cystocele
prolapse of the bladder into the vagina
rectocele
prolapse of the rectum into the vagina
enterocele
prolapse of the intestines into the vagina
Common or concerning symptoms
Menarche and menstruationAbnormal bleedingMenopausePelvic pain—acute and chronicVulvovaginal symptomsSTI'ssexual healthpregnancy
primary dysmenorrhea
results from increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline.
causes of secondary dysmenorrhea
endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease (PID), and endometrial polyps
Primary amenorrhea
the failure to begin menstruating at puberty
Causes of secondary amenorrhea
low body weight from any condition, including malnutrition, anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction.
menorrhagia
excessive menstrual bleeding
metrohagia
bleeding between periods
menometrorrhagia
excessive uterine bleeding at both the usual time of menstrual periods and at other irregular intervals
Causes of abnormal bleeding
-pregnancy-cervical or vaginal infection or cancer-cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, hormonal contraception or replacement therapy
polymenorrhea
the occurrence of menstrual cycles more frequently than is normal
oligomenorrhea
scanty menstrual flow
Postcoital bleeding
suggests cervical polyps or cancer or, in an older woman, atrophic vaginitis.
Ovarion torsion
Twisting of the ovarian artery or vein
PID
most common cause of acute pelvic pain, followed by ruptured ovarian cysts and appendicitis
Mittelschmerz
abdominal pain that occurs midway between the menstrual periods at ovulation
chronic pelvic pain
pelvic discomfort not limited to menses for > 6 months
endometriosis
a condition in which patches of endometrial tissue escape the uterus and become attached to other structures in the pelvic cavity
Chronic pelvic pain is a red flag for?
history of sexual abuse
pediculosis pubis
an infestation with lice in the pubic hair and pubic region
Bartholin gland
two glands located on either side of the vaginal opening that secrete a lubricant during intercourse
A yellowish discharge on the endocervical swab commonly represents mucopurulent cervicitis from?
Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex
Raised, friable, or lobed wart-like lesions are seen with?
condylomata or cervical cancer.
The most common type of hernias in women?
indirect inguinal hernias
HPV vaccine recommendations
females and males beginning at age 11 or 12 years, though vaccinations can be first given at age 9.For persons being vaccinated before age 15, the recommendation is two doses of HPV vaccine within 6 to 12 months. For persons first being vaccinated at ages 15 through 26 and immunocompromised persons ages 9 through 26, the recommendation is for three doses of HPV vaccine (0, 1 to 2, and 6 months). Vaccination is also recommended for all persons through age 26 who were not previously adequately vaccinated.
age to begin cervical cancer screening
21 years old
Cervical cancer screening method
Ages 21-65 yrs: cytology every 3 yrs ORAges 21-29 yrs: cytology every 3 yrsAges 30-65 yrs: cytology plus HPV testing (for high-risk or oncogenic HPV types) every 5 yrs; HPV testing alone (age 25 or 30)
Age to end cervical cancer screening
>65
Is screening after hysterectomy with removal of the cervix recommended?
No
The USPSTF recommends against the use of either estrogen alone (for women who have had a hysterectomy) or combined use of estrogen and progestin for preventing chronic conditions in postmenopausal women (D recommendations).
...
epidermoid cyst
A small firm round cystic nodule in the labiayellowish in colorLook for the dark punctum marking the blocked opening of the gland.
Syphilitic Chancre
firm painless ulcer from primary syphilis forms ∼21 d after exposure to Treponema pallidum. may remain hidden and undetected in the vagina heals regardless of treatment in 3-6 wks.
Genital Herpes
Shallow small painful ulcers on red basesUlcers may take 2-4 wks to heal. Recurrent outbreaks of localized vesicles, then ulcers are common.
Venereal Wart (Condyloma Acuminatum)
Warty lesions on the labia and within the vestibule are often condyloma acuminata from infection with human papillomavirus.
Secondary Syphilis (Condyloma Latum)
Large raised, round or oval, flat-topped gray or white lesions point to condylomata lata. These are contagious and, along with rash and mucous membrane sores in the mouth, vagina, or anus, are manifestations of secondary syphilis.
Urethral Caruncle
small, red, benign tumor visible at the post part of the urethral meatus. occurs chiefly in post-menopausal women. tender, pain w/ urination. can be asymptomatic
Trichomonal Vaginitis
discharge: Yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorouspruritispain on urination
Candidal Vaginitis
White and curdy; may be thin but typically thick; not as profuse as in trichomonal infection; not malodorousPruritus; vaginal soreness; pain on urination
Bacterial Vaginosis
Gray or white, thin, homogeneous, malodorous; coats the vaginal walls; usually not profuse, may be minimalUnpleasant fishy or musty genital odor; reported to occur after intercourse
Mucopurulent Cervicitis
produces purulent yellow drainage from the cervical os, usually from C. trachomatis, N. gonorrhoeae, or herpes infection. These infections are sexually transmitted and may occur without symptoms or signs.
Carcinoma of the Cervix
begins in an area of metaplasia. In its earliest stages, it cannot be distinguished from a normal cervix. In later stages, an extensive, irregular, cauliflower-like growth may develop. Early frequent intercourse, multiple partners, smoking, and infection with human papillomavirus increase the risk for cervical cancer.
Fetal Exposure to Diethylstilbestrol (DES)
Daughters of women who took DES during pregnancy are at greatly increased risk for several abnormalities, including (1) columnar epithelium that covers most or all of the cervix, (2) vaginal adenosis, i.e., extension of this epithelium to the vaginal wall, and (3) a circular collar or ridge of tissue, of varying shapes, between the cervix and vagina. Much less common is an otherwise rare carcinoma of the upper vagina.
Retroversion of the Uterus
a tilting backward of the entire uterus, including both the body and the cervix. It is a common variant occurring in approximately 20% of women.
Retroflexion of the Uterus
a backward angulation of the body of the uterus in relation to the cervix.
Myomas of the Uterus (Fibroids)
very common benign uterine tumors.feel like firm irregular nodules that are continuous with the uterine surface.
Prolapse of the Uterus
1st degree prolapse, the cervix is still well within the vagina.2nd degree prolapse, it is at the introitus.3rd degree prolapse (procidentia), the cervix and vagina are outside the introitus.
ovarian cancer
Symptoms include pelvic pain, bloating, increased abdominal size, and urinary tract symptoms; often there is a palpable ovarian mass.19 Currently, there are no reliable screening tests. A strong family history of breast or ovarian cancer is an important risk factor but occurs in only 5% of cases.
Ectopic Pregnancy, Including Rupture
Abdominal pain, adnexal tenderness, and abnormal uterine bleeding are the most common clinical features. In more than half of ectopic pregnancies, there is a palpable adnexal mass that is typically large, fixed, and ill-defined, at times with adherent omentum or small or large bowel. In milder cases, there may be a prior history of amenorrhea or other symptoms of a pregnancy.
Risk factors for ectopic pregnancy
tubal damage from PID, prior ectopic pregnancy, prior tubal surgery, age older than 35 yrs, presence of an IUD, subfertility (has altered tubal integrity), and assisted reproductive techniques.
PID
due to "spontaneous ascension of microbes from the cervix or vagina to the endometrium, fallopian tubes, and adjacent structuresadnexal, cervical, and uterine compression tenderness.
A 45-year-old driver's education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding?
FibroidsRationale: Fibroids, also known as myomas, are very common benign uterine tumors that can become quite enlarged.
A 32-year-old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient's history, what is the best explanation for her infertility?
Prior pelvic inflammatory disease (PID)Rationale: PID is a genital infection caused by gonorrhea, chlamydia, and other organisms.
A 24-year-old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most important area to obtain cells for a Pap smear?
Transformation zoneRationale: The transformation zone is where cancerous cells are most likely to develop and is thus the most important area to sample in a Pap test.
A 35-year-old grade school teacher presents for her annual exam. Her last Pap smear was 4 years ago and normal. She is a G1P1 with a 6-year-old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is done followed by a bimanual examination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass?
The mass dents with digital pressureRationale: Stool in the rectum simulates a rectovaginal mass. Unlike a malignant mass it is dented by digital pressure reassuring the examiner.
A 21-year-old college student presents for her first annual exam. She has been sexually active for 1 year and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions?
Raised friable or lobed lesionsRationale: Warts or condylomata are raised lesions that are often lobed in appearance.
A 23-year-old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam?
She is on her menses.Rationale: For best results with either a Pap smear or STI testing it is best to not have the patient menstruating.
An 18-year-old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID?
Cervical osRationale: An infection in the uterus, tubes, and ovaries would drain through the cervix and out of the os.
A 27-year-old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last week. She reached menarche at age 12 years, became sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix?
Withdraw the speculum slightly and reposition it on a different slope.Rationale: The first maneuver when the cervix is not easily within view is to switch the angle of how the speculum is being inserted.
A 63-year-old office worker comes to the clinic for her women's health exam. Her last Pap smear was 5 years ago and was normal. She is married and has been with the same sexual partner for the last 35 years. After performing the majority of the exam, the clinician decides to do a speculum exam to collect cytology for Pap smear. What is the correct position to have the patient in for her speculum exam?
lithotomy
A 68-year-old retired patient presents to the clinic complaining about feeling like something is falling out of her vagina. She is a G6P6007 and had all her children vaginally, even the twins. She went through menopause at age 55 years, and, for the last few months, she has felt this falling sensation. On exam, an anterior bulge in the vaginal wall is apparent when she bears down. Weakness in which muscle would best account for the anterior bulge in the vaginal wall?
Levatori aniRationale: The levatori ani muscle group consisting of the pubococcygeus muscle and the iliococcygeus muscle is responsible for the support of the pelvic floor.