Female reproductive anatomy is both external and internal. The external anatomy is collectively known as the vulva. Working posteriorly from the mons pubis, which overlies the symphysis pubis of the pelvis, the first specific structure of the vulva is the clitoris, which is a mass of erectile tissue and nerve fibers that is covered with the prepuce and becomes engorged with blood during sexual arousal. Dividing laterally and posteriorly from the prepuce are the labia. The labia majora are the most lateral and are immediately visible. The labia minora are thinner and lie medial to the labia majora.
The area between the 2 labia minora is known as the vestibule. At the anterior fold of the labia minora and within the vestibule is where the urethral opening, which drains urine from the bladder, is found. At the posterior end of the vestibule is the vaginal opening. The vagina serves 3 purposes:
Within the vagina are 2 openings for the Bartholin glands. These glands secrete lubricant into the vagina during intercourse. Finally, posterior to the vaginal opening and anterior to the anus is the perineum. The perineum can tear during normal vaginal deliveries. A thin membrane called a hymen may cover or partially cover the vaginal opening.
The internal anatomy includes the vagina, the uterus, the fallopian tubes, and the ovaries. The vagina extends from the vestibule outside the body superiorly and ends at the inferior opening of the uterus called the cervix. The opening of the cervix is called the os. The uterus is a very muscular organ in which the fetus develops from conception to birth. The walls are almost entirely muscle, sometimes called the myometrium, and are internally lined with highly vascular tissue called endometrium, which sloughs off during menstruation. The uterus is responsible for contractions during birth.
Extending laterally from the superior portion of the uterus on the right and left are the fallopian tubes. The fallopian tubes connect the ovaries with the uterus and serve as a passageway for the egg, or ovum. The end of the fallopian tube nearest the ovary is open to the abdominal cavity; the ovaries and the fallopian tubes are not directly connected. Fertilization of the egg with sperm will likely occur in the fallopian tubes, which will then travel to and implant in the endometrium within the uterus. The ovaries lie within the lower abdominal quadrants, one on each side. In each ovary are thousands of follicles, each of which can mature to become an oocyte and be released as an ovum.
The ability to reproduce is under hormonal control. Prior to puberty, the hypothalamus restricts the production of gonadotropin-releasing hormone (GnRH). At the start of puberty, this restriction is lifted as the hypothalamus releases pulses of GnRH, which then triggers the anterior pituitary gland to synthesize and release follicle- stimulating hormone (FSH) and luteinizing hormone (LH). These hormones trigger the production of other sex hormones that develop and maintain the reproductive system.
The ovaries, which are derived from the same embryonic structures as the testes, also are under the control of FSH and LH secreted by the anterior pituitary gland. The ovaries produce estrogens and progesterone.
Estrogens are secreted in response to FSH, and they result in the development and maintenance of the female reproductive system and female secondary sexual characteristics (breast growth, widening of the hips, and changes in fat distribution). In the embryo, estrogens stimulate development of the reproductive tract. In adults, estrogens lead to the thickening of the lining of the uterus (endometrium) each month in preparation for implantation of a zygote.
Progesterone is secreted by the corpus luteum—the remnant follicle that remains after ovulation—in response to LH. Interestingly, progesterone is involved in the development and maintenance of the endometrium but not in the initial thickening of the endometrium, which is the role of estrogen. This means that both estrogen and progesterone are required for the generation, development, and maintenance of an endometrium capable of supporting a zygote. By the end of the first trimester of a pregnancy, progesterone is supplied by the placenta, and the corpus luteum atrophies and ceases to function.
During the reproductive years (from menarche to menopause), estrogen and progesterone levels rise and fall in a cyclic pattern. In response, the endometrial lining will grow and be shed. This is known as the menstrual cycle and can be divided into 4 events: the follicular phase, ovulation, the luteal phase, and menstruation.
The follicular phase begins when the menstrual flow, which sheds the uterine lining of the previous cycle, begins. GnRH secretion from the hypothalamus increases in response to the decreased concentrations of estrogen and progesterone, which fall off toward the end of each cycle. The higher concentrations of GnRH cause increased secretions of both FSH and LH. These 2 hormones work in concert to develop several ovarian follicles. The follicles begin to produce estrogen, which has negative feedback effects and causes the GnRH, LH, and FSH concentrations to level off. Estrogen works to regrow the endometrial lining, stimulating vascularization and glandularization of the decidua.
Estrogen is interesting in that it can have both negative and positive feedback effects. Late in the follicular phase, the developing follicles secrete higher and higher concentrations of estrogen. Eventually, estrogen concentrations reach a threshold that paradoxically results in positive feedback, and GnRH, LH, and FSH levels spike. The surge in LH is important; it induces ovulation, the release of the ovum from the ovary into the abdominal (peritoneal) cavity.
After ovulation, LH causes the ruptured follicle to form the corpus luteum, which secretes progesterone. Remember that estrogen helps regenerate the uterine lining, but progesterone maintains it for implantation. Progesterone levels begin to rise, but estrogen levels remain high. The high levels of progesterone again cause negative feedback on GnRH, FSH, and LH, preventing the ovulation of multiple eggs.
Assuming that implantation does not occur, the corpus luteum loses its stimulation from LH, progesterone levels decline, and the uterine lining is sloughed off. The loss of high levels of estrogen and progesterone removes the block on GnRH so that the next cycle can begin.
On the other hand, if fertilization has occurred, the resulting zygote will develop into a blastocyst that will implant in the uterine lining and secrete human chorionic gonadotropin (hCG). This hormone is an analog of LH, meaning that it looks very similar chemically and can stimulate LH receptors. HCG maintains the corpus luteum and is critical during first trimester development because estrogen and progesterone secreted by the corpus luteum keep the uterine lining in place. By the 2nd trimester, hCG levels decline because the placenta has grown to a sufficient size to secrete progesterone and estrogen by itself. The high levels of estrogen and progesterone continue to serve as negative feedback mechanisms, preventing further GnRH secretion.
As a woman ages, her ovaries become less sensitive to FSH and LH, resulting in ovarian atrophy. As estrogen and progesterone levels drop, the endometrium also atrophies, and menstruation stops. Also, because the negative feedback on FSH and LH is removed, the blood levels of these 2 hormones rise. This is called menopause. Profound physical and physiological changes usually accompany this process, including flushing, hot flashes, bloating, headaches, and irritability. Menopause usually occurs between the ages of 45 and 55 years.
Assessment of the patient with a gynecological problem can be a sensitive issue. On the part of the paramedic, it requires asking some personal questions that may result in emotional answers. Maintaining the most professional and sensitive manner possible is essential to being able to complete a thorough and appropriate assessment. In such cases, the paramedic is a stranger asking about the patient’s sexual history. It is easy to ask these questions with an unintentional air of judgment, so be sure to preface them with why the information is needed. The answers to these questions can be used to rule out problems that could impact immediate treatment, such as the administration of certain medications. It could be to ensure that the patient is taken to an appropriate facility. It also could simply be medically necessary. Whatever the reason, good communication about it can make for a better experience for the paramedic and the patient.
Any patient deserves dignity and respect, especially the gynecological patient. The teenage patient likely will not want to answer such sensitive questions in the presence of her parents, for fear of getting into trouble, for example. Questions such as those that follow should be asked in privacy after ensuring the patient understands why they are being asked. Rarely are such patients such a dire emergency that the sensitive history and physical cannot wait until the patient is in the relative privacy of the ambulance.
If the patient is a minor, the paramedic may ask the questions away from a parent; however, he or she must share the information with the parent as part of informed consent for any treatment the paramedic determines is needed unless the patient is pregnant and this has been confirmed. Once the patient is pregnant, or has been pregnant, the patient is considered legally emancipated and is capable of making her own decisions regarding healthcare without the usually requisite approval from a parent or guardian. In addition, the parent or guardian may not be informed about the treatment or condition without written consent from the emancipated minor; he or she is permitted all the same privacy concerns as any other competent adult.
As with any patient, a thorough SAMPLE and OPQRST as appropriate should be completed. However, this may leave some important questions unanswered, particularly for the gynecological and potentially pregnant patient. Following that, as part of the history of present illness interrogation, more direct questions need to be asked and answered. What follows are some specific questions or question types that should be asked of any known or suspected gynecological patient, along with a brief explanation about why they should be asked.
During the physical examination, rarely is direct observation or evaluation of the vulva necessary for a paramedic’s assessment to be considered thorough. In most cases palpation of the lower quadrants of the abdomen can provide enough information about the internal anatomy of the gynecological patient, especially when combined with a good history of the present illness. In addition, do not omit the rest of a physical examination just because the complaint is gynecologic in nature; there could still be systemic effects, as will soon be seen.