Gynecology 1.

3
History, PE, Prevention + Interaction of Diseases & Physiology
OUTLINE
History
A. Direct Observation
B. Components of Effective Communication
C. Essence of Gynecologic History
D. Essence of general Health History
II.
Physical Examination
A. Breast Examination
B. Abdominal Examination
C. Pelvic Examination
D. Annual Maintenance Visit
III.
Interaction of Diseases & Physiology
A. Pulmonary Disease
B. Inflammation
C. Gastrointestinal Disease
D. Hematologic and Thrombotic Disease
E. Mental Health issues
F. Antibiotics and OCPs
G. CNS
H. Cancer
I. Vascular and Hypertensive Disease
J. Renal Disease
K. Endocrine Disease
References:
1. Lecturers powerpoint.
2. Recording italicized
3. Comprehensive Gynecology 6th Edition [3]
HISTORY
DIRECT OBSERVATION (NONVERBAL CLUES)

Look at the patient before speaking

Five general impressions that can be transmitted by both facial

expression and posture:
1. Happiness self-assured and in good personal control; relaxed
face with smile
2. Apathy blank facial expression; posture may be slouched;
answers to verbal questions are short and unemotional
3. Fear tense expression; maybe perspiring
4. Anger narrowed eyes, furrowed brows; radiates aggression;
harsh and overreacts
5. Sadness slouched, eyes may glisten with tears, may not
make eye contact; most likely to be depressed
I.

COMPONENTS OF EFFECTIVE PHYSICIAN COMMUNICATION

Be culturally sensitive
o Know the patients culture and respect it
o Do not force upon your own beliefs
Establish rapport
Listen and respond to womens concern
Be non-judgmental
o Baka di nman talaga buntis, ma-puson lang tlaga.
Verbal & non-verbal cues
o Observe patient
Engage the women in discussion and treatment
o Include them in your treatment plan, give options
Convey comfort in discussing sensitive topics
o Not all women are comfortable in giving out their sexual
history
o Dra. Ingles employs a checklist before the actual check-up
Abandon stereotypes

Group #6 | Mata, Mateo, Matibag, Maximiano, Medrano

DR. INGLES
NOV. 14 , 2014

Check for understanding of your explanations

Support
ESSENCE OF GYNECOLOGIC HISTORY
Chief complaint
o Record the chief complaint as how the patient tells it
o A concise statement of the womans problem in her own
words [3]
History of present illness
o Most important to establish timeline
o How the patient sees her problem and should only be
interrupted for specific clarifications or to offer direction if she
digresses too far. [3]
Menstrual history
o Includes the age of menarche, LMP, duration of monthly cycle,
number of days the menses occurs, and regularity of the
menstrual cycle. [3]
Previous pregnancies
o Includes the year, duration and type of delivery, size, sex,
present condition of the baby and complications should be
noted. [3]
Gynecologic history
o Vaginal and pelvic infections

Ask if there is unusual discharge, unusual odor and

color. Were there any antibiotics given?

Type of infections, medications, and complications

experienced should be asked. [3]

A Pap smear screening history is also obtained. [3]

o Gynecologic surgical infections
o Urologic history

Urinary complaints (incontinence, urgency)

o Pelvic pain

Pelvic Inflammatory Disease

o Vaginal bleeding

Any vaginal bleeding not related to menses.[3]

Most patients come in not knowing their regular

menstrual cycle. Ask specific questions in order to
elicit proper info
Sexual & contraceptive history
o Important points[3]:

(Presence of) sexual activity

Types of relationships

Individual(s) involved

Satisfaction? Orgasmic? Desire/Interest?

Dyspareunia

Sexual Dysfunction: Partner and patient herself

ESSENCE OF GENERAL HEALTH HISTORY
General health history
o Includes hospitalizations, operations, specific illnesses,
medications, history of bleeding and smoking history. [3]
o Family history, social history, occupational and safety issues
are also included. [3]
Review of Systems
o Necessary to uncover symptoms from other areas that may
relate to reproduction and gynecologic problems or other
important medical conditions. [3]
Complete Physical Examination

Page 1 of 6

GYNECOLOGY 1.3
o

Done to gather information and to teach the woman

information about herself and her body. [3]

PHYSICAL EXAMINATION
BREAST EXAMINATION
Clinical breast examination done by a professional
o Should be done at least once a year, but women should do
their self-breast examination.
Examination of each breast with the patient sitting with arms raised,
and with the patient supine
Attention to the entire breast mound from midsternum to the posterior
axillary line and from the costal margin to the clavicle.
Inspection and palpation to assess (RED FLAGS):
o Skin flattening or dimpling, erythema and edema
o Nipple retraction, eczema, discharge
o Breast fixation breasts do not move because lymph nodes
are fixed to wall
o Tissue thickening
o Palpable masses not all masses are malignant, ex. of benign
changes: fibrocystic changes
Evaluation for axillary and supraclavicular lymphadenopathy
ABDOMINAL EXAMINATION
Do the abdominal examination in this order:
o Inspection if there is discoloration, asymmetry, scars,
Auscultation listen for bowel sounds
o Palpation palpated for organomegaly, masses, rigidity,
rebound
o Percussion differentiate fluid waves and outline sold organs
and masses
Not all abdominal enlargements are due to pregnancy, so examine
carefully.
Some questions to ask the patient: last menstrual period, last sexual
contact.

Image 1. Graves (left) and Pederson (right)

PELVIC EXAMINATION

The patient is lying supine on the examining table with her legs in
stirrups. (Dorsal lithotomy position)

PID is becoming a common problemnowadays.

The patient should be relaxed; describe the procedure being done to

the patient. [3]
o Inspection pattern of hair in mons pubis & labia majora,
redness, excoriations, discoloration, other lesions, scars;
specific structures: clitoris, labia; introitus (hymen); perineal
body
o Palpation length of urethra, Skenes glands, pus/mucus,
Bartholins glands, opening of vagina
o Speculum Examination
o Bimanual examination
o Rectovaginal and rectal examination
** If you are a male, always have a female accompanying you when doing a
pelvic exam on a gyne patient.

SPECULUM EXAMINATION
Steps [3]:
o Warm the speculum with the use of a warming device or
warm water, and then touched to the patients leg to
determine that she feels the temperature is appropriate and
comfortable.

Group #6 | Mata, Mateo, Matibag, Maximiano, Medrano

Insert by placing the transverse diameter of the blades in the

anteroposterior position, then push downward, pointing to
the rectum.
o Turn the speculum so that the transverse axis of the blades is
in the transverse axis of the vagina.
o Open the blades and visualize the cervix, lock the speculum.
Inspect the vagina and cervix
Vaginal epithelium should be noted for evidence of erythema or lesions
The cervix should be pink, shiny and clear.
When nulliparous, external os is round; when parous, external os takes
on a fishmouth appearance.
Two types of speculum:
o Graves bigger, for multigravid patients
o Pederson longer and thinner; almost the same length as the
Graves but narrower. [3]
Be considerate! If patient is nullipara, use a smaller speculum;
if patient is G5, a bigger speculum may be used.

PAPSMEAR
Vaginal and cervical cytology as screening for cervical neoplasm.
To sample exfoliated cells in the endocervical canal and scrapes the
transformation zone (squamocolumnar junction).
Make sure to prepare everything you need before starting the
procedure.
Different types of materials used to get sample:
o Spatula
o Cotton tip
o Cytobrush
Prepare the following:
o Gloves
o Spatula/Cotton tip/Cytobrush
o Speculum
o Slide (if cotton tip)
o Fixing solution (if cytobrush)

Image 2. Materials used for Papsmear (L to R): spatula, cotton tip, gloves,
slide, fixing solution, speculum

Page 2 of 6

GYNECOLOGY 1.3

Visualize the cervix with the use of the speculum before using the
spatula to scrape the cervix.
Do not use KY jelly. You are getting epithelial cells.
Do not perform IE before pap smear. You will contaminate the area,
so do the papsmear before IE.

The uterus is elevated up by pressing up on the posterior fornix of the

cervix and delivering the uterus on the abdominal hand
REMEMBER: If uterus is at symphysis pubis 12 weeks; at umbilicus
20 weeks

Image 3. Obtaining cells from endocervix using either: cytobrush (L) and
spatula (R).
BIMANUAL EXAMINATION

Image 6. A. The cervix is palpated and any hardness or irregularity

noted. B. The whole uterus is identified, and size, shape position,
mobility and tenderness are noted. C. The lateral pelvis is palpated and
any swelling noted. Normal adnexa are difficult to feel unless the ovary
contains a corpus luteum. D. Sometimesrectovaginal examination is
helpful, if the vagina admits only one finger or if retro vaginal septum is
to be examined.
RECTOVAGINAL EXAMINATION
Image 4. Bimanual examination

You use both hands one on the abdomen and the other inside the
vagina
Make sure you are gloved.
Use the flat of the fingers for palpation.
Dont forget the lateral areas to examine ovaries and fallopian tubes.
o To examine the adnexa (fallopian tubes & ovaries), the 1st two
fingers of the pelvic hand are moved to the right or left lateral
fornix and the abdominal hand is placed just medial to the
ASIS, then the two hands are brought together, allowing the
adnexa to be palpated between them

Image 7. Rectovaginal examination

Image 5. Bimanual examination of the adnexa.

Assess the cervix, uterine size, shape (pear-shaped), mobility and

tenderness; adnexal mass & tenderness.
A gloved index and middle finger are inserted together in the vagina
until the cervix is reached and the opposite hand is placed on the
patients abdomen above the symphysis pubis

Group #6 | Mata, Mateo, Matibag, Maximiano, Medrano

An index finger is placed into the vagina and the middle finger into the
rectum.
The rectovaginal septum is palpated between the 2 fingers.
The uterosacral ligaments (Extends from the posterior wall of the cervix
posteriorly and laterally toward the sacrum) is also identified.
Any thickening or beadiness of these structures may imply
inflammatory reaction or endometriosis.

Age
13-18

ANNUAL MAINTENANCE VISIT

Routine
High Risk
HPV vaccine (1 series bet. Hgb, urinalysis, STD,
age 9 and 26)
HPV testing, genetic
Hep B vaccine
testing, Rubella titer,

Page 3 of 6

GYNECOLOGY 1.3

19-39

40-69

Tdap booster (once bet.

11-18 years)
Paptest (start at age 21)
Tdap once and Td (q 10
years)
HPV vaccine
Fasting lipid profile (q 5
years starting age 20)
HIV testing (once bet. 19
& 64)
Paptest (start at age 21)
Mammography
Colorectal screening (>50)
Tdap once and Td (q 10
years)
Fasting lipid profile
TSH (q 5 years at 50)

TB skin test, FBS (if

hypertension)
Hep C virus testing,
urinalysis,
mammography, FBS,
lipid profile, STD, HIV
testing, Genetic
testing, Rubella titer,
TB skin test, TSH

Hep C virus testing,

urinalysis,
mammography, FBS,
lipid profile, STD, HIV
testing,
Genetic testing,
rubella titer, TB skin
test, TSH
65 and Paptest, mammography
Hep C virus testing,
older
Tdap once and Td
urinalysis,
HPV vaccine, Fasting lipid
mammography, FBS,
profile (q 3-5 years)
lipid profile, STD, HIV
Colorectal screening
testing,
Bone density screening (q Genetic testing,
2 years)
rubella titer, TB skin
TSH (q 5 years)
test, TSH
Influenza vaccine yearly
Herpes zoster vaccine
at age 60
Table 1. Suggested Laboratory Studies for Annual Health Visit
THE INTERACTION OF MEDICAL DISEASE AND FEMALE PHYSIOLOGY

Image 9. Estrogen and Progesterone signaling pathways in the lungs.

Image 8. The Menstrual Cycle

Before ovulation: increased estrogen, decreased progesterone; LH surge.
Right before menstruation (day 21): increased progesterone.

PULMONARY DISEASE
Estrogen and progesterone increases both serotonin and histamine
release from granulocytes.
Increase risk of bronchial asthma attacks at the start of menstruation;
hormones affect smooth muscle bronchodilation[2]

Group #6 | Mata, Mateo, Matibag, Maximiano, Medrano

Estrogen increases eosinophilic adhesion to the bronchial lining.

Progesterone has a smooth muscle relaxing effect.
The effect E & P withdrawal on prostaglandin withdrawal
Increases premenstrual asthma

Asthma[3]
o Before puberty: more common in boys
o After puberty: women are more prone up until menopause
Oral contraceptives[3]
o Mildly protective in decreasing the severity of asthma
Effects of asthma on female physiology[3]
o Later menarche
o Increased incidence of abnormal menstrual cycles with severe
asthma
o Inhaled glucocorticoids of postmenopausal women

Decreased mineral density

Progesterone has a mild stimulatory effect on the CNS respiratory
center. [3]
INFLAMMATION
Important consequences for wound healing (estrogen increases collagen
production)
Estrogen stimulates fibroblast activity and nerve growth
(+) effect on re-epithelialization
Immune System
o Estrogen effects mediated by both estrogen alpha and beta
receptors. [3]

B-cell enhancer

T cell inhibitor
o Low estrogen Immune response is stimulated. During
periods of estrogen withdrawal, late luteal phase,
menstruation, postpartum, and early menopause, there are
often clinical rebounds and an increase in disease flares with
the release of T-cell suppression.[3]

SLE can flare up during menstruation

o HIGH Estrogen (pregnancy) estrogen inhibits cellular
response
Most autoimmune diseases have higher prevalence among women.[2]

Page 4 of 6

GYNECOLOGY 1.3

GASTROINTESTINAL DISEASE
Estrogen and progesterone affect symptoms of irritable bowel
syndrome. Most women experience exacerbations of symptoms with
menses.
Progesterone produces mild constipation through smooth muscle
relaxation.
o Decreased levels before menstruation increased chance of
diarrhea.
o Luteal phase increase in systemic prostaglandins +
withdrawal of smooth muscle relaxation DIARRHEA
GnRH agonists[3]
o For women in whom menstrual affects become debilitating
Oral contraceptives[3]
o Continually used to minimize the number of periods.
Women with celiac disease have more problems with menstrual
hormone fluctuations. [3]
HEMATOLOGIC & THROMBOTIC DISEASE

Image 10. Contraceptive Hormone Use and Cardiovascular Diseases

Estrogen prothrombotic effects

o Giving OCPs to 40 yr old is not advised since they have higher
risk of having DM, HT. [2]
Progesterone decreases smooth muscle venous tone leading to
increased clotting potential.
o Maybe given to women with sickle cell disease because it
stabilizes red cell membranes and significantly decreases the
frequency of sickling crises.[3]
Both combination and continuous oral contraceptives may be helpful in
women with Von Willebrand disease because estrogen increases this
factor. [3]

Group #6 | Mata, Mateo, Matibag, Maximiano, Medrano

MENTAL HEALH ISSUES

Changes in estrogen and progesterone levels have profound effects on
psychiatric and psychological symptomatology and on psychiatric
diseases. [3]
These symptoms are well controlled in most women and only those who
have mental health predisposition may be affected by the hormonal
fluctuations. [3]
Mental health disease symptomatology changes affected by menstrual
cycle changes include:
o Panic disorders
o Generalized anxiety disorder
o Obsessive compulsive disorder
o Bipolar disease
o Eating disorders
o Severe PMS
o Premenstrual dysphoric disease
o Schizophrenia
Emotional symptoms affected by changes in estrogen and progesterone:
o Anxiety
o Feelings of phobia
o Vulnerability
o Mood lability
o Depression
o Appetite change
o Temperature fluctuations
o Anger
o Irritability
o Increased sense of fatigue
o Decreased self-esteem
o Loss of pleasure
o Memory problems
ANTIBIOTICS INTERACTING WITH ORAL CONTRACEPTIVES
Systemic antibiotics may affect the metabolism of OCPs. Women should
be counseled about supplemental forms of contraception and antibiotic
use.
Antibiotics which interact with OCPs:
o Ampicillin
o Doxycycline
o Fluconazole
o Metronidazole
o Quinolones
o Tetracycline
CENTRAL NERVOUS SYSTEM
Estrogen is pro-convulsant, decreasing seizure threshold.
There are only 2 episodes of menses that can exacerbate epilepsy:
preovulatory, premenstrual (attributed to change in hormones)[2]
o Allopregnenalone acts rapidly and directly on the GABA
receptors to enhance their activity, producing a potent neural
inhibition throughout the CNS.
o Estrogen increases neuronal excitability directly on the nerves,
as well as secondarily through inhibition of the GABA system.
The GABA receptor network is the primary neural inhibitory
system within the CNS.[3]
20% of women have increased seizure activity related to changes in
menstrual hormones.[3]
o Catamenial epilepsy seizures that occur from 3 days rpior to
4 days after the onset of menses.[3]

Page 5 of 6

GYNECOLOGY 1.3

14% of all women with migraine have pure menstrual migraines and
46% have exacerbation of severity and frequency of their migraines
during menses.
o Menstrual migraine migraine headache without aura,
occurring within the last 2 days of the menstrual cycle and the
first 3 days of menses. Etiology is related to estrogen
withdrawal.[3]
Migraines with aura are more susceptible to stroke OCPs
contraindicated.
CANCER
Sexuality should be addressed from the beginning of cancer therapy. [3]
Radiation to the ovaries greater than or equal to 20 Gy may produce
ovarian failure
Antineoplastics and chemotherapeutic agents may produce ovarian
failure, sterility and premature menopause.

**The following are not discussed by the lecturer.

VASCULAR AND HYPERTENSIVE DISEASE

Estrogens have a positive effect in the vascular system by improving

lipid profiles but women with pre-existing thrombophilias and
dyslipidemias may have problems with estrogen due to its procoagulant
effects.

Women with dyslipidemia should avoid estrogen-based contraceptive

and HRT.

Women with hypertension have an increased risk of sexual dysfunction

with impaired genital congestion and decreased arousal.

RENAL DISEASE
Women with end-stage renal disease have an increase in endometrial
hyperplasia, and increased incidence of cervical dysplasia.
Those undergoing hemodialysis, with chronic renal disease and those
who have renal transplants suffer from an increased incidence of sexual
dysfunction.
ENDOCRINE DISEASE
Endocrinopathies have higher incidence and severity in women. Its
interaction with hypothalamic-pituitary-ovarian axis is an inhibition of
normal function, producing anovulation.
Those with Type II DM, and obese women have increased anovulation,
infertility and potential problems with endometrial hyperplasia.
Estrogen and progesterone mildly promote insulin resistance and
worsen carbohydrate intolerance.
Thyroid disease affects the hypothalamic-pituitary-ovarian axis with an
increased risk of anovulation and infertility.

Edited by: K.Torres

Group #6 | Mata, Mateo, Matibag, Maximiano, Medrano

Page 6 of 6