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375 Cards in this Set

  • Front
  • Back
Where can the symphysis pubis be identified on the surface anatomy of the female
It is covered by adipose tissue called the mons pubis
What are the anterior divisions of the labia minora?
It divides at the anterior of the vulva into two lamellae. The lower pair fuse to form the frenulum of the clitoris and the upper pair form the prepuce.
What are the posterior divisions of the labia minora?
There are none. It meets as two ridges that fuse to form the fourchette
What empties into the vestibule?
The two ducts of the Bartholin glands, two ducts of the Skene glands, the urethra, the vagina
What happens to hymen after it tears?
the edges either disappear or form hymenal tags
The female homolog of the penis
Clitoris, which is a small bud of erectile tissue. It's a primary center of sexual excitement.
Location of the urethra in females?
The lower 2/3rds of the urethra lies immediately above the anterior vaginal wall and terminates in the urethral meatus at the midline of the vestibule just above the vaginal opening and below the clitoris.
These drain a group of urethral glands and open onto the vestiblule on each side of the urethra
Skene ducts
Location of vaginal opening?
Occupies the posterior portion of the vestibule.
Where do the Bartholin glands open up to?
Batholin glands are located posteriorly on each side of the vaginal orifice where they open onto the sides of the vestibule in the groove between the labia minora and hymen.
Function of Bartholin glands?
During sexual excitement they secrete mucus into the introitus for lubrication.
What makes up the pelvic floor?
Composed of muscle fibers of the levator ani (pubococcygeus, puborectalis, and iliococcygeus) and the coccygeus.
What angle is the vagina found out in respect to a vertical plane?
45 degrees posteriorly.
What separates the anterior vaginal wall from the bladder and urethra?
Vesicovaginal septum.
What separates the posterior vaginal wall from the rectum?
Rectovaginal septum.
Why are the 'pockets' formed around the cervix of clinical importance?
Because the internal pelvic organs can be palpated through their thin walls.
Some functions of the vagina?
Carries menstrual flow from the uterus, serves as the terminal portion of the birth canal and is the receptive organ for the penis during sex (oh la la).
What is the Pouch of Douglas?
A deep recess formed by the peritoneum as it covers the lower posterior wall of the uterus and upper portion of the vagina, separating it from the rectum.
Why is the Pouch of Douglas important?
It can be the site ectopic pregnancies. It's also the lowest recess connected to the abdominal space, so you can find fluid build up there.
What position is the uterus usually found in?
Usually flattened anteroposteriorly, inclined forward at a 45 degree, although it can be anteverted, anteflexed, retroverted, or retroflexed.
How does prior pregnancy affect the size of the uterus?
It may be larger by 2 to3 cm in any of the dimensions
That are the anatomic divisions of the uterus?
the corpus and cervix
What regions are incorporated into the corpus of the uterus?
The fundus, the convex upper portion between the points of insertion of the fallopian tubes; the body; the isthmus which is the constricted lower portion adjacent to the cervix
What does the adnexa of the uterus consist of?
The fallopian tubes and ovaries.
What supports the fallopian tubes?
A fold of the broad ligmanet called the mesosalpinx.
What part of the fallopian tubes enters the uterus?
Isthmus.
Where in the pelvis are the ovaries found?
In the lateral pelvic wall
At what level are the ovaries found?
Level of the ASIS.
Hormones secreted by ovaries?
Estrogen and progesterone.
Four ligament pairs that support the internal genitalia?
The cardinal, uterosacral, round and broad ligaments.
What are the pelvic joints?
The symphysis pubis, the sacrococcygeal, the two sacroilial joints
How does the pelvis accommodate the growing preganancy?
The pelvic ligaments strenghten and gain elasticity; the cartilage softens --> this allows the pelvic joints to separate slightly i.e the symphysis pubis; the pelvis also tilts forward putting strain on the back and SI joints
Four bones that make up the pelvis
2 Innominates, sacrum and coccyx
What is responsible for the shallow female pelvis?
This is the false pelvis which consists mainly of the flared out iliac bones
What marks the upper border of the pelvic outlet?
the level of the ischial spines
What marks the lower border of the pelvic outlet?
It is bounded by the pubic arch and the ischial tuberosiies
During pregnancy how do circulating hormones such as relaxin and estrogen affect pelvic ligaments?
They contribute to the strengthening and elasticity of pelvic ligaments and softening of the cartilage. As a result, the pelvic joints separate slightly allowing some mobility.
What can separate during pregnancy that makes walking uncomfortable?
Symphysis pubis
In prepubertal females, what is the length of the corpus versus the cervix?
Corpus: 1/3; Cervix: 2/3
In adult nulliparous females, what is the length of the corpus versus the cervix?
Corpus: 1/2; Cervix: 1/2
In adult multiparous females, what is the length of the corpus versus the cervix?
Corpus: 2/3; Cervix: 1/3
During childhood, what genitalia grow and which remain about the same?
Most genitalia except for the clitoris grow incrementally at varying rates.
In adolescents whose hymen is intact, about how large is the vaginal opening?
1 cm
What are a few changes that occur in the vagina during puberty?
It lengthens, the epithelial layers thicken and the vaginal secretions become acidic.
On average, when does menstruation begin?
Between 11 and 14 in the United States.
How does the vagina change in adolecence?
The vagina lengthens, and the epithelial layer thicken and the vaginal secretion become acidic
Just before menarche, vaginal secretions _________.
increase
What two hormones are responsible for uterine enlargement during the first trimester?
Progesterone and Estrogen
What is responsible for uterine enlargement after the third month?
Mechanical pressure of the growing fetus.
What are some changes that occur as the uterus enlarge?
1. The muscular walls strengthen and more elastic. 2. It becomes larger and more ovoid. 3. Rises out of the pelvis.
Immediately after delievery, what is the approximate uterine size?
the size of a 20 week pregnancy
By the end of the first week, what is the approximate uterine size?
12 week uterus
At what point in time does the uterus reach into the abdominal cavity?
12 weeks of gestation.
Hormones responsible for the softening of the pelvic cartilage and strengthening of the pelvic ligaments?
Relaxin and Progesterone
What changes would you notice on a pelvic exam of a pregnant woman?
The vaginal mucosa would have a hobnailed appearance; The cervix and vagina would take on a bluish color; increased vaginal secretions; eversion of the columnar endocervical glands at the external os
The previous two hormones result in separation of the pelvic joints, which allows some mobility. These can result in what type of walk?
Waddle gait
When does this separation of the pelvic joints resolve itself?
3-5 months postpartum.
During pregnancy, how do the vaginal secretions change?
They increase and have an acidic pH due to an increase in lactic acid production by the vaginal epithelium.
Range of ages menstruation can stop?
40-55 years of age
Definition of menopause?
1 year without menses.
What is attributed to the decrease in size of the labia and clitoris during menopause?
The lack of estrogen
What is attributed to the decrease inlibido and muscle mass and strength during menopause?
Decrease in ovarian testosterone, and adrenal androgens
How soon before onset of menopause does ovulation cease?
1- 2 years.
Systemic effects of menopause?
1. Increase in body fat and abdominal deposition of fat (tendency towards male pattern of body fat distribution). 2. Total cholesterol and LDL increase.3. Thermoregulation is altered--> 'hot flashes'
At what phase do you expect breast proliferation of breast ducts to occur?
Preovulatory phase
When do you expect to see alveolar breast cells differentiate into secretory cells
Luteal phase
GTPALC=?
G- gravity: total number of pregnancies T- number of term pregnancies P- number of preterm pregnancies A- number of abortions, spontaneous or induced L- number of living children C- complications of pregnancy, delivery, abortion or with fetus or neonate
A shortened interval between periods is defined as _______ .
Less than 19- 21 days
A lengthened interval between periods is defined as _______.
More than 37 days
Prolonged menses is defined as more than ____ days.
7
Stages of egg in ovarian cycle?
Primary follicle--> graafian follicle (secretes estrogen)--> ovulation and release of egg--> corpus luteum (progesterone, some estrogen)--> degenerating corpus luteum
Length of menstruation?
Days 1-5
Proliferative phase?
Days 5-14
Secretory phase?
Days 14-26
Ischemic phase?
Days 26-28
Occurs during menstrual phase: days 1 to 4- OVARY
Estrogen levels begin to rise, preparing follicle and egg for the next cycle
Occurs during menstrual phase: days 1 to 4- UTERUS
Progesterone stimulates endometrial PGs that cause vasoconstriction; this allows the upper layer to become ischemic and shed
Occurs during menstrual phase: days 1 to 4- BREAST
Cellular activity in the alveoli decreases; breast ducts shrink
Occurs during menstrual phase: days 1 to 4- CNS HORMONES
FSH and LH levels decrease
Occurs during menstrual phase: days 1 to 4- SYMPTOMS
Variable bleeding
Occurs during post-menstrual, preovulatory phase: days 5 to 12- OVARY + UTERUS
Ovary and maturing follicle produce estrogen. Follicular phase--> egg develops within follicle. Proliferative phase--> uterine lining thickens
Occurs during post-menstrual, preovulatory phase: days 5 to 12- BREAST
Parenchymal and proliferation (increased cellular activity) of breast ducts occurs
Occurs during post-menstrual, preovulatory phase: days 5 to 12- CNS HORMONES
Secreted FSH stimulates ovarian follicular growth
Occurs during ovulation-- days 13 or 14
Egg is expelled from follicle into abdominal cavity and drawn into the uterine tubes. This signifies the end of the proliferative phase. Progesterone causes further thickening of the uterine wall. LH and estrogen levels increase rapidly; LH surge stimulates release of egg
What Symtoms can occur during ovulation?
Mittelschmerz can occur with ovulation.
What are the changes to cervical mucus during ovulation?
Cervical mucus is increased and is stringy and elastic (spinnbarkeit)
Occurs during the secretory phase- days 15-20
Egg/ovum moved by cilia into the uterus. After the egg is released, the follicle becomes a corpus luteum, which secretes progesterone. Levels of progesterone increases and predominates.
What happens to FSH and LH levels during the secretory phase?
Both decrease. Progesterone secreted by CL and dominates.
Occurs during the menstrual, luteal phase- days 21 to 28- OVARY
If implantation doesn't occur, CL degenerates. This causes progesterone levels to drop and then to slowly increase again as a new follicle develops.
Occurs during the menstrual, luteal phase- days 21 to 28- UTERUS
A woman's period begins around day 28, which begins day 1 of the menstrual cycle.
Occurs during the menstrual, luteal phase- days 21 to 28-BREAST
Alveolar breast cells differentiate into secretory cells.
Occurs during the menstrual, luteal phase- days 21 to 28- CNS Hormones
Increased levels of GnRH cause increased secretion of FSH
Symtoms that occur during the menstrual, luteal phase- days 21 to 28
Vascular engorgement and water retention occur.
What is considered a short menstrual cycle?
Less than 19-21 days
What is considered a lengthened period between periods?
More than 37 days
Prolonged menses= how many days?
More than 7 days
RIsk factors for cervical cancer?
1. Pap smear history- lack of regular screening for cervical cancer 2. High risk HPVs: 16, 18, 31, 33 and 45 3. Sex before 16, along with multiple partners (increases risk of HPV infection) 4. Cigarette smoking doubles risk 5. HIV infection 6. Diets low in fruits and veggies; overweight women more likely to develop this cancer. 7. Being black, hispanic or Native American (higher rates of invasive cancer) 8. DES exposure from moms (1940-1971) 9. Some say OC use longer than 5 years increases risk 10. Low socioeconomic status
Risk factors for ovarian cancer?
1. Age-- most develop after menopause; half are found in women older than 63 2. Menarche before 12, infertility, nulliparity or first child after 30, menopause after age 50. 3. Use of fertility drugs may increase the risk, especially if pregnancy not achieved. 4. Family history with one or more first degree relatives who've has ovarian and or breast cancer, strong family history of colon cancers, or having Ashkenazi jewish decent. 5. Personal history of any type of cancer 6. Inherited mutation of BRCA1 or BRCA2 gene7. Being white (occurs 50% more frequently) 8. Using hormone therapy replacement. 9. High-fat diet 10. Potentially the use of talcum products in hygiene sprays or in sanitary napkins
Risk factors for endometrial cancer?
1. Increased number of years that the endometrium is exposed to estrogen (so menarche before 12 years of age)2. Late menopause (after 50), again increases number of years exposed to estrogen 3. Total length of menstruation span-- early menarche is less of a risk factor for women who also have early menopause. 4.Infertility or nulliparity-- this is because during pregnancy the hormonal balance shifts toward more progesterone. Therefore, having many pregnancies reduces endometrial cancer risk and women who have not been pregnant have a higher risk 5. Being obese. Fat tissue increases a woman's estrogen levels. Increases risk 2-5 times.
Exposure to what drug would increase endometrial cancer risk?
Tamoxifen- an ANTIESTROGEN drug that acts like estrogen in the uterus. Estrogen replacement therapy- estrogen alone without progestin
95% of endometrial cancers occur in women older than ___________
40 years or older.
What genetic mutations can predispose to endometrial cancer?
mutations in BRCA1/2
Women may have occasional vaginal discharge. What might be signs this is may be due to an STI?
If it's yellow and thicker and has an odor.
When evaluating masturbation in children, what aspects would require further assessment?
1. If it's frequent and compulsive. 2. There's no regard for privacy. 3. Preferred over other activities or play. 4. Produces genital discomfort, irritation or physical signs. 5. Involves penetration of the genital orifices; includes bizarre practices or rituals.
What aspects of masturbation are considered healthy in growing children?
1. Occasional 2. discreet, private 3. not preferred over other activity or play 4. no physical signs or symptoms 5. external stimulation of genitalia
During the pelvic examination, what position should the table be facing in regards to the door?
The patient and table should be facing away from the door, so that way if a door is opened or someone walks in the patient is not exposed.
Why are assistants or chaperones often required during examination?
Because it's policy and protects both the examiner and patient.
Is bimanual examination of the pelvic region uncomfortable for women with full bladders?
Yep. Not only that, but it makes it harder to palpate the pelvic organs.
When you are about to begin the examination what should you do?
Tell the patient you are about to begin, then start with a neutral touch on her lower thigh, moving your examining hand along the thigh without breaking contact, to the external genitalia.
Patient should be in what position during examination?
Dorsal lithotomy.
Signs indicative of a Bartholin gland abcess in the labia majora?
Labial swelling, redness, or tenderness unilaterally.
What would suggest infections or inflammation of the labia majora?
Excoriation, rashes, lesions
If signs of Bartholin gland abscess or inflammation of the labia majora are present what should you ask the patient?
Whether she's been scratching down there.
Ulcers or vesicles of the labia minora may be signs of what?
STDs.
Average size of clitoris and enlargement suggests what?
2 cm or less in length, .5 cm diameter. Enlargement may be a sign of a masculinizing condition.
If you find signs of inflammation of the urethral opening (potentially secondary to UTIs or insertion of foreign objects) when should you ask questions about this?
At a later time, not during the pelvic examination when the woman feels most vulnerable.
Another name for hymenal remnants?
Myrtiform carnucles
Discharge from the Skene glands or urethra usually indicates what?
An infection, most commonly, but not necessarily, gonococcal.
Already asked before, but what are signs of Bartholin gland abscess?
The gland will be painful, hot to touch and fluctuant.
Where do you palpate for the Bartholin glands?
Along the posterolateral area of the labia majora
Organism responsible for Bartholin gland abscess?
Gonococcal or staphylococcal in origin
What would a non-tender mass of the Bartholin gland suggest?
A Bartholin cyst, which is the result of chronic inflammation of the gland.
When examining muscle tone, bulging of the anterior wall and urinary incontinence indicate the presence of what?
A cystocele.
When examining muscle tone, bulging of the posterior wall indicates?
A rectocele.
What marks uterine prolapse?
Protrusion of the cervix or uterus on straining.
Feel of the tissue of the perineum in nulliparous women versus multiparous women?
The tissue will feel thick and smooth in the nulli, while it will be thinner and rigid in multi women. In either case, it shouldn't be tender.
Concerns about using gel lubricants when collecting a pap smear?
That the gel will contaminate or obscure analysis and interpretation of findings.
SInce there is concern about using gel lubricants during a pap smear, what should be done?
Just use water as lubrication. If you do use gel, though, a thin layer on the external surface of the blades only will help avoid contamination of the specimen.
How should the speculum be held when using it?
Hold it in your hand with the index finger over the top of the proximal end of the anterior blade and the other fingers around the handle. This position controls the blades as the speculum is inserted.
Steps taken to insert the speculum into vagina?
Insert a finger of your other hand just inside the vaginal introitus and apply pressure downward. Ask patient to breathe slowly and try to get her to consciously relax the muscles of the buttocks. When you feel relaxation use the fingers to separate the labia MINORA very widely so that the hymenal opening becomes clearly visible. Then slowly insert the speculum along the path of least resistance, (usually slightly downward, avoiding trauma to the urethra and vaginal walls). Regardless of what position you prefer to insert the speculum, avoid the clitoris, catching pubic hair or pinching labial skin.
A bluish color of the cervix may indicate what?
Increased vascularity due to pregnancy!
What should a symmetric circumscribed redness around the os indicate to you?
Exposed columnar epithelium from the cervical canal
When would reddened areas of the cervix be considered unexpected findings?
When the borders are irregular or patchy.
A pale cervix is a sign of what?
Anemia.
A cervix pointing anteriorly indicates what type of uterus?
A retroverted uterus.
A cervix pointing posteriorly indicates what type of uterus?
An anteverted uterus. (Harder to get pregnant this way)
A cervis in the horizontal position indicates?
A uterus in modposition.
If there was a pelvic mass, uterine adhesions or pregnancy how would these affect the cervix?
You might see deviation to the right or left.
How far can the cervix protrude into the vagina to still be considered 'WNL'?
1-3 cm
If the cervix projects greater than 3 cm into the vagina, what might this suggest?
A pelvic or uterine mass.
Size of a cervix of a woman of childbearing age?
2-3 cm
Enlarged cervix sign of?
Cervical infection
What do Nabothian cysts on the cervix look like? What are they and are they expected?
Small, white or yellow, raised, round. These are retention cysts of the endocervical glands and are considered an expected finding.
What happens if a Nabothian cyst is infected?
It becomes swollen with fluid and distorts the shape of the cervix, giving it an irregular appearance.
Normal discharge versus discharge secondary to bacterial or fungal infections
Normal discharges are usually odorless, may be creamy or clear, thick or thin or stringy and is heavier midcycle or immediately before menstruation. Discharge of a bacterial or fungal infection will probably have an odor and can be white to yellow, green or gray.
Shape of a nulliparous os?
Small, round or oval
What is cervical ectropion?
Columnar epithelium from the cervical canal that appears as shiny red tissue around the os that may bleed easily
What visualization tools can differentiate between ectropion and early cervical carcinoma?
None, you need further diagnostic studies i.e. PAP smear or biopsy
What tools are being used now in conjunction with, or instead of, just the conventional spatula?
Brushes and brooms.
Which type of cells does the cylindric-type brush collect?
Endocervical cells. (Use a spatula first to collect the ectocervical cells)
What cells does a spatula collect?
Ectocervical cells.
What does the broom-type device collect?
Ectocervical and endocervical cells at the same time.
Why are broom-type devices somewhat better?
Reported to cause less blood spotting.
What is a DNA probe?
This test involves the construction of nucleic acid sequence that will match to a sequence in the DNA or RNA of the target tissues
How is a gonococcal culture specimen obtained?
Immediately after the pap smear is obtained, introduce a sterile cotton swab into the vagina and insert it inot the cervical os. Hold it there for 10-30 seconds, withdraw and spread the specimen in a large Z pattern over the culture medium, rotating the swab at the same time.
Vaginal discharge may be a sign of what kind of infection?
Bacterial vaginosis, candidiasis or Trichomonas vaginalis.
Once a wet mount is prepared of the discharge and examination is done under microscope, what would suggest infection with trichomonas vaginalis?
Presence of trichomonads.
What suggests bacterial vaginosis infection?
The presence of bacteria-filled epithelial cells (clue cells).
On a separate glass slide, you place some of that vaginal discharge specimen and apply KOH. You smell a 'fishy odor'... What does this suggest?
Again, bacterial vaginosis.
So if there is no fishy odor, what can the use of KOH actually help with?
It dissolves epithelial cells and debris and facilitates visualization of the mycelia of a fungus. This would allow you to see mycelial fragment, hyphae and budding yeast cells, which indicate candidiasis.
Normal vaginal secretions are usually?
Thin, clear or cloudy and odorless.
Secretions indicative of infection are often....?
Profuse, thick, curdy or frothy, gray, green or yellow and can smell foul.
Should women continue to have pap smears following a hysterectomy?
If hysterectomy was done for noncancerous reason, with the cervix removed, no evidence of malignancy and no history of abnormal cancerous cell growth then pap smears screening for cervical cancer can be discontinued. Annual pelvic examinations should be continued, though.
What two fingers are used for bimanual examination?
Index and Middle fingers
Be careful of what when examining with fingers?
Make sure to not let the thumb limit your exam and to not let the thumb touch the clitoris since it can cause discomfort.
Consistency of the cervix in a nonpregnant woman?
Firm like the tip of a nose.
Consistency of the cervix during pregnancy?
Softer than during nonpreg. state.
How do you examine the patient for cervical motion tenderness?
Grasping the cervix between the fingers and moving it from side to side. Observe the patient's expression for pain. It should move 1 to 2 cm in each direction with pain.
What does painful cervical movement suggest?
Acute PID, pelvic inflammatory process or ruptured tubal pregnancy.
Most common position of the uterus?
Anteflexed or anteverted.
If the uterus is anteflexed or anterverted (the position of most uteri) what will you feel between your inserted fingers the palm of the hand on the suprapubic area?
The fundus of the utuerus.
If the uterus is retroflexed or retroverted what technique should be used to palpate uterus?
By putting the fingers in the posterior fornix and pushing the uterus up so it can be felt more easily.
Uterus should usually be midline. What does it suggest of it's deviated?
Possible adhesions, pelvic masses, or pregnancy.
What is mittelschmerz?
Lower abdominal pain associated with ovulation. It can be accompanied by a degree of tenderness on the side in which ovulation took place that month and even by similarly unilateral and usually mild adnexal tenderness. Onset is usually sudden and remission is spontaneous.
Shape of uterus likened to which fruit?
Pear!
uterus larger than expected sign of?
Pregnancy or tumor.
If uterus not mobile in the anteroposterior plane, this could indicate?
Fixed uterus sign of: Adhesions.
When palpating a healthy ovary, what should the patient feel?
Slight tenderness. Marked tenderness, enlargement and nodularity are unexpected.
Why are the adnexa difficult to palpate?
Because of their location and position and the presence of excess adipose tissue. If you can't feel anything then you can assume there are no abnormalities present.
When observing sphincter tone, an extremely tight sphincter may suggest what?
Anxiety, scarring or spasticity due to fissures, lesions or inflammation.
A lax sphincter suggests?
Neurologic deficit.
Absent sphincter suggests?
Improper repair of 3rd degree perineal laceration after childbirth or trauma.
When would it be easiest to feel the uterus and fundus of the uterus when doing a rectovaginal exam?
If the uterus fundus was retroflexed.
When examining an infant's external genitalia, which position should the legs be in?
Infant's legs are held in frog position.
How do the labia majora look like prior to 36 weeks gestation?
Labia majora are widely separated and the clitoris is prominent up to 36 weeks.
How do they look by full term?
Full term, majora completely cover the labia minora and clitoris.
When a newborn girl is born, and the mother sees that the child's labia majora and minora are swollen and the hymen is slightly protruding what would you tell her?
That these are transient changes that simply reflect the mother's own hormones and will disappear in a few weeks.
What is the appearance of the clitoris in very premature girls?
Remember that all really premature female infants seem to have clitoromegaly. Only one as 5000 babies will have endocrine problems (adrenal hyperplasia).
Average size of central opening of they hymen?
.5 cm
An imperforate hymen can lead to what in a child? In adolescents?
Child- hydrocolpos; Adolescent- hematocolpos
A baby girl is brought into the physician's office because of white, mucoid vaginal discharge. The mother said it's occasionally mixed with blood. The kid is no older than 4 weeks old.
You would tell the parent that this finding is the result of passive hormonal transfer from the mom to the child. It's temporary and an expected finding.
Vaginal discharges in infants and young children that are mucoid in appearance are caused by?
Irritation from their diaper or powder.
When examining children, is an external examination adequate enough or do you need to do an internal one too?
External is enough. Only perform internal if there is bleeding, discharge, trauma or suspected sexual abuse.
What is anterior labial traction?
A technique used to visualize the interior of the vagina and the hymenal opening in prepubertal girls.
Are Bartholin and skene glands palpable in children?
No, if they are enlargement exists. It can indicate an infection, which is most often gonococcal.
If a girl has an imperforate hymen and you ask her to cough, what would you expect?
The imperforate hymen will bugle. A hymen with an opening will not.
Causes of genital bleeding in children:
1. genital lesions 2. vaginitis 3. foreign body 4. trauma 5. tumors 6. endocrine changes 7. estrogen ingestion 8. precocious puberty 9. hormone-producing ovarian tumor
When performing the rectal examination on a child, what is one method of getting them to relax their muscles?
Having the child 'pant like a puppy'.
For women who are not sexually active, when should the first pelvic examination take place?
21 years of age
What methods of screening for STDs do adolescents tend to prefer?
First-void urine specimens and self-collected vaginal swab specimens. Still, pelvic exams are the best.
How large should the hymenal opening be by the time menarche starts?
About 1 cm wide.
A pregnant patient comes in for a pelvic exam. You note that the cervix, vagina, and vulva have just become blue in color. Why is this happening and when does it indicate?
The color change begins in the second month of pregnancy and is due increased vascularity.
What pelvic type is more common in white women? Black women? Which has equal occurence?
White women-- android type. Black women-- anthropoid type. Equal occurrence- gynecoid. Rarest= platypelloid
In pregnant women, when should the bony pelvis be measured?
During the third trimester to ensure accuracy.
The following are early signs of pregnancy:
The following are early signs of pregnancy:
What is the Goodell Sign?
Softening of the cervix
When is the Goodell Sign seen?
4-6 wks gestation
What is the Hegar Sign
Softening of the uterine isthmus
When is the Hegar Sign seen?
6 to 8 weeks
What is the McDonald Sign
Fundus flexes easily on the cervix
When is the McDonald Sign ?
7 to 8 weeks
What is the Braun von Fernwald Sign ?
Fullness and softening of the fundus near the site of implantation
When is the Braun von Fernwald sign seen?
7 to 8 weeks
What is the Piskacek Sign?
Palpable lateral bulge or soft prominence of one uterine cornu
When is the Piskacek sign seen?
7-8 weeks
What is the Chadwick Sign?
Bluish color of the cervix, vagina and vulva
When is the Chadwick Sign
8 to 12 weeks
Shape of brim of gynecoid type?Usual mode of delivery?
Round; Vaginal, spontaneous, occiput anterior position
What are some of the measurements of fetal well-being?
The measurement of fetal heart rate and fetal movement
When is the fetal heart rate detected by doppler?
11 to 12 weeks
Shape of brim of android type? Usual mode of delivery?
Heart Shaped; Cesarean-- vaginal delivery difficult with forceps
When is the fetal heart rate detected by fetoscope?
19 to 20 weeks
When can fetal movement be usually detected by the mother?
between 16 and 20 weeks
Shape of brim of anthropoid? Usual mode of delivery?
Oval shaped; Vaginal, occiput posterior or occiput anterior position
What is the Cardiff count to 10 method used for?
Fetal movement counting technique
What amount of movement should your patient to watch for when contacting you about fetal inactivity?
It there are fewer than 10 movements in 12 hours
Shape of brim of platypelloid (only 3% of women!)? Usual mode of delivery?
Flat shaped; Vaginal, spontaneous
When you have identified the risks of uteroplacental insuffiency when should Mom start recording FM
She should start as early as 28 weeks
When you have identified the risks of uteroplacental insuffiency are not present, when should Mom start recording FM?
between 34 to 36 weeks
What is the most important clinical measurement for estimating the AP diameter of the pelvic inlet?
Diagonal conjugate.
When would you find that the pelvic inlet AP diameter was shortened?
When the pelvis is abnormal.
Is the midplane (transverse/interspinous diameter) measurable?
Nope. The interspinous diameter is estimated between the interspinous processes.
How is the outlet measured?
From the inferior border of one ischial tuberosity to the other.
What is noticed in Weeks 10-12 of preganancy in relationship to fundal height:
Uterus within pelvis, fetal heart beat detectable
What is noticed in Week 12 of preganancy in relationship to fundal height:
Uterus palpable just above the pubic symphysis
What is noticed in Week 16 of preganancy in relationship to fundal height:
Uterus palpable halfway between symphysis and umbilicus; ballottement of fetus is possible by abdominal and vaginal examination
What is noticed in Weeks 20 of preganancy in relationship to fundal height:
Uterine fundus at lower border of umbilicus, fetal heartbeat can be auscultated with fetoscope.
What is noticed in Weeks 24-26 of preganancy in relationship to fundal height:
Uterus changes from globular to avoid shape; fetus palpable
What is noticed in Weeks 28 of preganancy in relationship to fundal height:
Uterus approximately halfway between umbilicus and xiphoid; fetus easily palpable
What is noticed in Week 34 of preganancy in relationship to fundal height:
Uterine fundus just below xiphoid
What is noticed in Weeks 40 of preganancy in relationship to fundal height:
Fundal heigh drops as fetus begins to engage in pelvis
What measurement of the cervix is considered full/complete dilation in pregnancy?
10 cm
What is effacement of the cervix?
Refers to thinning of the cervix that results when myometrial activity pulls the cervix upward, allowing the cervix to becomepart of the lower uterine segment during prelaboror early labor. This reduces the cervix in length.
What does shortening of the cervix midpregnancy suggest the mom is at risk for?
Early delivery.
When does effacement usually occur?
Precedes dilation of the cervix in the primipara mother. Occurs with dilation in the multipara mother.
When should Leopold manuevers be used?
In the later half of the third trimester
What are the Leopold manuevers?
1. First manuever. Place hands over the fundus and identify the fetal part. 2. Second manuever. Use the palmar surface of one hand to locate the back of the fetus and the other hand to feel the irregularities 3. The third manuever. Use the thumb and third finger to grasp the presenting part over the symphysis pubis. 4. Fourth maneuver. Use both hands to outline the fetal head.
When you see that the station of a baby is 0, where do you understand the fetus is presently?
At the ishial spines
When you see that the station of a baby is +1, where do you understand the fetus is presently?
The station is at 1 cm below the ischial spines
What are stations?
Station describes the relationship of the presenting part of the ischial spines of the mother's pelvis to the descent of the presenting part of the infant.
When do uterine contractions start in pregnancy?
They may begin as early as the 3rd month; these are known as Braxton-Hicks
When does the occurrence of Braxton- Hicks become a concern ?
More than 4 -6 uterine contractions per hour before 37 weeks of gestation
When your patient states that she is having contractions and you cannnot indent the uterus with your fingertips how do grade the strength of the contractions?
Strong
When your patient states that she is having contractions and you have difficulty indenting the uterus with your fingertips how do grade the strength of the contractions?
Moderate
With what fontanelle do you determine the position of the fetal head and body?
Anterior fontanelle. The position of the fontanelle is determined by examining the anterior aspect of the sagittal suture and then using a circular motion to pass alongside the head until the other fontanelle is felt and differentiated.
What is meant by the lie of the fetus when recording the information from abdominal palpation?
The relationship of the long axis of the fetus to the long axis of the mother
What is meant by the attitude of the fetal head when recording the information from abdominal palpation?
Whether it's flexed or extended
If the presentation of fetus is breech, then where should we expect to find the FHR?
Above the umbilicus
If the presentation of fetus is vertex, then where should we expect to find the FHR?
Below the umbilicus
WHo is the knee-chest position best for?
Women who feel most comfortable and balanced lying on their side.
Best position for women with visual or hearing impairment?
A foot-stirrup position.
A 28 year old female comes to your office complaining of edema, weight gain, headache, irritability, nervousness, dysphoria and lack of coordination. She mentions that these happen to occur about 5 to 7 days before her period and stop when her period begins. What would you tell her is her diagnosis?
Premenstrual syndrome. It usually begins in a woman's late 20's and increases as menopause approaches.
A couple has been trying to conceive for over 1 year. They now come to your office seeking advice about figuring out what the problem is. What factors would you need to consider in females? In males? What are some factors that can effect both of them?
The inability to conceive over a period of 1 year of unprotected regular intercourse defines infertility.
What is the appearance of the inflammed vaginal mucosa with atrophic vaginitis?
The vaginal mucosa is pale and dry. It may become reddened and develop petechiae and superficial erosions
What is the pH of amniotic fluid?
7.15
What is the appearance of amniotic fluid on a slide?
Amniotic fluid place on a slide and air-dried will have a fern pattern
How is premature rupture of membranes verified?
PROM should be verified with a sterile speculum examination to collect fluid for testing with Nitrazine paper and micorscopic exam
What is the expected appearance of Nitrazine paper if amniotic fluid is detected?
It will turn it blue-green
What is likely the causative agent of vulvovaginitis after a recent upper respiratory infection or pharyngitis?
Group A beta-hemolytic Streptococcus
What symptoms would likely indicate a pinworm associated vulvovaginitis?
Vaginal pruritis especially at night
What is hydrocolpos?
It is the distention of the vagina caused by accumulation of fluid due to congenital vaginal obstruction
What are the likely causes for hydrocolpos?
It is likely caused by obstruction that is usually caused by imperforate hymen or a transverse vaginal septum
What is the expected appearace of hydrocolpos on abdominal ultrasound
It will show a large midline translucent mass displacing the bladder forward
What controls the development of the sex organs during fetal development?
The presence or absence of male hormones
A _____ of male homones in a genetic male fetus results in ambiguous genitalia
deficiency
A _____ of male homones in a genetic female fetus results in ambiguous genitalia
presence
What clues in the family history would predispose someone to developing ambiguous gentalia
Unexplained deaths in early infancy, Infertility in close relatives, Abnormal development in puberty or a history of known congenital adrenal hyperplasia
What other conditions also commonly occurs with males in the presence of ambiguous genitalia
Undescended testicles
What is the appearance of the genitalia in a genetic female in the presence of ambiguous genitalia?
There would be an enlarged clitoris that has the appearance of a small penis, the urethral opening would be anywhere alone, above, or below the surface of the clitoris, The labia would be fused resembling the scrotum, and a lump of tissue would be felt within the labia giving the appearance of testicles
What is the appearance of the genitalia in a genetic male in the presence of ambiguous genitalia?
There would be a small penis that resembles an enlarged clitoris that has the appearance of a small penis, the urethral opening would be anywhere alone, above, or below the penis or as low as the peritoneum, there would be a small scrotum with any degree of separation resembling labia
What are the two stages in acute salpingitis?
the first stage involves the acquistion of a vaginal or cervical infection; the second involves ascent of the infection to the upper genital tract
What are the most common organisms associated with acute salpingitis?
Neisseria gonorrhea and C.trachomatis
What is are the aggravating factors involving salpingitis?
motion or sexual activity
What findings on the bimanual exam would indicate a salpingitis?
Cervical motion tenderness and or adnexal tenderness
What other disease process also accompanies salpingitis?
pelvic inflammatory disease
What are the most common organisms associated with pelvic inflammatory disease?
Neisseria gonorrhea and C.trachomatis
What are some symptoms associated with PID?
Painful intercourse, painful urination, irregular menstrual bleeding and pain in the right upper quadrant
What findings on the bimanual exam would indicate a PID
Tender Bilateral adnexal areas, with voluntary guarding
What is the most common site for an ectopic pregnancy?
Fallopian tubes
What process is most likely involved in fallopian tube dysmotilty resulting in ectopic pregnancy?
Scarring
What disease processes can cause scarring in the fallopian tubes?
Past ectopic pregnancy, Past infection in the fallopian tubes, PID, or fallopian tube surgery
When should dyou expect rigidity and rebound to occur in an ectopic pregnancy?
These signs may be present early or late
What are the signs of ruptured ectopic pregnancy?
Worsening of current symptoms from a mild, vague abdominal pain to a severe onset of abdominal tenderness in the hypogastric area; Tachycardia and hypotension --> impending cardiovascular collapse
Where can the pain for an ectopic pregnancy be referred to?
Pain that is felt in the shoulder area or in the lower back
What is the most common form of ovarian cancer?
Epithelial tumor
During your bimanual exam of a postmenopausal woman, you notice unilateral enlargement of a single ovary. Is this normal?
NO, This is considered suspicious for cancer
Which population is most likely to have a germ cell ovarian tumor?
Young women, often teenage girls
What are some of the generalized complaints that could lead to ovarian cancer diagnosis?
Generalized abdominal discomfort, pressure. Swelling, bloating, cramps of the feeling of fullness after a light meal
When do most ovarian cysts occur?
During infancy and adolesence --> hormonally active periods of development
Why do ovarian cysts form?
As the result of hypothalamic-pituitary dysfunction or because of native anatomic defects in the reproductive system
What population is most likely to suffer from endometrial carcinoma?
Most often occurs in postmenopausal women
How is endometrial cancer diagnosed on physical exam?
It isn't. Endometrial biopsy provides the diagnosis
What drug increases your risk for developing endometrial cancer?
Tamoxifen
What is the biggest red flag for endometrial cancer?
Postmenopausal menstrual bleeding
How does the presence of uterine fibroids affect menstrual periods?
They become much heavier and is associated with abdominal cramping
What is the underlying tissue in uterine fibroids?
They arise from an overgrowth of smooth muscle and connective tissue in the uterus
What is the difference between menorrhagia and metorragia?
metrorrhagia is menstrual bleeding that occurs at irregular intervals but at regular amounts. Menorrhagia is excessive bleeding during a menstrual period that is longer in duration than usual
What is the difference between menorrhagia and hypomenorrhea?
Menorrhagia is excessive bleeding during a menstrual period that is longer in duration than usual. Hypomenorrhea is decreased menstrual flow
What is the difference between polymenorrhea and hypermenorrhea?
Polymenorrhea is increased frequency of menstruation that is not consistently associated with ovulation. Hypermenorrhea is increased bleeding during a menstrual period of usual duration
What is the difference between hypomenorrhea and oligomenorrhea?
Hypomenorrhea is decreased menstrual flow but oligomenorrhea is infrequent menstruation
What is the difference between metorrhagia and hypermenorrhea?
Metrorrhagia is menstrual bleeding that occurs at irregular intervals but at regular amounts but hypermenorrhea is increased bleeding during a menstrual period of usual duration
What are some causes for postmenopausal bleeding?
Endometrial hyperplasia, estrogen therapy, endometrial cancer
Which cancers can lead to irregular menstrual bleeding?
Uterine or ovarian cancer
What benign growths can lead to irregular menstrual bleeding?
Endometrial polyps
What type of contraception can lead to profuse menstrual bleeding?
IUD
What is resposible for midcycle spotting?
Midcycle estradiol flucutation associated with ovulation
What other conditions often accompanies uterine prolapse?
Cystocele and rectoceles
With uterine prolapse, the uterus becomes progressively _____ and descends into the vaginal canal.
retroverted
What symptoms accompany a uterine prolapse?
There is a sensation of pelvic heaviness and uterus falling out. There may urine leakage or urge incontinence, difficulty having a bowel movement, or low back pain
On physical exam of a postmenopausal patient, you immediately see both the cervix and the vagina outside the introitus. How would you grade this uterine prolapse?
Third degree prolapse
What defines first degree uterine prolapse?
the cervix is visible only in the vagina
What defines 2nd degree uterine prolapse?
The cervix is clearly visible at the introitus
At what age should we expect the onset of PMS?
It usually begins in a woman's late 20s
PMS _____ in severity as menopause approaches.
increases
What are some symptoms associated with PMS?
May include breast swelling and tenderness, acne, bloating and weight gain, headache, or joint pain, food cravings, irritability, difficulty concentrating, mood swings, crying spells and depression
During what mentrual phase does PMS occur?
Luteal
PMS symptoms occur _____ days before menses and subside with onset of menses
5 to 7
After how long of attempting to get pregnancy, can we diagnose infertility
one year
How does endometrial tissue arrive outside of the uterus?
Due to retrograde reflux of menstrual tissue from the fallopian tubes during menstruation
What are the symptoms of endometriosis?
Pelvic pain, dysmenorrhea and heavy or prolonged menstrual flow
The causative infection for condyloma acuminatum is ____ but the causative agent for condyloma latum is ___
HPV; Treponema pallidum
HPV invades the_____ layer of the epidermis.
basal
On physical exam, you note flat oval papules that are covered by a gray exudate. What should you suspect?
Condyloma latum
How soon after the syphilic infection would you expect condyloma lata to arise?
about 6 to 12 weeks
______ is the lesion of primary syphilis but ______ is the lesion of secondary syphilis.
syphilic chancre; condyloma latum
When does a syphilic chancre occur after infection?
2 weeks
How long would a syphilic chancre last without treatment?
3 to 6 weeks
Describe a syphilic chancre.
A lesion with indurated borders with a clear base
What is the most common cause of genital herpes?
HSV-2
When does the transmission of HSVmostly occur in individuals?
During the asymptomatic shedding of the virus
Which is more extensive, the initial presentation fo genital herpes or the recurrences?
The initial presentation; The recurrences are usually confined to a small, localized patch
Chronic inflammation of the bartholin gland will present as a ______ cyst in the _____.
nontender; labium
A child presents with a molluscum contagiosum infection of her lateral face, should we assume sexual abuse?
NO, this a common non-sexually transmitted infection in children.
What is the incubation period for molluscum contagiosum?
2 to 7 weeks
How does molluscum contagiosum enter the skin?
through small breaks of hair follicles
What are the microscopic indicators of molluscum infection?
Typical molluscum bodies within the epithelial cells
Describe a molluscum contagiosum lesion.
White or flesh colored dome shaped papule with a central umbilication
One risk factor for vaginal carcinoma includes _______ having taken DES during pregnancy
patient's mother
What area would most likely orginiate Melanoma vaginal cancer?
The lower or outer portion of the vagina
What are the precancerous lesions of squamous cell vaginal carcinoma
vaginal intraepithelial neoplasia (VAIN)
Which cancer also should include basal cell as a tissue diagnosis, vulvar or vaginal carcinoma?
vaginal
Which cancer also should include sarcoma as a possible tissue diagnosis, vulvar or vaginal carcinoma?
vulvar
What virus could possibly be the cause of vaginal squamous cell carcinoma?
HPV
What is the most common vulvar carcinoma?
squamous cell
Where would vuvlar adenocarcinoma likely occur?
Adenocarcinoma starts in the Bartholin glands or vulvar sweat glands
What increases the risk factor for vulvar carcinoma?
Women who have melanoma on other parts of their body
A vulvar lesion that lasts for longer than _____ is suspect for vulvar carcinoma
one month
What is the typical appearance of a lesion of squamous cell carcinoma of the vulva?
Ulcerated or raised lesion on the vulva; usually found on the labia
Where would melanoma vulvar carcinoma be found?
It is dark colored lesion most often found on the clitoris or the labia minora
Where is the usual place for vulvar adenocarcinoma to be located>
It is usually found on the sides of the vaginal opening
What is the causative agent of clue cells?
Bacterial vaginosis
What is the causative agent of strawberry cervix?
Trichomasis
What would the wet mount of trichomoniaisis?
You should see round or pear- shaped protozoa; motile gyrating flagella
What organism should we suspect with Skene/ Bartholin gland inflammation?
Neisseria gonorrhea
When you take the vaginal pH it measures under 4.5, what causative process should you consider?
Allergic vaginitis; Atrophic vaginitis;Physiologic vaginitis;Bacterial vaginosis; possible Candida
How can Candida be diagnosed?
KOH prep that displays mycelia, budding, branching yeast, pseudohypae
What patients should be evaluated for atrophic vaginitis?
Perimenopausal or postmenopausal women who complain of vaginal dryness and painful sex.
What should the wet mount should in the setting of atrophic vaginitis?
Folded, clumped epithlial cells
New onset bloody and foul smelling discharge in a six year old girl should indicate ______.
A possible foreign body
What is a likely cause of white curdy vaginal discharge and itching of labia/perineum?
Candida vulvovaginitis
What should the wet mount show in the setting of bacterial vaginosis?
clue cells and + KOH whiff
Where do dysplastic or premalignant lesions present in cervical carcinoma?
at the active squamocolumnar junction
What disease processes can cause easily cause confusion with early cervical carcinomas?
Ectropion
What is the ideal test to detect precancerous changes in cervical carcinoma?
PAP test
What is the single most causative agent in cervical carcinogenesis?
HPV