Female Genitourinary Flashcards
Female Tanner stages
Female Tanner staging is divided into two different sections: one looking at the development of the breast while the other looks at development of the pubic region.
Breast:
- Stage 1 - (pre-adolescent) - only the nipple is raised.
- Stage 2 - Budding stage - elevation of the breast and papilla as a small mound (bud).
- Stage 3 - breast and areola continue to enlarge. No change in contour. Acne, axillary hair, explosive height growth.
- Stage 4 - continued fat deposits into the breast tissue. The areola and papilla form a mound above the breast.
- Stage 5 - mature breast development. Most the time the areola returns to contour of the breast.
Pubic hair:
- Stage 1 - (pre-adolescent) - no pubic hair.
- Stage 2 - sparse, long, straight hair. Usually grows medially along the labia.
- Stage 3 - Darkening of the hair. Coarser. Still sparse.
- Stage 4 - Darker, coarse, curled pubic hair. Does not spread to medial portion of thighs as in adult.
- Stage 5 - mature pubic hair.
What are the risk factors for breast cancer?
- Breast cancer risk increases with aging.
- Inheritance of BRCA 1 and BRCA 2 genes have a significantly higher risk of developing breast cancer than when compared to those without. 45-80% increased risk.
- Personal or family history of breast cancer
- Caucasian ethnicity is at the highest risk of breast cancer development
- Menarche before age 12 or menopause after age 55
- Increased breast tissue density
- Nulliparity or late age at birth of first child
- Use of estrogen or progesterone replacement therapy increases risk
- Alcohol consumption
- Obesity
- Lack of exercise
What age range does each tanner stage correspond with?
Stage 1 - 8 years to 9 years old
Stage 2 - 9 to 11 years old
Stage 3 - After age 12
Stage 4 - Around 13 years old
Stage 5 - Around age 15
What are the different methods of performing a breast exam? What are the expected findings? How does the breast exam change for women who have had a mastectomy?
- Chest wall sweep
- Circular
- Wedge (start from the nipple going outward in different directions.)
Expected findings with a breast exam are non-palpable lymph nodes, no masses, lesions, discolorations. Breast are symmetrical. No abnormal discharge. Nipples are typically everted. No dimpling. No flattened nipple.
The mastectomy site requires the same level of assessment. Look for masses, lesions, color changes, rash, irritation. The scar should be examined closer to note an return of masses or thickening. The scar should be palpated.
What changes occur with a lactating patient? What problems can occur? How are these addressed?
- Breast tissue needs to be adequately supported with a well fitting bra.
- Engorgement - not unusual during the first 24-48 hours after breasts fill with milk. Feel heavy, dense. They are full of milk. Presence later on during breast feeding can be a precursor to mastitis. Patient needs to breast feed or express more often.
- Clogged milk ducts - not uncommon. Can occur when not enough milk is expressed or a bra that is too tight is worn. Can cause the breast to feel lumpy and hot. Treated with increased breast feeding frequency or expression and use of a warm compress.
- Nipple irritation/ cracked nipples - the patient’s nipples can become irritated, reddened and can even crack and bleed most commonly due to feedings.
Different types of breast masses. Documenting different breast masses.
- Fibrocystic changes - benign fluid filled cyst
- changes are seen bilaterally usually
- mass is round
- soft to firm consistency
- mobile
- no nipple retraction
- typically tender
- borders are well defined - Fibroadenoma - a non-cancerous breast tissue tumor.
- typically are seen bilaterally
- round or discoid
- firm and rubbery
- mobile
- no nipple retraction
- nontender
- borders are well defined - Cancerous
- Unilateral
- single mass
- irregular shape
- Hard, stone like
- immobile, fixed
- nipple retraction is often present
- poorly defined borders
Evidence-based practice for mammogram screenings
- Every other year starting at age 40 for women of average risk.
- High risk patients should begin screenings earlier and have them more often.
Describe the changes that are seen with the vagina during different stages of maturity.
- Infant and children
- Adolescents
- Pregnant patients
- Elderly
- Infant and children - smaller and functionally immature structures. Growth and development happens at varying rates.
- Adolescents - puberty occurs - growth of genitalia. Functionally mature. Pubic hair. Usually coincides with breast development.
- Pregnant patients -
1. UTERINE ENLARGEMENT - increased levels of estrogen and progesterone play the primary role in uterine enlargement until the growing fetus’s mechanical strain on the uterus takes over as the primary factor of growth.
2. RELAXIN and PROGESTERONE - these hormones result in softening of the pelvic cartilage allowing increased mobility. Results in pregnant waddle but is useful in preparation of delivery.
3. INCREASED ACIDITY - vaginal secretions increase in acidity - good for fighting infections, bad for candida infections. - Elderly patients -
1. Ovarian function decreases
2. Menopause occurs between ages 41-59.
3. Hormones decrease
4. Vaginal atrophy
Risk factors for cervical cancer (10)
- HPV - a common infection - only some strains are associated with cervical cancer, but strongly associated. HPV vaccination greatly decreases cervical cancer risks.
- Pap smear - regular screenings and followings are recommended, especially in patient’s with increased risk.
- High parity - patients with three or more full-term pregnancies are at increased risk for developing cervical cancer.
- Young age at parity - patients having babies at younger ages are at increased risk for developing cervical cancer.
- Smoking - tobacco use doubles the chances of developing cervical cancer.
- HIV
- Chlamydia
- Diet - a diet low in fruits and vegetables increases risk for cervical cancer.
- Long-term use of oral contraceptives
- Lower socioeconomic status
Risk factors for ovarian cancer (9)
- Age - risk increases with age. Highest risk after menopause.
- Inherited genetic mutation syndromes - BRCA1 or BRCA2 or PTEN genes.
- Family history - first-degree relatives
- Obesity - BMI of 30 or greater
- Reproductive history - nullparity or parity after age 35 increases risk.
- Use of fertility drugs - especially if conception was not achieved
- Hormone replacement therapy
- Oral contraceptives
- Diet - high fat diets
Risk factors for endometrial cancer (10)
- What hormone increases risk
Estrogen increases the risk for endometrial cancer - factors that increase estrogen levels and exposure increase risk.
- Increased risk related to the number of lifetime menstrual cycles (early menarche or late menopause).
- Infertility or nullparity - the shift away from estrogen as the primary hormone to progesterone (during pregnancy) decreases risk.
- Obesity - adipose tissue can store estrogen which increases exposure which increases risk for endometrial cancer.
- Tamoxifen - antiestrogen drug that acts like estrogen
- Estrogen replacement therapy
- Ovarian diseases - PCOS, ovarian tumors.
- Diet - high fat diet
- Diabetes - both 1 and 2
- Age - risk increases with age
- Family/ personal history
What risk factors are shared by endometrial, ovarian, and cervical cancer?
- Diet - high fat diet (shared by endometrial and ovarian cancers). Cervical is related to lack of vegetables and fruits.
- Age - increased age increases risk in endometrial and ovarian cancers.
- Parity - ovarian and endometrial cancers are both related to increased exposure to estrogen. Being pregnant replaces estrogen with progesterone as the primary hormone which decreases estrogen exposure. Cervical cancer is the opposite where increased parity increases risk for cervical cancer.
- Use of oral contraceptives increases risk with cervical cancer and ovarian cancer.
How to document obstetrical history?
GTPAL
G - gravidity - total number of times a woman has been pregnant
T - term - how many pregnancies have been carried to term
P - preterm - how many pregnancies have been preterm
A - abortions/miscarriages - how many pregnancies have been lost or aborted
L - living children
How to document gynecological history?
- Menstrual history - menarche, frequency, heaviness, noted abnormalities, menopause.
- Sexual history - 5Ps - partners, practices, protection, past history of STIs, and pregnancy intentions
- Medical history
- Gynecological conditions
Red flags for sexual abuse in children and adolescents
Medical:
- Physical abuse or neglect
- Trauma or scarring in the genital, anal, or perianal areas
- Unusual anal or perianal colors
- STI presence
- Anorectal issues (itching, redness, fissures, bleeding, pain, fecal incontinence, poor sphincter tone, sores, or rashes.
- Genitourinary issues - bleeding, UTI, dysuria, discharge, enuresis, abdominal pain
Nonspecific:
- Problems at school
- Weight changes
- Depression
- Anxiety
- Sleep disturbances or nightmares
- Personality changes
Sexual behaviors:
- Provocative
- Excessive masturbation
- Age-inappropriate sexual behaviors or knowledge
- Repeated insertion of objections
- Kissing and touching excessive
- Aggressive
Speculum Exam
1. What is it for?
2. How to perform?
3. Expected vs Unexpected findings
4. PID
- The speculum is used during vaginal exam to view internal portions of the female genitalia.
- The speculum should be lubricated. and should be age appropriate in size. The fingers are first inserted to spread the labia apart, the speculum that is positioned and appropriately spread is then slowly inserted along the path of least resistance. View the internal anatomy. Verbalize each step of the exam to help the patient prepare for sensations and feel more comfortable with the exam.
- The cervix can vary greatly in normal appearance. Pink is the normal color seen. Bluish coloration indicates vascularity which is seen with pregnancy. Should be smooth. Some discharge is okay, should be odorless. Os shape and size.
- PID -
The “hook” technique
is used to assess the lymph nodes around the clavicles, feeling for any enlargement that is highly specific for malignancy.
Sentinel Nodes
These are lymph nodes that are highly specific to malignancy when enlarged. The clavicles are sentinel nodes.
Three key signs that are suggestive of breast cancer?
- Skin dimpling
- Flattened nipples
- Nipple retraction
How is the rectovaginal exam performed? What is it’s importance?
The rectovaginal exam is done by placing the index finger in the length of the vagina while the middle finger is placed inside the rectum. Allows for increased palpation of the rectovaginal wall.
How does the vaginal exam change for infants and children when compared to adults?
External exam only for infants and children
Condyloma acuminatum
HPV warts
Molluscum contagiosum
Viral infections of skin/mucous membranes. STI in adults, can be spread non-sexually in children.
Syphilitic chancre
Primary syphilis skin lesion
