Gynecologic Patient Flashcards
What is the mons pubis and what is it covered by after puberty?
The mons pubis is a pad of adipose tissue and it’s covered by course terminal hair after puberty
What extends from the mons pubis and is also covered in hair after puberty?
Labia majora
What is inside and hidden by labia majora and meet at the anterior of the vulva? What does it form?
The labia minora are two hairless, reddish folds, which meet at anterior of the vulva and fused to form the prepuce in the clitoris
What is the clitoris?
A small bud of erectile tissue, it’s the homolog of the penis
What happens to the clitoris during sexual arousal?
It becomes erect
What does the labia minora enclose?
Vestibule
What are the six openings of the vestibule
Urethra, vagina, two ducts of Bartholin glands, two ducts of Skene glands
Which glands of the external genitalia are anterior? and posterior?
The Skenes glands are anteriorly located. They are also called the paraurethral glands.
The Bartholin glands are located posteriorly.
What is the hymen?
A very thin connective tissue membrane that surrounds the vaginal opening. It is very easily broken and the appearance varies and after tearing, edges disappear, or become hymenal tags
What does an imperforate hymen indicate?
Not sexually active
What does a parous introitus hymen indicate?
Sexually active or vaginal delivery
What do the Bartholin glands do?
During sexual arousal, they secrete mucus into introitus for lubrication
What happens during a Bartholin abscess?
The Bartholin ductile openings are not usually visible, and in this scenario ducts can get clogged from sweat and other substances so the patient can develop an abscess
What is the vagina and what does it extends from?
What is the upper vagina considered?
The vagina is a musculomembranous tube, extending from the vestibule to the uterus. Upper end of vagina contains the cervix.
What are characteristics of the vagina muscular wall?
The muscular wall has inner circular and outer longitudinal layers of smooth muscle and is very distensible
What is the rectovaginal septum?
Posterior vaginal wall is separated from the rectum by this
What occurs to the rectovaginal septum during a third-degree tear?
The barrier between the posterior vaginal wall and rectum is torn. This occurs often during birth.
What is the uterus in between and what is it covered and lined by?
The uterus is an inverted, pear-shaped muscular organ between the bladder and rectum. It is somewhat mobile and covered by the peritoneum, and lined by endometrium.
What happens to the uterus in parous woman?
The uterus may be a little larger
What is the uterus usually inclined forward at? And what may happen?
The uterus is usually incline forward at a 45° angle, but may be anteverted which is slightly tilted, anteriorly, anti-flexed, retroverted, which is slightly tilted posteriorly, and retroflexed
What type of pregnant women might not “show “ as much
Those with a retroverted or retroflexed uterus
Does the angle of the uterus affect fertility?
No
What is the uterus is divided into?
Corpus and cervix
Corpus consists of the fundus (convex upper portion), body, and the isthmus (constricted lower portion that opens into cervix)
What is the cervix considered? What does a protrude into?
The lower part of the uterus that protrudes into the vagina
What are the cervical internal and external os? What happens to them during labor?
They are the cervical openings, and they dilate during labor
What are the pockets that are formed around the cervix? What can they serve to do?
The pockets are anterior posterior and lateral fornices.
The internal pelvic organs may be palpated through their thin walls
What can often be shown or found in the posterior fornix?
Patients can lose a condom here or sexual assault victims can have lacerations
What is the usual length of the cervix?
2 to 3 cm
When should the cervical os be open?
Only during labor
What kind of tissue is the cervix made of?
The portion protruding into the vagina is covered with squamous epithelium
At the external cervical os, the squamous epithelium becomes columnar epithelium. This is called the squamocolumnar junction.
What does a nulliparous cervix indicate? What does it look like?
Looks like a dot
Indicates never have given birth
What does a parous cervix indicate? What does it look like?
That the patient is pregnant, or has given birth.
It looks like a slit, becomes like this because of dilation
This can happen with certain miscarriages that still have to be delivered or patient dilated by medicine
What do the adnexa consist of?
The fallopian tubes and ovaries
What are the typical lengths of fallopian tubes and what are they lined with?
Range from 8 to 14 cm in length and are lined by ciliated columnar epithelium
What are the fallopian tubes supported by?
A fold of the broad ligament called the mesosalpinx
what part of the fallopian tube is the patient at the most risk for rupture of a ectopic pregnancy? What is the timeline?
Isthmus is at the most risk for rupture (narrow portion close to the uterus)
Up to 6 weeks until rupture
What is the most common area of the fallopian tube for an ectopic pregnancy? What is the timeline for rupture?
The central portion called the ampula.
Up to nine weeks
What is the timeline for ectopic pregnancy rupture for implant in the infundibulum?
9 to 10 weeks before rupture
What is the segment of the fallopian tube within the uterine wall called?
The interstitial segment
Junction between fundus of the uterus and isthmus
How does the ovum get into the fallopian tube?
The fimbriated end of the fallopian tube opens into the pelvic cavity and captures the ovum
has rhythmic contractions to transport the ovum to the uterus
What attaches the ovary to the uterus
The utero ovarian ligament
What happens to the ovaries size after menopause?
decrease
What does the outer ovarian cortex consist of?
Follicles that are embedded in a connective tissue stroma
What hormones do the ovaries secrete
Estrogen and progesterone
What does the mature follicle release at ovulation?
An egg in hopes of fertilization
Where does the lymph from the vulva and lower vagina drain into? What can discharge, inflammation, and tenderness indicate?
The inguinal nodes
A lower infection
Where does lymph from the internal genitalia drain into? What does inflammation and tenderness here indicate?
Drain into pelvic an abdominal lymph nodes
Can indicate an upper infection like the uterus
What does the menstrual cycle result from an interaction between?
The hypothalamus, pituitary, ovaries, and endometrium
What does the hypothalamus secrete and what does it affect?
The hypothalamus secretes hormones that exerts specific effects on the pituitary gland
What hormones does the anterior pituitary release?
Follicle Stimulating Hormones (FSH), Luteinizing Hormone (LH), Prolactin, Thyroid Stimulating Hormone (TSH), Growth Hormone (GH), Adrenocorticotropic Hormone (ACTH)
What does the posterior pituitary release?
Oxytocin
What is the onset of menstruation called and when does it usually occur?
Menarche between ages 8 to 13
What is the termination of menstruation called and when does it usually occur?
Menopause occurs at 49 to 50
What is a normal menstrual cycle and average duration of menstrual bleeding?
Every 28 days with a range of 24 to 32 days. Average duration is 3 to 7 days.
What is the average blood loss of a. And when do you lose most? How do you ask a patient this?
Average blood loss is 35 to 90 mL mostly lost during the first two days
How many pets do you go through per day? Typical answer is three.
What does menstrual discharge contain?
Blood, endometrial and vaginal epithelial cells, cervical mucus, bacteria, and prostaglandins
What are the two phases of the menstrual cycle?
Follicular/proliferative phase
Luteal/secretory phase
In a normal menstrual cycle what days are the follicular/proliferative phase? What is it dependent on and what does it precede?
1-14
Estrogen dependent
Precedes ovulation
What days does the luteal or secretory phase occur and what is it depending on?
Usually occurs from 14 to 28 days
This is progesterone predominant
When is your basal body temperature lowest
During ovulation
What phase is considered day 1 to 4? What occurs in this phase?
Menstrual phase
Progesterone stimulates prostaglandins, causing vasoconstriction are you still looking at it and shedding of the endometrium
Estrogen levels will begin to rise, preparing follicle an egg for next cycle
What phase of the menstrual cycle is day 5 to 12 what occurs?
Post menstrual phase
FSH stimulates ovarian follicular growth
The ovary and maturing follicle produce estrogen
The egg develops within the follicle and the endometrium thickens
What marks the change from proliferative to secretory endometrium? When does it occur?
Ovulation
Occurs mid cycle
What occurs at day 13 or 14 in the cycle?
Ovulation
LH surge stimulates the release of the egg by thinning the walls of the ovary
Egg is expelled and drawn into the fallopian tube
Follicle closes and begins to form corpus luteum
Why are signs of the secretory/luteal phase?
Mittelschmerz
Spinnbarkeit
PMS
What is Mittelschmerz sign?
Mid cycle pain that can occur during ovulation
Sharp pain on left or right adnexa
What is Spinnbarkeit sign?
Cervical mucous is increased, stringy, and elastic “thin, watery, transparent” allows transport of sperm
Tell tale sign women are ovulating
Further away from ovulating- thicker and more opaque
What is premenstrual syndrome? (PMS) when does it usually occur
Takes place because of fluctuating hormones so you get behavior and mood changes
40% incidence between 25-40 yrs, occurs 7-14 days before ovulation; relieved with menses
What is day 15 to 20 in the menstrual cycle what happens in?
Secretory phase
Egg is moved by cilia into uterus
Follicle becomes corpus luteum, and secretes progesterone to support gestation
LH and FSH decrease
What is day 21 to 28 in the cycle? what happens
Premenstrual phase(luteal phase)
If implantation does not occur, corpus luteum degenerates
Menstruation starts about day 28 which begins the cycle again
How long is an egg viable for? Sperm?
An egg will usually rupture after 24 hours if not fertilized
Sperm can live up to five days
What does the corpus luteum produce? What happens if the egg fertilizes
Progesterone
if the egg fertilizes the corpus luteum will continue to produce progesterone until about nine weeks when the placenta will take over
What does the blastocyst produce?
hCG
What does hCG stimulate?
Tells the corpus luteum to continue to produce progesterone
What are common presenting problems for the gynecological patient?
- Abnormal bleeding
- Change in normal interval between periods, amenorrhea (absence of menstrual flow), menorrhagia (excessive flow), metrorrhagia (bleeding from uterus between periods)
What is especially considered abnormal bleeding?
Before age 8 (assault/molestation)
After age 52 (cancer)
Questions to ask about vaginal discharge
Character
Amount
Acute/chronic
Douching habits
Clothing
Symptoms in partner
Condom use
Associated symptoms : itching, pain, inflammation, bleeding, dyspareunia, dysuria, abdominal pain, pelvic fullness
Efforts to treat
Premenstrual symptoms history
Headaches
Weight gain
Edema
Breast tenderness
Irritability
Mood changes
Frequency
Effect on daily life
Relief measures
Aggravating factors
Medications
Menstrual history
Age at menarche
Date of LMP
Number of days in Cycle
Regularity of cycle
Flow: amount of pads or tampons
Dysmenorrhea: painful menstruation (characteristics, duration, frequency)
Intermenstrual bleeding : amount, duration, frequency, timing
Premenstrual symptoms : HA, weight gain edema breast, tenderness, irritability, mood changes frequency affect on life
Menopausal symptoms history
Age at menopause
Symptoms: menstrual changes, mood changes, tension, hot flashes, vaginal dryness
Postmenopausal bleeding : need to rule of endometrial cancer even if it’s just blotting
medications: HRT (hormone replacement therapy), nonprescription, alternative therapies
What categorizes menopause?
No full menstrual cycle in a period of a year
Contraceptive history
Type of contraceptive and duration of use
Problems or complications with use
Contraceptive failures
Sexual history
Current sexual activity: number of current and previous partners, gender of partner(s)
Types of sexual activity
Problems: dyspareunia, bleeding
Satisfaction
Gynecological history
Prior pap smears and results
Treatment of abnormal Pap smears(usually caused by HPV )
Gynecological procedures: tubal ligation hysterectomy, oophorectomy, laparoscopy, cryosurgery, conization (remove part of cervix)
STIs
Vaginal infections
PID
Cancer
All other hx that’s part of POMR
What does HPV 16 and 18 cause
70% cervical cancer, 70% vaginal cancer 50% vulvar cancer 80% anal cancer
Vaccines for this
What does HPV six and 11 cause?
90% genital warts
What types of HPV does Cervarix prevent
16/18
What HPV does Gardasil prevent (first dose)
6/11/16/18
What HPV does Gardasil 9 prevent
6/11/16/18/31/33/45/52/58
What does Gardasil vaccines prevent?
Multiple cancers
Obstetrics history what does GPFPAL stand for
G- Gravida total number of pregnancies
P- Parity result of pregnancies
F- number of full term pregnancies
P- number of preterm pregnancies
A- number of abortions (spontaneous or induced)
L- number of living children
Additional obstetric history
Complications of pregnancy or delivery like postpartum hemorrhage, gestational diabetes
Problems with fetus or neonate
What does G3 P1203 mean?
3 pregnancies
1 full-term 2 preterm 0 abortions 3 living children
What does G4 P1122 mean?
Pregnant 4 times
One full-term
One preterm
Two abortions
Two living children
What does G1 P0 mean?
Pregnant once
Pregnant right now
What does G8 P0070 mean
8 pregnancies
0 full term
0 preterm
7 abortions
0 living children
Pregnant now
What is the recommended screening for cervical cancer in women age 21 to 65 years with cytology (pap smear)
Every 3 years
What is the recommended preventative health screening for women with Pap smears aged 30 to 65 who want to lengthen the screening interval
Screening with a combination of cytology an HPV testing every five years if results are normal for HPV
How often should women with certain risk factors like HIV,DES exposure history or treatment of CIN or cervical cancer?
More frequently
HIV increases risk of aggressive cancers
DES synthetic estrogen exposure exposed in utero
Cervical intraepithelial neoplasia
When does mammogram screening typically start
Annually from age 40
When does a clinical breast exam usually occur?
Annually from age 40
every one to three years for women 20 to 39
When can a breast self exam be done?
Monthly
