GYNECOLOGY
PROTOCOL
Written by nn Mari Mari ley, ley, nd ye s. Mira Mira hait hait enee enee ol n, te aber aber hell hellie ie Kaha Kahane ne.S .She herr rr ra s, Rena Lefkowitz. Lauri Jane Jane Maxw Maxwel ell, l, Paoi Paoiin in tti, tti, rb tory tory Susa Susa Ye n, en Ye nd frie friend nds. s.
Written by nn Mari Mari ley, ley, nd ye s. Mira Mira hait hait enee enee ol n, te aber aber hell hellie ie Kaha Kahane ne.S .She herr rr ra s, Rena Lefkowitz. Lauri Jane Jane Maxw Maxwel ell, l, Paoi Paoiin in tti, tti, rb tory tory Susa Susa Ye n, en Ye nd frie friend nds. s.
TABLE OF CONTENTS
Anatomy
......................••..•••.................•
Physiology Hist Histor or
...........................
Ques Questi tion on
xpla xpla atio atio
........••.•••••...................
isto istory ry
ic
~.• • . • • . • . . . . . . . . . . . . . . . .
....••.•••................•...
••........
..••.••........•••.....
..
13
esti esti ns
.......•...••.•..••
......
Labo Labora rato tory ry Work Work
26 31
an id
agin aginit itis is (Yea (Yeast st
acter acterial ial Vagi Vagino nosi si
, •
4 •
(Gar (Gardn dner erell ella) a) ......
34 36
Trichomoniasis Alle Allerg rgic ic Vagi Vagini niti ti
40 Bartholinitis Folliculitis Cervicitis
42
..............
~ .. ~ ...................................................................................................
43
·4
54 56 61 65 67
INTRODUCTION things to
in
tr ific th 1) 2) Severe pelvic pain effort to te ch di fe ential di gnosis of pelvic pain in
any
be ex
an be treate with consultation of
If
is detected on bimanual physical shif profession l,
is to isa far- ro -compl te discussion of th co subacute pelvic pain tr inin an ust:
d s
tr
on vaginal. ervi al an
e q tubal
pregnancy. il
th if
proble s, consid woman
with pelvic
thes things
pain
hospita immediately.
Is
referral
to
~to gono rhea test ma be accurate
used tampons day.
within 24 hours of her
ANATOMY
Contents:
1. Overview 2. Cervix and Vagina 3. Uterus and Uterin tu es
introduction an as
uick resource
urin appointments
Illustrati ns were ta en from The ered Health Care
by Ginn Leonid Martin
assidy-Brinn
Franci Hornstei
xterna
ra
women.
enitalia
ro
m o n s pubis
f:
g: glan of clitoris
h: l ab i m i no r
prepuce of clitoris j: frenulu ofditoris fo rc :u rn pe in ct 0: vaginal openin r;
in French) araurethral" la ds
(introitus)
erinea body
anus
will be
The glans ro lans
frenulum ar no erectile tiss e, but re
th clit ris,
It
re
an vagina openings thin shee o f m u co u s rs many women av sexual activity involvin vagina penetration. arely, he hymen this is ca le an Imperforat it is removed sUrgically. smal skin tagS called hymcneal earuncles,
Th hyme
hymens.
is
P"Iu~(llS
floor, Un er th ~UPERflC ... TR-'NS I'EII.U,W EXTHN-'l
....N....
S1'H'NCTEI!.
~Ct1'-'l
TUaEl!.O~'T'r lEVATOR ANI
GLUTEUS
MAX'MUS
th es
form
ee er erectile is ue am er ct
Th clitoris is by fo rg sm exua
+: ligament
Sagittal view
f: labia majora
g: shaf an glands rectum
j: anus k; bladder
1: urethra er to eu
clitor
ti sues
im at
ul
may
r ea c o rg as m throug clitorial stimulatio only throug vagina timulation nl or throug ot ar perfectl
vervie a: ovary
ft
notmal
your fi t.
ro by
rv'l
t c
d t rd
names:
re ru
ff
un 0: cervix
Vagina called
It that
Y l t e r\ VOjill\.<:l1
wall
.forv\\x e , x + e . . . V " " V \a .
OVl+eV'lor ~oY"l'\i
it
1-
pOf>+eV"i
0....
+erni)"
he sa e. in ra
skin that
squamous
external
endocervical
one ou se when is the endocervix
is wher cervical muCU is made Betwee th endocervical c an a a n the
constriction the endocervical canal called th internal os. vagina wall attach to th cervix abou half-way alon it length. They fo ' V a g i n a l tissue around the cervixJha pouche back towards ut purp se f' escripti we re is side of the. square s, if Itwere separat thing. The arch vaginal top" as the woman lies on he called th anterior fornix. mean arch ault inLatin) ar m i a r n am e - - e e u s fo
tissue ,.on
ba is (fornix
he others an n,
is covere with is relatively toug an resistan to infection. that is ra ro
from ou endocervical ca al It cervical ucus an it is relati el
fragil an su ce tibl to infection.
that
present.
from th tt
can
quamo-columnar ju ctio ecau rv al el
th report will sa "endocervica -c
ha ag
re
em
as
cell
runs around th vagina
ri
ar
in
ifferent places in
teru is
mernbraneo wrappi uterine cavity is
called th perimetrium,
Th endometriu ha Unde th influenc
bladder
Th uterin
tubes at ap
otentially
serious.
ts
al
this
ri im el
broad of th peritoneum
re
he
called
called theutererectal ag
re
what and.
(Q
es
th body of th
an
flop
ct
th
teru at the .co
also
operations can
10
it is
very dimwit su ll
uterin
be ar
10
Sinc uter ar onlysupporte found, In
by
fundus
fundus th uterus points Sometime man' teru wiIJ change
u te ru s p o in t
Inmany as
depth
s in h
the most irnpeJUJnt th gs
toward
is ep nd -n on
to th vagina canal,
positten ate:
em mber ab ut uter
fundus
and
let~ion
er el
forwar
of
le
to
duding .l;Iot body an
ill
cervix It is ill coml11
In marked relro_nion,
often be celVill
be
fu back,
backward angulation of thr d y in on Itll! cervi!;. The C'e'M1I aintlins it usua pos'lion. The hindus m~ be bl he anterior Teclat wall. ill Villri.nl of normal.
as will ever use, They ar particular stag of development. When young woman reaches adolescence sh begins to ovulate. With each menstrua c yc le , fe ov ar gi to fini heir evel me c ol d s le e an Wi a c cycle, is woma
nger ov ates
surr in fo icle il
ov m. ulat on
Se
ec
en pause.
encirc in struct re he foll cl pens a t l P the OVUIl'1.()ozeS
4d ec
pregna t, th corp
he foll cl
).dt
(0I1ll
orpu
teum re ai uteu
ot secret
th ou
structure
albicans
ut
ormo es th
they ar se from ruct es
re ancy re
vo ed in th
at re
rnal arts
en tr
cy le ar an
PHYSIOLOGY is
it
cause mechanis
what happeas in
s,
eneral
read other
m e ns tr u a c y c e s ***************
hormone
he
(GnRH).
an
ormo es is called folflele-stimulating (L
A.
he asal/ora ca ity. This la hormone
ca le th pituitary.
(FSH),
•.
he
So, back
ovaries, fSH
exampl of positive feedback it
gonadotropins in
FSH.
to
(endometrium)
to
canal
uterus. io
pp oa
more salt, ch nn ls in th ce vi al
be I1iUCUS
or
tain forms long spira
ar easyfor
th
that is
ar ovulating, Yo
is
tr
ly
Ovulation (midcycle)
ly hi
tr
eof
ti ul te
su ge
se
it ta
yp
us
ti
than th LH surg .)
causes
of OVUin.
secrete enzymes that digest wa th wall
swept
ll
th so.
in
on
vi
to
th follicle.
at follicula fluid
lati
nt
th
ovum then pops out of the follicle
cf'vaginal bleeding at midcycle becaus in te in do day. or
Cycle
of th cycle.
Th
ma
At th helps to takes an uterus. It must
fert lize
clays in h e f ir s w o a y
w h c h m e n s that va ar fertilized in the
ferlilized. This relatively smal fertile when he ov la es ca effectivel
man,
preven pregnanc
days, th ovum
c a a cc u @ t el y predict by no having unprotecte intercours
acco,rate pret1jctjoll means that woman needs eervix and he cervical muCU dailYiP1(j'take her temperature eachmorning. People ar generall discduraged fr this le el ea many no observ them el es cl se en ug to effectivel preven pregna cy
is de enerat ra idly en to fo rtee corpus luteum means
th
normal
ag na
Th
egeneratio
of he
uterus, This tissue accorp:panie by bloo from wornar 'sme strual fl w. an become
ecretion .. here
menstrual eramps,
ay af er ov la io ha occurred
no health-related reason fo
However, many wome reasons
woma
(ari /o he rpar ners
to restric~he
ex al
refe fiot av exua s c O P e of this physiology
c. When
HCG.
fertilized
vu
im la ts in th endometrium, it mm diatel
eg ns to ma
struct re
corpus luteum
th
Be
g.
in
LH
keep th e st ro g en s a n d progesterone levels
of ou ca talk about th different pa,ns of th menstrua! c y c ovary
e i h e from th P Q i p t
of the CYcle,th,eenciOriletria tissue is called proliferative endometrium. is called secretor
endometrium,
follicular
phase,
Fat
first.half
th
is the first half is first half during th
Oyulation is the deflningpoint of tPidcyde th plac b e w e e h e fi~t ahdsecon phase. 110t Midcyc1 does lw~Y oc ur in th chronologica iddl however~ be~Jjse the first an T h w i be dlsc ssed soon last halves the menstrual ti
ti
th
JU
te th th th proliferativ
tr phas midcycle
te
tr
nd th secretor
in
ph se
sl
and Timing Textbook
describe th 'ideal menstrua cycl as having thes characteristics:
day.s, from the fJlS~ da of last fo ovulatio oeeurson da 14, precis:c::ly h e m i dd l .. menslIUationli1St. for -5 $ t y s _ . .. one-half cu of enstrual luid is produced
first
t..
·i.deal' only tarely onne te varyj,ng cycle lengms, varying length pfDle~tnlat~9rtahdvaryin
have be
is
ha
lo
li la
se
she will
to
enstru ,tirtg or awhile know Wh
35-day
UI AR
H O RM O N E
J.
........
---------
O V R IA N C YC L
'4
-------I
.. ..
OVULATION
OV
O RM O ..
ESTROGEN
,,
---------_
--
.....
.......
PHASE
1
1
I
,
I
28 DAYS
does pregnant
after
ovulation.
not apply
HISTORY A. Discharg
ma
2. ttributes: colo 3. History B.
1. Attr bu es
Gr wt s.
1.
tc in
odor consistency
te der,
ur in
esions masses
2. Initia onse an progression? as 4. re
D . U r n a symptoms 1.Attributes Pain burnin on ri ation? a. b.
Frequency? Urgency?
ai Fo ho long?- time in it deep enetra ion? Pain wi se ua contact? Quality a. continuous or ff an on b. sharp, dull tender debilitating 2. Abdomina pain Fo ow long time in Quality? Nausea, vomiting diarrhea constipation Fo ho Quality?
1.
en long?- timeli
ri
mi
e,
Se al st ry 1. Last sexual contact? months.
av th ar er 4 . D o (e s yo rpar er s) 5. Do( pa me have an genitaVurinary SYJIlptoInS,genita lesions, or an
6.
n ow n S TD '
..
months?
Birt Contro Histor 2.
type,
as
A CH E A IN S ny recent chan inbirth control me _crea birth contro methods? L O V E ' em). Menstrua Histor 1. date
date,
orma fl rm flow
jell
im ng mi g.
4. What is the variation iny o u r cycle length 5. bleedi ot in ts enstruat on ny ar at on ur me truati 7. Painfu menstruations?
K. Reproductive Histor en firs eg think you ay abortion,o
What was th result 2.
en was
me strUat ng
pregnant?
miscarriage?
L.1.ab
en
smear?
andl
mo t?
il
pe
M. Breast
1.
2.
nusual chan es noticed: lump discoloration? 3. Hist ry reas pr blems?
II ENVIRONMENTA
History. B. Recent antibiotic treatment?
DISEAS
uc ers, as mmetry
HISTOR
C.
DE
Vaginal sprays. non-treatmen
W h a t do ou hink
IV.
Questions
douches, deodoran tampons?
nipple ischar e,
Histor taking is opportunit fo rappor to evel p. medic. wo
sex
ll
accurate hist ry
in gyn.
rc
ak fr
subjects
Refrai in
fr
unnecessary
place will allo
ce
en is importan to remember that
el
honest compassionate
co munication
present, se sitive an awar will Watc ou assumption 2. Maintain privac 3. Validate concern fort 4. Pa attentio to intuitio
1.
an judgements
e t s q ft fe ro re is this th ap ropriate clinic fo them Us quotes
than
et What events coinci e? fore Create timeline if possible re
4. Qualit se escriptors 5. Ra iation attern ofsprcad 7. Past tx
16
ap
en
Ge
SOme vagina infections have characteristic discharges although accurate impression ca based on th discharg alone. B.
in the Some aginal nfec ions ca
m p re ss io n c a
C.
ha acteri ic itchin
Growths, lesions, masses
area
ex al tr nsmitted.. Inform tion ab ut th on et an infection in th eopl sh ul tr at d, if
rr tation
t, again,
rogr ssio
he ar ne 's
sm.
symptoms Pa ysti is pica ly ca es upra bi pain hich te to increase in intensit immediately after urination. U t e t i l r i U yn rome comm ly au es pain ly th p a s s e s over he external en ta th urethra. Pain ee lJTI protocol: is or trn. Recent UT re tm nt fa lure sh ul chlamydial cause,. ut ha p, lize Pelvic area t l J e ER immediately. Ovaria cyst is possibly bu no necessaril
ar an cy ts an P I D : C C U l c a u s e caus pelvic pain in ma form vaginal
some case ofPID.
in es ga ed fo
os ible
ai with po sibl pr na ould be referred to caus generalized, low-grad pelvic pain whic both
Thes condit on ar
ft
associat
it
crea ed
referred ou fo evaluation
Abdomina area It is important to diStinguiShpeIVic a n a bd om in a reas n, th roug abdomi al exam ne es ar th abdomi al protocol or details.
Back: Rule--out VA tenderness especially if ofPID is in during menses Fe er weat nd chills (FISIC) pyelonephritis (kidne infection) mp ms
piri
an
PID. ec op preg ancy
ce am no he
ower
vari
dy te pe at re
he
is rders.
It is
ma
secondar
to trauma
History Most ag nal, cerv ca an pe vi infections ar sexual seen at their partner(s} to rt on ro or The mostcomIilQIl 1- Urinary tract infections with iaphragm 2 . A l le rg i reaction to c on do m u b r c an t contraceptiv sponge w h ns
ra sm ssable
Encourag
an poSsibly with cerv ca ca s, p e m ic id e (usually nonoxyno nt x yn o1 9 (a
re
\1Se. bleeding)~ce.rvi.cal 4. or serious effect of the e ; P ID ; tubal scarring. which ca lead to eC op regnancy an uterin preg ancy with the
BFC.
ee mu
any
any birth
du
Abnormal bleeding Abdominal pain Infectio exposure String missing, differen length
Chest pain Severe le pain Ey problems
J.
Menstrual History
of e f 1.
rregular mens rual cycles hxof u n p r o te ct e i nt er co u r s
then
since L M P ·
es
ea
woman
is haVing breakthrough bleedi g, ha presCr be er birt co trol pill
prod
tive
he
History
Again, ifclient ha me icat on
is
ct
riot
rr week of termination, int
18
the
contac th original practitioner immediately.
L. Lab stor
an
ha
Ab orma pa
abnormalit
need fo low-
is present.
II ENVIRO ME TA
DISEAS
HIST RY
SystemiC
fl ra Preven at ve measures ur ng ar antibiotic trea ment ca be take
Ac dophil
ca sule
infections. ag na me ications ubri an s, perr ic es ouches ag na menstrua pads all cause with no identifiable concurrent infection, tr disc ntin in us
grow.
19
prays,
eo oran tampon an
he ro uc s)
At
Fr Cl we ve pp va ve mo wa u s u a ll y m a l p h y s c ia ns .
un mp we
w om e that x a m o w om e
We
ul xp us u s w om e a v C O In e ey pa pl as nt ev mf x am . T h probably been wi Be us me we an we though, have pp un W om en t we pp me ph pe a s h e h av e b e o re . One
that e lp s
c l e n to
n e v ou s
2) Cl x am in e pe vi Yo ma us D o n a ss um e pe wi wh room. D o n p u her
u mp s ma n s d e h e v ag in a ump wa yo wi va na nd pe
As
ve
ma us
x am i
he cl en
Ra ut feel that
w om a
wi xe ps wo
Pu
wa
ut wh v ou s
xt
ut
pe
wo
ve
me Ot
me mp
bard o r h e
Ut
un
ce
y.
me in h e p e lv i
lay flat.
ua
pr pa ud
y in g flat o n h e table, e xp la i w ha t y o are ng be x am in in g e r x t al k in g n d ng wi kn ut Th xp put ng ee o r a n B a o l n ' g la nd s w e n g o r e nd e n e wh ur va va po wa pe wamJ speculum va v ix . mi me w om e
me
p e v i x a is a lk in g er u. Af ve T h m o comfortable s h f ee l mo wi ve
ug we ng ki e m v in g u n w e ul ke ve w om a me Th pe we
Th
as
ur d oe sn ' h av e u l b la d e r a n u l of u r E xp h al pt u f n d p e u lu m .
xa ve
pe
mo
the stirrups yet.
Ab mi vi Whi
As e n if
Cl
past experience
ur ng
me Th n t m a e xp e e nc e w h c h y o a r e m~ rk i entogether, w i y ou , mo Wi ar e xp e n c y o a s p ra c o ne r 1) D o ur w ay s m o mf x am in e pa pa ut us pe me ne w om a ' p e is w h yo
Fr
xp
vi
up
x t Explain ny ve e xp la i what u nu su a v ix . T e wa ve Mo
w om e
th woma
ha to look the stirrups and to brin he
Yo shol!ldhav gloves on by now.. worker at gloves.
Before yo~ fQuchthe woman' genitals, . s a n d a t th
nd
kn e, look t. her:(eye, contact work wonders! an tell that yo touch h.ergenjtal fo anysores, etc. A.$lc:~erto l e h e tm e c s 9 p e n ",i(ie
sh.0'Y bttttoGks. Y o y ou w gentle. Bcforeypu at:tua1/y tduCbbersil
nowt
n h
l y
h h r g
by
gg
Or are· worry, though be ause ov ries ar
t im e ( w h
have wOrkin'g
th labb
women
ne ss pamphlet.
Finally.
to
ll oo at to relax
" Y ' Q U l e going id.feclr_netoudi d, ~t nn
c a , n feel your left ovary but of
your righ
tu to tr copy of'the American ance So iety
if breast ex
THE EXAM
Notes: Douching or use of oa n~
ss
ay
icid
is espe iallyif'ther
in
he isabdomirtall' in
yb tag( whic migh indicate PIDo
so
ig
sp
in
otbet:se ious condition.
lood pr ssure, temperature, pulse. Note an tenderness sw li
follow
swelling,
tati
Of
masses. te
USing WBrIIl,lllliIovedbands. palpat he abdomen. ut g/ove$ o ~ .P a p a n gu in a n od e area, noting arty is ti li er xamine hers lf'and yo own. She will on
pubic
is -21
en
et
B) In ec
tu es at rethra
C)
pe in
{m atus fo
re
sual re ness
AR NG
OR
CU
EXAM:
insert inJO v a g im l , (Wetting th~ finger us fot discharg andtbis. g(tena.cts suffici~t1y asa hlbric:ant. qu ~lrQ
wbic:hou
wann
el in
We forefinger
with
an
rt
IV.
v.
en er ss
come
th e~~~
n~!l bu Ps (p ss bl w i j r t S fip~eftra.:yel (t PtQ~.ho tbguideS~¢1li1in!)aDd'ho reach
INSERtING tH ater
is ub ic te
thig with it fo says
fa
you
will
SPEGULUM:
en
ee as
Thespec.ulilIIl wiJlhaveb~ensittingi C::Iii n. HQld th warm SPCC\lhJlllgainst
' Y 3 n D water. minute th air
er to. test th temperature.
vaginal
1)
relax 3) Pr ss
gh ly
utfirmly
jt
vaginal canal.. er carefu ensi ive. so,~be ery~refi.t 4)
\lri ng
t. P~on. tl tt ~tch
alon
th ur~tllJ:a dn~
clitoris; th~c: a re a a r very ai .b tw en t b r ; ilfs of th
finger, in
in position.
(W ALLS): Once th speculum fo
fo lo
nd ti s:
in place, inspect he er
an
vagi al muco a.
a) IUD string
touched (is: it frlilble) rs
oc
e) Vagina mucosa (walls): sores, redness, discharge, warts, acer tion ompletel
xa ined as yo ar removi
lab spec me
shou for urethral rectal an pharyngeal (throat) T he s is lab tes protocol.
vaginal th spec um
taken with th speculum in place, except done afte h e s p ec u lu m ha been
re clea tbescrew
ha
remo
pr se ce alls ca more
th
er ix
olds;th bill ll la e.
spec um fr
th
aginal ca al agai wi
ight
ow ward it.
the lab.
Take
X.
I-MANUAL EXAM:
Purpose: of any ~i teJlber-t9 le an a]so rtQtc a u s e
va ma wh or tubes. EXplain and-where sorrtethinghum. This is so that yo Unnecessary diScomfort. u"
make
Pro(:e~u.te: (Note: onlyusewatersolublejelly such 'especially dry. NOriIlally, er discharg~, orjtis plai water, is lubricant enough to do biinailtIalexarti. Wear VijU use to inSert in he Vagina. er re arin ak some e' hand insert th middle iI1dexfinger into th vaginal an l, si li ht downward pressure, (base) th cervix
an
vagina cervix,
for-any cysts d)
lo
woman, it 23
it
ad ex (ovary or tube). Careful1y movement.
so
ov th cervix
restrictions of
at yo is anteri
forward, or anterior flexed).
betwee your tw IIlid"position.
find an
to th cerv
(t lted
th uterus
hands. This
g) If h e u te ru s positiQn (tilte back or retro-flexed peritoneal cavity between felt by oing arectal'
be he cul- e-sa (pan of tile uterus). so th uterus ca
be
"a
Note ize, hape consiste cy
re ence
nodules, mobility an
h) w9man'
reetum.. A$~.
firmly agains th rect
en erne s.
di JiS
,i
yp~insert
y 0 1 . l t r l 1 . i C l d t . ~ finger an exer some PI"C Aure h~,together With tije wom~
.fi You.rmiddle (k>ngc::st)igger goesinto he rectum insert your index. finger into;her vagi~ on topor-he ceivix., Whil ou press doW11. her cervix p~ t l o v m abdome Wit yOUl,"gl()ved~d fmget. Y 0 1 . l ShQllldbeilhle to feel mebaclc.side of he utems, th.rollgb the t e c t a I wall ri (gen ly an feel fo onsistency rese ce of nodu es mo Uty,an tenderness. i) Bimanual exam is bo
x.
RE ST
XAM:
Us method
emonstra ed
th
merica
Ca ce Societ Ty
ormentioned
th client as to
breast screenin
MMA
OF HY CA
3) External genita exam
7)
Bima ua exam.
B re a
e x am .
X AM :
LABORATORY There ar several e s w h ic h a r routinely p e take of nt ns T h e e s are generally done h e following pt n d b e all p ec im en s o r a l tests.
I.
me
ne
WORK ur ng
pelvic is m p o a n no nt wi n ex t u t the a p p ro p r a t a b
rinalysi
ur na ys U /A ) should be performed ifurinary tract symptoms s.J,J,chsfreqlietlCY, urgency, to avoid painful sk urinate ptiprto x am . T h full b1adQer,~d to a l o w y o to feel discomfo during th examination due to th f u n d u s o f h e u te ru s w i h ou t h av in g to p a lp a t t hr ou g h f u l b la d de r . he u r in e s p ec im e n mu "c me Th obtained by to avoid contamination p f h e p ec im e with des~H;ted ( sh e d? s lo '- 1 g he ~ ~ o m c e ll s and b ac te r n or m a f ou n d on theSlilii. specimCil is ohtajpetlas
-Wash bands thoroughly with soapand-water,
- S p x e a d h e a b ( 1 ? o t h i nn ,e ra n d o u te r \ V i . t h th~thUmb a n f or ef m ge f and continue to hold h e 3 p a i w h U e dea.rtillg h e p e r u re th ra l a re a a n d p e r n e u m . •W~p.twi~ with an antiseptic-soaked g au z e wiping fro urethm(fmntofbody) bal;k to a nu s E ac h toWelette is u s e d o 'n ,l y on c e t wipeTrom back.end w ip e It foldso skin t he n d is ca rd e d i s i m p o rt an t between th basin o f w a rm 'w a te r o v e h e g en i a ls . - R in s h e w a sh e a re ab Y : P o l r in g M a k ¢ sure to rinse off'allof h e a n t s ep t i h e toilet. .•Hold th labia apart With hand an begin u r in a n g urination u c t h i ns id e o n n u e p a u r n e n t h e u r n e c on ta in e b e n g c a e fu l ri : w i t i l anything. Remove th container b e o r m i h in g u r n a o n n d pass th a s o f h e urine n t h e t o l et . Br ng pe me he Th
wo
o f h e u r n a y s - -d ip s c k a n d i e c o b e rv a o n- - a r h e p en o 1 ed , u su a various kinds test by th lab_worker o n s h f t . . .T h e dipstick is p l as ti c strip w i p a tc he s ma er al On e s f o g lu c os e . p to te ir r k e to ne s b i r u b n . blood~yri[laty;pH, "and bloqd C e : U $ i oThe sonleilInes fie graVity" u r o b il in o g en , n i tr it e a n d w l i i t e determined by b r e f m m e n g h e d ip s c k h e u r n e and h e c om p a n g h e colors t~! p a t; ch c he parts
'i_·,.
Fofthe direct 6bservatidnpnase.abOut
,~
U')ccofthe urine re p . u n c io w n, j c en tr if ag e h e drop SO~'a upe na nt p ou r nd sedi en is e xa m n e d . T o the sediment is pl Wi ve un po Ox and te b lo od 'c e l s w h i~ e b lQ 9 d .~ e ll s " t: ry sU ll s. ca st s a n e p i b e a l c el ls . I f e n se s f or ~ c na ~ u r jn c cul~re ~ b o ~ l d b e p r ep a re d tb.ere ar ahigb.JlutllQtt ofbacteriaand/ot WBe's, th~ Detecticmof 1 0 b ac te r p e r high p o w e r f ie l c or re la te s well wi h e o la t p n o f g re a e r than b ac te r p e m i e r o f u r n e T h is h e n u m be r that i s g e n er al l used to define cystitis.
he urine cult1lte'is p r p a ki me ur m ou n no ma nc nt urine Spun d o w n- « a n d s tr ea k in g it B ec au s e h i containing so needed, it i s i m p o rt an t that un pu ur ma g e enough sample is v e pe fan of he es Fo
ak ng
used. organisms/
c u u re , pe c a b ra te d p l n u m n no cu la t n g o o v e e xp en s v e 0 0 m l Therefore. when wt ur th plate, the. number is determined by ountin th number colonies a n d m u l t p l y in g by 1000.
Each colony is p r u m have arisen single bacterium. worker il r ec u l u r e h e bacteria gr wt up "s determining w h ic h d ru g ( the causative organism is sensitive to result verifies a n m p re ss io n o f u r e h ra ] s yn dr om e .
W e h av e
significant
vi y" wh wi he n o g r w th ,
ur
p re gn a m on o o na l n t o d n zy m m m un oa s y ) w h tests pr um pi HCG Th ur 10 ~a pt On ve ps ur ut C: Je Tb fOfJhe t~t are. very m p l a n ar stored with th pregnanc test kit. O c a ss io n aI 1 y s er u m ne¢deQ. pregnmlCY tW forms: S PT ) is sent to'an outside
The Pa
for t h e ar l d e te c ti o o t C a n c( :l 'Q ~ ~ P P J l :@ . 9 f et ol l cell P ap a u c a1 ou ) th cervix. Various organisms, including trichomonads an om acteria, hite blood c e a n h e a mo u n o f n f a mm a o n c;an be identified. this test is sent to o u d e b . smea should be Qfferc t.oany woman w ~ Q i a S n O lh tJ .d on e h e l~t year. a bn or ma l r es u l n ee ~ i. to U g. W " u ,p . S e "Inte;,rpretlt,tio .QfPap Smears" fo m.ore detail)
P a s l J l e a r is performed taking s a m p l e s . cervical. cells with w(>Qdcn:s patul h e c er v i ha o f d is cA A r s on it, deem it offb,efore sites d. v ag in a p oo l or T h , f l end , o th spa;'Utais ro~ed un he circumference of h e vi c h g e is u t r ;r is te d e p d d e T h e o n notched rotQ t h e : c;ervica1'0$.. The spatula is pressed an tamedagainst he pa ul he pl h e e d e s of the' as. andSIlleare4 onto tn sli.d~. ,A e n do c er v ic a l s am p l e is taken with sterile Calgi- swab. and th swab is rolled clockwise a n c ou n te r c lo ck w is e onto h e a m slide. The c e m u s t be x e w i c y o lo g c a x a v e immediately. D o n w o b ou t th thre sites.
V. Gonorrhe
ulture
renloye t h c ; , A . C e rV i ca l c i l tu r e I ns er t stenle c ot to n ' s w a i nt Q th cervical '"plyg"of mueus.anrldispose.of it. Using sterile Daeron } i a " l ) QrCalgi , s w a h . es a n e av e: fo r 3 0- 6 e co nd s Csamplesfor d l , c w b i f f e s g ~ p la c w a h n, n e K O H n d v a a l culture c a a l b e o h a in ep ,w hO e h e swab fr o r h e GC plate is h e os.) R em ov e th OS and immediatel roll the : s w a b iii a~~:pattemonthe pte,.WatftledMTM
pllUe.
Ne c r o s s
lB. Uretll1al nb et is touched lightly to the u~tllfaI opening foribO].it7 SFOndS. ibis swab i s t he n ro U e d overthc same th is h e c ro s $ t e ak e w i es Da ,cervica pIate.11ieplat o r c o o n $ wa b an placed in h e n cu b a o r 2. Rectal CUlture-- After the specuJum is removed: Because the v a g n a a n rectal dose together; it is possible o P en i a t infection in l oc a i o t o be
ttaIiSmitted We ut GC ul ur me wh ve v i u re th r u l u r d on e o n h em , w h o r n o h e w om e a d n a rectal o pe n n g h av e h e pt ve x. Da wa us ou insert woman bear d ow n w h fo abou 15seconds, "Z p a m ov e pa MTM pl Av ub appear clean. ma al on h e agar by ki pa wa wh
(I ther is trea
Th last
plat an plac it
ul ur
th wome
ha
th
the back streak with
fr sh
ab an
la
"Z:
in the jar in th incubator.
This test to detect th presence an quantity epithelial cells, clue cells, motile rich mo ad it bl ce ls re oo cell ac er fu ga forms. Th is he lace ma ub wi obtained from the vaginal drops salille in fue bottom of th ¢~ he am le must practical 1al? ca only be positively identified by th ir mmin ct result of the. we mount. is reported as it er si iv egat ve fo yeast, blood c;:eUsR B C ) O+WB HPF inpicatiVe of an infection.
VI
OH
as for
re ve epit elia ce ls few minutes. Care. must
ut no
is
fu gi
as in
th
vaporize th sample
Place KOHt Gatdnerella
fishy odor is characteristic of
Stain
gram stain is differentiates organism
into tw groups Gram
os ti
organi ms ar th
at re ai th
and
organism unde th $1lch second dy is llSed.The g r a m negative o r p r t i s m s take lip this dy appear microscOpe, pink in color.
Using
swab,
th vaginal p o
'TNTC" (too
er
ou ).
Ro
swab
yp ca fi di s:
clean
in detail above
,"
Yeast (Candida slbiauts): slightly bigger than hyphae. gram variab
thes epithelial cells.look "chewe
if
coccobacillu up." G a rd ne re l c a
acteria. Th
or er of basis
re
Dode lein
cy ol sis: Indicated the presence of many (4+) gram positive rods Sometimes h e o d cluster o un d h e epithelial cells. These re then called "false the KO whif es,t Many times Jots and lots of epithelia cells that appear m o e a e n and SOme With just
thei nuclei visible.
Gonorrhea (Neisseria gOilorrhea) Appears as gram negative diplccocci within b lo o c e g ra m - ) intracellula diplccocci". In They at reported WOman basis gram positive culture
wh
is necessary to
Ntni:nal
vastna.
th whIch help ar manybaetena normally presen ot er or anisms such as yeast. normal pH an contro th rowt
by epithe ia cell and ct er is importan to clean with akin th samp e. This is the reason whywe do the e nd oc er v c a s me a second to mo el wi in clea th cerv ca r, if th woman'sos isstnall,
asyou.takeJt
stain h e s l d e
Calgi
to touch
sure
fo
regularsterileswab
,Gram·
screen it on l o m a g n if ic a ti o to dentif strand cervical mucu an to elec representative area of cervical mucu fo
vaginal co tamination
in several representative fields-. The resenc of c:liagnosis ()ffi1uc~ulUlent e e v ic i
IX.
'Ibis is
mucus s ho t
to check ill' with th woman
it l'Cquire t h a . t YOIlswab ff columnar cell f r o m b e cleared away first. co lect he sample push ag lmst he swab if the B$
x.
This is
M N HPF in mucus supports the
J a s l e s a k e ~u.s~
discharge an
th
swab pre-warmed chocolat plate. Beware
swab
is
ai
lo
it
to
plate is then inverted labeled. and incubated. The:bacteriolog identification of th colonies that will
that is only perfor ed wh
le
Sometimes wart ha
watt.
la la worker will th
othe la test ar in onclusiv
io ny visibl ir it tion or rednes becaus th vinega will ause stinging warts back n"
rm
30
grow. The
lear th vaginiti
VAGI AL IN
IO
1) normal estrogen secretions whic
2)
hick
maintain ro ective quamou ep thel um containing lyco en contri utin
actobacilli, whic me ab lize glyc ge
to th
fo
Disruption of'any redisposes oman to infection. Other
Influences
are:
estr ge to main ai th glyc ge -ric ag na epithe ium. This conditio alkaline vagina pH leaves th vagina vulnerableto infection. conjunctio
transmission of sexually transmitte Me Ce
combined with an
with th alkaline
disease, ,a colomzadon by path.pgc:ns.
L u p u s Erythmostosm.
se of douc es de dorant tampons. sprays, -Hygiene: micr enviro me of th ag na an redispos response.
Q.
a..!'"
. :; .
.;;; c.._
i~
-~-:
~~ .::t
..
.!--..;
...... . 2
.j
.!!
:;
,~.E
'"
(Yeast Infection, Moniliasis Cause th fungus Candida Candida is re lt of change in resultin in thepreferentia
proliferatio
', i'Pregnancy: increase
Menstrua.don:
th
antibiQtic
yeast. Predisposing factor include: lyco en tore in in the honnonal1evels and increase in vaginal pH.
(e.g, penicillin cephalosporins tetracyclines)
Diabetes mellttus: Immune suppressive drugs .Genera immune suppressio ea ad er iIliciting an re an mpor an
he epitnelial ce ls an efen
or debilitation
en tr te in
ga st verg ow
killin
th
uper ic al la er of th vagina tiss e,
of Ca di a. Lact ac ll ca
ec fi al
inhi it to
richomonads.
Transmission
Candida can be read ly tran fe re fungus can also be
th
re ence of
andida
fm
.'
It
Differential Diagnosis Trichomoniasis H e p e infection Allergic reaction
in vagina
• P
Cl nica Features Symptoms:
ul ar itchin burnin xter al suri
irri at
32
Signs:
excoriations or pustule-papula
ab
vulvar dermititis
ork:
KOH: Presence of buddin yeas
Y e a s t with greenish refractile cell wall
Vaginal bloo cell Vaginal at that sh
bu diri yeas form in et moun
Diagnosis
yeast infection cart yeast be demonstrated in the Treatment Se Treatmen Schedules.
33
than white
VAG
(alias Gardnerella,
(Haemophilus) or Bacterial Vaginitis)
Cause acterial Vaginosi is an overgrowth of GardnereJIa vaginalis(previously known pleomorphi (variably- shaped gram a sH a em o p bi Ju s v ag in aJ is , or C o y ne ba c te ri a v a gi na J ~ variable h o o d whos presence in huge nu bers causes sy ptoms. Garnderella probably interacts with other anaerobic ni infection.
hy G a d ne re l c au s d i e a tIo clear. Fifty percent of healthy women have lo numbers of Gardnerella part of their normal flo@ SYJl1ptO of bact ri vaginosi ar correlated with .il: sign~ficantrise in th number of OIit(/j}t:tCJl vagjnaJis ·ilS· well as several anaerobic bactcn .. It is believed that symbioti relationship exists betWe, O. vaginaJis. ic in s, an th anaerobes. which use th amin acit.l nd give of vo le in in se thel'FI ofthevagJna to leve whic furthe avor th growth ir ta ts bu it ia sh dd vaginaiis. he ishy smel of th bacteria vaginosi discha ge Ga dn rell ca be pr sent or long penQds oftime it se to determin whic individual l l develop symptoms G. vagina/is
na
ia
in
sl
si
hi
sy
bu
to
or
ot
he is
in the discharge. Transmission Bacteria Vaginosi can
oy
th treate well.
dn
ay result ro
is
in on su first. Tr atment si ts
disruption in th norm ic iend
ue tl th prim us
tr
ll
ni
om
hs te
ly
ti te
ti
Incubation pr xi vagina. Differential Diagnosi ni ig os
wash
he is
vagina envi on en that oste la is
to
id
la
bo les, ti
he im ne dear th Gardnerell as
la ob
ll
po
Clinical Feature Symptoms: gh in se is om od ld tc in tati di Fishy/must crid odor from vagina (esp cially prominen
se or
fter inte course
th
Signs:
Lab Work conspicuously abse t. Fe Gram Stain:. KO
fme gram ar@, leshort ro (Gar nerellal an fe gram negative c : U r ' V e d rods an ()Ccf{~r bC S) ad ~reI to eplth~ilia1 cell with indistinct Ipbk.IPuIlched). Ab$~ce ofnoIIl12.11actobac Whiff odor (volatil amines give off when disc arge placed
K.OB.
.
VagiililJ .Cultll.re: tiny, tJfms]~t G a rd ne re J
Diagnosis Symptoms alone-ar
based
1) Characteri ti 4) Presence (rods)
grow
~ ;~ )
Do
.
Colonies of.gIani variable coecobacillus chocolat
plate.
oftbe folloWing signs;
homo en ou whit ad eren disc arge greater th~ 4.5. characteristic clue cell gram variable hort rods replac ng normal gram positive lactobacillu
Treatment
S e e T r ea tm e n Si:hedul~ -..
35
TRICHOMONIASIS Cause ic
ni is
tl give it
th distinctiv je ky swayin
in la
io
le
T ri ch o m o na s v ag in a Ji s nick-named TRICH. It is approxim tely 10·2
Pathophysiology Trichomonas vaginaiisin th Skene' Bartholin'
is ov obility.
gland an
sh pe with ou
th sq the urethra.
le
im
hip-like flag ll whtc
vaginal mucosa than normal fo th vagina. During lo vagina causes .ri in th pH to producin favorabl environment for these microbes to grow. SylIlptoms of trichomoniasis oftcl1 ri_ghtafter menses, C b a r t g e s th vaginal microenvironment, pH changes; and'changes in nomicnal levels ~y be predisposin fadorSininfcction. th tr
he
la
Transmission Tricho onas is transmitte
during onta
usually self limiting in in ecte wo in th pr viou ly antitricbomonal properties.
ia
Withvagina or urethr
secretions
is Me ca
exhibi; Tric afte unprotecte hOUIS, th prevalence drop to only exposure.
Tricho on ds ca asil be transf rr vagina se retion from on WOD)8Il
during sexu
intimacybetwee lv
transmissio in whirlpools, by mois towel, etc., degrees.) su vive (o 2 4 h ou r much-maligne public toilet seat ha receive itS ua role in transmission is highly unplausible, Incubation Th incubation period is pproxi atel
tt ti
is
se with an id
wo
;w
carry
some
ifinfected ll
li
to 28 days afte contac With infection.
Symptoms:
vaginal itching io Signs
us granular
ti area du to vulvar in
li
na vagina edem
ic is is introduced
be
walls ma appear
occurs
Complications Trichomoniasis is relatively devoid of complications.
La Work
Wt;tMQ\lnt:.
I M M E D I A T E L Y (infor orr:ierto ipcrea$¢
labbie yo suspec trich.~
ch
contrast.) Micr scopic examinat on hows moti flagella ed pr tozoan-o oid, sl ghtl than polymorphonuclea leukocytes (PMNs) with characteristic twitchin movement.
an increase in
(Concurren infectio
KOH:
Irich
number ofPMNs a n
with Candid an Gardnerell
are c l e s t r o . Y e d by K()H.
margin clean epithelial cell
is
mm
CandiQa
VIA: (Iloi).~when indicaJed by li tQry.) ii ri
ha
arge
se imen ma
reveal triehomonads.
last year), Differential
Diagnosis
tract infection Impression clinical si ns ar mp
ns fficie
accurately diagnose tric omonia is signsaccura el
he classi co stella io redict tr ch nl
0·70%
me Th n s n d y mp t m s us wi Ga ne Re ul wo va na wa wi no nt di ug ve of h, nd ypi "s wb y" vi no u t is o n o u n in 5% of clients with trich. diagnosis of om ni or p en d nd ng g an i h e v a n a p oo l ur ne e d m en t o n ch ee u f c ie n o r d ia gn o Treatment
t re a tm e n t s c he d u l e
A sy mp t m a w om e me p r v en t p r un ut y mp t m a w om e w i y mp t m s w i mo that F em a xu pa w om e ul Ma pa ul e i h c b e treated, abstain, us ms we ks mo ma nf ve wi o\ m en t Wome ng ou o m vaginal p e ne tr a o n o r c lo s contact With v a n a on ur ng he we m en t a te x b a e r o r n d m s S cx u p a past m on t h ou l b e n fo rm ed .
AL Due to mechanical or he ic linica eature Symptoms:
AG
irri at
he ag na or vu va
Itchin or burnin
Signs: Occasionally clea discharg Foul-smelling bloody Redness
(usually none
V~tis
be caused is ot eces aril ca se he sual atho en microorganisms. It by non-pathogenic microorganisms. It caused by v i se al ar er ho introduc foreig bacteria. Even if the bacteria ar ilot pathogc:ruCj they transien irritation an vaginitis. forgotte
tampon or diaphragm. Occasionally
od re
ro nish
bloo
ischar e.
diaphragms or condom can ca italiz on wome nsec rities to sell vaginal common producer ofallergies.
Advise
own cleanlines withou unpleasant
odOIS
-ex
normal vaginal ec lo itat es ec al
ra in he
an mo sture.
alle gi va niti sh ul be cons dere th wlva or ighs ar re
Treatment A v o i d allergen or irritant
he
ou find
is
spec fi
at gen,
AT
tr hi vagi itis is estr en timulation
Etiology
AG
on pe if inflamma on aginal mucosa,
he agin re ulti
fr
ecre se
vagina
atroph
occurs when estrogen production is
hi ni
th vaginal mucosa re er ng
vagina.
scep bl
tr um an
nf ct n.
Clinical Features Symptoms atrophic tissue hi scan aginal
sc ar
comm n.
Signs
that occu normally inthe postmenopausal
state.) Sp
nd ri le ub
ai
inrroims
urethral orific
Se ua tr nsmitted se se Irrita io trauma alle gi reaction Whit lesion (leukoplakia.Iiche sclerosis} Malignancy Atrophic cervicitis Postme pausal blee ng fr othe ca es
In
in
ia
ti
tu ie
hera y, an
as
in ally
icated
istory .of'vaginal bleeding.
wet m o u n t done to rule ou candidiasis. m a u ra t o n n de x (MI) show mi correlatewith menopausal symptoms.)
41
BARTHOLINITIS Symptoms:
Signs:
Lab:
ofvaginal lu rica
ring ex al exci em t, al ho
an pressing with th
mb
directly from
ex er or
ster
mo
he lu rica ng lu
part of th labi
flow
in th vagin ajora. Normally, the
painfu mass Abscesse ar caused by
Cysts may te be chro ic corrected by
su ll
ct rial infectio
ai es
an
an
an ec
it
ai ful, caus
si le
ad re ea ed infe ti s. They on requ re re tmen un es ac infe ti re urs.
gynecologist.
Treatment Refe out.
42
FOLLICULITIS Clinical Feature Symptoms:
Signs: Pustul
surroundin red,
hair follicles
in
u n u s u a l to it is well endowe with pimple or folliculitis,(infiam atio of ollicl in this re Usually problem, brought to YOurartennon'bec:ausepc:ople 3 . t e ' l 1 1 o r e concemed,about skin problems on thei genitals than in other places. grows back.
Tr.e.trnj::nt
Afi¢f l lH n g o u t syphilisart herpes treatment tlleh9dy --hot S6aksdrcolIlpresses ~-unlessthe in ti il io t, ti consultation with shif prof ssional.
it
for-any other part of to th ly ti te nd ca ed after
CERVICITIS ra
egativ
As
these result,
Neisseria gonorrhea and Chlamydia tmchomsti
acteria. Ch amydia is.a
STn
is
th more frequent cause of cervicitis. Itis estimated that chlamydia occurs concurrent with 25-50% of diagnose Gonorrhe cases in women.
endccervix,
columnar epithelial cells.
Both Gonorrhe an c;:hlagiydiaar sexually transmitted. contac with he cervix; to; infectien, woman usuall acquires cervicitis from intercourse,
condom, to anothe wa
cause
hand,
risk for cerviciti
columnar cells.
health issue.
vast
indicate thatthey are infected. Theunfortunate these asymptomatic spreads frqrn,the cervix infection rogre;ssed q_tb (Pelvic In.fla.IPnl,atory1)isease) occur. Thi c:ol).ditionqm bevery painfu an cart permanently damage el ic organs. He ce he mp rtance as soon as possible.
SY tlptom an
organism
igns o f c e rv i ci ti s
Gonococcal cervicitisis
history
2-10
there
esse tial bu
elpf l.
Clinical Symptoms:
experience: ag na discharge, sometime withmi
itch
than
causative bY'positive
sufficient sign caused, arc efJ"edive against both infections. woma
c u l u r e s n d ic at e otherwise. A l l o f h e r ea tm e nr op t o n infections
th
..spotting with intercours ..dysuria (indic te concur en urethr
Signs: sc
Cervix" section) taken
~.see
protocol)
C l in ic a l i m p re ss io n le
if
synd om
nt
ig
te
le
while
in
S m ea r
Who should be treated? ..women with positive gono rhea or chla ydia cultur ..w()met wh have trBIlSmissabl sexual contac with m a with either Ot diagnose or suspeeted(Le has drip NGU,GC, wo ..women w i more o f h e g n (a listed abov fo a J T 1p ~ o n ve u np r ur m c L M P ma b e t re a te d , if th ..women wh st at appointmen time tx schedule) .br
ld te te ..contacts of contacts .. female c on t c t o f w om e with positive cultures
ti
Epitreatment guidelines suggestthat allwomen; wlt0 ha tr.mStniS!iahte sexual contact it be t re a te d • . T h e s e people primar contacts. wa diagnosed with Secondat¥ contacts tmrtsmj,sS;:i.ble S e x w i someone ho ha prima.ry tC$!ed.ffa primary c on ta c t".S~ symPtomati or has positive cultur result then they;are no longer onsidere pitreatnieni Thei Partnet(s) ar th
primar
contacts an epitre te
it
be tested.
Inboth cases, treatment is to OcCuronly lJpOnpoSitiv test results. Who shrillld Do be treated? ho a~ pregnant wome w om e With IUD' .w
in
be referred
tr tm
ta to
"Low-gradePfl)" treatment
th schedule .. Treatment
il
tr tm is
li ly active with men.
45
ha it
lt
iv
unprot cted sexual intercours sinc thei last
tested
Follow-up crucial.
ly
tx schedule
ic ti
if'the test is negative ic io
ow
is
ta in th ll ti ot experien in an pelvic pain in se ua pannens) of exposur planning to return fo TOe
gonorrhea) client
se
enstrual pe iod. Th se
on
as re exposed, th
tr
t.
th
e-tr at
46
ic ll na
Neisseria TOe
It able to recogn ze ym toms an
iv ap ropr at
referrals.
causes
it
appendicitis an acut pyelonephritis
1.
(Pelvi
This is
Inflammatory Disease)
in th pe vi (t
cause PJ.D. are: chlamydia. gonorrhea, an mycoplasma
linica
Features of PID
2.) Fever/ChillsINausea/Vomitin 3.) Lower back pain .) Pain
bleeding af er nterco rs 6~)Increase menstrua cramps 1. Swolle abdome
.) Ac te SUdden nset of pa .) Chro ic Low- rade persiste Importan
istory
Rece
vagina
infect on whic ma flar
Gc ch amydia infect ons, ch ldbirth.Als,
eriodica ly IU
in ertion
ACUte a n d C h r o n ic : refe to Subacute: TX·schedule 2. Ectopic This is 'ovaries or abdomen.
carlyaspOssibJ~
is
treate as
fetu become threatening situation Clinical
.i
Features of Ectopic Pregnanc usually one-sided
e,
tenderness)
Important
mi
History
Recent ubal liga io as Be
Treatment Will undergo
immediately ltraso nd an surgical remo al of fetus If'necessary;
pregnanc es
She
cs As BFC, suspected ofbaving an ectopic
D· me
as an IU
uterus, or it ma perforat th
Clinical Features Symptoms:
Bleedin
FevertSweatSlChillsl NauseaIV omiting
Treatment mm
ID an ec op
IU as contrace ti method ar co sidere pregna cy fo the followin reasons:
PID:
IU
Ectopic: IUD'
er
fetus) and
ev
likelihood of tuba pregnancies.
4. W h e n tissue whic
the body, uterus This ti$SUebui1ds up and way to leav thebody,
nonnally lines the uterus
internal bleeding,
parts
ma
Clinical Features
at
me
Treatment Refe
R
48
an
ct
b.
ibroid
of al women will estrogen
5. Th
do
be removed.
Large or numerous fibroids cause: Pe vi pa Bleedi etween eriods Excess ve menstrua flow Treatment
If
OBIGYN.
cyst
tumors. Mo
ap
linica Features AbnonrialIIienstrual
el
With
cycl
ovulatio Pain during intercourse. Abdomina swelling Treatment
49
ry
ar
SUBACUTE uterus, N e is se ri a g o no r rh e a : and/or Chlll111ydiatmchomstis.
commonly it is the B F C ,
section.)
with subacute
realm of Free Clini medicine.
D . A cu r u s seriou complication whic ar
is
abdominal pain.
Signs; Clinical impressio is m i ld im o dC f il te - -c e rv ic a l m o ti on . t en d er ne s
exam.
detects re nanc reatme
in cervicitis section, plus ( C M T ) andlor adnexal pain on bimanual out;
prc:gnancy test which
te ts ar sensit ve enou h. ll iven re ar le he ex al istory
AU treatmen of subacute PID
person
or by phone.
Wh
ho ld mucopurulent discharg e d inflamed cervix significantl friabl cervix
Wh houl omen it th fo lo in , s posi iv
co di ions
p a preg ancy te
us ecte
re an
take Penicillin or Doxycyclin du to allerg or breastfeedin Treatment Co ul cu re reatme eo tp t w h s
chedule.
ef re reatin
be ur to
fo ow ng
Follow-up This is complication
will p ro ba b
follow-up
r es u l
follow-up.
is unsuccessful, further if Th fo lowla nc udes
imanua 48-7 hours. lfno improvement, refer out. c om p le t o n o f r ea tm e n to include:
culture, if original
positive
51
NORMAL CELLULAR PROCESSE woman'
vagina
begins in G en e
pe
Early
more resistant to dama e. unti1 30's,
DES
he ransformat on rapi change
adcnosis.
examination, th cervix in
s. This is ca ed c:ctopy.
endocervical cana1.
cells least thre system fo classifyin systems.
.
CrOII-lection
of
•~ ·-'X...
j~
....
..
qu
• •
'.
.i
·X·
WI
- .; .: ~ : r " :_ "
::";:"':~~f~:":','.
fT. 'l
.1.
A
,J
Norm"l
Sq Eptlh.
.~ ~
. . , :
S P
thr;r
"l~,
:.
~r.
)..
iJ.l ~ty~ P. .::~:
. -
_.~.::-.,"'&I
Bllement u _ _ . .
A"
_"..,rane
.Y
.:,~:. Tia.ut-Stroma
ImallYl
Underlying
~;;""';,oI!;
a.:,.: e,.. :'
i n u'rm n d 11Jr,'o Irrn hO'rt IUIJr ,T hi J iJ colltd
WBIIICl ,1)1.'11o ll l ' r p uM I t. V
:.
;t,~~ .,~', ..
. ~
. •
Mild
:.:.
M':
~·
dW'~"'I'''' l it , C / I C f I l~ ( ,I w s b l .' l. 'l f I "( ' lc m J t f'/ll'''rltlllll
r..,.o:,..
L:8. 0Vl: ~"qJ:~i4l~~
. _
• . ': '
, ,
• t
,:
•.- .
ll '>":~;~':-".:_'':: :: ""
~~t.
Ufof"
1:
;~-r..
~;.t ~:S"~.!~:~:'-
IA:Io"I
.i!i.
"Cu/mmUlI
cervical cellular abnormalities. T h e f o l ow i n Class
1"'
ES LT
ND CATI
AN INFECT ON
P a p s that report yeast, clue cell (suggestin symptoms.
gardnerella)
b e c on fi rm e d
wants to
ay
ra ai em mber that tr ch mo as ca careful to treat smear! report alone. is fo cerv ci is or an
re sp asti
hang
saline we mount.
an re io ly mi ed vaginal infection. Do
Rece
80
at pica Pa
be determined, ifpossible,
in
Ce tain cell la abno ma ties co si tent wi me r. e. os ommo uc nfec on
the inflammation
thorough-hi-manual
es that many (appro ma el
reports
smear
ecif infectio ca en if ed re th erpe ru (mul i-nucleate
vagina.
es on or area that
it th ap an cell
any
FOLLOW-UP
the Pap.isreturne shift
withan rofess na
repeat
it
ac ro is
at
nd
call
an ab orma ty
(Cass I), at th lab.
cyto gi ep rt
it
Ce vi pi Th "n ma
va
ma
ma
size ca
w om a
pea,
pp
w om a " sm i ur
sl
Orc
us D' ul precancerous. n o easy wh unusual, even if y o h i it is benign If
us
Th we
vi me u c as freckles on
things, too.
Ot us that looks wh A lw ay s p a yt doubt, g e h i p ro fe s o na l c on su l
Ab ma vi va ua ug po pi x am , we biopsy n e d , A . p o p e is gynecclogicalmicrosccpe vi he v i at ma ~i un h e c o lp o sc o p e exam, ma pi ue pu ue ue ps pr va ve x am i pa Th pa report mp ml pl We be C, ut p fu l xp ~i ~pr ur y ou r Se ut po py p sy .
ue ur
Th pQ wh
pi
cervix. G C a r u s S TD ' u s leSions m yd i m a us vi h om on a m a a u " s w b p a e s" ; h e p e m a us ve n d v en e a l warts m a c au s c au l o we r- l k e a t e ne d o r a ce to wh i u rn in g w h w i v in eg a es on oi he v ix . S e h o ns p ro to co l o r d e Va
Th
is b r
um de pt on of SOmeo he mo
Ettopy,cciropion This occurs w h n e h e e nd oc er v c a u su a pp
Tr um
This is
ul g en e W l
ka
{aka:
squamQ-columnar J u
canal mm
pn
pu
us mi he
vi wh po o mm o o nd i n S
wi
pp
ve an ue
ur Th
Th un ~e
ve
um us pe ut b u h Qu l be w a tc h e f o i nf ec ij ot L
us
ki
um Qeo
mm
Ec py also
wi
wh
v ix , This
OCQlr
ma
pi rauma will
y.
tears inthecervi~ radiating The~~ This i$ jQ$~ f~cy w o he os. C e rv ic a a ce ra t o n u su a l e su l from h i d b bo n. Th a n b e p ro b m s w i t i nf ec ti o an wh up vi W om e w h have lacerations o n e i v i h ou l be er b ac k h e p hy s w h d i h e o r g in a procedure
01' birth.
T h e e n do c er v ic a canal wi wh ys wh u su a vi ur the e rv ix , h e h e y s m a b e v i b l
54
mu us Th p e u lu m x am .
Cysts
ve pi
pea size
same pink co th problems. us
ervica polyps th cervical c:anal,and th
N OR MA L
N UL L P AR OU S
O RM A
CERVIX
Round
or
IS
A RO U
oval
Slit-like
slitlike appearance.
covered
An U NI LA T ER A L TRANSVERSE
vers
CERVIX
IlILATERAl TRANSYfRSE
or te late lacera ions
55
STELl.ATE
Table 1·1·]
c:.:: c:.::
:E =:I
-e
c. c.
ii:
.... CI
;;
....
0::
Cause er es ir with
nita
Type
fa il Th er es is co si ered
In 60-80%
rp
re nfecti s,
re ikel to caus symptomati rg area throug oral sex.
Pathophysiology Herpes v i u s infect an mucous membrane o r a n y wh e r
destruction in
ther is
icroscopic
disease,
reak
th
HERPES
rv
recurrences
Th
um
frequently
ru Pers
somewhat protecte
roduce
ntibodie
nd se itiz
wi
weakened im
yste
agains infectio with H S V - I I .
ymph cyte re
of en av
n d type Herpes ar is inct Type closel relate ir se it enit er es is co si ered re nfecti s. or li el and more likely to recur.
to er es virus rr er ever er es nfecti ·I
T yp e caus
usuall associate ot atic is ase,
Transmission rp
routine. shedding is pr ably insufficient
infect
co tact fr he ti they firs th le io is co letely e. Incubation
artner av
re
Shed in
ti li
co ti es thou
sensat on (bef re
rt
at
esio ac uall ap ears
il
past
mforrned)
-,
linica eature _ecl nica pict re fo ge ital erpe varies grea ly ep sode or recurrence
first episode
epending
part
he he it
HSV infection:
(Ist 3-4 days afte onset oflesions). ainf lles Il either diffuse or in clusteror groupe together that o m p ap u l -> vesicle ~>pustule -> we uIce _> cruste lesion
mu tiple, progress
tender insuinallymplwi~()path disease is often th sympto
pa
(increasing over
weeks
l a s t to resolve)
w he n u r i n e.'. passes over lesion '.
_.
v ag In a a i1 d1 o ~ r e h t l 1 discha,rge
clinic
the visit mUltiple vqikhe ma bil¥e coaJ~e jnroJargeil£e3 of ulceration time Th size ofthelesionsvaries lcer-act ve es ,o l$ persis fo to 5.days before ~dy. to IQ oftheilhlCSS 70... crtJ.sting wome thpr inatygen ta le ibrishav co comm ta SV cervic ti Pr ma HSV cervicitis ma be syrri:ptomatic (producing cervical discharge) J' asymptomatic Th cervix Areas .s
5Ymptotn.$ o( recurren HSYinfccti lesions • " -few
(1 r2)
shedding virus
r e m a i n a.s orte time --
-1
days
lS~ q f W t , · e tJ , hiV¢involvClPent o f h e c ~ w i W'hilt t 1 x ~ ' p r i m a r y
symptoms recurren original lesion
enital erpe
sual
reCllrrentmfection
w i t h both
systemic an loca confined to
Recu.rrenee: Th um er recurrence that individual cfgenita widely an ar approximately:
herpes experience varies
experienc
recurrences
than once ever year to
year afte initia outbreak
ar associated with
gene al lo er inth initiation of recurren infections include:
Recurrence
esistance.
redisposin
acto
or friction to th genita area
m ba la n
(particularl
vitami
deficiency)
an spee
Complications: le involv
th
si
en
of th nerv
whic cont ol ladd
yeast du to th imbalace in th vagina
having this conditio
is ls
unction.
nviron ent.
co plic tion
many, th
ti
Differential Diagnosi ll olluscum
ti ontagiosum
phil ly phog anulom candidiasi
venereum
Most he pe infections re di gnos by thei typi al appe ranc grouped, painfu vesi le nd ul eration, ccompani tend
58
-- ha acte isti multiple ly ph denopath -- an
The .abillty
in isolation
WET ul
obtained from from cr st ng esions
mp
two test ate:
All
th base of es cles in di ting ishing betwee
erpe
yp I.
is the m o
II.
en
that come from of v e e s a n also ha th ad anta
2.
Thi es
looks The lab
This test
rise in
'This lest
m o s useful
interpret. re or either no herpes anti od
foun
evidenceof re lous
infectio with er es oti~ iclr nc
10 viIUSeS pe milliliter is bqt. The lesion can with smal ga ge need e; ( C C i I S i swabs .l 'hey f t . f S (e rr ed im r p ¢d ia te l vi r u s. ) V e s c u la r f lu i vjpll transport r n c q i a (the blue to tube to the S ta t L a b) . A f te r n o cu l a i on , refrigerate in upright position.
is taken
vesicular
useful
this test
nfu
An
with ab
suspected.
primary syphilitic chancre.
viraVrickettsialla slip form me
an no trea treatm tmen en ha been been ound ound ompl ompl tely tely exho exhorb rbit itan an pric prices es
ff ctiv ctiv in pr thin thin
otin otin
virus
rapi rapi heal healin in or pr ve ti
Acyclovir isan anti anti-h -her erpe pe medi medica cati tion on whic whic ha be test test nd prov prov shortening i!!i!S lo te is nu le tide tide nalo nalo whic whic brea breaks ks th vi al DNA nd prev preven ents ts repl replic icat atio ion. n. IT e 1 tM tM e d c a However, C U IT
D ia ia gn gn os os i
an
ff ctiv ctiv in ec us of th
anne anne
T r a tm tm en en t (J 988) 988) says says "Lon "Longg-te term rm acyc acyclo lovi vi
that
L-Iysine, amin amin acid acid fo seve severa ra mont months hs are
be take take to redu redu recu recurr rren en is ie
vari vari ty of pall pallia iati tive ve trea treatm tm nt
th
ti
to redu reduce ce disc discom omfo fort rt an prev preven en bact bacter eria ia infe infect ctio ion. n.
to
inflamed
th 1pi
anesthetic) in oxid oxid crea crea (a acti active ve ingr ingred edie ient nt in ba ie te te th heal heal them them
He pe an
of
will
temperature
•.
grams daily,
iape iaperr-ra rash sh cr am
te he ij .\ie .\ie
Pregnancy
an
ca be tran transm smit itte te to th baby baby , 7 Q % of~· in Q " ,7 recurrences ft th 34th 34th
week. 1so
pregnant that
th cart; prov provid id im that they they beca became me preg pregna nant nt
60
wh
th
fi st beco beco
CONDYLOMA History general GYN history.)
venereal watts in
as sh expo expose sed? d? Warts for how long? W h a t kind(s) kind(s) ofttea oftteaune unent? nt? W h e n (dat (dates es of trea treatm tmen ent) t) Last treatment?
pap results? any abno to abnorm rmal al Paps Paps W h e n exactly? )\nytreatrnentorF~?
exam
io
VDRL VDRL When When Results? st sheillf:beenchecked yet? If es where and when? Is partnec
tm
IMP On any other Illeds? A n y o th th e m e d c a p ro ro b e m s or hlam hlamyd ydia ia test tests? s? psychosocial review whe approp appropria riate te coffee drin tr es es sf sf u l o b unem drinke ker, r, empl employ oyed ed In s tr unempl ploy oyed ed havi having ng ny problems with herl herlhi hi rela relati tion onsh ship ip fami family ly and/ and/or or friends, financ financial ial proble problems, ms, chronic stress wants to sc if io th
61
flat
in
and
and
vagina, and cervix in
virus
is
been reports of warts appearing
ut been
ev e ra ra l long a s s ev warts (sta (stati tist stic ical ally ly
about
unknown.
ea
vagi vagina na
Wart infe po ib infect ctio ion. n. peni ar subc subcli lini nica ca nd peni
It
human papilloma
abou abou
cases of cervical dysp dyspJa Jasi sias as (whi (which ch cause wome womenu nund nder er 30 in
appears
is strongly related to cervical Because we cannot di rn more benign,
he
er ca wart infections
ecau ecause se m a n y
(i.e.
will
colposcopic
with
all women
all
wart wart viru viru
treated, ed, it c a virus is treat
commitment
ofh
active active treatm treatment ent are
must must
it takes
c u without reexposure. to
vi ts
and abstinence
go
health, self-care,
(i.e.
Any Client ey Word --DjJjgt:Jlct pad, apply
an question.
us ci
growths
if
(i,e, plain,
to
Warn
Aller vinegar well some some cerv cervic ices es with with sign signif ific ican an ectr ectrop opia ia know that th re ar an ther ther re so fo teni teni at scre scre el ou li ed arca arca fthi fthick ck ra tice tice an ex erie erie to isce iscern rn
ncer ncerni ni
ap
with fo ed It is impo import rtan an to
on
so
te so etim etimes es is nfec nfec io
la
rt
It will take
ears ears
Pap
that
worker to unde unders rsta tand nd that that there is decr decrea ease se this this fals fals nega negati tive ve
me
tren tren;t ;ten endO dOlJ lJS1 S1 high high fals fals nega negati tive ve rate rate on Paps Paps that that is lablabbetter' better' thanothers thanothersat at ic in up to 60%) 60%) b e . a s high
to less than using
24
more more sens sensit itiv ive. e. Rare Rarely ly are.Papsmear re
ts al
immediately
os ti e. lt ug
me labs do screening to
wart infe infect ctio io
smears!
Bo om
ty a, atyp atyp a, ne er is: Do freq freque uent nt pa warty
Treatment We
ca
ist nenc nence, e, re la
evis evis ts
the ongo ongoin in natu nature re of
briefly inform her as f ir ir s l in in e tm (triawUe that. is awUe times) s) nt ne To al to 5- time p e rs rs er e r ve v e ra ra n c e a r th main artn artner er chec chec s, mainst stay ay of reco recove very ry
For flat warts, cerv cervic ical al wart warts, s, exte extens nsiv iv vagi vagina na warts specialist will be ell) ell) lect lectro roca ca er aser aser re tr atme atme ch ce Cr trea treatm tmen en of choi choice ce fo cerv cervic ical al infe infect ctio ions ns
urge urgery ry.( .(fr fr ez g)
ly
Self-Care immune system that will increa ealing
ecreas
Ge
ai
an en ance th
mu
sy te
dry exercise
reduct on techni es iv he su estion review abstinenc Vi alizatio ex rcises
an re urce
if
if desired)
any stress
tr
t,
th
th
te
of th
is th
ic
in
po
exclusively "saf sex, or no ..t ransmissabl history is
dete
in
tr
is used throughout this sectio to
ti or no activity
NO
HL
Unfonunately
you
ea non-transmissabl
sexual activity
DI
it
3-6
nf
le
ng negative TOC.
BACTERIAL
se ua
th ld
se treat ta
tent tr
ng
is appropriate, unti
(GARDN RELLA)
VAGINOSIS
s,
an TRICHOMONIASIS
tn lab
negative lab esults ma choose between: 1) 2- we ks of abstin nc 2) tr atment of comp rabl or less ef ectiveness than that of he pa tn
treatment
th ve usin differen treatments
th
ti
n,
nt
partners should be informed
ient
of th
Men Partners Fanners may choose between: 1) 2· week of abstin nc 2) tr atment of ompa able or less effe tiveness than that of hi partne
he
an pp
with equivalent treatments
tm
ou
an
ou
screenin
an
YEAS
VAGINITI
Wome Partners With first m e n fe c o n ur ng he m en t should be ke ye r e n fe c o n be d u e Me artner T h o up I h ou l Un ums ze me ye ma
bs ul
h e c ou p le t y mp t m a
du ng be du e.
s ho u l a b a i f ro m a ns m s ab l w om an . nf ur p r n t H ow ev e ur
m en t M e n u su a ow nd
no
qu un
exua ac vi pa ne ye ma no
pi
m en t k in ,
ecurrent east Infectio R e cu r re n t n fe c i on s c au se d b y treatment a i u r e p r ed i p o s n g f e y l a n health; S om e w om e u s mo pr ye At doesn't c u r a i h e c hr on i BFC, provide h e w o m e with o t o f nf n, he w om a ul -r ou Th nf ns wh nc us y e as t- li k e s ym p t om s . Also, the~ mote c om p l c a e d f ac to r n v o v e d R e ce n u d ie s me me pa me ve un c hr on i y e as t infections.
MENOPAUSE usually
and
years
tjo experience thes symptoms
vaginal
As
woma
year after. It 80%
me opau al wome
reaches mid-forties, he hormonal output varies
menstrual period
ecomin
closer oget er
aria ions on this ph sica stress
yp ca cenari eg ns With erha with heavier leedin sometimes. ater here are, however, becomes scantier will ~Illptly, usually afte sudden emotiona
Abnormal vagina bleeding ca bea indlcatienof'hormcnal imbalance, endometriosis, uterin fi ro ds or ca cer. Rc eate vezy heaV leeding; es eciall it is itl'egttlar, is ca se fo eoncemedabou ag na leedin in also
Western society ha
fa le
recogniz
he ignifica ce an ormalc he vari us pa sage "medical events requir ng reatme t, so to
that
As WithPMS, mo ing, alco ol caffeine sa t, ugar
and re
except blac women.
occur
effectiv also
ate
steo orosis is
treatmen is estr ge
which occurs in
replacemen therap
In ak of ca cium carbonat an vitami
women.
..-el;
"'eenwood.
me
O U TB o d e s O u e l e s G ro w in g Menopause. Naturally, by Sadja
