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During a visit for gynecologic care, doctors ask questions and do a physical examination.
Gynecologic History
A gynecologic evaluation starts with a series of questions related to menstruation and reproductive function. These questions usually focus on the reason for the visit to the doctor's office. The answers form the gynecologic history. A complete gynecologic history includes the following information:
Questions about abnormal bleeding—too much, too little, or between menstrual periods—are included.
A doctor usually asks about sexual activities to assess the risk of gynecologic infections, injuries, and pregnancy and to determine whether a woman has any sexual problems. A woman is asked whether she uses or wants to use birth control and whether she is interested in counseling or other information.
The doctor may ask the woman whether she has pain, cramps, or headaches during menstrual periods. She is asked whether she has pain during intercourse, in the middle of the menstrual cycle (which may indicate that the pain coincides with ovulation), or under other circumstances. If she has pain, she is asked how severe the pain is and what provides relief. The doctor also asks about breast problems, such as pain, lumps, areas of tenderness or redness, and discharge from the nipples. The woman is asked whether she examines her breasts, how often, and whether she needs any instruction on technique.
The doctor reviews the woman's history of past gynecologic disorders and usually obtains a general medical and surgical history that includes previous health problems. The doctor reviews all the drugs a woman is taking, including prescription and nonprescription drugs, illicit drugs, tobacco, and alcohol, because many of them affect gynecologic function. The woman is asked about mental, physical, or sexual abuse in the present and the past. Some questions about urination are asked to find out whether the woman has a urinary tract infection or has problems with leakage of urine (incontinence).
Gynecologic Examination
If a woman has any questions or fears about the gynecologic examination, she should talk with the doctor beforehand about her concerns. If any part of the examination causes pain, the woman should let the doctor know. The woman should empty her bladder before the physical examination and may be asked to collect a urine sample for analysis.
The doctor usually feels the neck and the thyroid gland to check for lumps and abnormalities. An enlarged, overactive thyroid gland can cause menstrual abnormalities. The doctor examines the skin for signs of acne, excessive hairiness (hirsutism), spots, and growths.
A breast examination is typically done before the pelvic examination. With the woman sitting, the doctor inspects the breasts for irregularities, dimpling, tightened skin, lumps, and a discharge. The woman then sits or lies down, with her arms above her head, while the doctor feels (palpates) each breast with a flat hand and examines each armpit for enlarged lymph nodes and for lumps and abnormalities. While performing the examination, the doctor may review the technique for breast self-examination with the woman (see Breast Disorders: How to Do a Breast Self-Examination ).
The doctor may use a stethoscope to listen for activity of the intestine and to check for abnormal noises made by blood flowing through narrowed blood vessels. The doctor may tap areas of the abdomen with the fingers. The doctor gently feels the entire abdomen to check for abnormal growths or enlarged organs, especially the liver and spleen. Although the woman may experience some discomfort when the doctor presses deeply, the examination should not be painful.
During the pelvic examination, the woman lies on her back with her hips and knees bent and her buttocks moved to the edge of the examining table. Special pelvic examination tables have heel stirrups that help a woman maintain this position. If a woman wants to observe the pelvic examination, she should tell the doctor, who can provide a mirror. The doctor may explain the examination or review the findings before, during, or after the examination. For the examination, the doctor first inspects the external genital area and notes the distribution of hair and any abnormalities, discoloration, discharge, or inflammation. This examination may detect no abnormalities or may give clues to hormonal problems, cancer, infections, injury, or sexual abuse.
The doctor spreads the tissues around the opening of the vagina (labia) and examines the opening. Using a speculum (a metal or plastic instrument that spreads the walls of the vagina apart), the doctor examines the deeper areas of the vagina and the cervix. The cervix is examined closely for signs of irritation or cancer. The doctor may use a swab, brush, or small plastic spatula to obtain a sample for testing, usually a Papanicolaou (Pap) test or a variation of it. The doctor checks for protrusion of the bladder, rectum, or intestine into the vagina (see Pelvic Floor Disorders).
After removing the speculum, the doctor feels the vaginal wall to determine its strength and support. The doctor also feels for growths or tender areas within the vagina. After inserting the index and middle fingers of one gloved hand into the vagina, the doctor places the fingers of the other hand on the lower abdomen above the pubic bone. Between the two hands, the uterus can usually be felt as a pear-shaped, smooth, firm structure, and its position, size, consistency, and degree of tenderness (if any) can be determined. Then the doctor attempts to feel the ovaries by moving the hand on the abdomen more to the side and exerting slightly more pressure. More pressure is required because the ovaries are small and much more difficult to feel than the uterus. The woman may find this part of the examination to be slightly uncomfortable, but it should not be painful. The doctor determines how large the ovaries are and whether they are tender.
A rectovaginal examination may be done. The doctor inserts the index finger into the vagina and the middle finger into the rectum to examine the back wall of the vagina for abnormal growths or thickness. In addition, the doctor can examine the rectum for hemorrhoids, fissures, polyps, and lumps. A small sample of stool can be obtained with a gloved finger and tested for unseen (occult) blood. A woman may be given a take-home kit to test for occult blood in the stool.
Last full review/revision March 2007 by Paula J. Adams Hillard, MD
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