females, typically between ovulation and a period (i.e. 1-2 weeks before a period starts)
• The cause of PMS isn't fully understood but likely involves changes in hormones during the menstrual cycle
• Symptoms of PMS


  • Physical functional symptoms such as fatigue, tender breasts, bloating, food craving
  • Mood swings including mood swings, irritability, anxiety and depression
• PMS can affect females of any socioeconomic, cultural or ethnic background
• Premenstrual dysphoric disorder (PMDD)


  A severe form of PMS with symptoms like anger, irritability, depression and internal tension that are severe enough to interfere with daily activities
• PMS is common, affecting up to 75% of females with regular cycles
• PMDD affects 3 to 8% of females
• Treatments for PMS


  • 600mg calcium carbonate twice daily
  • Chasteberry extract
  • Selective serotonin reuptake inhibitors or SSRIs. If taken in low doses before a period starts, may help the mood swings of PMS
  • Anti-prostaglandin for cramps
  • Anti-inflammatory or a Spiro lactone diuretic for bloating
  • Contraceptive pill - the pill can help relieves symptoms especially in those who also need contraception. The Pill stops ovulation which can make periods lighter and less-painful
  • Other hormonal contraceptive methods - contraceptive injections or implants which stop ovulation may also work to reduce PMS
• Polycystic ovarian syndrome (PCOS)


  Characterised by elevated androgen levels, menstrual irregularities and/or small cysts on one or both sides
• PCOS can be morphological (polycystic ovaries) or predominantly biochemical (hyperandrogenemia) - this means that the presence or absence or cysts on the ovaries does not define PCOS