I.

Female Reproductive System

1. Female External Genitalia
Mons Pubis rounded cushion of fatty and connective tissue lies over anterior surface of the symphysis pubis post puberty is covered with course curly hair Labia Majora two raised folds of adipose and connective tissue Borders vulva on both sides from the mons pubis to the perineum post puberty the outside has hair and the inside is moist and pink protect the inner vulvar structures highly vascular many nerve endings making them sensitive Labia Minora composed of connective tissue and smooth muscle has many sebaceous glands, secretes lubricants that act as bactericide no hair, moist and red or dark pink in color, few sweat glands lies within and alongside the labia majora each section divides to a lower and upper lamella prepuce 2 upper (Hood like covering over the clitoris) fourchette 2 lower (thin tissue fold along the anterior edge of the perineum Rich in blood vessels and nerve endings swells in response to sexual stimulation-a reaction that triggers other changes that prepare the genitalia for coitus Clitoris located underneath the prepuce composed erectile tissue numerous sensory nerve endings during sexual arousal increases in size Vaginal Vestibule almond shaped area enclosed by the labia minora that contains openings to the urethra, Skene glands, vagina, Bartholin glands urethra-not a reproductive organ, found about 2.5 cm below the clitoris Skene gland- located on each side of the urethra and produce mucus-aids in lubrication of the vagina vaginal opening-lower portion of the vestibule, varies in shape and size hymen-connective tissue membrane that surrounds the vaginal opening, can be perforated during strenuous exercise, insertion of tampons, masturbation, and vaginal intercourse Bartholin glands-lie under the constrictor muscle of the vagina, located posteriorly on the size of the vaginal opening, usually are not visible. During sexual arousal to glands secrete clear mucus to lubricate the vaginal introitus Perineum between the fourchette and the anus skin covered muscular area that covers the pelvic structures forms the base of the perineal body wedge shape mass that serves as an anchor for the muscles fascia and ligaments of the pelvis muscles and ligaments form a sling that support the pelvic organs

2. Female Internal Structures

Vagina fibromuscular, collapsible, tubular structure that lies between the bladder and the rectum, extends from the vulva to the uterus lower segment has few sensory nerve endings secretions are slightly acidic (pH 4-5) susceptibility to infection is limited serves as a passageway for menstrual flow, female organ of copulation, part of the birth canal rugae-mucosal lining arranged in transverse folds during reproductive years, allow the vagina to expand during childbirth, estrogen deprivation causes smoothing of the rugae Uterine cervix projects into a blind vault at the upper end of the vagina, fornices (singular fornix)-anterior, posterior, and lateral pockets that surround the cervix, internal pelvic organs can be palpated through the thin walls of these fornices Uterus muscular organ shaped like an upside down pear that sits midline in the pelvic cavity between the bladder and rectum and above the vagina supported by four pairs of ligaments: Cardinal, uterosacral, round, and broad also supported by single anterior and posterior ligaments cul-de-sac of Douglas-recessed pouch posterior to the cervix formed by the posterior ligament divided into two major parts: upper triangular portion (corpus), lower cylindrical portion (cervix) isthmus-lower uterine segment, short constricted portion that separates the corpus from the cervix service for reception, implantation, retention, and nutrition of the fertilized ovum and later of the fetus, for expulsion of the fetus during child birth responsible for cyclic menstruation fundus-dome shaped top of uterus, site at which the uterine tubes enter the uterus Uterine wall made up of three layers: endometrium, myometrium, and part of the peritoneum endometrium-highly vascular lining, made up of three layers, outer two shed during menstruation myometrium-made up of layers of smooth muscles that extend in three different directions (longitudinal, transverse, and oblique) longitudinal fibers mostly found in the fundus and assist in expelling the fetus, middle layer contains fibers from all three directions and forms a figure 8 pattern itersecting large blood vessels, these fibers assist in ligating blood vessels after childbirth (control blood loss) Cervix made up of mostly fibrous connective tissues and elastic tissue, makes it possible for the cervix to stretch during childbirth internal OS (endocervical canal)-opening between the uterine cavity and the canal that connects to the uterine cavity to the vagina external OS-narrow opening between that and endocervix and the vagina, small circular opening in women who have never been pregnant.feels firm with the dimple in the center that marks the external OS outer cervix-covered with a layer of squamous epithelium mucosa of the cervical canal-covered with columnar epithelium, contains numerous glands that secrete mucus in response to ovarian hormones cervical OS (transformation zone)-location of squamocolumnar junction, most common site for neoplastic changes, site where Pap smear is performed

Uterine tubes (fallopian tubes) attached to uterine fundus supported by broad ligament and range from 8 to 14 cm divided into four sections: interstitial portion (closest to uterus), isthmus and the ampulla (where the ovum is usually fertilized) on the middle portions; and the infundibulum (closest to the ovary) has fimbriated ends that pull the ovum into the tubes provide a passage between ovaries and uterus for the movement of the ovum ovum is pushed along the tubes by rhythmic contractions of muscles and by the currents produced from cilia Ovaries almond shaped organs located on each side of the uterus below and behind the uterine tubes diminishing size after menopause before menarche each ovary has a smooth surface, after they are nodular because of repeated ruptures of follicles at ovulation two functions: ovulation and hormone production (1) ovulation-release of a mature ovum, (2) hormones-estrogen, progesterone, androgen

3. Female Bony Pelvis

Bony Pelvis three primary purposes: (1) protection of the pelvic structures, (2) accommodation of the growing fetus, (3) anchorage of the pelvic support structures two innominate (hip) bones (consisting of Ilium, ischium, and pubis), the sacrum; coccyx makeup the four bones of the pelvis Cartilage and ligaments form the symphysis pubis, sacrococcygeal joint, and two sacroiliac joints that separate the pelvic bones divided into two parts: false pelvis-small upper portion above the pelvic brim or inlet, true pelvis-lower curved bony canal which includes inlet, the cavity, and the outlet through which the fetus passes pelvic ossification is complete at about 20 years of age

4. Female Breast
paired mammary glands located between the second and sixth ribs tale of Spence-extension to the axilla attached to the muscles by connective tissue or fascia contours should be smooth with no retractions, dimpling, or masses estrogen stimulates growth of the breasts by: (1) inducing fat deposition, (2) development of stromal tissue (increases in its amount and elasticity), (3) growth of the extensive ductile system estrogen also increases the vascularity of breast tissue when ovulation begins progesterone levels increase and causes maturation of mammary gland tissue (lobules and acinar) full development not achieved until after the end of the first pregnancy or in the early period of lactation function of lactation, and organs for sexual arousal made of 15 to 20 lobes, which are divided into lobules (clusters of acini) Acini acinus (alveolus)-sack like terminal part of a compound gland emptying through a narrow lumen or duct lined with epithelial cells that secrete colostrum and milk below the epithelium is the myoepithelium which contracts to expel milk from the acini ducts from the clusters of acini that form the lobules merged to form larger ducts draining the lobes

 ducts from the lobes converge in a single nipple (mammary papilla) rounded by an areola ampullae-converged ducts that dilate to form common lactiferous sinuses (serve as milk reservoirs and drain the ampullae out the nipple) glandular structures and ducts are surrounded by protective fatty tissue and are separated and supported by fibrous suspensory Cooper's ligaments Cooper's ligaments-provide support to the mammary gland while permitting their mobility on the chest wall Nipple usually round, slightly elevated, and projects slightly upward and laterally contains 15 to 20 openings from lactiferous ducts surrounded by fibromuscular tissue and covered by wrinkled skin except during pregnancy and lactation there is usually no discharge from nipple nipple and surrounding areola are usually more deeply pigmented then the skin of the breast Montgomery tubercles (sebaceous glands) cause rough appearance of the areola, directly beneath the skin (these glands secrete a fatty substance thought to lubricate the nipple) smooth muscle fibers in the areola contract to stiffen the nipple to make it easier for the breast-feeding Vascular supply is abundant nonpregnant state there is no obvious vascular pattern in the skin normal skin a smooth without tightness or shininess skin covering the breast contains an extensive superficial lymphatic network that serves the entire chest wall and is continuous with the superficial lymphatics of the neck and abdomen (lymphatics form a rich network in the deeper portions of the breast, primary deep lymphatic pathway drains laterally towards the axillae) Changes in Breast (Menstruation) increasing levels of estrogen and progesterone in the 3 to 4 days before menstruation increases the vascularity of the breasts, induced growth of the ducts and acini, and promote water retention epithelial cells lining the ducts proliferate in number, the ducts dilate, and the lobules distend acini become enlarged and secretory, and lipid is deposited within their epithelial cell lining, as a result breast swelling, tenderness, and discomfort are common symptoms just before menstruation the physiological alterations in breast size activity reached your minimum level about 5-7 days after menstruation

II. Menstruation
1. Menarche and Puberty
menarche-denotes first menstruation puberty-a broader term that denotes the entire transitional stage between childhood and sexual maturity initially menstrual periods are a regular, unpredictable, painless, and anovulatory (no oum) after one or more years of hypothalamic-pituitary rhythm develops, and the ovary produces adequate cyclic estrogen to make a mature ovum ovulatory-(ovum release from the ovary) tend to be regular, monitored by progesterone 2. Menstrual Cycle periodic uterine bleeding that begins approximately 14 days after ovulation controlled by a feedback system of three cycles: endometrial, hypothalamic-pituitary, and ovarian average blood loss is 50 mL blood clots within the uterus, but usually liquefies before being discharged from the uterus uterine discharge includes mucus and epithelial cells in addition to blood complex interplay of events that occur simultaneously in the endometrium, the hypothalamus, the pituitary glands, and the ovaries prepares your uterus for pregnancy, when pregnancy does not occur menstruation follows woman's age, physical and emotional status, and environment influences the regularity of her menstrual cycles

A. Endometrial Cycle four phases: menstrual phase, proliferative phase, secretory phase, and the ischemic phase (1) menstrual phase-shedding of the functional two thirds of the endometrium (compact and spongy layers) is initiated by periodic vasoconstriction in the upper layers of the endometrium. Basal layer is always retained, and regeneration begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells in this layer (2) proliferative phase-period of rapid growth lasting from about the fifth date to the time of ovulation. Endometrial surface is completely restored in approximately 4 days, or slightly before bleeding ceases. From this point on an eightfold to tenfold thickening occurs, with a leveling off of growth at ovulation. Depends on estrogen stimulation derived from ovarian follicles (3) secretory phase-extends from the date of ovulation to about three days before the next menstrual period. After ovulation larger amounts of progesterone are produced. edematous, vascular, functional endometrium is now apparent. At the end the fully mature secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions, a suitable protective and nutritive bed for a fertilized ovum (3A) implantation of the fertilized ovum generally occurs about 7 to 10 days after ovulation. If fertilization and implantation does not occur, the corpus luteum, which secrete estrogen and progesterone, regresses. With rapid decrease in progesterone and estrogen levels, the spiral arteries go into spasm (4) ischemic phase-blood supply to the functional endometrium is blocked, and necrosis develops. Functional layer separates from the basal layer, and menstrual bleeding begins, marking day one of the cycle B. Hypothalamic-Pituitary Cycle end of the normal menstrual cycle blood levels of estrogen and progesterone decrease low levels stimulate the hypothalamus to secrete gondatropin-releasing formal (GnRH) GnHR stimulates anterior pituitary secretion of follicle-stimulating hormone (FSH) FSH stimulates development of ovarian graafian follicles and their production of estrogen estrogen levels begin to decrease, and hypothalamic GnHR triggered the anterior pituitary to release luteinizing hormone (LH) a marked surge of LH and the smaller peak of estrogen (day 12) precede the expulsion of the ovum from the graafian follicle by about 24 to 36 hours LH peaks at about date 13 or 14 of the 28 day cycle if fertilization and implantation of the ovum have not occurred by this time regression of the corpus luteum follows levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is once again stimulated to secrete GnHR C. Ovarian Cycle primitive graafian follicles contain immature oocytes (primordial ova) before ovulation from 1 to 30 follicles begin to mature in each ovary under the influence of FSH and estrogen preovulatory surge of LH affects a selected follicle follicular phase (preovulatory phase)- oocytes matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum, almost all variations in ovarian cycle length are the result of variations in the length of the follicular phase after ovulation, estrogen levels drop mid cycle bleeding-small amount of withdrawal bleeding that usually goes unnoticed, and 10% of women there is sufficient bleeding to be visible luteal phase (post ovulatory phase) begins immediately after ovulation and ends with the start of menstruation, usual requires 14 days the corpus luteum reaches its peak of functional activity eight days after ovulation, secreting the steroids estrogen and progesterone

D. Other Cyclic Changes when the hypothalamic-pituitary-ovarian axis functions properly, other tissues undergo predictable responses before ovulation the woman's basal body temperature is often less than 37 C; after ovulation, with increasing progesterone levels basal body temperature rises changes in the cervix and cervical mucus follow a generally predictable pattern preovulatory and postovulatory mucus is viscous so that sperm penetration is discouraged spinnbarkeit -at the time of ovulation cervical mucus is thin and clear, it looks skills and stretches like egg white mittelschmerz-localized lower abdominal pain during ovulation, some spotting may occur 3. Prostaglandins (PGs) oxygenated fatty acids classified as hormones different kinds are distinguished by letters, numbers, and letters of the Greek alphabet are produced in most organs of the body, including the uterus menstrual blood is a potent PG source are biologically active in minute amounts in the cardiovascular, gastrointestinal, respiratory, urogenital, and nervous systems exert a marked effect on metabolism, particularly on glycolysis plan important role in many physiological, pathological, and pharmacological reactions affects smooth muscle contractility and modulation of hormonal activity newly synthesized PG are rapidly metabolized by tissues in such organs as the lungs, kidneys, and liver if PG levels do not rise along with the surge of LH, the ovum remains trapped within the graafian follicle introduction of PG into the vagina or the uterine cavity (from ejaculated semen) increases the motility of uterine musculature, which may assist the transport of sperm to uterus and into the oviduct PG produced by the women cause regression of the corpus luteum and regression and sloughing of the endometrium, resulting in menstruation PG increases myometrial response to oxytocic stimulation, enhance uterine contractions, and cause cervical dilation maybe a factor in that initiation of labor, the maintenance of labor, or both may also be involved in dysmenorrhea and preeclampsia/eclampsia may play a key role in ovulation after ovulation may influence production of estrogen and progesterone by the corpus luteum indirect evidence indicates that PG have an effect on ovulation, fertility, changes in the cervix and cervical mucus that affect receptivity to sperm, tubal and uterine motility, sloughing of endometrium (menstruation), onset of miscarriage and induced abortion, and onset of labor (term and preterm) 4. Climacteric and Menopause transitional phase during which ovarian function and hormone production decline phase spans the years from the onset of premenopausal ovarian decline to the postmenopausal time when symptoms stop menopause-refers only to the last menstrual period, can be dated with certainty only one year after menstruation ceases, average age at natural menopause is 51.4 years, within an age range of 35 to 60 years perimenopause- a period proceeding menopause that last about four years, during this time the ovarian function declines, ova slowly diminishes, and menstrual cycles may be anovulatory, resulting in irregular bleeding, ovary stops producing estrogen and eventually menses no longer occurs

III. Sexual Response

hypothalamus in anterior pituitary gland in females regulate the production of FSH and LH, target tissue for these hormones is the ovary, which produces ova and secrete estrogen and progesterone feedback mechanism between hormone secretion from the ovaries, the hypothalamus, and the anterior pituitary aids in the control of the production of sex cells and steroid sex hormone secretion both male and female achieve physical maturity at approximately 17 years of age, individual development varies greatly the glans clitoris and that glans penis are embryonic homologues physiological sexual response can be analyzed in terms of two processes: vasocongestion and myotonia vasocongestion-sexual stimulation results in increase in circulation to circumvaginal blood vessels (lubrication in the female), causing engorgement and distention of the genitals, venous congestion is localized primarily in the genitals, but it also occurs to a lesser degree in the breast and other parts of the body myotonia-how arousal is characterized, increased muscular tension, resulting in voluntary and involuntary rhythmic contractions sexual response cycle is divided into four phases: excitement, plateau, orgasmic, and resolution. They occur progressively, with no sharp dividing line between any two phases. Specific body changes take place in sequence. Time, intensity, and duration for cyclic completion vary for individuals and situations Both Sexes Excitement Phase HR and BP increase. Nipples become erect. Myotonia begins Female Reactions Clitoris increases in diameter and swells. External genitals become congested and darkened. Vaginal lubrication occurs; upper two thirds of vagina length in an extended. Cervix and uterus pull upward. Breast size increases. Clitorial head retracts under the clitoral hood. Lower one third of the vagina becomes engorged. Skin color changes occur-red flash may be observed across breast, abdomen, or other surfaces Strong rhythmic contractions are felt in the clitoris, vagina, and uterus. Sensations of warmth spread through the pelvic area Male Reactions Erection of the penis begins; penis increases in length and diameter. Scrotal skin becomes congested and thickens. Testes begin to increase in size and elevate toward the body. Head of penis may enlarge slightly. Scrotal continues to grow tense and thicken. Testes continue to elevate and enlarge. Pre-orgasmic emission of two or three drops of fluid appears on the head of the penis Testes elevate to maximum level. Point of "inevitability" occurs just before ejaculation and an awareness of fluid in the urethra. Rhythmic contractions occur in the penis. Ejaculation of semen occurs 50% of erection is lost immediately with ejaculation; penis gradually returns to normal size. Testes and scrotum return to normal size. Refractory period varies according to age and general physical condition.

Plateau Phase HR and BP continued to increase. Resp increase. Myotonia becomes pronounced; grimacing occurs. Orgasmic Phase HR, BP, and Resp increase to maximum levels. Involuntary muscle spasms occur. External rectal sphincter contracts Resolution Phase HR, BP, and Resp return to normal. Nipples erection subsides. Myotonia subsides.

Engorgement and external genitalia and vagina resolves. Uterus descends to normal position. Cervix dips into all, seminal pool. Breast size decreases. Skin flush disappears.

IV. Health Assessment

1. Interview
interview should be conducted in a private, comfortable, and relaxed setting and begins with an open ended question facilitation-using a word or posture that communicates interest such as leaning forward, making eye contact, or saying "mm-hmm" or "go on" reflection-repeating a word or phrase that a woman has used clarification-asking the woman what is meant by a stated word or phrase empathetic responses-acknowledging the feeling of a woman by statements such as "that must have been frightening" confrontation-identifying something about the woman's behavior or feelings not expressed verbally or apparently inconsistent with her history interpretation-putting into words which you infer the woman's feelings or about the meaning of her symptoms, even, or other matters direct questions may be necessary to elect specific details

2. Cultural Considerations
conversational style and pacing-silence may show respect or knowledge meant that the listener has heard. In cultures in which a direct "no" is considered rude, silence may mean no. Repetition or loudness may mean emphasis or anger personal space-cultural conceptions of personal space differ. For example, based on one sculpture, someone may be perceived as distant for backing off when approached or aggressive for standing too close. Eye contact-varies among cultures from intense to fleeting. Consistent with the effort to refrain from invading personal space, avoiding direct eye contact may be a sign of respect touch-the norms about how people should touch each other vary among cultures. In some cultures physical contact with the same sex is more appropriate then that with an unrelated person of the opposite sex time orientation-in some cultures involvement with people is more valued than being "on time." In other cultures life is scheduled and paste according to clock time, which is valued over personal time

V. Women with Special Needs

1. Women with Disabilities
women with emotional or physical disorders have special needs communicate openly, directly, and with sensitivity often helpful to learn about the disability directly from the woman while maintaining eye contact family and significant others should be relied on only when absolutely necessary many women with disabilities cannot comfortably lie on the lithotomy position for the pelvic examination several alternatives positions may be used, including a lateral position, a V-shaped position, a diamond shaped position, and an M-shaped position

2. Abused Women
should screen all women for abuse, is a life-threatening public health problem risk for intimate partner violence increases during pregnancy and after separation and divorce fear, guilt and embarrassment may keep women from giving information about family violence most common injury sites and women are the head, neck, chest, abdomen, breast, and upper extremities attention should be given to women who repeatedly seek treatment for somatic complaints such as headaches; insomnia; choking sensation; hyperventilation; gastrointestinal symptoms; and pain in the chest, back, or pelvis

3. History
biographic data-name, age, race, sex, marital status, occupation, religion, and ethnicity reason for seeking care-what problem or symptom brought you here today? Present health history of present illness past health family history screen for abuse review of systems functional assessment

4. Physical Examination
head to toe pelvic examination-external inspection, external palpation, vuvlar self-examination internal examination-collection of specimens (Pap smear), vaginal wall examination (bimanual palpation, rectovaginal palpation, pelvic examination during pregnancy, pelvic examination after hysterectomy

5. Laboratory and Diagnostic Procedures

the following laboratory and diagnostic test are ordered at the discretion of the clinician, considering the patient and family history hemoglobin hearing, visual acuity fasting blood glucose electrocardiogram, chest x-ray, pulmonary function total blood cholesterol fecal occult blood, flexible sigmoidoscopy lipid profile bone mineral density urinalysis test for HIV, hepatitis B, and drug screening may be offered within form consent in high-risk populations, these test syphilis serology results are usually reported in person other screening test for STIs mammogram tuberculosis skin test