Most of the conditions and complaints that bring women to seek medical attention will be no different than those of their male counterparts. However, there are some conditions that are obviously limited to females. To effectively treat these conditions, you must become familiarized with the female anatomy and physiology, techniques of physical examination, and diagnosing and treating the more commonly encountered female specific conditions.

With the exception of the female genitals and the breasts, the techniques for physical examination, as discussed earlier in this chapter, will apply to both males and females. The Navy policy as set forth in the Manual of the Medical Department (MANMED) establishes the requirement that in other than emergency situations or when totally impractical, no member of the Medical Department will examine or treat a member of the opposite sex without the presence of a witness. That witness, whenever possible, must be a member of the same sex as the patient.

• Age of Onset - An unusually late or early menarche (beginning of menstrual function) may be indicative of various endocrinopathies.
• Interval - Although the typical menstrual interval is 28 days, there are many variations even in otherwise normal women. The normal range is 21 to 35 days and any departure from normal must be viewed as potentially produced by various pathologic conditions.
• Duration - As stated above, any change from the normal must   be viewed as possibly the result of a pathologic condition. The quantity of the flow frequently parallels the duration; a prolonged flow will generally be excessive. The normal duration of flow is from 2 to 7 days.
• Quantity - A marked reduction in the flow may indicate certain endocrinopathies, while a marked excess may indicate a dysfunctional disorder or other problems.
• Character of Menstrual Flow - Normal appearance of menstrual blood is dark venous and unclotted. Bright red, clotted blood is the type of flow seen in excessive menstruation.
• Menstrual Pain - Painful menstruation (dysmenorrhea) is one of the most frequently encountered of all gynecologic complaints. The character of the pain or cramps, onset, and duration should be determined. Most menstrual pain will begin the day of onset of menses. Any increase of severity of pain or the appearance of pain in a previously asymptomatic woman requires further investigation.
• Intermenstrual Bleeding - Intermenstrual bleeding is a serious symptom. Even light bleeding frequently can indicate organic causes, such as polyps, erosion of the cervix, and occasionally cervical malignancy.
• First Day of the Last Menstrual Period (LMP) - Many women are unsure of the exact date their LMP began; however, it is important to establish it. Dates are necessary to determine whether the cycle is irregular as well as to establish the time of conception.
• Other Specific Areas to Record - List histories of vaginal discharge (leukorrhea) and such character4istics as the duration, odor, consistency, and color. When recording the obstetric history, include past and present urinary symptoms and any nausea or vomiting. It is important to list the patient's sexual history when STD is suspected or when there are complaints of painful coitus or postcoital bleeding.

The examination of the genitals will be divided into three distinct parts.

• External Genitalia - Inspect the mons pubis, labia, perineum, thighs, and lower abdominal regions. These are illustrated in figures 2-1 and 2-2. Using a gloved hand, separate the labia majora and inspect the labia minora, the clitoris, urethral orifice, and the introitus. Make note of any swellings, ulcerations, inflammations, and nodules. Note any sign of discharge and any sores or lesions. Insert your index finger into the vagina, and milk the urethra gently from the inside to the outside. If there is any discharge, culture it on room temperature, Thayer-Martin media. If the labia are swollen, or if the patient has a history of past infections of the Bartholin's gland duct, insert your finger into the vagina at the posterior aspect of the introitus and your thumb on the outside posterior aspect of the labia majora. Palpate for swelling or tenderness, and check for signs of discharge around the duct openings. Repeat the procedure for the opposite side. Note any bulgings of the anterior vaginal wall.
• Internal Genitalia - Use a vaginal speculum that has been warmed to body temperature. Use a medium-sized Graves for women without a hymen and medium-sized Pederson for women with an intact hymen. Instruct the patient to bear down. Place your gloved index and middle fingers at or just inside the introitus as shown in figure 2-3 (I), and exert downward pressure on the perineum. With your other hand, gently insert the speculum at a 45 degree downward angle (fig. 2-3 (II)). When inserting the speculum, make sure that the blades are closed and held at an oblique angle. Remove your fingers from the introitus, and rotate the blades of the speculum horizontally while maintaining downward pressure with the speculum. When the blades are fully inserted, open the blades and rotate the speculum until the cervix comes into view. Lock the blades into the open position using the thumbscrew (fig. 2-3(III)). Inspect the cervix, making note of the color, position, bleeding, discharge, ulcerations, and masses. After obtaining the necessary cervical specimens, withdraw the speculum while slowly rotating it to observe the vaginal mucosa. Release the thumbscrew, but keep the speculum blades in the open position with hand pressure. During withdrawal of the speculum, note the color of the vaginal mucosa and any signs of masses, ulcerations, inflammations, and discharges. Allow the blades to close only when the speculum is free of the introitus.

• Bimanual Examination - Insert your well-lubricated gloved index and middle fingers into the vagina, exerting pressure posteriorly. Note any areas of tenderness or swelling in the vaginal walls. Identify the cervix and note its position, consistency, mobility, and indications of cervical tenderness on motion. Palpate the fornix as illustrated in figure 2-4 (I). Using your other hand (referred to as the abdominal hand), palpate downward midway between the umbilicus and the symphysis pubis toward your pelvic hand. Identify the uterus between your hands, noting any masses or tenderness, the size, shape, consistency, and mobility (fig. 2-4(II)). Place your pelvic hand in the right lateral fornix and your abdominal hand in the right lower abdominal quadrant. Exert downward pressure with your abdominal hand and palpate the ovary. Note the size, shape, consistency, and presence of any masses or tenderness. Repeat the procedures for the left side.
  
  Withdraw your fingers from the vagina. Relubricate, if necessary, and then slowly introduce your middle finger into the patient's rectum and your index finger into her vagina (fig.2-4(III)). The anal sphincter may be relaxed by asking the patient to bear down while you are introducing your fingers. Repeat the steps of the bimanual examination. Pay special attention to the region that lies behind the cervix and the posterior uterine surface itself, as these areas may only be accessible to the rectal finger. Take note of any masses or areas of tenderness. Look for signs of rashes, excoriation, and external hemorrhoids.

Vaginitis

• Trichomonas Vaginitis - The etiologic agent in this form of vaginitis is Trichomonas vaginalis.
  
  SYMPTOMS -  The most prominent symptom will be leukorrhea. With this type of vaginitis, the discharge may be thick or thin and profuse, may have a fetid odor, and will range in color from white to greenish-yellow. The discharge is often pooled in the vaginal fornix and is quite often bubbly in appearance. Visualization of the vaginal mucosa will disclose a red, inflamed, mucosa and a cervix with small red, granular, strawberry-looking spots. The patient will normally reveal a history of vulvar (external genitalia) irritation, vaginismus (painful spasms of the vagina), dyspareunia (painful coitus), and itching. Motile Trichomonas vaginalis. organisms may be noted in a fresh wet preparation made by diluting the secretions with normal saline and examining the preparation under a microscope
  
  TREATMENT - Flagyl (metronidazole) is administered in 250-mg doses 3 times a day for 1 week. However, this drug is contraindicated in pregnancy and should, therefore, not be administered until pregnancy has been ruled out. A vinegar douche (2 tablespoons of vinegar to 1 quart of warm water) administered once or twice a week may prove beneficial.
  
• Monilia Vaginitis - This inflammation is the result of an overgrowth of the Candida albicans yeast. History may show a recent period of antibiotic therapy. Yeast infections are more common in warm, moist climates. Patients with persistent or recurrent monilial infections should be investigated for possible diabetes.
  
  SYMPTOMS - The discharge is most often thick, curdlike, white in color, and may have a musty odor. This discharge is not usually as profuse as the discharge of Trichomonas. Visual examination may reveal a red, inflamed vaginal mucosa, with white or grayish patches of discharge. When these patches are scraped off, there is frequently a small amount of bleeding. Vulvar irritation, itching, vaginismus, and dyspareunia are common. Preparation of a wet smear with 15 percent potassium hydroxide added will help to visualize the Candida hypae and spores.
  
  TREATMENT - MONISTAT 7 (R) vaginal cream (miconazole nitrate 2 percent) administered once daily over a 2-week period is the treatment of choice. Hydrocortisone 1 percent cream applied locally to the vulva 3 times a day will help to relieve local irritation and itching. Mycostatin (r) vaginal tablets taken once daily at bedtime for 15 days may also be used.
  
• Bacterial Vaginitis - The etiologic agent may range from Haemophilus vaginitis to Neisseria gonorrhea and a wide range of other bacteria.
  
  SYMPTOMS - The discharge in this form of vaginitis may range from scanty to profuse, may have a foul or musty odor, may be viscid to watery in consistency, and the color may range from greenish-yellow, brown, pink, gray, or milky white. The vaginal mucosa may be red and swollen, but this is not always true. Vulvitis, urethritis, and ulceration of the cervix are commonly accompanying symptoms. Infections of the Bartholin's and Skene's glands are common, especially, gonorrheal infections. A purulent discharge is often seen exuding from the cervical os, and pain and swelling of the cervix itself is often noted. The only definitive method of determining the specific etiologic agent is through a culture.
  
  TREATMENT - General measures consist of perineal and vulvar hygiene to control pruritus and local itching. Specific measures include vaginal application of sulfa creams once daily for 2 weeks. Ampicillin taken orally may also be beneficial.
  When the causative agent is unknown, a broad-spectrum drug such as Betadine (r) vaginal gel may prove effective in treating any of the more commonly encountered types of vaginitis. A culture for Neisseria gonorrhea should always be considered in sexually-active women.

SYMPTOMS - They include burning, severe pain, pruritus, redness, swelling, ulceration, pustular formation, edema, and vesicular itching. Areas of irritation may extend to the perineal region and the inner areas of the thighs.

TREATMENT - When a specific infection exists, treat the cause. Symptomatic relief may be obtained by the use of cool compresses of Burrow's solution or tepid sitz baths. The area should be kept as clean and dry as possible, and the use of soaps and other harsh cleansing agents should be avoided, as they tend to dry the tissues and increase irritation. If an allergic reaction is the suspected cause, oral antihistamines may prove beneficial. Hydrocortisone 1 percent cream is often helpful. Chronic or intractable cases should be referred to a medical treatment facility as soon as possible.

TREATMENT - If there is no abscess formation apparent, treat the patient with broad-spectrum antibiotics. Warm saline soaks will help to localize the infection. If an abscess is present, refer the patient to a medical facility.

SYMPTOMS - The patient will frequently reveal a history of vaginal coitus. There may be a greenish-yellow discharge present. The patient normally experiences severe nonradiating lower abdominal cramps in acute cases. Chills, moderate fevers, and a history of menstrual irregularity are common complaints. When a patient presents with an acute abdominal condition, it is essential to diagnose it correctly. Pain accompanied by uterine bleeding and signs of shock would be suspect of ectopic pregnancy. Examination of the internal genitalia may reveal pus exuding from the cervical os or urethra, and the tender adnexal (pelvic) masses may be palpable.

TREATMENT - Whenever an acute abdominal condition is evident, transfer the patient for definitive treatment as soon as possible. Start the patient on 4.8 to 12 million units of aqueous penicillin G IM in divided doses. If the patient is allergic to penicillin, she is given Vibramycin (R) (Doxycycline) 200 mg to start, followed by 100 mg twice a day for 7 to 10 days. Analgesics may be administered to relieve pain.

TREATMENT - Generally, with the exception of a sympathetic ear and reassurance, no treatment is required. Mild analgesics may be prescribed to relieve headaches and mastalgia. In severe cases, limiting salt and using intermittent diuretics during the last 7 to 10 days of the menstrual cycle may be of value. The course of this syndrome is progressive and self-limiting, and it will usually clear up within the first few hours of onset of the menstrual cycle.

SYMPTOMS - Pain may develop approximately 1 to 2 days before the onset of menses. The pain may be dull or sharp and cramping and may be referred to the legs and suprapubic regions. Associated symptoms include mastalgia, nausea, vomiting, depression, and abdominal distention.

TREATMENT - This condition is also self-limiting and is best treated symptomatically. Treatment is dependent upon the severity and extent of the symptoms. Many women have pain, but few will be incapacitated by it. the basic keynotes of patient care, understanding, sympathy, and reassurance are essential in relieving some of the patient's anxieties. Advise the patient ot engage in a program of physical exercise; however, fatigue should b avoided, as it tends to decrease the patient's tolerance of pain. Mild analgesics and antispasmodics may be administered, and for severe and incapacitating pain, light duty and bed rest for 1 or 2 days may be indicated. Refer the patient to a medical treatment facility for evaluation if the dysmenorrhea is interfering with the performance of duties.

In addition to amenorrhea, any other type of abnormal uterine bleeding patterns should be referred as soon as possible for definitive diagnosis and treatment.

• Ectopic Pregnancy - This condition results when a fertilized ovum is implanted and develops outside of the uterine cavity. Ectopic gestation occurs in approximately 1 out of every 200 pregnancies. Most of the time the implantation occurs in the fallopian tube.

SYMPTOMS - The patient will reveal a history of amenorrhea or irregular menses, followed by a sudden onset of  bleeding. There may or may not have been a previously diagnosed pregnancy. She may complain of severe abdominal cramping pain in the lower quadrant. The pain is nonradiating, and a soft,k tender pelvic mass may be palpable. The decidual tissues may pass and the patient may show signs of shock.

TREATMENT - Transfer the patient to a medical facility as soon as possible. Surgical treatment is required.

• Spontaneous Abortion - This is termination of gestation before the 24th week of pregnancy. Most spontaneous abortions are the result of ovular or sperm defects. It may be the result of anatomic malformation of the fetus or diet deficiencies.

SYMPTOMS - The patient will reveal a history of amenorrhea or irregular menses. A previous diagnosis of pregnancy may or may not have been established. The usual signs and symptoms of pregnancy are often lacking. An abortion is classified as follows:

• Threatened - This is any time vaginal bleeding or cramping occurs after conception.
• Imminent - Bleeding is heavier and cervical effacement or dilatation is present, and it may be accompanied by cramping pain.
• Inevitable- The membranes are ruptured and portions of tissue may be visible at the cervical os.
• Incomplete - Some tissue has been passed, and the remainder of the conceptus remains in the uterus.
• Complete - There is total passage of all parts of the conceptus, the uterus has returned to normal size, and the cervix has closed.
• Missed - The viability of the pregnancy has been terminated for at least 1 month, but the conceptus has been retained.

TREATMENT - Place the patient on complete bed rest until the transfer is completed. If bleeding is severe, replace fluids and treat for shock. Analgesics may be administered to relieve pain. Administer antibiotics if signs of infection are present. Transfer the patient to a medical facility as soon as possible.

Although discussed earlier in this chapter, it would be appropriate to again stress that the cultivation of a professional, mature, sincere, and compassionate attitude by the hospital corpsman is essential. medical ethics is stressed at all times and is indeed mandatory when treating patients, regardless of the sex.