Female Reproductive Anatomy, Screening, and Tanner Stages

What is the vulva?

The external genitalia

Where are Skene's glands located?

Posterior to the urethral meatus

Where are Bartholin's glands located?

On both sides of the introitus

Are Bartholin's glands normally visible or palpable?

No, not normally visible or palpable

What are vaginal folds made of?

Rugae

What two structures make up the uterus?

The fundus and the cervix

What structures make up the adnexa?

The fallopian tubes and ovaries

What shape is the external cervical os in a multiparous woman?

Slit-like

What shape is the external cervical os in a nulliparous woman?

Round

What type of epithelium is found centrally at the cervical os?

Columnar epithelium

What type of epithelium surrounds the central cervical os?

Squamous epithelium

What is the transformation zone of the cervix?

The squamocolumnar junction

Why is the transformation zone clinically significant?

It is at the greatest risk of dysplasia

What shape is a normal ovary?

Almond shaped

How often is the ovary palpable on exam during reproductive years?

About half of the time

What is the definition of infertility?

Inability to conceive after 1 year of sexual intercourse

What maternal medication history is important to ask about?

Whether the patient's mother received diethylstilbestrol (DES) while pregnant with her

Which HPV subtypes are most associated with cervical cancer?

Subtypes 16 and 18

What are risk factors for cervical cancer related to screening and lifestyle?

No screening, multiple sexual partners, smoking, immunosuppression

What are additional risk factors for cervical cancer?

Long-term contraception use, prior cervical cancer history, and family history

At what age should average-risk women begin Pap smears, and how often?

Age 21, every 3 years until age 30

What are the cervical cancer screening options for ages 30-65?

3-year cervical cytology, 5-year high-risk HPV testing alone, or a 5-year cotest

When can cervical cancer screening be stopped or is not needed?

After age 65, after hysterectomy, or if younger than 21

At what age should the HPV vaccine be given?

Ages 11-12, or as early as age 9

Who should receive annual gonorrhea/chlamydia screening?

All sexually active women under 25, and older women if still sexually active

What screening should all pregnant women receive?

Chlamydia, syphilis, hepatitis B, and HIV screening

How often should HIV testing be performed in adults?

At least once in all adults ages 13-64

What position should the patient be in for a pelvic exam?

Lithotomy position

What are the normal characteristics of the cervix on exam?

Pink, even, midline, projecting 1-3 cm into the vagina, about 2.5 cm in diameter

What is the Chandelier sign?

Cervical motion tenderness

What condition does a positive Chandelier sign indicate?

Pelvic inflammatory disease (PID)

What should be avoided before performing a Pap smear?

Avoid during menstruation; avoid topical products or intercourse for 48 hours prior

How many specimens are taken for a Pap smear, and from where?

One from the endocervix and one from the ectocervix, or combined using a broom/brush

What additional tests should be done alongside a Pap smear?

Culture for gonorrhea and chlamydia; wet mount for trichomonas, vaginosis, or candidiasis

What are the three purposes of a rectovaginal exam?

Palpate a retroverted uterus, uterosacral ligaments, and adnexa; screen for colorectal cancer; assess pelvic pathology

How do you evaluate a female patient for a groin hernia?

Have the patient stand and perform Valsalva while checking for bulging in the inguinal region

What is the special test for urethritis in women?

Milk the Skene's/paraurethral glands and send the obtained discharge for testing

What physical changes can occur in transgender men on testosterone therapy?

Increased hair growth, clitoromegaly, alopecia, and acne

What effect does testosterone have on the vagina in transgender men?

Vaginal atrophy

What new FDA-approved option is available for vaginal discharge and Pap testing?

Self-collection

What exam considerations apply to transgender women?

Anoscopy may be more appropriate; may have retained prostate tissue, so consider prostatitis

At what age do breast and pubic hair development typically begin?

8-10 years old

What is Tanner staging based on?

A sexual maturity rating based on a study of Caucasian females

Pubic hair Tanner Stage 1 — what does it look like?

Preadolescent; only vellus hair present

Pubic hair Tanner Stage 2 — what does it look like?

Sparse, straight, downy hair

Pubic hair Tanner Stage 3 — what does it look like?

Darker, more coarse/curly hair

Pubic hair Tanner Stage 4 — what does it look like?

Adult-type hair, not yet extending to the medial thigh

Pubic hair Tanner Stage 5 — what does it look like?

Adult pattern, inverse triangle, extending to the medial thigh

Breast Tanner Stage 1 — what does it look like?

Small elevated nipple only

Breast Tanner Stage 2 — what does it look like?

Breast bud with a small mound and widened areola

Breast Tanner Stage 3 — what does it look like?

Further enlargement, with the nipple flush with the breast surface

Breast Tanner Stage 4 — what does it look like?

A secondary mound of areola and nipple above the breast contour

Breast Tanner Stage 5 — what does it look like?

Areola flush with the breast contour; only the nipple protrudes

What is endometriosis?

Presence and growth of endometrial tissue outside of the uterus

What symptoms may endometriosis present with?

Pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and infertility

What is condyloma acuminatum, and what causes it?

Genital warts caused by HPV

What do condyloma acuminatum lesions look like?

Painless, flesh-colored, single or cauliflower-like

What does a syphilitic chancre look like?

Small, solitary, silver, erodes to a red ulcer; painless

What virus most commonly causes genital herpes?

HSV-2

What are the symptoms of genital herpes?

Pain, dysuria, fever, vesicles, and possible inguinal adenopathy

What are the exam findings of a Bartholin's cyst?

Painful, swollen, and fluctuant

What is the most common histologic type of vulvar carcinoma?

Squamous cell carcinoma

What symptoms may vulvar carcinoma present with?

Pruritus, burning, a lesion, or pain

What are the characteristic features of candidiasis discharge?

Very itchy, thick, white, cottage-cheese-like discharge, not malodorous

How is candidiasis diagnosed?

KOH prep, showing branched hyphae

What are the characteristic features of trichomoniasis?

Itchy, watery, malodorous, frothy green discharge with petechiae

How is trichomoniasis diagnosed?

Wet mount showing flagella

What are the characteristic features of bacterial vaginosis?

Diffuse, creamy discharge with a fishy odor

How is bacterial vaginosis diagnosed?

Presence of clue cells on wet mount

What are the symptoms of chlamydia infection?

May be asymptomatic, dysuria, postcoital bleeding, yellow-green discharge, friable cervix

How is chlamydia diagnosed?

Urine NAAT

What are the symptoms of gonorrhea infection?

Vaginal discharge, bleeding, dysuria; may be asymptomatic

How is gonorrhea diagnosed?

Culture

What is Chadwick's sign?

Bluish discoloration of the cervix/vagina due to increased blood flow

When does Chadwick's sign appear, and what does it indicate?

6-8 weeks post-conception; an early sign of pregnancy

What are the presenting symptoms of cervical carcinoma?

Bleeding, pain with intercourse, and an irregular lesion

What are the bimanual exam findings of cervical carcinoma?

An enlarged, firm, immobile cervix

What is a cystocele?

A prolapsed bladder

What are the symptoms/findings of a cystocele?

An anterior bulge that is soft and round, a feeling of pressure, and stress incontinence

What is a rectocele?

A prolapsed rectum, presenting as a posterior bulge

What are myomas of the uterus?

Common, benign uterine growths

What common benign finding can occur in the adnexa?

Ovarian cysts

What is PID?

Infection of the uterus, tubes, and other pelvic organs

What is PID typically a complication of?

Many sexually transmitted infections

What is salpingitis?

Inflammation of the fallopian tubes

What condition is salpingitis often associated with?

Pelvic inflammatory disease (PID)