1. Gynecology

2. External Genitalia

3. External Genitalia (Vulva) n Mons Pubis n Labia –majora –minora n Perineum n Prepuce n Clitoris n Uretheral opening (meatus) n Vestibule –Skene’s glands –Bartholin’s glands n Vaginal entrance (Introitus) n Anus

4. Female Reproductive System

5. Internal Reproductive Organs n Vagina n Cervix n Uterus –Corpus –Fundus n Fallopian Tubes n Ovary

6. Female Reproductive System

7. Female Reproductive Organs n Endometrium –Mucosal n Myometrium –Circulation –Smooth Muscles n Perimetrium –Serous –Fundus & 1/2 Corpus

8. Menstrual Cycle n Menarche –usually between 9 and 13 –initially irregular n Normal –usually 28 day n Hormones –FSH –LH –Estrogen –Progesterone n Menopause –45 - 55 years old

10. Menstrual Cycle n Pituitary produces follicle stimulation hormone (FSH) n FSH stimulates ovarian follicle maturation n Follicles mature, release estrogen n Estrogen stimulates thickening of endometrium n Estrogen acts on pituitary to decrease FSH release n FSH levels begin to fall, LH levels rise

11. Menstrual Cycle n After ovulation, luteinizing hormone (LH) acts on remains of follicle n Promotes corpus luteum formation n Corpus luteum produces progesterone n Progesterone stabilizes, maintains uterine lining

12. Menstrual Cycle n If ovum is not fertilized –Corpus luteum dies –Progesterone levels drop –Endometrium deteriorates, sloughs –Menstrual period occurs

13. Menstrual Cycle n 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

14. Menstrual Cycle

15. Pelvic Inflammatory Disease n Pathophysiology –Acute or chronic infection involving female reproductive tract, associated structures: Cervix (cervicitis) Uterus (endometritis) Fallopian tubes (salpingitis) Ovaries (oophoritis) Pelvic peritoneum

16. PID n Pathophysiology –Causative organisms include: Gonorrhea Chlamydia E. coli, other gram negative bacilli Gram positive cocci Mycoplasma Viruses

17. PID n Most cases sexually transmitted n Risk factors include: –Previous infection –Multiple partners –Adolescence –Presence of IUD

18. PID n 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

19. PID n History –Pain worsened by intercourse (Dyspareunia) –Associated symptoms Fever Chills Nausea, vomiting Vaginal discharge Erratic periods

20. PID n Physical Exam –Patient appears ill –Fever usually present –Tender abdomen –Rebound tenderness –Walks bent forward holding abdomen

21. PID n Management –Position of comfort –General supportive care (oxygen, IV) –Transport n May be at risk for rupture of pyosalpinx or tubo-ovarian abscess

22. Dysfunctional Uterine Bleeding n Pathophysiology –Usually younger women –Ovum not released from ovary regularly –Without ovum release/corpus luteum formation, menstrual cycle is not completed

23. Dysfunctional Uterine Bleeding n Pathophysiology –Endometrium continues to thicken –Outgrows blood supply, breaks down –Massive vaginal bleeding results

24. Dysfunctional Uterine Bleeding n History –History of “missed”, irregular periods –Continuous, profuse vaginal bleeding possibly persisting > 8 days

25. Dysfunctional Uterine Bleeding n Physical Exam –Signs/symptoms of hypovolemic shock –Positive tilt test –Passage of tissue with vaginal bleeding

26. Dysfunctional Uterine Bleeding n Management –Do not pack vagina to stop bleeding –High concentration oxygen –IV LR –MAST if indicated

27. Endometriosis n Presence of normal endometrium at ectopic locations n Signs, symptoms –Pelvic pain –Dysmenorrhea –Pain on intercourse –Lower abdominal tenderness

28. Endometriosis n History –Painful intercourse –Painful menstruation –Painful bowel movements

29. Endometriosis n Rupture of endometrial masses may cause severe pain, internal hemorrhage n May require surgery n Long term management is gynecologic issue

30. Ruptured Ovarian Cyst n Ovarian cyst = Sac on ovary n Causes include –Growth of endometrial tissue in ovary –Hemorrhaging into mature corpus luteum –Over-distension of ovarian follicle

31. Ruptured Ovarian Cyst n Cysts rupture into peritoneal cavity –Peritonitis –Hemorrhage, shock

32. Ruptured Ovarian Cyst n Signs, symptoms –History of menstrual irregularities, chronic pelvic pain –Unilateral abdominal pain –Unilateral tenderness –Pallor, tachycardia, diaphoresis, hypotension

33. Ruptured Ovarian Cyst n Management –High concentration oxygen –IV LR –MAST if indicated –Rapid transport

34. Cystitis n Inflammation of the bladder n Usually bacterial n Occurs frequently n May lead to pyelonephritis

35. Cystitis n Assessment –Suprapubic tenderness –Frequent urination –Dysuria –Blood in urine

36. Cystitis n Management –Supportive care

37. Mittelschmertz n Pain at menstrual cycle midpoint n Caused by ovulation n Occurs on day 14 to 16 n Unilateral, mild to moderate n Lasts a day or less n Possible light vaginal spotting

38. Mittelschmertz n Management –Rule out more serious causes of pain –Analgesia may be required –Self-limiting problem –Can be confirmed by keeping calendar

39. Sexual Assault n Any sexual contact without consent n Legal rather than medical diagnosis n Seldom creates medical emergency n If medical emergency exists, usually is from trauma secondary to assault

40. Sexual Assault n 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

41. Sexual Assault n Physical Exam –Examine genitalia only if severe injury present –Avoid touching without permission –Explain procedures before proceeding –Maintain the patient’s modesty

42. Sexual Assault n Management –Priority to immediate life threats –Psychological support is important –Limit intervention to that needed for immediate problems –Protect patient’s privacy

43. Sexual Assault n 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

44. Sexual Assault n Management –May be preferable for female paramedic to attend patient –Honor patient’s wishes –Do not abandon patient at scene –Complete trip report carefully

45. Gynecological Assessment Abdominal Pain Bleeding

46. Gynecological PA Abdominal Pain + Female Gender = Gynecologic Problem Until Proven Otherwise

47. Gynecological PA n Abdominal pain –When was last period? –Was it normal? –Bleeding between periods? –Regularity?

48. Gynecological PA n Abdominal pain –Pregnant? Missed period? Urinary frequency? Breast enlargement or tenderness? N/V? –Contraception? What kind? –Vaginal discharge? Color, amount, odor

49. Gynecological PA n Abdominal Pain –Aggravation/Alleviation –OPQRST –Tenderness/masses at pain’s location? –Tilt test

50. Gynecological PA n Vaginal bleeding –More, less heavy than normal period? –Possibility of pregnancy? –Associated pain/tenderness? –Perform tilt test

51. Gynecological PA n Fever/Chills