The Gynecologic History and Examination

Taking a history is the initial step in the physician–patient encounter. This provides a basis for emphasizing aspects of the subsequent physical examination, and for initial decisions about diagnostic testing and treatment. The information gained during the physical examination helps the clinician to narrow the list of possible diagnoses to explain a patient’s symptoms, and to refine plans for additional testing and treatment. This chapter outlines the components of a basic gynecologic history and gynecologic examination.

General Considerations

Because a discussion of reproductive issues may be difficult for some women, it is important to obtain the history in a relaxed and private setting. The patient should be clothed, particularly if she is meeting the provider for the first time. Ordinarily, the patient should be interviewed alone. Exceptions may be made for children, adolescents, and mentally impaired women, or if the patient specifically requests the presence of a caretaker, friend, or family member. However, even in these circumstances, it is desirable for the patient to have some time to speak with the clinician privately.

The manner of address should be formal using the title Mrs., Ms., Miss, or Dr. with the patient’s surname, unless the patient requests otherwise.

In some settings, it may be appropriate for nursing staff to be involved with history taking. A nurse may be perceived as less threatening, and may be able to take the history in a less hurried manner.¹ The provider can verify the history and focus on areas of concern. Alternatively, it may be helpful to ask the patient to complete a self-history form on paper or by computer prior to speaking with the provider. This allows the provider to devote time to addressing positive responses, and ensures that important questions are not missed.  Hasley² showed that responses to a computer-based questionnaire designed to update a patient’s gynecologic history were equivalent to those obtained during a personal interview.  Several studies involving patients in non-gynecologic settings have shown that patients are more likely to provide sensitive information when responding to a computer-based questionnaire as opposed to a personal interview or even a paper questionnaire.³ 

In order to increase a patient’s level of comfort during the interview, questions should be asked in an open-ended and nonjudgmental way. Assumptions should not be made about aspects of the patient’s background such as sexual orientation. At the conclusion of the interview, patients should be asked whether there are concerns that they would like to discuss that were not addressed previously in the interview.

Content

While the focus of the history may vary depending on whether the patient is being seen for evaluation of a gynecologic problem or for an annual gynecologic examination, the gynecologic history must include an evaluation of the patient’s overall health. An outline of a comprehensive gynecologic screening history is shown in Table 1. Aspects of the comprehensive history include:

Table 1. The gynecologic history

1. Chief complaint
   
2. History of present illness
   
3. Menstrual history
   1. Age at menarche
      
   2. Last menstrual period
      
   3. Menstrual pattern
      1. Cycle length
         
      2. Duration of flow
         
      3. Amount of flow
         
      4. Moliminal symptoms?
         
      5. Associated pain (dysmenorrhea, mittelschmerz)
         
      6. Intermenstrual bleeding
         
      
      
   4. Perimenopause/menopause
      1. Bleeding pattern
         
      2. Vasomotor symptoms
         
      3. Hormone replacement therapy
         
      
      
   
   
4. Contraception
   1. Current method; satisfied with method?
      
   2. Previous methods, including complications, reasons discontinued
   
   
5. Cervical and vaginal cytology
   1. Most recent Pap smear result
      
   2. History of abnormal Pap smears? If so, nature of diagnosis, treatment, and follow-up
      
   
   
6. Infection
   1. History of sexually transmitted infections

       2.      History of vaginitis, including types, frequency, and treatment

    3.      History of pelvic inflammatory disease

   
   
7. Fertility/infertility
   1. Desire for future fertility
      
   2. Any difficulty conceiving in past? If so, prior evaluation and treatments
      
   
   
8. Sexual history
   1. Type
      
   2. Concerns about libido, dyspareunia, or orgasm?
      
   3. History of sexual abuse or sexual assault?
      
   
   
9. Obstetric history
   1. Describe each pregnancy and the outcome.
      
   2.  Describe any maternal, fetal, or neonatal complications
   
   
10. Past medical history
    1. Current or past illnesses
       
    2. Hospitalizations
       
    
    
11. Past surgical history
    1. Past gynecologic surgeries
       
    2. Past nongynecologic surgeries
       
    
    
12. Medications and allergies
    1. Prescribed medications
       
    2. Over-the-counter medications
       
    3. Herbal preparations
       
    4. Allergies to medications and nature of reactions
       
    
    
13. Family history
    1. Significant illnesses of family members
       
    2. Known hereditary conditions in family
       
    
    
14. Social history
    1. Marital or relationship status
       
    2. Level of education
       
    3. Occupation
       
    
    
15. Review of systems
    1. Abdomino-pelvic
       1. Gynecologic
          
       2. Urinary
          
       3. Gastrointestinal
          
       
       
    2. Breast
       
    3. Other
       
    
    
16. Health maintenance
    1. Tobacco, alcohol, illicit drug use
       
    2. Diet
       
    3. Calcium and folate intake
       
    4. Exercise
       
    5. Use of seatbelts, helmets, sunscreen, smoke detectors
       
    6. Firearms in the home?
       
    7. Dates and results of screening tests such as mammography, sigmoidoscopy or colonoscopy, bone densitometry, lipid analysis, glucose and thyroid testing
       
    8. Immunizations and dates administered
       
    
    

1. Chief complaint (CC). Even if the patient is being seen for an annual gynecologic examination, it is helpful to begin the interview by asking whether the patient is experiencing any problems.
   
2. History of present illness (HPI). The patient is asked to describe any symptoms in her own words. Additional information about the nature of the problem can then be obtained by asking specific questions. It is helpful to know:
   1. The circumstances at the time the problem began, including activities that the patient was engaged in, medical problems that she was experiencing at the time, and any medications that she was taking around that time.
      
   2. The time course of the problem. Was this a transient problem, or has this been chronic, recurrent, or persistent? Are the symptoms temporally related to the menstrual cycle?
      
   3. Is this a new problem, or has the patient experienced similar symptoms in the past? If the problem involves disruption of an otherwise normal function (such as amenorrhea), did the patient have normal function at some point in the past?
      
   4. Characteristics of the problem, and associated symptoms. In the case of pain, this would include questions about the location, severity, nature (e.g., sharp, dull, cramp-like), exacerbating factors, relieving factors, and whether the pain radiates to another location. With respect to bleeding, this would include the frequency, amount, and duration of flow, and whether the patient is experiencing fatigue or lightheadedness.
      
   5. To what extent is the problem interfering with the patient’s usual activities?
      
   6. Has the patient undergone any previous evaluation or treatment for the problem? If so, it is helpful to obtain the patient’s permission to request these medical records.
      
   7. Why did the patient seek evaluation of the problem at this point? Have the symptoms changed or increased in severity?
      
   
   
3. Menstrual History.
   1. Age at menarche. Puberty marks the beginning of the reproductive years and includes a series of events that occur over 2–4 years including an increase in height, breast development (thelarche), pubic hair growth (pubarche or adrenarche), and the onset of menses (menarche). The average age at menarche is 12–13 years, with a range from 9 to 17 years.  Initially, menstrual cycles are typically anovulatory and menses occur at irregular intervals.
      
   2. Last menstrual period (LMP). By convention, the first day of the last menstrual period is recorded.
      
   3. Menstrual pattern and associated symptoms.
      1. Cycle length. The cycle length is the interval from the first day of one menstrual period to the first day of the next menstrual period. The median cycle length is 28 days, but ovulatory cycles have been noted to occur at intervals of 23–39 days. There is often a gradual decrease in cycle length in the later reproductive years. A change from a patient’s previous pattern is often a more reliable sign of a problem than a particular interval.
         
      2. Duration of flow. Menses commonly last for 3–5 days, with a range of 1–7 days. The withdrawal bleeds experienced by women who take oral contraceptives are often shorter than spontaneous menstrual periods.
         
      3. Amount of flow. The average blood loss during a menstrual period is 30 mL, with a range of 10 to 80 mL. An objective measure blood loss can be obtained by weighing used menstrual pads or tampons. However, estimates of blood loss based simply on the number of pads or tampons used are quite inaccurate, given that there is significant variation in the absorbency of different sanitary products and even between sanitary pads or tampons in the same package.⁴ A reported increase in the amount of menstrual flow is probably the most helpful indication of a problem. Contraceptive method can affect the amount of flow; withdrawal bleeds associated with oral contraceptive use are typically lighter than spontaneous menses, whereas menses of women who use an intrauterine contraceptive device are often heavier.
         
      4. Presence of moliminal symptoms. Many women experience predictable physical and emotional symptoms during the late luteal (premenstrual) phase of ovulatory menstrual cycles. Symptoms typically begin a few days before menses and resolve with the onset of bleeding. Commonly reported symptoms include breast tenderness, abdominal distension, weight gain, food cravings or increased appetite, irritability, and lability of mood. Severe or prolonged symptoms that interfere with a patient’s usual activities warrant further evaluation.
         
      5. Associated pain. Midline cramp-like lower abdominal or back pain at the time of menses (dysmenorrhea) is common. The pain generally begins within a few hours of the onset of menses and subsides by the second day of flow. Some women experience associated symptoms such as diarrhea, nausea, or headache. Severe or prolonged symptoms may occur with pathologic conditions such as endometriosis or adenomyosis, and require further evaluation. Some women experience unilateral pelvic pain at midcycle associated with ovulation (mittelschmerz). This is usually mild, and rarely lasts for more than 24 hours. It may be accompanied by an increase in clear vaginal discharge, related to estrogen stimulation of cervical mucus production.
         
      6. Intermenstrual bleeding. Some women note a small amount of bleeding (spotting) at midcycle. Intermenstrual bleeding at other times that occurs spontaneously or after intercourse is considered abnormal.
         
      
      
   4. Perimenopause/menopause.
      1. Bleeding pattern. In the late reproductive years, the intermenstrual interval typically becomes less predictable. Often the interval shortens and then becomes variable. Menopause is defined as the absence of menses for 1 year. While women rarely will have a subsequent menstrual period with typical associated symptoms, bleeding after this time is considered abnormal (postmenopausal bleeding) and warrants evaluation. The average age at the cessation of menses is 51 years, with a range from 40 years to the late 50s.
         
      2. Associated symptoms. Several symptoms have been associated with the hormonal changes that occur around the time of menopause.  Vasomotor symptoms, including hot flushes and sweats at night, are commonly reported.  Poor memory, disturbances of sleep, and aches in the neck, shoulders, and back have a similar prevalence.  Vaginal dryness and difficulties with sexual arousal are reported less commonly.⁵  Clusters of these symptoms appear to vary somewhat across ethnic groups.⁶
         
      3. Hormone replacement therapy. In order to evaluate a perimenopausal or menopausal patient’s bleeding pattern and associated symptoms, it is important to know whether she is taking hormone replacement therapy, and if so, the regimen of estrogen, or estrogen and progesterone that she is taking. It is also helpful to know whether she is consuming soy products in her diet or in tablet form, and whether she is taking herbal preparations.
         
      
      
   
   
4. Contraception.
   1. Current method of contraception. If the patient is premenopausal and sexually active with men, it is important to ask about her current method of contraception and whether she is satisfied with this method or desires a change.
      
   2. Past methods of contraception. A list of past methods of contraception should be obtained, including when they were used, any complications associated with their use, and why the patient discontinued their use.
      
   
   
5. Cervical and vaginal cytology. The date and result of the most patient’s most recent cervical smear (Pap smear) should be recorded. It is important to ask whether the patient has had a history of abnormal cervical smears, and if so, what was undertaken in the way of evaluation and treatment. It is helpful to know at what frequency the patient has undergone cytologic screening in the past.
   
6. Infection.
   1. History of sexually transmitted infections. Currently, approximately 20 infections are known to be transmitted by sexual contact. These include bacterial infections caused by Neisseria gonorrhea, Chlamydia trachomatis, Treponema pallidum (syphilis), Hemophilus ducreyii (chancroid), and Calymmatobacterium granulomatis (donovanosis), viral infections caused by herpes simplex, the human papillomavirus virus (HPV), the hepatitis B and hepatitis C viruses, and the human immunodeficiency virus, as well as parasites such as Trichomonas vaginalis. Patients should be asked about whether they have had any of these infections and if so, the treatment that was rendered.
      
   2. History of monilial vulvo-vaginitis or bacterial vaginosis.
      
   3. History of salpingo-oophoritis (pelvic inflammatory disease).
      
   
   
7. Fertility/infertility. It is important to assess whether patients have a desire for future fertility, and if so, whether they have had any difficulty conceiving in the past. Any prior evaluation or treatment for infertility should be described.
   
8. Sexual history. The sexual history includes an assessment of the type of sexual activity that the patient is having and whether the patient has any questions or concerns about this. It is appropriate to ask whether the patient has any concerns about libido, and, if she is having intercourse, whether she experiences dyspareunia. It is important to ask the patient whether she has had a history of sexual abuse or sexual assault.
   
9. Obstetric history. Patients should be asked to list all pregnancies and the outcome of each, with attention to whether the pregnancy was intrauterine or ectopic. If the pregnancy ended in abortion it is important to know whether this was spontaneous or induced, and whether dilation and curettage was performed. The treatment of molar pregnancies should be recorded. For pregnancies lasting more than 20 weeks, the gestational age at delivery, route of delivery, type of anesthesia for delivery, weight of the fetus at delivery, any maternal, fetal, or neonatal complications, and whether the child is currently living should be recorded.  Inquire about history of group B streptococcal (GBS) colonization in previous pregnancies or a history of GBS disease in the neonate. 
   
10. Past medical history. The patient should be asked to list any major medical illnesses that she has had, or has currently, and any hospitalizations.
    
11. Past surgical history. The patient should be asked to list all gynecologic and nongynecologic surgical procedures that she has undergone, the dates of these procedures, and any complications that she experienced.
    
12. Medications and allergies. The patient should be asked to list all medications that she is currently taking, including over-the-counter medications, herbal medications, and vitamins. Allergic reactions to medications should be recorded, including the type of reaction experienced.
    
13. Family history. Illnesses experienced by family members should be listed, including cancer, diabetes mellitus, cardiovascular diseases, hyperlipidemia, osteoporosis, and other hereditary disorders. It is helpful to know which family members are affected, and the age at which each diagnosis was made.
    
14. Social history. Pertinent aspects of a patient’s social history include her marital or relationship status, level of education, and occupation.
    
15. Review of systems.
    1. Abdomino-pelvic.
       1. Gynecologic.
          1. Abnormalities of uterine bleeding. The gynecologic review of systems for the premenopausal woman includes an assessment of abnormalities of intermenstrual interval and menstrual flow, including a lack of bleeding (amenorrhea), short or long intermenstrual interval (polymenorrhea or oligomenorrhea), excessive or prolonged menstrual flow (menorrhagia), and intermenstrual bleeding (metrorrhagia). The postmenopausal patient should be asked about the presence of any bleeding (postmenopausal bleeding). All women should be asked about postcoital bleeding.
             
          2. Pelvic pain. Pelvic pain should be characterized as cyclic (predictably occurring at certain times of the menstrual cycle such as with ovulation or with menses), or noncyclic. The mode of onset, character, location, radiation, severity, duration, exacerbating and relieving factors, whether there is pain with intercourse (dyspareunia), and any associated symptoms should be recorded. Given that the reproductive organs are in close proximity to the urinary tract and the gastrointestinal tract, pain that is perceived in the pelvis may be related to one of these organ systems. Consequently, urinary and gastrointestinal symptoms should be assessed (see below). Pain associated with the abdominal wall musculature, fascia, or nerves often increases with activities such as lifting.
             
          3. Symptoms of uterine or vaginal prolapse. Patients with genital tract prolapse (uterine prolapse, cystocele or cystourethrocele, or rectocele) may be aware of a sense of pelvic pressure or the presence of tissue at or protruding through the introitus. Patients with a cystocele or cystourethrocele may note urinary incontinence with activities that increase intra-abdominal pressure such as coughing and sneezing, or with athletic activities such as running. Patients with a rectocele may note constipation and may need to splint (place pressure on the perineum or on the posterior vaginal wall) in order to defecate.
             
          4. Vaginal discharge. The patient should be asked about a change or increase in vaginal discharge, and if present, whether there are any associated symptoms such as vulvo-vaginal pruritus or burning, and malodor.
             
          5. Vaginal dryness. Dryness or decreased vaginal lubrication may be noted when estrogen levels are low postpartum or at the time of menopause, or may be associated with disorders such as Sjögren’s syndrome.
             
          6. Vulvar lesions. Inquiries should be made about the presence of raised or ulcerative vulvar lesions. The patient should be asked about any changes in the appearance of lesions that have been present for a period of time.
             
          7. Vulvar pruritus or burning. The patient should be asked about symptoms of vulvar pruritus and burning, which may be symptoms of vulvo-vaginitis, a contact dermatitis, or vestibulitis. These symptoms may also be noted with conditions such as lichen simplex, lichen sclerosus et atrophicus, vulvar intraepithelial neoplasia, and carcinoma of the vulva.
             
          8. Sexual dysfunction. Symptoms of sexual dysfunction fall into several categories and include abnormalities of arousal (decreased libido), pain with intercourse (dyspareunia), and inability to achieve orgasm (anorgasmia).
             
          
          
       2. Urinary symptoms.
          1. Symptoms of urinary tract infection include dysuria, urinary frequency, urinary urgency, and hematuria.
             
          2. Symptoms of urolithiasis include flank pain and hematuria.
             
          3. Urinary incontinence. Urinary incontinence may be experienced with a variety of conditions including urinary tract infections, congenital anomalies, vesico- or uretero-vaginal fistulae, cystocele or cystourethrocele, detrusor instability, and various neurologic conditions. It is helpful to know when the incontinence characteristically occurs (continuously, with activities such as coughing, sneezing, or running, on the way to the bathroom, or with stimuli such as running water or jingling keys).
             
          4. Urinary retention. Inability to void may caused by compression of the urethra (e.g., by a leiomyoma or periurethral edema) or occur after pelvic surgical procedures. Incomplete emptying of the bladder may occur in patients with a cystocele.
             
          
          
       3. Gastrointestinal symptoms. Patients should be asked about symptoms of nausea, vomiting, constipation, diarrhea, blood with the stools, pain with defecation, the need to splint to defecate, and incontinence of stool or flatus. Patients with the irritable bowel syndrome often report alternating symptoms of constipation and diarrhea, associated with crampy abdominal pain. Incontinence of stool or flatus may be noted after injuries to the anal sphincter during childbirth, or in association with anal or rectovaginal fistulae.
          
       
       
    2. Breast. Patients should be asked about the presence of breast masses, discharge, pain, and a prior history of breast biopsy. When a mass is noted, it is helpful to know how long this has been present, and whether it varies in size with the menstrual cycle. Breast discharge should be characterized as unilateral or bilateral, and the color noted. Galactorrhea (a milky discharge) may be unilateral or bilateral, and can be seen with hyperprolactinemia, hypothyroidism, and with the use of certain medications, including oral contraceptives. A unilateral bloody discharge is typically seen with an intraductal papilloma. A unilateral greenish discharge may be seen with ductal ectasia. Mild cyclic pain is common, related to the hormonal changes of the menstrual cycle. More prolonged or severe pain may be associated with fibrocystic changes.
       
    3. Other. A review of symptoms related to other organ systems should be undertaken in order to assess for nongynecologic conditions that warrant evaluation and treatment, and because many nongynecologic conditions have associated gynecologic symptoms. Symptoms that are particularly likely to be associated with gynecologic conditions include a history of significant weight loss or weight gain, excess hair growth (hirsutism), and symptoms of depression.
       
    
    
16. Health maintenance. A history of general health habits should be elicited, including an assessment of tobacco use, alcohol intake, and the use of illicit substances. It is important to ask about the patient’s diet, including calcium intake, folic acid intake, and whether she exercises regularly. A preventive care history includes questions about habits such as seatbelt use, helmet use for sports activities, the use of sunscreen, whether there are working smoke detectors in the home, and whether there are firearms in the home. The health maintenance history includes the dates and results of screening tests such as mammography, bone densitometry, and sigmoidoscopy or colonoscopy. Various medical organizations have made recommendations for screening asymptomatic individuals with mammography, stool hemoccult testing and sigmoidoscopy, colonoscopy, or barium enema, as well as screening for hyperlipidemia, hypothyroidism, and diabetes mellitus. The United States Preventive Services Task Force evaluates the strength of research to support such recommendations, and periodically publishes their recommendations. The health maintenance history also includes a history of immunity to infectious diseases such as rubella and varicella, and whether vaccines have been administered for high risk human papillomavirus (HPV,)  hepatitis B, tetanus and diphtheria, pertussis, the pneumococcus, and influenza.
    

General Considerations

The gynecologic examination includes examination of the breasts, abdomen, and pelvic organs. However, many women see their gynecologist as their primary health care provider, and will seek a complete physical examination when they come into the office for their gynecologic evaluation. In addition, many gynecologic problems have symptoms that involve other organ systems. Consequently, the gynecologist must be prepared to perform a general physical examination competently.

Timing and Frequency of Examinations

Genital examinations are often part of routine well-baby and well-child pediatric care. A genital examination should be performed if a child has a symptom in the genital area (e.g., vulvar itching) or there any concerns about a developmental problem (e.g., early development of secondary sexual characteristics).

Adolescents often benefit from a visit to a primary care provider to discuss any health care concerns they may have, and to ensure that appropriate preventive primary care is administered (e.g., immunizations, blood pressure checks, and general physical examinations, as well as counseling regarding smoking and safety habits). This visit will hopefully pave the way for a relaxed relationship between the adolescent and the provider when it is time for the first pelvic examination. A pelvic examination is recommended at age 18 or with onset of sexual activity, whichever occurs first.

Hormonal contraception can be provided safely based on a careful review of a patient’s medical history and measurement of the patient’s blood pressure⁷. Unless the patient has symptoms, the pelvic and breast examinations and screening for cervical neoplasia and sexually transmitted diseases can wait until a subsequent visit. Especially in the adolescent population it is important to not always require tests and procedures prior to an initial prescription for hormonal contraception. These patients may be reluctant to undergo examination, and an unintended pregnancy may result, with all of its inherent risks.⁸

The recommended interval for examinations during the reproductive years varies with a woman’s health and risk status. Women should undergo annual cytologic screening for cervical intraepithelial neoplasia beginning at age 21 or 3 years after the onset of sexual activity, whichever comes first. Beginning at age 30, cervical smears may be obtained every 3 years in the selected low-risk patient. Women at risk for cervical intraepithelial neoplasia should continue to have annual cervical cytologic screening. Screening may be discontinued at age 65 if there is no history of abnormal smears or HPV, or at any age after hysterectomy for benign disease if the patient has not previously had abnormal cervical cytology. Whether or not a smear for cervical cytology is performed, many women benefit from annual well-woman examinations that include assessments of height, weight, and blood pressure, as well as examinations of the thyroid and breasts, and the other components of the pelvic examination. Women receiving contraceptive hormone therapy should be assessed at least annually.⁹

Women’s Experiences and Gynecologic Examinations

Women are often apprehensive about undergoing a pelvic examination. A previous examination that was not a good experience contributes to even more anxiety. Women feel vulnerable and exposed during this examination. The positioning necessary for the examination creates a significant imbalance of power in the patient/provider interaction, and carries sexual connotations for many women. The practitioner may unintentionally use words or actions that the patient may find threatening or offensive. The provider may feel that the interaction was satisfactory, but the patient may feel completely the opposite. On the other hand, if a woman is at ease with the examination experience, she is more likely to spontaneously contribute information that may prove valuable in her evaluation.

Patients will have a more positive experience if they feel that adequate time was allowed for their visit and that the practitioner was prepared to answer questions. A study of adolescents' views about their first pelvic exams showed that a positive experience was associated with a sense of control during the examination.  This depended on a thorough explanation of the procedure before it was undertaken, allowing the patient to participate in decision making, and receiving assurance that the exam could be discontinued at any point.¹⁰ 

Most patients indicate that they are more comfortable if the provider talks to them during the examination. Silence can cause the patient to think that something is wrong. If the provider explains what is coming next, maintains eye contact as much as possible, and comments on findings, the patient is more likely to feel relaxed and safe. Some women will feel more at ease if they are allowed to view their own anatomy by using a hand-held mirror during the examination. Warming instruments and trying to be as gentle as possible during the examination are good habits. Some women desire an attendant to be present during their examination but many prefer not. Ideally a woman is empowered to choose whether a chaperone is present during her examination. There are situations where the provider must have a chaperone present for examinations due to liability or security concerns. If so, this should be explained to the patient.¹¹

The examiner should be conscious of patient behaviors that suggest anxiety during the examination. These include holding hands, covering or shutting the eyes, placing hands on shoulders, hands covering the pelvis, placing hands on legs, or hands holding the table. Such behaviors signal the need for a more careful or respectful approach. The examiner may suggest techniques to promote relaxation, such as slow exhalation, and may provide more information about what is coming next in the examination and what the patient may feel. The provider should endeavor to individualize the consultation and examination style so that it meets the needs of the patient.^{12, 13}

Patient Positioning

The pelvic examination is usually performed with the patient lying supine on an office examination table with the knees flexed, and with the feet in supporting stirrups. Some examination tables have supports that fit behind the knees instead. Electric examination tables are available, with which the patient’s head can be lowered from a seated position; these can be advantageous for the elderly or for patients with mobility problems. The patient’s head is often elevated with a pillow, or by slightly elevating the head of the examining table. This allows better eye contact between the practitioner and the patient and may help the patient to relax.

Equipment

In order to perform a pelvic examination the practitioner should have a good light source, non-sterile gloves, a speculum of proper size, and water-soluble lubricant. A variety of the most commonly used specula, materials with which to obtain cervical cytologic samples, fixative, and large cotton-tipped swabs should be immediately available in the examination room. Swabs and transport media for the collection of samples for Neisseria gonorrhea, Chlamydia trachomatis, and saline wet mounts, as well as pH paper should be on hand.

Performance of the Gynecologic Examination

BREAST EXAMINATION.

The breast examination is included in a routine gynecologic examination. The technique for breast examination is outlined in another chapter. The health care provider should instruct the patient about how to undertake a breast self-examination.

EXAMINATION OF THE ABDOMEN.

Examination of the abdomen is likewise included in the general gynecologic examination. The abdomen should be examined utilizing the standard techniques of inspection, auscultation, percussion, and palpation. The contour of the abdomen and appearance of the skin should be noted. Auscultation aids in the assessment of intestinal peristalsis (bowel sounds) and in the detection of abdominal bruits. Percussion is utilized to determine the size of abdominal and pelvic structures such as the liver and masses, as well as any abdominal fluid collection such as ascites. Percussion is also useful for assessing abdominal and pelvic tenderness. Finally, palpation is performed to assess for tenderness, organ enlargement, and masses.

If tenderness is noted, the examiner should assess for involuntary guarding and rebound tenderness. In addition, it may be helpful to ask the patient to raise her head from the examination table so as to flex the rectus abdominus muscles. Tenderness localized to the abdominal wall will typically worsen with this maneuver.

PELVIC EXAMINATION.

External genitalia. There can be a tendency to focus on insertion of the speculum for obtaining cytology specimens. The examiner should always remember to inspect the external genitalia first for normalcy of appearance and hair distribution. Any lesions or developmental abnormalities are noted. Hormonal abnormalities may cause changes in the external genitalia, such as clitoromegaly. States accompanied by low levels of estrogen are associated with atrophy of the mucosae. The skin should be inspected and palpated for superficial and subcutaneous lesions.

The Bartholin’s (greater vestibular) gland openings are located at approximately the 5 and 7 o’clock positions, just lateral and posterior to the vaginal orifice. They may be visible, but the normal Bartholin’s gland is not palpable. The Skene’s (paraurethral) glands are likewise not palpable in the healthy state. The urethra is inspected for the presence of caruncle and other findings.

Vagina and cervix. The vagina is inspected with the use of a speculum. There are many different sizes of specula varying both in length and width. The largest size that is comfortable allows the best visualization. The examiner should be ready to switch to a narrower or shorter speculum if the patient is uncomfortable with the size selected.

Speculum insertion is more comfortable if the instrument is warmed. The speculum can be moistened with warm water, which does not interfere with the results of cultures, cytology, or wet mount. Lubricants can alter the results of these studies, and should only be used if none of these studies will be undertaken. The examiner may exert gentle downward (posterior) pressure at the introitus with one or two fingers before inserting the speculum. The speculum blades can be inserted at an oblique to horizontal angle but should never be inserted vertically so as to avoid the sensitive suburethral area. Utilizing steady posterior pressure, the blades are advanced to the vaginal apex. The speculum can then be gently opened to expose the cervix. Sometimes a gentle rocking motion will allow the cervix to come into view.

The vagina and cervix are inspected for lesions. The vagina is also inspected for the presence or absence of rugae to assess the level of estrogen present. The examiner assesses any vaginal discharge that is present for normalcy in appearance, color, consistency, and odor. Physiologic vaginal discharge is scant in amount, flocculent, and white. The pH of the normal vagina is less than 4.2. Normal cervical mucus is clear.

Samples are taken for cervical or vaginal cytology. Cervical cytology should include a sample from the ectocervix taken with a spatula and a sample from the endocervical canal taken with a brush. Cervical cytology should be fixed immediately after obtaining the sample in order to avoid air-drying artifact. In the absence of a cervix, a spatula can be used to obtain a smear from the vaginal cuff.  If a liquid-based technique is employed for cytology, a plastic "broom" is used to collect the specimen. 

If indicated, samples are then obtained for cervical cultures and vaginal wet mount. Swabs used to collect samples for cervical cultures should be left in the endocervical canal for 15 to 30 seconds. A swab of vaginal sidewall secretions is placed in normal saline for direct microscopic examination (wet mount) to evaluate for vaginitis. The pH of vaginal secretions can be assessed with pH paper.

The vagina is inspected for lesions as the speculum is withdrawn, again with care to avoid anterior discomfort.

If indicated, the examiner now proceeds to evaluate vaginal wall relaxation and uterine prolapse. This can be done by removing the anterior blade of the speculum and using the posterior blade as a retractor, or by using one’s hand as the posterior retractor. The integrity of the vaginal walls is examined throughout 360 degrees, and at the apex. The patient may be asked to increase intra-abdominal pressure with the Valsalva maneuver to accentuate the findings. Examination can also be performed with the patient standing to better assess the integrity of pelvic support when the patient is upright.

Bimanual examination. Typically, the bimanual examination is performed with the aid of lubricating jelly. The examiner usually places two fingers in the vagina and uses the opposite hand to palpate the lower abdomen. Sometimes only a single digit is placed in the vagina for patient comfort. The examiner palpates the vagina, cervix, uterus, adnexa, and surrounding structures by elevating structures with the vaginal hand and palpating in a downward fashion with the abdominal hand. Tenderness with lateral movement of the cervix (cervical motion tenderness) is assessed, as well as the size, mobility, position and contour of the uterus. The adnexa are palpated. Any masses that are appreciated are assessed for size, location, mobility, tenderness, and contour. The posterior cul-de-sac and utero-sacral ligaments are checked for nodularity and masses.

Rectovaginal examination. Some believe that a rectal examination is an important element of every gynecologic examination. Others feel that it is only necessary in the age group for whom colon cancer screening is recommended for routine preventative health care (beginning at age 50). A reasonable middle-ground approach involves including a rectovaginal examination when the bimanual examination alone has been insufficient to fully assess the pelvic anatomy, when one suspects endometriosis or a pelvic mass, or if there are symptoms attributable to the rectal area.

The examiner inserts an index finger into the vagina, and utilizing lubricant, inserts the middle finger into the rectum. The examiner palpates the rectovaginal septum and again places the opposite hand on the patient’s lower abdomen to palpate the previously assessed structures. The uterosacral ligaments may be palpated more easily with the rectovaginal examination than the bimanual examination. The rectum is assessed for masses.