Other  causes  include  inflammatory  necrosis, neoplasms,  and  granuloma. TREATMENT—Refer  the  patient  for  defini- tive  evaluation. FEMALE  SPECIFIC  CONDITIONS As the roles and numbers of women entering the naval service have increased, so has the role of   the   independent   duty   hospital   corpsman expanded.   With   the   assignment   of   women   to duty aboard ships, the responsibilities for taking care   of   the   health   care   needs   of   the   ship’s personnel have expanded to include those of the Navy’s  women. 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 examina- tion, 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  Depart- ment  (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. MENSTRUAL   HISTORY Just as there are certain aspects of the physical examination   of   women   that   differ   from   the physical  examination  of  men,  there  are  also different  types  of  information  to  be  extracted during  the  medical  history.  The  single  most important  part  of  the  history  to  be  taken  when a  woman  presents  with  a  gynecologic  condition is  the  menstrual  history.  It  should  be  remembered that  many  women  are  currently  taking  oral contraceptive  pills  that  may  modify  the  menstrual cycle.   No   history   of   the   menstrual   cycle   is complete  without  making  a  note  of  the  form  of contraception employed. The following points are important  data  concerning  the  menses. l  Age  of  Onset—An  unusually  late  or  early menarche (beginning of menstrual function) may be  indicative  of  various  endocrinopathies. l  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  excesive.  The normal  duration  of  the  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. l  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  re- quires  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. l  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. 2-33