Introduction to Gynecology

Question 1

Approach to the female patient

Answer 1

• Communication is the key to women – use language your patient can understand but remain professional
• Gynecologists are often the primary care providers for women
  
  • Context of general health, psychological, social and emotional status of the patient
• Open relationship between patient and provider; nonjudgmental attitude and trust
• Initial contact with the patient while she is fully clothed and comfortable
• Good eye contact, active listening
• Invite the patient to participate in the examination process, ask questions and give feedback
• Explain everything you are about to do before you do it
  *

Question 2

Types of pelvis

Answer 2

• Gynecoid: female – round, wide, spacious; 40-50% of women
• Android: male – narrow, flat, wedge shaped; 30% of women
• Anthropoid: narrow, long oval; 20% of women
• Platypelloid: wide, short oval; 2% of women
• Mixed types occur in some patients

Question 3

Axis of pelvis, pelvic inlet, pelvic outlet

Answer 3

• Axis of pelvis: curve of sacrum and coccyx
• Pelvic inlet: plane from top of pubis to sacral promontory
• Pelvic outlet: plane from bottom of pubis to top of coccyx

Question 4

Contents of the pelvic cavity

Answer 4

• Bladder
• ureters and urethra
• uterus
• fallopian tubes and ovaries
• vagina

Question 5

Pudendum

Answer 5

• External genitalia
• vulva
  
  • mons pubis
  • labia majora, labia minora
  • clitoris (female penis)
  • urethra
  • vestibule with skene’s glands, hymen, bartholin’s glands, vaginal entroitus
• perineum
• anus

Question 6

vagina

Answer 6

• Muscular tube from the vestibule to the uterus
• 7.5cm in length, long axis parallel with lower sacrum
• Covered by the hymen in children
• Surrounded by 2 bulbocavernosus muscles which act as a sphincter at the opening
• Vaginal wall consists of mucous membrane and 3 external smooth muscle layers to make the vagina very distensible
• Lumen lined by stratified squamous epithelium, submucosal layer of connective tissue
• Submucosal rugae produce vaginal folds in the lumen
• Normally colonized with aerobic bacteria and lactobacilli
• Low acidic pH between 3.5 – 4.0
• Estrogen effect makes vaginal epithelium thick with large amount of glycogen, normal vaginal secretions and cervical mucous
• Hostile to infection and semen
• Meets the uterus at the cervix at a 45-90 degree angle
• Circular area around the cervix is called the fornix: anterior fornix, 2 lateral fornices, and posterior fornix that forms the pouch of Douglas
• Pouch of Douglas allows access to the peritoneal cavity from the vagina during culdocentesis

Question 7

Cervix

Answer 7

• Distal part of the uterus, connected via the uterine isthmus to the uterine body
• External cervical os opening to the vagina
• Round in nulliparous women
• Transverse slit after childbirth
• Cavity of the cervix is barrel shaped with longitudinal folds that extend through the canal
• Covered with stratified squamous epithelium at the external os, which changes to simple columnar epithelium in the transformation (transition) zone
• Transformation zone is at the level of the external cervical os, but is higher up in the endocervical canal in postmenopausal women; may be more superficial with ectropion (everted cervix)
  
  • Transformation zone important in Pap smear, dysplasia and cervical cancers

Question 8

Uterus

Answer 8

• (uterine corpus or body)
• Pear shaped muscular organ between the base of the bladder and the rectum
• Covered on each side by the broad ligament
• Connects with the Fallopian tubes at the cornu, at the superior-lateral angles
• Area above and between the cornu is the fundus; area of greatest breadth
• 7-8cm long and 4-5cm wide in the nulliparous adult female
• Position of the uterus is determined by the angle of the long axis of the corpus with the cervix
• Normal position is anteversion (anteflexion); may also be in retroversion, lateral version, or military position – these may all be normal variations

Question 9

Adnexa

Answer 9

uterine tubes and ovaries

Question 10

Fallopian tubes (oviducts)

Answer 10

• Convey the ova to the uterus
• Run along the superior border of the broad ligament from the superior-lateral aspect of the uterine body to the ovaries on each side
• 7-14cm in length and has 3 portions:
• Isthmus
• Ampulla
• Infundibulum
• Isthmus is narrow and straight, adjoining the uterus
• Ampulla is wider part of the tube that opens in a funnel-like dilatation that is the infandibulum
• Infandibulum is fringed by finger-like processes called fimbriae that surround the ovary and help collect the oocyte at ovulation
• Lining of the tubes is ciliated columnar epithelium, assisting oocyte transport to the uterus body

Question 11

Ovaries

Answer 11

• 2 paired organs measuring 3-5cm long, 2-3cm wide, 1-3cm thick
• Decrease in size after menopause when follicular development ceases
• Attached to the uterus by the ovarian ligament
• Covered by a low columnar epithelium
• Consist of a cortex and medulla
• Medulla: connective tissue fibers, smooth muscle cells, and supporting tissues
• Cortex: areolar stroma, vessels, scattered follicles of epithelial cells which house the oocytes in various stages of maturity
• Follicles enlarge as they mature until they burst, releasing the ovum and becoming transformed into a corpus luteum

Question 12

Lymphatics

Answer 12

• Complicated! Usually follow venous distribution
• External genitalia generally drain to the superficial inguinal nodes or superficial femoral nodes
• Uterus and cervix drain via several chains of lymph nodes into para-aortic chains
• Oviducts and ovaries have retroperitoneal drainage into para-aortic chains

Question 13

Breast anatomy

Answer 13

• Secondary reproductive glands of ectodermal modified sweat gland origin
• Organs of lactation; contain the mammary glands
• Tissue protrudes anterior to the pectoralis major muscle and includes the axillary tail of Spence
• Breast lymphatics drain to the axilla; less into supraclavicular nodes
• The areola is a circular pigmented zone at the tip of the breast
• Glands of Montgomery in the skin of the areola are sebaceous glands responsible for lubrication of the nipple
• Circular and longitudinal smooth muscle bands at the nipple encircle the lactiferous ducts where milk is expelled during breastfeeding

Question 14

Tanner Stages

Answer 14

• Stage 1 – Prepubertal
• Stage 2 – Breast buds
• Stage 3 – Further breast enlargement
• Stage 4 – Areola forms distinct mound on breast
• Stage 5 – Breast fills out, areola forms single contour with breast

Pubic hair:

• Stage 1 – No hair
• Stage 2 – Wisps of hair on labia
• Stage 3 – Hair on mons pubis in midline
• Stage 4 – Hair spreads outward
• Stage 5 – Hair froms inverse triangle, reaching inner thighs

Question 15

Well woman exam - history

Answer 15

• Age
• 1st day of last normal menstrual period (LMP)
• Gravidity and Parity (GxPtpal)
  
  • X=pregancies
  • T=term pregnancies
  • P=premature deliveries
  • A=abortions (spontaneous and elective)
  • L=living children
  • Example: G4P2113 – 4 pregnancies, 2 full term deliveries, 1 premature delivery, 1 abortion, and 3 living children
• Chief complaint, HPI with pertinent ROS
• PMH
  
  • Contraception method
  • Medications and habits
  • Medical history
  • Surgical history
  • Allergies
  • Bleeding disorders (personal or family)
  • Social history (especially domestic violence)
  • Family history (especially genetic disorders)

Question 16

Gynecologic history

Answer 16

• Menstrual history
  
  • Age at menarche, duration of cycle, duration of flow, amount and character of flow, degree of discomfort, age at menopause
• History of STDs or other pelvic infections, abnormal Pap smears
• Sexual history
  
  • Currently sexually active, how many partners, sexual orientation, satisfaction

Question 17

Obstetric History

Answer 17

• Each pregnancy in chronological order
• Date of birth, sex and weight of the baby, duration of the pregnancy, length of labor, type of delivery, type of anesthesia, and any complications

Question 18

Physical exam

Answer 18

• Provide a gown and drape with instructions for the patient
• Step out of the room while the patient changes her clothes
• Female assistant or chaperone may be used at the discretion of the patient and provider
• Spouses or partners in the room at the discretion of the patient and provider
• Vital signs: Ht, Wt, BMI, BP, LMP
• Urinalysis, UPT
• Chest, extremities, and abdomen should all be examined as part of a well woman examination
• Breast exam
• Pelvic exam: vaginal, bimanual, rectal

Question 19

Breast Exmination

Answer 19

• Ideal time to discuss breast self exam
• Inspection with patient sitting with arms at her side, hands pressed at the hips, and arms above the head
• Inspecting for skin dimpling, lumps, or shadows
• Palpation of the axillary and supraclavicular nodes with patient sitting, arms extended 60-90 degrees
• Palpation of breasts with patient sitting and leaning forward with arms outstretched
• Palpation of all quadrants of the breasts with the patient supine, first with arms at the sides, and then with one arm over the head on each side
• Palpate using flattened fingers in either circular motion or in each quadrant including the tail of Spence
• Palpate under the areola and nipple and test for expression of fluid from the nipple

Question 20

Pelvic Examination

Answer 20

• Save the dreaded pelvic for last
• Be organized so you are not fumbling around looking for equipment; warm instruments
• Have a chaperone if indicated
• Be slow and gentle, explain everything, and show the equipment to the patient before you start
• Inspection & Palpation (lithotomy position)
  
  • Pubic hair – pattern, infection, lice, etc.
  • Skin of the mons pubis, vulva, perineum
  • Expose the vaginal introitus by gently parting the labia to inspect for any discharge or lesions; palpate Bartholin’s glands
  • Urethra, Skene’s glands
  • Anus for hemorrhoids, fissures, etc.
• When the examination is completed, help the patient sit up
• Offer a tissue so she can clean herself before getting dressed
• Leave the room so she can dress in private
• Come back to discuss your findings and answer any questions

Question 21

Types of Speculums

Answer 21

• Pederson speculum
  
  • Small, medium, large
  • Narrow blades with a lower lip
• Graves speculum
  
  • Small, medium, large, extra large
  • Wide blades with matching lips
• Pediatric speculum
• Size of the pt does not equal size of the speculum!

Question 22

Vaginal Exam

Answer 22

• Insert a warmed, dampened speculum into the vagina while pushing down gently on the perineum
• If the patient is tense, ask her to relax by taking a deep breath or by bearing down, to help open the vaginal canal
• Insert the speculum and open it to visualize the cervix, locking the speculum in the open position
• With the cervix visualized, collect your samples for the Pap smear, etc.
• Note any abnormality in the appearance of the cervix:
• Friable cervix
• Discharge in the vaginal vault or on the cervix
• Erosions or ectropion on the surface of the cervix
• Cysts or polyps on or around the cervix
• Inspect the vaginal walls as you remove the speculum for lesions and discharge
• Palpate the vagina by inserting one or two fingers, depending on the patient’s comfort
• Vaginal walls should feel smooth, elastic, and nontender
• Have the patient squeeze your fingers to assess pelvic musculature

Question 23

Normal variants of the cervix

Answer 23

• Condyloma accuminata
• marked eversion of cervical os
• endocervical polyp
• postmenopausal atrophic vaginitis
• nabothian cyst

Question 24

Bimanual exam

Answer 24

• Insert 1-2 fingers (index and middle fingers of the dominant hand) into the vagina
• Palpate the vaginal walls, and place the finger tips on the cervix
• Place the opposite hand on the lower abdomen and palpate the size, shape and position of the uterus; note any tenderness or masses
• Ok to use lubrication at this point
• Cervix is round 3-4cm in diameter, and feels like the tip of your nose
• Cervix should be mobile and nontender to palpation or movement
• Adnexal structures are difficult to palpate, especially in overweight and postmenopausal women
  
  • Tenderness or a mass needs to be evaluated

Question 25

Rectovaginal exam

Answer 25

• Should be routinely performed after age 50 years
• Well lubricated middle finger inserted into the rectum, then the index finger inserted into the vagina
• Guaiac testing can be performed following this exam

Question 26

gynecologic exam

Answer 26

• Be open and communicate with your female patients
• Get the history while she is clothed and comfortable
• Go slow and be gentle during your exam
• Have time for questions after the exam when she is clothed and comfortable again