1. Wollega University
College of Health sciences
Department of Midwifery
Gynecology for Midwives
1

2. Unit I
REPRODUCTIVE BASICS
Approach to the Patient
2

3. Chapter outline……
– Approach to the Pt
– Gynecological assessment and dxtic procedures
– The role of imaging techniques in GYN
– Embryology of the urogenital system &
congenital Anomalies of the female genitalia
– Genetic disorders & sex chromosome
Abnormalities
3

4. Introduction to Gynecology
 Gyn , gyne-, gyneco-, gyno- means= female
 Gynecology is the medical specialty concerned with diseases
of the female genital tract, as well as endocrinology and
reproductive physiology of the female.
 Gynecology is health care for women. It helps to take good
care of sexual and reproductive health.
• Routine gynecological care
 Prevents illness and discomfort
 Allows for early detection of cancerous disorders of female
reproductive organs
 Detects sexually transmitted infections and other conditions
before they cause serious damage
 Prevents sterility
 Promotes healthy pregnancy and childbirth
4

5. Approach to the patient
• An effective relationship b/n health care provider &
patient is based on the knowledge and skill of provider.
• These qualify the provider for:
Adequate communication between the individuals &
An appreciation of the ethical standards that govern
the conduct of the participants in the relationship.
• The health care of women encompasses all aspects of
medical science and therapeutics.
• The special medical needs and concerns of women
vary with the patient's age, reproductive status, and
desire to reproduce.
5

6. Approach to the patient cont...
• The diagnostic possibilities and the choice of
diagnostic or therapeutic intervention will be
influenced by the possibility of, or desire for,
pregnancy or, in some cases, by the patient's
hormonal profile.
• In addition, the gynecologic or obstetric assessment
must include an evaluation of the patient's general
health status and should be placed in the context of
the psychologic, social, cultural, and emotional
status of the patient.
• Assessment of the patient is done by history taking
& physical examination
6

7. History
• To offer each woman optimal care, the information
obtained at each visit should be as complete as
possible.
• The clinical database should include general
information about the pt & her goals in seeking care.
• History includes Id. history (IH), chief complaint
(CC), history of present illness (HPI), past medical
history (PMH), medications used, Allergies, etc.
• The developmental history, menstrual history, sexual
history, & obstetric history obviously assume central
importance for the gynecologic or obstetric visit.
7

8. History cont…
ID: Age :
Problems and approach to them differ at various age group.
Prepubertic Age of menarche
Adolescent Age of telarche
Reproductive age Menopause ---
(15-49)
Premenopausal
Perimenopausal
Post menopausal
8

9. Cont…
b) Marital status: single , married, widowed, divorced,
separated /geographical
C) Sexual status:
Monogamous –one partner
Heterosexual /Lesbian
Polygamous –many sexual partner
d)Occupation – occupational hazards, allergies,
industrial factor/carcinogenic---neoplastic d/se,
heavy work---uterine prolapse
e) Religious affilation
f) Detail contact address etc…
9

10. History cont…
CC/Chief compliant
 Cc is the main very cardinal problem of the patient
which explained by the pt & which make him/her
visits health facility.
 State the problem with duration
What kind of problem are you having? How can I
help you?
 E.g. – AVB- Vaginal bleeding/ discharge
–LAP- lower abdominal pain –chronic /acute
–Pelvic pressure - Amenorrhea
–Inability to conceive 10

11. CC cont…
- Dyspareunia – pain full sex
- Dysmennorrhea – pain during menses
- Mass protruding out of vagina
- Ulcer on genital area
- Urinary incontinency
- Abdominal distention
- Hersutism - abnormal hair growth on female
- Sexual assault, Vulvar itching
- Inguinal swelling, Recurrent abortion/misscurrhge
- Sexual dysfunction,
- Psychosomatic complaint- no pathological finding
seen but they have complaint
11

12. HPI
 HPI- is an elaboration of CC
- Start from their last sexual, reproductive
performance
- Gynecological illness related to parity-
– Where? Anatomical location?
– Date of onset?/duration? Intensity/worse?
– Duration of the symptom?
– Related problems?
– Aggravating factors? Relieving factors?
– Emotional change in patients life?
12

13. History cont…
Menstrual History
 LNMP, LMP (last menstrual period)
 Age of menarche, menopause
 Cycle length, duration, regularity, flow
 Associated symptoms: pain,
 Abnormal menstrual bleeding: intermenstrual, post-coital
• Normal Menses:
- Menarche 11-14 yrs, Menopause 45-55 yrs,
- Menstrual interval 21-35dys (av. 28 days),
- Volume – 10- 80ml/ av.50ml
- Duration 2-8 days( av. 5 days) - non offensive odor
- Dark non clotting, associated with mild abdominal cramp
13

14. History cont…
Sexual History
 If the women is in RAG- sexual activity, chxs
of intercourse
 Age when first sexually active
 Number and sexual of partner
 Oral, anal, vaginal
 Current relationship and partner’s health
 Dyspareunia or bleeding with intercourse
 Satisfaction
 History of sexual assault or abuse
14

15. History cont…
Contraceptive History
 Present and past contraception modalities
 IUCD---- may cause PID
 Compliance
 Complications / failure/side-effects
Gynecological Infections
• Sexually transmitted diseases (STDs),
• Pelvic inflammatory disease (PID)
• Vaginitis, vulvitis , lesions
• Include treatments, complications 15

16. History cont…
Gynecological Procedures
• last Pap smear
• history of abnormal Pap
• follow-up and treatments
• gynecological or abdominal surgery
• previous ectopic pregnancies
16

17. Physical Examination
 P/E is the 2nd component of the pt assessment.
 P/E should also be directed toward evaluation of
the total patient health.
 The patient again should be encouraged to view the
examination as a positive opportunity to gain
information about her body
 Pt should be offered feedback regarding the general
physical examination and any significant findings.
 The examination should always include a
discussion of any concerns expressed by the
patient. 17

18. P /E Cont…
 GA: General appearance- comfortable, ASL,
CSL, orientation, conscious level …
 Vital signs: PR, RR, BP, To
 Wt , ht- is important for postmenopausal women
in decrease in ht due to osteoporosis
 The following examinations are essential in
gynecologic physical examination.
 Breast examination
 Abdominal examination
 Pelvic examination
18

19. P/E Cont…
 The Breast & axillary Exam
The breast examination provides a good opportunity to
reinforce the practice of breast self-examination.
 Patient will change into an examination gown or be
covered with a drape sheet.
 Put the mother in lying position on back, head tilt,
adequate positioning help to gain accurate screen
1. Inspection: - inspect for
- Symmetricity /size, position , shape
- Any observable scar, swelling, discharge ,color
- The size of two breast may not necessarily equal,
slight difference is normal but not too much
19

20. Bt ex. cont…
2. Palpation:
Clinician will examine the breasts for lumps,
thickening, irregularities, and discharge.
Breast lumps are often discovered by a woman or her
sex partner.
Ask the pt changes noticed in the breasts since last
exam, if any. Should become familiar with the way
breasts normally look and feel.
That way patient will be more likely to notice any
changes
Classify in to 4 quadrant 20

21. Bt ex. cont…
 Start from axillary lymph node / using your finger
 Support the quadrant you are examining
 Feel :- tenderness – advanced Ca, tenderness during
1st trimester
– Mass
– Discharge while palpation
– Retraction- in advanced case of breast problem
– Engorgements
 Sitting position- arm above the head
 Litotomy – arm on the side of examiner/under the head
21

22. 22

23. Macromastia.
23

24. INFLAMMATION?
Peau d’orange
24

25. Brest self examination
 Some women use breast self-exams (BSEs) to get to know
their breasts.
 The best time for a BSE is one week after the period, when
breasts are not swollen or tender.
 Lumps are also noticed during day-to-day activities such as
showering or sex play. Most lumps are not cancerous.
 But report anything unusual to the clinician as soon as
possible.
 Ninety percent of breast cancers are found by the woman or
her partner.
 For this reason it is important that women understand the
importance of examining the breast on a monthly basis.
 During pregnancy there is no special time of the month that
is best to reform the examination.
 In non pregnant women, 5 days after cessation of
menstruation, it is the optimum time to detect changes
25

26. Four-Step Breast Self-Exam
1. Inspection in the Shower
- It is easier to examine breast when hands are soapy.
- With your right hand behind your head, examine your
right breast with your left hand using a grid or circular
motion
- Reverse the procedure to examine the other breast.
2. In front of the mirror
A. With arms at sides looks for:
– Changes in size and shape of breasts
– Changes in skin dimpling, puckering, scaling, redness,
swelling
– Changes in nipple inversion, scaling, discharge from
26
nipples pointing in different directions.

27. Four-Step Breast Self-Exam cont…
B. Holding arms over the head, inspect closely in the mirror
for masses, breast symmetry, puckering.
C. Press hands firmly on hips, below slightly forward.
– Inspect in mirror for lumps or pulling of the skin.
D. Each breast should be a mirror image of the other.
– If you think you detect a lump in breast, check the
other side to see if it feels the same.
– If so this is undoubtedly normal tissue.
– Examine using the circular or grid motion as in the
shower.
E. Gently squeeze the nipple of each breast b/n your thumb
& index finger to check for signs of discharge or bleeding.
27

28. 28

29. Four-Step Breast Self-Exam cont…
3. Inspection on Lying Down
• Lying flat on your back, with your right hand under
your head and a pillow or towel under your right
shoulder, use your left hand to gently feel your right
breast, using concentric circles to cover the entire
breast and nipple.
• Examine every part of the breast with the fingers of
the left hand held flat.
• Gently press in small circles. Start at the top
outermost edge and spiral in to the nipple.
• Feel for lumps, bumps, or thickening.
• Repeat on your left breast. 29

30. 30

31. 31

32. P/E Cont…
 Abdominal examination: follow the same procedure as
obstetric abdominal examination
 What methods/skills are used during abdominal
examination?
 Pelvic examination
• The pelvic examination is a procedure feared by many
women, so it must be conducted in such a way as to
allay her anxieties.
• A patient's first pelvic examination may be especially
disturbing, so it is important for the care giver to
attempt to allay fear and to inspire confidence and
cooperation.
• Reassurance of the patient is helpful in securing patient
relaxation and cooperation.
32

33. P/E Cont…
 There are four steps:
1. The External Genital Exam
2. The Speculum Exam
3. The Bimanual Exam
4. The Rectovaginal Exam
Step 1. The External Genital Exam
 The pubic hair should be inspected for:
Pattern (masculine or feminine),
The nits of pubic lice, for infected hair
follicles, and for any other abnormalities.
33

34. P/E Cont…
 The skin of the vulva, mons pubis, and perineal
area should be examined for evidence of dermatitis
or discoloration.
 The glans clitoridis can be exposed by gently
retracting the surrounding skin folds.
 The clitoris is at the ventral confluence of the 2
labia; it should be no more than 2.5 cm in length,
most of which is subcutaneous.
 The major and minor labia usually are the same
size on both sides, but a moderate difference in
size is not abnormal.
34

35. P/E Cont…
 The urethra, just below the clitoris, should be the same
color as the surrounding tissue and without
protuberances.
 Normally, vestibular (Bartholin's) glands can be neither
seen nor felt, so enlargement may indicate an
abnormality of this gland system.
 The perineal skin may be reddened as a result of vulvar
or vaginal infection.
 Scars may indicate obstetric lacerations or surgery.
 The anus should be inspected at this time for the
presence of hemorrhoids, fissures, irritation, or perianal
infections (eg, condylomata or herpesvirus lesions).
35

36. P/E Cont…
 The clinician visually examines the soft folds of
the vulva and the opening of the vagina to check
for signs of irritation, discharge, cysts, genital
warts, or other conditions.
36

37. Step 2. The Speculum Exam
¤ The clinician inserts a metal or plastic speculum
into the vagina.
¤ When opened, it separates the walls of the vagina,
which normally are closed and touch each other, so
that the cervix can be seen.
¤ Feels some degree of pressure or mild discomfort
when the speculum is inserted and opened.
¤ Will likely feel more discomfort if tensed or if
vagina or pelvic organs are infected.
37

38. P/E Cont…
¤ The position of the cervix or uterus may affect the
comfort as well.
¤ Talk with your client about any feeling of
discomfort.
¤ Once the speculum is in place, check for any
irritation, growth, or abnormal discharge from the
cervix.
¤ Tests for gonorrhea, human papilloma virus,
chlamydia, or other sexually transmitted infections
may be taken by collecting cervical mucus on a
cotton swab.
¤ These tests could be done according to the patients
symptoms.
38

39. 39

40. •Speculae, from left to right: small metal Pedersen,
medium metal Pedersen, medium metal Graves, large
metal Graves, and large plastic Pedersen 40

41. Speculum insertion
41

42. 42

43. Step 3. The Bimanual Exam
¤ Wearing an examination glove, the clinician inserts one or
two lubricated fingers into the vagina.
¤ The other hand presses down on the lower abdomen.
¤ Then feel the internal organs of the pelvis between the two
fingers in the vagina and the fingers on the abdomen.
¤ Examine the internal organs with both hands to check for
– Size, shape, and position of the uterus
– An enlarged uterus, which could indicate a pregnancy
or fibroids
– Tenderness or pain, which might indicate infection
– Swelling of the fallopian tubes
– Enlarged ovaries, cysts, or tumors 43

44. Bimanual exam. Cont…
¤ The bimanual part of the exam causes a
sensation of pressure.
¤ May find it somewhat uncomfortable.
¤ Deep breathing through the mouth helps.
¤ Instruct the patient to tell you when feeling
pain,.
44

45. Bimanual Pelvic Exam
45

46. Step 4. Rectovaginal Exam
¤ Many clinicians complete the bimanual exam by
inserting a gloved finger into the rectum to check the
condition of muscles that separate the vagina and rectum.
¤ Check for possible tumors located behind the uterus, on
the lower wall of the vagina, and in the rectum
¤ Feel for tenderness, masses, or irregularities.
¤ Insert one finger in the anus and another in the vagina for
a more thorough examination of the tissue in between.
¤ When the examining finger has been inserted a short
distance, the index finger can then be inserted into the
vagina until the depth of the vagina is reached
46

47. • This is normal and lasts only a few seconds.
• During this procedure, she may feel as though she
need to have a bowel movement.
47

48. Gynecological Diagnostic procedures
 In addition to routine gynecologic examination
some other diagnostic procedures could be
performed upon necessity .
Mammography
 Mammography has long been used as a screening
test for breast cancer.
 It involves taking an X-ray of the breast.
 It is widely accepted that screening
mammography leads to early detection of breast
cancer
48

49. Gyn. Dx procedures cont…
 Pap smear test- is an important part of the gynecologic
examination.
¤ Usually a small spatula or tiny brush is used to gently collect
cells from the cervix for a Pap test.
¤ The cells are tested for abnormalities — the presence of
precancerous or cancerous cells.
¤ May have some staining or bleeding after the sample is taken.
¤ The Pap smear is a screening test only.
¤ Positive tests are an indication for further diagnostic
procedures, such as colposcopy, endocervical curettage,
cervical biopsy or ,endometrial biopsy, or D&C
¤ The properly collected Pap smear can accurately lead to the
diagnosis of carcinoma of the cervix in approximately 95%
of cases. 49

50. Cont…
 Hysterosonography. This diagnostic technique uses an
ultrasound probe to obtain images of the uterine cavity.
 Hysterosalpingography. This technique uses a dye to
highlight the uterine cavity and fallopian tubes on X-ray
images.
 Hysteroscopy. Insertion of a small, lighted telescope
called a hysteroscope through the cervix into the uterus.
The tube releases a gas or liquid to expand uterus,
allowing you to examine the walls of uterus and the
openings of fallopian tubes. Its application is used
evaluation for abnormal uterine bleeding, resection of
uterine synechiae and septa, removal of polyps and
intrauterine devices (IUDs), resection of submucous
myomas, and endometrial ablation
50

51. Cont…
Culdocentesis: is the passage of a needle into the
cul-de-sac—culdocentesis—in order to obtain fluid
from the pouch of Douglas .The type of fluid
obtained indicates the type of intraperitoneal lesion,
eg, bloody with a ruptured ectopic pregnancy, pus
with acute salpingitis, or ascitic fluid with malignant
cells in cancer. Is performed less frequently today,
due presence of U/S, which could provide definative
diagnosis.
51

52. Culdocentesis …
52

53. Cont…
 Colposcopy
 The method of examining the VAGINA & CERVIX UTERI
by means of the binocular instrument known as the
colposcope.
 It is used to screen for cancer of the cervix and in
investigation of child sexual abuse
 Diagnostic use
 Provides a magnified view of the surface structures of the
vulva, vagina and cervix
 Special green filters allow better visualization of vessels
 Application of 1% acetic acid wash dehydrates cells and
reveals white areas of increased
 Nuclear density (abnormal) or areas with epithelial changes
 Biopsy of visible lesions or those revealed with the acetic
acid wash allows early identifica of dysplasia and neoplasia
53

54. Cont…
 Bloodwork
 CBC - evaluation of abnormal uterine bleeding, preoperative
investigation
 ßhCG - investigation of possible pregnancy or ectopic pregnancy
• work-up for gestational trophoblastic neoplasia
(GTN)
• Monitored after the medical management of ectopic and in
GTN to assess for cure and recurrences
 LH, FSH, TSH, PRL
• Amenorrhea, menstrual irregularities, menopause,
infertility
54

55. The role of imaging techniques in GYN
Ultrasound (U/S)- it records high-frequency sound waves
as they are reflected from anatomic structures. As the
sounds waves pass through tissues, they encounter variable
auditory densities. Each of the tissues returns a different
echo, depending on the amount of energy reflected. This
echo signal can be measured and converted into a 2-
dimensional image of the area under examination, with the
relative densities shown as differing shades of gray.
 Simple & painless procedure that has the added advantage
of freedom from any radiation hazard
 It is especially helpful in patients in whom an adequate
pelvic examination may be difficult, such as in children,
virginal women, and uncooperative patients.
55

56. Cont…
 Imaging modality of choice for pelvic structures
Transvaginal U/S provides enhanced details of structures
located near the apex of the vagina (i.e. intrauterine and
adnexal structures)
 Used to
 Rule in or out ectopic pregnancy, intrauterine
pregnancy, type of abortion
 Assess uterine, adnexal, ovarian masses (i.e.
solid or cystic)
 Determine uterine thickness
 Monitor follicles during assisted reproduction
56

57. A: Longitudinal view. B: Transverse section
C: Longitudinal view D: Longitudinal 57

58. Cont…
Hysterosalpingography
 X-ray after contrast is introduced through the cervix
into the uterus
 Contrast flows through the tubes and into the
peritoneal cavity if tubes are patent
 Used for evaluation of size, shape, configuration of
uterus, tubal patency or obstruction
 Sonohysterography
 Saline infusion into endometrial cavity under U/S
visualization expands endometrium, allowing
visualization of uterus and fallopian tubes 58

59. Cont…
 Useful for investigation of:
AUB
Uncertain endometrial findings on vx U/S,
Infertility, Amenorrhea, Allergies to iodine dyes
Abnormal x-ray hysterosalpingogram
Congenital/acquired uterine abnormalities (i.e. uterus
didelphys, uni/bicornate, arcuate uterus)
 Easily done, minimal cost, extremely well-tolerated,
sensitive and specific
• Frequently avoids need for hysteroscopy
59

60. Cont…
Angiography
 Angiography is the use of radiographic contrast medium
to visualize the blood vascular system. By demonstrating
the vascular pattern of an area, tumors or other
abnormalities can be delineated. Angiography also is
used to delineate continued bleeding from pelvic vessels
postoperatively, to visualize bleeding from infiltration by
cancer in cancer patients, or to embolize the uterine
arteries in order to decrease acute bleeding and/or reduce
the size of uterine myomas. These vessels then can be
embolized with synthetic fabrics to stop the bleeding or
indicate therapy that can prevent the need for a major
abdominal operation in a highly compromised patient.
60

61. Cont…
Computed tomography (CT) scan: is a diagnostic
imaging technique that provides high-resolution 2-
dimensional images. In gynecology, the CT scan is
most useful in accurately diagnosing retroperitoneal
lymphadenopathy associated with malignancies. It
also has been used to determine the depth of
myometrial invasion in endometrial carcinoma as
well as extrauterine spread. It is an accurate tool for
locating pelvic abscesses that cannot be located by
ultrasonography.
61

62. CT scan of the pelvis showing a large fibroid uterus with 3
62
calcified fibroids in the body of the uterus.

63. Cont…
Magnetic Resonance Imaging
 Magnetic resonance imaging (MRI) is a diagnostic
imaging technique that creates a high-resolution,
cross-sectional image of the body like a CT scan.
 Its main use in gynecology appears to be staging and
follow-up of pelvic cancers. MRI in obstetrics is
limited to its use as an accessory prenatal diagnosis
of fetal anomalies.
 It allows for multiple image cuts that can help
interpret complex anomalies. Other potential uses of
MRI include evaluation of placental blood flow and
accurate performance of pelvimetry
63

64. Embryology of the Urogenital system
 The female urinary and genital tracts are closely
related, both anatomically & embryologically.
 Both are derived largely from primitive mesoderm
and endoderm.
 About 10% of infants are born with some
abnormality of the genitourinary system, and
 Anomalies in one system are often mirrored by
anomalies in another system.
 Developmental defects may play a significant role in
the DDx of certain clinical signs and symptoms.
 Thus it is important for you to have a basic
understanding of embryology.
64

65. Embryology of Urinary System
•The kidneys, renal collecting system, and ureters derive
from the longitudinal mass of mesoderm (known as the
nephrogenic cord) found on each side of the primitive
aorta.
•This process gives rise to three successive sets of
increasingly advanced urinary structures, each
developing more caudal to its precursor.
•The pronephros , or ―first kidney, ‖ is rudimentary and
nonfunctional; it is succeeded by the ―middle kidney,‖
or mesonephros, which is believed to function briefly
before regressing.
•Although the mesonephros is transitory as an excretory
organ, its duct, the mesonephric (wolffian) duct, is of
singular importance for the following reasons:
65

66. Cont…
1. It grows caudally in the developing embryo to
open, for the first time, an excretory channel into
the primitive cloaca and the ―outside world.‖
2. It serves as the starting point for development of
the metanephros, which becomes the definitive
kidney.
3. It ultimately differentiates into the sexual duct
system in the male
4. Although regressing in female fetuses, there is
evidence that the mesonephric duct may have an
inductive role in development of the
paramesonephric or müllerian duct
66

67. 67

68. Cont…
Bladder and Urethra
 The bladder and urethra form from the most superior
portion of the urogenital sinus, with surrounding
mesenchyme contributing to their muscular and
serosal layers.
 The remaining inferior urogenital sinus is known as
the phallic or definitive urogenital sinus.
 Concurrently, the distal mesonephric ducts and
attached ureteric buds are incorporated into the
posterior bladder wall in the area that will become the
bladder trigone.
 As a result of the absorption process, the
mesonephric duct ultimately opens independently
into the urogenital sinus below the bladder neck
68

69.  The allantois, which is a vestigial diverticulum of
the hindgut that extends into the umbilicus and is
continuous with the bladder, loses its lumen and
becomes the fibrous band known as the
 urachus or median umbilical ligament. In rare
instances, the urachal lumen remains partially
 patent, with formation of urachal cysts, or
completely patent, with the formation of a urinary
 fistula to the umbilicus.
69

70. Embryology of the Urogenital system
70

71. Embryology of the Urogenital system
71

72. 72

73. Embryology of the Urogenital system
73

74. Embryology of the Urogenital system
74

75. Embryology of the Urogenital system
75