Clinical Skills II: Female Reproductive (NSFW - Pictures Included)

Small, irregular, fleshy projections that are remnants of a ruptured hymen

What are hymenal caruncles?

o Family history - mother or sisters o Early menarche o Shortened menstrual cycles o Periods lasting 7+ days

What are the 4 risk factors for endometriosis?

*1.* Painful menstrual cycles *2.* Abdominal Cramping 2 weeks prior and during menstruation *3.* Low back, abdominal, or pelvic pain *4.* Pain with bowel movements or sexual intercourse

What are the 4 symptoms of Endometriosis?

Hormonal imbalance, endometriosis, fibroids, cancer

What are the causes of Metrorrhagia?

*Congenital*: Congenital adrenal hyperplasia or fraser syndrome *Acquired*: Hormone imbalance affecting adults like polycystic ovarian syndrome, neurofibromatosis, anabolic steroids/testosterone supplementation, female bodybuilders using androgens

What are the causes of clitoromegaly?

Bartholins: Secrete mucus to lubricate vagina. Are homologous to bulbourethral glands in males. Skenes: Drain into urethra near urethra opening.

What are the female genital glands?

Symptomatic in the acute phase (5-10) but otherwise symptom free. *1.* Pain in lower abdomen *2.* Fever *3.* Unusual discharge from vagina *4.* Pain and/or bleeding during sex *5.* Burning sensation when you urinate *6.* Bleeding between periods. (Those 6 symptoms are FYI. Not tested.)

What are the symptoms of Pelvic Inflammatory disease (PID)?

Redness and a thin grayish discharge. Signs/symptoms can be all over the place.

What are the symptoms of nonspecific vaginitis?

Birth control, medications, PCOS, and chronic conditions like diabetes and thyroid

What can cause Oligomenorrhea?

Irregular menstruation, PID, and endometriosis.

What can cause female infertility? (3 things presented in class)

congenital, hormonal, poor nutrition, tumors/infection/long term illness.

What can cause primary amenorrhea?

Irritation of peritoneum by bleeding from ovulation site.

What causes Mittelschmerz?

STI's. Chlamydia and Gonorrhea Microbes that ascended into pelvic region due to intercourse, childbirth, or surgery.

What causes Pelvic Inflammatory disease?

*Occurs with lack of estrogen* Itching Dryness Decreased elasticity Thinning of the labia minora

What causes atrophy of labia minora and intriotus? What are the symptoms?

Metrorrhagia

What do you call any uterine bleeding that is not related to menstruation?

Fishy smell

What does Bacterial Vaginosis smell like?

Usually pregnnacy, birth control medication, or as a postmenstrual phase. Can also indicate malignancy and infection.

What does Leukorrhea indicate?

*-* Soaking through one or more sanitary pads/tampons every hour for several consecutive hours. *-* Bleeding for longer than 7 days *-* Passing blood clots *-* Restricting daily activities due to condition *-* Symptoms of anemia (fatigue, SOB, etc)

What does Menorrhagia look like?

*-* Bluish discoloration of the cervix and vagina *-* Softening and compressibility of lower segment of the uterus in early pregnancy. (About 7th week)

What does a Gravid Cervix look like?

Common yeast like fungal organism (candida albicans) which infects vagina. Symptoms: *1.* itching *2.* Redness *3.* Swelling *4.* White curdy discharge which is a malodorous

What is Monilial Vaginitis? (Give 4 symptoms)

Acute or chronic inflammation of pelvic cavity. Particularly, suppurative lesions of upper female genital tract

What is Pelvic Inflammatory Disease (PID)?

o Involuntary loss of urine with increased intra abdominal pressure o Damaged external sphincter and pelvic diaphragm

What is Stress Incontinence?

Protozoal infection that is sexually transmitted. Symptoms: *1.* Itching *2.* Burning *3.* Malodorous frothy, yellow green discharge

What is Trichomonas Vaginitis?

Urogenital diaphragm problem The uterus may migrate to the vaginal opening with increased intraabdominal pressure

What is Uterine Prolapse?

One finger in the vagina and one finger in the rectum (so two fingers from same hand). Your free hand places pressure on bladder. This test is often omitted.

What is a Recto-Vaginal Palpation procedure?

Benign, reddish, fleshy growth situated at urethral meatus. Pain and bleeding present.

What is a Urethral Caruncle?

Two fingers in vagina. Palpate the abdomen with the other hand starting at the umbilicus. Press in and down toward the vaginal fingers attempting to "trap" structures inbetween.

What is a bimanual exam? How do we perform it?

Scarring. Accounts for a share of tubal infertility. May also raise the risk of ectopic pregnancies.

What is a complication of PID?

Associated with aging and diminished vaginal lubrication. Symptoms: *1.* Itching *2.* Redness *3.* Thin yellowish discharge *4.* Superficial erosions may be present. *5.* Leukoplakia or petechia may appear

What is atrophic vaginitis? (Give 5 symptoms)

Endometrial tissue in abnormal locations. These tissues do NOT shed with menstruation but will react to hormones. This creates *cyclic problems*.

What is endometriosis?

Amenorrhea in which menses has never occured. Diagnosed by: *1.* Failure to menses to occur by 16 in presence of normal secondary sexual charateristics *2.* Failure of menses to occur by age 13 without onset of puberty. (no secondary characteristics)

What is primary amenorrhea?

Amenorrhea in which menses appear at puberty but subsequently ceased. *Risk Factors*: Obesity, low body weight, sudden weight loss, emotional distress *Causes*: Pituitary tumors, chemotherapy, hyperthyroidism, PCOS, following a D and C.

What is secondary amenorrhea? What are the risk factors and causes?

The vaulted upper part of the vagina surrounding the uterine cervix. It is the ringed recess that forms around the cervix at it projects into the vaginal vault. (Anterior, posterior, lateral)

What is the Fornix?

Resembles tip of nose. Normally painlessly mobile

What is the cervix consistency like?

Papaniculoaou Smear A test for cervical cancer in which a smear of exfoliated cells is specially stained and examined under a microscope for pathological changes

What is the full name of a PAP smear? What is it?

BCP or hormone treatment. Should also be noted, endometriosis is better during pregnancy.

What is the treatment for Endometriosis?

Endocervical Polyp Benign growth or a tumor protruding from mucous lining of cervix. Observed as the cervical os.

What is this? Tell me about it.

Condyloma Acuminatum (Venereal wart) Soft wart papillomatous projection. Appears on vagina and within vaginal vestibule. Viral (HPV) in origin. Causes increased chances of cervical cancer.

What is this? What causes it and what complications can it cause?

Condyloma Latum Slightly raised, moist, flattened papules that appear on labia or within vagina vestibule. Sign of secondary syphilis.

What is this? What causes it?

Nabothian Cyst Small white/purplish firm nodule that commonly appears on the cervix. Forms wtihin the mucus-secreting Nabothian gands present in large numbers on the uterine cervix.

What is this? What causes it?

Uterine Fibriods (Leiomoyomas). Common benign masses of myometrium. Symptoms: *1.* Heavy menstrual bleeding *2.* Pelvic pressure *3.* Back or leg pain *4.* Frequent urination with incomplete voiding.

What is this? what are the symptoms?

10-15%

What percentage of U.S. couples experience fertility issues?

75% of women. Symptoms peak during the 20s and 30s.

What percentage of women experience PMS? What is the peak age for these symptoms? (When is PMS worse)

Buttocks should be just over the edge of the table, dorsal lithotomy, heels in stirrups at 45˚, knees dropped to the sides

What position should a patient be in during a pelvic exam?

deep in the labia majora close to the perineum

Where are Bartholin's gland?

both sides and below the urethra

Where are Skene's glands?

Below Clitorus. Check for discharge or inflammation

Where is the Urethral meatus? What do we examine it for?

Women 20-29 years old.

Which demographic has the highest PID instance?

Leukorrhea

White vagina discharge is called...

Because 74% of persons have been infected between the ages of 15-24. It is considered underestimated due to its asymptomatic nature.

Why is it so important to have annual Chlamydia tests?

Gravida (Often adds a number for how many pregnancies a woman has had "Gravida 3")

A pregnant woman is called a...

Para (followed by roman numerical to designate number of times a pregnancy has culminated in a single or multiple birth)

A woman who has given birth to one or more infants is called...

Mittelschmerz

Abdominal pain occuring at time of ovulation is called...

Dysmenorrhea

Abnormal pain associated with the menstrual cycle is called....

*Primary dysmenorrhea* is unrelated to a specific problem with the uterus or other pelvic organs. *Secondary dysmenorrhea* is often caused by endometriosis, fibroids, copper IUD, PID, PMS, STI, stress

Compare and contrast primary and secondary dysmenorrhea.

The uterus is about 3 inches long, 2 inches wide and an inch thick shaped like an inverted Bartlett pear with the head protruding into the vagina

Describe the uterus

When the woman have active ovarian functions

During bimanual palpation of the ovary, we usually do not feel it. When is it normal to feel?

Severe and disabling. - Nausea - Vomiting - Fainting - Intestinal cramping

Dysenorrhea becomes abnormal when it is.... (Include symptoms)

*1.* Mood swings *2.* Anxiety *3.* Cravings *4.* Appetite changes *5.* trouble sleeping *6.* Fatigue *7.* Poor concentration *8.* Tender breasts *9.* Headaches *10.* Joint Pain *11.* Abdominal Bloating *12.* Constipation *13.* Diarrhea *14.* Weight gain and fluid retention.

Give the symptoms of PMS (Generally). There are 14. Give me as many as you can remember.

*1.* Cervicitis *2.* Cervical cancer

Give the two causes of post coital bleeding.

1 in 16 with PID vs 1 in 147 for all women.

How much more likely does PID make an ectopic pregnancy?

*1.* Endocervical *2.* Cervical Scrape *3.* Vaginal Pool

In a PAP smear, three sample are obtained from....

*1/3*: Female related infertility *1/3*: Male related infertility *1/3*: Both partners. Its equal.

In females having fertility issues, is the female or male the more likely cause of the infertility.

*Uterine pathologies*: o Fibroids o Endometrial carcinoma o Retained conception products o Hormonal imbalance

Intermenstrual spotting of blood is caused by...

Hormonal imbalance Anovulation Fibroids Polyps Cancer Miscarriage or ectopic pregnancy Genetic bleeding disorders Medication

List 8 causes of Menorrhagia.

12.6 (on average)

Menarche usually occurs at age...

12 months after your last menstrual period. This marks the end of menstrual cycles.

Menopause occurs when?

Oligomenorrhea

Menstruation that is abnormally light or abnormally infrequent is called...

Antibiotics

Monilial Vaginitis occurs common after administration of...

More than 1 pregnancy

Multigravida designates...

Smears and cultures of vaginal secretions.

Since symptoms can be all over the radar for nonspecific vaginitis, how do we confirm a diagnosis?

False. Both are not.

T/F: Skenes are normally visible and bartholins are not.

True

T/F: When beginning a standard pelvic examination, we need to touch the patients thigh first to signal that the exam is beginning.

*Fungal (Candida or yeast)*: Thick, white, curd-like *Bacterial (Gardnerella)*: Thin vaginal discharge with a fishy odor *Protozoal (Trichomonas)*: STDS, white/grey/yellow/green vaginal discharge.

Tell me about the different types of vagina discharge and what causes them.

Perimenopause.

Term used to describe months leading up to true menopause is called...

Amenorrhea

The absence of menstruation is called...

Vestibule

The small cavity or space at the entrance of a canal is called the....

Lithotomy Position. It allows you to see the entire vagina.

This position is called....

General term meaning adjacent or related structures

Adnexa means...

Menorrhagia

An anormally heavy or extended menstrual period is called...

Clitoromegaly

An enlarged clitoris is called...

Gardnerella Vaginitis

Bacterial Vaginosis was formerly called...

Cystocele/Cystourethrocel Caused by protrusion of the urinary bladder through relaxed or weakened musculature

Bulging of the anterior vaginal wall is called what? What causes it?

Rectocele Caused by protrusion of the intestinal contents through relaxed or weakened pelvic musculature

Bulging of the posterior vaginal wall is called what? What causes it?

Squamocolumnar Junction

Cancer commonly occurs at the cervix where exactly?

Chlamydia, Gonorrhea, Herpes, Trichomonis

Cervicitis (inflammation with discharge) will be seen in what conditions?

Menarche

Onset of menstruation in adolescence or young adulthood is called...

Dyspareunia. Causes include: vaginal spasms, lack of lubrication, genital lesions, and abuse.

Pain associated with sexual intercourse is called what? (Include causes)

A woman who has given birth for the second time to one or more infants.

Para II, Secondipara is...

Irregular menses Hot flashes Night sweats Vaginal dryness Sleep disruption Emotional changes - anxiety, sadness Weight gain Hair thinning or loss Loss of breast fullness

Perimenopause symptoms include... (9)