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What is Bartholin's Gland, where is it, and why do we care?
- Glands posterior to the vaginal opening which produce lubricating mucous.
- They can sometimes get infected or develope cysts. Both can be painful.
Why is a torn hymen not a great indicator of virginity?
Because heavy menses or use of tampons can also tear it.
What is Infibulation?
- Sewing the vaginal canal shut to prevent intercourse or pleasure during intercourse.
- It's a cultural thing.
Cultural Competence: Aging Woman
- Female’s hormonal milieu decreases rapidly in contrast with slow decline in aging male
- Uterus shrinks in size because of decreased myometrium
- Ovaries atrophy to 1 to 2 cm and are not palpable after menopause
- Uterus droops as sacral ligaments relax and pelvic musculature weakens
- Vagina becomes shorter, narrower, and less elastic because of increased connective tissue
- Externally, mons pubis looks smaller because fat pad atrophies
- Labia and clitoris gradually decrease in size
- Pubic hair becomes thin and sparse
Subject Health Hx questions concerning reproductive system
- Menstrual history: When was your first? When was your last normal? Can help if determining the possibility of pregnancy.
- Obstetric history: remember all the uncomfortable questions we four weeks ago? Review those.
- Menopause: Technically, is not menopause until 1 year after last normal period.
- Self-care behaviors: Shower? IUD? Partners? Pap smears? DES?
- Urinary symptoms
- Vaginal discharge
What is menorrhagia?
Unusually heavy bleeding.
What is Dyspareunia?
- Pain during intercourse. Can be caused by:
- Lack of estrogen--> dry, unelastic vaginal canal.
- Fear/reluctance to engage. Great time to ask about childhood/current abuse, peer pressure, educate about date rape, etc...
What is an STI?
- Sexually Transmitted Infection
- Changed from STD to avoid negative connotation with the word, "disease."
What are some additional questions for the aging woman?
- Postmenopausal bleeding? Always cancer until proven otherwise.
- Atrophic vaginitis: Lack of estrogen
- Uterine prolapse. Normal, may need to be meshed.
- Sexual satisfaction
Preping for a pelvic exam
- Lithotomy position (feet in stirrups) and draping
- Measures to enhance comfort during exam
- Mirror pelvic examination. Pt need need a mirror to follow along and to identify structures and/or areas of concern.
What do you need to condut a pelvic exam?
- Protective clothing for examiner
- Goose-necked lamp with a strong light
- Vaginal speculum of appropriate size/shape
- Large cotton-tipped applicatorsn (aka Proctoswabs)
- Materials for cytologic study (microscope slides)
- Water soluble lubricant (e.g., K-Y)
Do's and don'ts of the pelvic exam
- External genitalia—Palpation
- Skene’s glands
- Bartholin’s glands
- Support of pelvic musculature: less intrinsic support in children and aged.
- Have pt empty bladder before exam.
- Don't have the table facing the door.
What might you see when inspecting the cervix using a speculum?
- Nullparous, parous, and Nabothian cycsts are normal findings.
- Cervical eversion: Can be normal in children/teens women through their 20s. Important because HPV (which can cause cancer) can attach to exposed mucosa. After it involutes it becomes less likely.
Things to think about when obtaining a cervical smear/culture.
- Vaginal pool
- Cervical scrape
- Endocervical specimen
- Data to include for the
- laboratory: When was last menestral cycle? Any IUD, DC, BC, etc.
- Inspect vaginal wall
Abnormal findings of the external female genitalia.
- Pediculosis pubis (crab lice)
- Syphilitic chancre: Sore or blister. Can be open and painless. Is syphilitic so can travel to brain.
- Herpes simplex virus—type 2 (herpes genitalis): 1st outbreak always most painful.
- Red rash—contact dermatitis: Can be contracted via bubble bath, condoms, intercourse, etc.
- Human papillomavirus (HPV) warts: Four types are known to cause cancer, worst are 16-18. Cannot be seen with naked eye. Can also show up in throat mouth due to oral sex.
What is cystocele?
- Downward migration of the urinary bladder.
- Usually due to age and decreased musculature.
What is a uterine prolapse?
Downward migration of the uterus.
What is rectocele?
Downward migration of the rectum.
Abnormal findings of the cervix...
- Bluish cervix—cyanosis. Also called Chadwick's sign. Indicates pregnancy.
- Human papillomavirus (HPV, condylomata)
- Diethylstilbestrol (DES) syndrome
- Polyp: Protrusion from cervix, always benign. Must be biopsied (painless) to rule out carcinoma.
Abnormal findings of the Vulvovaginal orifice.
- Atrophic vaginitis: Lack of estrogen.
- Candidiasis (moniliasis): Yeast nfxn
- Trichomoniasis: sexually transmitted bacterial nfxn.
- Bacterial vaginosis: Fishy smell.
- Vulvodynia: Pain during sex @ vulva. Red-haired, fair skinned women most at risk.
- Vulvar Vestibulitis: Pain during sex @ vulva. Red-haired, fair skinned women most at risk.
Considerations for the older woman during a pelvic exam.
- To avoid painful examination, take care to lubricate instruments and examining hand adequately
- Use Pedersen speculum, rather than Graves, because its narrower, flatter blades are more comfortable in women with vaginal stenosis or dryness
- Menopause and resulting decrease in estrogen production cause numerous physical changes
- Older women may have special needs and will appreciate following plans of care