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L1
D. Alaa
Objectives
1. Perform the medical interview &physical exam of women incorporating ethical, social
and diversity perspectives to provide culturally competent health care.
2. Apply recommended prevention strategies to women throughout life span.
3. Apply knowledge of gynecological problems.
4. History taken clinical exam of patient in gynae. Department.
5. Communication &clinical skills
Gynecology is the medical practice dealing with the health of the female reproductive systems
(vagina, uterus and ovaries) and the breasts. Its counterpart is andrology.
Assessment of the gynecologic history and the pelvic examination is part of the assessment of
female patients in many clinical contexts. Clinician familiarity with the gynecologic evaluation
can help reduce anxiety for both patients and health care professionals.
Gynecologic History
The history should be obtained in a relaxed and private setting, before the patient is asked to
disrobe. She should be interviewed alone under most circumstances, unless there is a hearing or
language barrier. Questioning should proceed from very straightforward, objective information
to more delicate issues. The provider should evaluate and respond to the patient's comfort level
and make every effort to remain supportive.
One should begin the history with an open-ended question that will elicit the woman's
gynecologic concerns. She should be encouraged to describe the situation in her own words and
without frequent interruptions. Maintaining eye contact, nodding, and brief clarification of
important points convey the provider's attention to the woman's issues. The provider can then
ask questions to proceed with the evaluation
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Basic history
Menstrual history All women
Age of menarche (onset of first period)
Prior history of menstrual irregularity
Prior history of heavy or intermenstrual bleeding
Prior history of dysmenorrhea
Women of reproductive age and in the menopausal transition
Date of last menstrual period (Lmp) (first day of bleeding or spotting)
Date of previous menstrual period
Current cycle length (interval between lmp and previous menstrual period) and regularity
(cycle pattern over past year)
Number of days of bleeding in an average menses
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Current or recent heavy or intermenstrual bleeding
Current or recent postcoital bleeding
Current or recent dysmenorrhea
Presence of moliminal or premenstrual symptoms
Postmenopausal women
Age at last menses
History of hormone therapy
History of postmenopausal bleeding
Obstetric history
Obstetrical history of any pregnancies
History of miscarriages, terminations, or ectopic pregnancies
History of assisted reproduction
For each pregnancy carried:
Date of delivery
Gestational age at delivery
Mode of delivery with indication for operative delivery
Maternal complications, such as hypertension or diabetes
Fetal complications, such as growth restriction, anomalies or stillbirth
Delivery or operative complications
Neonatal problems
Current health of children
Current symptoms or history
pelvic, vaginal, or vulvar infections – vaginal discharge, vulvar or vaginal lesions, fever, pelvic
pain, abnormal genital tract bleeding, prior sexually transmitted infections or pelvic
inflammatory disease (diagnosis, frequency, and treatment)
Cervical cytology (Pap test) history
Date and result of last test; diagnosis and follow-up of abnormal Pap smears
History of other gynecologic problems
Such as ovarian cysts, uterine fibroids, infertility, endometriosis, or polycystic ovarian syndrome
- mode of diagnosis and treatment
Symptoms of pelvic organ prolapse or urinary or anal incontinence
History of gynecologic procedures
D&C removal of uterine contents for various reasons, including completing a partial
miscarriage and dx sampling for dysfunctional uterine bleeding refractive to medical
therapy
Hysterectomy removal of the uterus
Oophorectomy removal of ovaries
Tubal ligation permanent sterilization
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Hysteroscopy inspection of uterine cavity
Laparoscopy inspection of pelvis through abdomen to dx and Rx gynecological disease
Laparotomy for gynecological reasons
Cervical excision procedure
Pap smear (date, indication, complications)
Screening for intimate partner violence.
Menopause is defined by 12 months of amenorrhea after the final menstrual period.
Postmenopausal bleeding refers to any uterine bleeding in a menopausal woman (other than the
expected cyclic bleeding that occurs in women taking sequential postmenopausal hormone
therapy). While menopause may occur in some women in their 40s, other causes of amenorrhea
and abnormal uterine bleeding should be considered, particularly for patients in their early 40s.
Pelvic pain — The characterization of pelvic pain should include the time of onset, duration,
location, quality, and severity. The relationship of the pain to menstruation, physical activity, or
sexual activity and alleviation of the pain with analgesics, hormonal contraceptives, or position
change are useful components of the pain history. Associated gastrointestinal or urinary
symptoms could point to a nongynecologic source of the pain. However, ovarian torsion is often
accompanied by nausea and vomiting.
Urinary incontinence and pelvic organ prolapse — Urinary incontinence occurs among women
of all ages and requires evaluation when the involuntary loss of urine is bothersome. Historical
factors, such as leakage of urine with physical activity (exercise, lifting, coughing, sneezing)
versus an overwhelming urge to void with leakage of urine before reaching a toilet, can help to
differentiate stress incontinence from detrusor instability. A careful voiding and intake history
will help the clinician determine the underlying cause.
Women with pelvic organ prolapse may complain of a vaginal bulge, vaginal pressure, or the
need to place a finger in the vagina to void or defecate. Such symptoms should be evaluated
further with physical examination.
Sexual function — many sexual problems result from and/or cause reproductive dysfunction and
gynecologic problems. Sexual issues include prevention of sexually transmitted infections,
contraception, sexual dysfunction, and prevention and management of sexual assault.
Do you have sexual concerns?
Are you currently having or have you ever had sexual relations?
Have you recently had any new partners or sexual contacts?
Do you protect yourself from pregnancy and sexually transmitted infections?
Would you like to be screened for sexually transmitted infections?
Do you need contraception or preconceptional counseling?
Are you currently experiencing or have you experienced previous sexual abuse?
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Infertility is defined as failure of a couple to conceive after 12 months of regular intercourse
without use of contraception in women less than 35 years of age, and after six months of regular
intercourse without use of contraception in women 35 years and older. Before proceeding with
an infertility evaluation, the provider should confirm that the couple is having regular, frequent
intercourse during the middle of the menstrual cycle. Once the diagnosis is established, the
infertility history should focus on three factors: ovulation, tubal and uterine problems, and male
factors.
Pelvic Examination
Pelvic examination is indicated in any patient with genital or pelvic symptoms and in other
patients for preventive care.
Age at initial examination — A pelvic examination is not included unless indicated due to
symptoms or for screening for a sexually transmitted infection.
Preparing for the examination
Patient consent — the clinician should request permission before starting a pelvic examination.
Written consent is not required, with the exception of examination under anesthesia, female
chaprone should be present, unless urinary incotinenance female should be asked to empty her
bladder.
Equipment — the basic equipment needed to perform a pelvic examination includes:
An examining table with stirrups (or means for elevating the buttocks when stirrups aren't
available [eg, the patient is on a stretcher or in bed])
Good light source (preferably cold light)
Speculum of appropriate size.
Materials to obtain cervical cytology
Materials to test for common infections – chlamydia, gonorrhea, herpes simplex virus
Cotton swabs for obtaining samples of vaginal discharge
PH indicator paper
Dropper bottles of saline and potassium hydroxide for performing wet preps
Large cotton swabs to absorb excess vaginal discharge or blood
Test kits for fecal occult blood
Water soluble lubricant, disposable gloves, material to drape the patient
Components of the examination — The pelvic examination traditionally includes the internal
and external genitalia, and pelvic organs. Comprehensive examination also includes evaluation
of some components of the urinary and gastrointestinal tracts, including the urethra, anus, and
rectum. A more comprehensive examination, involving the abdomen, breast, and other sites,
may be indicated to provide complete primary care or to evaluate gynecologic problems that
involve other organ systems.
Abdomen — Examination of the abdomen should be performed using the standard techniques
of inspection, auscultation, palpation, and percussion. The examiner should observe for
abnormalities of skin color and intestinal peristalsis, hernias, organomegaly, masses, fluid
collection, and tenderness.
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External genitalia — The external genitalia are inspected and palpated ( The hair distribution,
skin, labia minora and majora, perineal body, clitoris, urethral meatus, vestibule, and introitus
are evaluated for developmental abnormalities, skin lesions (eg, discoloration, ulcers, plaques,
verrucous changes, excoriation), masses, and evidence of trauma or infection. Bartholin and
paraurethral glands — The Bartholin gland openings are located at the 4 and 8 o'clock positions
just outside the hymenal ring. The glands are not palpable when healthy.The paraurethral glands,
the largest of which are Skene's glands, are adjacent to the distal urethra; the gland ducts open
into the urethra or just outside the urethral orifice. If enlarged or tender, an attempt should be
made to express exudate, which suggests infection.
Speculum examination
The vagina is first inspected using a speculum of appropriate size, lubricated with warm water
or a water soluble lubricant. Lubricants do not appear to interfere with sampling for cervical
cytology.
A traumatic insertion is aided by assisting muscle relaxation at the opening of the vagina. This
may be accomplished by advising the patient to relax her legs to the sides and also by inserting
a finger into the distal vagina and gently applying downward pressure. The speculum is then
inserted and downward pressure applied. The speculum is advanced in a direction free of
resistance and opened as the apex of the vagina is reached.
Vaginal lesions, anomalies, or atrophic mucosa are noted. If abnormal discharge is identified,
the volume, color, consistency, and odor should be noted and a sample taken with a cotton swab.
The pH of physiologic vaginal discharge is less than 4.5; an elevated pH may be due to infection
(eg, bacterial vaginosis) or exogenous substances (eg, semen).
The degree of vaginal wall relaxation and uterine prolapse is evaluated, if indicated, by removing
the top blade of the speculum and using the posterior blade as a retractor. It is helpful to ask the
patient to bear down to determine the degree of uterovaginal descensus.
Lesions or discharge of the cervix are noted. Cervical cultures and cervical cancer screening are
performed, as appropriate.
Bimanual examination
The index and middle fingers of the dominant hand are normally used to examine the vagina and
uterus, although some providers find that switching hands during the examination facilitates
evaluation of the adnexa. Only a single finger can be inserted comfortably in patients with a
narrow introitus or small vaginal orifice. The abdominal hand should be used to sweep the pelvic
organs downward, while the vaginal hand is simultaneously elevating them.
The uterus is assessed for size, shape, symmetry, mobility, position, and consistency. The uterine
size and consistency vary according to reproductive status (parity, menopausal status). the terms
used to describe this are:
Axial — the axis of the uterus is the same as the vaginal axis
Version — position of the entire uterus relative to the axis of the vagina; eg, anteverted,
retroverted
Flexion — position of the uterine fundus relative to the axis of the cervix; eg, anteflexed,
retroflexed
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The adnexal areas are checked for the presence of appropriately sized, mobile ovaries (eg, about
2 by 3 cm), which are normally somewhat tender. Palpable ovaries in postmenopausal women
are not a "normal" finding (detectable in about 30 percent of postmenopausal women. and
require investigation, although most are associated with benign or no disease.
The ability to palpate the ovaries during a clinical examination in the office depends upon several
factors, including the patient's body habitus, the examiner's experience, the time taken to perform
the examination, and the presence of other pelvic abnormalities. Ovaries can be difficult to
palpate, even by experienced clinicians under ideal circumstances.
Rectovaginal examination
Another potential component of the gynecologic assessment is the rectovaginal examination.
This allows optimal palpation of the posterior cul-de-sac and uterosacral ligaments, as well as
the uterus and adnexa.it performed as an alternative to vaginal exam.in children and adult never
have sexual activity it will help to pick up pelvic mass, differn. enteroceole and rectoceole
palpate uterosacrl ligament.(index finger vagina,middle finger rectum).
If a rectovaginal examination is performed, anorectal findings should be documented (eg,
hemorrhoids, rectal mass). If indicated, stool on the examining glove can be tested for occult
blood. However, a single sample does not suffice for colorectal cancer screening; screening is
better accomplished by home collection of stool samples.
When performing the rectovaginal examination, using a lubricated examining glove and asking
the patient to strain against the examiner's finger will usually allow the sphincter to relax and
decrease discomfort. The same finger should not be used to examine both the vagina and rectum
to avoid transmission of HPV or contamination with blood, which may alter fecal occult blood
testing, if performed.
Mubark A. Wilkins