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CHAPTER 7: FEMALE GENITALIA
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- PAST HISTORY:
- Gravida: Number of pregnancies
- Para: Number of live deliveries
- Number of planned and spontaneous abortions.
- ABNORMALITIES in MENSTRUATION: Normal menstrual period = about 40 mL of blood.
- Amenorrhea: No menstruation for 3 months or more.
- Primary Amenorrhea: Failure of menarche
- Kallman's Syndrome: Primary GnRH deficiency
- Turner's Syndrome: XO
- Testicular Sensitization Syndrome: Androgen insensitivity. Genotypic male may be
diagnosed with testicular feminization when he presents as a teenager with primary
- Imperforate hymen
- Congenital malformations of GU tract: Uterine agenesis, vaginal malformations.
- Secondary Amenorrhea: Amenorrhea occurring any time after menarche has occurred.
- Environmental Factors:
- Weight-reduction amenorrhea: Anorexia and related disorders, malnutrition.
- Psychogenic amenorrhea
- Exercise-induced amenorrhea
- Post-pill amenorrhea
- Pituitary Disease:
- Sheehan Syndrome = post-partum hemorrhage causing pituitary infarct from lack of
blood-flow and increased pituitary demand.
- Premature ovarian failure: Menopause occurring before age 35. Can be caused oophoritis
(mumps virus), or may be idiopathic.
- Polycystic Ovary Syndrome
- Asherman's Syndrome: Amenorrhea caused by intrauterine adhesions (synechiae) that
obliterate part of the uterine cavity. This can occur subsequent to vigorous dilatation and
curettage (D&C) of the endometrium.
- Hypomenorrhea: Decrease in volume of flow or duration of periods.
- Menorrhagia, Hypermenorrhea: Abnormally heavy volume of flow or abnormally long periods.
- Most common causes: Uterine fibroids (leiomyomas), PID, Endometriosis, IUD
- Metrorrhagia: Bleeding at mid-cycle. It is usually precipitated by the drop in estrogen that occurs after
- Dysmenorrhea: Painful menstruation. Symptoms = lower abdominal pain, nausea, vomiting, fatigue,
- Primary Dysmenorrhea: Unexplained, idiopathic dysmenorrhea. Believed to be caused by high
uterine levels of PGE2.
- Secondary Dysmenorrhea: Endometriosis, PID, imperforate hymen, uterine polyps, adhesions.
- Dysfunctional Uterine Bleeding (DUB): Abnormal uterine bleeding in which no etiologic agent can be
found after history and pelvic exam.
- OTHER THINGS RELATING TO MENSTRUATION:
- PRE-MENSTRUAL SYNDROME:
- NON-MENSTRUAL VAGINAL BLEEDING: Bleeding not related to menstruation. When vaginal bleeding
presents, we must determine whether it is menstrual or non-menstrual.
- Post-Menopausal Bleeding: Consider uterine cancer, cervical cancer. Atrophic vaginitis if patient is
not on ERT.
- Pregnancy, either intrauterine or ectopic, may cause bleeding for a variety of reasons.
- Birth control methods: IUD, breakthrough bleeding with pill.
- PELVIC PAIN:
- ACUTE PELVIC PAIN:
- Mittelschmerz: Pelvic pain occurring at mid-cycle and related to ovulation.
- Torsion of Ovary: Cystic ovary can get large and twist on itself, cutting off its blood supply ------>
acute-onset pelvic pain.
- Ruptured tubal pregnancy.
- CHRONIC PELVIC PAIN:
- Endometriosis: Dysmenorrhea, dyspareunia, infertility. Often have chronic pelvic pain, associated
with the location of the ectopic glandular tissue.
- Pain of endometriosis tends to be constant, and tends to radiate to coccyx, lower back.
- Onset of disease is usually between 25 and 40. Undifferentiated dysmenorrhea often presents
younger than age 25.
- URINARY TRACT INFECTIONS:
- PREGNANCY and INFERTILITY:
- Early Pregnancy: Common symptoms
- Secondary amenorrhea. Patient may also see reduced flow, or slight vaginal bleeding at time of
- Morning Sickness: Nausea and vomiting
- Breast tenderness
- Urinary frequency: cause may be anatomical or hormonal.
- Weight change: weight loss is common in early pregnancy, followed by weight gain later.
- Late Pregnancy:
- Chloasma: Characteristic darkening of skin around eyes, nose, cheeks. Darkening also occurs in
areolae, skin between umbilicus and pubic ridge.
- Striae Gravidarum: Stretch marks of pregnancy.
- Spider angiomas may occur in skin, because of high estrogen.
- Pelvic Changes with Pregnancy:
- Chadwick's Sign: Blue or purple discoloration of the vagina.
- Leukorrhea: Clear or white vaginal discharge with faint musty odor. It may occur during pregnancy
or in other circumstances.
- Goodell's Sign: Bluish discoloration and softening of the cervix.
- Braxton Hicks Contractions: Painless uterine contractions occurring after the 28th week.
- Quickening: The first fetal movement of which the patient is aware. Normally occurs at 18 weeks
during first pregnancy, and at 16 weeks in subsequent pregnancies.
- Hydatidiform Mole: Signs of a molar pregnancy:
- Uterus increases rapidly in size shortly after implantation.
- Persistent vaginal bleeding, no fetal movement, and no fetal heart tones by 12 weeks.
- Nausea and vomiting more intense than usual.
- Grape like clusters of tissues may be expelled through the vagina.
- ABNORMALITIES in SEXUAL FUNCTION:
- Vaginismus: Spasmodic, guarding contraction of vagina upon attempt of intercourse. Often occurs
subsequent to rape or trauma.
- VAGINAL DISCHARGE and ITCHING
- Physiologic Discharge: Clear or white discharge occurring at midcycle.
- Trichomonas Vaginalis:
- Discharge: Gray, foamy discharge having bad odor.
- Mucosa: Red, strawberry cervix.
- Confirm: Confirm with wet-mount (saline suspension microscopy).
- Discharge: Profuse mucoid discharge with foul odor.
- Mucosa: Red, tender mucosa.
- Confirm: Confirm with culture.
- Gardnerella Vaginalis: Also called Non-specific vaginitis. Co-infection with anaerobes usually also occurs.
- Discharge: Gray or white, fishy odor
- Mucosa: Normal
- Confirm: Clue cells = large epithelial cells with many coccobacilli adherent to them.
- Discharge: Little, yellow, mucous and pus in cervical canal.
- Mucosa: Cervical erosion.
- Confirm: FA stain of smear shows elementary bodies.
- Candida Albicans: Yeast infection.
- Discharge: White, cottage-cheese like
- Mucosa: White patches stuck to a red base.
- Confirm: KOH preparation, look for pseudohypha.
- Atrophic Vaginitis: Estrogen deficiency
- Discharge: Little discharge, some blood
- Mucosa: Atrophic, pale or red.
- Confirm: history, age.
- PELVIC RELAXATION: Loss of pelvis support due to atrophy of muscular viscera,
- Urethrocele: Urethra herniates into the vaginal canal.
- Cystocele: Bladder herniates into the vaginal canal.
- Rectocele: Rectum herniates into the vaginal canal.
- Uterine Prolapse: Descent of the uterus into the vaginal canal. Graded from 1 (mild) to 3 (uterus descends
past the vulva).
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Copyright 1999, Scott Goodman, all rights reserved