Introduction to the Female Exam

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Introduction to the Female Exam

• Anatomy
• Pelvic Exam
• Hormonal cycles
• Uterine conditions
• Ovarian conditions
• Breast evaluations

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So, who should have a pelvic exam and
why?Annually for all women who are sexually
active, or as a baseline, women at the age of
21.
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Important issues related to this exam

• Cultural issues
• Patient modesty
• Anxiety about exam
• History of rape, molestation or abuse
• Office environment

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Office environment

• ALWAYS have another person in the room while
  examining female genital area or breasts.
• Explain what you are going to be doing, before
  you do each step/manuever
• Insure patient comfort, and modesty.

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Patient comfort/modesty

• Use gowns AND sterile drapes over pt legs
• Allow patient to wear socks, bra (if no breast
  exam is being done), sweater, etc.
• Foot of exam table does not face the door
• Door is clearly marked to avoid interruption
• Another person in the room all the time, taking
  notes or somehow attentive

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3 Parts to the Pelvic Exam

• 1. Observation and the speculum exam
• 2. Bimanual exam
• 3. Recto-Vaginal Exam (includes DRE)

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But first, we ask history, inspect and palpate.

• Pubic hair-triangle pattern
• Lymph nodes
• Orifices
• Palpate
• Urethral meatus-incontinence
• Labia
• Skenes, then Bartholins glands
• Perineum

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The Speculum Exam

• Performed prior to the bi-manual exam so as not
  to disturb the tissues/samples
• Performed without lubricant jelly
• Always inserted with the speculum blades warmed
  with warm water and closed
• Inserted at a 45 degree angle posteriorly

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Proper position of speculum
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Visual Observation of the Cervix

• Positionis it anteverted, deviated, etc
• The position of the cervix gives clues to the
  position of uterus
• Colorshould be flesh-colored, but ranges from
  pink to dark brown (blue or pale??)
• Surface characteristicscysts, erythema
• Discharge
• Size and shape of os

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Nulliparous cervix
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Multiparous cervix
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Everted cervix
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Nabothian cystsaka retention cysts
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The Papanicolaou Exam (Pap)

• Developed over 50 years ago by Dr. George
  Papanicolaou
• A minimum of two samples will be taken
• Cervical cells
• Vaginal secretion
• Other tests may be done to screen for STDs

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• What are the three most common STDs among women?
• HPV, Herpes, Chlamydia, (Now 10s of millions of
  existing cases)
• The Quad Cities has the highest incidences of
  STDs in Iowa
• In women, often no visible symptoms
• Protect Yourself!

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Whats the goal of a Pap Smear?

• The Pap smear evaluates the condition of the
  cervical cells (taken with cervical brush or
  spatula)
• SCREENS FOR CERVICAL CANCER
• Assessing transitional zone of the cervix

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Accuracy of the Pap Smear

• It is estimated that the Pap Smear has decreased
  the death rate due to cervical CA by 75
• False-positives range from 10 to 40
• False-negatives range from 1 to 15
• (This is good)

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Vaginal Secretion Samples

• In addition to the cell sample, additional
  information can be gained from the surrounding
  secretions
• Sampling methods are dependent upon the goal of
  the screening

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Bacterial Vaginosisaka Vulvovaginitis

• General description for anything that causes
  symptomatic discharge (an irritant)
• May be due to bacteria, viruses, fungi, or
  protozoans
• Patient may talk to you about vaginal or vulvar
  itching, burning, or change in color, texture or
  odor of discharge

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The Bimanual Exam

• The bimanual exam is the second part of a
  complete pelvic exam
• Necessary to evaluate the cervix, uterus, and
  adenexal regions (ovaries, fallopian tubes,
  surrounding areas)
• Move the cervix to assess for PID/Endometriosis
• Important even if patient is not sexually active

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Recto-Vaginal Exam DRE

• The Recto-Vaginal exam is the 3rd and final part
  of the pelvic exam
• May help evaluate the posterior aspect of the
  uterus (esp. if retroverted)
• Allows exam of rectal walls (initial screen for
  colo-rectal cancer or polyps)

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Uterine Fibroids

• AKA myoma, leiomyoma, fibroma
• Very, very common (40 of women gt 40)
• The most common tumor of the pelvis
• The most common reason for a hysterectomy
• 33 of 600,000/yr.
• Benign, benign, benign!

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Risk Factors

• Nulliparity or delayed childbearing
• African American women have 2-3 times the
  incidence

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Locations
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Uterine Fibroids Symptoms

• Heavy menstrual bleeding
• Abdominal distortion
• Pelvic pressure
• Low back pain dyspareunia
• Infertility
• Frequent urination
• Constipation
• Miscarriage or premature labor

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Plain Film FindingsCauliflower-like
radio-opaque mass seen in the pelvic cavity, in
the area of the uterus.
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Is it any wonder problems include low back pain,
urinary frequency, constipation, infertility?
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Treatment Options(from least to most invasive)

• Wait and see
• Drug therapy (GnRH agonists)
• Uterine Artery Embolization (UAE)
• Myomectomy
• Hysterectomy

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Pelvic ArteriogramUsed to identify blood vessels
feeding the myoma.
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Polyvinyl particles block blood flow
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Endometriosis

• Endoinner metrlayer osiscondition
• Normal endometrium found in abnormal places
• Therefore, ectopic tissue responds to hormone
  levels just like the inner layer of the uterus
• How?
• Retrograde menstrual flow, fallopian tubes,
  abdomen
• Lymphatic or circulatory systems cause spread

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Risk Factors

• Young age 10-15 of women ages 25 to 44 have
  endometriosis
• Family History (6 - 12 of cases)
• Nuliparity or delayed childbearing
• Asians and Caucasians are at highest risk

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When?

• Onset of endometriosis is at onset of menses
• Delay in seeking care 4.67 years
• Delay in diagnosis 4.61 years
• Delay for ages 15-19 years is 8.3 years
• Symptoms confused with typical dysmenorrhea or
  UTIs
• 1/3 of women say doctor took symptoms not at all
  seriously and 1/4 said not very seriously

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Signs and Symptoms

• Pain, pain, pain (low back and pelvic)
• Pelvic mass
• Alterations of menses
• Dysmenorrhea (pattern pain just prior to
  menses)
• Infertility
• Dyspareunia
• Pain with defecation, urination

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Pattern of Menstruation

• Women with endometriosis have
• earlier onset of menses
• regular cycles
• shorter intervals between periods (less than 27
  days)
• more severe menstrual cramps
• prolonged menstrual flow (gt 1 week)

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What do the lesions look like?

• Endometrial deposits can occur anywhere in pelvis
• Ovarymost common (75) an ideal site for growth
• Posterior cul-de-sac70
• Between the uterus and bowel35
• Uterosacral ligament30
• Ureters
• Uterus
• Bowel
• Also known to occur on appendix, gall bladder,
  stomach, spleen, liver, lung

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Red Endometrial Lesions
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Endometrial Deposits on Appendix
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Complications

• Rememberthis normal uterine tissue in an
  abnormal location responds to fluctuations in
  hormone levels just as the rest of the uterus.
  So
• Bleeding lesions inflammatory
  response
• fibrin deposition
  adhesion formation
• distortion of the peritoneal surfaces

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Peritoneal AdhesionsAdhesions, caused by
inflammation around site of endometriosis, cause
uterus and cervix to be fixed, and the cervix
is very painful upon movement (during female
exam, and during intercourse).
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Confirming the Diagnosis

• Suspected by case history
• Visible lesions on the vulva or cervix
• Red, brown, black (remembermay bleed)
• Speculum exam (shotty nodules)

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Definitive Diagnosis

• The definitive diagnosis can only be made by
  direct visualization of the lesions
• Presently, confirmed by laparoscopy

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Treatment Options

• Keep in mind that these patients typically suffer
  a prolonged course of multiple therapies/surgeries
  
• Leave it alone
• Drug therapy
• Laparotomy
• Hysterectomy
• Child-bearing (or pseudo-pregnancy conditions)

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FAQs

• How successful is laparotomy? 70-90 pain
• Does it recur after treatment? 10-20 within 3
  yrs
• Can tubal ligation help? Theoretically
• Does intercourse during menses risks? No
• Does use of tampons risks? No
• Does early pregnancy protect against it? Maybe
• C-sections and endometriosis? A possibility

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Infertility and Endometriosis?

• Peritoneal fluid normally acts as a lubricant.
• Endometriosis causes changes in the volume and
  cellular content of the peritoneal fluid.
• Fluid level is increased
• Leukocytes are increased
• Prostaglandin levels are increased
• Enzyme levels are increased
• These all cause a localized inflammatory reaction
  around the lesions
• The peritoneal fluid can then act as a toxin to
  the embryo and/or can alter the normal function
  of the ovaries and fallopian tubes.

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www.bioscience.org/books/endomet/end34-65.htm

• Great website for FAQs of endometriosis

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Other Pelvic Conditions that Deserve Your
Attention

• Uterine sarcoma (endometrial carcinoma)
• Cervical carcinoma
• Ovarian carcinoma
• Hint I often ask about risk factors and CA
• Ovarian cysts
• Uterine, vaginal prolapse