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Flashcards in Female Genitalia / Pap Deck (59):
1

Female anatomy image

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Types of specula

A. Pediatric Pederson speculum. This may be selected for child, adolescent, or virginal adult examination.

B. Graves speculum. This may be selected for examination of parous women with relaxed and collapsing vaginal walls.  (long as Pederson, but wider)

C. Pederson speculum. This may be selected for sexually active women with adequate vaginal wall tone. (regular size)

 

There are larger ones. Why use them – obesity. Vaginal walls collapse.

Also some better for virginal adults – like Pederson but skinnier

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Speculum procedure

  • Labia separated gently
  • Insert below urethral meatus
  • 45o angle
  • Downward pressure
  • Rotate blades, open
  • Visualize cx
  • Inspect (tighten blade)

Wet prep before cervical specimen

4

Ectropion 

endocervical cells protrude out through os into vaginal portion. Normal in pregnancy, on OCPs, in teens.

5

Os after vaginal birth

Smiling/slit

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Where to collect cervical specimen

specimen at os. Squamocolumnar junction & transformation zone

 

7

Nabothian cyst

Benign. Glandular secretion – mucous secreting columnar cells covered by squamous epithelium

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Bimanual exam procedure

  • Insert gloved index & middle finger
  • Lubricant vaginal hand
  • Palm up, watch thumb (clit)
  • Palpate vagina for masses
  • Cervical motion tenderness
  • Cervix – size, shape, consistency, mobility, position, dilatation
  • Palpate uterus with fingers
    • Abdominal hand pressing down
  • Position
  • Size, consistency, mobility, contour
  • Fibroids? Pregnant?
  • Ovaries – often not palpable
  • Pelvic tone (squeeze fingers – w/pelvic muscles)
  • Rectocele, cystocele (bear down)

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palpating uterine position

  • Sweep index finger up along anterior length
    • Anteverted – isthmus sweeps upward.
    • Retroverted, may feel flatter, may feel it going backward (harder to feel for when retroverted).
    • Obese – you may not feel – document this.

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HPV common types

  • Types 6,11: 90% genital warts
  • Types 16,18: 70% cx CA

11

Risk Factors Cervical CA

  • Onset intercourse ≤18
  • Multiple sexual partners
  • Partner with multiple partners
  • Smoking (2-3 x ↑ risk cx CA)
  • Immunosuppression (HIV, meds)
  • OCPs
    • Less barrier use, ↑ risk STIs, HPV

12

pap <21 

not recommended

13

Pap recommendatations 21-65

q 3 years cytology

14

HPV cotest recommendations

  • <30 not recommended
  • 30-65 q 5 years preferred 

15

HPV testing alone

not recommended

16

Pap >65yo

not indicated unless hx CIN2/3/AIS

17

pap post-hysterectomy

Cx removed – stop screening unless cervical CA
Cx present – continue per guidelines

18

Normal vaginal secretions, characteristics, pH

  • Leukhorrea
  • Changes – hormonal
  • Normal secretions
    • PH 3.8-4.5
    • No itching or irritation
    • Heterogeneous suspension
    • Clear or white
    • Consistency depends on cycle

19

Equipment for wet prep

  • Microscope
  • Slides, cover slips
  • Cotton-tipped applicator
  • 10% KOH solution
  • Saline
  • PH paper 3.0-5.5 range

20

Normal wet prep organisms

  • Lactobacilli – predominate normal d/c
  • Epithelial cells
  • WBCs
    • WBC: Epithelial  ≤ 1:1
  • RBCs

21

Wet prep: abnormal pathogens

Candida & trich: not seen 40% time
BV: often seen asymptomatic women

22

BV: discharge

  • Thin, homogenous milky white, gray or yellowish
  • Adherent, often increased
  • Odor (d/t amines)

23

BV pH

>4.5

24

BV dx

  • pH >4.5
  • + whiff test
  • Wet prep
    • No ↑ WBCs
    • No candida
    • + Clue cells

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BV bacteria

gardnerella vaginalis, bacteriodes, microplasma, reduced lactobacilli

26

Vaginitis: Trichomonas Vaginalis

What to expect on exam

  • D/C yellow-green frothy, adherent
  • Dysuria may be present
  • Pruritis may be present
  • Dyspareunia may be present
  • Strawberry spots cx

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Vaginitis: Trichomonas Vaginalis

What to expect on wet prep

  • pH > 4.5 often > 5.5
  • +/- “Whiff”
  • ↑ WBCs
  • Motile trichomonads

 

Can present similarly to BV, discharge different

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28

Candidal Vulvovaginitis

what to expect on exam

  • Intense burning, itching
  • May have dysuria (esp if scratching, adds to dysuria)
  • Often worst immediately preceding menses
  • Often have dyspareunia
  • Discharge white, cottage cheese-like

29

Candidal Vulvovaginitis

What to expect on wet prep

  • pH usually < 4.5
  • No amine odor
  • KOH (wet prep): Hyphae, spores

may see lots or very little on wet prep, not correspond to symptoms

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30

Condylomata Acuminata

  • Genital warts
  • They are bumps, st cauliflower like
  • Can be all over, to perianal
  • NO test

  • Treat w/acid, creams, laser, etc

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31

Herpes Simplex Virus

 

  • Mucocutaneous lesions
  • Herpes has many stages – this stage is easiest to do swab, get positive culture result
  • Earlier stages can show bumps/vesicles
  • Severe dysuria, pain
  • Can treat pain

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32

primary dysmenorrhea, causes

d/t increased PG production during luteal phase of menstrual cycle, when estrogen adn progesterone levels decline

33

secondary dysmenorrhea, causes

e.g., endometriosis, adenomyosis (endometeriosis in the muscular layers of uterus), PID, endometrial polyps

34

Primary amenorrhea

period never starts

35

secondary amenorrhea

cessation of periods - e.g., d/t pregnancy, lactation, menopause

low body weight (d/t malnutrition, anorexia, stress, chronic illness, hypothalamic pituitary ovarian dysfunction)

36

postcoital bleeding

cervical polyps or cancer, or, in older women, atrophic vaginitis

37

causes of postmenopausal bleeding

endometrial cancer, hormone replacement therapy, uterine & cervical polyps

38

amenorrhea followed by heavy bleeding suggests

threatened abortion or dysfunctional uterine bleeding related to lack of ovulation

39

gravida para notation

GPFPAL

#, outcome, Full term, Premature, Abortion, LIving

40

dyspareunia suggests

Superficial: local inflammation, atrophic vaginitis, inadequate lubrication

Deep pain: pelvic d/os or pressure on a normal ovary

41

Most common causes of acute pelvic pain

  1. PID
  2. Ruptured ovarian cyst
  3. appendicitis

always r/o ectopic 1st w/UPT, and consider mittelschmerz, tubo-ovarian abscess

42

mittelschmerz

pain from ovulation at midcycle

43

Endometriosis

causes chronic pelvic pain

from retrograde menstrual flow and extension of uterine lining outside uterus (50-60% of women w/pelvic pain)

44

Chronic pelvic pain, consider

endometriosis, adenosis, fibroids, red flag for hx sexual abuse

also consider pelvic floor spasm from myofscial pain w/trigger points on exam

45

reasons for delayed puberty

familial or r/t chronic illness

abnormal function of hypothalamus, anterior pituitary gland, ovaries

46

pediculosis pubis

lice/crabs

on exam: excoriations or itchy, small, red maculopapules. Nits or lice at bases of pubic hairs

47

why enlarged clitoris

in masculinizing conditions

48

menarche unduly late in relation to development of breasts, pubic hair, check for...

imperforate hymen

49

lateral displacement of cervix suggests

endometriosis involving uterosacral ligaments

50

yellowish discharge on endocervical swab suggests

mucopurulent cervicitis d/t chlamydia trachomatis, neisseria gonorrhoeae, or herpes simplex

51

Raised wartlike lesions occur in...

condylomata or cervical cancer

52

vaginitis w/discharge can result from...

candida, trichomonas vaginalis, bacterial vaginosis

53

rectovaginal mass could be...

stool or malignancy

Stool: can usually be dented by digital pressure. Do rectovaginal exam

54

cervical motion tenderness suggests

PID, ectopic pregnancy, appendicitis

55

ovaries 3-5 y after menopause

usually atrophic and nonpalpable. If palpable, investigate for ovarian cyst or cancer.

If pelvic pain bloating, increased abdominal size, urinary tract sx, more common in women w/ovarian cancer

56

most common hernia in women

indirect inguinal. Femoral is 2nd

57

lab eval trich

saline wet mount for trichomonads

58

lab eval candidal vaginitis

Potassium hydroxide (KOH) prep for branching hyphae of Candida

59

lab eval BV

  • saline wet mount for clue cells (epithelial cells w/stippled borders);
  • sniff for fishy odor after applying KOH (whiff test)
  • vaginal secretions pH >4.5