Assessment of the

Female Genitalia
Liza G. Floresca, RN, MAN, PhD, DNS
Joel Mikee A. Beldua Jr. RN, MN
Anatomy and Physiology:
Female Genitalia
 The Female Genitalia

• Knowing the basics of pelvic anatomy will enhance your

examination skills and improve your detection of abnormal
finding.
• Mons pubis – hair-covered fat pad overlying the symphysis
pubis.
• Labia majora – rounded folds of adipose tissue forming the
outer lips of the Vagina.
• Labia minora – the thinner pinkish – red folds or inner lips that
extend anteriorly to form the prepuce.
• Clitoris – the most sensitive part and the pleasure center of
the vulva.
• Vestibule – boat-shaped fossa between the labia minora
• Vaginal opening/orifice/introitus – the posterior part of the
vestibule, which virgins may be hidden by the hymen.
• Perineum – refers to the tissue between the introitus and the
anus
 The Female Genitalia

• Urethral Meatus – opens into the vestibule

between the clitoris and the vagina.
• Just posterior and adjacent to the meatus
on either side lie the opening of the Skene
Glands
• Bartholin glands – located posteriorly on
both sides of the vaginal opening but are
not usually visible.
• Vagina – musculomembranous tube
extending upward and posteriorly between
the urinary bladder and urethra and
rectum.
 The Female Genitalia

• Uterus – a thick walled fibromuscular structure

shaped like an inverted pear.
• Fundus – Convex upper surface
• Corpus – Body of the uterus
• Isthmus – where cervix joined inferiorly in the
uterus
• Uterine walls is composed of :
- Perimetrium – serosal coating from the
perineum
- Myometrium – muscle wall of the uterus
(smooth muscle)
- Endometrium – the adherent inner coating
 The Female Genitalia

• Cervix – cylinder shaped neck of tissue that

divides the uterus and the vagina.
• Location – inferior part of the uterus
• Ectocervix – seen easily with the help of a
speculum.
• External Os – Located in the center, round,
oval, or slit-like depression, which marks
the opening into the endocervical canal.
 The Female Genitalia
• Fallopian tube – with a fanlike tip, the fimbria, extends
from the ovary to the each side of the uterus.
• Conducts oocyte from the periovarian peritoneal cavity
to the uterine cavity.
• Ovary – almond-shaped glands that vary considerably in
size from adulthood through menopause.
• Functions :
- Production of oocytes
- The secretion of hormones: Estrogen and progesterone
- Increased hormonal secretion during puberty stimulates
the growth of the uterus and its endometrial lining,
enlargement of the vagina, thickening of vaginal
epithelium, and development of secondary sex
characteristics.
 5 stages of Pubic Hair Development in
Females
I. Preadolescence. No pubic hair except for
fine body hair.
II. Usually occurs at ages 11 and 12. Sparse,
long, slightly pigmented curly hair develops
along labia
III. Usually occurs at ages 12 and 13. Hair
become darker in color and curlier and
develops over the pubic symphysis
IV. Usually occurs between ages 13 and 14.
Hair assumes texture and curl of the adult
but not as thick and does not appear on the
thighs
V. Sexual maturity. Hair assumes adult
appearance and appears on the inner
aspect of the upper thighs.
Assessing the Female
Genitalia
Health History

• Common and Concerning Symptoms

- Menarche
- Menstruation
- Menopause
- Postmenopausal bleeding
- Pregnancy
- Vulvovaginal symptoms
- Sexual Health
- Pelvic Pain
- STIs
The Menstrual History – Helpful Definitions

• Menarche – age at onset of menses

• Dysmenorrhea – pain with menses, often with bearing down,
aching or cramping sensation in the lower abdomen or pelvis.
• Amenorrhea – absence of menses
• Abnormal uterine bleeding – bleeding between menses; includes
infrequent, excessive, prolonged, or postmenopausal bleeding.
• Menopause – absence of menses for 12 consecutive months,
occurring between ages 48 – 55 years
• Postmenopausal bleeding – bleeding occurring 6 months or more
after cessation of menses
 Menarche and Menses

• When talking with an adolescent

girl about menarche, opening
questions might include:
• “How did you first learn about
monthly periods?”
• “How did you feel when they
started?”
• “Many girls worry when their
periods aren’t regular or come late,
has anything like that bothered
you?”
 Menstrual History

• Ask the patient her age when menses began, or age

at menarche.
• When did her last menstrual period start.
• How often does she have periods, as measured by
the interval between the first day of two
consecutive periods?
• How regular or irregular are they?
• How long do they last?
• How heavy is the flow?
• What color is it?
• Number of pads or tampons used daily.
 Dysmenorrhea

• Ask if the patient has any

discomfort or pain before or
during her periods.
• If so, what is it like, how long
does it last, and does it interfere
with usual activities.
• Are there any associated
symptoms?
• May be primary or secondary
 Premenstrual Syndrome

• Includes emotional and behavioral

symptoms such as depression, angry
outbursts, irritability, anxiety, confusion,
crying spells, sleep disturbance, poor
concentration, and social withdrawal.
• Ask about signs such as bloating and
weight gain, swelling of the hands, and
feet and generalized aches and pains.
• Criteria for diagnosis are symptoms and
signs in the 5 days prior to menses for at
least three consecutive cycles.
 Amenorrhea

• Absence of ever initiating periods is primary

amenorrhea
• Cessation of periods
• Pregnancy, lactation, and menopause are the
physiologic cause of amenorrhea.
• Other causes :
• Malnutrition
• Anorexia Nervosa
• Stress
• Hypothalamic – pituitary ovarian dysfunction
Menopause

• Occurs between ages 48 and 55 years, peaking at a median age of

51 years.
• Cessation of menses for 12 months, progressing through several
stages of erratic cyclical bleeding.
• Stages of variable length, often with vasomotor symptoms like hot
flashes, flushing and sweating represent perimenopause
• Ovaries stop producing estradiol or progesterone and estrogen
levels drop significantly.
 Signs and Symptoms

• Female individuals may

experience:
• Mood shifts
• Changes in self-image
• Hot flashes from vasomotor
changes
• Accelerated bone loss
• Increases in total and low-density
lipoprotein cholesterol
• Vulvovaginal dystrophy
• Insomnia
What to ask?

• Ask a middle-aged or older woman if she has stopped

menstruating. When?
• Continue with “How did you feel about not having your periods
anymore?”
• “Has this affected your life in with a positive or negative way?”
• Always be sure to ask about any bleeding or spotting after
menopause as this may be an early sign of cancer
 Pregnancy

• Includes questions as, “Have you ever been

pregnant?”
• “How many times?”
• “How many living children do you have?”
• “Have you ever had a miscarriage or
abortion?”
• “How many times?”
• Ask about any difficulties during pregnancy
and the timing and circumstances of any
abortion, whether spontaneous or induced.
The Gravida Para Notation

• G - Gravida, or total number of pregnancies

• P – Para, or outcomes of pregnancies
• F or T – Full term or Term
• P – Preterm (25 weeks to 37 weeks of pregnancy)
• A - Abortion
• L - Living
 Vulvovaginal Symptoms

• Common symptoms :
• Vaginal discharge
• Itching

• If the patient reports a discharge, inquire about its

amount, color, consistency, and odor.
• Ask about any local sores or lumps in the vulvar area.
• Are they painful? Any itching near your vagina?
Between your legs?
Sexual Health

• Maintain a neutral, nonjudgemental tone helps your patients feel

safe and trust you with their concern.
• Reassure hem that sex in a mature consensual relationship is
healthy, and that you explore sexual health with your patients.
• Be aware of your own body language, facial expressions, and tone
of voice, so that you create an open environment for discussion.
• In younger patients and adolescents, consider asking the parents
to leave the room so that the patients feel free to answer
questions without fear of parental disapproval or repercussions
especially when discussing possible sexual abuse.
 Examples of Neutral Question about Sexual
Orientation and Gender Identity:
• “Are you currently dating?, sexually active?,
or in a relationship?”
• “ How would you identify your sexual
orientation ” Responses include heterosexual
or straight, lesbian, gay, women who have sex
with women, men who have sex men,
bisexual, transsexual , and questioning,
among others.
• Continue with “do you use protection such as
birth control or condoms?”
• “Has anyone ever tried to touch or have sex
with you without your consent?”
 Sexual Response

Explore the patient’s sexual

response. “How is your current
relationship?”
“ Are you satisfied with your
relationship and your sexual
activity?”
“ What about your ability to perform
sexually?” (Sexual behaviors)
 Other questions to assess sexual response:

• “How is sex for you?”

• “Are you having any problems with sex?”
• This includes sexual intercourse and anal
and oral sex
• “Are you satisfied with your sex life as it is
now?”
• “Are you satisfied with you ability to
perform sexually?”
• “How does your partner feel?”

-Studies show that patients are often

uncomfortable bringing up these topics. Many
prefer to have them initiated by their
providers, and most welcome information about
sexual health.
 Other Questions in Assessing the Sexual
Response:
“Do have an interest in (appetite for) sex?” –
Question about libido.
“Has your interest increased or decreased?”
“Are you and your partners having difficulties
or problems?”
“Do you get sexually aroused?”
“Do you lubricate easily? (get wet, or slippery)?
“Do you stay too dry?” – Questions for about
arousal
“Are you able to reach the climax?”
“Is it important for you to reach climax?”
“Do you enjoy sex if you do not reach climax?”
-Questions about orgasm
 Other deviations:

• Dyspareunia – pain with intercourse.

• If present, try to localize where the
pain occurs. Is it near outside, at the
start of intercourse, or does she feel
it inside, when her partner is pushing
deeper?

• Vaginismus – refers to an involuntary

spasm od the muscles surrounding
the vaginal orifice that makes
penetration during intercourse
painful or impossible
 STIs

• Inquire sexual contacts and

establish the number of sexual
partners in the past 3 – 6 months.

• Ask about oral and anal sex and if

indicated , about symptoms
involving the mouth, throat, anus
and rectum.

• Review any history of STIs “Have

you ever had herpes? Any other
problems such as gonorrhea?
Syphilis?
How to assess the Female
Genitalia
Important Areas of Examination

External Examination Internal Examination

• Mons Pubis • Vagina
• Labia Majora and Minora • Vaginal walls
• Urethral Meatus • Uterus
• Vaginal Introitus • Ovaries
• Clitoris • Pelvic Muscles
• Perineum
 Tips for the Successful Assessment
The Patient
• Avoids intercourse, douching, or use of
vaginal suppositories for 24-48 hours
before examination
• Empties her bladder before the
examination
• Lies Supine, with her shoulders elevated,
arms at her sides or folded across the
chest to enhance eye contact and reduce
tightening of abdominal muscles
The Examiner
• Obtains permission; selects chaperone.
• Explains each step of the examination in
advance
• Drapes the patient from midabdomen to
knees; depresses the drape between the
knees to provide eye contact with patient.
• Avoid unexpected or sudden movements
• Chooses a speculum that is the correct size
• Warms the speculum with tap water
• Monitor the comfort of the examination by
watching the patient’s face
• Uses excellent but gentle technique
especially when inserting the speculum
 Equipment to assemble:

• A movable source of light

• Vaginal Speculum
• Water soluble lubricant
• Equipment for taking pap smear, bacteriologic
cultures, and DNA probes or other diagnostic
testing materials
Positioning the patient

• Drape the patient appropriately and then assist her into the
lithotomy position.
• Place one heel, then the other into the stirrups.
• She may be comfortable in socks or shoes then bare feet.
• Then ask her to slide all the way down the examining table until
her buttocks extend slightly beyond the edge.
• Her thighs should be flexed, abducted.
• Make sure her head is supported with a pillow.
Assessment Procedure

• Inspect the distribution of, amount and characteristics of pubic

hair

Normal Findings:
- There are wide variations: Generally kinky in the menstruating
adult, thinner and straighter after menopause

Deviation
- Scant pubic hair (may indicate hormonal problem)
Assessment Procedure

• Inspect the skin of the pubic area for parasites, inflammation, swelling and
lesions. To assess pubic skin adequately, separate the labia majora and labia
minora.

• Normal:
- Pubic skin intact, no lesions
- Vulva area slightly darker than the rest of the body.
- Labia round, full and relatively symmetric in adult females.

• Deviations:
- Lice, lesions, scars, fissures, swelling, erythema, excoriations, varicosities
Assessment Procedure

• Inspect the clitoris, urethral orifice, and vaginal orifice when separating the
labia minora

• Normal:
- Clitoris does not exceed 1cm in width and 2cm in length
- Urethral orifice appears as a small slit and is the same color as surrounding
tissues
- No inflammation, swelling, or discharge

• Deviation:
- Presence of lesions
- Presence of inflammation, swelling or discharge
Assessment Procedure

• Palpate the inguinal nodes

• Use the pad of the finger in a rotary motion, noting any
enlargement or tenderness

• Normal: No palpable lymph nodes

• Deviation: Enlargement and tenderness

Deviation
 Lifespan Considerations: Infants

In newborns, because of maternal

estrogen, the labia and clitoris may
be edematous and enlarged, and
there may be a small amount of white
or blood vaginal discharge
 Elders

• Labia are atrophied and flatter in older

females
• Vulva atrophies as a result of reduction in
vascularity, adipose tissue and estrogen
levels. Easily irritated
• Vulva becomes drier and more alkaline,
there will be alteration of the normal flora
present may predispose to vaginitis.
• The cervix and uterus decrease in size
• Fallopian tubes atrophy
• Uterine prolapse can occur especially those
who have had multiple pregnancies