Chapter VI - Female Reproduction

Physical Assessment

The physical assessment starts with an evaluation inquiring about past gynecologic history which includes questions about menarche (age of onset of menstruation), frequency of cycle, regularity, duration of periods, amount of flow, and the last menstrual period date. She is then inquired regarding onset of pain or cramps during periods, heavy flow, and bleeding be­tween periods, or bleeding after menopause. Last but not the least is inquiry about patient's sexual activity, use of birth control pills and other medications, use of hormones, or other contraceptive methods. The patient may also be asked questions regarding her past reproduc­tive history like number of pregnancies, abor­tions, stillbirths, C-section, normal deliveries, or any complications during pregnancy. The physician inquires about pelvic pain, vaginal discharge, any infections, itching, rashes, dis­charge from nipples. The subject is also ques­tioned about family history of gynecologic problems and any surgeries undergone in the past for gynecologic illnesses.

Thorough examination includes an examination of the external and internal genital organs as well as the breasts. The breasts are examined for irregularities, size, and shape, and then palpated for abnormal masses, lumps, tight­ened skin, and tenderness. The physician then performs pelvic examination, which is performed with the subject being placed in lithotomy position. The examining tables have heel or knee stirrups, which help the subject to maintain or hold this position. The physician first examines the external genital area, notes the distribution of hair in that area or any other abnormalities, lesions, inflammation, swelling, discoloration, and discharge. The examiner inspects the urinary meatus, Bartholin glands, and Skene glands by palpating them.

After inspecting the external genitalia, the physician then examines the deeper areas of vagina and cervix with the help of a lubricated speculum that spreads the walls of vagina apart for good visual examination. The cer­vix can be examined closely by passing a col­poscope to look for signs of infection or cancerous growths. When this is over, a bi­manual pelvic examination is performed. Herein, the exam­iner inserts the lubricated index and middle fingers of one gloved hand in to the vagina and places the other hand on the lower abdomen above the pubic bone. Between the two hands, the examiner can assess the uterus for its shape, firmness, position, size, and amount of tenderness, and can detect any masses if present. The physician then performs a rectovaginal exam by inserting an index finger in the va­gina and the middle finger in the rectum and examines the back wall of vagina for its thick­ness, masses, or abnormal growths.

Pathology

Ectopic pregnancy/tubal pregnancy
An ectopic or tubal pregnancy occurs when the fertilized egg becomes implanted in one of the fallopian tubes and develops there (or elsewhere in the pelvic cavity) rather than the uterus (See Fig. 11.3). Tubal pregnancy is a leading cause of maternal death during the first trimester. As the embryo grows in­side the fallopian tubes, it stretches it. If left untreated or unnoticed, it can result in rup­ture of the tube and sudden and massive bleeding. If the tube ruptures, immediate, surgery is necessary to save the woman's life.

Endometriosis
Endometriosis is a female reproductive system's disorder in which the endometrial tissue that normally lines the uterus, grows in other parts of the body, most likely on the pelvic area, including fallopian tubes, ova­ries, outer surface of the uterus, colon, and other pelvic structures (See Fig. 11.4). The endometrial tissue responds to hormonal changes that occur during the menstrual cycle in the manner the endometrium itself does. During the menstruation just like en­dometrium, this endometrial tissue also breaks and bleeds but finds no outlet. As a result, the tissue becomes inflamed and swollen and results in intense cramps during latter days of menstruation. There is no cure for endometriosis but its growth can be slowed down by hormonal treatments.

Genital herpes
Genital herpes is a sexually transmitted dis­ease in which red blister-like sores develop in the genital area and anorectal area. In women, these sores may be present in the vagina, cervix, and urethra. It is caused by herpes simplex virus type 2. In men, lesions appear on the glans penis, foreskin, or penile shaft.

Pelvic inflammatory disease
Pelvic inflammatory disease is a general term for the infection of woman's internal repro­ductive organs, which may be acute, sub­acute, or chronic in nature. It may include endometriosis or inflammation of lining or uterus, myometritis or inflammation of uterine muscles, cervicitis or inflammation of the cervix, oophoritis or inflammation of ovaries, or salpingitis or inflammation of fallopian tubes. Most pelvic inflammatory diseases are sexually transmitted. Gonorrhea and chlamy­dia are two very common causes underlying pelvic inflammatory disease. Symptoms of acute pelvic inflan1matory disease include severe abdominal pain, tenderness and high fever. Pelvic inflammatory disease, if left un­treated, may lead to infertility. It also increases chances of ectopic pregnancy in females.

Premenstrual syndrome
Premenstrual syndrome is collection of nu­merous physical and psychological (emo­tional) symptoms associated with menstrual cycle/menstruation. Premenstrual symptoms usually begin a week before menstruation and disappear as soon as it starts. There are myriad manifestations of premenstrual syn­drome. Common physical manifestations of premenstrual syndrome may include swell­ing of the breasts and tenderness, headaches, backaches, cramps, dizziness, digestive dis­orders, joint and muscle pain, flare up of acne, and palpitations. The psychologic symptoms may include mood swings, feelings of anxiety, irritability, depression, fatigue, foods cravings, insomnia aggressive behavior, lethargy, and panic attacks.

Toxic shock syndrome
Toxic shock syndrome is a rare but fatal dis­ease caused by toxins produced by a strain of Staphylococcus aureus bacteria. Maxi­mum percentages of those affected by toxic shock syndrome are women who use vaginal tampons and vaginal sponges. A painless red rash develops, starting on the trunk and quickly spreading to legs, arms, soles, and palms, followed a week or two later by peel­ing of skin, especially on the soles and palms. If left untreated, this disease can be fatal.

Vaginitis
Inflammation of vagina and often vulva as well is called vaginitis. Most common symp­toms include intense itching, vaginal discharge which varies in color, odor, and consistency, depending upon the cause. It may also lead to painful intercourse or urination. It can be caused by protozoa Tri­chomonas vaginalis, which causes a profuse, frothy discharge with an unpleasant odor; by Gardnerella vaginalis bacterium, which pro­duces blood-streaked, white or yellow dis­charge with fishy odor; or by Candida albicans which produces a cheesy discharge with yeast-like odor.