Introduction to gynecology
Professor Alaa AL-Nasser
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 gynaecological proplems.
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.
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
Current or recent heavy or intermenstrual bleeding
Current or recent postcoital bleeding
Current or recent dysmenorrhea
Presence of premenstrual symptoms
Postmenopausal women
Age at last menses
History of hormone therapy
History of postmenopausal bleeding
Obstetrical history 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
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?
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
anaesthesia, 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.
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.
Atraumatic 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
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, performed.