Gynecology

CHAPTER 39

Topics

 Anatomy and Physiology of the female reproductive system.

 Menstrual Cycle  Management of gynecological emergencies  Specific Gynecological emergency.

Introduction

 Gynecology: The branch of medicine that deals with the disease and routine physical care of the female reproductive system.

 Obstetrics is the branch of medicine that deals with the care of women throughout pregnancy.

 Both field were not studied openly until the 20 th century.

 Dr. Wert 1522 burned for curiosity  Women's suffrage movement (1848-1920)

Anatomy and Physiology

 Female reproductive System  Internal Genitalia  External Genitalia

External Genitalia

    Mons pubis   Round pad of adipose tissue over symphysis Coarse dark hair appears in early puberty Labia    Describes as the “lips” Surround and protect the vaginal opening and urethra Labia Majora and Labia Minora Clitoris   Just below the prepuce Erectile tissue becomes enlarged with blood upon “tactical” stimulation Urethra  Drains urinary bladder

External Genitalia

 Hymen  Membrane forms a border around vaginal orifice partially enclosing it.

 Imperforate hymen (completely covered) Perineum  Muscular tissue between anus and vaginal opening  About an inch in size

External Genitalia

Internal Genitalia

    Vagina     Lower portion of the birth canal Serves and a passage for menstrual flow Receptacle of penis during intercourse Bartholin glands Uterus  Site for fetal development Fallopian Tubes    About 4” long Transports egg from ovaries to uterus Fertilization on takes place here Ovaries    Primary female gonades Beginning point for reproduction Each contain about 200,000 ova within ovarian follicles

Internal Genitalia

Menstrual Cycle

 Cyclic and periodic discharge of blood, mucus and tissue.  Average cycle is 28 days  Phases of Menstrual Cycle  Proliferative Phase  Secretory Phase  Ischemic Phase  Menstrual Phase

Proliferative Phase

  The First two weeks of the Menstrual cycle  Thickening of uterine lining  Surge of Luteinizing hormone (LH)  At approximately day 14 ovulation takes place Once during every cycle a follicle reaches maturation  Ruptured follicle develops the corpus luteum  Corpus luteum will produce progesterone  Egg is moved through the fallopian tubes by cilia  If fertilized: implants into thickened lining of the uterus  If NOT fertilized: passes into uterine cavity and expelled

The Secretory Phase

 Referred to as Ovulation phases  Immediately surrounding ovulation  Uterine vascularity increases  If the egg is not fertilized  Estrogen levels drop sharply  Progesterogen levels dominate

The Ischemic Phase

 If fertilization does not occur, estrogen and progesterone levels drop levels drop.

 Breakdown of endometrium  Small vessels rupture  Endometrium becomes pale and ischemic

The Menstrual Phase

 The ischemic endometrium is shed  Discharge of blood, mucus and cellular debris  Average blood loss is Approximately 50ml  Last from 3-5 days  Varies from women to women  Absents should rise suspicion of Pregnancy in sexually active women between ages 12-55

Phases of the Menstrual Cycle

Life of the Menstrual Cycle

 Menarche  Female reaches child bearing age  Between Age 10-14  Depending genetics, socioeconomic factors, and health  Menopause  Woman has reached the end of her child bearing years  Typically begins between the ages of 40 and 50  Menstrual cycle becomes less frequent

Menopause

 Gradually decreasing production of estrogen and other hormones.

 Signs and Symptoms:  Copious diaphoresis  Hair loss  Hot flashes (accompanied tachycardia)  Dyspnea and vertigo  Muscle aches and pains  Susceptible to atherosclerosis, osteoporosis, and heart disease

Disorders of Menstrual Cycle

May be seen in pre-hospital setting A patient may call EMS because she perceives her condition to be an emergency.

 Provide Supportive Care

Disorders of Menstrual Cycle

 Premenstrual Syndrome (PMS)  Normally occurs 7 to 14 days before menstrual flow begins  Affects 1/3 of premenopausal women  Cluster of symptoms  Headache, cramping, emotional changes, breast pain, edema  Mittelschmerz  Abdominal pain and cramping 2 weeks before menses  Ovulation process  Nausea and blood spotting  Pain may switch sides

Disorders of Menstrual Cycle

 Dysmenorrhea  Severe pain during menstruation  Often causes severe cramping for first day or two  Primary and Secondary  Amenorrhea  Absents or cessation of menses  Most common cause is pregnancy

Gynecologic Emergencies

MEDICAL

Medical Gynecological Abdominal Pain

 Gynecological Abdominal Pain  Endometritis & Endometriosis  Pelvic Inflammatory Disease (PID)  Ruptured Ovarian Cyst  Cystitis  Mittelscherz  Toxic Shock Syndrome  Ectopic Pregnancy

Endometritis

 Endometritis  Inflammation of the endometrium  My be caused by STD, surgery, miscarriage or childbirth  Can be serious if not treated with antibiotics  Signs & Symptoms  Malaise  Fever  Vaginal bleeding  Pelvic pain  Constipation

Endometriosis

 Endometriosis  Occurs when endometrial tissue grows outside the uterus  Most commonly found in abdomen or pelvis  Can be found all over the body  Signs and Symptoms  Can range from zero to severe pain  Can cause painful and heavy mentration

Pelvic Inflammatory Disease

 PID       Infection of the female upper reproduction Chief complaint is abdominal pain General Starts during or after menses Bacterium, virus, or fungus Many women can have it for years Use of UID, multiple sex partners  Signs & Symptoms  Fever, Chills, Nausea, Vomiting   Abdominal Pain Sepsis

Ectopic Pregnancy

 Ectopic Pregnancy  A fertilized egg implanted outside the uterus  Most common in Fallopian tubes  Life threatening condition  Signs and Symptoms  Unilateral Abdominal pain  Late or missed menses  Vaginal Bleeding

Ectopic Pregnancy

 Predisposing Factors  History of PID  Endometriosis  Use of IUD  Past history of Ectopic Pregnancy  Treatment  Immediately Transport  Oxygen and IV therapy  No Vaginal Exam

Ovarian Cysts

 Ovarian Cysts  Fluid-Filled pockets on the ovary  Can mimic ectopic pregnancy  Blood can irritate the peritoneum  Signs and Symptoms  Irregular bleeding or delayed period  Achy Abdominal Pain  Nausea and Vomiting  Painful intercourse or during physical activity

Toxic Shock Syndrome

 Toxic Shock Syndrome  Form of septic shock caused by A strep  Associated with tampon use  Can affect men and women  Signs and Symptoms  Diarrhea, Nausea and Vomiting  Fever, Headache, Soar throat  Syncope  Skin Rash

Cystitis

 Cystitis  Urinary Bladder Infection  Bacteria enters via urethra  If untreated can lead to kidney infection  Signs and Symptoms  Abdominal Pain  Frequent urination  Low grade fever  Burning during urination

Gynecological Emergencies

TRAUMA

Traumatic Gynecological Emergencies

 Traumatic Gynecological Emergencies  Blunt Trauma  Penetrating Trauma  Foreign bodies inserted into Vagina  Abortion attempts  Sexual assault

Sexual Assault

 Rapid growing Crime   700,000 women sexually assaulted annually 60% never get reported   Most common form is rape Can cause serious physical and psychological implications  Management  Treat patient with psychological support       Attempt to preserve the evidence Do not cut clothing (place articles in paper bag) Persuade not to wash If possible allow female to treat patient Do not ask specific details Documentation

Sexual Assault

 Rape Drugs  GHB   Colorless liquid that causes amnesia Intoxication, Respiratory depression, Seizures, Coma    Ketamine    Veterinary Anesthetic Blocks pain without respiratory or circulatory compromise Loss of Coordination, Slurred Speech, Muscle Rigidity Ecstasy  Methamphetamine with hallucinogenic properties  Mental Confusion and Heightened sexual experience Rohypnol    Benzodiazepine with amnestic properties Impairs judgment and motor skills Hypotension, drowsiness, confusion, and memory loss

Sexual Assault Drugs

Assessment of Gynecological Patient

    Primary Assessment & Sample History  Vaginal Bleeding or Abdominal Pain  OPQRST  Associated Symptoms Last Menstrual Cycle  Was it normal?

Pregnancy History  Gravida, Parity, Abortion Contraceptive Use?

 What type and Regular use

Gravida and Parity

   Gravida   Number of Pregnancies in a women’s life Abortions Miscarriages Parity  Number if live births for a women (TPAL)     T pregnancy went to term P premature deliveries

A abortions (therapeutic or miscarriage) L live births

Women has three year old child?

Women had abortion at age 15, and now has a six year old child born premature?

Women has had four miscarriages, has two children, and currently pregnant? Women has twins, and is 30 weeks pregnant?

Contraceptives

Management of Gynecological Emergencies

 Supportive care  Do not pack dressings in Vagina  Vaginal Exam should not be performed unless massive hemorrhage is suspected  Identify any signs of shock

Conclusion

 Anatomy and Physiology of the Female Reproductive system.

 The Menstrual Cycle  Gynecological Emergencies Medical and Trauma  Assessment of Gynecological Patient  Management of Gynecological Patient

Name my STD…

 I have the most common type of STD  The Dr. says its caused by the Human Papillomavirus (HPV)  My boyfriend noticed growths on my genital area….

 What do I have?

The STD is????

 Genital Warts  If the virus transfers to the fetus, the child can develop laryngeal papillomatosis.

Name my STD…

 I have a very common STD, that is said to affect 2.8 million Americans each year…  I was having lower abdominal pain, lower back pain, running a fever, and bleeding between my periods…  The Dr. said it started as an infection of my cervix, and now because I didn’t treat it I have PID  What do I have?

The STD is????

 Chlamydia  Cause by bacterium Chlamydia trachomatics

Name my STD?

 This is sometimes called the great imitator  It manifests in three stages (primary, secondary, and late stage)  Primary I had a chancre sore  Secondary rash, headaches, weight loss, muscle aches, soar throat  Late attached my organs, loss of eye sight, dementia, still born  What do I have?

The STD is???

 Syphilis  20,000 to 30,000 cases each year

Name my STD

 One in four women in the US have what I have  It started off with small red bumps around my rectum and now they have turned into blisters.

 I have swollen glands in my groin area, and I have been muscle aches and pains.

 What do I have??

The STD is???

 Genital Herpes  Herpes simplex Virus  Type I effects mouth and lips  Type II genitals

Name my STD…

 I had sex with a guy I met on a blind date…  Now a month later, I’m having painful urination, I’m having a yellowish vaginal discharge that has a foul odor, and a little bit of abdominal pain.

 The Dr. says that I caught this just in time because this bacterium grows fast in warm moist areas of the reproductive tract. She said it could have progressed into PID if left untreated.

 What do I have?

The STD is????

 Gonorrhea  Caused by Neisseria gonorrhoeae