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Female Genitalia

Anatomy and Physiology - Pain with menses; determine the characteristics of pain

Ovaries Classification:
Primary fxns 1. Primary Dysmenorrhea
1. production of ova - w/out organic cause; Due to prostaglandin production during the
2. secretion of hormones estrogen, progesterone, testosterone luteal phase of the menstrual cycle, when estrogen and
3. Development of secondary sex characteristics progesterone levels decline
1. Secondary Dysmenorrhea
Pelvic Organ Support: muscle,ligaments,fascia - with organic cause
- ex: Endometriosis, Adenomysosis, PID, Endometrial polyps
Pelvic Diaphragm
- coccygeus m PMS
- levator ani (pubococcygeus m, iliococcygeus m) Emotional and behavioral symptoms
-weakness in levator ani results in: Bloating? Weight gain? Swelling of hands and feet? Generalized
1. sagging of the pelvic floor aches and pains?
2. widening of the urogenital hiatus Criteria:
3. pelvic organ prolapse (POP) 1. ssx 5 days prior to menses for at least 3 consecutive cycles;
2. cessation of ssx within 4 days after onset of menses;
Urogenital Diaphragm 3. interference with daily activities
- ischiocavernosus m support distal
- bulbocavernosus m urethra Amenorrhea
- perineal body Classification:
- perineal membrane 1. Primary Amenorrhea: has not started menses at all
- anal sphincter 2. Secondary Amenorrhea
: cessation of periods after they have been established
Pelvic Floor : Pelvic Diaphragm + Urogenital Diaphragm : Physiologic causes - pregnancy, lactation, menopause
Stress Incontinence -loss of urethral support : Other causes - low BW, HPO dysfunction, stress, chronic illness
Rectocoeles, Enterocoeles - weakness of the perineal body from childbirth
Tanners stages of sexual maturity: pubic hair growth, breast development Abnormal Bleeding: Definition of Terms
Leukorrhea -just before menarche, physiologic Polymenorrhea less than 21 day intervals between menses
-coincide with ovulation, sexual arousal Oligomenorrhea infrequent bleeding
Menorrhagia excessive flow
Lymphatics Metrorrhagia intermenstrual bleeding
Inguinal nodes: vulva, lower vagina Post coital bleeding
Pelvic and abdominal lymph nodes: internal genitalia, upper vagina
C. Menopause
HEALTH HISTORY: Common Concerns 48-55 yrs (51 mean)
1. Menarche, menstruation, menopause, postmenopausal bleeding Cessation of menses for 12 months
2. Pregnancy Perimenopause stages of erratic cyclical bleeding associated with
3. Vulvovaginal symptoms vasomotor symptoms
4. Sexual orientation and sexual response
5. Pelvic painacute and chronic
6. Sexually transmitted infections (STIs) D. Post menopausal bleeding
Endometrial cancer
Definition of Terms Uterine and cervical polyps
Menarcheage at onset of menses
Menopauseabsence of menses for 12 consecutive months, usually Health concern #2
occurring between 48 and 55 years PREGNANCY
Postmenopausal bleedingbleeding occurring 6 months or more
after cessation of menses Gravida Para Notation
Amenorrheaabsence of menses G gravida, or total number of pregnancies
Dysmenorrheapain with menses, often with bearing down, aching, P para or outcomes of pregnancies
or cramping sensation in the lower abdomen or pelvis -FPAL
Premenstrual syndrome (PMS)a cluster of emotional, behavioral,
and physical symptoms occurring 5 days before menses for three Health concern #3
consecutive cycles Vulvovaginal symptoms
Abnormal uterine bleedingbleeding between menses; includes Vaginal dishcarge : amount, color, consistency, odor
infrequent, excessive, prolonged or postmenopausal bleeding Vaginal itching
Sores or lumps
Health Concern # 1
Problems with Health Concern #4
Sexual Orientation/Response
A. Menarche Sexual Orientation
Onset: 9-16 yrs, regularity : 1 year -Sensitive area
Age of onset- variable genetic endowment, socioeconomic status, nutirtion -Use neutral and non judgmental questions
Menstrual Flow: interval 24-32 days; -What is your relationship status? sexual preference, men, women or both?
duration: 3-7 days
Sexual Response
B. Menstrual Hx: Qs to ask - How is sex for you? Are you having any problems with sex?
Menarche - direct questions help assess each phase of sexual response
LMP desire phase: do you have interest in sex?
PMP arousal phase: do you lubricate easily? Do you stay too dry?
How often? Regular? How long does it last? Flow? Color? orgasmic phase: are you able to reach climax?
Intermenstrual bleeding? Post coital bleeding?
Middle aged: has menses stopped? When? S and sx
accompanying? Bleeding sice then?
Health Concern #5 Speculum/a
PELVIC PAIN -metal/plastic
-Pedersen: sexually active women; small inroitus
Dyspareunia -Graves:parous; POP
Pain with intercourse
Superficial pain: local inflammation, vaginitis, inadequate lubrication Position
Vaginismus: involuntary spasm of the muscles surrounding the Drape pt appropriately
vaginal orifice that makes penetrationnduring intercourse painful and Lithotomy position
impossible; physical or psychologic causes Heel unto the stirrups
Slide down the examining table, buttocks extend slighlty beyond the
PAP Smear edge
See guidelines in the book Thighs flexed, abducted, externally rotated at the hips
Cervical Cancer Head with pillow
HPV vaccine : Gardasil (quadrivalent)
-HPV 16,18,6,11 External examination
-administration: 0,2,6 mos Assess sexual maturity
- 9-26y Note for inflammation, ulceration, discharge, swelling or nodules,
Pelvic Pain lesions
Acute PID, ruptured ovarian cyst, AP Check Bartholins glands :swelling, tenderness
- mittelschmerz or pain from ovulation at midcycle
- red flag: STI, recent IUD insertion
Chronic pain more than 6 months and does not respond to Cervix
treatment Color, position, surface, ulcerations, nodules, masses, bleeding or
- endometriosis, adenosis, fibroids discharge
- red flag: sexual abuse Inspect cervical os for discharge

Health Concern #6 PAP SMEAR

STI Cervical Broom
Ask attributes of the symptom Cervical scrape
Identify sexual orientation Cervical brush
Sexual contacts
Establish the number in the prior month Vagina
Past hx of sti As speculum is withdrawn
Color of vaginal mucosa, inflammation, discharge, ulcers or masses
Techniques of examination Bulges: cystocoeles, POP

The Patient Bimanula Pelvic Examination (BPE)

Avoids intercourse, douching, or use of vaginal suppositories for24 to 48 Cervix
hours before examination Uterus
Empties bladder before examination Adnexae
Lies supine, with head and shoulders elevated, arms at sides or folded
across chest to enhance eye contact and reduce tightening of abdominal Rectovaginal Examination
muscles Palpate retroverted uterus, uterosacral ligaments, cul de sac and
To screen for colorectal ca in 50 y and older
The Examiner Assess pelvic pathology
Obtains permission; selects chaperone
Explains each step of the examination in advance Hernias
Drapes patient from midabdomen to knees; depress drape between knees to Indirect inguinal hernia: palpate labia majora and upward to just
provide eye contact with patient lateral to the pubic tubercles
Avoids unexpected or suddden movements Most common hernia in women
Chooses a speculum that is the correct size
Warms speculum with tap water
Monitors comfort of the examonation by watching patients face
Uses excellent but gentle technique, especially when inserting the spceulum