Gynaecology & Paramedicine Care

Gynaecology, HLTH3021 PARAMEDICINE CARE 4

Module Learning Outcomes

• Describe the epidemiology of select gynecological presentations
• Understand female sexual physiology and pathophysiology related to out-of-hospital assessment and management
• Describe and demonstrate appropriate history taking, assessment, and out-of-hospital management for select gynaecological presentations

Gynaecological History Taking

• Gynaecology includes disorders of the female genital tract and reproductive system
• Gynaecological history is like other systems, but has further questions relating to the patient's menstrual, sexual, and past reproductive history
• A patient’s age influences the questions asked and the potential differentials for the presenting complaint
• History taking and assessment may overlap with abdominal-based questions due to close proximity of the anatomy

General History

• Includes the presenting complaint, history of complaint, general medical history, allergies, and medications (CHAMPSS)
• Includes a review of systems, cardiovascular, respiratory, neurological, integumentary, gastrointestinal, genitourinary, and reproductive

Pain Assessment

• SOCRATES is useful
• Differentiate between acute and chronic pain
• Differentiate from abdominal pathologies with the location and characteristics of pain

Gynaecological Past Medical History

• Look for any abdominal, pelvic, or reproductive organ surgery
• Look for any family history of gynaecological cancer, breast cancer, or genetic disorders
• Look for any pelvic or vaginal infections

Menstrual History

• Ask about when was their first menstrual period (menarche)
• What is the normal length of their menstrual cycle
• What is the normal length of their menstruation
• When was your last period
• Are periods regular or irregular and if experiencing irregular periods, is this normal
• How heavy are periods, how many pads/tampons are used daily and do they have any clots
• Any other associated symptoms

Menstrual History Terminology

• Menorrhagia is excessively prolonged or heavy periods
• Primary amenorrhoea is the absence of the first menstrual period
• Secondary amenorrhoea is the cessation of menses for six or more months in a person who previously menstruated
• Oligomenorrhoea is when there are five or fewer periods over twelve months
• Primary dysmenorrhoea is painful menstruation, occurring in the absence of any significant pelvic pathology
• Secondary or acquired dysmenorrhoea is painful menstruation caused by an organic pelvic pathology
• Menopause is the cessation of periods for at least twelve months at the end of the menstrual life

Contraceptive History

• Ask about the contraception they use, if any
• How long have they been using the contraception
• Any side-effects since commencing that contraception
• What is the reason for their contraceptive method
• Do they take the pill every day, at the same time?, have they missed any pills?
• When is their IUD/contraceptive implant due to expire/need replacing?
• Ask if there is any chance they are pregnant

Sexual History

• Are they sexually active?
• What is the gender of their sexual partners?
• Any pain before, during or after intercourse?

Dyspareunia

• Superficial dyspareunia is pain on penetration
• Deep dyspareunia is pain that feels deeper inside
• Have they had a recent cervical screening test? have the results been normal or abnormal?
• Screening should be conducted every five years if aged 25 – 74, have a cervix and have ever been sexually active
• Can be a self-collection test, or conducted by a healthcare professional
• Any of the following symptoms: vaginal discharge, abnormal vaginal or rectal bleeding, genital and extragenital rashes, lumps or sores, itching and/or discomfort in the perineum, perianal and public regions?
• Have they ever had unprotected intercourse (may be applicable to oral, vaginal and rectal)?
• Do they use protection against sexually transmitted infections?
• Have any of their recent sexual contacts had any symptoms of sexually transmitted infections?
• Have they been tested for any sexually transmitted infections and if so, how recent?
• Have they been vaccinated for Hepatitis A, B or HPV?

Urinary/Prolapse History

• Have they experienced an increased frequency or urgency in urination?
• Do they urinate after sexual intercourse?
• Any urine leakage and if so, is it associated with any task, such as lifting, coughing or sneezing?
• Do they experience dysuria (pain) or haematuria (blood) on urination?
• Do they ever get a dragging sensation or feel a mass in or at the vagina?

Obstetric History

• How many pregnancies have they had (gravidity)?
• How many children do they have (parity?)
• Were they natural births or caesareans?
• Any complications?

Abdominal Examination

• Inspection of the abdomen
• Look for surgical scars
• Look for abdominal distension
• Auscultation and percussion of the abdomen
• Palpation of the abdomen for superficial or deep masses (palpate from the umbilicus down to the pubic symphysis)
• Palpate for pelvic pain or tenderness

Pelvic Examination

• Pelvic examination is not completed in the out-of-hospital context
• The general recommendation is do not look, touch or examine

Ovarian Cysts

• Are fluid-filled sacs located in or on the ovaries
• Ovarian cysts are common in women of all ages: 6.6% of pre-menopausal women
• 14% of post-menopausal women have ovarian cysts
• There are three main groups of ovarian cysts, functional cysts

Functional Cysts

• This is most common and also known as physiological cysts
• Functional cysts: forms when a follicle does not release an egg and continues to grow
• Corpus luteum cysts: forms when the corpus luteum, the follicle after it releases an egg, doesn't shrink and continues to grow
• Both are functional cysts which are common, benign, and usually resolve on their own without treatment
• Some may be more complicated, leading to rupture or torsion

Non-Cancerous Cysts Also Known as Pathologic Cysts

• Dermoid cysts (teratomas) contain many different body tissues, fat, hair, skin and even teeth
• Dermoid cysts mainly occur in young women, sometimes children, grow slowly with surgery only recommended when they reach 5cm
• Cystadenomas contain clear, water like fluid or mucous fluid
• Cystadenomas differentiated from functional cysts as they do not self-resolve and need to be surgically removed
• Endometriomas can form in endometriosis patients
• They are made from the lining of the uterus, meaning they will bleed during a period, causing blood to be trapped over time and are removed surgically if symptomatic

Ovarian Cancers Also Known as Pathologic Cysts

• Cancerous growths of the ovaries
• Usually asymptomatic until growth has progressed

Symptoms of Ovarian Cysts

• Most are asymptomatic
• Feeling full in the lower abdomen
• Pressure in bladder, with increased sensation of needing to urinate
• Pressure in bowels, with discomfort when passing stool
• Discomfort during intercourse
• Mild, unilateral pain, caused by the cyst wall stretching
• Abnormal menstrual cycles (particularly with functional cysts)

Differentials of Ovarian Cysts

• Pelvic inflammatory disease
• Ectopic pregnancy
• Appendicitis
• Urinary tract infection
• Nephrolithiasis
• Psoas abscess

Ovarian Torsion

• Occurs when an ovary twists around the ligaments that support it, cutting off blood flow to the organ, leading to tissue necrosis
• The fifth most common gynecological emergency
• Occurs most commonly in women of reproductive age (onset of menarche to menopause)

Causes of Ovarian Torsion

• Ovarian masses (cysts, benign and malignant tumours)
• Pregnancy
• Assisted reproductive procedures
• Congential abnormalities of the ovary

Symptoms of Ovarian Torsion

• Sudden onset of severe, unilateral lower abdominal/pelvic pain
• Nausea and vomiting
• Systemic findings such as tachycardia, hypotension and fever
• Peritonitis indicating possible infarction or irritation

Differentials of Ovarian Torsion

• Ectopic pregnancy
• Ruptured ovarian cyst
• Pelvic Inflammatory Disease
• Appendicitis
• Endometriosis

Management of Ovarian Torsion

• Analgesia
• Anti-emetic
• Fluid resuscitation
• Transport to hospital

Ruptured Ovarian Cyst

• Occurs when a cyst in the ovary ruptures and releases fluid or blood into the abdominal cavity
• May be asymptomatic or symptomatic, is not always a life-threatening presentation
• Rupture of a simple cyst with serous fluid may remain asymptomatic

Rupture of a Haemorrhagic Cyst

• It’s associated with pain, due to blood accumulating in the ovary, or into the abdominal cavity
• Rupture of a dermoid cyst with sebaceous material can cause a granulomatous reaction and peritoneal irritation

Symptoms of Ovarian Cyst Rupture

• Sudden, sharp pain in the lower belly or back
• Vaginal spotting or bleeding
• Abdominal bloating
• Pain during intercourse
• Frequent urination
• Difficulty emptying bowels
• Fever
• Foul-smelling vaginal discharge
• Burning sensation on urination
• Hypovolaemic shock (hypotension, tachycardia, pallor)

Differentials of Ovarian Cyst Rupture

• Ectopic pregnancy
• Pelvic inflammatory disease
• Appendicitis
• Ovarian torsion
• Endometriosis
• Diverticulitis
• Gastrointestinal perforation
• Nephrolithiasis
• Thrush or bacterial vaginosis
• Urinary tract infection
• Constipation

Management of Ovarian Cyst Rupture

• Analgesia
• Anti-emetic
• Fluid resuscitation
• Transport to hospital

Polycystic Ovaries (PCO) and Polycystic Ovarian Syndrome (PCOS)

• Ovarian cysts are not related to PCO or PCOS
• The cysts are follicles containing eggs that have not fully developed
• PCO refers to the presence of more than 12 small follicles in an enlarged ovary
• PCOS is based on Rotterdam criteria

Diagnostic Criteria for Rotterdam Diagnosis Of PCO

• Two of the three criteria are required: Oligo/anovulation, Hyperandrogenism, Polycystic ovaries on ultrasound
• Other aetiologies must be excluded, such as congenital adrenal hyperplasia, androgen secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia

Features of PCOS

• Metabolic, endocrine, and reproductive disorder
• Affects 8-13% of women during reproductive age
• Caused by a combination of genetic, hormonal and environmental factors

Symptoms of PCOS

• Irregular or absent periods
• Infertility due to chronic anovoluation
• Hirsutism
• Male-pattern hair loss
• Weight gain/obesity (abdominal)
• Insulin resistance
• Increased risk of Type 2 diabetes
• Hypercholesterolaemia
• Hypertension
• Mood disorders (anxiety, depression)
• Increased risk of clots due to contraceptive use

Differentials of PCOS

• Hypothyroidism
• Cushing syndrome
• Diabetes

Management of PCOS

• Primarily referral and management of chronic symptoms include:
  • Hypoglycaemia/hyperglycaemia
  • Mental Status Examination (MSE)
  • Cardiac abnormalities
  • DVT and PE

PCOS and Pregnancy

• For those who become pregnant, increased risk of:
  • Pre-term birth
  • Pre-eclampsia
  • Miscarriage
  • Gestational diabetes

Endometriosis and Adenomyosis

Difference Between Endometriosis and Adenomyosis

• Endometriosis, cells that relate to the endometrium in the uterus that grow outside of the uterus, lesion types include superficial, cystic ovarian, deep or outside of the pelivs.
• Adenomyosis, cells grow inside the muscle wall of the uterus
• Both can lead to adhesions and fibroids

Epidemiology Of Endometriosis And Adenomyosis

• Australian research suggests that 11.4% of females will be diagnosed with endometriosis by the age of 44
• The number of females affected by endometriosis in Australia is approximately 1 in 7
• In 2021-2022, there were more than 3600 endometriosis-related emergency department (ED) presentations and 40,500 hospitalisations which as doubled in the last decade
• An estimated 247.2 million was spent on endometriosis in the Australian health system in 2021-2022
• Females with adenomyosis often have endometriosis too
• Current research suggests that about 1 in 5 females have adenomyosis

Signs and Symptoms of Endometriosis

• Chronic pelvic pain, often cyclical and linked to menstruation
• Pain during intercourse (dyspareunia)
• Painful periods (dysmenorrhea)
• Pain with bowel movements or urination during menstruation
• Infertility
• Fatigue, bloating and nausea

Signs and Symptoms of Adenomyosis

• Heavy or prolonged menstrual bleeding (menorrhagia)
• Severe menstrual cramps that worsen over time (dysmenorrhea)
• Chronic pelvic pain unrelated to the menstrual cycle
• Enlarged, tender uterus
• Pressure on the bladder or rectum due to the enlarged uterus

Importance and Management in the Out of Hospital Context

• History taking and forming a broader clinical picture
• Pain management
• Addressing chronic versus acute presentations
• Appropriate patient disposition, transport to emergency department of referral to alternative dispositions
• Patient education
• Clinician understanding

Differentials of Endometriosis and Adenomyosis

• Pelvic inflammatory disease
• Ovarian cysts
• Irritable bowel syndrome (IBS)
• Cystitis
• Fibroids
• Ectopic pregnancy
• Appendicitis
• Malignancy of colon

Bartholin Cysts

• Benign blockage of the Bartholin glands, located in the lower left and right portion of the vaginal opening
• Usually asymptomatic and located unilaterally
• May occur due to trauma, episiotomy or childbirth, obstruction of the ductal region, sexually transmitted infections or may be idiopathic in nature
• Predominantly found in women of childbearing age, from the onset of puberty until menopause
• In more severe cases, the cyst can progress to an abscess

Importance and Management in the Out of Hospital Context for Bartholin Cysts

• Provisional diagnosis based on review of symptoms and medical history
• Most cases will not require further management; the cyst can self-resolve on its own
• Larger cysts may require referral to the patient's GP for microbial culture, STI testing and biopsy
• If the cyst is large or painful, a clinician may perform a drainage procedure, where a catheter is inserted to prevent recurrence. The patient may require a marsupialisation procedure
• An abscess will require antibiotics and depending on the severity, may warrant assessment, management and/or transport to hospital

Thrush and Bacterial Vaginosis

• Common vaginal infections, but have different causes and symptoms
• Thrush is a yeast infection caused by candida albicans
• Bacterial vaginosis is a bacterial infection caused by a change in the levels of lactobacilli, replaced by an overgrowth of mixed bacteria

Thrush Facts

• About 75% of women will have vaginal thrush in their lifetime
• Causes of thrush that impact vaginal flora include recent antibiotic use
  • Oral contraceptive use
  • Pregnancy
  • Hormonal contraception
  • Menstrual cycle changes
  • Health conditions such as diabetes and immune system disorders
  • Associated vulval skin conditions such as psoriasis or eczema
  • Immunosuppressive medications
• Other risk factors may include wearing tight, synthetic clothing and frequent douching or use of irritants such as perfumed products

Symptoms of Thrush

• Vaginal and vulval itching and burning
• Thick, white discharge with a "cottage cheese" appearance
• Redness or swelling of the vagina or vulva
• Stinging or burning during urination or intercourse

Differentials of Thrush

• Bacterial vaginosis
• Trichomoniasis
• Contact dermatitis
• Lichen sclerosus
• Sexually transmitted infections

Bacterial Vaginosis (BV) Facts

• The cause of the bacterial change is not known but is more likely to occur in people who
  • Are sexually active
  • Recent change in sexual partner
  • Have an intrauterine device (IUD)
  • Inconsistent use of barrier contraception
  • Use of perfumed products
  • Douching (washing the inside of the vagina)
• Most cases of BV will self-resolve. However, untreated bacterial vaginosis can lead to pelvic inflammatory disease (PID) or STI
• Even after treatment, about half of people with BV will get the condition back in 6-12 months

Symptoms of Bacterial Vaginosis

• A thin, grey, white or green vaginal discharge
• A strong "fishy" odour, especially after intercourse
• Vaginal itching or irritation
• Burning when urinating

Differentials of Bacterial Vaginosis

• Thrush
• Trichomoniasis
• Chlamydia/gonorrhoea
• Physiological discharge
• Atrophic vaginitis

Importance and Management of Thrush and Bacterial Vaginosis

• Provisional diagnosis through symptom assessment and history
• Appropriate referral to services, may include pharmacist or GP
• Patient education regarding condition, potential causes, and future management

Management of Thrush

• Referral to pharmacist/GP
• Anti fungal medication including pessaries (clotrimazole) or oral tablets (fluconazole)
• Consider underlying chronic conditions for recurrent thrush (i.e. diabetes)

Management of Bacterial Vaginosis

• Referral to GP
• Treated with oral or topical antibiotics (metronidazole)

Pelvic Inflammatory Disease (PID)

• It can be due to sexually or non-sexually acquired circumstances
• Sexually transmitted circumstances are caused by chlamydia trachomatis and Neisseria gonorrhoeae
• The infection spreads from the lower genital tract to the normally sterile upper reproductive tract
• The inflammation caused by the bacteria causes tissue damage, scarring and in severe cases, abscess formation
• PID can be caused by non-sexually acquired circumstances, such as gynaecological surgery, IUD insertion, termination of pregnancy or complications of pregnancy
• Complications include tubo-ovarian-abscess leading to sepsis, chronic pelvic pain, infertility due to fallopian tube damage and increased risk of ectopic pregnancy

Symptoms Of PID

• Severe pelvic or lower abdominal pain
• Fever and chills
• Abnormal vaginal discharge, with or without odor
• Pain during intercourse (dyspareunia)
• Painful urination (dysuria)
• Irregular menstrual bleeding
• Peritonitis, including rebound tenderness and guarding, when progressed

Differentials Of PID

• Ectopic pregnancy
• Appendicitis
• Ovarian cyst rupture or torsion
• Endometriosis
• Urinary Tract Infection

Management Of PID

• Referral for antibiotic prescription in mild cases
• Analgesia (NSAIDs)
• Transport to hospital for severe symptoms: sepsis, pregnancy

Ectopic Pregnancy

• This is an extrauterine pregnancy where the developing blastocyst attaches outside the uterus, usually the fallopian tube (98%).
• 2% occurs in the cervical, ovarian or intra-abdominal regions
• 2 of every 100 pregnancies will be ectopic and Tubal pregnancies are more common

Causes of Tubal Pregnancies

• Damage to the fallopian tubes from prior STIs or pelvic infections such as PID
• Previous fallopian tube surgery or other surgery relating to c-section, ovarian cysts, endometriosis or appendicitis
• Pregnancy while using an intrauterine device or the progestogen only pill and increased age (> 35 years)
• Fertility treatment
• Endometriosis
• Untreated, the outcome to mother and developing foetus can be fatal due to tubal rupture

Symptoms of Ectopic Pregnancy

• Early signs include unilateral abdominal or pelvic pain and vaginal spotting or bleeding.
• The patient may have a delayed or missed menstrual period with positive pregnancy test.
• Advanced or ruptured ectopic: sudden, severe abdominal pain, shoulder tip pain, hypovolaemic shock (dizziness, tachycardia, hypotension), abdominal distension, signs of peritonitis
• All Ectopic pregnancies require transport to hospital

Differentials Of Ectopic Pregnancy

• Incomplete miscarriage
• Pelvic inflammatory disease
• Ovarian cysts rupture or torsion
• Appendicitis
• Implantation cramping

Management Of Ectopic Pregnancy

• Transport to hospital
• Analgesia
• Fluid resuscitation

Miscarriage Facts

• It's a pregnancy loss occurring before 20 weeks gestation and mostly occurs in the first trimester (before 12 weeks)

Causes of Miscarriage

• Chromosomal abnormalities: accounts for 50-60% of miscarriages
• Maternal health conditions: uncontrolled diabetes, uterine abnormalities, infections, dietary and lifestyle choices
• Advanced maternal age
• Previous miscarriages

Types of Miscarriage

• Threatened miscarriage: vaginal bleeding occurs, the cervix remains close, and the pregnancy may continue
• Inevitable miscarriage: bleeding and cramping with open cervix, cannot be avoided
• Incomplete miscarriage: some pregnancy tissue is expelled, some remains in the uterus
• Complete miscarriage: all pregnancy tissue is expelled and bleeding subsides
• Missed miscarriage: the foetus is longer viable, but no symptoms occur
• Recurrent miscarriage: more than three consecutive pregnancy losses

Symptoms of Miscarriage

• Vaginal light spotting to heavy bleeding with clots
• Cramping or pain in the lower abdomen or back
• Fever or chills (if infective)
• Hypovolaemic shock (tachycardia, hypotension)
• Refer them to hospital

Differential for Miscarriage

• Ectopic pregnancy
• Physiological bleeding
• Normal menstruation (if not known pregnancy)

Abortion In Australia

• Abortion is legal in all states and territories under certain circumstances when completed by a registered doctor
• Approximately 80,000 abortions are performed per year (primarily in women aged 20-29)
• NSW: abortion was removed from the Crimes Act of 1900 in October 2019 with the passage of the NSW Abortion Law Reform Act 2019
• Women & people are at no risk of prosecution for procuring their own abortion, gaining informed consent up to 22 weeks of pregnancy
• After 22 weeks of pregnancy, abortions must occur in a hospital or a/ health facility
• Medical doctors with a conscientious objection to abortion must provide how to contact/ transfer another doctor or service at which the termination can be performed

Medical Abortions

• Early medical abortion is an option available up to nine (9) weeks gestation and involves two medications
• Mifepristone: one tablet taken at the start of the process
• Misoprostol: used for four days or greater is taken 36-48 hours

Medical Side Effects Abortion:

• Consists of bleeding, cramping, nausea and vomiting
• Complications include arising may include significant bleeding (more than two pads every hours, with clots) with dehydration, infection, incomplete abortion, & continued pregnancy

Surgical Abortions

• Surgical abortion is performed in a hospital or / completed in the first or second trimester.
• may be used in cases where a miscarriage is not complete
• Has three procedures manual vacuum aspiration (MVA), dilation and curettage, dilation and evacuation and include bleeding, cramping, nausea, & vomiting
• Risks include bleeding (more than two pads every hours, with clots) or infection

In-Hospital Management For Abortion

• Analgesia
• IV fluids for hypovolemic patients, & paracetamol if febrile

Out Of Hospital Management

• Anti-emetic
• Counselling

Sexual Assault Facts

• Physical assault is intentional use of force to cause bodily injury; sexual assault is non-consensual sexual contact
• In 2023, police recorded 36, 138 victims of sexual assault in Australia and majority were female (84%)
• 41% were between the ages of 10-17 years of age and 39% were domestic violence
• 92% majority of women never inform police (92%)
• 69% mostly occur at a private dwelling

Considerations for Sexual Assault Patients

• Safety of yourself, your partner and the patient
• If police are already not on scene - wait and may require a discussion with the patient that calling the police does not mean that a report needs to be filed

Management of the Patient Affected by an Assault

• Psychological first aid and compassionate response to disclosure and do not debrief patient
• Assessment for life-threatening injuries, including non-fatal strangulation, (head, penetrative, or blunt force trauma)
• Physical examination, with documentation of all known injuries
• Wanting to complete police report, patient should not shower to perserve evidence
• Transport for STI and prophylaxis, emergency contraception, if is competent should respect decisions
• Report the assault, with a safety plan