Chapter 22: Ready for Review
• Gynecology 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 pudendum,
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, cervix,
uterus, fallopian tubes, and ovaries.
• Menstruation (menses or period) is the vaginal discharge of primarily blood that generally
occurs every 24 to 35 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 diaphoresis,
hair loss, hot flashes, muscle aches and pains, headache, dyspnea, vertigo, digestive
problems, and emotional instability.
• When assessing a patient with a gynecologic emergency, begin by focusing on the ABCs.
• Protect the patient’s modesty at all times. Gynecologic 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.
• General management for gynecologic emergencies is simple, including addressing life
threats, being supportive, and protecting the patient’s modesty.
• The three life-threatening gynecologic 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.
• Mittelschmerz is abdominal pain and cramping that occur about 2 weeks before
menstruation. Dysmenorrhea is painful menstruation. Prehospital treatment is supportive.
• Amenorrhea is the absence or cessation of menses. The most common cause is pregnancy.
Amenorrhea 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,
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fever, bowel problems, vaginal bleeding, abdominal distention, 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; painful coitus;
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.
Patients with pelvic inflammatory disease will present with abdominal pain starting during
or after menstruation. Obtain a thorough history and transport gently.
Vaginitis and vulvovaginitis are inflammations of the vaginal tissues and external vulva
caused by an infection. Symptoms include itching, irritation, discharge, odor, painful
intercourse, and lower abdominal pain. Both of these common conditions are treated with
antibiotics.
A patient with a Bartholin gland abscess will report a painful lump, irritation (swelling and
redness), painful intercourse, and possibly fever. The abscess is usually on one side of the
vaginal opening and may need to be drained by a physician.
In ectopic pregnancy, a fertilized oocyte implants somewhere other than the uterus, usually
in a fallopian tube, which can lead to rupture of the fallopian tube.
Ruptured ovarian cyst, tubo-ovarian abscess, and ovarian torsion are other gynecologic
conditions that can become an emergency.
A prolapsed uterus is when the uterus drops into the vagina. There are varying degrees of
prolapse from a small protrusion of visible tissue to the entire uterus being outside of the
vagina. Treat with warm, moist dressings and emotional support.
Toxic shock syndrome is a form of septic shock that can result from an infection in the
body. Symptoms include syncope, myalgia, diarrhea, vomiting, headache, fever, sore throat,
petechiae, rash, and bloodshot eyes. Transport patients rapidly.
Sexually transmitted diseases (STDs) can cause pelvic inflammatory disease. STDs include
bacterial vaginosis, chancroid, chlamydia, cytomegalovirus, genital herpes, gonorrhea,
syphilis, and trichomoniasis.
Symptoms of sexually transmitted diseases 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.
Sexual assault is a category of crime that includes molestation 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 same-sex paramedic
treat the patient when possible.
Remember that your job is to medically 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.
Document cases of sexual assault properly and professionally. On your patient care report,
report the patient’s words in quotation marks. Record facts obtained from the physical
examination.
• Drugs used to facilitate rape include gamma-hydroxybutyric acid, ketamine hydrochloride,
Ecstasy, and Rohypnol. These drugs can cause sleepiness, forgetfulness, numbness, loss of
inhibitions, or rapid pulse rate and increase in body temperature, depending on the drug.
• 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.