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- Physical Examination
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General Gynecologic Evaluation
Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation.
Gynecologic evaluation may be necessary to assess a specific problem such as pelvic pain, vaginal bleeding, or vaginal discharge (see also Pelvic Pain). Women also need routine gynecologic evaluations, which may be provided by a gynecologist, an internist, or a family practitioner; evaluations are recommended every year for all women who are sexually active or > 18 yr. Many women expect their gynecologist to provide general as well as gynecologic health care. Obstetric evaluation focuses on issues related to pregnancy (see Approach to the Pregnant Woman and Prenatal Care).
Gynecologic history consists of a description of the problem prompting the visit (chief complaint, history of present illness); menstrual, obstetric, and sexual history; and history of gynecologic symptoms, disorders, and treatments.
Current symptoms are explored using open-ended questions followed by specific questions about the following:
Patients of reproductive age are asked about symptoms of pregnancy (eg, morning sickness, breast tenderness, delayed menses).
Menstrual history includes the following:
Usually, menstrual fluid is medium or dark red, and flow lasts for 5 (± 2) days, with 21 to 35 days between menses; average blood loss is 30 mL (range, 13 to 80 mL), with the most bleeding on the 2nd day. A saturated pad or tampon absorbs 5 to 15 mL. Cramping is common on the day before and on the first day of menses. Vaginal bleeding that is painless, scant, and dark, is abnormally brief or prolonged, or occurs at irregular intervals suggests absence of ovulation (anovulation).
Obstetric history (see Evaluation of the Obstetric Patient : History) includes dates and outcomes of all pregnancies and previous ectopic or molar pregnancies.
Sexual history should be obtained in a professional and nonjudgmental way and includes the following:
Past gynecologic history includes questions about previous gynecologic symptoms (eg, pain), signs (eg, vaginal bleeding, discharge), and known diagnoses, as well the results of any testing.
Screening for domestic violence should be routine. Methods include self-administered questionnaires and a directed interview by a staff member or physician. In patients who do not admit to experiencing abuse, findings that suggest past abuse include the following:
The examiner should explain the examination, which includes breasts (see Breast examination), abdomen, and pelvis, to the patient.
For the pelvic examination, the patient lies supine on an examination table with her legs in stirrups and is usually draped. A chaperone is usually required, particularly when the examiner is male, and may also provide assistance. The pubic area and hair are inspected for lesions, folliculitis, and lice. The perineum is inspected for redness, swelling, excoriations, abnormal pigmentation, and lesions (eg, ulcers, pustules, nodules, warts, tumors). Structural abnormalities due to congenital malformations or female genital mutilation are noted. A vaginal opening that is < 3 cm may indicate infibulation, a severe form of genital mutilation (see Female Genital Mutilation ).
Next, the introitus is palpated between the thumb and index finger for cysts or abscesses in Bartholin glands. While spreading the labia and asking the patient to bear down, the examiner checks the vaginal opening for signs of pelvic relaxation: an anterior bulge (suggesting cystocele), a posterior bulge (suggesting rectocele), and displacement of the cervix toward the introitus (suggesting prolapsed uterus—see Uterine and Vaginal Prolapse).
Before speculum and bimanual examination, the patient is asked to relax her legs and hips and breathe deeply.
The speculum is sometimes kept warm with a heating pad and may be moistened or lubricated before insertion, particularly when the vagina is dry. If a Papanicolaou (Pap) test or cervical culture is planned, the speculum is rinsed with warm water; lubricants have traditionally been avoided, but current-generation water-based lubricants can be used to increase patient comfort. A gloved finger is inserted into the vagina to determine the position of the cervix. Then, the speculum is inserted with the blades nearly in the vertical plane (at about 1 and 7 o’clock) while widening the vagina by pressing 2 fingers on the posterior vaginal wall (perineal body). The speculum is fully inserted toward the cervix, then rotated so that the handle is down, and gently opened; it is pulled back as needed to visualize the cervix. When the cervix is seen, the blades are positioned so that the posterior blade is deeper than the cervix (in the posterior fornix) and the anterior blade is allowed to rise gently and rest anterior to the cervix (in the anterior fornix). The examiner should take care to open the anterior blade slowly and gently and not to pinch the labia or perineum as the speculum is opened. Normally, the cervix is pink and shiny, and there is no discharge.
A specimen for the Pap test is taken from the endocervix and external cervix with a brush and plastic spatula or with a cervical sampler that can simultaneously collect cells from the cervical canal and the transition zone; the specimen is rinsed in a liquid, producing a cell suspension to be analyzed for cancerous cells and human papillomavirus. Specimens for detection of sexually transmitted diseases (STDs) are taken from the endocervix. The speculum is withdrawn, taking care not to pinch the labia with the speculum blades.
The index and middle fingers of the dominant hand are inserted into the vagina to just below the cervix. The other hand is placed just above the pubic symphysis and gently presses down to determine the size, position, and consistency of the uterus and, if possible, the ovaries. Normally, the uterus is about 6 cm by 4 cm and tilts anteriorly (anteversion), but it may tilt posteriorly (retroversion) to various degrees. The uterus may also be bent at an angle anteriorly (anteflexion) or posteriorly (retroflexion). The uterus is movable and smooth; irregularity suggests uterine fibroids (leiomyomas). Normally, the ovaries are about 2 cm by 3 cm in young women and are not palpable in postmenopausal women. With ovarian palpation, mild nausea and tenderness are normal. Significant pain when the cervix is gently moved from side to side (cervical motion tenderness) suggests pelvic inflammation.
The examination should be adjusted according to children’s psychosexual development and is usually limited to inspection of the external genitals. Young children can be examined on their mother’s lap. Older children can be examined in the knee-chest position or on their side with one knee drawn up to their chest. Vaginal discharge can be collected, examined, and cultured.
Sometimes a small catheter attached to a syringe of saline is used to obtain washings from the vagina. If cervical examination is required, a fiberoptic vaginoscope, cystoscope, or flexible hysteroscope with saline lavage should be used.
In children, pelvic masses may be palpable in the abdomen.
Testing is guided by the symptoms present.
Most women who are of reproductive age and have gynecologic symptoms are tested for pregnancy (see Physiology of Pregnancy : Diagnosis). Urine assays of the β subunit of human chorionic gonadotropin (β-hCG) are specific and highly sensitive; they become positive within about 1 wk of conception. Serum assays are specific and even more sensitive.
Specimens of cervical cells taken for the Pap test are examined for signs of cervical cancer; the examination may also detect uterine cancer and human papillomavirus. Pap tests are done routinely for most of a woman’s life (see Cervical Cancer : Prevention).
Culture or molecular methods (eg, PCR) are used to analyze specimens for specific STD organisms (eg, Neisseria gonorrhoeae, Chlamydia trachomatis) if patients have symptoms or risk factors; in some practices, such analysis is always done. (See also the US Preventive Services Task Force practice guideline Screening for gonorrhea and the US Preventive Services Task Force practice guideline Screening for chlamydial infection .)
Bedside inspection of a cervical mucus specimen by a trained examiner can provide information about the menstrual cycle and hormone states; this information may help in assessment of infertility and time of ovulation. The specimen is placed on a slide, allowed to dry, and assessed for degree of microscopic crystallization (ferning—see Cervix), which reflects levels of circulating estrogens . Just before ovulation, cervical mucus is clear and copious with abundant ferning because estrogen levels are high. Just after ovulation, cervical mucus is thick and ferns little.
Imaging of suspected masses and other lesions usually involves ultrasonography, which may be done in the office; both transvaginal and transabdominal probes are used. MRI is highly specific but expensive. CT is usually less desirable because it is somewhat less accurate, involves significant radiation exposure, and often requires a radiopaque agent.
This procedure is done if women > 35 have unexplained vaginal bleeding. A thin, flexible, plastic suction curette is inserted through the cervix to the level of the uterine fundus; dilation is often not required. Suction is applied to the device, which is turned 360° and moved up and down a few times to sample different parts of the endometrial cavity. Sometimes the uterus must be stabilized with a cervical tenaculum.
Pituitary and hypothalamic hormones (see Overview of the Endocrine System : Hypothalamic-Pituitary Relationships) and ovarian hormones (see Menstrual Cycle) may be measured when infertility is evaluated or when abnormalities are suspected.
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