This chapter should be cited as follows:
Senanayake H, Premaratne S, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.418493

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 4

Benign gynecology

Volume Editor: Professor Shilpa Nambiar, Prince Court Medical Centre, Kuala Lumpur, Malaysia

Chapter

Assessment of the Gynecological Patient

First published: December 2024

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INTRODUCTION

Gynecological problems have a variety of presentations, ranging from long-standing to acute conditions. It is essential to remember that this spectrum includes potentially life-threatening conditions such as ectopic pregnancy or ovarian cancer. Gynecological conditions feature prominently in commonly missed diagnoses in medicine. Early diagnosis may make a significant difference in the outcome of treatment. Malignancies and endometriosis are prime examples of these. Diligent assessment will ensure that these diagnoses are not missed.

Although technology is widely used in evaluating patients in modern-day practice, information gathered by taking a good history and through physical and pelvic examinations is invaluable and yields important information that points toward a diagnosis, ensuring optimal use of further investigations.

HISTORY-TAKING

Gynecological patients may be from any point in the life cycle, from infants to elderly women. History-taking should be tailored to fit the individual circumstances. By its very nature, a gynecological history requires delving into sensitive and very personal information, which may not be freely divulged under normal circumstances. For example, an adolescent who attends with her mother may not want to reveal that she is sexually active. Such information may prove vital in the case of an ectopic pregnancy or a septic abortion. It is important to be aware of these nuances in gynecological practice. Attitudes and what is acceptable vary between cultures and these must be given due consideration. It is important to reassure the patient that any information given will be treated in confidence and shared only with team members contributing to her care. Similarly, history-taking and gynecological examinations must be conducted in settings with adequate privacy.

History-taking is an art. Placing the patient at ease and building a good rapport is important. It is mandatory to introduce yourself and explain your position in the team. Addressing the patient by her name and having a reassuring demeanor is very helpful in building the necessary rapport. Active listening is an essential component of this art. Maintaining eye contact and showing empathy in response to verbal and non-verbal cues from the patient are important components of this.

Details obtained should include those of the current problem and other aspects of the illness, such as how her illness affects her quality of life and family. Being non-judgmental is essential. For example, in the case of a woman who has procured an abortion, being judgmental may discourage her from divulging other important facts. Whatever the legal position or one’s own views regarding her actions, remaining non-judgmental is an expected professional standard.

Evaluation of any patient should begin with a quick assessment of her general condition. History-taking in a woman who is in extreme pain or a collapsed state needs to be brief and directed. The ‘ABCDE approach’ must be applied to any patient who presents for care.¹ This chapter deals with women who do not require immediate resuscitation.

It is important to develop a method and sequence that ensures coverage of all the relevant domains, enabling findings to be presented coherently and smoothly. As much as possible, a history should be presented in the client’s own words, rather than using technical terms. The traditional rule to be followed is that one should use her words as much as possible when presenting facts mentioned by her, while technical terms may be used to describe what has been elicited by questioning. For example, ‘she complains of severe pain during menses’ should be the words to be used when it is the complaint, whereas ‘she has severe dysmenorrhea’ is acceptable when it has been elicited by questioning. Another general principle is to ask ‘open’ questions and avoid ‘leading’ or ‘closed’ questions. For example, it is better to ask ‘Do you get pain during your period?’ rather than ‘Do you have severe pain at the time of your period?’. The history should start with basic information such as name, age and place of residence. A good way to start taking a history is by asking ‘What brought you to the hospital today?’, or ‘How can we help you today?’.

The presenting complaint is the main complaint that a client has. The presenting complaint must be recorded, together with its duration. Similarly, subsidiary complaints should be listed along with their durations.

Menstrual history

An important aspect of assessing a gynecological patient is her menstrual history, which should be considered under various headings.

• Age at menarche.
• Date of the last menstrual period. Most women can recall this accurately, but an approximate timeline in months or years is adequate in menopausal women.
• Length of the menstrual cycles, i.e. the number of days from the commencement of one menses to the commencement of the next. The modal duration of a cycle is 28 days, but many normal women have irregular cycles.² It is important to understand whether the irregularity is of recent onset or whether it has always been the pattern, what the duration of the shortest and longest cycles is, and the most common cycle length. Cycles that are shorter than 21 days are considered more likely to be anovulatory (meaning that it is unlikely that the woman would have ovulated during that cycle). Similarly, a cycle length of longer than 35 days is also considered more likely to be anovulatory. However, the probability of ovulation during a given cycle remains consistent between cycle lengths of 23 to 35 days.²
• Blood loss at menstruation. The average volume of blood lost at menstruation is usually considered to be 80 ml, but the volume is impossible to assess in an individual woman. The most practical way to assess abnormal blood loss would be to compare the present loss with what she considers ‘normal’ for her. The number of days that menstruation lasts or the number of sanitary napkins or tampons used may be misleading. Comparing the degree of soakage of sanitary napkins or tampons against a ‘pictorial blood assessment chart’ is a more objective way to assess blood loss.³ Questions such as ‘Are the sanitary napkins completely soaked when changed?’, ‘Is there bleeding through the sanitary napkins?’, ‘Is there a need to wear two sanitary napkins at a time?’ or ‘Is there leakage onto clothes or bed linen?’ may indicate the extent of loss. Inquiry should also be made regarding the passage of clots. If the answer is affirmative, an inquiry must be made about the diameter of the clots. Menstrual blood is usually passed as a fluid due to the action of plasmin present within the uterus. Anything more than the passage of small clots indicates that the volume lost is significant.
• It is important to elicit any history of reduced menstrual loss, which may also indicate a problem. Uterine synechia (adhesions between the uterine walls) following curettage or intrauterine surgery is a well-known cause of scanty or absent menses. This condition is referred to as Ascherman syndrome, and is typically associated with the discomforts associated with menstruation but without the passage of menstrual blood or with only minimal bleeding. Scanty blood loss (referred to as oligomenorrhea) is also a symptom of hyperprolactinemia and polycystic ovary syndrome.
• Pain associated with menstruation. Pain is commonly associated with menstruation, but this is mild for most women, requiring either no or mild analgesia. Menstrual pain that interferes with daily activities is referred to as ‘dysmenorrhea’. Although this is a common complaint, it is often ignored or accepted as normal. The inability to function normally by having to take time off work, not being able to attend school, and being unable to participate in sporting or physical activities are good indicators of the severity of dysmenorrhea. Severe menstrual pain that is not relieved with simple analgesics is not normal and requires investigation. It is important to determine when pain begins during the cycle, when it reaches the maximum, and when it disappears. It is also useful to ask the patient to give a score to the pain, for example out of 10.
• Dysmenorrhea is divided into two categories. Primary dysmenorrhea refers to menstrual pain or abdominal cramps that occur in the absence of an underlying pathology. It typically starts shortly before or with the onset of menstruation.⁴ Its onset usually occurs within 6 to 24 months after menarche.⁵ Secondary dysmenorrhea refers to pain that has newly developed, usually as a result of an underlying pathology. Worsening primary dysmenorrhea may also be considered a type of secondary dysmenorrhea. Endometriosis, adenomyosis, uterine fibroids, pelvic inflammatory disease and intrauterine contraceptive devices are some causes of secondary dysmenorrhea.
• Intermenstrual bleeding. This refers to vaginal bleeding unrelated to menses. It does not necessarily indicate disease, as it is normal for a small amount of vaginal bleeding (usually ‘spotting’) to occur with ovulation. Almost 5% of women are known to experience this phenomenon.⁶ It is important to elicit the patient’s drug history. Intermenstrual bleeding may be the result of improper use of hormones or hormonal emergency contraception. It is also important to elicit whether the intermenstrual bleeding occurs with sexual intercourse. Intermenstrual bleeding that occurs during or following sexual intercourse (postcoital bleeding) may be a feature of carcinoma of the cervix.
• Other factors. Women may experience various other symptoms related to the menstrual cycle. Premenstrual syndrome is a well-recognized condition that is seen in the second half of the cycle, characterized by changes in mood and dysphoria. Some women experience changes in their bowel habits, such as constipation or diarrhea, during menses. These may indicate the presence of endometriosis. Sometimes the manifestation may be painful defecation (dyschezia) or passing of blood per rectum. Women with endometriosis of the bladder may experience dysuria and/or hematuria. Extrapelvic endometriosis has the potential to cause a myriad of bizarre symptoms. Fatigue is another feature of endometriosis that is not appreciated adequately.⁷

Non-menstrual history

The presence of pain independent of menses should be inquired into. The pattern of the pain, i.e. its cyclic or non-cyclic nature, is a useful clue to the diagnosis. Many women experience lower abdominal pain or discomfort with ovulation, known as ‘mittelschmerz’. It typically lasts only a few hours and is felt in mid-cycle, coinciding with ovulation. Non-cyclic pain may indicate various conditions, varying from constipation or irritable bowel syndrome to pelvic inflammatory disease. Non-cyclic pain is a leading feature of endometriosis in adolescents.⁸ In sexually active women, pain during intercourse (called dyspareunia) is an important symptom. Apart from being an indicator of a possible underlying pathology, it is a symptom that may affect the relationship between the woman and her partner. Pain felt during deep penetration (deep dyspareunia) is strongly indicative of endometriosis or pelvic inflammatory disease. Superficial dyspareunia felt at the vaginal introitus may be due to other causes, such as a thick hymen, vaginismus or scarring of the perineum following birth injuries.

The past obstetric history should be elicited in detail. How many times has she been pregnant? What were the outcomes? Were there any complications? What were the modes of delivery?

Drug history is an important part of evaluating a gynecological patient. Improper use of hormonal medications causing abnormalities in menstrual bleeding is mentioned above. Women who use selective estrogen receptor modulators such as tamoxifen may develop endometrial hyperplasia and carcinoma.⁹ Women using long-term anticoagulants may have heavy menstrual bleeding. Patients who use clopidogrel may be at risk of intraoperative bleeding.¹⁰ This information is invaluable if an operation is required so that the medication may be stopped preoperatively. Use of the antituberculosis drug rifampicin reduces the efficacy of oral contraceptives.¹¹

The history of medical diseases should be elicited. Thyroid disorders are known to affect menstrual patterns and loss. However, newer data suggest that these effects are seen in only about a fifth to a quarter of women with thyroid disorders.¹² This is a lower figure than cited previously.¹³ Amenorrhea is a common presenting feature of hyperprolactinemia.¹⁴ Use of antipsychotic drugs in women with psychiatric illnesses is known to cause oligomenorrhea or amenorrhea by inducing hyperprolactinemia.¹⁵ Peritoneal tuberculosis is a well-recognized cause of infertility, and a history of tuberculosis is very relevant in such patients.

Surgical history is also an important factor. The details of procedures and any surgical or anesthetic complications should be elicited. A history of endometrial curettage or surgical evacuation of the uterus is important in a woman with secondary amenorrhea. A history of multiple Cesarean sections or multiple laparotomies may indicate the possible presence of adhesions and a higher risk of visceral damage during subsequent surgery.

When the presenting complaint is infertility, the history needs to include for how long she has been trying to become pregnant, the frequency of sexual intercourse, whether she has had unprotected intercourse during her ‘fertile period’, adequacy of penetration, and any sexual problems in the partner, such as erectile dysfunction or premature ejaculation. The occurrence of pain during intercourse should also be elicited.

Whether a contraceptive method is being used is important information. If there is an unmet need, this will allow the subject to be broached. Being on the contraceptive pill has implications for elective surgery due to the increased risk of thrombosis, while progesterone-only contraceptives may cause intermenstrual bleeding.

Any history of allergies to food, drugs or dust should also be elicited.

In addition, the importance of social history is often underestimated. When a mother is admitted to hospital, it may cause a major disruption in her home. For example, she may have to leave an infant or young child at home and there may be childcare concerns. If a prolonged hospital stay is anticipated, it is important to find out what her support system is. Consumption of alcohol, recreational drug use and smoking should also be inquired into in the social history. Alcohol consumption should be expressed as units,¹⁶ and smoking should be expressed as the number of cigarettes smoked each day.

The distance from her home to the closest healthcare facility is very relevant. How will she commute to the facility for treatment? The level of income of her family may also have great relevance.

A history of domestic or intimate partner violence is very relevant whenever a woman presents herself to a healthcare facility. This is an area that did not receive due recognition until recently. It is well known that victims often seek medical advice for vague gynecological symptoms such as non-specific abdominal pain and vaginal discharge. Unfortunately, the perpetrator often makes a point of being present during these consultations, making it difficult to elicit this information.

The history should also include whether the woman is up-to-date with her cervical smear test.

A review of her systems should be carried out next, to ensure that relevant details are not missed. The questions are considered under various headings:

• Alimentary: How is her appetite, has there been any change in her weight? Have her bowel habits changed recently? Does she experience pain when eating meals?
• Cardiovascular: How good is her exercise tolerance? Does she become breathless with light day-to-day activity? Does she experience chest pain on exertion?
• Respiratory: Does she have a cough? Or does she bring up bloody sputum on coughing?
• Neurological: Has she noticed recent changes in her vision? Has she ever suffered seizures?

Figure 1 shows a framework for evaluation of the gynecological patient. Evaluations should be carried out in the order: history, examination and investigation (where needed).

EXAMINATION

A systematic general examination is an important part of assessing a gynecological patient. Table 1 gives a suggested framework.

Examination of the systems

The systems should be reviewed next. The aspects that are relevant to the gynecological patient are shown in Table 2.

Examination of the abdomen

The abdomen is of special importance in gynecology due to it being contiguous with the pelvis. Examination of the abdomen should follow the sequence: inspection, palpation, percussion and auscultation.

Inspection

Is the abdomen distended? The presence of ascites, a tumor, pregnancy or intestinal obstruction will distend the abdomen. The nature of the distension should be noted, i.e. whether it is localized or generalized.

The presence or absence of abdominal surgical scars should be noted. Localized distension over a surgical scar may indicate an incisional hernia. Striae or ‘stretch marks’ may be observed in women who have previously had the abdominal wall stretched due to pregnancy. These are referred to as ‘striae gravidarum’. Rarely, distended veins may be noted in the abdominal wall. This may indicate the presence of a pelvic mass obstructing the inferior vena cava.

Palpation

The general rule about abdominal palpation is that non-tender areas should be examined first. This will help to win the confidence of the patient before palpating areas that are tender. Inquiries should be made about abdominal pain or tenderness before starting palpation.

First, superficial palpation should be performed to elicit any obvious lumps or tenderness. The patient should be encouraged to breathe normally, and palpation is done during expiration when the abdominal wall is relaxed. Patients who find it difficult to relax the abdominal wall may find it easier to do so when the thighs are flexed slightly. Evidence of incisional hernias should be looked for over previous scars.

Next, a deeper palpation should be performed. It may either be performed with both hands kept together, or with one hand if the abdominal wall is relaxed. If a lump is palpable, the features listed in Table 3 should be assessed for a differential diagnosis. Much can be learned about the nature of a lump by clinical examination.

Palpation of the liver is also an important part of a gynecological examination. The liver is a common site for metastases. The normal liver is not palpable as its margin does not extend below the right costal margin. The following protocol is recommended for palpation of the liver.

• As the maximum extent to which the liver can enlarge is to the right iliac fossa, palpation should begin from there.
• Either the radial border of the right forefinger or fingers pointing in a cephalad direction should be used for palpation of the liver
• The patient should be asked to breathe slowly and deeply.
• The fingertips should be directed in a slightly posterior direction to coordinate with inspiration. The hand should gradually be moved cephalad about a centimeter at a time.
• If the liver is palpable, the edge will be felt nudging the palpating hand.
• The distance to the edge from the costal margin should be noted (e.g. 2 cm below the costal margin).
• When the liver is palpable below the costal margin, it is important to delineate the level of its dome by percussing in a progressively caudad direction, starting from the third intercostal space along the mid-clavicular line. The point at which dullness is felt is the upper border. The dome of a normal liver is situated at the level of the fifth intercostal space.

Where the liver is enlarged, various features should be elicited, as listed in Table 4. It should be noted that some of these clinical features may be difficult to demonstrate.

Percussion

Percussion is used to detect the presence of free fluid (ascites or blood in the peritoneal cavity) and to delineate the margins of a lump or enlarged viscera. It is useful in delineating the upper and lower borders of the liver. The presence of moderate amounts of fluid in the abdominal cavity is demonstrated by the clinical signs referred to as ‘shifting dullness’ and ‘horseshoe dullness’.

The principle of percussion is to continue percussing from an area of resonance to an area of dullness, usually starting near the umbilicus, and proceeding laterally towards the flank. The persistence of resonance in the flanks indicates the absence of free fluid in the abdomen. If the percussion note becomes dull in the flank, the patient should be requested to turn on her side such that the area of dullness is superior, while the examiner continues to keep the hand where dullness was noted. Percussion should be repeated over the area, and if there is no dullness, the sign referred to as ‘shifting dullness’ is said to be positive.

Similarly, when a moderate amount of fluid is present in the abdomen, it will settle in the flanks and the pelvis, leading to ‘horseshoe dullness’. To determine whether this sign is present, percussion should begin from near the umbilicus where the percussion note is usually resonant, and proceed radially towards the flanks and the pelvis. This sign is not reliable in the presence of a pelvic mass occupying the lower abdomen. Figure 3 shows the direction in which percussion should be performed to demonstrate this sign.

Auscultation

Auscultation of the abdomen with the diaphragm of a stethoscope should be used to detect the presence or absence of peristaltic sounds and bruits. The absence of peristaltic sounds may indicate postoperative paralytic ileus or peritonitis. Auscultation should be done over all four quadrants of the abdomen.

Pelvic examination

A vaginal examination can be considered a major invasion of a woman’s privacy. Verbal consent and the offer of the presence of a female chaperone are minimum standards. Adequate privacy must be achieved by making sure that the examination area is screened, and that the woman is not subjected to unnecessary exposure. In addition, the woman’s body must be exposed as little as possible to carry out the examination. Reassurance that the examination should not cause pain and an undertaking to stop the examination if it does cause pain will go a long way towards helping the woman to relax. This will in turn help with the examination.

A vaginal examination has two components: inspection and bimanual examination.

Inspection

The vulva and labia should be inspected first. In premenopausal women, the vulval skin has a rugose appearance. Following menopause, it begins to take on a smoother appearance due to the deficiency of estrogen. The features to be elicited are listed in Table 5.

Speculum examination helps to visualize the vaginal wall and the cervix. Two types of speculum are used in gynecological practice: Cusco’s bivalve self-retaining speculum and Sims’ speculum.

Cusco’s speculum is the one that is used most during routine gynecological procedures, including obtaining cervical smears and vaginal swabs for microbiology, performing intrauterine inseminations, and visualizing the cervix. Sims’ speculum is used mostly during surgical procedures, such as dilation and curettage, hysteroscopy, repair of fistulae, and vaginal hysterectomy.

Women are naturally apprehensive about vaginal examinations. The procedure must be explained to the woman and her consent obtained. A female chaperone should be present. When using Cusco’s speculum, the woman may lie either in the dorsal position or with legs supported on stirrups as in the lithotomy position. The speculum should be lubricated and inserted with its jaws closed, and held slightly obliquely to the sagittal plane to avoid causing discomfort by pressing on the urethra. The instrument should then be rotated clockwise while advancing it into the pelvis so that the handles come to rest in a posterior position, in line with the anus. The jaws of the speculum should then be opened to bring the cervix into view. Small adjustments may be needed to bring the cervix into view. Observations to be made during the speculum examination are listed in Table 6. The appearance of the normal cervix is described as ‘pale pink and smooth’.

Bimanual examination

A bimanual examination can elicit important and useful information. This examination should be carried out with the non-dominant hand placed on the lower abdomen and the fore and middle fingers of the dominant hand in the vagina. As the name suggests, both hands should be used simultaneously to palpate the pelvic organs and to elicit tenderness. The gloved fingers that are inserted into the vagina must be lubricated adequately to minimize discomfort. It is also advisable to first advance the forefinger into the vagina and then insert the middle finger only after the latter has been held there for a few seconds. This helps the woman to relax and to minimize discomfort. Features that may be elicited are listed in Table 7.

Features elicited by vaginal examination may help to delineate the cause of enlargement of the uterus. These are listed in Table 8.

Rectal examination

Rectal examination has hardly any place in gynecology. Women or girls who have not engaged in vaginal intercourse may have reservations about vaginal examination, and rectal examination may be of some use in such situations. However, interpretation of the findings will be difficult even for an experienced gynecologist. Hence, it is of limited value.

However, rectal examination may have a role in assessing women with carcinoma of the cervix, to assess the spread of the disease into the parametrium. For this purpose, a combined vaginal/rectal examination should be performed, with the forefinger in the vagina and the middle finger in the rectum. The fingers should be slowly swept laterally to elicit thickening of the broad ligament, indicating lateral spread of the disease. This is usually done under general anesthesia.

INVESTIGATION

Ultrasound scanning

Two main types of ultrasound scanning are used in gynecology. These are transabdominal sonography (TAS) and transvaginal sonography (TVS). In addition to obtaining a two-dimensional grayscale image, ultrasound provides a means to study the blood flow characteristics using the Doppler facility, and to obtain a three-dimensional picture. Of the two options, TVS generally has higher diagnostic sensitivity and specificity.

TAS

Although TVS has become the most desired method of imaging in gynecology, it is recommended that TAS is performed with every ultrasound assessment of the pelvis. This is because some related pathologies may manifest higher in the abdomen, e.g. hydronephrosis resulting from ureteric obstruction due to a pelvic pathology. Also, sometimes a large ovarian cyst may be sited in the abdomen, and not be obvious on TVS. It may also be the only way to perform an ultrasound assessment on women who do not agree to a TVS, e.g. for fear of pain or for social reasons. The patient’s bladder needs to be full. This moves the bowel away from the uterus to allow the ultrasound waves to be carried via the bladder into the uterus and adnexa. The quality of the image is poorer than with TVS.

TVS

Advances in technology and techniques have expanded the capability of TVS. A major guideline recommends its use or the use of magnetic resonance imaging (MRI) for diagnosing endometriosis, in preference to laparoscopy, which is an invasive procedure.¹⁷ TVS has the advantage of being a more widely available and much cheaper method than MRI.

This modality has also become an integral part of evaluating most gynecological patients. TVS is performed using a probe with a higher frequency than that of the standard TAS probe (6.5 MHz vs 3.5 MHz), resulting in a sharper image. Also, TVS allows the probe to be moved next to the structure so that a closer inspection is possible. It also allows the possibility to elicit tenderness in specific structures. This is referred to as ‘probe tenderness’.

There are four components in TVS to ensure a complete examination of the pelvis. These are as follows:

• Examination of the anterior compartment of the uterus, i.e. the structures that lie anterior to the uterus, mainly the bladder. Bladder tumors or endometriosis deposits in the bladder wall may be demonstrated in this way.
• Examination of the uterus. This includes a demonstration of the size and direction of the uterus, features of fibroids and adenomyosis, and a study of the endometrium. The uterus is measured in three planes to calculate its volume. Retroflection of the uterus, in which the lower part of the uterus is directed anteriorly while its upper part is directed backwards, is best demonstrated in this way. This is usually associated with endometrial deposits in the cul de sac. The ability to diagnose adenomyosis through ultrasound is a major advance in gynecology. Previously, it was believed that this condition could be diagnosed only from a histology specimen. Papers by Van Den Bosch et al.¹⁸ and Harmsen et al.¹⁹ provide further details on the criteria for diagnosis of adenomyosis.
• Examination of the adnexa. The adnexa should be examined and the presence of tumors and cysts should be demonstrated. In addition, mobility of the ovaries should be demonstrated. Normal ovaries lie separate from the uterus and move freely when applying pressure with the probe. In endometriosis and pelvic inflammatory disease, the ovaries may become adherent to the uterus and show limited mobility. TVS may also accurately differentiate between benign and malignant tumors of the ovary. Publications from the International Ovarian Tumor Analysis (IOTA) Group provide further information on this topic.^20,21
• Examination of the posterior compartment. In this stage, structures that lie posterior to the uterus are examined. These include the presence or absence of bowel adhesions to the posterior uterus, and endometrial nodules in the uterosacral ligaments or in association with bowel adhesions. The ‘sliding’ sign demonstrates sliding of the uterus over the rectum, indicating the absence of bowel adhesions to the uterus, suggesting the absence of conditions such as endometriosis and pelvic inflammatory disease.

MRI and CT

While transvaginal ultrasound is a widely available method for imaging the female pelvis, magnetic resonance imaging (MRI) and computed tomography (CT) provide useful additional information. However, these investigations are costly in terms of resources, and should be reserved for instances in which TVS is unable to provide adequate information. MRI is superior to CT in diagnosing benign and malignant disorders of the uterus, whereas, for characterization of adnexal masses, CT imaging more reliably differentiates ovarian tumors. CT is still the preferred imaging modality for evaluating ovarian cancer.

CONCLUSION

While technology dominates medical science today, diligent history-taking and examination still have an important place in reaching a diagnosis or a differential diagnosis. Effective history-taking and examination may optimize the use of technology and laboratory investigations to make a diagnosis. Gynecological evaluations often cross boundaries of confidentiality and dignity and thus require respect and attention during history-taking and examination. Offer of the presence of a female chaperone and appropriate consent are non-negotiable requirements for a gynecological examination. In terms of investigations, transvaginal ultrasound plays a prominent role in modern gynecology due to its utility and availability.

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