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external female genitalia
vulva
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a hair-covered fat pad overlying the symphysis pubis
Mons pubis
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rounded folds of adipose
labia majora
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thinner pinkish-red folds that extend anteriorly to form the prepuce and clitoris
labia majora
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the boat-shaped fossa btwn the labia minora
vestibule
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Distal cervix protrudes into the vagina, dividing upper vagina into 3 recesses:
- Anterior fornice
- Posterior fornice
- Lateral fornice
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2 parts of the uterus:
the body (or corpus) and the cervix
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marks the opening into the endocervical canal
external os of the cervix
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what are the cellular types of the ectocervix?
- plushy, red columnar epithelium surrounding the os, which resembles the lining of the endocervical canal
- the squamous columnar junction (forms the boundary)
- a shiny pink squamous epithelium continuous with the vaginal lining
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what is the ectropion
- the broad band of columnar epithelium encircling the os before puberty
- during puberty, the ectropion is replaced with columnar epithelium
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what area is sampled for pap smear?
- the Transformation zone
- it is created by the squamocolumnar junction migrating towards the os
- This area is at risk for later dysplasia
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what are the ovaries shaped like?
average size?
are they palpable?
- Almond-shaped structures
- Varies in side, averages 3.5 x 2 x 1.5 cm from adulthood thru menopause
- Are palpable on pelvic exam in ab ½ women during reproductive years
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2 primary function of the ovaries:
- production of the ova
- secretion of hormones (estrogen, progesterone, & testosterone)
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what is leucorrhea?
- physiological increased secretions (usually just before menarche)
- Normal change
- Can worry girls and their mothers
- Coincides with ovulation
- Accompanies sexual arousal
- Normal discharge must be differentiated from
- infectious processes
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Tanner assessment of sexual maturity in girls depends on:
- internal exam
- growth of pubic hair
- dev of breasts
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Lymph from vulva and lower vagina drain into:
inguinal nodes
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lymph from internal genitalia (including upper vagina) flows into:
- pelvic & abd lymph nodes
- not palpable
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what are the common concerns?
- Menarche, menstruation, menopause, postmenopausal bleeding
- Pregnancy
- Vulvovaginal symptoms
- Sexual preference and sexual response
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menarche of girls in the US usually begins:
9-16 y
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menopause is usually btwn:
48-55 yrs
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interval betwn periods range from:
24-32 days
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period flow lasts from:
3-7 days
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age of menarche depends on:
- genetics
- socioeconomic status
- nutrition
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Primary dysmenorrhea:
results from:
- s/ an organic cause
- Results from ↑ prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels ↓
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Secondary dysmenorrhea:
causes include:
- c/ an organic cause
- Causes include endometriosis, adenomyosis, pelvic inflammatory disease, and endometrial polyps
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Criteria for dx of PMS:
- S & S in the 5 days prior to menses for at least 3 consec cycles
- Cessations of S & S c/in 4 days after onset of menses
- Interference c/ daily activities
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primary amenorrhea:
failure of periods to initiate
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secondary amenorrhea:
cessation of periods after they have been established
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causes of amenorrhea
- Preg, lactation, & menopause
- Other causes include: low body wt (from any cause- stress, malnutrition, anorexia nervosa, chronic illness) hypothalamic- pituitary- ovarian dysfunction
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causes of abnormal uterine bleeding
Causes vary by age and include: preg, cervical or vag infection or CA, cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, & hormonal contraception or replacement therapy
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polymenorrhea
fewer than 21-d intervals btwn menses
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oligomenorrhea
infreq bleeding
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menorrhagia
- excessive flow
- "its raining men"
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metorrhagia:
- intermenstrual bleeding
- -bleeding btwn expected periods
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postcoidal bleeding suggests:
- Suggests cervical polyps or CA
- In older adults, atrophic vaginitis
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menopause follows a period of:
of fluctuation in pituitary secretion of FSH and LH and ovarian function
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what drugs can help with menopause?
- Estrogen replacements relieves symptoms, but ↑ risk of thrombosis
- Antidepressants and alpha-blockers can be helpful
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what are the vasomotor symptoms?
- hot flashes
- flushing
- sweating or night sweats
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symptoms of menopause?
- Vaginal dryness
- Dyspareunia (painful intercourse)
- Hair loss, mild hirsutism as the androgen-to-estrogen ratio ↑
- Urinary symptoms may occur s/ infection bc of atrophy of urethra and urinary trigone
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what is the GP notation?
- Gravida: total # of pregnancies
- Para: outcomes of pregnancies
- F (fullterm, 37 wks)
- P (premature, 20-37 wks)
- A (abortions, <20 wks)
- L (living children)
- Abortions= spontaneous & elective
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symptoms of pregnancy
- Tenderness, tingling, increased size of breasts, urinary freq, N/V, easy fatigability
- 20 wks: Feelings that baby is moving
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what are the MC vulvovaginal symptoms?
- Vaginal discharge (Note: amt, color, consistency, & odor) Ask ab local sores or lumps in vulvar area… painful?
- Local itching
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vaginismus
involuntary spasm of the muscles surrounding the vaginal orifice that makes penetration painful or impossible
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causes of vaginismus
Superficial pain?
deeper pain?
- physical or psychological
- Superficial pain: suggests local inflammation, atrophic vaginitis, or inadequate lubrication
- Deeper pain: suggests pelvic disorders or pressure on a normal ovary
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probs with sex?
Lack desire, failure to become aroused, failure to obtain adequate lubrication, failure to reach orgasm.
causes??
Causes include: lack of estrogen, medical illness, & psychiatric conditions. MCly related to situational or psychosocial factors
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2 primary types of cervical CA:
- 80-90% are squamous cell carcinomas
- 10-20% are adenocarcinomas in glandular cells
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MC STD in the US
HPV infection
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70% of cervical CA are caused by:
HPV 16 & 18
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90% of genital warts are caused by?
HPV 6 & 11
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Pap guidelines:
1st screen:
- 3 y after 1st sex OR
- by 21 y; whichever is 1st
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pap guidelines:
up to age 30:
- Screen annually c/ regular test OR
- q 2 y c/ liquid-based cytology test
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pap guidelines
30 & older:
- Q 2-3 y if 3 consec annual cytology results are negative OR
- If combined cytology testing & high-risk HPV testing results are negative
- Screen more freq if (+) pap OR
- (+) high-risk HPV test results, HIV infection, immunosuppressed, DES exposure in utero, prior Hx of cervical CA
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epithelial cell abnorms:
- Squamous cells
- Glandular cells (Atypical endocervical cells or atypical endometrial cells)
- Other malignant neoplasms (Sarcomas or lymphomas)
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HVP vac is recommended for?
what does it target?
reduces risk for?
what does it prevent?
- girls 11-26 yo
- targets 6, 11, 16, 18
- reduce risk of cervical CA & anogenital dz
- Almost 100% effective preventing 16 & 18-related cervical intraepithelial neoplasia grade 2 or 3 and adenocarcimona in situ in those c/ no prior exposure to those types
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strongest RF of ovarian CA
- FH of breast or ovarian CA
- BRCA1 and BRCA2 mutations
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MC reported STD in the US and MC STD in XX
Chlamydia trachomatis
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indications for pelvic exam:
Menstrual abnormalities, unexplained abd pain, vaginal discharge, Rx of contraceptives, sexually active, pts desire for assessment
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delayed puberty causes:
- Often familial or related to chronic illness
- Abnoms in hypothalamus, ant pituitary gland, or ovaries
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Excoriations (itchy, small,red maculopapules) can be from=
pediculosis pubis
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cystocele:
- is a bulge of the upper two thirds of the anterior vaginal wall, together with the bladder above it
- it results from weakened supporting tissues
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rectocele
herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia
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yellowish d/c on endocervical swab suggests mucopurulent cervicitis, commonly caused by:
Chlamydia trachomatis, Neisseria gonorrhea, or herpes simplex
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what should pts be advised before exam?
pt should avoid intercourse, use of douches, tampons, contraceptive foams or creams, vaginal suppositories for 48 h before exam. And should not be menstruating
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options for obtaining pap:
- cervical scrape
- endocervical brush
- cervical broom
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Chlamydia infection is linked to:
- urethritis, cervicitis, pelvic inflammatory dz, ectopic preg, infertility, & chronic pelvic pain
- Rf: age <25, multiple partners, prior hx of STDs
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pain on movement of the cervix, together c/ adnexal tenderness
PID
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uterine enlargement can be from:
preg, uterine myomas, or malignancy
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nodules on the uterine surface=
myomas
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Adnexal masses can arise from:
tubo-ovarian abscess, salpingitis or inflammation of the fallopian tubes from PID, or ectopic preg
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Pelvic pain, bloating, ↑ abd size, and urinary tract symptoms are more common in:
ovarian CA
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3-5 yrs after menopause ovaries are:
- atrophic and usually nonpalpable.
- In postmenopausal XX, investigate a palpable ovary for ovarian cyst or ovarian CA
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impaired strength of pelvic muscles can be from:
from age, vaginal deliveries, or neurological deficits, or from urinary stress incontinence
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3 purposes for rectovaginal exam:
- To palpate retroverted uterus, uterosacral ligaments, cul-de-sac, and adnexao
- To screen for colorectal CA in XX 50 yrs or oldero
- To assess pelvic pathology
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MC hernia that occurs in the XX groin
Indirect inguinal hernia
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Urethritis may arise from:
Infection c/ Chlamydia trachomatis or Neisseria gonorrhea
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small, red benign tumor visible at the posterior part of the urethral meatus
menopausal women
no symptoms
urethral caruncle
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slightly raised, round, or oval, flat-topped papules covered by a gray exudate
secondar syphilis (condyloma latum)
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types of cervical lacerations from delivery
- bilateral transverse
- stellate
- unilateral transverse
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