Female Genitalia.pdf

CHAPTER

Female Genitalia

ANATOMY AND PHYSIOLOGY

Review the anatomy of the external female genitalia (vulva), including the

mons pubis, a hair-covered fat pad overlying the symphysis pubis; the labia

majora, rounded folds of adipose tissue; the labia minora, thinner pinkish

red folds that extend anteriorly to form the prepuce; and the clitoris. The

vestibule is the boat-shaped fossa between the labia minora. In its posterior

portion lies the vaginal opening ( introitus ), which in virgins may be hidden

by the hymen. The term perineum, as commonly used clinically, refers to the

tissue between the introitus and the anus.

Mons pubis

Prepuce

Labium majus

Clitoris

Labium minus

Urethral meatus

Hymen

Opening of

paraurethral

(Skene's) gland

Vagina

Vestibule

Introitus

Opening of

Bartholin's gland

Perinium

Anus

The urethral meatus opens into the vestibule between the clitoris and the

vagina. Just posterior to it on either side lie the openings of the paraurethral

(Skene’s) glands.

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The openings of Bartholin’s glands are located posteriorly on either side of

the vaginal opening, but are not usually visible. Bartholin’s glands themselves

are situated more deeply.

The vagina is a hollow tube extending upward and posteriorly between the

urethra and the rectum. Its upper third takes a horizontal plane and termi-

nates in the cup-shaped fornix. The vaginal mucosa lies in transverse folds,

or rugae.

At almost right angles to the vagina sits the uterus, a ﬂattened ﬁbromuscu-

lar structure shaped like an inverted pear. The uterus has two parts: the body

(corpus) and the cervix, which are joined together by the isthmus. The con-

vex upper surface of the body is called the fundus of the uterus. The lower

part of the uterus, the cervix, protrudes into the vagina, dividing the fornix

into anterior, posterior, and lateral fornices.

Location of

Bartholin's glands

Fallopian tube

Sacrum

Ovary

Rectum

Uterus

Rectouterine pouch

Fornix

Isthmus of uterus

Bladder

Cervix

Urethra

Introitus

Vagina

Perineum

The vaginal surface of the cervix, the ectocervix, is seen easily with the help

of a speculum. At its center is a round, oval, or slitlike depression, the exter-

nal os of the cervix, which marks the opening into the endocervical canal.

The ectocervix is covered by epithelium of two possible types: a plushy, red

columnar epithelium surrounding the os, which resembles the lining of the

endocervical canal; and a shiny pink squamous epithelium continous with

the vaginal lining. The boundary between these two types of epithelium is

the squamocolumnar junction. In puberty, the broad band of columnar ep-

ithelium encircling the os, called ectropion, is gradually replaced by columnar

epithelium. The squamocolumnar junction migrates toward the os, creating

the transformation zone. (This is the area at risk for later dysplasia, which is

sampled by the Papanicolaou, or Pap, smear.)

A fallopian tube with a fanlike tip extends from each side of the uterus to-

ward the ovary. The two ovaries are almond-shaped structures that vary con-

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External os of

the cervix

Columnar eithelium

Transformation

zone

Squamocolumnar junction

Squamous epithelium

siderably in size but average about 3.5 × 2 × 1.5 cm from adulthood through

menopause. The ovaries are palpable on pelvic examination in roughly half

of women during the reproductive years. Normally, fallopian tubes cannot

be felt. The term adnexa (a plural Latin word meaning appendages) refers

to the ovaries, tubes, and supporting tissues.

The ovaries have two primary functions: the production of ova and the se-

cretion of hormones, including estrogen, progesterone, and testosterone. In-

creased hormonal secretions during puberty stimulate the growth of the

uterus and its endometrial lining. They enlarge the vagina and thicken its ep-

ithelium. They also stimulate the development of secondary sex characteris-

tics, including the breasts and pubic hair.

The parietal peritoneum extends downward behind the uterus into a cul de

sac called the rectouterine pouch (pouch of Douglas). You can just reach this

area on rectovaginal examination.

The pelvic organs are supported by a sling of tissues composed of muscle,

ligaments, and fascia, through which the urethra, vagina, and rectum all pass.

Lymphatics. Lymph from the vulva and the lower vagina drains into the

inguinal nodes. Lymph from the internal genitalia, including the upper

vagina, ﬂows into the pelvic and abdominal lymph nodes, which are not pal-

pable clinically.

CHANGES WITH AGING

During the pubertal years, the vulva and the internal genitalia grow and

change to their adult proportions. Assessment of sexual maturity in girls, as

classiﬁed by Tanner, depends not on internal examination, however, but on

the growth of pubic hair and the development of breasts. Tanner’s stages,

or sexual maturity ratings, as they relate to pubic hair and breasts are shown

in Chapter 17, Assessing Children: Infancy Through Adolescence.

In most women, pubic hair spreads downward in a triangular pattern, point-

ing toward the vagina. In 10% of women, it may form an inverted triangle,

pointing toward the umbilicus. This growth is usually not completed until

the middle 20s or later.

Just before menarche there is a physiologic increase in vaginal secretions—

a normal change that sometimes worries a girl or her mother. As menses

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THE HEALTH HISTORY

EXAMPLES OF ABNORMALITIES

become established, increased secretions ( leukorrhea ) coincide with ovula-

tion. They also accompany sexual arousal. These normal kinds of discharges

must be differentiated from those of infectious processes.

Ovarian function usually starts to diminish during a woman’s 40s, and men-

strual periods cease on the average between the ages of 45 and 52, some-

times earlier and sometimes later. Pubic hair becomes sparse as well as gray.

As estrogen stimulation falls, the labia and the clitoris become smaller. The

vagina narrows and shortens and its mucosa becomes thin, pale, and dry.

The uterus and ovaries diminish in size. Once menopause has occurred, the

ovaries may no longer be palpable. The suspensory ligaments of the adnexa,

uterus, and bladder may also relax.

THE HEALTH HISTORY

Common or Concerning Symptoms

Menarche, menstruation, menopause

Pregnancy

Vulvovaginal symptoms

Sexual activity

Questions in this section focus on menstruation, pregnancy and related top-

ics, vulvovaginal symptoms, and sexual function.

Menarche, Menstruation, Menopause. For the menstrual history,

ask the patient how old she was when her monthly, or menstrual, periods

began (age at menarche ). When did her last period start, and, if possible, the

one before that? How often do the periods come (as measured by the inter-

vals between the ﬁrst days of successive periods)? How regular or irregular

are they? How long do they last? How heavy is the ﬂow? What color is it?

Flow can be assessed roughly by the number of pads or tampons used daily.

Because women vary in their practices for sanitary measures, however, ask

the patient whether she usually soaks a pad or tampon, spots it lightly, etc.

Further, does she use more than one at a time? Does she have any bleeding

between periods? Any bleeding after intercourse or after douching?

The dates of previous periods may

alert you to possible pregnancy or

menstrual irregularities.

Unlike the normal dark red men-

strual discharge, excessive ﬂow

tends to be bright red and may in-

clude “clots” (not true ﬁbrin clots).

Does the patient have any discomfort or pain before or during her periods?

If so, what is it like, how long does it last, and does it interfere with her usual

activities? Are there other associated symptoms? Ask a middle-aged or older

woman if she has stopped menstruating. When? Did any symptoms accom-

pany her change? Has she had any bleeding since?

Questions about menarche, menstruation, and menopause often give you an

opportunity to explore the patient’s need for information and her attitude

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toward her body. When talking with an adolescent girl, for example, opening

questions might include: “How did you ﬁrst learn about monthly periods?

How did you feel when they started? Many girls worry when their periods

aren’t regular or come late. Has anything like that bothered you?” You can

explain that girls in the United States usually begin to menstruate between the

ages of 9 and 16 years, and often take a year or more before they settle into a

reasonable, regular pattern. Age at menarche is variable, depending on genetic

endowment, socioeconomic status, and nutrition. The interval between peri-

ods ranges roughly from 24 to 32 days; the ﬂow lasts from 3 to 7 days.

Menopause, the absence of menses for 12 consecutive months, usually oc-

curs between the ages of 45 and 52 years. Associated symptoms include

hot ﬂashes, ﬂushing, sweating, and disturbances of sleep. Often you will ask,

“How do (did) you feel about not having your periods anymore? Has it af-

fected your life in any way?” Postmenopausal bleeding is deﬁned as bleeding

that occurs after 6 months without periods and warrants further investigation.

Postmenopausal bleeding raises the

question of endometrial cancer,

although it also has other causes.

Other causes of secondary amenor-

rhea include low body weight from

any cause, including malnutrition

and anorexia nervosa, stress,

chronic illness, and hypothalamic–

pituitary–ovarian dysfunction.

Amenorrhea refers to the absence of periods. Failure to initiate periods is

called primary amenorrhea, while the cessation of periods after they have

been established is termed secondary amenorrhea. Pregnancy, lactation, and

menopause are physiologic forms of the secondary type. Oligomenorrhea refers

to infrequent periods, which may also be irregular. This pattern is common

for as long as 2 years after menarche, and it also occurs before menopause.

Dysmenorrhea is pain with menstruation, and is usually felt as a bearing

down, aching, or cramping sensation in the lower abdomen and pelvis.

Women may report premenstrual syndrome (PMS), a complex of symptoms

occurring 4 to 10 days before a period. PMS symptoms include tension, ner-

vousness, irritability, depression, and mood swings; weight gain, abdominal

bloating, edema, and tenderness of the breasts; and headaches. Though usu-

ally mild, PMS symptoms may be severe and disabling.

Polymenorrhea means abnormally frequent periods, and menorrhagia refers

to an increased amount or duration of ﬂow. Bleeding may also occur be-

tween periods, termed metrorrhagia or intermenstrual bleeding, after inter-

course ( postcoital bleeding ), or after other vaginal contact from practices such

as douching.

Increased frequency, increased

ﬂow, or bleeding between periods

may have systemic causes or may

be dysfunctional. Postcoital bleed-

ing suggests cervical disease

(e.g., polyps, cancer) or, in an

older woman, atrophic vaginitis.

Pregnancy. Questions relating to pregnancy include: “Have you ever

been (or how often have you been) pregnant? Have you ever had a miscar-

riage or an abortion? How often? How many living children do you have?”

Inquire about any difﬁculties with the pregnancies and the timing and the

circumstances of any abortion (spontaneous or induced). What kind of birth

control methods, if any, have the patient and her partner used, and how sat-

isﬁed is she with them?

If amenorrhea suggests a current pregnancy, inquire about the history of

intercourse and common early symptoms: tenderness, tingling, or increased size

of the breasts; urinary frequency; nausea and vomiting; easy fatigability; and

feelings that the baby is moving (the last usually noted at about 20 weeks).

Amenorrhea followed by heavy

bleeding suggests a threatened

abortion or dysfunctional uterine

bleeding related to lack of ovulation.

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