GYN part 1 Flashcards
Gynecological exams maybe necessary for the following
Assess a specific problem: Pelvic pain Vaginal bleeding Vaginal d/c Routine gyn evaluations: Yearly for women sexually active or after 18 yo (21 yo for pap tests)
Things to keep in mind when performing gynecological examinations
Pt Issues:
Possible past history of sexual abuse, rape
Previous bad experiences with gynecological exams
Modesty and shame issues
Fear due to a sense of helplessness
Fear of disease or pregnancy
Denial
Poor body awareness
Sexual orientation – language usage very important
The physician’s own issues in this context need to be looked at:
Fear of causing pain
Personal space issues
Respect for the patient
Uninhibited patients
Support role when doing the exam
Confidentiality
Teenagers and their special needs
Mental or sexual (due to sexual abuse), including
contraception – pt consent as young as 10 yo
Vaccines – age 15 yo if a pt wants a vaccine without
parents knowledge (HPV is the big one)
Identify primary complaint and get details (concurrent sxs)
Pelvic pain
AbN vaginal bleeding
Vaginal d/c
Menstrual history (exceedingly important to get this info)
Age at menarche
Number of days of menses
Length and regularity of interval between cycles
Last menstrual period (LMP)
Menstrual period - first day of period to last day of before new cycle
Previous menstrual periods (PMP)
Color and volume of flow
Symptoms with menses
Cramps, loose stools
Anovulation: may present with vaginal bleeding that is painless, scant, dark, abnormally brief or prolonged, and occurs at irregular intervals
Normal Menses: Blood is medium to dark red Flow lasts 5 (+/- 2) days 21-35 days in between menses Average blood loss = 30mL (range 13-80mL) Most bleeding is on second day Saturated pad or tampon absorbs 5-15mL Cramping is common the day before and 1st day of menses
Sexual activity and History
Frequency:
Number of sexual partners
Participation in unsafe sex
Effects of sexual activity (pleasure, orgasm,
dyspareunia)
Orientation
Types of sexual activity – vaginal, anal, oral, sex toys,
etc.
Possibility of pregnancy, along with attitudes and contraception (use of):
Symptoms of pregnancy
Morning sickness, breast tenderness, delayed menses
Contraception
History (why d/c certain types)
What she is currently using
Length of time used
History of pregnancy and outcomes
Review of past illnesses, surgeries or hospitalizations
Psychological status: depression, anxiety, drugs
List medications, including OTC & supplements
ROS
GI symptoms
Urinary symptoms
Breast problems
Endocrine status
Bleeding history – clotting issues, anemia
Symptoms of pelvic pain - location, duration, character, quality, triggering and relieving factors
Abnormal vaginal bleeding - quantity, duration, relation to cycle
Cardiac status
Screen for Domestic Violence
Questionnaires and interview look for: Inconsistent explanations for injuries Delay in seeking treatment for injuries Unusual somatic complaints Psychiatric sx. Frequent ER visits Head and neck injuries Having given birth to low birth weight infants
Family history of disease (family member/age of diagnosis)
CVD DM Osteoporosis Breast CA Other CA Endometriosis PCOS Infertility
Gynecological examination
Start by letting the patient know what to expect – what exams will be performed and give her permission to let you know at any point if she experiences pain.
Have the patient empty their bladder before the exam
Vitals, including height and weight, waist circumference (more important than BMI, predicts insulin resistance)
Heart, lung and lymph node examination (cervical)
Thyroid examination
Breast examination –complete CBE and check axillary and clavicular lymph nodes
Abdominal examination
Pelvic examination: external inspection, speculum exam & specimen collection, bimanual, and rectovaginal exam (in certain circumstances and at 40 yo annually)
External genital exam
Lymph nodes - inguinal
Hair (distribution, inspect for lesions, folliculitis, lice)
Clitoral size
Vulva and perineum (inspect for lesions, masses, swelling, excoriations, erythematous changes, AbN pigmentation)
Vestibule
AbN pigmentation
Discharges
Inflammation and patency of the introitus
Rectocele (posterior bulge when pt. bears down) - prolapse of wall between rectum and vagina
Cystocele (anterior bulge when pt. bears down) - tear of the tough fibrous wall btwn the vagina and bladder allowing the bladder to herniate into the vagina
Optional: palpation of bartholin glands (at 5 and 7 o’clock, secrete mucus to lubricate the vagina) & skene’s glands (just inferior to the urethra, part of the clitoris tissue)
Palpate pelvic floor with lubricated and gloved index finger ask pt to squeeze as if stopping flow of urine – assess strength
Speculum exam
Make sure to warm and lubricate speculum
Insert speculum with blades applying pressure downward (pulling speculum down toward the perineum), slowly moving it forward – follow the path of the vagina (keep blades away from the urethra as this causes pain)
Make sure the speculum is fully inserted before opening the blades and remember cervices are in all different positions!
Inspect for cervical changes, polyps, mucosal atrophy, tumors, cysts, masses, vaginal wall ruggae, bleeding or discharge (quantify & describe)
Normal Speculum Exam findings:
Cervix is pink, shiny with clear/white discharge, no masses or lesions
Vagina has appropriate ruggae for her age, no masses or lesions
This is when you can collect pH, wet preps, cultures, GC/CT, a pap smear to look at cellular health and for HPV DNA (if appropriate).
Remove the speculum taking care to not pinch the cervix and to allow the blades to close as you remove the speculum so as not to press against the urethra.
Bimanual exam
Insert lubricated middle and index finger of dominant hand with lubrication. Once you feel the cervix move it side to side to assess for cervical motion tenderness (CMT), also move it up & down to assess for uterine mobility (normally it should move some, it should not be fixed or move excessively), (if fixed = adhesions due to endometriosis, if excessively mobile = multiple births)
Move your fingers just superior to cervix while top hand is placed just above pubic symphysis and gently presses down to assess uterus.
Uterus: position, size, shape, consistency, mobility and tenderness
Normal findings on bimanual exam
Anteverted (most common position), anteflexed, retroflexed, retroverted
Normal size: 6cm x 4cm
Mobile, smooth and NT
Abnormal findings on bimanual exam and DDX
Irregularity in shape suggests uterine fibroids or tumor
Enlargement: pregnancy, adenomyosis, malignancy, or myomas
Softening (bogginess): pregnancy, malignancy, degenerating myoma, sarcoma, PID
Cervical motion tenderness (CMT): PID, ovarian cysts, endometriosis, adhesions
Adnexal structures (structures most closely related structurally and functionally to the uterus)
Normal ovary (reproductive age): 3 x 2 x 2 cm Normal ovary (menopausal): 1 x 0.7 x 0.5 cm Note size, shape, consistency, mobility and tenderness Palpate in lateral fornix with top hand gently pushing down, bring internal fingers up to meet the top hand to catch ovary bt them. It may cause her to have a slight bit of pain when palpating the ovary
Rectovaginal Exam
Insert index finger vaginally and middle finger rectally with lubrication
Assess septum, utero-sacral ligaments, uterus, cul-de-sac, adnexae, and cervix
Done in women > 40 y/o or in any age women with suspicion of endometriosis or CA
Testing (common tests done related to Gynecology)
Pregnancy tests
Urine βhCG: specific, highly sensitive, + within 1 wk of conception
Serum qualitative βhCG: more specific and sensitive than urine
Serum quantitative βhCG: used specifically with miscarriages, ectopic pregnancy
PAP smear
Cervical cells examined for signs of dysplasia or CA
Can add on HPV DNA to liquid Paps, can also add GC/CT
It may also detect uterine CA
Wet Prep
Microscopic exam of vaginal secretions to identify vaginal infections (trich, BV, yeast, etc)
Cervical Mucus Inspection
Used in cases of infertility – place mucus on slide, allow to dry, assess for degree of microscopic crystallization (Ferning) – reflects levels of circulating estrogens
Genital Culture Helps to identify bacteria and fungus DNA probes or Urine Aptima test For GC/CT pH of cervical secretions Normal 3.5-4.5
Other STI testing Herpes testing (viral PCR from lesion and serum IgG HSV 1 & 2) HIV blood testing RPR for syphilis – serum test Hepatitis B & C – serum tests
Imaging
Ultrasound most commonly used with suspicion of masses-transvaginal (TVUS) and abdominal are the most common
MRI/CT used less often
Surgical Procedures
Laparoscopy – used for exploration of dz process & tx at the same time
Endometrial Biopsy (EMB) (In office procedure for unexplained vaginal bleeding or thickened endometrium seen on TVUS)
Colposcopy (recommended for abnormal pap smears)
Vulvar Biopsy (performed to diagnose lesions of the vulvar epithelium)
Hysteroscopy (has a light and camera hooked to it so your doctor can see the lining (endometrium) on a video screen, can be used for removal of fibroids and polyps)
Pelvic mass
may be detected during a routine gyn exam
Pelvic mass: etiology
May originate from gyn organs – cx, uterus, adnexae
May originate from other pelvic organs – intestine, bladder, ureters, skeletal msl, or bone
Types of masses per age group:
In utero – adnexal cysts dt maternal hormones (rare)
Puberty – hematocolpos - accumulated menstrual blood forms vag mass dt obstruction – imperforate hymen or congenital malformations of uterus, cx, or vagina
Reproductive age women – pregnancy, myomas or fibroids (most common cause of mass), functional ovarian cysts, ectopic pregnancy, benign teratomas, Hydrosalpinges, endometriomas.
Postmenopausal women – more likely to be cancerous.
Pelvic mass: Hx
General medical hx
Complete gyn hx –
including menstrual hx, pelvic pain, irregular bleeding
vaginal bleeding and pelvic pain suggest ectopic pregnancy
dysmenorrhea suggests endometriosis/adenomyosis and uterine fibroids
Pelvic mass: PE
Vitals
Thyroid
Abdominal
Complete gyn exam
Pelvic mass: Labs/Imaging
TVUS
CT/MRI – if TVUS does not clearly identify size, location & consistency of mass
Biopsy & tumor markers – mb needed if masses have characteristics of cancer
Pregnancy test – women of reproductive age
common causes of pelvic pain
Related to menses:
dysmenorrhea
endometriosis
Mittelschmerz
Unrelated to menses:
PID
Ruptured Ovarian Cyst
Ruptured Ectopic Pregnancy
Acute degeneration of uterine fibroid
Adnexal torsion
Adhesions
Uterine or ovarian CA
Spontaneous abortiondysmenorrhea
Sharp or cramping pain before or at onset of menses, often with h/a, N/D, constipation, or urinary frequency
endometriosis
Sharp or cramping pain always exacerbated by menses, often with dysmenorrhea, dyspareunia, or painful defecation
May eventually cause pain unrelated to menses
In advanced stages, s/t uterine retroversion, tenderness, ↓ mobility.
S/t a fixed pelvic mass (possibly an endometrioma) or tender nodules noted during bimanual and rectovaginal exam
Mittelschmerz
ovulatory pain, mid-cycle
Sudden onset of severe, sharp pain, most intense at onset and abating over 1-2 d
Often accompanied by light, spotty vaginal bleeding
PID
Gradual onset of pelvic pain, mucopurulent cervical d/c
S/t fever, dysuria, dyspareunia
Typically, marked CMT & adnexal tenderness (fundal tenderness)
Rarely, an adnexal mass (abscess)
Not always STI related
Ruptured ovarian cyst
Sudden onset of pain (unrelated to menses), most severe at onset and often rapidly ↓ over a few hours
S/t with slight vaginal bleeding, N/V, and peritoneal signs
Ruptured ectopic pregnancy
Sudden onset of localized, constant (not cramping) pain, often with vaginal bleeding and sometimes syncope or hemorrhagic shock
Closed cervical os
Sometimes acute abdominal distension or tender adnexal mass
Will be on the ground from severe severe pain
Acute degeneration of uterine fibroid
Sudden onset of pain, and vaginal bleeding
Most common during the 1st 12 weeks of pg or after delivery or termination of a pg
Get hx of fibroids and whether they’ve had tx
Adnexal torsion
Sudden onset of severe, unilateral pain, occasionally colicky (because of intermittent torsion)
Often with N/V, peritoneal signs, and CMT
Presence of risk factors (pg, induction of ovulation, ovarian enlargement >4cm)
will become gangrenous from lack of blood supply to tissue
Adhesions
Gradual onset of pelvic pain (often becoming chronic) or dyspareunia in pts who have had an abdominal surgery or s/t pelvic infxns
No vaginal bleeding or d/c
S/t N/V (suggesting intestinal obstruction)
Get hx of PID, surgeries, inflammation of colon
Uterine or ovarian CA
Gradual onset of pain, vaginal d/c (which precedes bleeding), AbN vaginal bleeding (post-menopausal bleeding, pre-menopausal recurrent metrorrhagia)
Rarely, a palpable pelvic mass
Ovarian CA - seeds and falls off
Uterine CA - can work it’s way through myometrium and METS
Spontaneous abortion (SAB)
Vaginal bleeding associated with cramping lower abdominal pain or back pain during early pg and accompanied by other symptoms or early pg such as breast tenderness, N, delayed menses
Clues to dx pelvic pain: syncope or hemorrhagic shock
Ruptured ectopic pregnancy, possible ovarian cyst
Clues to dx pelvic pain: Vaginal discharge, fever, and bilateral pain and tenderness
PID
Clues to dx pelvic pain: Severe, intermittent colicky pain, sometimes with nausea, which may develop and reach peak intensity within seconds or minutes
Adnexal torsion
Renal colic
Clues to dx pelvic pain: Nausea followed by anorexia, fever, and right sided pain
Appendicitis
Clues to dx pelvic pain: Constipation, diarrhea, and relief or worsening of pain with defecation
GI disorder (IBS, IBD)
Clues to dx pelvic pain: LLQ pain in women > 40, wake up with pain, can’t clear feces, constipation
Diverticulitis
Clues to dx pelvic pain: generalized abdominal tenderness or peritoneal signs
Peritonitis (eg, due to appendicitis, diverticulitis, another GI disorder, PID, adnexal torsion, or rupture of an ovarian cyst or ectopic pregnancy)
Clues to dx pelvic pain: Tenderness in the anterior vaginal wall
Bladder or urethral pain due to a lower urinary tract disorder
Always do UA
Clues to dx pelvic pain: Uterine fixation detected by bimanual examination
Adhesions, endometriosis, or late-stage cancer
Clues to dx pelvic pain: Tender adnexal mass or tenderness with cervical motion
Ectopic pregnancy, PID, ovarian cyst or tumor, or adnexal torsion
Clues to dx pelvic pain: Tenderness of the pubic bone in parous women, particularly if pain occurs during ambulation
Diastasis of the pubic symphysis
≥ 1cm on any imaging, occurs with pregnancy, worse touch, movement, esp lifting leg
Clues to dx pelvic pain:
Painful defecation plus localized tender mass felt during internal or external examination of rectum, with or without fever
Chronic painful defecation plus localized firm woody mass felt during internal or external rectal exam; without fever
Perirectal abscess
Severe endometriosis
Late stage cervical cancer
Clues to dx pelvic pain:
Gross or microscopic rectal blood
GI disorder
Emergency situations that may require surgery:
Tubo-ovarian abscess Ectopic pregnancy Ruptured or torsion of ovarian cysts Appendicitis Bowel perforation
History (for pelvic pain)
gyn, GI, GU, musculoskeletal hx
pain - onset, severity, relationship to menses, quality, radiation, location and associated findings
concomitants - vaginal bleeding or d/c, symptoms of hemodynamic instability
relationship to various activities - sleep, vaginal penetration/intercourse, eating, BM’s, urination
ROS - morning sickness, breast swelling/tenderness or missed menses (pg); fever, chills, N/V (infxn); abdominal pain, N/V or change in stool habits (GI d/os); urinary frequency, urgency, dysuria (Urinary d/os)
PMHx - infertility, ectopic pg, PID, urolithiasis, diverticulitis, GI/GU cancers, previous abdominal or pelvic surgery
PE (for pelvic pain)
Vitals - including orthostatic BP
Abdominal exam - complete including all tests R/O appendicitis (McBurney’s, Rovsings, Psoas, Oburator & DRE)
Pelvic exam
Check for CVA tenderness
Check pubic symphysis
Rectal exam- check for tenderness, mass or occult blood
Red flags during PE (for pelvic pain)
Syncope or hemorrhagic shock
Peritoneal signs (rebound, rigidity, guarding)
Post-menopausal vaginal bleeding
Fever or chills
Sudden, severe pain with N/V, diaphoresis or agitation
Labs (for pelvic pain)
UA complete & culture
Wet prep, genital culture, GC/CT DNA probe
CBC - for anemia, with N/V, fever and chills for infxn
Pregnancy test - if heterosexual and sexually active, must rule out before proceeding with tx
TVUS - consider if cannot examine pt due to pain or if mass is suspected
MRI/CT - do if results from TVUS are indeterminate
Laparoscopy - if cause of severe or persistent pain remains unidentified
Key points
Pelvic pain is common and may have a gynecological or non-gyn cause
Pregnancy should always be R/O in women of childbearing age
Quality, severity, location of pain and its relationship to menstrual cycle can suggest the most likely causes
Dysmenorrhea is a common cause of pelvic pain but is a Dx of exclusion
Definition of abnormal vaginal bleeding
prolonged, painful, excessive, or irregular bleeding
Menorrhagia
excessive duration (longer than 7 days) and/or amount >80 ml of bleeding Polymenorrhea
Polymenorrhea
too frequent menses (less than 21 days) too close together
Metrorrhagia
bleeding that’s unrelated to menses, occuring freq and irregularly bt menses
Oligomenorrhea
too few periods (more than 35 days)
Amenorrhea
no menses
Postmenopausal bleeding
vaginal bleeding more than 6 mos (most sources use 12 mos) after last normal menses needs to be evaluated
Etiology of AUB (abnormal uterine bleeding)
most AUB results from hormonal AbN in HPO axis
Anovulation → no progesterone → unopposed E → stimulation of endometrial glands → sloughs irregularly, incompletely, & s/t excessively or > duration
Other causes: structural, inflammatory, tumors, or bleeding d/o
Common causes of AUB in infants
in utero spotting from estrogen from mom
Common causes of AUB in children
foreign body trauma
sexual abuse - if see cervical or vaginal warts, tears or lesions need to rule out
Common cause of AUB in women of reproductive age with syncope or hemorrhagic shock
ruptured ectopic pregnancy
Common cause of AUB in women of reproductive age with positive pregnancy test
Spontaneous complete or incomplete abortion, ectopic pregnancy, gestational trophoblastic disease, endometritis secondary to retained products of conception
Women of reproductive age with negative pregnancy test
hormonally related- anovulation (most common) or hypothyroidism
Postmenopausal women
mostly structurally related - endometrial cancer most common (CA of uterus), polyps, atrophy, tumors
History (for AUB)
Complete gyn hx
Incl: Sxs of bleeding - quality & duration of bleeding, quantity (number of pads/tampons and size used per hour/day), relationship to menses and vaginal penetration, & r/o trauma
Menstrual hx should include – date of LMP, age at menarche and menopause (when appropriate), cycle length and regularity, quantity and duration of typical menstrual bleeding
Previous episodes of AbN bleeding, including frequency, duration, quantity, and pattern (cyclicity) of bleeding should be identified.
Sxs of blding d/o – easy bruising, gingival blding, excessive blding with cuts or venipuncture
Sxs of pregnancy, pelvic pain
Sxs of hemorrhagic shock – light-headedness, syncope, tachycardia
Sxs of infection related to: Retained products of conception (POC) or endometritis - recent SAB or TAB presenting with blding with pelvic pain, fever, & vaginal d/c
PCOS – hirsutism, obesity, hx irregular menses
Cancer - Chronic pain and wt loss
Structural d/os – uterine fibroids, endometrial polyps, ovarian cysts
Risk factors for endometrial cancer – Obesity DM HTN Prolonged unopposed estrogen use PCOS Age – older than 35 yo
PE (for AUB)
Vitals, BMI, waist circumference
Skin – signs of bleeding d/o, jaundice, hirsutism & acne
Thyroid exam
Abdominal exam – look for hepatosplenomegaly (liver d/o)
Complete gyn exam
Speculum exam – help determine if bleeding originates from vagina, cx, or uterus. If no blood is visualized – rectal exam needs to be done to R/O GI bld.
Bimanual – may palpate mass – a tender pelvic mass suggests ruptured ectopic pregnancy or ovarian cyst. Nontender mass in uterus is commonly uterine fibroids
Red Flags:
Hemorrhagic shock
Premenarchal and postmenopausal vaginal bleeding
Vaginal bleeding in pregnant patients
Labs (for AUB)
Pregnancy – ALL reproductive age women
CBC – if bleeding is heavy - > 1 pad/tampon per hr or has lasted several days or s/sxs of anemia or hypovolemia are present.
Ferritin, iron panel
Thyroid panel
Prolactin (with oligomenorrhea & amenorrhea, rarely in other bleeding presentations, seen with hypothyroidism)
TVUS (in any of the following – age > 35, risk factors for endometrial CA, bleeding that continues despite use of empiric therapy) or sonohysterogram (saline infused ultrasonography) – identify submucosal or intracavitary pedunculated myomas, endometrial polyps or endometrial hyperplasia
EMB (endometrial biopsy) – if TVUS & exam do not detect AbN in women > 35 yo, who have risk factors for cancer or TVUS shows thickened endometrium (greater than 4mm)
PT & PTT, von Willebrand’s factor – if bleeding d/o is suspected.
Vulvar biopsy – if source of bleeding is from vulva
Pap smear/HPV – r/o cervical cancer
If PCOS is suspected – serum testosterone, DHEAS, fasting glucose/insulin, FSH/LH (day 3 of cycle)
KEY POINTS (for AUB)
Always exclude pregnancy in women of reproductive age even when history does not suggest it
DUB – the most common cause of AUB during reproductive years
Vaginitis, foreign bodies, trauma & sexual abuse are common causes of vaginal bleeding before menarche
Post-menopausal vaginal bleeding needs further evaluation to exclude cancer as the cause.
Endometrium
Consists of glands and stroma, has a basal layer, an intermediate spongiosa layer and a layer of compact epithelial cells that line the uterine cavity
Functionalis – transient layer that is sloughed during menses composed of spongiosa and epithelial layers
After menstruation, the endometrium is generally < 2mm thick
Endometrial proliferative phase
Corresponds to the follicular phase of the ovary
E causes proliferation and vascularization
Cervix produces fertile mucus: from endocervical columnar cells
The endometrium can increase to a maximum thickness of 11mm late in the follicular phase (during cycle)
Endometrial secretory phase
Corresponds to the luteal phase of the ovary
Secretory glands develop in the endometrium: stabilizes the endometrium
Thickening of the cervical mucus (so sperm can’t escape)
Secretory endometrium is necessary for embryonic implantation
The endometrium in the secretory phase will increase to 14mm thick (max thickness, right before menstruation)
Vaginal changes throughout the cycle
Early follicular phase
Vaginal epithelium thin and pale
Late follicular phase with E increasing
Vaginal epithelium thickening occurs
Luteal phase
Mature squamous cells are shedOther hormones produced in the ovary
In the stroma (tissue surrounding the follicle): androgens and their precursors, androstenedione, testosterone & dehydroeiandrosterone (DHEA)
Stromal hypertrophy seen in diseases like PCOS with a hyperandrogen state & menstrual dysfunction
Three types of estrogen:
Estrone (E1) - highest during menopause
Estrone persists after menopause in small amounts via
conversion of androstenediol in fat & muscle cells
Estradiol (E2) - highest in childbearing years, produced by
follicles of the ovary
Estriol (E3) - highest during pregnancy - produced by the
placenta, it is also a breakdown product of E1 & E2 in
liver.
Menstrual cycle (normal):
Day 1: bleeding starts; interval is 28 +/- 3 days for 65% of women
Normal range 21-35 day cycle – cycle lengthens in puberty & perimenopause
Average duration of bleeding: 5 days +/- 2
Blood loss average: 30 mL with a range of 13-80 mL – usu greatest on day 2 of menses
Menstrual blood usually doesn’t clot due to fibrinolysin & other fxs inhibiting clotting
Menarche: average age of onset 12.5 years in US (range 12-15 years)
For normal periods to occur the following must be present:
- Pulsatile discharge of LH and FSH
- Ovary capable of responding with appropriate E and
P production - Normal levels of other hormones: thyroid, prolactin
and androgens - Anatomically correct and responsive reproductive
organs (Uterus)
- Ovary capable of responding with appropriate E and
