Chapter 14 Female Genitalia

1. Chapter 14 Female Genitalia

2. Anatomy of the Female Genitalia Female External Genitalia

3. Anatomy of the Female Genitalia (cont.) Lateral View of Female Reproductive System

4. Anatomy of the Female Genitalia (cont.) Cervix

5. Gynecologic History • Ask about the age of menarche (when the first menses started); in the United States the range is between the ages of 9 and 16 • Ask about menstruation patterns • How often does the patient have menses? (Every 24 to 32 days is normal.) • How long are the menses? (3 to 7 days is normal.) • How heavy are the menses? (The number of pads or tampons used is an indicator.) • If applicable, at what age did menopause occur? Menopause is defined as no menses for 12 months. The average age of menopause is 45 to 52 years.

6. Gynecologic History (cont.) • 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)

7. Gynecologic History (cont.) • 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, and 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

8. Question A 26-year-old female presents to clinic complaining of heavy periods lasting 10 to 12 days. Which of the following is the most appropriate term to describe this patient’s symptoms? • Dysmenorrhea • Polymenorrhea • Menorrhagia • Metrorrhagia

9. Answer • Menorrhagia • Dysmenorrhea: painful periods with cramping or aching in the lower pelvis and lower back • Polymenorrhea: having too frequent of periods • Menorrhagia: an increased amount of bleeding or duration of flow • Metrorrhagia: bleeding that occurs between periods

10. Gynecologic History (cont.) • 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, or delivery? • What kind of birth control is currently used or desired? • Ask about vulvovaginal symptoms including burning, itching, and the quantity and quality of discharge (including texture, amount, color, and smell)

11. Gynecologic History (cont.) • Ask about sexual preference and sexual response; be professional and “matter of fact” in questioning and never assume all patients are heterosexual • Ask open-ended questions such as, “How is sex for you?” “Is 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, or discomfort during intercourse • Vaginismus, or spasms of the muscles surrounding the vagina making penetration painful and difficult

12. Health Promotion and Counseling • Cervical cancer screening: Pap smear and HPV screening • Options for family planning • Sexually transmitted diseases and HIV • Changes in menopause

13. The Patient Avoid intercourse or douching for 1 to 2 days before exam Empty the bladder before exam Lie on the back, 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 Obtain permission Explain each step of the examination in advance; select a chaperone Drape the patient from the abdomen to the knees Avoid sudden movement Choose a speculum of appropriate size Warm the speculum with tap water Monitor the comfort of the examination by watching the patient’s face Use gentle insertion of the speculum Physical Examination of the Female Genitalia: Tips for the Successful Exam

14. Proper Sequence of the Female Genital Examination • Examine external genitalia • Perform speculum examination • Perform bimanual examination • Perform rectovaginal examination • Perform rectal examination

15. Physical Examination of the Female Genitalia • Inspect the patient’s external genitalia • Mons pubis • Labia majora and minora • Clitoris • Urethral meatus • Introitus • Perineum • Note any inflammation, discharge, swelling, or nodules; palpate any lesions • Check the Bartholin’s glands by inserting the index finger into the vagina and placing the thumb at the posterior labia; palpate between finger and thumb

16. Physical Examination of the Female Genitalia: Internal Exam by Speculum • Place the index finger of your non-dominant hand on the posterior portion of the introitus and push down gently • With the speculum in your dominant hand, turn it to the entry angle (approximately 45 degrees) and gently insert into the introitus; continue inserting the length of the speculum • Rotate the speculum horizontally and gently open it, catching the cervix in between the blades; it is common to have to close the speculum and reposition the blades to locate the cervix

17. Physical Examination of the Female Genitalia: Cervix Inspection • Once the cervix is visualized, inspect the cervix and the os; note the color, position, and characteristics of the cervix • Look for discharge or bleeding from the os • Note any ulcerations, masses, or nodules on the cervix • Obtain one specimen from the endocervix and one from the ectocervix, or a combination specimen using the cervical brush “broom” • If indicated, obtain cultures for chlamydia, gonorrhea, or herpes; wet prep (saline slide of the vaginal and cervical secretions) for vaginitis

18. Physical Examination of the Female Genitalia: Inspecting the Vagina • While withdrawing the speculum, assess the walls of the vagina • When removing the speculum, make sure the blades are closed; removing an open speculum can cause lacerations to the vaginal walls and to the urethral meatus • If indicated, place two fingers inside the labia and ask the patient to bear down in order to see if the vaginal walls bulge or if any part of the rectum protrudes from the anus

19. Physical Examination of the Female Genitalia: Bimanual Exam • Stand 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 • Make sure the 4th and 5th digits are flexed against your palm and that your thumb is abducted (away from the patient’s body) • Palpate the vaginal walls, feeling for any irregularities (note that the vaginal walls have rugae and will feel “bumpy”) • Palpate the cervix, noting its position (anterior, posterior, deviated to the left or right), shape, consistency (firm or soft), mobility, and tenderness

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

21. Physical Examination of the Female Genitalia: Bimanual Exam (cont.) • Palpate the left ovary by placing your dominant hand in the left lateral fornix and your non-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, shape, consistency, mobility, and tenderness of each adnexal area • Before removing your hand, ask the patient to bear down on your fingers to assess the strength of the pelvic muscles

22. Question • Is the following statement true or false? The speculum exam should be performed after the bimanual exam to ensure adequate sampling.

23. Answer False • The speculum exam should be performed before the bimanual exam.

24. Physical Examination of the Female Genitalia: Rectovaginal Exam • Rectovaginal exams has three primary purposes • Palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa • Screen for colorectal cancer • Assess pelvic pathology • Glove the dominant hand and lubricate the index finger • Place the index finger of the dominant hand inside the vagina as before but this time and place the middle finger within the anus; ask the patient to bear down so that the anal sphincter will relax

25. Physical Examination of the Female Genitalia: Rectal Exam • Gently place the index finger in the anus; palpate for hemorrhoids and masses • If needed, check for occult blood with a hemoccult test • Wipe off the external genitalia and anus with gauze or tissue; give the patient some to clean herself after the exam • Always ask the patient to get dressed before discussing any findings; unclothed patients have difficulty concentrating

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