Gynecology
Department of EMS Professions Temple College
External Genitalia
External Genitalia (Vulva)
Mons Pubis Labia
– majora – minora
Perineum Prepuce Clitoris Uretheral opening (meatus) Vestibule
– Skene’s glands – Bartholin’s glands
Vaginal entrance (Introitus) Anus
Female Reproductive System
Internal Reproductive Organs
Vagina Cervix
Uterus
– Corpus – Fundus
Fallopian Ovary
Tubes
Female Reproductive System
Female Reproductive Organs
Endometrium
– Mucosal
Myometrium
– Circulation – Smooth Muscles
Perimetrium
– Serous – Fundus & 1/2 Corpus
Menstrual Cycle
Menarche
– usually between 9 and 13 – initially irregular
Normal
– usually 28 day
Hormones
– – – – FSH LH Estrogen Progesterone
Menopause
– 45 - 55 years old
Menstrual Cycle
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
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
If
ovum is not fertilized
– Corpus luteum dies – Progesterone levels drop – Endometrium deteriorates, sloughs – Menstrual period occurs
Menstrual Cycle
If
ovum is fertilized
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
Pathophysiology
– Acute or chronic infection involving female reproductive tract, associated structures:
• • • • • Cervix (cervicitis) Uterus (endometritis) Fallopian tubes (salpingitis) Ovaries (oophoritis) Pelvic peritoneum
PID
Pathophysiology
– Causative organisms include:
• • • • • • Gonorrhea Chlamydia E. coli, other gram negative bacilli Gram positive cocci Mycoplasma Viruses
PID
cases sexually transmitted Risk factors include:
– Previous infection – Multiple partners – Adolescence – Presence of IUD
Most
PID
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
History
– Pain worsened by intercourse (Dyspareunia) – Associated symptoms
• • • • • Fever Chills Nausea, vomiting Vaginal discharge Erratic periods
PID
Physical
Exam
– Patient appears ill – Fever usually present – Tender abdomen – Rebound tenderness – Walks bent forward holding abdomen
PID
Management
– Position of comfort – General supportive care (oxygen, IV) – Transport
May
be at risk for rupture of pyosalpinx or tubo-ovarian abscess
Dysfunctional Uterine Bleeding
Pathophysiology
– Usually younger women – Ovum not released from ovary regularly – Without ovum release/corpus luteum formation, menstrual cycle is not completed
Dysfunctional Uterine Bleeding
Pathophysiology
– Endometrium continues to thicken – Outgrows blood supply, breaks down – Massive vaginal bleeding results
Dysfunctional Uterine Bleeding
History
– History of “missed”, irregular periods – Continuous, profuse vaginal bleeding possibly persisting > 8 days
Dysfunctional Uterine Bleeding
Physical
Exam
– Signs/symptoms of hypovolemic shock – Positive tilt test – Passage of tissue with vaginal bleeding
Dysfunctional Uterine Bleeding
Management
– Do not pack vagina to stop bleeding – High concentration oxygen – IV LR – MAST if indicated
Endometriosis
Presence of normal endometrium at ectopic locations Signs, symptoms
– – – –
Pelvic pain Dysmenorrhea Pain on intercourse Lower abdominal tenderness
Endometriosis
History
– Painful intercourse – Painful menstruation – Painful bowel movements
Endometriosis
Rupture of endometrial masses may cause severe pain, internal hemorrhage May require surgery Long term management is gynecologic issue
Ruptured Ovarian Cyst
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
Cysts
rupture into peritoneal cavity
– Peritonitis – Hemorrhage, shock
Ruptured Ovarian Cyst
Signs,
symptoms
– History of menstrual irregularities, chronic pelvic pain – Unilateral abdominal pain – Unilateral tenderness – Pallor, tachycardia, diaphoresis, hypotension
Ruptured Ovarian Cyst
Management
– High concentration oxygen – IV LR – MAST if indicated – Rapid transport
Cystitis
Inflammation
of the bladder Usually bacterial Occurs frequently May lead to pyelonephritis
Cystitis
Assessment
– Suprapubic tenderness – Frequent urination – Dysuria – Blood in urine
Cystitis
Management
– Supportive care
Mittelschmertz
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
Management
– Rule out more serious causes of pain – Analgesia may be required – Self-limiting problem – Can be confirmed by keeping calendar
Sexual Assault
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
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
Physical
Exam
– Examine genitalia only if severe injury present – Avoid touching without permission – Explain procedures before proceeding – Maintain the patient’s modesty
Sexual Assault
Management
– Priority to immediate life threats – Psychological support is important – Limit intervention to that needed for immediate problems – Protect patient’s privacy
Sexual Assault
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
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 PA
Abdominal Pain + Female Gender = Gynecologic Problem Until Proven Otherwise
Gynecological PA
Abdominal
pain
– When was last period? – Was it normal? – Bleeding between periods? – Regularity?
Gynecological PA
Abdominal
pain
– Pregnant?
• • • • Missed period? Urinary frequency? Breast enlargement or tenderness? N/V?
– Contraception? What kind? – Vaginal discharge?
• Color, amount, odor
Gynecological PA
Abdominal
Pain
– Aggravation/Alleviation – OPQRST – Tenderness/masses at pain’s location? – Tilt test
Gynecological PA
Vaginal
bleeding
– More, less heavy than normal period? – Possibility of pregnancy? – Associated pain/tenderness? – Perform tilt test
Gynecological PA
Fever/Chills