Western+Diagnosis+-+Gynecology

Pelvic Pain Vulvovaginitis Salpingitis Premenstrual Syndrome - PMS Dysmenorrhea Abnormal Uterine Bleeding Amenorrhea Menopause Endometriosis Fibrocystic Breast Disease Breast Cancer Gynecological Neoplasms Cervical Carcinoma

Pelvic Inflammatory Disease Breech Position Cervicitis Contraception Delayed Parturition Infertility Labor Pains Lactation Mastitis Ovarian Cancer Ovarian Cyst Preeclampsia Miscarriage Uterine Cancer

=Anatomy=

external genitalia - vulva
1. labia majora and minora 2. clitoris 3. urethral opening: a. Skene’s glands 4. Bartholin’s glands

vagina
1. cervix a. os

uterus
1. isthmus, body, fundus 2. endometrium, myometrium 3. anteverted, anteflexed

Ovaries
=Physiology= hormonal events of menstrual cycle

follicular phase - preovulatory - about 12 days
1. 1st day of bleeding to day before preovulatory LH surge 2. inc FSH in 1st half: initiates follicular development 3. LH slowly rises 1-2 days after FSH rise 4. E & P low 5. E rises 7 days before preovulatory LH surge: endometrial proliferation 6. at this time, slow inc in LH and dec in FSH

ovulatory phase - about 2 days
1. massive release of LH 2. simultaneous great inc E: release of follicle 16-32 hours after initial surge - surge lasts 36-48 hours 3. small inc FSH 4. as LH rises, E falls 5. P continues to rise

luteal phase - postovulatory - 14 days
1. from lifespan of corpus luteum in ovary ---supports ovary by secreting P ---P causes coiling of endometrial glands and inc vascularity 2. LH and FSH low - inc again with menstruation 3. E lowers from pre and ovulatory highs 4. both E & P dec in late luteal phase ---endometrium becomes more edematous & necrotic, and bleeding occurs ---PG may play role: vasoconstriction, necrosis; uterine contractions

=History=

menstrual
1. age of menarche 2. LMP and previous menstrual period ---age of menopause ---menopausal sx: hot flashes ---postmenopausal bleeding 3. length of cycle 4. regularity of cycle 5. duration of bleeding 6. amount of bleeding 7. character of bleeding: color, clots 8. cramping or pain and its timing to menses 9. premenstrual sx

obstetric
1. number of pg (gravidity) 2. number of births (parity) ---birth complications ---type of delivery ---postpartum complications 3. abortions - spontaneous and induced 4. infertility ---frequency and timing of intercourse ---previous testing ---partner’s status

sexual
1. contraceptives 2. libido 3. difficulties 4. venereal disease

bleeding
1. character and amount 2. relation to periods 3. frequency, duration, onset 4. associated pain

discharge
1. amount, color, odor, consistency 2. associated sx - itching, burning, pain 3. relation to menses

pain
1. OPQRST 2. relation to menses 3. associated sx: GI, urinary ---low back or gluteal region: endometriosis, PID, fibroids, CA ---lower abdomen: uterine, ovarian, vaginal, bladder ---lower abdominal quadrants, often radiating down medial thigh: fallopian tubes, ovaries
 * radiation patterns**

testing
1. last PAP smear and results

breasts
1. BSE 2. lumps, pain, nipple discharge

past hx
1. abdominal or pelvic illnesses 2. abdominal or pelvic surgeries

family
1. ovarian, uterine, breast CA

=IV. Physical= A. empty bladder B. appropriate draping C. breast exam D. lithotomy position E. warm hands and speculum F. explain each step of exam G. wear gloves H. inspection ---external genitalia ---color, vulvar lesions, swellings, discharge I. palpation: external genitalia J. speculum ---warm with warm water ---no lubrication if PAP smear ---view cervix ---PAP smear: samples of vaginal pool, cervix, endocervix ---inspect vagina as withdrawing speculum: color, discharge, masses K. bi-manual exam ---1. index and middle finger of one hand in vagina, other hand on surface of lower abdomen ---2. press in all directions in vagina ---3. palpate uterus, adnexa with both hands: a. size, consistency, contour, mobility, tenderness, masses

=Laboratory= A. CBC, chem screen, thyroid function tests B. serum HCG - human chorionic gonadotropin: qualitative and quantitative [tests pregnancy] C. hormonal assays ---Gonadatropin Releasing Hormone (GnRH ), Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), Estrogen (E), Progesterone (P), androgens, adrenal steroids ---serum, urine D. cultures: vaginal - bacteria, candida, herpes

=Imaging=

x-rays
1. plain film of abdomen (KUB - Kidney, Ureter, Bladder) 2. hysterosalpingogram - dye insertion 3. gynecography - carbon dioxide insufflation 4. mammography

ultrasound
=Special Studies= 1. cytology: PAP smear (Papanicolaou); endometrial biopsy 2. wet prep: trichomonas, candida, gardnerella 3. colposcopy: magnification of cervix 4. Schiller’s test: staining of cervix - abN does not stain 5. cervical biopsy: cone biopsy, laser 6. D&C - dilatation and curettage: scraping of endometrium 7. culdocentesis: aspiration of peritoneal sac posterior to cervix through vagina - to determine the presence of free blood or pus in abdomen 8. laparoscopy: small incision inferior to umbilicus - direct visualization of pelvis/lower abdomen with magnifying lens 9. laparotomy: surgery to visualize pelvis

=Emergencies=

pelvic pain
1. difficult to differentiate pain in abdomen, pelvis 2. surgical emergencies include: twisted ovarian cyst, ectopic pg, ruptured tubal or ovarian abscess, appendicitis, bowel obstruction or perforation 3. sudden onset from ischemia or perforation 4. insidious onset from inflammation or obstruction 5. tender adnexal mass from ectopic pg, ovarian cyst 6. with fever from pelvic infection 7. questions ---discharge ---bleeding ---duration of sx ---relation of sx to menstrual cycle: LMP ---multiple sex partners: contraceptives and their use ---hx of trauma, rape, illegal abortion 8. often ER referral or sometimes for primary evaluation ---outside the endometrial cavity - in tubes most commonly ---inc likelihood if previous tubal disease, ectopic pg, self done abortions ---any unilateral, progressive lower abdominal quadrant pain in a woman of reproductive age in the presence of a missed or strange period must be sent for immediate gyn evaluation ---cramping pain soon after missed period ---spotting common ---hemorrhage causes pain and pressure ---possible hypotension and shock ---tender adnexal mass ---possible rupture of tube with fainting and shock ---dx: HCG; culdocentesis; ultrasound ---tx: refer immediately if suspected to gyn or ER - surgery
 * ectopic pregnancy:**

vaginal bleeding
---excess menstrual flow: soaking more than 4 pads in an hour - refer to gyn for evaluation immediately ---with dizziness, refer to ER
 * menorraghia**
 * postmenopausal bleeding :** refer to gyn