Transcript No Slide Title

Gynecology
By
Donald G. Hudson, D.O., FACEP/ACOEP
External Genitalia
External Genitalia (Vulva)
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Mons Pubis
Labia
– majora
– minora
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Perineum
Prepuce
Clitoris
Uretheral opening (meatus)
Vestibule
– Skene’s glands
– Bartholin’s glands
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Vaginal entrance (Introitus)
Anus
Female Reproductive System
Internal Reproductive Organs
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Vagina
Cervix
Uterus
– Corpus
– Fundus
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Fallopian Tubes
Ovary
Female Reproductive System
Female Reproductive Organs
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Endometrium
– Mucosal
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Myometrium
– Circulation
– Smooth Muscles
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Perimetrium
– Serous
– Fundus & 1/2 Corpus
Menstrual Cycle
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Menarche
– usually between 9 and 13
– initially irregular
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Normal
– usually 28 day
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Hormones
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FSH
LH
Estrogen
Progesterone
Menopause
– 45 - 55 years old
Menstrual Cycle
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Pituitary produces follicle stimulation
hormone (FSH)
FSH stimulates ovarian follicle maturation
Follicles mature, release estrogen
Estrogen stimulates thickening of
endometrium
Estrogen acts on pituitary to decrease FSH
release
FSH levels begin to fall, LH levels rise
Menstrual Cycle
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After ovulation, luteinizing hormone (LH) acts
on remains of follicle
Promotes corpus luteum formation
Corpus luteum produces progesterone
Progesterone stabilizes, maintains uterine
lining
Menstrual Cycle
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If ovum is not fertilized
– Corpus luteum dies
– Progesterone levels drop
– Endometrium deteriorates, sloughs
– Menstrual period occurs
Menstrual Cycle
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If ovum is fertilized
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Zygote implants in endometrium
Human chorionic gonadotropin (HCG) released
HCG sustains corpus luteum
Corpus luteum produces progesterone
Endometrium remains stable
– Pregnancy continues
Menstrual Cycle
Pelvic Inflammatory Disease
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Pathophysiology
– Acute or chronic infection involving female
reproductive tract, associated structures:
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Cervix (cervicitis)
Uterus (endometritis)
Fallopian tubes (salpingitis)
Ovaries (oophoritis)
Pelvic peritoneum
PID
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Pathophysiology
– Causative organisms include:
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Gonorrhea
Chlamydia
E. coli, other gram negative bacilli
Gram positive cocci
Mycoplasma
Viruses
PID
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Most cases sexually transmitted
Risk factors include:
– Previous infection
– Multiple partners
– Adolescence
– Presence of IUD
PID
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History
– Moderate to severe diffuse lower
abdominal pain
– May localize to one quadrant or radiate to
shoulders
– Gradual onset over 2-3 days beginning 1 2 weeks after last period
PID
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History
– Pain worsened by intercourse
(Dyspareunia)
– Associated symptoms
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Fever
Chills
Nausea, vomiting
Vaginal discharge
Erratic periods
PID
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Physical Exam
– Patient appears ill
– Fever usually present
– Tender abdomen
– Rebound tenderness
– Walks bent forward holding abdomen
PID
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Management
– Position of comfort
– General supportive care (oxygen, IV)
– Transport
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May be at risk for rupture of pyosalpinx
or tubo-ovarian abscess
Dysfunctional Uterine Bleeding
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Pathophysiology
– Usually younger women
– Ovum not released from ovary regularly
– Without ovum release/corpus luteum
formation, menstrual cycle is not
completed
Dysfunctional Uterine Bleeding
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Pathophysiology
– Endometrium continues to thicken
– Outgrows blood supply, breaks down
– Massive vaginal bleeding results
Dysfunctional Uterine Bleeding
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History
– History of “missed”, irregular periods
– Continuous, profuse vaginal bleeding
possibly persisting > 8 days
Dysfunctional Uterine Bleeding
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Physical Exam
– Signs/symptoms of hypovolemic shock
– Positive tilt test
– Passage of tissue with vaginal bleeding
Dysfunctional Uterine Bleeding
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Management
– Do not pack vagina to stop bleeding
– High concentration oxygen
– IV LR
– MAST if indicated
Endometriosis
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Presence of normal endometrium at ectopic
locations
Signs, symptoms
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Pelvic pain
Dysmenorrhea
Pain on intercourse
Lower abdominal tenderness
Endometriosis
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History
– Painful intercourse
– Painful menstruation
– Painful bowel
movements
Endometriosis
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Rupture of endometrial masses may cause
severe pain, internal hemorrhage
May require surgery
Long term management is gynecologic issue
Ruptured Ovarian Cyst
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Ovarian cyst = Sac on
ovary
Causes include
– Growth of endometrial
tissue in ovary
– Hemorrhaging into
mature corpus luteum
– Over-distension of
ovarian follicle
Ruptured Ovarian Cyst
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Cysts rupture into peritoneal cavity
– Peritonitis
– Hemorrhage, shock
Ruptured Ovarian Cyst
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Signs, symptoms
– History of menstrual irregularities, chronic pelvic
pain
– Unilateral abdominal pain
– Unilateral tenderness
– Pallor, tachycardia, diaphoresis, hypotension
Ruptured Ovarian Cyst
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Management
– High concentration oxygen
– IV LR
– MAST if indicated
– Rapid transport
Cystitis
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Inflammation of the bladder
Usually bacterial
Occurs frequently
May lead to pyelonephritis
Cystitis
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Assessment
– Suprapubic tenderness
– Frequent urination
– Dysuria
– Blood in urine
Cystitis
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Management
– Supportive care
Mittelschmertz
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Pain at menstrual cycle midpoint
Caused by ovulation
Occurs on day 14 to 16
Unilateral, mild to moderate
Lasts a day or less
Possible light vaginal spotting
Mittelschmertz
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Management
– Rule out more serious causes of pain
– Analgesia may be required
– Self-limiting problem
– Can be confirmed by keeping calendar
Sexual Assault
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Any sexual contact without consent
Legal rather than medical diagnosis
Seldom creates medical emergency
If medical emergency exists, usually is
from trauma secondary to assault
Sexual Assault
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History
– Do not question patient regarding details of
event.
– Do not question patient about sexual
history or practices
– Avoid taking lengthy histories
– Do not ask questions which may lead to
guilt feelings
– Anticipate reactions such as anxiety,
withdrawal, denial, anger, fear
Sexual Assault
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Physical Exam
– Examine genitalia only if severe injury
present
– Avoid touching without permission
– Explain procedures before proceeding
– Maintain the patient’s modesty
Sexual Assault
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Management
– Priority to immediate life threats
– Psychological support is important
– Limit intervention to that needed for
immediate problems
– Protect patient’s privacy
Sexual Assault
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Crime Scene
– Handle evidence as little as possible
– Ask patient not to change, bathe, or
douche
– Do not allow patient to drink or brush their
teeth
– Do not clean wounds unless absolutely
necessary
Sexual Assault
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Management
– May be preferable for female paramedic to
attend patient
– Honor patient’s wishes
– Do not abandon patient at scene
– Complete trip report carefully
Gynecological Assessment
Abdominal Pain
Bleeding
Gynecological Physical Assessment
Abdominal Pain + Female Gender =
Gynecologic Problem
Until Proven Otherwise
Gynecological PA
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Abdominal pain
– When was last period?
– Was it normal?
– Bleeding between periods?
– Regularity?
Gynecological PA
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Abdominal pain
– Pregnant?
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Missed period?
Urinary frequency?
Breast enlargement or tenderness?
N/V?
– Contraception? What kind?
– Vaginal discharge?
• Color, amount, odor
Gynecological PA
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Abdominal Pain
– Aggravation/Alleviation
– OPQRST
– Tenderness/masses at pain’s location?
– Tilt test
Gynecological PA
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Vaginal bleeding
– More, less heavy than normal period?
– Possibility of pregnancy?
– Associated pain/tenderness?
– Perform tilt test
Gynecological
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Fever/Chills