Approch to the GYN Patient (CMPP)

What type of visit are most GYN visits

Preventive care

For the first time meeting a patient, how should you meet the patient

Fully dressed for history taking before preparing for the PE

What are some general tips for the GYN exam

performed slowly, gently, and with adequate explanation

Chaperone during breast and pelvic examination

To “talk before your touch,” as an unexpected touch may startle the patient

Patient should be instructed to empty her bladder before the examination

What are the aspects of menstrual hx

First day of LMP

Age of Menarche

Number of days of bleeding and number of days between

Duration and Quantity of Menses

Any recent changes

How do we write mesntrual hx in shorthand

Menarche x Cycle Length x # of days bleeding

(14×28×5)

How do we quantify the amount of menstrual flow per menses

Number of pads / tampons used during the heaviest days

If a patient reports clots in their menstural blood, what is considered normal size

Size of dime

What should be asked in menstrual history of reproductive / menopausal transition women

Current or recent heavy or intermenstural bleeding

Current or recent post-coital bleeding

Current or recent dysmenorrhea

Presence of molinimal or premenstural symptoms

What should be asked int he menstural hx of postmenopausal women

Age of last menses

Hx of Hormone Therapy

Hx of Postmenopausal Bleeding

Metrorrhagia

irregular bleeding between cycles

Menorrhagia

heavy bleeding

Menometrorrhagia

heavy bleeding and intermenstrual bleeding

Postcoital bleeding

bleeding after intercourse

If menses are predictable and associated with premenstural symptoms, then the patient

Is likely ovulating (If not on OCPs)

What is normal pad/tampon use for a regular volume mensus

Changing every 3+ hours

< 21 pads/tampons per cycle

Seldom need to change overnight

Clots < 1 in

Not anemic

Mittelschmerz

pain with ovulation

What should be done at every annual visit for GYN

Medication and allergies

Past medical history

Family history

Full review of systems (ROS)

How long is the average cycle

28 days ± 7 days

Menstruation

The sloughing off of endometrium

What regulates the ovarian and uterine cycle

LH

FSH

Estrogen

Progesterone

What are the phases of the uterine cycle

Menstrual (Day 1-5)

Proliferative (Day6-14)

Secretory (Day 15-28)

Menstrual Phase

Phase of the uterine cycle where the uterus sheds the endometrium in menses

Proliferative Phase

Phase of the uterine cycle

Estrogen is released from follicles and endometrium increases in thickness

Secretory Phase

Phase of the uterine cycle

Corpus luteum releases estrogen and progesterone that highly vascularize the uterus

Glands become coiled, tortuousm abd secreted clear fluid

Endometrium is prepared for implantation

What are the phases of the ovarian cycle

Follicular (Day 1-14)

Luteal (Day 15-28)

Follicular Phase

Phase of the ovarian cycle

Follicles release estrogen

Dominant follicle matures leading to ovulation

What marks the start and end of follicular phase

Start = 1st day of menses

End = LH surge

How is the ovarian cycle affected by age

Follicular phase shortens (along with mean cycle length)

Luteal phase stays constant

What marks the start and end of luteal phase

Start = LH surge

End = Menses

Luteal Phase

Phase of the ovarian cycle

Ruptured follicle from ovaulation becomes corpus luteum and secretes progesterone

Without implantation, corpus luteum degenerates increasing estrogen and progesterone

What causes menstruation to occur

The drop of progesterone at the end of luteal phase

What causes uterine cramping during menstruation

Prostaglandins

What occurs in the first part of follicular phase (Day 1-4)

Menstruation from progesterone withdrawl

Prostaglandins are released causing cramps

Follicle starts to grow and secrete estrogen

What causes the follicle to grow in follicular phase

FSH

granulosa cells

Follicular cells that secrete estogen

What stimulates granulosa cells to secrete estrogen

FSH

What effect does estrogen have on LH/FSH

Negative feedback

Dominant Follicule

The follicle during the follicular phase that secretes more estrogen than androgen

What occurs during the follicular phase (Day 1-14)

Estrogen is building up the endometrium

FSH is stimulating multiple follicles

Enough estrogen is produced to create a positive feedback, causing the LH surge

What causes ovaluation to occur

LH surger

When does ovaluation occur

Day 14`

What occurs during ovalution

LH surge causes the ovum to be released

Follicule becomes the corpus luteum and secreting estrogen and progesterone

What causes the LH surge

Enough estrogen is built up to cause a positive feedback

What occurs in the luteal phase (Day 14-28)

Corpus luteum secrete estrogen and progesterone

Estrogen and Progesterone causes secretory glands of the endometrium to develop

Progesterone prepares the endometrium for implantation

How long does corpus luteum last without presence of hCG

11 days

What releases hCG

Embryo

What effect does progesterone have on LH/FSH

Inhibits

What occur if fertilizaiton does not occur

Corpus luteum resolves

Progesterone and estrogen levels fall

Menses occur

Hypothalamic-pituitary axis is released from inhibition

What occurs if fertilization occurs during luteal phase

THe blastocyst will keep the corpus luteum working

Continues to secrete estrogen and progesterone

Endometrium will be prevented from sloughing

Blastocyst

Maturing zygote

Gravida

The total number of pregnanices

How are twins documented with OB hx

G1

P1

(Only affects living)

How is OB hx written

Gravida

Para

Full Terms

Prematures

Abortions / Miscarriages

Ectopics

Living

How is OB hx abbratived

G#P# (TPAL)

Para

outcomes of pregnancies

What should be asked about each pregnancy

Date of Delivery

Gestational Age at Delivery

Mode of Delivery with Indications for Operative

Maternal Complications

Fetal Complications

Delivery / Operative Complications

Neonatal Problems

Current health of child

What should be assessed for seuxal hx

Orientation

Marital Status

Number of Partners

Exposure to STIs

Contraceptions

Safe Sex Practicess

What should be asked about contraptive hx

When started

Complicaitons

Patient Satisfaction

Need for Contraception

Use of Natural Family Planning

Contraceptive Failure

Emergency Contraception Use

What other areas are important for the GYN PE

Vitals

General Apperance

Head and Neck

Heart

Lung

Abdomen

What important head and neck strucutre shoud be assessed with GYN exams

Thyroid

Why is the thyroid assessed for GYN appointments

Hypothyroid and Hyperthyroid both causes menstrual abnormalities

How frequently should a Clinical Breast Exam done

Annual

CBEs are most effective when combined with

Mammogrphy

As opossed to self breast exam, providers are now recommending to patients

Greater breast self-awareness

Why is a heart exam important for pregnant patients during GYN appointment

May be the first time a heart murmur will present

What are we looking for on abd exam for GYN?

Tenderness

Pain to Palp

Guarding

Rebound

Mass

Organomegaly

Ascites

What is inspected on pelvic exam

External Genitalia

Bartholin and Skene Glands

Developmental Abnormalities

Skin Lesions

Evidence of Infections

What is included in inspection of the external genitals

Hair

Labia Majora/Minora

Clitoris

Urethral Orfice

Hymen / Remant

Introtius

Perineum

Perianal

What hand is the speculum held in

Dominant

What is evaluated for on speculum exam

Vaginal

Cervical

Obtain Pap

Obtain Culture (PRN)

Pederson speculum

Flat and narrow blades

What speculum is used for nulliparous women

Pederson

What speculum is used for postmenopasual women

Pederson

What speculum is used for parous women

Graves

Graves Speculum

Blades that are wider, higher, and curved on the sides

Why are Graves speculum used for parous women

Wider, curved blades keep the looser vaginal walls separated for visualization

Failure to find the cervix on speculum exam is most commonly

not inserting the speculum far enough into the vagina

What should be assessed on the cervix

Lesions

Friability

Polyps

Signs of Infeciton

What is the order of obtaining samples for Pap Smear

transformation zone with Ayers spatula 1st

2nd insert cervical brush into the endocervical canal to obtain endocervical cells

Why do we place Pap samples in a thin prep liquid

For HPV typing

squamoucolumnar junction (SCJ)

The junction between the squamous epithelum outside and the columnar epithelium inside the endocervix

How does the SCJ change with age

Before puberty = SCJ is at / slighly above external os

As cervix matures, SCJ rolls outward and exposes columnar cells to the vagina

Squamous metaplasia occurs and a new SCJ forms

During menopause, the uterus and cervix decrease in size and the new SCJ comes to lie into the endocervical canal, out of view

transformation zone

The area betwen the original SCJ and the new SCJ where squamous metaplasia occurs

squamous metaplasia

The conversion of columnar cells from the endocervix is transformed into squamous epithelium due to exposure to mature hormones

External os

The orifce in the cervix separate the ectocervix from endocervix

Where is the most common site for cervical squamous cell carcinoma

Transformation zone

How is a vaginal culture obtained

Wipe away excessive vaginal secretion or discharge with Procto swab

Obtain secretions from mucosal membrane of vaginal vault with swab

Place swab in transport media

Send to lab

How is a cervical culture obtained

Visualize cervix via speculum

Wipe away secretions from cervix with Procto swab

Firmly, yet gently, sample endocervical canal with sterile swab

Place culture in transport media

Send to lab

How does sexual orientation affect STI screening in wome

It doesn’t

When do we screen for genital chlamydia in women

All sexually active women < 25 y/o (Annual)

High risk women > 25 y/o (Annual)

First Trimester Pregnancy (If < 25 y/o or high risk)

HIV infected (Annual)

When do we screen for genital gonorrhea in women

All sexually active women < 25 y/o (Annual)

High risk women > 25 y/o (Annual)

First Trimester Pregnancy (If < 25 y/o or high risk)

HIV infected (Annual)

When do we screen for HIV in women

At least once during lifetime

For pregnancy, during 1st trimester

When do we screen for HepB in women

At least once during lifetime

For pregnancy, during 1st trimester

First visit of HIV patient

When do we screen for Syphilis in women

At risk sexual active women (Annual)

First trimester, third trimester, and at birth

HIV patient (Annual)

What should be done for all at risk women for STIs and pregnan

Test again in the 3rd trimester

When do we screen women for HepC

At least once for at risk women (Over 18)

First prenatal visit for at risk or no prior screening

First visit with HIV patient

When do we screen women for trichomonais

At risk women (Annual)

First prenatal visit (If HIV +)

HIV patient (Annual)

How do STI screenings work for transgender patients

Screen via the guidelines for cisgender opposite

introitus

Vaginal opening

How is bimanual examination performed

Index and middle finger in vagina, evaluate for cervical motion tenderness (CMT)

Both fingers behind the cervix and other hand on the abdomen palpate the uterus for its position and size

Pelvic structures are caught and palpated between hands

Move internal fingers to the side of the uterus and gently press to evaluate the adnexa; repeat with the other side