AHA CH 18 Female Genitalia

Case Study Ms. Harris is a 33-year-old woman who presents to the urgent care center. Listed below are data collected by the examiner during the interview and examination. Interview Data Ms. Harris tells the examiner, "I have a really bad pain in front of my butt. It hurts so much that I can't even wipe with a tissue after I go to the bathroom." She indicates that the pain started 2 days ago and is much worse now. When asked about her sexual activity, Ms. Harris says, "I have a guy that I'm with, but it's not exclusive or anything. We see other people and try not to be real serious." Examination Data External: Typical hair distribution; urethral meatus intact; no redness or discharge. Perineum intact. Extreme pain response to palpation of vaginal opening. Swelling, redness, and mass detected on right side. Foul-smelling discharge noted. Internal: Examination deferred because of extreme pain associated with inflammation . 1. What data deviate from normal findings, suggesting a need for further investigation? 2. What additional questions could the examiner ask to clarify symptoms? 3. What additional physical examination, if any, should the examiner complete? 4. What primary problems does the patient have?

1. What data deviate from normal findings, suggesting a need for further investigation? Pain in front of butt. Swelling, redness, mass detected on right side. Foul-smelling discharge. Extreme pain. 1. Data deviating from normal: History suggests some type of acute inflammation. History is also suggestive of multiple sex contacts; primary partner has multiple sex contacts. Mass with inflammation, discharge, and extreme pain to palpation needs further evaluation. 2. What additional questions could the examiner ask to clarify symptoms? When was the last time she had sexual intercourse. Did she use a condom, or other form of birth control? Is there a chance she could be pregnant? How soon after intercourse did symptoms develop? 2. Ask patient about sexual history and associated medical problems, if any. Identification of protection (or lack of) would also be helpful. 3. What additional physical examination, if any, should the examiner complete? LAB for STI panel 3. A culture of discharge should be obtained for evaluation. If patient is too uncomfortable for internal examination, this may need to be delayed until the inflammation has resolved. 4. What primary problems does the patient have? An STI 4. Based on symptoms and findings, the patient most likely has an acute abscess of the Bartholin gland. This is frequently associated with gonococcal or staphylococcal infection.

Amenorrhea

Absence of period

10. Infection with HPV O: ovarian cancer C: cervical cancer E: endometrial cancer

C: cervical cancer

2. Smoking O: ovarian cancer C: cervical cancer E: endometrial cancer

C: cervical cancer

5. Multiple pregnancies O: ovarian cancer C: cervical cancer E: endometrial cancer

C: cervical cancer

7. Multiple sex partners O: ovarian cancer C: cervical cancer E: endometrial cancer

C: cervical cancer

Ovulation

Day 13 or 14 Ovary - Egg is expelled from follicle into abdominal cavity and drawn into the uterine (fallopian) tube by fimbriae and cilia; follicle closes and begins to form corpus luteum; fertilization of egg may occur in outer third of tube if sperm are unimpeded Uterus -End of proliferative phase; progesterone causes further thickening of the uterine wall. CNS hormones LH and estrogen levels INCREASE rapidly; LH surge stimulates release of egg Symptoms Mittelschmerz (ovulation pain) may occur with ovulation; cervical mucus is increased and is stringy and elastic (spinnbarkeit).

Secretory phase

Day 15 to 20 Ovary -Egg (ovum) is moved by cilia into the uterus Uterus -After the egg is released, the follicle becomes a CORPUS LUTEUM; secretion of progesterone increases and predominates. CNS hormones LH and FSH levels DECREASE

menstrual phase

Days 1 to 4 Ovary -Estrogen levels begin to rise, preparing follicle and egg for next cycle Uterus - Progesterone stimulates endometrial prostaglandins that cause vasoconstriction; upper layers of endometrium shed Breast -Cellular activity in the alveoli decreases; breast ducts shrink. Central nervous system (CNS) hormones -Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels DECREASE Symptoms - Menstrual bleeding may vary, depending on hormones and prostaglandins.

Premenstrual, Luteal phase

Days 21 to 28 Ovary - If implantation does not occur, the corpus luteum degenerates; progesterone production decreases, and estrogen production drops and then begins to rise as a new follicle develops. Uterus -Menstruation starts around day 28, which begins day 1 of the menstrual cycle. Breast -Alveolar breast cells differentiate into secretory cells. CNS hormones Increased levels of gonadotropin-releasing hormone (GnRH) cause increased secretion of FSH. Symptoms Vascular engorgement and water retention may occur.

Post menstrual phase

Days 5 to 12 Ovary - Ovary and maturing follicle produce estrogen; follicular phase—egg develops within follicle Uterus- Proliferative phase—uterine lining thickens Breast-Parenchymal and proliferation (increased cellular activity) of breast ducts occurs CNS -hormones FSH stimulates ovarian follicular growth.

Hypomenorrhea

Decreased flow during normal duration

4. High socioeconomic status O: ovarian cancer C: cervical cancer E: endometrial cancer

E: endometrial cancer

9. Obesity O: ovarian cancer C: cervical cancer E: endometrial cancer

E: endometrial cancer

Changes in female genitalia in the older adult

Endocrine changes, ovarian function diminishes during the 40's. Menstrual periods cease, although fertility may continue. Median age for menopause in the US is 51 (41-59) Estrogen levels decrease, labia and clitoris become smaller. Labia major becomes flatter due to loss of body fat. Public hair turns gray and is sparser. Adrenal androgens and ovarian testosterone levels decrease, which may account for decreases in libido and muscle mass and strength. Vaginal introits gradually constricts. The vagina narrows, shortens and loses its rug. The mucosa becomes thin, pale, and dry. Cervix becomes smaller and paler. Uterus decreases in size and the endometrium thins. Ovaries decrease 1 to 2 cm. Follicles disappear and the surface of the ovary convolutes. Ovulation ceases 1 to 2 years after menopause. Ligaments and connective tissue of the pelvis sometimes loses elasticity and tone, weakening the supportive sling for pelvic contents. Vaginal walls may lose structural integrity. Systemic effects include increase in body fat and intraabdominal deposition of body fat. Low-density lipoprotein cholesterol increases. Thermoregulation is altered producing hot flashes.

Hypermenorrhea

Excessive flow during normal duration

1. Lillian is a 42-year-old blind patient who requests a routine examination. How should the examiner approach this patient to best meet her needs?

Explain what is going to happen and let the patient know when she is about to be touched. 1. The key concept when performing an examination on a patient with a visual impairment is to explain everything that is to occur, as well as what you want the patient to do. Before the examination, the patient should be given an opportunity to explore the instruments used during the examination. Other general concepts to keep in mind include introducing yourself, remembering to identify others who enter the room, and letting the patient know when others are leaving the room. Also, orient the patient to the surroundings. This patient may need assistance in getting into the proper position for examination.

6. Average age, 46 years O: ovarian cancer C: cervical cancer E: endometrial cancer

O: ovarian cancer C: cervical cancer

8. Early menarche O: ovarian cancer C: cervical cancer E: endometrial cancer

O: ovarian cancer E: endometrial cancer

1. History of breast cancer O: ovarian cancer C: cervical cancer E: endometrial cancer

O: ovarian cancer, E: endometrial cancer

3. Infertility or nulliparity O: ovarian cancer C: cervical cancer E: endometrial cancer

O: ovarian cancer, E: endometrial cancer

Symptoms of STI's

Pain in pelvis area bleeding between periods Itchy was around vagina Vaginal discharge - yellow, thicker and have odor

Obstetric stirrups

Patient lies on back near foot of bed with legs supported under the knees in obstetric stirrups. These offer more support than the traditional foot stirrups.

Diamond shape examination position

Patient lies on back with knees bent so legs are spread flat and heels meet at the foot of table. Patient must be able to lie flat on back for this position and have flexible legs.

V-shape

Patient lies on back with legs straightened out and spread wide to either side of the table. Assistance is needed to maintain this position.

M-shape

Patient lies on back, knees bent apart, feet resting on the examination table close to buttocks. Entire body can be supported by the table.

Knee-chest position

Patient lies on side with both knees bent with top leg closer to chest. May be difficult or uncomfortable for patient who is obese or has very large breasts.

Menorrhagia

Regular and normal interval between periods. excessive flow and duration.

Polymenorrhea

Shortened interval btw periods less than 19 to 21 days

Self exam for STI's

Start by examining area that the pubic hair covers. Use a mirror to see entire genital area. Look for bumps, sores, warts or blisters on the skin. New spread vaginal lips and look at hood of the clitoris. Gently pull th hood up to see the clitoris and again look for any bumps, blisters, sores, or warts. Then examine inner vaginal lips. exam urinary and vaginal openings looking for same.

2. Judy is a 16-year-old girl who is in the clinic for a school sports physical. How should her health history and an examination of her genitalia differ from that of an adult?

The history is vital to obtain. At this age, it is necessary to talk with her while her parents are out of the room. Questions should be simple, gentle, and nonjudgmental. These will greatly improve the accuracy of the information she is willing to share. There is no one set rule to determine the age when a full examination of the genitalia is necessary. However, a good rule of thumb is that if the patient is sexually active, then an examination should be done. The examination should be carried out similarly to that of an adult.

19. A sexually active, single, 22-year-old patient complains of a "gross" vaginal discharge. Which of the following questions would help the examiner understand this symptom? a. "Do you use condoms?" b. "What type of oral contraceptives do you take?" c. "At what age did you start menstruating?" d. "Do you have a family history of ovarian or breast cancer?"

a. "Do you use condoms?"

3. DNA probe for chlamydia and gonorrhea uses what instrument

a. Dacron swab

2. Which finding would be of concern during an examination of an older female patient? a. Palpable ovaries b. Small and pale cervix c. Constriction of the vaginal introitus d. Absence of vaginal rugation

a. Palpable ovaries an introitus is thus an entrance, one that goes into a canal or hollow organ such as the vagina vaginal rogation a new surgical technique for an acquired sensation of wide/smooth vagina

5. The vagina, uterus, fallopian tubes, and ovaries are supported by four ligaments. Which of the following is a normal examination finding that evaluates this support? a. The uterus can be moved back and forth with manipulation. b. The patient is able to tolerate a wide-blade speculum during examination. c. The uterus and ovaries are easily assessed with bimanual palpation. d. The vagina and uterus are fixed and do not move with manipulation.

a. The uterus can be moved back and forth with manipulation.

12. Which finding suggests an infection with a sexually transmitted infection? a. Ulcers and vesicles on the vulva b. Atrophy of labia minora c. Dilation of the urethral orifice d. Bluish color to the cervix

a. Ulcers and vesicles on the vulva

11. A patient complains of urinary incontinence when she is active. Which associated finding might explain this problem? a. Hernial protrusion in the posterior wall of the vagina b. Hernial protrusion through the anterior wall of the vagina c. Symptoms associated with PMS d. Enlargement and protrusion of the cervix into the vaginal vault

b. Hernial protrusion through the anterior wall of the vagina

3. While palpating the introitus of the vagina, the patient jumps and complains of severe tenderness. A mass is palpated that is warm to touch. With which of the following problems are these clinical findings consistent? a. Cancer of the cervix b. Inflammation of the Bartholin glands c. A cystocele d. Acute genital wart infection

b. Inflammation of the Bartholin glands

17. In what way is the pelvic outlet estimated on a pregnant patient? a. Insert a speculum into the patient's vagina and open as widely as possible. Measure the distance between the two blades. b. Insert two fingers into the vagina until fingers touch the cervix. Measure the distance to the cervix. c. Place the palm of the hand over the perineum, spread fingers to the width of the ischial tuberosities, and measure. d. Use a Thom pelvimeter to measure the bi-ischial diameter.

b. Insert two fingers into the vagina until fingers touch the cervix. Measure the distance to the cervix.

15. The mother of a 6-year-old girl expresses concern that her daughter seems to be experiencing vaginal bleeding. Which statement regarding vaginal bleeding in children is true? a. Vaginal bleeding in children is always a sign of sexual abuse. b. Vaginal bleeding in children is always clinically important. c. Vaginal bleeding in children is most commonly caused by carcinoma of the cervix. d. Occasional vaginal bleeding in the child is considered a benign finding.

b. Vaginal bleeding in children is always clinically important.

6. Candidiasis uses what instrument

b. Wet mount with KOH

16. Softness of the cervix is an expected finding for a. an adolescent. b. a pregnant woman. c. a nonpregnant woman. d. an older adult.

b. a pregnant woman. Softening of the cervix from this increase in vascularity is called the Goodell sign.

4. Which finding may be indicative of a pelvic mass? The cervix is a. pale in color. b. deviating to the right. c. protruding 2.5 cm into the vagina. d. pointing anteriorly.

b. deviating to the right.

7. A patient complains of pain; dysmenorrhea; and heavy, prolonged menstrual flow. Tender nodules are palpable along the uterosacral ligament. These symptoms and findings suggest a. PID. b. endometriosis. c. ectopic pregnancy. d. ovarian cancer.

b. endometriosis.

10. When examining a woman who has had a hysterectomy, the examiner should a. delete the bimanual and palpation maneuvers. b. obtain a Pap smear from the suture line. c. omit cultures and specimens from the vagina. d. palpate internal areas before inserting the speculum.

b. obtain a Pap smear from the suture line.

20. A 62-year-old female patient went through menopause about 14 years ago. Which statement made by this patient indicates a need for further follow-up? a. "I have not been sexually active for about 4 years." b. "My pubic hair has become very thin." c. "I have small amounts of vaginal bleeding a couple of times a week." d. "I have been taking extra calcium since I reached menopause."

c. "I have small amounts of vaginal bleeding a couple of times a week."

1. Which finding is suggestive of PID? a. Enlargement of the ovaries b. Everted cervix c. Pain resulting from movement of the cervix d. Unilateral labial swelling, redness, and tenderness

c. Pain resulting from movement of the cervix

18. A cauliflower-like mass found on the labia of a female patient is most likely caused by a. primary syphilis. b. condyloma latum. c. condyloma acuminatum. d. venereal herpes.

c. condyloma acuminatum.

8. An examiner plans to collect samples for cytologic studies during a vaginal examination. Before the examination, the examiner should lubricate the speculum with a. a water-soluble lubricant. b. topical anesthetizing ointment. c. warm water. d. vaginal secretions.

c. warm water.

6. Which information is accurate and appropriate for an examiner to share with the patient following a Pap smear? a. "You may have heavier bleeding with your next menstrual period." b. "You may experience abdominal cramping for the next couple of days." c. "You will feel nauseated for the rest of the day." d. "You may experience mild bleeding or spotting over the next couple of hours."

d. "You may experience mild bleeding or spotting over the next couple of hours."

1. Gonococcal culture uses what instrument

d. Sterile cotton swab

9. Symptoms associated with PMS are caused by a. ovulation. b. thickening of the uterine lining. c. elevations in body temperature. d. fluctuations in hormone levels.

d. fluctuations in hormone levels.

13. The examiner observes a slit-shaped cervical os in a nulliparous woman. Which of the following data in her history explains this finding? The patient a. had an early onset of menarche. b. has had multiple sex partners. c. has had infection with the HPV. d. had an abortion as a teenager.

d. had an abortion as a teenager.

14. A prominent labia minora in a newborn a. indicates a maternal infection. b. suggests ambiguous genitalia. c. is consistent with prematurity. d. is a normal finding.

d. is a normal finding

2. Endocervical cells uses what instrument

e. Cytobrush

7. Ectocervical cells uses what instrument

e. Cytobrush

4. Trichomonas vaginalis uses what instrument

f. Wet mount with NaCl

5. Both ectocervical and endocervical cells uses what instrument

g. Cervix brush

•Metrorrhagia:

irregular interval between periods, excessive flow and duration

Oliogomenorrhea

lengthened interval btw periods more than 35 days

Syphilitic chancre

—Skin lesion associated with primary syphilis; caused by the bacterium treponema pallidum.

Chadwick sign

—a bluish discoloration of the cervix that normally occurs in pregnancy at 8 to 12 weeks gestation.

Premenstrual syndrome (PMS)

—a collection of physical, psychological, and mood symptoms related to a woman's menstrual cycle.

Inflammation of Bartholin gland

—a condition characterized by swelling of the Bartholin gland; commonly, but not always, caused by Neisseria gonorrhea.

Hymen

—a connective tissue membrane that may be circular, crescentic, or fibriated.

Rectouterine pouch

—a deep recess formed by the peritoneum between the rectum and cervix (cul-de-sac of Douglas).

Ambiguous genitalia

—a newborn's genitalia are not clearly either male or female; usually caused by genetic abnormalities.

Genital herpes

—a sexually transmitted infection of skin and mucosa most commonly caused by the herpes simplex virus type 2.

Clitoris

—a small bud of erectile tissue, the homolog of the penis and primary center of sexual excitement, that is tucked between the frenulum and the prepuce.

Caruncle

—a small, bright red growth protruding from the urethral meatus; most urethral caruncles do not cause symptoms.

Molluscum contagiosum

—a viral infection of the skin and mucous membranes; considered a sexually transmitted infection in adults, in contrast to the nonsexually transmitted infection occurring in young children.

Uterine bleeding

—abnormality in menstrual bleeding and inappropriate uterine bleeding are common gynecologic problems.

Myomas

—common benign uterine tumors that arise from the overgrowth of smooth muscle and connective tissue in the uterus.

Uterine prolapse

—descent or herniation of the uterus into or beyond the vagina; the result of weakening of the supporting structures of the pubic floor.

Hydrocolpos

—distention of the vagina resulting from an accumulation of fluid caused by congenital vaginal obstruction; obstruction usually caused by an imperforate hymen; or, less commonly, a transverse vaginal septum.

Skene ducts

—ducts that drain a group of urethral glands and open into the vestibule on each side of the urethra.

Tubal pregnancy

—ectopic pregnancy; pregnancy that occurs outside the uterus; most common site is the fallopian tubes.

Ovarian cyst

—fluid filled sac in an ovary; follicles undergo varying rates of maturation, and a cyst can occur as a result of hypothalamic-pituitary dysfunction.

Bartholin glands

—glands located posteriorly on each side of the vaginal orifice, open onto the sides of the vestibule in the groove between the labia minora and the hymen.

Rectocele

—hernial protrusion of part of the rectum into the vagina.

Cystocele

—hernial protrusion of the urinary bladder into the vagina, sometimes exiting the introitus.

Pelvic inflammatory disease (PID)

—infection of the uterus, fallopian tubes, and other reproductive organs.

Atrophic vaginitis

—inflammation of the vagina caused by the thinning and shrinking of tissues, as well as decreased lubrication; caused by a lack of estrogen during perimenopause and menopause.

Vaginitis

—inflammation of the vagina.

Vulvovaginitis

—inflammation of the vulvar and vaginal tissues; possible causes include sexual abuse or trichomonal, monilial, or gonococcal infection.

Salpingitis

—inflammation or infection of the fallopian tubes, often associated with PID; can be acute or chronic.

Mittelschmerz

—lower abdominal pain associated with ovulation; may be accompanied by tenderness on the side where ovulation took place that month.

Hegar sign

—softening of the cervix that is a sign of pregnancy, occurring at 6 to 8 weeks gestation.

Infertility

—the inability to conceive over a period of 1 year; contributing factors with women include abnormalities of the vagina, cervix, uterus, fallopian tubes, and ovaries.

Menarche

—the onset of first menstruation, which usually occurs between 12 and 14 years of age.

Endometriosis

—the presence or growth of endometrial tissue outside the uterus; the pathogenesis is not definitive, but it is thought to be caused by retrograde reflux of menstrual tissue from the fallopian tubes during menstruation.

Condyloma acuminatum

—warty lesions caused by sexually transmitted infection with human papillomavirus (HPV); HPV invade the basal layer of the epidermis.

Menometrorrhagia

•: irregular or excessive bleeding during periods and between periods