Thursday, September 23, 2010

8.20 Gynecology Self Exam & Mutual

Physician's Notebooks 8 - - See Homepage

Note: Here is self-help info preliminary to menstrual extraction, removal of IUD, pap smear, early diagnosis of pregnancy and determining fertile or infertile time of menstrual cycle.
20. Female Reproductive Tract Update 28 Aug. 2021  
Diagram of uterus & upper vagina straightened out and sliced open seen from front. Note at top of uterus the external roof that bulges up into the lowest part of abdominal cavity; on upper left and right, the entrances to the triangular uterine cavity; with the near-orange color uterine lining called endometrium - the fertile soil in which pregnancy grows, and sheds every month as menstruation and where intra-uterine cancer starts. At bottom of diagram, note the cervix with its funnel shape canal (label 8) and its opening cervical os (label 9) which opens into the upper vagina. The cervical os can get cancer and is where a Pap smear is taken by rubbing a cotton tip on its surface, smearing the rubbings on a glass slide, spraying-on preservative and sending the slide for micro-analysis. And note the vagina with its side to side ridging (label 10). Cervical os & upper vagina is the place to look for the string of an intra-uterine-device IUD during the internal exam and by catching the string in a clamp and pulling down one can remove the IUD

Below: Drawing of Actual Uterus & Tubes with Ovaries in Pelvic Cavity (Use loupe for inspection)
Top drawing is looking down on the front lower abdominal part of a flat-on-her back, up-facing woman whose lower abdominal wall is removed. In the middle on her right, the front wall of uterus is removed and you see the inside uterus cavity endometrium. Also note her right side uterine (Fallopian) tube & ovary. In a better picture you could note the tube is wide at its end where it is draped over the ovary and it narrows at its connection with the upper angle of uterine cavity. Now look towards top of uterus on the woman’s left side (the viewer's right). Note the two anchoring cords that keep the uterus stable. The lower obliquely downward cord is the round ligament and the upper cord is the uterine (Fallopian) tube and its distal end is seen to be wrapped about the ovary. (A reason for the occasional failure of the tubal ligation surgery to stop having babies is the surgeon mistaking the round ligament for the Fallopian tube.
 Lower drawing is as if the woman were cut down her middle and you are looking at exact body mid line center of her pelvic organs from her left side. First, the uterus (On your left more frontward in body). Note how it lies almost horizontal in the lowest part of the abdomen cavity with its upper part (fundus) pointing toward the front abdomen wall and its vaginal exit (cervix os) pointing toward the rectum. This is an anteverted (forward) uterus, which is normal. In some women the uterus body angles 180 degrees backwards (retroverted, cervix pointing forward), a cause of menstrual pain and poor fertility  The lower, exit part of uterus, the cervix, is at the upper end of the vagina and can be seen on the vaginal exam. The cervix (as seen in the first diagram) provides an opening to the uterine cavity through a canal into the upper vagina and at birth the canal widens and is stretched for the soon-born baby. This side view also shows the relation of the urinary bladder in front of vagina and the urethra high on the vulva, where the urine comes out, and also it shows, in rear, the rectum that shares the rear wall of the vagina as its front wall.

Figure: The vulva and vaginal entrance with abnormalities (Use Loupe)
These are views of vulva (female external sex opening between thighs) with the big lips (labia majora) spread open. In the upper, smaller views, the one on your (reader's) right is labeled from above downward showing locations of the clitoris (the center of female sexual feeling); just below clitoris is the external urethra opening where the urine stream comes out; and, lowest, is the hymen (maidenhead), a tissue extension of the entrance to the vagina that blocks access except for a small central opening. In the lower, larger set of 3 views you see three types of abnormal hymens. On your left is imperforate hymen not even allowing menstrual blood to exit, in the middle a hymen with many small holes that allows menstruation but not completely and causes much menstrual pain and on your right is either a double vagina or a strip of vertical hymen simulating it. The double vagina would have two barrels - left and right.

The Gynecologic Examination: Before you do it, wash hands and instrument in warm water and rinse off the soap. If one person examines another, use gloves. A woman may examine self, with hand-mirror, flashlight or goose-neck lamp, and vaginal speculum. A position for it is squatting with buttocks off the floor and knees widely apart. Another good position is sitting on toilet with thighs apart and mirror positioned.
   In one person examining another, the person who will be examined should be on a bed or table, or in Japan she could be on a floor futon with her buttocks raised high by pillows. She may assist the examiner by grasping her own under-thighs to keep her buttocks widely apart. With two women, each one should examine the other as part of a seminar
   Start by inspecting the sex entrance, the gap between thighs – called the vulva. If you are doing self examination, position your mirror (It can be handheld or fixed in best position) to view between thighs. You will see rear anus (back hole) and rear angle closed lips of vulva forward of and a little above the anus. Note the appearance and size of anus, then turn attention to the vulva, or front hole. With thumb and forefinger of dominant hand spread the outer lips of the vulva apart and view the inner vulva.
   Inside, you should see the entrance to the vagina and, looking a little upwards, the outer and inner vulva lips coming together below the clitoris. Note just below the clitoris is the external opening of the urethra where the urine stream comes out. A woman needing to catheterize herself to remove urine, inserts a lubricated, freshly boiled or otherwise sterile catheter tip into the opening and pushes it into her bladder until urine comes out.
   On and into each side of the vulva wall near where both inner lips come together are openings of left and right Bartholin glands (not normally visible), which eject sexual lubricating secretion during coitus, and when infected make painful golf ball-size cysts.
   Next insert 2nd and 3rd fingers together, lubricated with warm water or jelly, into the sexual opening and advance them gently into the vagina. In a virgin, the fingers will be blocked by the hymen, which is an extension of vaginal wall which can be seen by one’s self in the hand mirror by spreading the fingers widely. Normally, the hymen should have an opening at its center, into which a pinkie finger may be inserted. In a woman who has had coitus or who has herself manually dilated it, the hole or opening may admit 2 fingers. In one who has already vaginally birthed a child, there is no hymen. If you can enter vagina easily with 2 fingers, do so and spread fingers to get a look at vaginal wall. The vagina at rest is collapsed upon itself with walls forming an H-shape. The vagina is a muscular sac with elasticity.  It can be contracted by voluntary muscle.
   Contract the muscle around your anus back hole. That muscle is the same one that contracts the vagina.
A speculum upside down as for insertion for self examination.
The speculum should be lubricated with warm water. Inserting it should start by first putting 2 fingers of other hand deep in the vagina and spreading and pulling downward on vagina in direction of rectum. Then with dominant hand grasping closed speculum in upside-down position as shown in above figure (for self exam; if a separate examiner, the spreading parts are up and the handle down), insert the closed tip (not like in above figure, which has a spread-open tip) with the closed tip oblique (angled c.45 degrees) to the long axis of the vagina, guiding with vaginal fingers, and keeping pressure of the advancing tip, obliquely downward, in direction of rectum. Once the speculum enters vagina, push it gently deeper while withdrawing vaginal fingers. When you have pushed the speculum in as deep as possible, open it by squeezing handles slowly. Once you note the cervix, popping into view, tighten the screws of the speculum to fix it in its open position. Now, adjust mirror (if self exam), get comfortable and inspect the vagina with the external cervix at its back end.
   About dilation of the hymen's opening: A virgin who wishes to dilate hymen, uses jelly lubricated pinkie (5th) finger and gentle forward pressure into the opening at center of the hymen. Once the finger  has entered the hole several times, an index finger may be tried. With patience, two fingers should be accepted. This dilation is a preparation for first coitus (sexual penetration by penis). Without it, first time sex may be a painful, bloody mess.
   The vagina once entered may be peach color, and looks like a smooth-wall muscular canal; it is a little longer than the length of an erect penis, with constriction at hymen and, inside, a comfortable capacity to accept the erect penis. It is normally well lubricated, and should have a pleasant fragrance and taste.
   At the end of vagina, the lower tip of the cervix juts out; and at center of cervix is the opening called cervix os, where the Pap smear is done for cancer.  Cervical glands produce thick mucus that peaks on 12th or 13th day from 1st seeing blood from menstruation.
   Examining self or partner with speculum at phases of menstrual cycle, you will see as follows: 1) during the menses, the view may be obscured by blood. If you see cervix, you may note dark blood oozing from its opening; blood clots are sign of abnormally heavy menses.
    2) On day-6 from first day of menses the field has cleared of blood and starts to appear at its driest (least moist, no cervical mucus) for next few days.
     3) Starting day-8, on each successive day, more and more of a watery-clear, oily secretion is seen at cervix-opening, indicating good estrogen production from ovary sexual cycle output.
    4) As mid cycle (day-13) approaches, the mucus will be seen dripping from the cervix-opening, like saliva drooling from lips; it is easy to catch on a cotton-tip applicator and when you inspect it you will see has great stretch, being able to be pulled out in long strings between the opening tips of a thin-tip surgical clamp.
If you are scientific, smearing a bit of cervix-mucus on glass slide and looking at the dried secretion through even a cheap pocket microscope 5 minutes later may show ‘ferning” (pattern of fern leaf, see above).
   Ferning is useful; 1st, it tells a woman she is not pregnant up to that moment; it tells her she is at highest risk (or best) time to get pregnant by having coitus; and is point of peak estrogen stimulation and most probable soon ovulation.
    5) After ovulation (latest, day-14 usually) cervix mucus will suddenly stop and whitish sparse discharge will start, signaling the end of the fertile phase of the sexual cycle (and tells, you cannot get pregnant till next month, but you may have already got pregnant this month if you were not careful).
    6) On day before next menstruation you may see beginning blood at cervix-opening and that is useful because it may relieve your mind a day or two before you actually see blood come out from vagina.

Next we concentrate the uterus and ovaries examination. The uterus is a thick-walled organ that can enlarge to hold a newborn infant. Its lining is shed monthly as menstruation. In upper uterus the reproductive tract divides on the sides into the 2 uterine tubes that end just before left and right ovary in abdominal cavity.

Here is the digital pelvic exam, with vaginal inserted finger(s) of one hand and abdominal pressing fingers of the other. Obviously it needs an examiner other than self. The person examined should have just urinated and emptied her bladder and have empty stomach and, ideally, an empty rectum (within few hours after Bowel Movement but before eating). 
    Best position: The person being examined should lie on her back, knees up and relaxed apart, and soles of feet well separated and toes facing away. (She may grab on to her rear thighs to help keep them apart.) For comfort of the examiner, it is best done with the person being examined on a bed or table. The examiner should use clean lubricated glove for inserting hand.
   Instructions from now are to the examiner: “Spread lips of vulva and insert 2nd and 3rd fingers of non-dominant hand slowly and deeply into vaginal tunnel. Direction of pressure of your hand is obliquely forward and downward. Slide the fingers into vagina as deeply as possible and you may feel, at tip of the finger, the firm bulb of the external cervix.
   If right-handed, you should have left hand fingers as deeply back in vagina as you can put them. (But do not poke!) Now feel around with the inside-vagina fingers. Feel cervix and its opening, if possible. (Cervix should be touching the tip of a finger but, if not, you ask the person to strain down, and the straining may cause the cervix to touch the fingers) Then feel vaginal wall on each side, and behind upper vaginal wall you may feel body of uterus. Finally press down against rectum. (You may feel firm impression of feces through rectal wall)
   Once you are satisfied that you got as much as you can from feeling with the vaginal hand in the vagina, place the other hand, flats of fingers down, on lower front abdomen, just above pubis in mid line and try to catch the uterus body between the two examining hands and fingers with the downward examining hand-on-abdomen pressing with fingers flats, not poking, and the upward examining hand in-vagina elevating and gently pushing up so that the uterus gets caught between the hands. Normally it feels medium to small peach size, shape and its consistency firm. Be gentle.
   Examination should be practiced much. At first, you will not make out much and may fumble around. But then you and partner will become relaxed and each time repeating an exam you will learn and succeed more.
   Enlarged ovaries may be felt on pelvic exam, but do not try to feel too hard for them because they are sensitive to pressure.
   The Gynecology exam should not be limited to sexual organ. Observe whole body starting with pubic hair, breasts and other signs of sexual maturation.
OK, this should just be an introduction to self help. Build on it with your own seminars.
END OF CHAPTER. To read next now, click 8.(21-22) Vaginitis/Endometriosis/PID/Ovarian Tum...