Repro #2
Wednesday March 26, 2003, 2:00 pm
LaPonna IrvineMoore
Dr. Bowling
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Female Reproductive Exam
Assigned Reading
Chapter 15: pgs 407- 425
Chapter 18: pgs 495-526
Recommended Viewing
Video: Bates, Novey
CD: Swartz
Dr. Bowling reminds us to read the assignment and study the protocol BEFORE
we come to lab. The recommended viewing includes the well woman and well
man exam especially the breast and pelvic exam that in on our c.d. that came with
the text book. The Bates tapes will be shown during lab and will be available in
the library for our viewing.
Dr. Still “Know well the normal before treating the afflicted.”
Dr. Bowling advice: He is always impressed with this quote from Still because if
you don’t know the normal then you can’t figure out the abnormal to treat it.
Postulates of AT Still
- The rule of the artery is supreme
- Structure and function are interrelated
- The human body has the inherent capability to maintain health
Purpose:
- to assess all systems,
- looking for diseases
- examine for infections
- assess hormonal status
- cancer screening
- looking for opportunity to educate,
- other health screening
- thyroid
- cardiovascular
- musculo-skeletal
- skin
Dr. Bowling: This is an opportunity to address other health issues as well and
take care of those things up to my ability
Indications of the 1st Exam
- At age 21 or at age of first intercourse – this is a recent change in the literature
- Symptoms
- Vaginal discharge
- abnormal bleeding
- suspected trauma or abuse
- Amenorrhea
Dr. Bowling: Please be aware of social, emotional, and cultural issues. He then
told a story about a young girl who became pregnant and was very difficult to do an
exam on. She was very tense and he could barely get the speculum in. After time
passed he found out that she had been abused by her father. So be aware of body
Repro #2
Wednesday March 26 2003, 2:00 pm
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language and other issues that may be involved. Be especially sensitive for a young
girl on her 1st exam maybe have a video explaining it.
Terminology
Dr. Bowling: Most of it is Greek not Latin so if you can understand prefixes and
suffixes you can figure a lot of things out.
- colp(o) = vagina
o Ex: colposcopy = microscopic exam of the vagina
- oophor = ovary
o oophorectomy = removal of the ovaries
- salping(o) = fallopian tube
o bilateral salpingo-oophorectomy = removal both ovaries and fallopian tubes
- itis = inflammation (does not necessarily mean infection)
o cystitis = inflammation of the bladder
- cyst = vessel
- retro = back
o retroverted uterus = a uterus that’s back
- ante = forward
o anteverted uterus = a uterus that’s forward
- ectomy = to remove
o mastectomy = to remove a breast
- arche = beginning
o menarche = beginning of menses
- plasia = growth
o hyperplasia = too much growth; metaplasia; dysplasia
- rhea = flow
o menorrhea = monthly flow; hypermenorrhea = increased monthly flow
- rhagia = discharge
- dys = pain
o dysmenorrhea = painful menses; dysuria = painful urination
- a = without
o amenorrhea = no monthly flow
- men = monthly
- metrorrhagia
- menorrhagia = monthly discharge
- squamouscolumnar junction = the transition zone between squamous and columnar
epithelium where carcinoma of the cervix arises (during a PAP it is important to get
this area)
- adenexa = tubes and ovaries
o left adenexa = left ovary and tube
- dyspareunia = pain with sex
Terminology: cont’d
- Hysterectomy
- hyst = womb
- ectomy = removal
- Partial hysterectomy = to remove part of the uterus
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- they used to do this in the 40’s when a women had heavy menses (you rarely see
it now adays)
- they would take the fundus of the uterus and leave the cervix (all the blood
supply goes into the cervix and lower uterus so it was easier to just take the
uterine body off)
- a partial hysterectomy does not mean that they take the entire uterus but leave
the ovaries – This is wrong terminology that is often used in practice
- if a patient says they had a partial hysterectomy but all you see is a vaginal cuff
(no cervix) then they had a total hysterectomy but they probably still have their
ovaries
- BSO = it’s the abbreviation for bilateral salpingo-oophorectomy
- Vaginal hysterectomy = removal of vagina
Dr.Bowling: When you get into the anatomy lab I want you to look in the pelvis of
a female cadaver and observe where the tubes, ovaries, and uterus lie. Think in
your head where your hands are going to be when you are doing the bimanual
exam – Get the picture in your mind form that gross specimen that is in front of
you. Don’t rely on pictures in the book and don’t rely on trying to visualize it in
clinic.
What questions should you ask?
- Risk factors for cancer
- Complete systems review
- Menstrual history
- last menstruation, length of flow, pain, amount of flow
-menorrhagia, metrorrhagia, menometrorrhagia, dysmenorrheal
- it is common for a woman to follow the same pattern as her mother
- menarche = (beginning of menstruation) age of first menstruation
- vaginal discharge
- itching, pain
- dyspareunia – there are two kinds
1. a burning irritation –> often with a vaginal infection
2. bumper dyspareunia (pain with deep penetration) –> often associated
with pelvic problem such endometriosis - can sometimes reproduce it with
the bimanual exam
- Reproductive history
- # of pregnancies, # of miscarriages, # of live births
- Sexual history
- number of sexual partners
- age at first intercourse
- changes in sexual behavior or desire
- STD’s, HIV
- Surgical history – important to find out exactly what kind they had
- Medication history
- you need to know what kind of estrogen they are on or if they are on any
hormones or DES
Dr. Bowling: DES was a medicine they used back in the 40’s and 50’s if a women
was pregnant and threatened with miscarriage or bleeding to stop the bleeding
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but that put her offspring at increased risk for vaginal cancer – so you need to ask
about the patients’ mothers’ pregnancies)
- Health Habits
- last PAP and results
- last mammogram
- last self breast exam (do they do it?)
- smoking – a risk factor for cervical cancer
- Symptoms
-abdominal symptoms –
- bloating - that cannot be explained any other way can be caused by
ovarian cancer which there is no screening test for
Student question: I thought that there was a screening test for ovarian cancer?
Dr. Bowling: You are talking about the C125. That is not a screening test. It has
many false positives and is not used to diagnose or screen for ovarian cancer. It is
a tumor marker that is sometimes used after they are diagnosed and to follow it,
but it is not adequate for diagnosis.
- pain
- indigestion
- bowel symptoms –
- diarrhea = frequent or loose bowel movements
- constipation = bowel movements that are less often that normal, straining
- hematachesia = blood in stools
- urinary symptoms –
- urgency = must go right now
- dysuria = pain with urination
- frequency = how often
- hematuria = blood in urine
- doesn’t always come from the kidney but can come from vaginal
mucosa that is irritated (postmenopausal women)
- women that have had multiple births, cystocyle, urerthrocyle that cause
cystitis problems, postmenopausal women causes a decrease in estrogen
which causes their vaginal and bladder mucosa to become susceptible to
inflammation
- other symptoms
- chest pain
- shortness of breath
- difficulty swallowing
- painful joints
Established Patient – Female
- Have you had any problems since your last exam?
- I see you are here for your yearly exam. Do you have any special concerns you would
like to discuss today?
New Patient – Female
- I see you are here for your well woman exam. Have you been having any particular
problems or symptoms that you would like to tell me before we begin?
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Dr. Bowling: you are going to have an opportunity during your experience to take a
history from the patient (they will be in their street clothes). It is important to do that
interaction before the nurse gets them into a gown.
Breast Cancer Risk Factors
- age
- gender
- personal family history
- early menarche and late menopause (an expanded reproductive period)
- atypical hyperplasia
- high fat diet
- obesity
Cervical Cancer Risk Factors
- age between 40-50 years old
- personal history
- dysplasia – abnormal growth
- HPV
- Herpes
- HIV
- multiple sex partners
- early age of first intercourse
- multiple pregnancies
- low socioeconomic level – because they don’t have access to care and aren’t getting
Pap smears and other preventive measure
Dr. Bowling: if every woman got PAP’s there would be no cervical cancer
- smoking
Ovarian Cancer Risk Factors
- Age 40-60
- family hx: ovarian cancer or other gyno cancers that put you at increase risk
- cancer of the breast or endometrium
- ovarian dysfunction, anovulation
- spontaneous abortions
- radiation to pelvic organs
- endometriosis
- null parity
- infertility
- exposure to talc or asbestos
Endometrial Cancer Risk Factors
- postmenopausal
- early menarche and late menopause (like breast cancer)
- infertility or low parity
- obesity
- personal history of hypertension, diabetes, liver disease
- endometrial hyperplasia – condition that usually precedes endometrial cancer (we
can screen for this)
- unopposed estrogen therapy
- family hx: breast, endometrial or colon cancer
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- high socioeconomic status
Breast Cancer Screen
- self breast exam
- begin at age 20
- clinical exam done by the physician
o start at age 20 –every three years
o over 40 – yearly
- mammograms
- yearly beginning at age 40
Cervical Cancer Screen
- PAP smear – the best screening for cancer we have and if done it could eradicate
cervical cancer
Ovarian Cancer Screen
- bimanual
Endometrial Cancer Screen
- endometrial biopsy – procedure where we put a catheter canule in the endometrial
cavity and take a sample similar to the PAP smear
He then went through some interactive questions reviewing the material he just covered.
The questions are on the power points. On the tape, he didn’t give the answer to many
of the questions (he just that’s good) however the answers are found in the power point
material. The cases we went over are also in the power points.
Case 1
What would be your response if…
- the spouse called and told you the patient had asked him to call and get the
results of her tests = with HIPPA it’s very important that we maintain
confidentiality (don’t give him the results)
- the patient called for the results = give them only if you can confirm the identity
of the patient
- the patient is in your office, your staff pulls up the lab results on the computer
and leaves the screen visible to other staff = council your staff on HIPPA
regulations and proper handling of sensitive material
Case 2
What is the most ethical way to notify this patient of her results?
- Wait until Monday and speak to her personally and tell her that her mammogram
was abnormal, that she needs additional tests and you have taken the liberty to
schedule it for tomorrow
Dr. Bowling: There is no right answer here. Our radiologist routinely sends a letter to
our female patients about their mammography and if it’s normal I don’t send them
another letter. I think it is inappropriate for the radiologist to notify my patients of an
abnormality. I think they should call me and I should notify them. Don’t call patients on
Friday and tell them that they have bad news of any kind and ruin their weekend unless
it’s going to kill them before Monday (then get ahold of them in a hurry). Don’t call and
leave a message on their answering machine at home. I don’t think that’s professionally
ethical.
Case 3
Your most appropriate response would be?
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- Acknowledge her beliefs, but counsel her regarding misinformation about the
radiation effects and request that she see you in 2-3 weeks to discuss this further.
Dr. Bowling: If you encourage her to receive unacceptable or out of main stream care, it
might put you at risk liability wise. Don’t kick her out but continue to educate your
patients.
Case 4
This behavior is most likely due to?
- fear of cervical cancer – probably not at this age
- embarrassment - maybe
- fear of pain – yes
- low room temp. – maybe
Dr.Bowling: if she is that severe then there is probably something else psychologically
such as abuse going on
Student question: Do you allow the mother in the room?
Dr. Bowling: It depends on the situation, how they came in to the office. I think that it is
appropriate to ask the patient if they want their mother to leave. It is her prerogative.
But certainly the patient has the right. I don’t know the laws in Texas but in Ohio you
were allowed to treat a minor for pregnancy and drug abuse without parental consent.
That’s been a long time ago, but that gives you the right to treat a teenage girl that is
sexually active because you are talking about pregnancy and potential problems. I think
sexually transmitted diseases is the other thing you are allowed to treat without consent.
Student question: Do the same colorectal screening exam apply to the female as in the
male?
Dr. Bowling: Yes, certainly.