2. Topics
• Anatomy and Physiology
• The Menstrual Cycle
• Assessment
• Management
• Specific Gynecological Emergencies
3. Introduction
• Gynecology
o Branch of medicine that deals with the health
maintenance and the diseases of women.
• Most patients that you will encounter will be
experiencing either abdominal pain or
vaginal bleeding.
5. Anatomy and Physiology of the
Female Reproductive Organs
• External Genitalia
o Accessory functions
• Protect body openings
• Important role in sexual functioning
• Internal Genitalia
o Most important organs of reproduction
o The ovaries, fallopian tubes, uterus, and vagina
6. External Genitalia
• Perineum
o Muscular tissue
that separates the
vagina and the
anus
• Mons Pubis
o Fatty layer of tissue
over the pubic
symphysis
• Labia
o Structures that
protect the
vagina and the
urethra
7. External Genitalia
• Clitoris
o Vascular erectile tissue that lies
anterior to the labia minora
• Urethra
o Drains the urinary bladder
8. Internal Genitalia
• Vagina
o Female organ of
copulation
o Birth canal
o Outlet for
menstruation
• Uterus
o Site of fetal
development
9. Internal Genitalia
• Fallopian Tubes
o Transports the egg from the ovary
to the uterus
o Fertilization usually occurs here
• Ovaries
o Primary female gonads
10. The Uterus
• Site for fetal
development
• Two major parts:
o Body (or corpus)
o Cervix (or neck)
• Tissue layers
o Endometrium
o Myometrium
o Perimetrium
13. The Menstrual Cycle
• Monthly hormonal cycle, usually 28 days
o Estrogen and progesterone
• Influenced by FSH and LH
• Prepares the uterus to receive a fertilized
egg
• The onset of menses, known as menarche
o Usually occurs between the ages of 10 and 14
• Menopause
14. Phases of the
Menstrual Cycle
• The Proliferative Phase
• The Secretory Phase
• The Ischemic Phase
• The Menstrual Phase
15. Proliferative Phase
• First two weeks of the menstrual cycle
o Dominated by estrogen
o Uterine lining will gradually thicken and become
engorged with blood
• Day 14
o Surge in leutenizing hormone (LH)
o Ovulation occurs
o Follicle develops the corpus luteum
• If fertilization occurs, egg implants in uterus
o If not, the endometrium sheds in normal menses
16. Secretory Phase
• Stage immediately surrounding ovulation
o If the egg is not fertilized, the woman’s estrogen
level drops sharply
o Progesterone dominant hormone during this
phase
17. The Ischemic Phase
• Estrogen and progesterone levels fall
without fertilization
• The endometrium breaks down
o Vascular changes cause the endometrium to
become pale and small blood vessels to rupture
18. The Menstrual Phase
• Menstruation
o Ischemic endometrium is shed, along with a
discharge of blood, mucus, and cellular debris
o A “normal” menstrual cycle depends on the
regular pattern
• Premenstrual syndrome (PMS)
o Symptoms include:
• Breast tenderness or engorgement, transient weight
gain or bloating, excessive fatigue, and/or cravings for
specific foods, migraine headaches
19. The Menstrual Phase
• Menopause
o Menstruation occurs until a woman is 45 to 55
o Menopause signals the cessation of ovarian
function and the cessation of estrogen secretion
• Periods decline in frequency and length until they
ultimately stop
• Surgical menopause
o Hormone replacement therapy
21. Assessment of the
Gynecological Patient
• The most common emergency complaints
of women in the childbearing years are
abdominal pain and vaginal bleeding.
o Often due to problems of the reproductive
organs.
• Conduct an initial assessment, focused
history, and physical exam as normal.
• Conduct yourself professionally.
• If patient is reluctant to discuss, transport
while treating any life-threats.
22. History
• Initial Assessment—SAMPLE
• Does the patient complain of pain?
• Use OPQRST
o Dysmenorrhea/dyspareunia
• Associated signs or symptoms
• Has she ever been pregnant?
o Gravida/parity/abortion
• Document last menstrual cycle
• Medications—Contraceptives
24. How Birth Control Works
• Two types of pills
o Estrogen and Progestin
o Progestin only
25. Physical Exam
• Respect patient’s privacy
• Be professional and explain all procedures
• Observe patient
• Check vital signs
• Assess bleeding or discharge:
o Do not perform an internal vaginal exam in the
field
• Abdominal examination
27. Management of
Gynecological Emergencies
• General management of gynecological
emergencies is focused on supportive
care
o Administer oxygen or assist ventilation as
necessary
o Treat for shock if indicated
• Intravenous therapy
• Cardiac monitoring
• PASG consideration
o Hemorrhage control
• Do not pack dressings in the vagina
31. Pelvic Inflammatory
Disease
• Predisposing factors
o Multiple sexual partners, prior history of PID,
recent gynecological procedure, or an IUD
o Infertility results from scarring of the fallopian
tubes
• Signs and symptoms
o Abdominal pain (may intensify either before or
after the menstrual period)
• Worsens during intercourse
o Patients may walk with a shuffling gait
o A yellow, foul-smelling vaginal discharge
o Midcycle bleeding
32. Pelvic Inflammatory
Disease
• Physical Exam
o Appearance reveals ill or toxic patient
o Moderate to severe abdominal pain
• Worse with palpation
• Rebound tenderness may be present
o Fever may or may not be present
• Treatment
o Definitive treatment is IV antibiotics
o Prehospital treatment is supportive
33. Ruptured Ovarian Cyst
• Cyst is a fluid-filled pocket
o Usually the result of a ruptured follicle
• Corpus luteum cyst, is often left in its place
• Blood causes irritation of peritoneum
o Results in pain
34. Ruptured Ovarian Cyst
• Physical Exam
o Moderate to severe unilateral abdominal pain
• May radiate to back
o Dyspareunia, irregular bleeding, or a delayed
menstrual period
• Cyst may rupture during sexual activity or physical
activity
o Vaginal bleeding may be present
35. Cystitis
• Urinary bladder infection
o Usually result of bacteria
• May progress to kidneys
• Signs and Symptoms
o Abdominal pain
o Urinary frequency, pain or burning with urination
(dysuria)
o Low-grade fever
36. Mittelschmerz
• Mid-cycle abdominal pain
o Peritoneal irritation during follicular rupture
o Usually self-limited
• Signs and Symptoms
o Unilateral lower quadrant pain
o Low-grade fever
• Treatment is symptomatic
37. Endometritis
• An infection of the uterine lining
o Results from miscarriage, childbirth, or
gynecological procedures
• Dilation and Curettage (D & C)
• Signs and Symptoms
o Mild to severe lower abdominal pain
o Bloody, foul-smelling discharge
o Fever (101°F to 104°F)
o Onset of symptoms usually 24-48 hours post-
procedure
• Complications of endometritis may include
sterility, sepsis, or even death
38. Endometriosis
• Condition in which endometrial tissue is
found outside of the uterus
o Most commonly in abdominal cavity and
pelvic cavity
o Tissue responds to the hormonal changes
associated with the menstrual cycle
o Usually seen in women between the ages of
30 to 40
• Signs and Symptoms
o Dull, cramping pelvic pain, dyspareunia,
abnormal uterine bleeding, painful bowel
movements
39. Ectopic Pregnancy
• Implantation of a fetus
outside of the uterus
o Most commonly the
fallopian tubes
• Signs and symptoms
o Severe, unilateral pain with
referred shoulder pain on
the same side
o Shock
o A late or missed period
40. Management of Gynecological
Abdominal Pain
• Administer oxygen and establish
intravenous access if indicated
• Make the patient comfortable and
transport
41. Non-Traumatic
Vaginal Bleeding
• Rarely seen in the field unless it is severe
o Obtain history
• Menorrhagia
o Excessive menstrual flow
o Be alert for signs of shock
• Spontaneous abortion (miscarriage)
o Most common cause of non-traumatic bleeding
o Often associated with cramping abdominal pain
and the passage of clots and tissue
• Other causes
o Cancerous lesions, PID, or the onset of labor
42. Non-Traumatic
Vaginal Bleeding
• Management
o Will depend on the severity of the situation
• Initiation of oxygen therapy and intravenous access
o Absorb blood flow
• Never pack the vagina
o Transport any blood or tissue to hospital
43. Traumatic Gynecological
Emergencies
• Causes of Gynecological Trauma
o Blunt Trauma
o Sexual Assault
o Blunt force to Lower Abdomen
o Foreign Bodies Inserted in Vagina
o Abortion Attempts
44. Management of
Gynecological Trauma
• Apply direct pressure over laceration
o Source of bleeding may not be readily apparent
o Apply cold pack to hematoma
• Establish IV if needed
• Potential organ rupture may lead to
peritonitis
• Transport
45. Sexual Assault
• The most rapidly growing violent crime in
America
o 60 percent never reported
o Male victims represent 5 percent of reported
sexual assaults
o No “typical victim” of sexual assault
• Most victims know assailants
o Sexual assault is a crime of violence
46. Sexual Assault
• Assessment
o Medical treatment and
psychological support
o Legal concerns
o Victims of sexual abuse should
not be questioned about the
incident in the field
o Respect the patient’s modesty
47. Management
Considerations
• Protect the scene
• Handle clothing as little as possible
• If removing clothing, bag each item
separately
• Do not cut through any tears or holes in
clothing
• Place bloody articles in brown paper bags
48. Management
Considerations
• Do not examine the perineal area
• Do not allow patient to change clothes,
bathe, or douche
• Do not allow patient to comb hair, brush
teeth, or clean fingernails
• Do not clean wounds, if possible
49. Documentation
• State patient remarks accurately
• Objectively state your observations of
patient’s physical condition, environment, or
torn clothing
• Document evidence turned over to hospital
staff
• Do not include your opinions as to whether
rape occurred
