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what are the glands of the vestibule?
Skene’s and Bartholin’s (greater vestibular)
where are the Skene’s glands?
paraurethral
where are the Bartholin’s glands?
posterolateral to the vaginal orifice
what is the vagina?
passage connecting uterus and introitus
what is the introitus?
opening of vagina
what are the borders of the vagina?
anterior = urethra
posterior = rectum
inferior = vulva
superior = cervix
what are rugae?
transverse folds where vaginal mucosa lies
what is the function of the vagina?
intercourse and birthing canal
what are the forcines of the vagina?
anterior
posterior
lateral (2)
where is the anterior fornix?
near vesico-uterine pouch
where is the posterior fornix?
betw posterior vagina and cervix near rectovaginal pouch
what can be palpated from the lateral fornices?
ovaries and fallopian tubes
what is the arterial supply of the vagina?
internal iliac a.
uterine a.
vaginal a.
where does the upper 1/3 of the vagina drain into?
inguinal nodes
where does the lower 2/3 of the vagina drain into?
pelvic, sacral, and abdominal nodes
what is the arterial supply of the uterus?
uterine and ovarian a.
where does the uterus drain into?
lumbar nodes
what is the ectocervix?
covering cervical face
what is the endocervix?
in cervical canal (AKA os)
what are the squamous cervical epithelium?
shiny, pink (outer)
what are the columnar cervical epithelium?
deep, red, plushy (inner)
where do the squamous and columnar cervical epithelium meet?
squamocolumnar junction
what is the transformation (transitional) zone?
AKA squamocolumnar junction, where pap smears are obtained
what occurs at the squamocolumnar junction?
area of constant cellular activity
highly sensitive to irritants, mutagens, and viral agents (HPV)
what is an anteverted/anteversion uterus?
NORMAL POSITION
forward facing
right angle to vagina
posterosuperior to bladder
anterior to rectum
what is a retroverted/retroversion uterus?
BACKWARD TILTED
tipped back aiming towards rectum INSTEAD of toward abdomen
what is a retroflexed uterus?
uterus is bent backwards towards rectum
what are the components of the adnexa?
ovaries
fallopian/uterine tubes
supporting ligaments (broad, round, ovarian)
what conditions are related to the adnexa?
masses or tenderness
what are the primary functions of the ovaries?
production of ova (eggs)
secretion of hormones
what hormones are secreted from the ovaries?
estrogen
progesterone
testosterone
what hormone is secreted by the hypothalamus?
GnRH
what hormones are secreted from the pituitary?
FSH and LH
what hormone is secreted from the follicle?
estrogen
what is menarche?
1st period
what are the aspects of the menstrual cycle?
days between day 1 and day 1
days of bleeding
regularity
associated moliminal sxs
what is menopause?
cessation of menses x 1 yr
what does G stand for in the GPA system?
gravida, total number of pregnancies
what does P stand for in the GPA system?
parity, pregnancies > 20 wks
what does A stand for in the GPA system?
abortions (spontaneous or induced termination)
what is a normal menstrual frequency?
> 24 and < 38 days
what is a normal menstrual duration?
< 8 days
what is dysmenorrhea?
painful menses
what is primary dysmenorrhea?
begins shortly after menarche and occurs with every menses
what causes primary dysmenorrhea?
increased endometrial prostaglandin synthesis —> increased tone
how is primary dysmenorrhea treated?
decrease prostaglandins (NSAIDs)
what is secondary dysmenorrhea?
acquired disorder as a result of endometriosis, IUDs, polyps, fibroids, obstruction of flow, etc
how is secondary dysmenorrhea treated?
treat primary cause
what is an imperforate hymen?
blockage of normal vaginal opening
what results from an imperforate hymen?
amenorrhea as a result of a vaginal outlet obstruction
what s/sxs are associated with amenorrhea?
lower abdominal pain, dysuria, bowel movement changes
how is an imperforate hymen treated?
perforation
what causes a painless vaginal chancre?
syphilis
what causes painful vaginal vesicles?
HSV
what causes painful vulva masses?
abscess of Bartholin gland
what causes vaginal venereal warts?
HPV
what is the normal vaginal pH?
< 4.5
what is leukorrhea?
vaginal discharge
what bacteria is predominant in a healthy vagina?
lactobacilli
during what part of the menstrual cycle are vaginal secretions clear and elastic?
estrogen surge
during what part of the menstrual cycle are vaginal secretions thicker and white?
Luteal phase
what is the most common cause of candida vaginitis?
Candida albicans
what risk factors are associated with candida vaginitis?
antibiotics/steroids
diabetes
OCP
immunosuppression
douching
tight clothing
what s/sxs are associated with candida vaginitis?
white, curd-like “cottage cheese” discharge
no odor
pruritis
dysuria
dyspareunia
how does candida vaginitis present on exam?
inflammed vulva/vagina mucosa
+/- friability with thick adherent white discharge
how is candida vaginitis diagnosed?
KOH prep with branching/pseudohyphae
how is candida vaginitis treated?
antifungal (oral, topical, intravaginal)
-AZOLE!!
what is bacterial vaginosis?
elusive pathogenesis, polymicrobial anaerobic overgrowth
what is the most common cause of bacterial vaginosis?
Gardnerella vaginalis
what risk factors are associated with bacterial vaginosis?
multiple sex partners
frequent intercourse
after douching
how is bacterial vaginosis diagnosed?
Gram stain and Amsel criteria (3/4)
what are the Amsel criteria?
homogenous, non-clumping VD
amine (fishy) odor when potassium hydroxide solution is added to vaginal secretions
presence of clue cells (> 20%) on microscopy
vaginal pH > 4.5
in what pathologies can the “whiff" test” be positive?
BV and trich
what are clue cells?
stippled appearance due to adherent coccobilli and fuzzy, obscured borders
how is BV treated?
metronidazole (Flagyl or Metrogel) (PO or topical/vaginal)
clindamycin (Cleocin or Clindesse) (PO or topical/vaginal)
what risks are increased with BV?
pregnancy complications
STIs
what is a common side effect of clindamycin?
C. diff infections
what is a common side effect of metronidazole?
disulfuram rxn
what are the signs/symptoms of trichomonas?
vulvovaginitis (dysuria, dyspareunia)
leukorrhea (yellow/gray/green, frothy, odor)
how does trichomonas present on exam?
vaginal erythema
“strawberry cervix” (punctate erythema on cervical face)
how is trichomonas diagnosed?
wet mount
culture
detected on pap smears
what is seen on a positive trich wet mount?
motile trichomonads (single celled parasite with 2-5 plagellae)
how does gonococcal cervicitis present?
green, yellow, no odor, adherent
pus from cervical os
what is vulvitis?
external genital pruritus, burning, redness, rash
what is vaginitis?
inflammation of the vagina
what is vulvovaginitis?
vaginal irritation, pain, and pruritus
what can cause vaginal itching?
candidiasis
glucosuria (DM, DM rx, renal tubule acidosis)
vulvar leukoplakia
external irritant
psychosomatic
what treatment should be AVOIDED for vaginal itching?
talcum powder on vulva
what can cause abdominal pain?
complication of pregnancy
acute inflammation
chronic inflammation
what acute inflammation can cause abdominal pain?
infections
ovulatory (mittelschmerz)
IUD
what chronic inflammation can cause abdominal pain?
structural/functional disorder
infections
what is dyspareunia?
pain during or after intercourse
what physiologic causes can cause dyspareunia?
infection
tumors (rectovaginal septum, uterus, ovaries)
atrophic vaginitis
inadequate lubrication
vaginismus
what is vaginismus?
severe pelvic pain and spasm when labia is merely touched
what psychogenic causes can cause dyspareunia?
fear of pregnancy
penetration anxiety
what can cause general changes in hair distribution?
dermatologic alopecia
dieting, stress
infection
idiopathic, autoimmune
thyroid disease
what is hirsutism?
excess hair on face, trunk, or limbs (male pattern)
what condition is associated with hirsutism?
PCOS
what s/sxs are associated with PCOS?
amenorrhea
oligomenorrhea
infertility
acne
obesity
aconthosis nigricans
what is virilization?
excessive hirsutism with receding temporal hair, deep voice, or clitoral enlargement
