The Female History & Exam

Fall, 2010

Gynelogical History
‡ Amenorrhea ± Amenorrhea is defined as the absence of menses. ± Primary amenorrhea refers to the failure of menses to be initiated (causes: chromosomal abnormalities, malnutrition, hypothalamic-pituitary-ovarian dysfunction) ± Secondary amenorrhea refers to a cessation of periods after they have previously existed (physiologic causes: pregnancy, breast feeding, menopause; pathologic causes: pituitary tumor, hypothyroidism, anorexia nervosa)

Gynelogical History
‡ Dysmenorrhea: Painful periods with cramping or aching in the lower pelvis and lower back ‡ PMS (Premenstrual Syndrome) ± Complex of symptoms occurring 4 to 10 days before the onset of menses ± Psychological symptoms include tension, irritability, depression, mood swings ± Physical symptoms include weight gain, bloating, edema, headaches, and breast tenderness ‡ Polymenorrhea means having too frequent of periods ‡ Menorrhagia refers to an increased amount of bleeding or duration of flow ‡ Metrorrhagia is bleeding that occurs between periods

or delivery? ± What kind of birth control is currently used or desired? ‡ Ask about vulvovaginal symptoms including burning. color and smell) . amount.Gynelogical History ‡ Ask about pregnancies ± How many pregnancies in total? How many births were term? Preterm? Miscarriages? Induced Abortion? ± Were there any complications in prenatal care. labor. itching and the quantity and quality of discharge (including texture.

³How is sex for you?´. be professional and ³matter of fact´ in questioning. never assume all patients are heterosexual ‡ Ask open-ended questions: ex.Gynelogical History ‡ Ask about sexual activity. ³Is your partner satisfied with your sex life?´ ‡ Ask about symptoms of sexual dysfunction ± Lack of interest ± Lack of physiologic response to desire (decreased lubrication) ± Lack of orgasm ± Dyspareunia is discomfort during intercourse ± Vaginismus refers to spasms of the muscles surrounding the vagina making penetration painful and difficult .

with head and shoulders elevated (such as on a pillow). with arms to the side or folded across the chest to reduce tightening the abdominal muscles The Examiner ‡ Explain each step of the examination in advance ‡ Drape the patient from the abdomen to the knees ‡ Avoid sudden movement ‡ Use a warm speculum with water ‡ Monitor the comfort of the examination by watching the patient¶s face ‡ Use gentle insertion of speculum .Physical Examination of the Female Genitalia: Tips for the Successful Exam The Patient ‡ Avoid intercourse or douching for 1-2 days before exam ‡ Empty bladder before exam ‡ Lie on back.

assess their sexual maturity by checking the pubic hair pattern along the perineum and abdomen ‡ Inspect the patient¶s external genitalia ± Labia minora ± Clitoris ± Urethral meatus ± Introitus ‡ Note any inflammation.Physical Examination of the Female Genitalia ‡ If patient is a child or adolescent. swelling or nodules. discharge. palpate any lesions ‡ Check the Bartholin¶s glands by inserting the index finger into the vagina and placing the thumb at the posterior labia .

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. Continue inserting it the length of the speculum. catching the cervix in between the blades. it is common to have to close the speculum and reposition the blades to locate the cervix.Physical Examination of the Female Genitalia: Internal Exam by Speculum ‡ Select a speculum of appropriate size and shape and wet it under warm water. ‡ Take the speculum in your dominant hand and turn it to the entry angle (approximately 45 degrees) and gently put it into the introitus. ‡ Now rotate the speculum horizontally and gently open the speculum. ‡ Take the index finger of your non-dominant hand and place it on the posterior portion of the introitus and push it gently down.

Physical Examination of the Female Genitalia: Cervix Inspection ‡ Once the cervix is visualized. masses or nodules on the cervix ‡ Scrape with a broom. or brush the cervix and os to send for a Papanicolaou smear ‡ Take cultures for Chlamydia. position and characteristics of the cervix ‡ Look for discharge or bleeding from the os ‡ Note any ulcerations. gonorrhea or herpes ‡ Take a wet prep (saline slide of the vaginal and cervical secretions) . note the color. inspect the cervix and the os. spatula.

assess the walls of the vagina ‡ When removing the speculum. make sure the blades are closed before removal.Physical Examination of the Female Genitalia ‡ While withdrawing the speculum. The examiner can see if the vaginal walls bulge or if any part of the rectum protrudes from the anus . removing a speculum open can cause lacerations to the vaginal walls and to the urethral meatus ‡ In the appropriate patient. place two fingers inside the labia and have the patient bear down.

Anatomy of the Female Genitalia Female External Genitalia .

Anatomy of Female Genitalia Lateral View of Female Reproductive System .

Anatomy of Female Genitalia The Cervix .

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Anatomy of the Female Genitalia Female External Genitalia .

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Anatomy of the Female Genitalia Female External Genitalia .

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consistency (firm or soft). feeling for any irregularities (remember the vaginal walls have rugae and will feel ³bumpy´) ‡ Palpate the cervix noting its position (anterior.Physical Examination of the Female Genitalia: Bimanual Exam ‡ Stand up at the end of the table between the patient¶s legs ‡ Lubricate the index and middle finger of the dominant hand and carefully place them inside the introitus. deviated to the left or right). adolescents. posterior. in small women. or virgins you may just use the index finger if needed ‡ Make sure the fourth and fifth digits are flexed against your palm and that your thumb is abducted (away from the patient¶s body) ‡ Palpate the vaginal walls. and tenderness. shape. mobility. .

mobility and tenderness (easier in thin patients) ‡ If you cannot feel the uterus. the uterus is tipped posterior (retroflexed) . shape. take your nondominant hand and place it over the suprapubic area just superior to the pubic bone ‡ While you elevate the cervix with your dominant hand you press your non-dominant hand over the bladder. feeling for its size. if so. catching the uterus between your hands.Physical Examination of the Female Genitalia: Bimanual Exam ‡ Palpate the uterus in the midline. consistency. slide the fingers in the pelvis into the posterior fornix and see if you can feel the uterus butting against the fingers.

shape. have the patient bear down on your fingers to assess strength of the pelvic muscles . consistency. mobility and tenderness of each adnexal area ‡ Before removing your hand.Physical Examination of the Female Genitalia: Bimanual Exam ‡ Palpate the left ovary by placing your dominant hand in the left lateral fornix and your dominant hand just left of the midline superior to the pubic bone ‡ Palpate the right ovary by placing the dominant hand in the right lateral fornix and the non-dominant hand just right to the midline ‡ Identify the size.

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Positions of the Uterus .

Common variant occurring in ~20% of women. including body and cervix.Retroversion of the Uterus: refers to a tilting backwards of the entire uterus. .

Compare: Normal Anatomy of Female Genitalia Lateral View of Female Reproductive System .

body of uterus can be felt posteriorly. Marked Retroversion: . Ususally mobile and asymptomatic. either through the posterior fornix. or through the rectum.

Compare: Normal Anatomy of Female Genitalia Lateral View of Female Reproductive System .

The cervix maintains its usual position .Retroflexion of the Uterus: refers to a backward angulation of the body of the uterus in relation to the cervix.

Compare: Normal Anatomy of Female Genitalia Lateral View of Female Reproductive System .

.Prolapse of the Uterus: results from weakness of the supporting structures of the pelvic floor and is ofter associated with a cystocele and a rectocele.

Compare: Normal Anatomy of Female Genitalia Lateral View of Female Reproductive System .

ask the patient to bear down so that the anal sphincter will relax ‡ Repeat the maneuvers of the bimanual exam. this exam is especially useful in retroflexed uteri .Physical Examination of the Female Genitalia: Rectovaginal Exam ‡ Rectovaginal exams are useful in younger patients or virgins when placing two fingers in the vagina would be painful ‡ Place the index finger of the dominant hand inside the vagina as before but this time place the middle finger within the anus.

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palpate for hemorrhoids and masses ‡ If needed. unclothed patients have difficulty concentrating .Physical Examination of the Female Genitalia: Rectal Exam ‡ Change gloves on the dominant hand and place lubricant on the index finger ‡ Gently place the index finger in the anus. check for occult blood with a hemoccult test ‡ Wipe off the external genitalia and anus with gauze or tissue and also make sure she has some available to clean herself up with ‡ Always have the patient get dressed before discussing any findings with them.

culture any discharge that has been milked out . a woman should stand up to be examined ± Palpate the labia majora just upward and lateral to the pubic tubercles ‡ Urethritis ± If you suspect a urethritis or inflammation of paraurethral glands insert your index finger into the vagina and milk the urethra gently from inside outward.Physical Examination of the Female Genitalia: Special Circumstances ‡ Hernias ± Although thought of as primarily a male problem women can have hernias in the groin also ± Examination techniques are similar to men.

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Pathology .

May be single or multiple and vary greatly in size (see page 456).Myomas (Fibroids) of the Uterus: very common benign uterine tumors. .

together with the bladder above it. It results from weakened supporting tissues.Cystocele: a bulge of the upper two thirds of the vaginal wall. .

.Cystourethrocele: when the entire anterior vaginal wall. together with the bladder and the urethra is involved in the bulge.

Rectocele: a herniation of the rectum into the posterior wall of the vagina. . resulting from a weakness or defect in the endopelvic fascia.

Urethral Caruncle: a small, red, benign tumor visible
at the posterior part of the urethral meatus. Usually noted in postmenopausal women. Usually asypmtomatic.

Forms a swollen red ring around the urethral meatus. Usually occurs before menarche or after menopuase. Identify the urethral meatus at the center of the swelling to make the diagnosis.

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Look for the dark punctum marking the blocked opening of the gland. firm nodule in the labia suggests an epidermoid cyst. round.Epidermoid Cyst: a small. . Yellowish in color.

Conyloma Acuminatum: human papillomavirus .

as shown. small. Initial infection may be extensive.shallow. Genital Herpes: . Recurrences are usually confined to a small local patch. painful ulcers on red bases suggest a herpes infection.

Syphilitic Chancre: a firm. . they often go undetected. painless ulcer suggests the chancre of primary syphilis. Because most chancres in women develop internally.

Secondary Syphilis: (Condyloma Latum) slightly raised. round. These constitute one manifestation of secondary syphilis and are contagious. flat-topped papules covered by a gray exudate suggest condyloma lata. . or oval.

Carcinoma of the Vulva: an ulcerated or red vulvar lesion in an elderly woman may indicate vulvar carcinoma. .

anaerobes. Chronically. tense. it is a hot. a non-tender cyst is felt. Acutely. . gonococci. very tender abscess. and Chlamydia trachomatis.Bartholin¶s Gland Infection: causes include trauma.

a yeast (normal overgrowth of vaginal flora). Use KOH prep and look for branching hyphae. .Candida albicans.

Scan saline wet mount for ³clue cells´ (epithelial cells with stippled borders).probably from anaerobic bacteria. Bacterial Vaginosis: . may be transmitted sexually. May have fishy odor after application of KOH (³whiff test´).

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