week 8- gyn 1 Flashcards
• why are gyn exams necessary?
o Assess a problem: Pelvic pain, Vaginal bleeding, Vaginal d/c, etc
o Routine gyn eval: Yearly for women sexually active or >18 (21 for pap)
• What are some pt issues to keep in mind?
o Possible hx sexual abuse, rape o Previous bad experiences w gyn exams o Modesty and shame issues o Fear, sense of helplessness o Fear dz, preg o Denial o Poor body awareness o Sexual orientation – language usage very important
• What are some physician issues?
o Fear causing pain o Personal space issues o Respect for pt o Uninhibited pts o Support role when doing the exam o Confidentiality o Teenagers and their special needs: Mental or sexual (dt sexual abuse), contraception (pt consent as young as 10); Vaccines (15 if pt wants vaccine w/o parent knowledge (HPV is the big one))
• How do you take a gyn hx?
o Establish rapport o Identify primary complaint and get details (concurrent sxs): Pelvic pn, AbN vaginal bleeding, d/c o Menstrual hx o Sexual activity and hx o Possibility of pregnancy, attitudes and contraception (use of) o Hx of preg, outcomes o PMHx, surgery, hospitalization o Psych status: depression, anxiety, drugs o medications, OTC & supplements o ROS o Screen for Domestic Violence o FHx of dz (family member/age of dx)
• What do you need for menstrual hx?
o Age at menarche o Number of days of menses o Length and regularity of interval bw cycles o Last menstrual period (LMP) o Previous menstrual periods (PMP) o Color and volume of flow o Sxs w menses: Cramps, loose stools
• What is a normal menses like? Anovulation?
o N: Blood is medium to dark red, Flow lasts 5 (+/- 2) d, 21-35 d, avg blood loss 30mL (r 13-80), Most bleeding on 2nd d, Saturated pad or tampon absorbs 5-15mL, Cramping is common day before and 1st day
o A: mb vaginal bleeding, pnless, scant, dark, abn brief or prolonged, irregular
• What do you ask about sexual activity and hx?
o Freq
o # sexual partners
o Participation in unsafe sex
o Effects of sexual activity (pleasure, orgasm, dyspareunia)
o Orientation
o Types: vaginal, anal, oral, sex toys, etc.
• What do you ask about pregnancy and contraception?
o Possibility of pregnancy, along with attitudes and contraception (use of)
o Symptoms of pregnancy
o Morning sickness, breast tenderness, delayed menses
o History of pregnancy and outcomes
o Contraception: hx (why d/c certain types), currently using, Length of time used
• What ROS do you ask in gyn exam?
o GI sxs o Urinary sxs o Breast problems o Endocrine status o Bleeding hx (clotting issues, anemia) o Sxs of pelvic pain: location, duration, character, quality, triggering and relieving factors o Abn vaginal bleeding: quantity, duration, relation to cycle o Cardiac status
• How do you screen for domestic violence?
o Questionnaires and interview; Look for: o Inconsistent explanations for injuries o Delay in seeking tx for injuries o Unusual somatic complaints o Psychiatric sxs o Frequent ER visits o Head and neck injuries o Having given birth to low birth weight infants
• What FHX of dz do you ask for in gyn exam?
o family member/age of diagnosis
o CVD, DM, Breast CA, Other CA
o Osteoporosis, Endometriosis, PCOS, Infertility
• How do you begin the gyn exam?
o letting pt know what to expect, exams performed, she can let you know at any point if pain
o empty bladder prior
o Vitals, ht & wt, waist circumference
o Heart, lung, LN (cervical), Thyroid exams
o complete CBE; check axillary and clavicular LN
o Abd exam
o Pelvic exam: external inspection, speculum exam & specimen collection, bimanual, rectovaginal exam (in certain circumstances and at 40 annually)
• How do you do the external genital exam?
o LN: inguinal
o Hair (distribution, lesions, folliculitis, lice)
o Clitoral size
o Vulva and perineum (lesions, masses, swelling, excoriations, erythematous changes, AbN pigmentation)
o Vestibule
o AbN pigmentation
o D/c
o Inflammation and patency of introitus
o Rectocele (posterior bulge on bear down)
o Cystocele (anterior bulge on bear down)
o Optional: palpate bartholin & skene’s glands
o Palpate pelvic floor w lubed, gloved index finger: “squeeze as if stopping urine”, assess strength
• How is the speculum exam done?
o warm and lubricate speculum
o Insert, w downward pressure, slowly move forward, path of vagina (away from urethra, causes pain)
o fully inserted before opening blades (cervices are in all different positions!)
o Inspect: cervical changes, polyps, mucosal atrophy, tumors, cysts, masses, vaginal wall ruggae, bleeding, d/c (quantify & describe)
o collect pH, wet prep, culture, GC/CT, pap smear for cellular health and HPV DNA (if appropriate)
o Remove, don’t pinch cervix, allow blades to close, don’t press against urethra
• What are normal speculum exam findings?
o Cervix is pink, shiny, clear/white d/c, no masses, lesions
o Vagina has appropriate ruggae for her age, no masses, lesions
• How is the bimanual exam done?
o Insert lubed middle and index finger of dominant hand
o move cervix side to side, assess for cervical motion tenderness (CMT)
o move it up & down, assess for uterine mobility (should move some, not excessively or be fixed)
o Move your fingers under cervix, Top hand just above pubic symphysis, gently presses down to assess uterus (position, size, shape, consistency, mobility, tenderness)
o Adnexal structures
• What are normal uterus findings in bimanual? Abn w ddx?
o N: Anteverted (mc), anteflexed, retroflexed, retroverted; 6x4cm, Mobile, smooth, NT
o Irregular shape: uterine fibroids or tumor
o Enlargement: pregn, adenomyosis, malignancy, myomas
o Softening (bogginess): preg, malignancy, degenerating myoma, sarcoma, PID
o CMT: PID, ovarian cysts, endometriosis, adhesions
• How do you asses adnexal structures in bimanual?
o Palpate in lateral fornix, top hand gently pushing down, bring internal fingers up to meet the top hand to catch ovary bt them. Mb a bit pnful
o Note size, shape, consistency, mobility, tenderness
o Normal ovary (reproductive age): 3x2x2 cm
o Menopausal: 1x0.7x0.5 cm
• How is a rectovaginal exam done?
o Lubed index finger vaginally, middle finger rectally
o Assess septum, utero-sacral ligaments, uterus, cul-de-sac, adnexae, cervix
o > 40 y/o or if suspect endometriosis, CA
• What are common tests done in gyn exam?
o Preg: Urine BhCG: sp, ↑ sn, + in 1 wk; Serum qualitative BhCG: more sp, sn; Serum quantitative BhCG: specifically w miscarriages, ectopic pregnancy
o PAP smear: Can add on HPV DNA to liquid Paps, GC/CT, may detect uterine CA
o Wet Prep: Micro exam of vaginal secretions, identify infx (trich, BV, yeast, etc)
o Cervical Mucus Inspection: infertility, assess crystallization (Ferning), reflects levels of circulating estrogens
o Genital Culture: identify bacteria and fungus
o DNA probes or Urine Aptima test: For GC/CT
o pH of cervical secretions: Normal 3.5-4.5
o Other STI testing: Herpes (Viral PCR from lesion, Serum IgG HSV 1 & 2), HIV blood test, RPR for syphilis (serum), Hep B & C (serum)
• What imaging may be done w gyn exam?
o US mc for suspicion of masses; transvaginal (TVUS) and abd are mc
o MRI/CT less often
• What surgical procedures may be done with gyn exam?
o Laparoscopy: exploration of dz process & tx at same time
o Endometrial Bx (EMB): In office, unexplained vaginal bleeding, thickened endometrium on TVUS
o Colposcopy
o Vulvar Bx
o Hysteroscopy
• What is etio of a pelvic mass (mb found on routine gyn exam)? Hx?
o mb from gyn organs: cx, uterus, adnexae
o other pelvic organs: intestine, bladder, ureters, skeletal mm, bone
o PMHx, Complete gyn hx, menstrual hx, pelvic pain, irregular bleeding
o vaginal bleeding and pelvic pain suggest ectopic pregnancy
o dysmenorrhea suggests endometriosis/adenomyosis, uterine fibroids
• What are the types of pelvic masses, by age group?
o In utero: adnexal cysts dt maternal hormones (rare)
o Puberty: hematocolpos: accum menstrual blood forms vag mass dt obstruction (imperforate hymen, congenital malformations of uterus, cx, vagina)
o Reproductive age: preg, myoma, functional ovarian cysts, ectopic preg, benign teratoma, Hydrosalpinges, endometrioma
o Postmenopausal: more likely to be cancerous
• What PE, labs, imaging is done for a pelvic mass?
o PE: Vitals, Thyroid, Abd, Complete gyn
o TVUS
o CT/MRI: if TVUS doesn’t clearly identify size, location, consistency
o Bx, tumor markers: if masses have characteristics of CA
o Preg test: women of reproductive age
• What is pelvic pain? Common menstrual causes, ssx, dx?
o Common complaint, many causes, gyn or non-gyn organs, st unknown etio
o Dysmenorrhea: Sharp, cramping pn before or onset menses, h/a, N/D, constipation, urinary frequency; clinical eval
o Endometriosis: Sharp, cramping pn in early menses, dysmenorrhea, dyspareunia, painful defecation, eventual pn unrelated to menses, adv st uterine retroversion, tender, ↓mobility; clinical eval, st laparoscopy
o S/t a fixed pelvic mass (possibly an endometrioma) or tender nodules noted during bimanual and rectovaginal exam
o Mittelschmerz: Sudden severe, sharp pain, intense onset, 1-2 d, light, spotty vaginal bleeding; mid-cycle (ovulation), dt mild, brief peritoneal irritation dt ruptured follicular cyst; clinical eval, dx of exclusion
