COLLEGE OF NURSING,MADRAS MEDICAL

COLLEGE, CHENNAI -03

CLINICAL SPECIALITY
MEDICAL SURGICAL NURSING-1

ASSESSMENT OF
Female
REPRODUCTIVE SYSTEM
 LEARNING OBJECTIVES
 Describe the structures and functions of the female reproductive
systems.
 Summarize the functions of the major hormones essential for the
functioning of the female reproductive systems.
 Select the significant subjective and objective data related to the
female reproductive systems
 Select the appropriate techniques to use in the physical assessment of
the female reproductive systems.
 Differentiate normal from common abnormal findings of a physical
assessment of the female reproductive systems.
 Describe the purpose, significance of results, and nursing
responsibilities related to diagnostic studies of the female reproductive
systems.
 INTRODUCTION
Women are becoming more knowledgeable about
their health

Nurses who work with them need to understand

normal female anatomy and physiology and the
physical, developmental, psychological and socio
cultural influences on women's health.

Gynaecology is the specialized branch of medicine

concerned with the diagnosis and treatment of
diseases of the female reproductive system
 FEMALE REPRODUCTIVE
SYSTEM
EXTERNAL GENITALIA
INTERNAL GENITALIA
 EXTERNAL GENITALIA
VULVA(PUDENDU
M)
• Mons pubis -
Elevation of
adipose tissue
covered by
skin and pubic
hair ;
• Cushions
symphysis
pubis
LABIA MAJORA
 Two longitudinal folds of skin extend inferiorly
and posteriorly; Covered by pubic hair ;
 Contain an abundance of adipose tissue, sebaceous
(oil) glands, and apocrine sudoriferous (sweat)
glands
LABIA MINORA
 Medial to the labia majora are two smaller folds of
skin
 The labia minora are devoid of pubic hair and fat
and have few sudoriferous glands
 But they do contain many sebaceous glands
CLITORIS
 Small cylindrical mass;
 Composed of two small erectile bodies, the
corpora cavernosa, and numerous nerves
and blood vessels.
 Located at the anterior junction of the labia
minora.
 A layer of skin called the prepuce of the
clitoris is formed at the point where the labia
minora unite and covers the body of the
clitoris. The exposed portion of the clitoris is
VESTIBULE :
 Region between the labia minora.
 The hymen ,the vaginal orifice, the external
urethral orifice, and the openings of the ducts of
several glands.
 The vaginal orifice, the opening of the vagina to
the exterior, occupies the greater portion of the
vestibule and is bordered by the hymen.
 Anterior to the vaginal orifice and posterior to the
clitoris is the external urethral orifice
 On either side of the external urethral orifice are
the openings of the ducts of the paraurethral
 On either side of the vaginal orifice itself are the
greater vestibular glands or bartholin’s glands,
which open by ducts into a groove between the
hymen and labia minora.
 Produce a small quantity of mucus provides
lubrication.
 Several lesser vestibular glands also open into the
vestibule
BULB OF THE VESTIBULE:
 Consists of two elongated masses of erectile tissue
just deep to the labia on either side of the vaginal
orifice
PERINEUM
 The perineum is the diamond-shaped area medial
to the thighs and buttocks of both males and
females.
 It contains the external genitals and anus.
 Anterior-pubic symphysis ; Lateral -Ischial
tuberosities; Posterior-coccyx.
 A transverse line drawn between the ischial
tuberosities divides the perineum into an anterior
urogenital triangle that contains the external
genitals and a posterior anal triangle that contains
the anus.
 INTERNAL GENITALIA
 Vagina
 Uterus
 Ovaries
 Fallopian tubes or uterine tubes
 VAGIN
• Tubular, 10-cm (4-in.) A
• Long fibromuscular canal lined with mucous membrane
that extends from the exterior of the body to the uterine
cervix
• Between the urinary bladder and the rectum; directed
superiorly and posteriorly, where it attaches to the uterus
• FORNIX ( ARCH OR VAULT) : A recess surrounds the
vaginal attachment to the cervix.
• A thin fold of vascularized mucous membrane, called the
hymen ( membrane), forms a border around and partially
closes the inferior end of the vaginal opening to the
exterior, the vaginal orifice
HISTOLOGY THE MUCOSA
OF VAGINA  Series of transverse folds
called RUGAE;
Nonkeratinized stratified
squamous epithelium and
areolar connective tissue
THE MUSCULARIS
 Outer circular layer
 Inner longitudinal layer of
smooth muscle (Stretch
during birth process)
THE ADVENTITIA
 The superficial layer
 Areolar connective tissue.
 UTERUS(Womb)
 Part of the pathway for sperm
deposited in the vagina to reach the
uterine tubes.
 Site of implantation of a fertilized
ovum, development of the fetus
during pregnancy, and labor
UTERUS
 ANATOMY OF THE UTERUS
LOCATION:
 Situated between the urinary bladder and the
rectum
SIZE AND SHAPE
 An inverted pear
 7.5 cm (3 in.) long, 5 cm (2 in.) wide, and 2.5 cm
(1 in.) thick.
POSITION
The body of the uterus projects anteriorly and
superiorly over the urinary bladder in a position
DIVISIONS OF
UTERUS :
Fundus (above the
entrance points of
fallopian tubes)
Body (between
fundus and isthmus)
Cervix (below
isthmus)
• Between the body of the uterus and the
cervix is the isthmus, a constricted region
about 1 cm (0.5 in.) long.
• The interior of the body of the uterus is
called the uterine cavity, and the interior
of the cervix is called the cervical canal
• The cervical canal opens into the uterine
cavity at the internal os (os mouthlike
opening) and into the vagina at the
external os
SUPPORTING STRUCTURES
Extensions of parietal peritoneum or fibromuscular cords

• BROAD LIGAMENTS- Paired;Attach the uterus to either

side of the pelvic cavity
• UTERO SACRAL LIGAMENTS - Lie on either side of
the rectum and connect the uterus to the sacrum
• CARDINAL LIGAMENTS- Located inferior to the bases
of the broad ligaments and extend from the pelvic wall to
the cervix and vagina.
• ROUND LIGAMENTS - Bands of fibrous connective
tissue between the layers of the broad ligament; they extend
from a point on the uterus just inferior to the uterine tubes to
a portion of the labia majora of the external genitalia.
 HISTOLOGY OF UTERUS
Three layers:
Perimetrium or outer serosa layer
Myometrium or middle muscular layer
Endometrium or inner mucus layer.
 OUTER PERIMETRIUM
 Simple squamous epithelium and areolar
connective tissue.
 Laterally, it becomes the broad ligament.
 Anteriorly, it covers the urinary bladder and forms
a shallow pouch, the vesicouterine pouch
 Posteriorly, it covers the rectum and forms a deep
pouch between the uterus and urinary bladder, the
rectouterine pouch or pouch of Douglas— the most
inferior point in the pelvic cavity
 MYOMETRIUM
• The middle layer of the uterus, the myometrium
(myo- muscle), consists of three layers of
smooth muscle fibers that are thickest in the
fundus and thinnest in the cervix.
• The thicker middle layer is circular;
• the inner and outer layers are longitudinal or
oblique.
 ENDOMETRIUM
• The inner layer of the uterus, the endometrium
(endo- within), is highly vascularized and has three
components:
• (1) An innermost layer composed of simple
columnar epithelium (ciliated and secretory cells)
lines the lumen.
• (2) An underlying endometrial stroma is a very
thick region of lamina propria (areolar connective
tissue).
• (3) Endometrial (uterine) glands develop as
invaginations of the luminal epithelium and extend
TWO LAYERS.
• The stratum functionalis (functional layer) lines
the uterine cavity and sloughs off during
menstruation.
• The deeper layer, the stratum basalis (basal
layer), is permanent and gives rise to a new
stratum functionalis after each menstruation
INTERNAL ILIAC BLOOD SUPPLY
ARTERY TO THE UTERUS-
ARTERIAL

Uterine arteries

Arcuatearteries
(myometrium)

Radial arteries(deep into

myometrium)

Spiral arterieoles
Straight arterioles
Stratum
Stratum basale functionAlis
VENOUS DRAINAGE
UTERINE VEINS
Blood leaving the uterus is drained by the uterine
veins into the internal iliac veins.
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,
NERVE SUPPLY: AUTONOMIC
NERVOUS SYSTEM

SYMPATHETIC
NERVES
• The nerve supply to
the pelvis is
autonomic.
Sympathetic nerves
from the inferior
hypogastric plexus
(T10–L1) supply the
uterus and cervix.
NERVE SUPPLY: AUTONOMIC
NERVOUS SYSTEM
PARASYMPATHETIC
NERVES
• The pudendal nerve
(S2,3,4) suplies the
vagina and pelvic
outlet. There is also a
minor supply from the
genito-femoral nerve
(L1,2) and the
perineal branch of the
posterior femoral
 CERVICAL MUCUS
• The secretory cells of the mucosa of the
cervix produce a secretion called cervical
mucus, a mixture of water, glycoproteins,
lipids, enzymes, and inorganic salts.
• During their reproductive years, females
secrete 20–60 mL of cervical mucus per
day
• Less viscous and more alkaline pH 8.5
• Internal os and external os
 UTERINE TUBES
• Two uterine tubes, also called fallopian tubes or
oviducts, that extend laterally from the uterus
• 10 cm (4 in.) long
• INFUNDIBULUM - Funnel-shaped portion of
each tube, is close to the ovary but is open to the
pelvic cavity.
• FIMBRIAE - Fringe of fingerlike projections, one
of which is attached to the lateral end of the ovary.
• AMPULLA -Widest, longest portion, making up
about the lateral two-thirds of its length.
• THE ISTHMUS -More medial, short, narrow,
 LAYERS OF UTERINE TUBE
 THE MUCOSA
• Epithelium and lamina propria (areolar
connective tissue). The epithelium contains
ciliated simple columnar cells, which function
as a “ciliary conveyor belt” to help move a
fertilized ovum (or secondary oocyte) within the
uterine tube toward the uterus, and nonciliated
cells called peg cells
 MUSCULARIS
Circular and longitudinal smooth muscle
 SEROSA.
 OVARIES
 Gonad or primary sex organs
 2 functions
1. Endocrine functions (hormones)
2. Gametogenic function{ production
and release of ovum or egg)
 FUNCTIONAL ANATOMY
SIZE:
 LENGTH = 4 CM
 WIDTH = 2 CM
 THICKNESS = 1 CM
SHAPE:
UNSHELLED ALMOND
LOCATION
ON EITHER SIDE OF UTERUS
 SUPPORTING
STRUCTURES
 THE BROAD LIGAMENT of the uterus, which
is a fold of the parietal peritoneum, attaches to the
ovaries by a double layered fold of peritoneum
called the mesovarium
 THE OVARIAN LIGAMENT anchors the
ovaries to the uterus,
 THE SUSPENSORY LIGAMENT attaches
them to the pelvic wall.
 Each ovary contains a hilum (HI¯-lum), the point
of entrance and exit for blood vessels and nerves
 HISTOLOGY OF OVARIES
• THE GERMINAL EPITHELIUM - Layer of
simple epithelium (low cuboidal or squamous) that
covers the surface of the ovary
• THE TUNICA ALBUGINEA Is a whitish capsule
of dense irregular connective tissue located
immediately deep to the germinal epithelium
• THE OVARIAN CORTEX -region just deep to
the tunica albuginea. It consists of ovarian follicles
(described shortly) surrounded by dense irregular
connective tissue that contains collagen fibers and
fibroblast-like cells called stromal cells
HISTOLOGY
OF
OVARIES
• THE OVARIAN MEDULLA
 Deep to the ovarian cortex.
 Consists of more loosely arranged connective
tissue and contains blood vessels, lymphatic
vessels, and nerve
• OVARIAN FOLLICLES are in the cortex and
consist of oocytes in various stages of
development, plus the cells surrounding them.
• When the surrounding cells form a single layer,
they are called follicular cells: later in
development, when they form several layers,
they are referred to as granulosa cells
• A MATURE (GRAAFIAN) FOLLICLE
• Large, fluid filled follicle that is ready to
rupture and expel its secondary oocyte, a
process known as ovulation
• A CORPUS LUTEUM ( YELLOW
BODY) contains the remnants of a mature
follicle after ovulation. The corpus luteum
produces progesterone, estrogens, relaxin,
and inhibin until it degenerates into fibrous
scar tissue called the corpus albicans
 MAMMARY GLAND
• A hemispheric projection of variable size
• Anterior to the pectoralis major and serratus
anterior muscles and attached to them by a layer
of fascia composed of dense irregular connective
tissue
• THE NIPPLE -one pigmented projection
• LACTIFEROUS DUCTS - a series of closely
spaced openings of ducts where milk emerges.
• THE AREOLA The circular pigmented area of
skin surrounding the nipple it appears rough
contains modified sebaceous (oil) glands.
• Contd…
• 15 to 20 lobes,
• In each lobe are several smaller compartments
called lobules, composed of grapelike clusters
of milk-secreting glands termed ALVEOLI
• Contraction of myoepithelial cells surrounding
the alveoli helps propel milk toward the nipples.
Milk produced in alveoli

Series of secondary lobules

Mammary ducts

Lactiferous sinuses (storage)

Lactiferous duct
 FUNCTION
 The functions of the mammary glands are the
synthesis, secretion, and ejection of milk; these
functions, called lactation
 Milk production is stimulated largely by the
hormone prolactin from the anterior pituitary,
with contributions from progesterone and
estrogens.
 The ejection of milk is stimulated by oxytocin,
which is released from the posterior pituitary
in response to the sucking of an infant on the
mother’s nipple
 HORMONE
REGULATION
 PHASES OF
MENSTRUAL CYCLE
 LACTATION
• Lactation means synthesis, secretion and
ejection of milk. Two processes:
• A. Milk secretion B. Milk ejection
MILK SECRETION Synthesis of milk by
alveolar epithelium and its passage through the
duct system is called milk secretion.
Milk secretion occurs in two phases:
1. Initiation of milk secretion or lactogenesis
2. Maintenance of milk secretion or
galactopoiesis
 MILK
EJECTION
REFLEX
ASSESSMEN
T
 History collection
 Physical examination
 Diagnostic evaluation
 HISTORY
• Biographical and geographical data
Age , ethnicity , work and living environment
 CHIEF COMPLAINTS
• General pelvic pain
• Breast pain
• Abnormal uterine bleeding
• Infertility
• infection
 Location Specific
GENERAL PELVIC PAIN

BREAST PAIN
Missed or lengthy

ABNORMAL UTERINE BLEEDING

Duration aggravating
periods
Radiation of pain
factors &
alleviating factors Painful periods
Burning Heavy flow
Timed to
Throbbing’ menstrual cycle Recent Ic
History of pelvic Skin colour and Recent procedure
or abdominal History of cycle
consistency
surgeries
Masses or lumps Old problem vs
Trauma?? changes to the
OTC Temperature existing problem
changes Duration Pain with bleeding
Specific
aggravating Changes in breast Possible
factors & size/appearances pregnancy
alleviating factors Nipple discharge
Last
mammogram’
Cancer history
 Age of partner Location

INFECTION
INFERTILITY Length of time trying Duration
to conceive Fever/chills
Menstrual cycle Constitutional
details complaints
STD Discharge location and
Pap history characteristics
PID Urinary complaints
Previous Sexual partner history
pregnancies/abortions Recent GU OR GYN
Birth control methods procedure
Fertility drug use Self treatment
 GYNAECOLOGIC AND
OBSTETRIC
BREAST HEALTH
HISTORY
 Routine BSE
 History of masses or lumps or abnormal
discharge,pain
 location
 Duration
 Radiation of pain
 Unilateral or bilateral
 Aching/heaviness
 Mammogram / results
• GYNAECOLOGIC
 UTI/urinary incontinence
 Fertility issues
 Premenstrual disorder
 Premenstrual syndrome
 Vaginal infection
 Stds
 Uterine infections
 History of abnormal pap test
• SEXUAL HEALTH
 Risk behaviors
 Types of relationships
 Sexual issues
 Sexual abuses
 Current use of contraceptives
• OBSTETRICAL HISTORY
 Currently pregnant
 History of spontaneous or elective abortions
 Early pregnancy
 Complications
 Date week of gestation’
 Labor length
 Ty[pe of delivery
 Where delivered
 Status of infant
 PAST MEDICAL HISTORY
• History of rubella? Hypertension?
Cardiovascular disease? Migraines? Seizures?
Breast/gyn cancer? Anemia? Uterus or bladder
prolapse? GU infections? Previous pregnancy?
Reproductive trauma? Vaccinations?
 PAST SURGICAL HISTORY
• Cesarean section? Tubal ligation Prolapse
surgery? Hysterectomy Dilation & curettage?
Cryosurgery? Other pelvic abdominal or retro
peritoneal surgery?
 MEDICATIONS, OTC
MEDICATIONS,
NUTRACEUTICALS
• Current contra ceptive use? Vitamins? Herbal
supplements? Prescription and OTC
medication use?
• New clinical manifestation related to new
medication or supplement?
 DIETARY HABITS
• Body mass index General diet overview
Calcium, iron intake Exercise regimen

Allergies
IVP dye? Antibiotics? Food? Latex?
 SOCIAL HISTORY
• Smoking history? ETOH intake? Caffeine
intake? Domestic abuse? Environmental and
occupational hazards
 Family history
• Breast,uterine,ovariancancer?mellitus?
vascularDiabetes Cardio disease?
Hypertension? Mental illness? Congenital
anomalies?Maternal diethyl
stilbestrolexposure? • Positive response to any
diagnosis ,including age at diagnosis •
Treatment
 Other related histories
• Female genital mutilation or cutting
• Domestic violence
• Incest and childhood abuse
• Rape and sexual assault
 PHYSICAL EXAMINATION
 Explain each step in advance
 Drape patient from mid-abdomen to knees, depress
drape between knees to provide eye contact with patient
 Avoid unexpected or sudden movement :Warm
speculum with tap water.
 Monitor comfort of the examination by watching
patients face
 Uses excellent but gentle technique, especially when
inserting speculum
 Empty bladder before examination
 The examination should flow from head to toe, more
invasive pelvic procedures performed at with the end of
examination
 BREASTS AND AXILLAE -
INSPECTION
• A thorough breast examination requires
exposure of both breasts for comparison.
• Breasts are best inspected in three positions.
1. Begin breast inspection while the cli ent is
seated with her arms at her sides.
2. Next, ask her to raise her hands over her head
while you examine the lateral and
undersurfaces of each breast.
3. Finally, have her press her hands firmly on
her hips to tighten the pectoral muscles
 Contd…
• Watch for symmetry, contour, stretch masks,
areas of edema or hyperpigmentation,
dimpling.
• Inspect the areola and nipples for size, shape
& contours, symmetry, surface characteristics
and masses or lesions
 NORMAL FINDINGS
• Breasts and Axillae.
Breasts symmetrical, full, rounded, smooth in
all positions, without dimpling, retractions, or
masses. Faint, even vascular pattern and striae
are noted. Nipples everted, areolae even. Axillae
even color, without masses or rash.
 PALPATION
• Palpate the axillae while the client is seated.
Examine the five sets of axillary lymph nodes
• The client's arm should be relaxed to ease palpation.
• Nodes should be nonpalpable, though detection of one
or two small, nontender, mobile nodes is often a normal
finding.
• Abnormal findings include firm, fixed nodes that may or
may not be tender. If nodes are palpated, note the
number of nodes felt,their location
size.shape,mobiity,consistency and tenderness
FINDING DESCRIPTION POSSIBLE
ETIOLOGY AND
SIGNIFICANCE
Nipple inversion or Recent onset, Abscess, inflammation,
retraction erythematous, pain, cancer
unilateral. Recent onset
(usually within past year),
unilateral presentation,
lack of tenderness.
Nipple secretions Milky, no relationship to Drug therapy, particularly
Galactorrhea (female) lactation, unilateral or phenothiazines, tricyclic
bilateral, intermittent or antidepressants,
consistent presentation. methyldopa.
Hypofunction or
hyperfunction of thyroid
or adrenal glands.
Tumors of hypothalamus
or pituitary gland.
Excessive estrogen.
Prolonged suckling or
breast foreplay
• Galactorrhea (male) Milky, bilateral presentation Chorioepithelioma of
testes, manifestation of
pituitary tumor

Purulent Gray-green or yellow color. Puerperal (after birth)

Frequent unilateral mastitis (inflammatory
presentation. Association with condition of breast) or
pain, erythema, induration, abscess.
nipple inversion.

Same as above but usually Infected sebaceous cyst

without nipple inversion
Serous discharge Clear appearance, unilateral Intraductal papilloma.
or bilateral, intermittent or
consistent presentation

Dark green or Thick, sticky, and frequently Ductal ectasia (dilation of

multicolored discharge bilateral. mammary ducts).

• Serosanguineous or Unilateral presentation. Papillomatosis

bloody drainage (widespread development
of nipple-like growths),
intraductal papilloma,
carcinoma (male and
Scaling or irritation of Unilateral or bilateral Paget’s disease, eczema,
nipple presentation, crusting, infection.
possible ulceration.

Nodules, lumps, or Multiple, bilateral, well- Fibrocystic changes

masses delineated, soft or firm,
mobile cysts. Pain.
Premenstrual occurrence

Rubbery consistency, fluid- Ductal ectasia.

filled interior, pain.

Soft, mobile, well- Lipoma, fibroadenoma

delineated cyst, absence
of pain

Erythema, tenderness, Infected sebaceous cysts,

induration. abscesses.

Usually singular, hard,

irregularly shaped, poorly Neoplasm.
delineated, nonmobile

Dimpling of breast Unilateral, recent onset, no Neoplasm.

 EXTERNAL GENITALIA
• Start with a general inspection of the external
genitalia
• Place one hand on the client's thigh before
touching the perineum.
• Inspect the mons pubis (mound of tissue
superior to the labia), labia majora. and labia
minora.
• The labia majora are symmetrical, rounded,
and full, and may gape slightly if the client
has had a previous vaginal delivery.
 CONTD
• The labia minora are thinner than the labia
majora, and one side may be larger than the
other side.
• Use the thumb and index finger to separate the
labia minora for inspection of the vulva and
remaining external structures.
• All areas should be free of edema, mal odor,
inflammation, and lesions.
• The meatus should be free of discharge,
inflammation, or swelling.
• If a discharge is present, collect a specimen for
culture.
• Inspect the clitoris, hymen (mostly absent in a
sexually active client), and vaginal orifice
(introitus).
• Discharge, inflammation, edema, or lesions
should be absent
 SPECULUM
EXAMINATION
• The bivalved speculum, either metal or plastic, is
available in many sizes.
• Metal specula are soaked, scrubbed, and
sterilized between patients.
• The speculum is gently inserted into the
posterior por tion of the introitus and slowly
advanced to the top of the vagina; this should not
be painful or uncomfortable for the woman.
• The speculum is then slowly opened and the
screw of the thumb rest is tightened to hold the
speculum open
 The cervix is inspected. In nulliparous women,
the cervix usually is 2 to 3 cm wide and smooth.
 In women who have borne children, the cervix
may have a laceration, usually transverse,
giving the cervical os a "fishmouth"
appearance.
 . Epithelium from the endocervical canal may
have grown onto the surface of the cervix,
appearing as beefyred surface epithelium
circumferentially around the os
 ABNORMAL GROWTH
• Malignant changes may not be obviously differentiated
from the rest of the cervical mucosa.
• Small, benign cysts may appear on the cervical surface.
These are usually bluish or white and are called nabothian
cysts.
• A polyp of endocervical mucosa may protrude through the
os and usually is dark red.
• A carcinoma may appear as a cauliflower-like growth that
bleeds easily when touched.
• Bluish coloration of the cervix is a sign of early pregnancy
(Chadwick’s sign).
 BIMANUAL PALPATION
 Standing position.
 The examination is performed with the forefinger
and middle finger of the gloved and lubricated
hand.
 These fingers are placed in the vaginal orifice,
while the other fingers are held tightly out of the
way, with the thumb completely adducted.
 The fingers are advanced vertically along the
vaginal canal, and the vaginal wall is palpated
BIMANUAL PALPATION
 CERVICAL PALPATION
• The cervix is palpated and assessed for its
consistency, mobility, size, and position.
• The normal cervix is uniformly firm but not
hard.
• Softening of the cervix is a finding in early
pregnancy.
• Hardness and immobility of the cervix may
reflect invasion by a neoplasm.
• Pain on gentle movement of the cervix is called
a positive chandelier sign or positive cervical
motion tenderness (recorded as +CMT) and
 UTERINE PALPATION
 To palpate the uterus, the examiner places the
opposite hand on the abdominal wall halfway
between the umbilicus and the pubis and presses
firmly toward the vagina.
 Movement of the abdominal wall causes the
body of the uterus to descend, and the pear-
shaped organ becomes freely movable between
the abdominal examining hand and the fingers of
the pelvic examining hand.
 Uterine size, mobility, and contour can be
estimated through palpation.
• The body of the uterus is normally twice the
diameter and twice the length of the cervix,
curving anteriorly toward the abdominal wall.
• Some women have a retroverted or retroflexed
uterus, which tips posteriorly toward the
sacrum, whereas others have a uterus that is
neither anterior nor posterior but is midline.
 ADNEXAL PALPATION
 Next, the right and left adnexal areas are palpated
to evaluate the fallopian tubes and ovaries.
 The fingers of the hand examining the pelvis are
moved first to one side, then to the other, while the
hand palpating the abdominal area is moved
correspondingly to either side of the abdomen and
downward.
 The adnexa (ovaries and fallopian tubes) are
trapped between the two hands and palpated for an
obvious mass, tenderness, and mobility. Commonly,
the ovaries are slightly tender, and the patient is
informed that slight discomfort on palpation is
 VAGINAL AND RECTAL
PALPATION
• Bimanual palpation of the vagina and cul-de-
sac is accomplished by placing the index
finger in the vagina and the middle finger in
the rectum.
• To prevent cross-contamination between the
vaginal and rectal orifices, the examiner puts
on new gloves.
• A gentle movement of these fingers toward
each other compresses the posterior vaginal
wall and the anterior rectal wall and assists the
cont.
• During this procedure, the patient may sense
an urge to defecate.
• The nurse assures the patient that this is
unlikely to occur.
• Ongoing explanations are provided to reassure
and educate the patient about the procedure.
 NORMAL FINDINGS
• Triangular hair distribution. clean, coarse, no
lesions, redness, swelling, or inflammation in
perineal region. Labia minora is pink, smooth .
Clitoris midline, smooth; urethral meatus pink,
discharge absent, Vaginal orifice clean, without
bulges .No vaginal discharge noted. No
tenderness with palpation of Skene’s ducts and
Bartholin’s glands.
 ABNORMAL FINDINGS
FINDING AND DESCRIPTION POSSIBLE ETIOLOGY AND
SIGNIFICANCE
VULVAR DISCHARGE
White, thick, curdy, frequent itching and Candidiasis (Candida or yeast infection),
inflammation, lack of odor or yeast-like smell vaginitis

Thin gray or white, copious flow, malodorous or

fishy, vulvar irritation Bacterial vaginosis infection

Frothy green or yellow color; malodorous

Trichomonas vaginalis
Bloody discharge
Chlamydia trachomatis or Neisseria
gonorrhoeae infection, menstruation, trauma,
cancer

VULVAR ERYTHEMA Candida albicans, allergy, chemical

Bright or beefy red color, itching vaginitis

Reddened base, painful vesicles or

ulcerations Genital herpes

Macules or papules, itching Chancroid (STI), contact dermatitis,

scabies, pediculosis
Vulvar Growths
Soft, fleshy growth, nontender Condyloma acuminatum
Flat and warty appearance, nontender
Same as either of above, possible pain Condyloma latum
Reddened base, vesicles, and small Neoplasm
erosions; pain Lymphogranuloma venereum, genital
Indurated, firm ulcers, no pain herpes, chancroid

Chancre (syphilis), granuloma inguinale

Abdominal Pain or Tenderness Salpingitis (infection of fallopian tube),

Intermittent or consistent tenderness in ectopic pregnancy, ruptured ovarian cyst,
right or left lower quadrant PID, tubal or ovarian abscess

Periumbilical location, consistent Cystitis, endometritis (inflammation of

occurrence endometrium), ectopic pregnancy

Abnormal Vaginal Bleeding Dysfunctional uterine bleeding, usually

Unusual and inappropriate uterine anovulatory bleeding, menorrhagia (heavy
bleeding menstrual bleeding), metrorrhagia
(irregular, frequent bleeding),
postmenopausal bleeding
 DIAGNOSTIC STUDIES
• Serology studies
• Cultures and Smears
• Cytologic Studies
• Radiologic Studies
• Invasive Procedures
• Fertility Studies
• Urine Studies
 SEROLOGY STUDIES
DIAGNOSTIC STUDIES AND NURSES RESPONSIBILITY
DESCRIPTION

PROLACTIN Observe venepuncture site for bleeding or

Detects pituitary dysfunction that can cause hematoma formation.
amenorrhea.

Female: 3.8-23.2 ng/mL (3.8-23.2 mg/L) Male:

3.0-14.7 ng/mL (3.0-14.7 mg/L)

PROSTATE-SPECIFIC ANTIGEN (PSA) No food or fluid restrictions. Collect 5 mL blood.

Detects prostate cancer. Also a sensitive test for Observe venipuncture site for bleeding
monitoring response to therapy.

Reference interval: <4 ng/ml

HCG DETECTS PREGNANCY. Can also be Find out where patient is in her menstrual cycle,
used as a tumor marker for testicular whether she has missed menses, and if so, how
malignancy. Also used to detect hydatidiform late she is
mole
TESTOSTERONE Collect health history to eliminate
Determines whether elevated androgens potential sources of interference with
are due to testicular, adrenal, or ovarian accuracy of results (e.g., use of
dysfunction or pituitary tumors. corticosteroids or barbiturates,
Serum testosterone also drawn to hypothyroidism or hyperthyroidism).
assess male infertility and tumors of
testicle or ovary

PROGESTERONE Observe venipuncture site for bleeding or

Determines cause of infertility, monitors hematoma formation.
success of drugs for infertility or the effect Include information about last menstrual
of treatment with progesterone, period and trimester of pregnancy
determines whether ovulation is because progesterone levels vary with
occurring, and diagnoses problems with gestation
the adrenal glands and some types of
cancer.
Female: Follicular phase: 15-70 ng/dL
(0.5-2.2 nmol/L)
Luteal phase: 200-2500 ng/dL (6.4-79.5
nmol/L) Postmenopause:
ESTRADIOL Observe venipuncture site for
Measures ovarian function. bleeding or hematoma
Useful in assessing estrogensecreting tumors and states of formation.
precocious female puberty.
May be used to confirm perimenopausal status.
Increased serum estradiol levels in men may be indicative
of testicular tumors.
Female:
Follicular phase: 20-150 pg/mL (73-1285 pmol/L)
Luteal phase: 30-450 pg/mL (110-1652 pmol/L)
Postmenopause: ≤20 pg/mL (≤73 pmol/L)

FSH No food or fluid restrictions

Indicates gonadal failure due to pituitary dysfunction. required. State phase of
Used to validate menopausal status. Female: menstrual cycle, if
Follicular phase: 1.37-9.9 mU/mL Ovulatory phase: 6.17- menopausal, or if on oral
17.2 mU/mL Luteal phase: 1.09-9.2 mU/mL contraceptive or hormones.
Postmenopause: 19.3-100.6 mU/mL

VENEREAL DISEASE RESEARCH LABORATORY (VDRL) Observe venipuncture site for

(FLOCCULATION) Nonspecific antibody tests used to bleeding or hematoma
screen for syphilis. Positive readings can be made within 1- formation.
2 wk after appearance of primary lesion (chancre) or 4-15
wk after initial infection. Reference interval: Negative or
nonreactive
RAPID PLASMA REAGIN (RPR) Obtain data to identify conditions such
(AGGLUTINATION) as hepatitis, pregnancy, and
Nonspecific antibody test used to autoimmune diseases that may
screen for syphilis. Reference interval: interfere with accuracy of results.
Negative or nonreactive

FLUORESCENT TREPONEMAL Inform patient that blood sample will

ANTIBODY ABSORPTION (FTA- be drawn.
ABS) Observe venipuncture site for
Detects syphilis antibodies. Also bleeding or hematoma formation.
detects early syphilis with great
accuracy.
Usually performed if results of VDRL
and RPR are questionable. Reference
interval: Negative or nonreactive
 CULTURES AND SMEARS
DARK-FIELD MICROSCOPY Avoid direct skin contact with open lesion.
Direct examination of specimen obtained
from potential syphilitic lesion (chancre) is
performed to detect Treponema pallidum

WET MOUNTS Explain procedure and purpose to patient. Instruct

Direct microscopic examination of specimen patient not to douche before examination.
of vaginal discharge is performed Prepare for collection of specimens (glass slide,
immediately after collection. 10%-20% potassium hydroxide [KOH] solution,
Determines presence or absence and sodium chloride [NaCl] solution, and cotton-tipped
number of Trichomonas organisms, bacteria, applicators).
white and red blood cells, and candidal buds
or hyphae.
Other clues or causes of inflammation or
infection may be determined.

CULTURES Obtain specific contact and sexual history, including

Specimens of vaginal, urethral, or cervical oral and rectal intercourse. Instruct against douching
discharge are cultured to assess for before examination. Obtain urethral specimen from
gonorrhea or Chlamydia organisms. men before they void. Instruct sexually active women
Rectal and throat cultures may also be with multiple partners to have at least a yearly
taken, depending on data obtained from culture for gonorrhea and Chlamydia. Instruct
sexual history sexually active men to have any discharge evaluated
immediately to rule out gonorrhea strains that do not
cause classic symptoms of dysuria
GRAM STAIN Same as above.
Used for rapid detection of gonorrhea.
Presence of gramnegative intracellular
diplococci generally warrants treatment.
Not highly accurate for women.
Also a valid alternative for Chlamydia
testing

CYTOLOGIC STUDIES Instruct sexually active women to have

PAPANICOLAOU (PAP) TEST Pap test according to American Cancer
Microscopic study of exfoliated cells via Society guidelines (www.cancer.org).
special staining and fixation technique to Instruct patient not to douche for at least
detect abnormal cells. 24 hr before examination. Collect careful
Most commonly studies cells obtained menstrual and gynecologic history
directly from the endocervix and
ectocervix

NIPPLE DISCHARGE TEST Indicate if patient is taking hormonal

Cytologic study of nipple discharge. preparations or other drugs, is
breastfeeding, or has a history of
amenorrhea. Instruct patient that nipple
discharge should always be evaluated
 RADIOLOGIC STUDIES
MAMMOGRAPHY Nurses need to provide teaching about
Screening X-ray image of breast tissue on screening guidelines for women in the
general population and those at high risk
radiographic film is used to assess breast
so that these women can make informed
tissue.
choices about screening
Detects benign and malignant masses
abnormality found on screening
mammogram.
Additional views of affected breast are
taken.

ULTRASOUND (ABDOMINAL AND Instruct patient that a full bladder may be

TRANSVAGINAL) Measures and required depending on reason for the
study.
records high-frequency sound waves as
they pass through tissues of variable
density. In women, useful in detecting
masses >3 cm, such as ectopic pregnancy,
IUD, ovarian cyst, and hydatidiform mole.
In men, used to detect testicular torsion or
masses
ULTRASOUND-GUIDED BIOPSY Inform patient of purpose for this
Use of ultrasound guidance while procedure. It is usually done as an
performing a biopsy. outpatient procedure.
Ultrasound is used to direct the biopsy
needle into the region of interest and
obtain a sample of tissue.
Removal of small tissue sample to
diagnose infection, inflammation, or mass

COMPUTED TOMOGRAPHY (CT) of Inform patient of procedure. Patient must

pelvis Detects tumors within the pelvis. lie still during the procedure. If IV contrast
medium is used, check for iodine allergy.

MAGNETIC RESONANCE IMAGING Screen patient for metal parts and

(MRI) pacemaker. Inform patient the procedure is
painless. Patient must lie still during the
Radio waves and magnetic field are used
procedure
to view soft tissue.
Useful after an abnormal mammogram or
for breast dysplasia.
Also used to diagnose abnormalities in the
female and male reproductive systems
 INVASIVE PROCEDURES

BREAST BIOPSY Before biopsy:

Histologic examination of excised breast Instruct patient about operative
tissue, obtained either by needle procedures and sedation.
aspiration or excisional biopsy After biopsy:
Perform wound care and instruct patient
about breast self-examination.

HYSTEROSCOPY Explain purpose and method of

Allows visualization of uterine lining procedure and that it may be done in the
through insertion of scope through cervix. physician’s office.
Used mainly to diagnose and treat Inform patient that mild cramping and
abnormal bleeding such as polyps and slight bloody discharge after procedure is
fibroids. normal
Biopsy may be taken during procedure
HYSTEROSALPINGOGRAM Inform patient about procedure and that it
Involves instillation of contrast media may be fairly uncomfortable. Ask about
iodine allergy
through cervix into uterine cavity and
subsequently through the fallopian tubes.
X-ray images taken to detect abnormalities
of uterus and its adnexa (ovaries and
tubes) as contrast progresses through
them.
Test may be most useful in diagnostic
assessment of fertility (e.g., to detect
adhesions near ovary, an abnormal uterine
shape, blockage of tubal pathways)

COLPOSCOPY Instruct patient about this outpatient

Direct visualization of cervix with binocular procedure. Inform patient that this
microscope that allows magnification and examination is similar to speculum
study of cellular dysplasia and cervix examination.
abnormalities.
Used as follow-up for abnormal Pap test
and for examination of women exposed to
DES in utero. Biopsy of cervix may be
taken during examination.
Valuable in decreasing number of false-
negative cervical biopsies
CONIZATION Explain purpose and method of procedure
Cone-shaped sample of squamocolumnar and that it requires use of surgical facilities
tissue of cervix is removed for direct study. and anesthesia.
Instruct patient to avoid sexual intercourse
and tampons for about 3-4 wk.
Also discuss necessity for 3-wk follow-up.

LOOP ELECTROSURGICAL Explain purpose and method of procedure

EXCISION PROCEDURE (LEEP) and that it may be done in the physician’s
office.
Excision of cervical tissue via an
Patient may feel slight tingling or
electrosurgical instrument.
abdominal cramping during procedure.
Diagnoses and treats cervical dysplasia.
Discharge, bleeding, and cramping may
Minimizes amount of tissue removed,
occur for 1-3 days after procedure
preserves childbearing ability.
CULDOTOMY, CULDOSCOPY, AND Explain purpose and method of
CULDOCENTESIS Culdotomy is an procedure.
Prepare patient for vaginal operation with
incision made through posterior fornix of
preoperative instruction and sedation.
cul-de-sac and allows visualization of
Perform assessment of bleeding and
peritoneal cavity (i.e., uterus, tubes, and
discomfort after surger
ovaries). Culdoscopy can then be used to
closely study these structures. This
technique is valuable in fertility
evaluations. Withdrawal of fluid
(culdocentesis) allows examination of fluid
LAPAROSCOPY Before surgery, instruct patient about
(PERITONEOSCOPY) procedure, prepare abdomen, and
reassure patient about sedation.
Allows visualization of pelvic structures via
Inform patient of probability of shoulder
fiberoptic scopes inserted through small
pain because of air in the abdomen.
abdominal incisions.
Instillation of CO2 into cavity improves
visualization.
Used in diagnostic assessment of uterus,
tubes, and ovaries.
Can be used in conjunction with tubal
sterilization.

DILATION AND CURETTAGE (D&C) Before surgery, instruct patient about

Operative procedure dilates cervix and procedure and sedation.
allows curetting of endometrial lining. Used Perform postoperative assessment of
in assessment of abnormal bleeding and degree of bleeding (frequent pad check
cytologic evaluation of lining. during first 24 hr).
 FERTILITY STUDIES
BASAL BODY TEMPERATURE Instruct woman to take temperature using
ASSESSMENT special basal temperature thermometer
(calibrated in tenths of degrees) every
Measurement indirectly indicates
morning before getting out of bed. Instruct
whether ovulation has occurred.
to record temperature on graph.
(Temperature rises at ovulation and
remains elevated during secretory phase
of normal menstrual cycle.)
HUHNER, SIMS-HUHNER, TEST Instruct couples to have intercourse at
Mucus sample of cervix is examined estimated time of ovulation and be
within 2-8 hr after intercourse. Total present for test within 2-8 hr after
number of sperm is assessed in relation intercourse.
to number of live sperm. Used to
determine whether cervical mucus is
“hostile” to passage of sperm from vagina
into uterus.
ENDOMETRIAL BIOPSY Small Tell patient test must be performed
curette is used to obtain piece of postovulation. Explain that procedure
endometrial lining to assess endometrial should cause only short period of uterine
changes common to progesterone cramping and light, bloody vaginal
secretion after ovulation. Also used to discharge for about
assess abnormal menstrual or
postmenopausal uterine bleeding.
 SUMMARY
Review of anatomy Hormonal regulation
and physiology Lactation physiology
External genitalia Assessment
Internal genitalia History collection
Accessory organs Physical examination
Oogenesis Diagnostic studies and
Female reproductive nurses responsibility
cycle
 CONCLUSION
• The nurse is typically the first health care
professional to assess the patient with a
reproductive system health problem or hear a
patients concern about a reproductive problem
• Nurses need to model a healthy life style for
their patients,it is important that nurses promote
positive practices and behaviours related to the
reproductive and sexual health of all patients
Thank
you