Gynecologic diagnostic tests and procedures help identify vaginal infections (eg, trichomoniasis, bacterial vaginosis, yeast infection) and cancer and provide information on menstrual cycle and hormone levels.
Pregnancy Testing
Women who are of reproductive age may be tested for pregnancy if they are trying to become pregnant, are concerned about an unintended pregnancy, or have gynecologic symptoms. Quantitative serum hCG measurement is preferred when ectopic pregnancy, pregnancy of unknown location, or early pregnancy complications are suspected.
A serum test of the beta-subunit of human chorionic gonadotropin (hCG) is the most sensitive pregnancy test. It can detect pregnancy as early as just before or after the missed menstrual period. An hCG level ≤ 5 mIU/mL is undetectable with the assays used at most laboratories and is considered a negative pregnancy test result by most of the labs. Some assays can detect levels as low as 1 or 2 mIU/mL.
Urine pregnancy tests also measure beta-hCG, but they are less sensitive than serum tests. Urine tests typically detect beta-hCG levels of 12 to 50 mIU/mL (1). Also, the hCG concentration is lower in urine than in serum. Urine tests are typically positive at about 1 week after the first day of the missed menstrual period. On the first day after the missed period, approximately half of pregnant women will have a negative test result due to very early pregnancy or, rarely, because of the high-dose hook effect.
Home urine pregnancy test sensitivity and specificity can be variable depending upon the specific test kit, user's technique, and interpretation. Thus, any positive home pregnancy test should be confirmed by either a laboratory urine or serum pregnancy test. Urine tests remain appropriate for many clinical settings, but a negative urine test does not exclude early pregnancy if clinical suspicion is high (2).
Pregnancy testing references
1. Cole LA. The hCG assay or pregnancy test. Clin Chem Lab Med. 2012;50(4):617-630. doi:10.1515/CCLM.2011.808
2. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice. Opinion No. 755: Well-woman visit. Obstet Gynecol. 2018;132(4):p e181-e186. doi: 10.1097/AOG.0000000000002897
Testing for Infection
Testing for vaginitis
Tests to evaluate for vaginitis include
Vaginal pH: Tested with pH paper (normal vaginal pH is 3.8 to 4.2; increased [more alkaline] pH is found in bacterial vaginosis and trichomoniasis)
Saline wet mount: Prepared with 0.9% sodium chloride; findings can indicate bacterial vaginosis (clue cells, polymorphonuclear leukocytes) or trichomoniasis (motile trichomonads); wet mount microscopy has limited sensitivity compared with molecular testing
Potassium hydroxide (KOH) wet mount: Prepared with 10% potassium hydroxide; findings can indicate bacterial vaginosis (positive whiff test) or candidiasis (hyphae)
Nucleic acid amplification testing (NAAT): NAAT vaginitis panels are increasingly used because of higher sensitivity than microscopy alone, especially when office microscopy is unavailable or inconclusive.
Testing for sexually transmitted infections
Tests for sexually transmitted infections of the female genital tract include the following (see CDC: Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources):
NAAT of a sample from the cervix, vagina, or urethra or a urine sample to test for certain local infections (eg, with Trichomonas, Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium); the preferred specimen varies depending upon organism, symptoms, and physical examination findings (eg, purulent cervical discharge should be evaluated with a sample of the discharge). NAAT is also used to test a sample from a suspicious lesion for genital herpes simplex virus infection. NAAT is also used for detection of macrolide resistant to guide treatment of M. genitalium. Routine screening for M. genitalium is not recommended in asymptomatic individuals.
Culture is used to test antimicrobial susceptibilities in N. gonorrhoeae infection in cases of suspected cephalosporin-resistant gonorrhea, treatment failure, or test of cure for pharyngeal infection.
Blood tests for systemic infections (HIV, hepatitis B or C, or syphilis)
Gram stain and culture are rarely used for diagnosis of STIs, unless NAATs are not available.
Cervical Cancer Testing
Cervical cancer screening
Routine cervical cancer screening effectively detects preinvasive and early-stage disease and decreases cervical cancer incidence and mortality rates.
Two types of screening tests for cervical abnormalities are used:
Tests for high-risk human papillomavirus (HPV) genotypes
Pap test (cervical cytology)
Recommendations vary regarding the choice of screening test, frequency, and age to begin and discontinue screening (see table ). The American College of Obstetricians and Gynecologists (ACOG) follows the recommendations of the United States Preventive Services Task Force (USPSTF) (1, 2):
21 years: Begin cervical cancer screening
21 to 29 years: Cervical cytology every 3 years (alternatively, average-risk patients ≥ 25 years may begin screening with primary HPV testing alone every 5 years)
≥ 30 to 65 years: Cervical cytology alone every 3 years; or HPV test alone every 5 years; or cytology and HPV co-testing every 5 years
> 65 years: Discontinue screening if patient has adequate negative screening for the prior 10 years; for women without documentation of prior screening, continued screening until criteria for stopping are met
For women with certain indications (eg, women who have HIV infection, are immunosuppressed, have previous abnormal cervical cancer screening results), more frequent screening may be required.
If patients have had a total hysterectomy (cervix and uterus removed) and have no history of cervical cancer or high-grade cervical intraepithelial neoplasia, further cervical cancer screening is not indicated.
Abnormal results of cervical cancer screening tests require further evaluation, as appropriate. Management of abnormal screening results should follow the risk-based framework developed by the American Society for Colposcopy and Cervical Pathology (ASCCP) and endorsed by the American College of Obstetricians & Gynecologists (ACOG) (2).
Cervical diagnostic and treatment procedures
Diagnostic or treatment procedures of the cervix are performed if there are abnormal findings on pelvic examination, cervical cytology, or HPV testing. A cervical biopsy is also done if there is a grossly visible cervical lesion and the diagnosis is uncertain on examination.
Diagnostic procedures include
Colposcopy: Examination of the vagina and cervix with a magnifying lens after the addition of acetic acid to the vagina and cervix. Targeted biopsies should be obtained from acetowhite or otherwise abnormal areas identified during colposcopy.
Cervical biopsy: Biopsy of cervix, usually taking a 1 to 2 mm specimen
Endocervical curettage: Insertion of a curet to obtain tissue from inside the cervical canal
Cervical conization (cone biopsy) procedures can be used for diagnosis and/or treatment. These procedures remove a conical wedge of cervical tissue using different techniques including
Loop electrical excision procedure (LEEP): Performed with a thin wire loop that conducts an electrical current
Cold knife conization: Performed with a scalpel
Laser conization: Performed with laser
Procedures used only for treatment include
Cervical ablation: Techniques include cryotherapy, carbon dioxide therapy, thermal ablation, or diathermy. Ablative procedures should only be performed after invasive cancer has been excluded and the entire transformation zone is adequately visualized.
Cervical testing references
1. U.S Preventive Services Task Force. Screening for Cervical Cancer: US Preventive Services Task Force recommendation statement. JAMA 320 (7):674–686, 2018. doi:10.1001/jama.2018.10897
2. American College of Obstetricians and Gynecologists. Updated cervical cancer screening guidelines. Published 2021
Other Gynecologic Biopsies
In addition to cervical biopsy, biopsy may be indicated for other parts of the lower genital tract.
Vulvar biopsy
Vulvar biopsies are indicated for patients with
Symptoms or examination findings suggestive of vulvar intraepithelial neoplasia, vulvar malignancy (eg, squamous cell carcinoma), or vulvar dermatoses (eg, lichen sclerosus, lichen planus)
Any visible vulvar lesion for which a definitive diagnosis cannot be made on physical examination
Lesions that did not respond fully to or recurred after medical treatment
Lesions with an abnormal vascular pattern
Lesions requiring definitive treatment by excisional procedures
Lesion with rapid change in size, color, border, ulceration, or persistent pain or itching
Pigmented vulvar lesions suspicious for melanoma or atypical melanocytic lesions
Vulvar biopsy is an office procedure performed under local anesthesia (1 to 2% lidocaine) with or without epinephrine, which is injected subdermally into the area to be biopsied. A 3- to 5-mm punch biopsy is most commonly performed, depending on lesion size and location, using a punch biopsy instrument . In some cases, a lesion is removed using a surgical scissor (eg, a small pedunculated lesion), an excisional biopsy is performed with a scalpel (eg, for wide local excision for vulvar neoplasia), or a shave biopsy (eg, for skin tags, warts) is done. Hemostasis is achieved using pressure, ferric subsulfate (Monsel) solution, silver nitrate sticks or, very rarely, electrocautery. A suture may be needed if bleeding persists or the biopsied area is large. Biopsy should be obtained from the edge of an ulcer or from the most abnormal-appearing portion of a lesion while avoiding completely necrotic tissue whenever possible. In suspected lichen sclerosus, biopsy should be obtained from active disease rather than areas of dense scarring whenever feasible.
Relative contraindications to vulvar biopsy include bleeding diathesis and current anticoagulant therapy; however, biopsy may still be performed after individualized risk assessment. Patients should receive instructions regarding local wound care, hygiene, and signs of infection or bleeding following the procedure.
Vaginal biopsy
Vaginal biopsies are not commonly performed and are indicated when there is a concern for vaginal intraepithelial neoplasia, vaginal malignancy, or persistent vaginal ulceration; unexplained vaginal bleeding associated with a visible lesion also warrants biopsy.
Suspicious vaginal lesions are often evaluated under colposcopic guidance before biopsy to improve diagnostic accuracy. Biopsy is commonly performed using Tischler biopsy forceps, Kevorkian biopsy forceps, a punch biopsy instrument, or a stitch-and-cut method (a stitch is placed into the suspected lesion or area and a pair of scissors is used to excise the lesion). Hemostasis is achieved by placing another stitch or by using ferric subsulfate (Monsel) solution or silver nitrate sticks.
Relative contraindications to vaginal biopsy include bleeding diathesis and current anticoagulant therapy. Patients should avoid vaginal intercourse, tampon use, and intravaginal medications until healing is complete unless otherwise directed.
Endometrial biopsy
Endometrial sampling may be done as an office endometrial biopsy procedure or as an operative procedure (dilation and curettage with or without hysteroscopy).
Indications for endometrial biopsy include the following (1):
Postmenopausal uterine bleeding
Abnormal uterine bleeding (AUB) in patients who are ≥ 45 years or < 45 years with endometrial cancer risk factors (eg, obesity, history of unopposed estrogen exposure), failed medical management, or persistent AUB
Follow-up monitoring for endometrial hyperplasia
Cervical cytology with glandular cells associated with an increased risk of endometrial cancer: benign-appearing endometrial cells in patients ≥ 45 years; atypical glandular cells [AGC]-endometrial; AGC or adenocarcinoma in-situ (AIS) in patients ≥ 35 or in those < 35 with endometrial cancer risk factors or symptoms; or persistent abnormal cervical cytology results in patients with any AGC category (2)
Screening in patients at high risk for endometrial cancer (eg, Lynch syndrome)
Endometrial biopsy should also be considered in patients with persistent intermenstrual bleeding or abnormal uterine bleeding that is unexplained despite medical management, particularly when risk factors for endometrial hyperplasia or carcinoma are present.
The only absolute contraindication for endometrial biopsy is a known or suspected intrauterine pregnancy. Relative contraindications are
Bleeding diathesis or current anticoagulant therapy
Acute infection of the vagina, cervix, uterus, or fallopian tubes
Cervical stenosis
Congenital female reproductive tract anomalies
An endometrial biopsy is usually performed as an office procedure. Routine cervical preparation with misoprostol is not recommended before office endometrial biopsy because it has not consistently improved procedural success and is associated with increased cramping and adverse effects. However, cervical preparation may be considered in selected patients with cervical stenosis, previous failed biopsy, or anticipated difficult cervical access, particularly in postmenopausal women. Cervical preparation with misoprostol (200 to 400 mcg vaginally or orally the night before the procedure) may help to dilate the cervix (3). Anesthesia is not required, but preprocedure nonsteroidal anti-inflammatory drugs may reduce postprocedural cramping. Topical lidocaine, intracervical anesthesia, or paracervical block may be used selectively in patients expected to experience significant discomfort (4). Antibiotic prophylaxis is not required.
During the procedure, a thin (< 3 mm), flexible, disposable, plastic, low-pressure suction curette is inserted through the cervix to the level of the uterine fundus; mechanical dilation is not usually required. Usually, tenaculum is placed on the anterior cervix to stabilize the uterus. Suction is applied by withdrawing an internal plunger. To obtain an adequate sample of the endometrial cavity, the clinician turns the device 360° and moves it 3 times in a cephalic to caudal motion. Alternative but not routinely recommended for postmenopausal women, endometrial sampling with a brush device can can yield an adequate sample (5).
The most common adverse effects are uterine cramping or vasovagal reactions. Uterine perforation is a rare but more serious potential complication.
Office endometrial biopsy is highly sensitive for detecting endometrial carcinoma and atypical hyperplasia but is less sensitive for focal intracavitary lesions, including endometrial polyps and submucosal leiomyomas. When clinical suspicion remains despite a benign or insufficient biopsy result, hysteroscopy with directed biopsy should be considered.
Other gynecologic biopsies references
1. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197-206. doi:10.1097/AOG.0b013e318262e320
2. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors [published correction appears in J Low Genit Tract Dis. 2020 Oct;24(4):427]. J Low Genit Tract Dis. 2020;24(2):102-131. doi:10.1097/LGT.0000000000000525
3. Al-Fozan H, Firwana B, Al Kadri H, Hassan S, Tulandi T. Preoperative ripening of the cervix before operative hysteroscopy. Cochrane Database Syst Rev. 2015;(4):CD005998. Published 2015 Apr 23. doi:10.1002/14651858.CD005998.pub2
4. Charoenkwan K, Nantasupha C. Methods of pain control during endometrial biopsy: A systematic review and meta-analysis of randomized controlled trials. J Obstet Gynaecol Res. 2020;46(1):9-30. doi:10.1111/jog.14152
5. Williams AR, Brechin S, Porter AJ, et al. Factors affecting adequacy of Pipelle and Tao Brush endometrial sampling. BJOG. 2008;115(8):1028-1036. doi:10.1111/j.1471-0528.2008.01773.x
Imaging Studies
Pelvic ultrasonography is the first-line imaging modality for evaluation of most gynecologic disorders.
Transvaginal ultrasonography is performed during examinations whenever feasible because it provides superior resolution of the uterus, endometrium, ovaries, and adnexa.
Transabdominal ultrasonography helps with large pelvic masses, pregnancy, or when transvaginal examination is not appropriate.
Transrectal ultrasonography may be used in selected patients when transvaginal imaging is not feasible (eg, patients who have not had vaginal intercourse or those with significant vaginal stenosis).
Color and spectral Doppler ultrasonography are routinely used to evaluate vascularity of pelvic masses and may assist in the assessment of ovarian torsion, adnexal masses, and suspected gynecologic malignancy.
Standardized imaging terminology and reporting systems, including the Ovarian-Adnexal Reporting and Data System (O-RADS) for ultrasound and MRI, are recommended to improve risk stratification and management of adnexal masses (1, 2).
MRI or CT: MRI is the preferred second-line imaging modality for further characterization of indeterminate pelvic masses identified on ultrasonography. MRI is recommended to evaluate deep infiltrating endometriosis, adenomyosis, congenital uterine anomalies, and complex adnexal masses when ultrasonographic findings are inconclusive or surgical planning is required (2, 4). CT is mainly useful for staging malignancy, identifying metastatic disease, evaluating acute abdominal or pelvic conditions, and assessing postoperative complications (1, 2).
Sonohysterography (saline infusion sonography): Isotonic fluid is injected through the cervix into the uterus during ultrasonography. Saline infusion sonohysterography improves detection of intracavitary pathology, including endometrial polyps, submucosal leiomyomas, intrauterine adhesions, retained products of conception, and focal endometrial abnormalities (1, 2).
Hysterosalpingography: Fluoroscopic imaging of the uterus and fallopian tubes is done after injection of a radiopaque agent into the uterine cavity. Hysterosalpingography remains an important component of infertility evaluation by assessing tubal patency and the contour of the uterine cavity. However, hysterosalpingo-contrast sonography (HyCoSy) using ultrasound contrast is increasingly used in some centers as a radiation-free alternative.
Diagnostic Procedures
Diagnostic procedures are performed when the diagnosis cannot be established with history, physical examination, laboratory testing, and imaging, or when tissue diagnosis or therapeutic intervention is required. Many procedures are both diagnostic and therapeutic.
Dilation and curettage
Endometrial sampling using an office endometrial biopsy is the preferred initial method for evaluating abnormal uterine bleeding and suspected endometrial hyperplasia or carcinoma because it is less invasive and has high diagnostic accuracy. Dilation and curettage (D&C) is now performed less frequently and is generally reserved for patients in whom office biopsy is unsuccessful, inadequate, contraindicated, or when surgical management of abnormal uterine bleeding or retained products of conception is required. During the procedure, the cervix is dilated, and the curette is introduced to remove endometrial tissue (1).
Hysteroscopy
Diagnostic and operative hysteroscopy permit direct visualization of the endometrial cavity and are considered the gold standard for evaluation and treatment of many intracavitary lesions. After cervical dilation, a camera (hysteroscope) is inserted through the cervix into the uterine cavity. The cavity is inspected for abnormalities. Procedures such as directed biopsy, endometrial polypectomy, adhesiolysis, septum resection, and hysteroscopic myomectomy can often be performed during the same procedure. Office hysteroscopy is increasingly used because it avoids general anesthesia in many patients (1).
Laparoscopy
This is an abdominal procedure in which a camera (laparoscope) is inserted through small skin incisions to inspect the abdominal cavity or perform surgical procedures. Diagnostic laparoscopy is indicated when imaging studies are inconclusive, or pathology requires direct visualization (endometriosis, chronic pelvic pain, pelvic adhesions, ectopic pregnancy, or adnexal masses) (1, 3). Whenever appropriate, minimally invasive laparoscopy is preferred over laparotomy because it is associated with shorter hospitalization, reduced postoperative pain, faster recovery, and lower complication rates. Although laparoscopy remains the definitive method for visual diagnosis of endometriosis, empiric medical therapy may be initiated in selected patients with typical symptoms before surgical diagnosis (3).
Culdocentesis
Culdocentesis is rarely performed; it iinvolves aspiration of fluid using a needle puncture through the posterior vaginal fornix from the cul-de-sac. It was used to detect hemoperitoneum in suspected ruptured ectopic pregnancy or pelvic abscess. Currently, ultrasound-guided aspiration is preferred when clinically indicated (1, 2)
Diagnostic procedures references
1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol. 2016;128(5):e210-e226. doi:10.1097/AOG.0000000000001768
2. American College of Radiology. ACR Appropriateness Criteria: Acute Pelvic Pain and Adnexal Masses. J Amer Coll Radiology. 2023;21:S3-S20. Accessed July 8, 2026.
3. European Society of Human Reproduction and Embryology Guideline Development Group. ESHRE Guideline Endometriosis. 2022. Accessed July 8, 2026.
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