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• PAST HISTORY:
• Gravida: Number of pregnancies
• Para: Number of live deliveries
• Number of planned and spontaneous abortions.
• ABNORMALITIES in MENSTRUATION: Normal menstrual period = about 40 mL of blood.
• Amenorrhea: No menstruation for 3 months or more.
• Primary Amenorrhea: Failure of menarche
• Kallman's Syndrome: Primary GnRH deficiency
• Turner's Syndrome: XO
• Testicular Sensitization Syndrome: Androgen insensitivity. Genotypic male may be diagnosed with testicular feminization when he presents as a teenager with primary amenorrhea.
• Imperforate hymen
• Congenital malformations of GU tract: Uterine agenesis, vaginal malformations.
• Secondary Amenorrhea: Amenorrhea occurring any time after menarche has occurred.
• Environmental Factors:
• Weight-reduction amenorrhea: Anorexia and related disorders, malnutrition.
• Psychogenic amenorrhea
• Exercise-induced amenorrhea
• Post-pill amenorrhea
• Pituitary Disease:
• Prolactinoma
• Sheehan Syndrome = post-partum hemorrhage causing pituitary infarct from lack of blood-flow and increased pituitary demand.
• Premature ovarian failure: Menopause occurring before age 35. Can be caused oophoritis (mumps virus), or may be idiopathic.
• Polycystic Ovary Syndrome
• Asherman's Syndrome: Amenorrhea caused by intrauterine adhesions (synechiae) that obliterate part of the uterine cavity. This can occur subsequent to vigorous dilatation and curettage (D&C) of the endometrium.
• Hypomenorrhea: Decrease in volume of flow or duration of periods.
• Menorrhagia, Hypermenorrhea: Abnormally heavy volume of flow or abnormally long periods.
• Most common causes: Uterine fibroids (leiomyomas), PID, Endometriosis, IUD
• Metrorrhagia: Bleeding at mid-cycle. It is usually precipitated by the drop in estrogen that occurs after ovulation.
• Dysmenorrhea: Painful menstruation. Symptoms = lower abdominal pain, nausea, vomiting, fatigue, diarrhea.
• Primary Dysmenorrhea: Unexplained, idiopathic dysmenorrhea. Believed to be caused by high uterine levels of PGE₂.
• Secondary Dysmenorrhea: Endometriosis, PID, imperforate hymen, uterine polyps, adhesions.
• Dysfunctional Uterine Bleeding (DUB): Abnormal uterine bleeding in which no etiologic agent can be found after history and pelvic exam.
• OTHER THINGS RELATING TO MENSTRUATION:
• MENOPAUSE:
• PRE-MENSTRUAL SYNDROME:
• NON-MENSTRUAL VAGINAL BLEEDING: Bleeding not related to menstruation. When vaginal bleeding presents, we must determine whether it is menstrual or non-menstrual.
• Post-Menopausal Bleeding: Consider uterine cancer, cervical cancer. Atrophic vaginitis if patient is not on ERT.
• Pregnancy, either intrauterine or ectopic, may cause bleeding for a variety of reasons.
• Birth control methods: IUD, breakthrough bleeding with pill.
• PELVIC PAIN:
• ACUTE PELVIC PAIN:
• Mittelschmerz: Pelvic pain occurring at mid-cycle and related to ovulation.
• Torsion of Ovary: Cystic ovary can get large and twist on itself, cutting off its blood supply ------> acute-onset pelvic pain.
• Ruptured tubal pregnancy.
• CHRONIC PELVIC PAIN:
• Endometriosis: Dysmenorrhea, dyspareunia, infertility. Often have chronic pelvic pain, associated with the location of the ectopic glandular tissue.
• Pain of endometriosis tends to be constant, and tends to radiate to coccyx, lower back.
• Onset of disease is usually between 25 and 40. Undifferentiated dysmenorrhea often presents younger than age 25.
• URINARY TRACT INFECTIONS:
• PREGNANCY and INFERTILITY:
• Early Pregnancy: Common symptoms
• Secondary amenorrhea. Patient may also see reduced flow, or slight vaginal bleeding at time of normal period.
• Morning Sickness: Nausea and vomiting
• Breast tenderness
• Urinary frequency: cause may be anatomical or hormonal.
• Constipation
• Weight change: weight loss is common in early pregnancy, followed by weight gain later.
• Late Pregnancy:
• Chloasma: Characteristic darkening of skin around eyes, nose, cheeks. Darkening also occurs in areolae, skin between umbilicus and pubic ridge.
• Striae Gravidarum: Stretch marks of pregnancy.
• Spider angiomas may occur in skin, because of high estrogen.
• Pelvic Changes with Pregnancy:
• Chadwick's Sign: Blue or purple discoloration of the vagina.
• Leukorrhea: Clear or white vaginal discharge with faint musty odor. It may occur during pregnancy or in other circumstances.
• Goodell's Sign: Bluish discoloration and softening of the cervix.
• Braxton Hicks Contractions: Painless uterine contractions occurring after the 28^th week.
• Quickening: The first fetal movement of which the patient is aware. Normally occurs at 18 weeks during first pregnancy, and at 16 weeks in subsequent pregnancies.
• Hydatidiform Mole: Signs of a molar pregnancy:
• Uterus increases rapidly in size shortly after implantation.
• Persistent vaginal bleeding, no fetal movement, and no fetal heart tones by 12 weeks.
• Nausea and vomiting more intense than usual.
• Grape like clusters of tissues may be expelled through the vagina.
• ABNORMALITIES in SEXUAL FUNCTION:
• Vaginismus: Spasmodic, guarding contraction of vagina upon attempt of intercourse. Often occurs subsequent to rape or trauma.
• VAGINAL DISCHARGE and ITCHING
• Physiologic Discharge: Clear or white discharge occurring at midcycle.
• Trichomonas Vaginalis:
• Discharge: Gray, foamy discharge having bad odor.
• Mucosa: Red, strawberry cervix.
• Confirm: Confirm with wet-mount (saline suspension microscopy).
• Gonorrhea:
• Discharge: Profuse mucoid discharge with foul odor.
• Mucosa: Red, tender mucosa.
• Confirm: Confirm with culture.
• Gardnerella Vaginalis: Also called Non-specific vaginitis. Co-infection with anaerobes usually also occurs.
• Discharge: Gray or white, fishy odor
• Mucosa: Normal
• Confirm: Clue cells = large epithelial cells with many coccobacilli adherent to them.
• Chlamydia:
• Discharge: Little, yellow, mucous and pus in cervical canal.
• Mucosa: Cervical erosion.
• Confirm: FA stain of smear shows elementary bodies.
• Candida Albicans: Yeast infection.
• Discharge: White, cottage-cheese like
• Mucosa: White patches stuck to a red base.
• Confirm: KOH preparation, look for pseudohypha.
• Atrophic Vaginitis: Estrogen deficiency
• Discharge: Little discharge, some blood
• Mucosa: Atrophic, pale or red.
• Confirm: history, age.
• PELVIC RELAXATION: Loss of pelvis support due to atrophy of muscular viscera,
• Urethrocele: Urethra herniates into the vaginal canal.
• Cystocele: Bladder herniates into the vaginal canal.
• Rectocele: Rectum herniates into the vaginal canal.
• Uterine Prolapse: Descent of the uterus into the vaginal canal. Graded from 1 (mild) to 3 (uterus descends past the vulva).
• HIRSUTISM

PHYSICAL EXAM:

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