Female Genitalia Flashcards
What is the mons pubis
Hair covered fat pad overlying the kyphosis pubis
What is the labia majora
Rounded folds of adipose tissue
What is the labia minora
- Hairless, thinner, pinkish-red folds
- Joint anteriorly to form prepuce and clitoris
What is the clitoris
Small bud of sensitive erectile tissue
What is the vestibule
Boat shaped fossa between labia minora
What can the vaginal opening be covered by?
- The hymen in virgins
- The vaginal opening is the inferior portion of the vestibule
What is the perineum,
- Tissue between the introitus and anus
What is the urethral meatus
- Opens into the vestibule
- Between the clitoris and vagina
What are skene’s glands
- Paraurethral gland
- Just posterior to urethral meatus
What are bartholin glands
- Inferior aspect of the vestibule
- On either side of the vaginal opening
* 4 and *8 o’clock - Usually not visible
- Secrete mucous into the inttroitus for lubrication
What are the ligament support of the internal genitalia
- Round ligaments
- Broad ligaments
- Cardinal ligaments
- Uterosacral ligaments
What does the vagina lie between ?
- The rectum and the urethra
What is the vesicovaginal septum
- Anterior wall separates the vagina from the bladder and urethra
What is the rectovaginal septum
Posterior wall that separates vagina from rectum
What is the function of the vagina
- Carries menstrual flow from the uterus
- Severed as the terminal portion of the birth canal
- Receptive organ for the penis during sexual intercourse
What is the internal os
- The upper part of the cervix that opens into the endometrium
What is the external os
- The lower part of the cervix that opens into the vagina
What is the ectocervix
The vaginal surface of the cervix, is seen during speculum exam
*opening is the external os
*round = nullipara
*silt = multipara
What are the two types of cervical epithelium ?
- Columnar epithelium
- Squamous epithelium
What is columnar epithelium
- Surrounds the external os
- Glandular type cells
- Plushy, red to resemble the lining of the endocervical canal
What is squamous epithelium
- Continuous with the vaginal lining
- Stratified squamous non-keratinized epithelium
- Shiny pink outer layer
What is the SCJ (squamocolumnar junction)
The area where the two types of epithelia meet
In childhood where is the SCJ located
Just inside the external os
What is metaplasia and how does it relate to the cervix
It is the process of tissue transformation
1. Under hormonal influence
2. Causes the SCJ to evert or roll out to a position on. The enlarged cervical surface
3. The columnar epithelium is gradually replaced by squamous epithelium
*SCJ will migrate toward the os
What is the transformation zone
- Represents the area between the original SCJ and the active SCJ
- Contains the newest and least mature cells in the cervix
- Most vulnerable tot ontogenetic change (dysplasia)
What is target in the Pap smear?
- The transformation zone
*rate of metaplasia is highest during adolescence and pregnancy
Where does the uterus lie?
- Lies between the bladder and the rectum consists of two parts that are joint at the isthmus
*cervix
*body or corpus (upper part is the fundus)
What is the outer, middle, and inner portion of the uterus
Perimetrium: outer, serous layer of visceral peritoneum
Myometrium: muscular layer middle
Endometrium: inner, shed during menstruation
What is the normal position of the uterus
Inclines forward at a 45 degree angle
*anterversion most commone
What is a mid-position uterus
- Slightly forward but functionally straight
What is an anterverison uterus
- Uterus bent forwards
What is an anteflexion uterus
Top of the uterus is folded forward
What is a retro vision uterus
Bent backwards
Wha is a retro flexion uterus
Top of the uterus is folded backward
What is a didelphic uterus
Double cervix and double vagina
What is an arcuate uterus
Concave fundus
What is a septate uterus
Normal uterus but wall of tissue creating two cavities
*can be partial or complete
What is a bicornuate uterus
- Heart-shaped
*composed of two “horns: separated by a septum
What does the Adnexa refer to
- Fallopian tubes
- Ovaries
- And supporting structures
Where do the fallopian tubes insert into
- Insert on either side of the uterine fundus and extend laterally to the ovaries
*8-14cm - Supported by the mesosalpinx
What is at the end of each fallopian tube?
- Fimbriae
*tips which capture the ovum
Where are the ovaries at
- They rest on the lateral pelvic wall at the level of the anterosuperior iliac spine
*approx 3cm Long X 2 cm wide X 1cm thick - Palpable by pelvic exam in abut 50% of women during reproductive years
What is the true pelvis
- Contains the urinary bladder and reproductive organs
- Includes the inlet, cavity, and outlet
What is the false pelvis
- Upper broader portion of the pelvic cavity
- Mainly consists of the flared out iliac bones
What are gynecoid and android pelvis
G: round (normal)
A: wedge or heart-shaped
What are anthropoid or platypelloid pelvis
A: oval-long
P: oval/flat
Where do the vulva and lower vagina lymphatics drain to?
- Into the inguinal nodes
Where do the internal genitalia, lymphatics drain to
Into the pelvic and abdominal lymph nodes
*non palpable
What are the changes in infants and children (anatomy)
- Vagina small and narrow tube
- Ovaries are tiny and functionally immature
- Hymen is thin
- Growth of structure are incremental
What are the changes in adolescents (anatomy)
- External genitalia increase in size
- Clitoris is more erectile
- Labia minor more vascular
- Labia major and mon pubis become more prominent and begin hair development
- Vagina lengthens
- Uterus, ovaries, and tubes increase in size and weight
What happens to the endometrial lining in adolescents
- Thickens in preparation for menstruation
*happens between 8-16 - Just before menarche vaginal secretions increase
What are stages 1 and 2 of tanner stages (pubic hair)
- Preadolescent no pubic hair
- sparse growth of long, slightly pigmented, straight or only slightly curled, chiefly along the labia
What are stage 3 and 4 of tanner stages (pubic hair)
3: darker, coarser, curlier hair, spreading sparsely over the pubic symphysis
4: greater than stage 3 not yet including the thighs
What is stage 5 of tanner stages (pubic hair)
Adult hair in quantity and quality, spread over medial surfaces of things but not over the abdomen
In pregnant women what is responsible for uterine enlargement
High levels of estrogen and progesterone
*after the third month, enlargement result from the growing fetus
What are the anatomical changes that occur in older adults
- Vagina shortens and narrows
- Uterus decreases in size
- ovaries decrease to 1 to 2 cm
- Ligament and connective tissue lose elasticity and tone
What happens to the body during menopause
- Increase in body fat and intraabominal deposition of body fat
- Levels of total and LDL cholesterol increase
- Thermoregulation is altered
- Increased risk of cardiovascular disease
What are some concerning symptoms in a pregnant woman
- Involuntary passage of fluid
- Bleeding
- GI symptoms
How to screen for cervical cancer
- PAP smear
*get a sample from the transformation zone (area where height proportion of dysplasia and cancer arise)
What are the most common cervical cancer types
- Squamous cell carcinoma (80 to 90%)
- Adenocarcinomas in glandular cells 10 to 20%
How are majority of genital HPV infections cleared by?
- The immune system
What is the most important risks factor for cervical cancer
- Persistent infection with risk HPV
*HPC 16 and 18 account for 70% of cervical cancers
What are the cervical cancer screening recommendations
- Screen with Pap smear alone every 3 years for women 21 to 29
- Women age 30 to 65
*screen with cytology alone every 3 years OR
*every 5 years with high risk human papillomavirus (HrHPV) OR
*cotesting with hrHPV and cytology
Who should you not screen for cervical cancer
- Women younger than 21
- Women older than 65
- Women after a hysterectomy with removal of the cervix
When is the HPV vaccine recommended
- All children age 11 to 12
*protects against cervical, oropharyngeal, anal, vulvar, vagina, penile
What is the most common HPV vaccine
Gardasil 9
*<15 2 doses separated by 6 to 12 months
*>15 3 doses 0, 1 to 2 moths, 6 months
*can be administered with other vaccines
*cant be given to pregnant women
*can be given to males and females ages 27-45
Are there any effective screening tests for ovarian cancer
No, keep in mind these three symptoms for women over 50
1. Abdominal distention
2. Abdominal bloating
3. Urinary fluency
What is the strongest risk factor of ovarian cancer
- BRCA1 or BRCA2 mutations
*prophylactic oophorectomy and or mastectomy may be done if found to have gene mutation
What is CA-125 tumor marker used for
- For women who have been diagnosed with ovarian cancer to detect recurrence of disease
*will be elevated if treatment is not working
*will be decreased if treatment is working
When should non pregnant women be screened by chlamydia
- < age 25 screened annually
- > 25 screened if risk factors are present
*repeat testing of all women 3 months after treatment
What are the risk of menopausal hormone therapy
- Increased risk of cardiovascular disease
- Increased risk of dementia
- Increase in invasive breast cancer
- Gallbladder disease
What does unopposed estrogen cause in women
Increased risk for endometrial cancer
What are some of the benefits of menopausal hormone therapy
- Decrease in hip fracture
- Decrease in colon cancer
- Helps with vasomotor symptoms
*use minimal dose for shortest amount of time
What are some things you should have the patient do before the pelvic exam
- Avoid intercourse or anything inside the vagina for 1 to 2 days
- Empty the bladder before the exa,
When is the graves speculum used
- Wider, higher and curved on the sides
- Best for parous women with vaginal prolapse
- Will keep looser vaginal walls separated for visualization
What are the pedersen speculums and when should they be used
- Medium most comfortable for sexually active women
- Flat and narrow blade best for a patient with relatively small introitus
*virgin, elderly, nulliparous
What is the proper sequence of female genitalia examination
- External genitalia
- Perform speculum exam
- Perform bimanual exam
- Perform rectovaginal exam
- Perform rectal exam
What is the correct way to examine the external genitalia
- Retract prepuce to examine clitoris
- Retract labia and examine urethral meatus, skenes ducts and introitus
- Palpate bartholin glands
How to palpate bartholin glands
- Insert index finger into the vagina and thumb at the posterior labia
- Palpate between finger and thumb
- 4 and 8 o’clock positions
How to complete the speculum exam
- Place index finger of non-dominant hand no the posterior portion of the introitus and push down gently
*remove finger and replace with tip of speculum - Insert speculum with gentle posterior pressure at an angle
*bills should be closed - Gently insert at a downward angle
- rotate speculum horizontally
- Consider the bills angle/depth before opening
*then gently open - Secure with thumb screw
When you locate the cervix what should you be inspecting
- Size
- Shape
- Color
- Discharge
- Lesions
How does the cervical position correlate to the uterus
- If the cervix is pointed anterior, indicted retroverted uterus
- If the cervix is pointed posteriorly indicated anteverted uterus
If the cervix is deviated to the right or the left what could that indicate?
- Mass
- Adhesions
- Pregnancy
How to perform the PAP smear
- Insert spatula (exocerical sample 360)
*rinse spatula in solution 10 times - Insert cytobrush (endocervical smaple 180)
*tell patient she may experience some pain
*rinse - Insert broom (alternative pap choice for non-menopausal patient)
*rinse
What is the goal of a PAP smear>
- To sample the transformation zone
*common place for dysplasia and cancer to arise
How to inspect the vagina
- Gently remove speculum
*release the thumb screw completely
*hold pressure on the thumb lever - Slowly withdraw the speculum to observe the walls of the vagina
- Allow the bills to close before citing the introitus
How to perform the bimanual exam
- Stand between patients legs
- Position drape
- Lubricate index and middle finger of dominant hand
- Inert one finger, apply downward pressure at 6 o’clock, then insert second finger
- Palpate the entire vaginal canal
How to do bimanual exam (cervix)
- Sweep finger around cervix
- Palpate the cervix
- Rock the cervix gently between fingers (check for motion tenderness)
- Use finger of abdominal hand to stabilize and draw organs to vaginal fingers
*palpate the uterus, place non dominant hand above the suprapubic area
How to palpate for the Andexa (bimanual)
- Palpate the left ovary by placing you dominant hand in the left lateral fornix and the non dominant hand just left of midline superior to the pubic bone
*check for mass and tenderness
What are the first, second and third degree uterine prolapse
First: cervix is still well within the vagina
Second: cervix is at the introitus
Third: cervix and vagina are outside the introitus
What is the purpose of the rectovaginal exam
- To palpate retroverted uterus, the uteruosacral ligaments, cul-de-sac and adnexa
- Screen for colorectal cancer in women 50 years or older
How to complete rectovaginal exam
- Use new gloves and lubricate fingers
- Introduce index fingers into the vagina and middle finger into the rectum
*tell patient to strain down - Reassure patient sensation of defecation
How to perform the rectal exam
- Always change gloves
- Gently place index finger in anus and palpate for masses and hemorrhoids
3, if needed, check for occult blood
After the completion of the pelvic exam what should yo do?
- Re-drape the patient
- Assist the patient to upright position
- Discus assessment and answer questions
- Discuss protocol for informing patient of Pap test results
How to examine infants
Frog positions
*mucoid whitish vaginal discharge is frequently seen due to hormone transfer
*clitoris may appear large
