Female Gu

who gets pelvic exam

all women 21+, unless you have an OB or GYN problem-specific complaint

<21 years old, inspect lesions but do not perform internal

what does the pelvic exam look at

size, position of vagina, cervix, uterus, and ovaries

when do you get a pelvic exam

• annually over 21 (regardless of sexual activity)

• during pregnancy

• suspect infection

• women with pain in her pelvic or low back area

why do you do a pelvic exam

diagnosis pathology such as pregnancy, infection or cancer

Mons pubis

fat pad over pubic symphysis

Labia majora

rounded folds of adipose tissue

labia minora

thinnner, pinkish red folds that extend anteriorly to form prepuce

vestibule

boat-shaped fossa btw labia minora

introitus

vaginal opening

perineum

tissue btw introitus and anus

urethral meatus

open into vestibule btw clitoris and vagina

paraurethral (skenes) glans

posterior to the urethral meatus on either side

• lubrication during sexual activity

Bartholins glands

located posteriorly on either side of vaginal opening

• normal secretion for lubrication

vagina

musculomembranous tube extending upward and posteriorly btw urethra and rectum

uterus

flattened fibromuscular structure shaped like inverted pear

cervix

lower part of the uterus (extend into vagina)

Adnexa

refer to ovaries, fallopian tubes and supporting tissues

where is the clitoris found

between the prepuce

size of ovaries

3.5 cm

when are ovaries palpable

only in childbearing age

shrink after menopause due to increase in hormones→ if felt may indicate cancer

ectoervix

outer surface, squamous epithelium surround the os

transformation zone

squamocolumbar junction migrates toward os as patient ages

where is cervix located

top of vaginal canal

where is pap smear sampled from

transformation zone

describe cervix during puberty

broad band of deep red columnar epithelium around os is replaced by squamous epithelium

why do you look at cervical os when doing an exam

slit like indicate pregnancy

average age of menarche

12.5

normal cycle length

21-35 days

average 28 days

why is menarche before average age concerning

increased exposure to hormones = increased risk for endometrial or breast cancer

typical length of menses

3-7 days

why is long menses (7+ days) of concern?

risk of anemia (same with heavy flow)

dyspareunia

pain with intercourse

how to classify heavy, light, moderate flow?

number of tampons per hour

amenorrhea

absence of menses

no menarche by 15 yo (primary) or >3 missed menstrual periods (secondary)

PMS

emotion, behavioral and physical sx occurring 5 days before menses for 3 consecutive days

menopause

12 mo without menses

premenopausal

intermittent menses

premature ovarian failure

menopause < 40 yo

post menopausal bleeding

bleeding >6 mo or more after cessation of menses

polymenorrhea

cycle last <21 days

oligomenorrhea

infrequent bleeding

menorrhagia

abnormally heavy menstrual bleeding

metrorrhagia

uterine bleeding at irregular intervals

postcoital bleeding

bleeding after intercourse

Gravida

total # of pregnancies

Para

outcome of pregnancies

GP (FPAL)

full term

premature

abortions

living children

what is considered premature

under 37 weeks but over 20

20-36 weeks

what is considered a full term pregnancy

37 weeks

what is considered abortion

under 20 weeks

acute pelvic pain is considered? chronic

< 6 mo

at least 6 mo

DES exposure if likely if pt born before

1971

may be at risk for vaginal or cervical cancer due to exposure

myomectomy

removal of fibroids (benign)

common surgeries

• hysterectomy

  • partial or complete

• Ovarian cystectomy

• C section

• Myomectomy

A 34 yo female present today for her first pre-natal visit. She tells you that she has 1 living child that was preemie. She had 2 elective abortions when she was 17, 1 miscarriage, 1 full term child that passed away at 6 mo due to SID. What are her G and P

G6 P(F1 P1 A2 L1)

patients should have nothing in the vagina for …. hours prior to a pelvic exam

48 hours

no sexual activity, tampons, douching

T/F you should no void prior to exam

F- you should void

pressing on bladder can be uncomfortable

position of pelvic exam

dorsal lithotomy

bimanual exam palpation

used to check a woman's internal pelvic organs

• inserts two fingers into the vagina and then places pressure with the other hand to the lower part of the belly

tanner stage 1 (typically prior to age 11)

elevation of nipple only

no pubic hair, only fine hair

tanner stage 2 (typically age 11-12)

breast bud stage. Elevation of breast and nipple as small bud

sparse pubic hair, mostly along labia

tanner stage 3 (typically age 12-13)

further elevation of breast and areola with no separation of their contour

pubic hair become darker, coarser, curlier

tanner stage 4 (typically 13-14)

projection of areola and nipple to form a secondary moud

almost adult like, but pubic hair does not cover medial thigh

tanner stage 5 (14-15)

mature breast, projection of nipple, but areola receded to general contour

adult quality and quantity of hair, extending to thigh

inspect external genitalia

1. mons pubis

2. vulva

3. vaginal introitus

4. clitoris / urethral meatus

5. perineum

T/F hymnal ring break with pregnancy, intercourse, tampons

F- stretches, it doesnt break

risk factors of vulvar carcinoma

HPV and DES exposure

anatomic variation of normal hymen

vulvar carcinoma

cancer of labia and genital skin

Bartholin cyst

usually 4 and 8 oclock

need drainage

Condyloma Accuminata (HPV)

genital region and anus

difficult to treat

M and F

Syphilitic chancre

1st sign of syphilis

NOT painful

indurated red base

same in M and F

Genital herpes

itchy, burning and tingling (may occur before lesion even appear)

2 types

I- cold sores

II- genital

• only distinguish with culture

Pubic lice

Different speculums

• Pederson or Graves

• Metal or plastic

• Small, medium and large

what you need for internal pelvic exam

1. speculum

2. culture supplies

3. pap smear: scrap, brush, broom

4. water based lubricant / gloves

5. good lighting

regular culture screening should be done on individuals who are…

under 25 and sexually active → over 25+ dont need culture unless abnormality

screen for chlamydia

pederson or graves

pederson: long and skinner

Graves: shorter and wider

what angle do you hold speculum at when youre inserting for a pelvic exam

45 degree downward slope

yellow-green d/c indicative of

STI

red d/c indicative of

menstruation, cervical infection, cervical polyps, endometrial or cervical cancer

pink d/c indicative of

cervical bleeding, vaginal irritation, implantation bleeding

grey d/c indicative of

BV

clear d/c indicative of

healthy, pregnancy, ovulation, hormonal imbalance

white d/c indicative of

healthy, yeast infection

candidal vaginitis

white, curdy, thick and not malodorous

“cottage cheese”

may see yeast bugs on culture (not always, diagnose by sx)

BV

gray or white, thin, milky, malodorous

associated with fish odor

CLUE CELLS on wet mount

can do whiff test

whiff test

test for BV

mix sample with KOH solution

Trichomonal vaginitis

yellowish green and gray, frothy, malodorous

not fishy

mobile parasites on culture (distinguish BV) present in 75% pt

cervical scrape during pap smear

press turn and scrape clockwise

• full circle

• extocervix

endocervical brush

roll it btw thumb and index finger, clockwise and counter clock wise

what two fingers do you use to perform bimanual exam

index and middle finger

normal position of uterus

ante-verted (AV) at mid position (M)

when to do a recto vaginal exam

• recto-vaginal wall

• recto- vaginal pouch

• retroverted uterus

• rectal masses

• anal sphincter tone

• pelvic structure and pathology when vaginal exam is not possible

• screen for colorectal cancer

hemoccult examines

blood in stool not visible to naked eye

what does the inguinal nodes drain

vulvar and lower vagina

pelvic and abdominal lymph nodes drain

internal genitalia and upper vagina

non palpable

cervical cancer screening: pap smear according to ACOG/ACS/ USPSTF

begin at age 21

age 21-29: PAP q3 years

30-65: PAP q3 years

<30 yo: do not offer HPV co-testing

age 30-65: can opt for HPV cotesting q 5 years (preferred)

can d/c if pt has a total hysterectomy or >65 years with adequate screening hx and are not otherwise at high risk for cervical cancer (no recent abnormal PAP)

HPV

most common sexually acquired infection in the words

can be passed even when infected person has no signs or sx; sx can develop years after exposure

most HPV infections are self-limiting; persistent infection with oncogenic HPV type cause cervical cancer