Introduction to the Female Exam

1. Introduction to the Female Exam • Anatomy • Pelvic Exam • Hormonal cycles • Uterine conditions • Ovarian conditions • Breast evaluations

2. So, who should have a pelvic exam and why?Annually for all women who are sexually active, or as a baseline, women at the age of 21.

3. Important issues related to this exam: • Cultural issues • Patient modesty • Anxiety about exam • History of rape, molestation or abuse • Office environment

4. Office environment • ALWAYS have another person in the room while examining female genital area or breasts. • Explain what you are going to be doing, before you do each step/manuever • Insure patient comfort, and modesty….

5. Patient comfort/modesty • Use gowns AND sterile drapes over pt legs • Allow patient to wear socks, bra (if no breast exam is being done), sweater, etc. • Foot of exam table does not face the door • Door is clearly marked to avoid interruption • Another person in the room all the time, taking notes or somehow attentive

6. 3 Parts to the Pelvic Exam • 1. Observation and the speculum exam • 2. Bimanual exam • 3. Recto-Vaginal Exam (includes DRE)

7. But first, we ask history, inspect and palpate. • Pubic hair-triangle pattern • Lymph nodes • Orifices • Palpate: • Urethral meatus-incontinence • Labia • Skene’s, then Bartholin’s glands • Perineum

8. The Speculum Exam • Performed prior to the bi-manual exam so as not to disturb the tissues/samples • Performed without lubricant jelly • Always inserted with the speculum blades warmed with warm water and closed • Inserted at a 45 degree angle posteriorly

9. Proper position of speculum

10. Visual Observation of the Cervix • Position—is it anteverted, deviated, etc • The position of the cervix gives clues to the position of uterus • Color—should be flesh-colored, but ranges from pink to dark brown (blue or pale??) • Surface characteristics—cysts, erythema • Discharge • Size and shape of os

11. Nulliparous cervix

12. Multiparous cervix

13. Everted cervix

14. Nabothian cystsaka: retention cysts

15. The Papanicolaou Exam (“Pap”) • Developed over 50 years ago by Dr. George Papanicolaou • A minimum of two samples will be taken: • Cervical cells • Vaginal secretion • Other tests may be done to screen for STDs

16. What are the three most common STDs among women? • HPV, Herpes, Chlamydia, (Now 10’s of millions of existing cases) • The Quad Cities has the highest incidences of STDs in Iowa • In women, often no visible symptoms • Protect Yourself!

17. What’s the goal of a Pap Smear? • The “Pap smear” evaluates the condition of the cervical cells (taken with cervical brush or spatula) • SCREENS FOR CERVICAL CANCER • Assessing “transitional zone” of the cervix

18. Accuracy of the Pap Smear • It is estimated that the Pap Smear has decreased the death rate due to cervical CA by 75% • “False-positives” range from 10% to 40% • “False-negatives” range from 1% to 15% (This is good)

19. Vaginal Secretion Samples • In addition to the cell sample, additional information can be gained from the surrounding secretions • Sampling methods are dependent upon the goal of the screening

20. Bacterial Vaginosisaka: Vulvovaginitis • General description for anything that causes symptomatic discharge (an irritant) • May be due to bacteria, viruses, fungi, or protozoans • Patient may talk to you about: vaginal or vulvar itching, burning, or change in color, texture or odor of discharge

21. The Bimanual Exam • The bimanual exam is the second part of a complete pelvic exam • Necessary to evaluate the cervix, uterus, and adenexal regions (ovaries, fallopian tubes, surrounding areas) • Move the cervix to assess for PID/Endometriosis • Important even if patient is not sexually active

23. Recto-Vaginal Exam; DRE • The Recto-Vaginal exam is the 3rd and final part of the pelvic exam • May help evaluate the posterior aspect of the uterus (esp. if retroverted) • Allows exam of rectal walls (initial screen for colo-rectal cancer or polyps)

25. Uterine Fibroids • AKA: myoma, leiomyoma, fibroma • Very, very common (40% of women > 40) • The most common tumor of the pelvis • The most common reason for a hysterectomy • 33% of 600,000/yr. • Benign, benign, benign!

26. Risk Factors • Nulliparity or delayed childbearing • African American women have 2-3 times the incidence

27. Locations

28. Uterine Fibroids: Symptoms • Heavy menstrual bleeding • Abdominal distortion • Pelvic pressure • Low back pain; dyspareunia • Infertility • Frequent urination • Constipation • Miscarriage or premature labor

29. Plain Film Findings:Cauliflower-like radio-opaque mass seen in the pelvic cavity, in the area of the uterus.

30. Is it any wonder problems include low back pain, urinary frequency, constipation, infertility?

31. Treatment Options(from least to most invasive) • “Wait and see” • Drug therapy (GnRH agonists) • Uterine Artery Embolization (UAE) • Myomectomy • Hysterectomy

32. Pelvic ArteriogramUsed to identify blood vessels feeding the myoma.

33. Polyvinyl particles block blood flow

34. Endometriosis • Endo=inner metr=layer osis=condition • Normal endometrium found in abnormal places • Therefore, “ectopic tissue” responds to hormone levels just like the inner layer of the uterus • How? • Retrograde menstrual flow, fallopian tubes, abdomen • Lymphatic or circulatory systems cause spread

35. Risk Factors • Young age: 10-15% of women ages 25 to 44 have endometriosis • Family History (6 - 12% of cases) • Nuliparity or delayed childbearing • Asians and Caucasians are at highest risk

36. When? • Onset of endometriosis is at onset of menses • Delay in seeking care = 4.67 years • Delay in diagnosis = 4.61 years • Delay for ages 15-19 years is 8.3 years • Symptoms confused with “typical” dysmenorrhea or UTIs • 1/3 of women say doctor took symptoms “not at all seriously” and 1/4 said “not very seriously”

37. Signs and Symptoms • Pain, pain, pain (low back and pelvic) • Pelvic mass • Alterations of menses • Dysmenorrhea (pattern = pain just prior to menses) • Infertility • Dyspareunia • Pain with defecation, urination

38. Pattern of Menstruation • Women with endometriosis have: • earlier onset of menses • regular cycles • shorter intervals between periods (less than 27 days) • more severe menstrual cramps • prolonged menstrual flow (> 1 week)

39. What do the lesions look like? • Endometrial deposits can occur anywhere in pelvis • Ovary—most common (75%); an ideal site for growth • Posterior cul-de-sac—70% • Between the uterus and bowel—35% • Uterosacral ligament—30% • Ureters • Uterus • Bowel • Also known to occur on appendix, gall bladder, stomach, spleen, liver, lung

40. Red Endometrial Lesions

41. Endometrial Deposits on Appendix

42. Complications • Remember—this normal uterine tissue in an abnormal location responds to fluctuations in hormone levels just as the rest of the uterus. So… • Bleeding lesions inflammatory response fibrin deposition adhesion formation distortion of the peritoneal surfaces

43. Peritoneal AdhesionsAdhesions, caused by inflammation around site of endometriosis, cause uterus and cervix to be “fixed”, and the cervix is very painful upon movement (during female exam, and during intercourse).

44. Confirming the Diagnosis • Suspected by case history • Visible lesions on the vulva or cervix • Red, brown, black (remember—may bleed) • Speculum exam (“shotty nodules”)

45. Definitive Diagnosis • The definitive diagnosis can only be made by direct visualization of the lesions • Presently, confirmed by laparoscopy

46. Treatment Options • Keep in mind that these patients typically suffer a prolonged course of multiple therapies/surgeries • “Leave it alone” • Drug therapy • Laparotomy • Hysterectomy • Child-bearing (or pseudo-pregnancy conditions)

47. FAQs • How successful is laparotomy? 70-90% pain • Does it recur after treatment? 10-20% within 3 yrs • Can tubal ligation help? Theoretically • Does intercourse during menses risks? No • Does use of tampons risks? No • Does early pregnancy protect against it? Maybe • C-sections and endometriosis? A possibility

48. Infertility and Endometriosis? • Peritoneal fluid normally acts as a lubricant. • Endometriosis causes changes in the volume and cellular content of the peritoneal fluid. • Fluid level is increased • Leukocytes are increased • Prostaglandin levels are increased • Enzyme levels are increased • These all cause a localized inflammatory reaction around the lesions • The peritoneal fluid can then act as a toxin to the embryo and/or can alter the normal function of the ovaries and fallopian tubes.

49. www.bioscience.org/books/endomet/end34-65.htm Great website for FAQs of endometriosis

50. Other Pelvic Conditions that Deserve Your Attention • Uterine sarcoma (endometrial carcinoma) • Cervical carcinoma • Ovarian carcinoma • Hint: I often ask about risk factors and CA • Ovarian cysts • Uterine, vaginal prolapse