- time period where education, STD discussion and pregnancy prevention should be done

Adolescence

- age of menarche

- Date of last menstrual period and last normal period (LMP & LNMP)

- duration of menses (3-7 days)

- interval and regularity of cycles

- character and amount of flow (# of tampons/pads a day)

Details of menstrual cycle

- excessive menstrual bleeing, either amount or duration

Menorrhagia

- bleeding occurring irregularly in between periods

Metrorrhagia or intermenstrual bleeding

- painful menstruation, usually cramping or aching

Dysmenorrhea

- Current sexual activity

- # of prior partners and partner Hx

- Sexual gender preference

- Method/Use of contraception or condoms

- STD Hx

- Satisfaction with sexual relationship

Components of a Sexual History

- Frequency of Pap smears (every 3 yrs after 3 normal)

- History of abnormal Pap smears

- Gynecologic procedures (IUD, hysterectomy, etc)

- Risk factors for Gyn cancers

Components of Gynecologic History

- 2nd most common cancer in women worldwide

- Risk factors include age, early age of 1st intercourse, history of cervical dysplasia, history of infection with human papillomavirus, HIV+, smoking

Cervical cancer

- majority of women are asymptomatic or have non-specific symptoms which makes diagnosis hard

- tumors can spread throughout peritoneum

- risk factors include age, early menarche (<12), late menopause (>55), infertility or nulliparity, Hx of fertility drug use, family or personal Hx

Ovarian cancer

- this can decrease a woman's risk of ovarian cancer

Prolonged use of oral contraceptives

- most common gynecologic malignancy in Americans

- most common type from excess exposure to exo(endo)genous estrogens

- Risk factors include Postmenopausal (age), Early menarche/late menopause, women with nulliparity or chronic anovulation (irregularity), obesity, Family Hx

Endometrial (Uterine) cancer

- total number of pregnancies, regardless of outcome

Gravida

- number of pregnancies carried past 20 weeks

Para

- number of fetal losses, both spontaneous and induced

Aborta

- Gravida, para, aborta, living children

- complications of prior pregnancies

- preterm labor, bleeding, timing, transfusions

- tubal pregnancies, diabetes or HTN w/ pregnancy

Components of Obstetric History

- age at menopause (absence of menses for 1 yr) (51)

- age of mother at menopause

- associated symptoms (mood, vasomotor changes, vaginal dryness)

- menopausal bleeding --> endometrial cancer

- medications or alternative therapies used (side effects)

Components of Menopausal History

- glands that surround the urethra

Skene's glands

- usually not visible, their opening is between the labia minora and the hymen

- secrete mucous for lubrication

Bartholin's glands

- area between the vaginal opening and the anus

Perineum

- posterior fusion of the labia minora

Fourchette

- area enclosed by labia minora

Vestibule

- gowned with a drape over pt's legs

- speculum, brush, spatula, slide and fixative

- Gloves, lubricant, light source

- culture material (for higher risk individuals)

Equipment for the Gynecological exam

- metal or plastic piece of equipment that comes in two shapes, and different sizes

Speculum

- Ask pt to empty their bladder

- Ask pt's permission to proceed

- chaperone present, pt in dorsal lithotomy postion

- have pt move until buttocks are at edge of table

- make pt as comfortable as possible

- arrange bed angle so eye contact is maintained

- ask pt to let her legs fall open

- begin with neutral touch (thigh)

Pelvic Exam Intro

- place index finger with palm upwards into the vagina

- exerting upward pressure, milk the Skene's glands by moving finger outward

- Repeat on opposite side

Skene's glands palpation

- due to chronic inflammation

- acute usually due to gonorrhea or staphylcoccus

- found on posterior border of labia minora

Bartholin cyst

- bearing down will cause bulging of the anterior vaginal wall to create this

cystocele

- bearing down will cause bulging of the posterior vaginal wall and cause this

Rectocele

- bearing down causes cervical protrusion

Uterine prolapse

- done with the examiner seated, gloved hands

- lubricate speculum, water if a Pap smear

- place finger into vaginal introitus and apply gentle pressure down on the perineum

- insert speculum gently over finger inward and downward

- avoid clitoris, skin or hair

- open speculum

- cervix should come into view, lock blades

Speculum Exam Intro

- if the cervix is bluish in color it indicates increased vascularity and you should think this

Pregnancy

- appear as one or more translucent nodules on the cervical surface

- result from blocked secretions from the columnar epithelium and are of no pathologic significance

Nabothian cysts

- this woman will have a small round or oval os compared to a parous woman that might have an irregularly shaped os

Nulliparous

- most sensitive test for High Grade Squamous Epithelial lesions

Conventional Pap and HPV testing

- Most specific test for High Grade Squamous Epithelial lesions

Conventional Pap (plastic spatula)

- Annual conventional Pap

- Semiannual thin prep Pap

- discontinue screening at 70 if all previous Paps are normal

American Cancer Society recommendations

- <30 yrs, annual Pap smear

- >30 yrs, 3 normal Paps --> frequency of Pap smears decreased to every 2 or 3 years

- 65-70 yrs and at least 3 normal Paps and no abnormal in ten years, you may consider discontinuing them

American College of Ob-Gyn Recommendations

- if pt is immunocompromised because of transplant, chemotherapy or steroid use

- if pt has maternal Hx of diethylstilbestrol (DES) use while pregnant

- if pt is HIV positive

Yearly Pap test

- high prevalence of infection which varies with age

- greater than 90% of infections resolve within 5 yrs

- persistent infection is major risk for invasive cervical cancer

- test approved in April 2003 along with conventional Pap

- Vaccine now available

Human Papillomavirus

- this type of probe is more common than the Gonococcal Culture Specimen Collection

DNA probe

- a DNA probe is rapid and sensitive test for these two diseases

- constructs a nucleic acid sequence that will match to a sequence on target tissue

- Uses a Dacron swab with plastic or wire shaft

Gonorrhea and Chlamydia

- used to detect Trichomonas vaginalis, bacterial vaginosis, and Candidiasis

- obtain saw of vaginal discharge

- smear on glass slide, add drop of saline

Wet Mount

- pH 3.8-4.2

- white, clear, flocculent discharge

- absent amine odor

- no pt complaints

- lactobacilli, epithelial cells under microscope

Normal Wet Mount

- pH >4.5

- thin, homongeneuous, white, gray, adherent, often increased discharge

- fishy amine odor

- pt complains of discharge, bad odor, itching

- clue cells w/ adherent coccoid bacteria, no WBCs under microscope

Bacterial Vaginosis wet mount

- pH >4.5

- yellow-green, frothy, adherent, increased discharge

- fishy amine odor may be present

- Pt complains of frothy discharge, bad odor, vulvar pruritius, dysuria

- Trichomonads WBCs>10/hpf under microscope

Trichomonas Vaginosis wet mount

- pH <4.5 (usually)

- white, curdy, 'cottage cheese-like', sometimes increased discharge

- no amine odor

- pt complains of itching/burning, discharge

- budding yeast, hyphae, pseudohyphae under microscope

Candida Vulvovaginitis wet mount

- dissolves epithelial cells and facilitates visualization of the mycelia of a fungus

KOH prep

- done with examiner standing

- change gloves, explain to pt, lubricate, insert tips of index/middle fingers into vaginal opening and press down

- palpate for cysts, nodules, masses, or growths

- palpate cervix, uterus, adnexa and ovaries

Bimanual Exam

- locate cervix with palmar surface of fingers

- palpate for size, length and consistency

- pregnancy makes cervix softer than normal (softer than the tip of your nose)

- note the position, indicating uterine position

- move cervix to test for pelvic inflammatory disease or ruptured tubal pregnancy

Bimanual Cervical Exam

- Palm of non-dominant hand on pt's abdomen just above pubic symphysis

- place fingers in anterior fornix

- push abdominal hand down and forward, cervical hand inward and upward

- if uterus is anteverted or anteflexed you will feel the fundus

Bimanual Uterine Position Exam

- place abdominal hand in lower right quadrant

- place intravaginal fingers in right lateral fornix

- palpate for the ovaries

Bimanual Ovarian Exam

- allows you to reach 2.5 cm higher into pelvis

- place index finger in vagina and middle finger in the rectum

- rotate finger to explore the anterior rectal wall

- palpate rectovaginal septum

- may be only way to palpate retroflexed uterus

Rectovaginal Exam

- start of sexual activity

- Age 18

- discretion of physician for complaints of severe dysmenorrhea, abnormal bleeding, etc

Indications for Pelvic Exams in teens

- possible prolapse, urinary concerns, atrophy, dryness, pt comfort

Concerns of Older Pts

- this should be taken into consideration late in pregnancy regarding OB-Gyn physical exams

Avoiding introducing infection

- at 12 and 20 weeks gestation the uterus is in these locations respectively

Pelvic brim/Umbilicus

- this occurs just prior to delivery

- measured in cm's (0-10)

Cervical dilatation

- thinning of the cervix that occurs when uterine contractions pull the cervix upward

Effacement

- position/location of the fetus in relation to the mother's ischial spines

- recorded in cm's

- positive cm tells you the baby's present part is below the ischial spines

- negative cm, above ischial spines

- +2 closer to delivery than -2

Station