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Gynaecology is the study of and care for diseases of the female reproductive
system.
The external anatomy of the female genitalia, sometimes referred to as the vulva,
includes the mons pubis, labia majora, labia minora, perineum, clitoris, prepuce,
and vestibule.
The internal anatomy of the female genitalia includes the vagina, Bartholin
glands, and the hymen (before rupture).
Menstruation (menses or period) is the vaginal discharge of primarily blood that
generally occurs every 25 to 34 days in premenopausal women.
A woman can experience physical changes during the menstrual cycle that result
in fluid retention, breast pain and tenderness, headache, cramping, and more
intense emotional states. This premenstrual syndrome can be debilitating.
The last menses is called menopause; it generally occurs between the ages of 40
and 50 years. Women may experience physical symptoms of menopause,
including perspiring, hair loss, hot flushes, muscle aches and pains, headache,
dyspnoea, vertigo, digestive problems, and emotional instability.
Mittelschmerz is abdominal pain and cramping that occur about 2 weeks before
menstruation. Dysmenorrhoea is painful menstruation. Prehospital treatment is
supportive.
Amenorrhoea is the absence or cessation of menses. The most common cause is
pregnancy. Amenorrhoea can also occur in athletes and in people with anorexia
nervosa or emotional problems.
Endometritis is inflammation or irritation of the endometrium. Symptoms include
malaise, fever, bowel problems, vaginal bleeding, abdominal distension, and
lower abdominal or pelvic pain.
Endometriosis is the growth of endometrial tissue outside of the uterus. It can
cause infertility. Symptoms include low back, pelvic, or abdominal pain; pain
experienced during sexual intercourse; elimination problems during menstruation;
menstrual cramping; and heavy menstruation.
Pelvic inflammatory disease (PID) is an infection of the female upper
reproductive organs. One of the most common causes of abdominal pain in
women, it can cause infertility.
Interstitial cystitis is a chronically inflamed or irritated bladder wall. Symptoms
may mimic those of gynaecological origin.
In ectopic pregnancy, a fertilised egg implants somewhere other than the uterus,
usually in a fallopian tube, which can lead to rupture of the fallopian tube.
Ruptured ovarian cyst and tubo-ovarian abscess are other gynaecological
conditions that can become an emergency.
Toxic shock syndrome is a form of septic shock that can result from an infection
in the body. Symptoms include syncope, mylagia, diarrhoea, vomiting, headache,
fever, sore throat, petechiae, rash, and bloodshot eyes. Transport patients rapidly.
Sexually transmitted infections (STIs) can cause PID. STIs include bacterial
vaginosis, chancroid, chlamydia, cytomegalovirus, genital herpes, gonorrhoea,
syphilis, and trichomoniasis.
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Symptoms of STIs can include itching, burning, pain, fishy smelling discharge,
sores around the genitals, swollen or painful lymph glands, lower abdominal or
back pain, nausea, fever, painful intercourse, bleeding between menstrual periods,
fatigue, headache, and painful urination.
When assessing a patient with a gynaecological emergency, begin by focusing on
the ABCs.
Protect the patient’s modesty at all times. Gynaecological emergencies can be
very embarrassing for the patient.
If the chief complaint is abdominal pain, investigate the pain by following the
mnemonic LORDS TRACHEA: Location, Onset, Radiation, Duration, Severity,
Timing, Relief, Aggravation, Character, History, Eating, and Associated
symptoms.
Determine when the patient had her last menstrual period, if it is unusual in any
way, whether she could be pregnant, and whether she uses contraception.
Vaginal bleeding that does not occur during the course of regular menstruation is
cause for concern. Consider whether there is a mechanism of injury. Try to obtain
an accurate description of the bleeding.
During the patient history, obtain the patient’s obstetric history, including any
previous pregnancies, miscarriages, or abortions. If the patient has a vaginal
discharge, obtain a description of it.
During the physical examination, determine whether there is a life-threatening
condition. Inspect the abdomen for signs of abuse. Palpate the painful quadrant
last.
Abdominal pain can be visceral, parietal, or referred. Management should be
psychologically supportive.
General management for gynaecological emergencies is simple, including
recognising immediate threats to life, preventing deterioration where possible, and
protecting the patient’s modesty.
Gynaecological trauma may cause profuse bleeding. Control external bleeding
using pressure over the area, but never pack the vagina. Attempt to estimate the
patient’s blood loss.
Patients with PID will present with abdominal pain starting during or after
menstruation. Take a thorough history and transport gently.
The three life-threatening gynaecological emergencies are ectopic pregnancy,
ruptured ovarian cyst, and tubo-ovarian abscess. Patients will present with
abdominal pain and possibly vaginal bleeding, nausea, vomiting, or fever. Identify
when each symptom began. Management includes airway maintenance,
supplemental oxygen, positioning the patient on the left side, IV fluids, keeping
the patient warm, monitoring the ECG, and transporting.
Sexual assault is a category of crime that includes indecent assault and rape. Your
compassion and professionalism in these situations are of the utmost importance.
It may be difficult to obtain a history from a victim of rape. Have a female
paramedic treat the patient when possible.
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Remember that your job is to clinically treat the patient. Ask only medical
questions, and do not judge the patient. Limit the physical examination to
addressing life-threatening injuries.
Preserve evidence when possible. Try to persuade the rape victim not to clean
herself.
If a rape victim refuses transport, try to call a friend or relative with whom she
can stay.
Document cases of sexual assault properly and professionally. Report the
patient’s words in quotation marks. Record facts obtained from the physical
examination.
Sexual emergencies may involve foreign objects stuck in the vagina or anus,
which may potentially lead to internal injury. Do not remove the object. Remain
professional, and transport the patient.
Drugs used to facilitate rape include gamma-hydroxybutyrate (GHB), ketamine
hydrochloride, ecstasy, and Rohypnol. These drugs can cause sleepiness,
forgetfulness, numbness, loss of inhibitions, or rapid heart rate and increase in
body temperature, depending on the drug.