For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to menopause. The practitioner may be a doctor, a nurse-midwife, a nurse practitioner, or a physician assistant.
A gynecologic evaluation includes the gynecologic history and gynecologic examination.
The gynecologic examination refers specifically to examination of a woman's reproductive system, but the doctor (or other health care practitioner) may provide more general medical care and do a more general physical examination during the gynecologic visit.
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 may feel the neck and the thyroid gland to check for lumps and abnormalities. An enlarged, overactive thyroid gland (hyperthyroidism) can cause menstrual abnormalities. The doctor examines the skin for signs of acne, excess body hair that is more typical of men (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 doing the examination, the doctor may review the technique for breast self-examination with the woman (see Figure: 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.
The doctor may also check the groin for a pulse (which is normally present), enlarged lymph nodes, and hernias.
A pelvic examination is not usually done before age 21 unless there is a problem, such as irregular periods, pelvic pain, or a vaginal discharge. Generally, pelvic examinations are recommended for all women, starting at age 21. However, a woman can talk with her health care practitioner about whether these examinations need to be started at this age and how often they need to be done. Also, at age 21, most women should start having tests to screen for cervical cancer, such as a Papanicolaou (Pap) test.
The pelvic examination includes the following:
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. Usually, a drape is provided, and an assistant is asked to be present to chaperone and sometimes to help with the examination. 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.
Before the pelvic examination begins, the doctor asks the woman to relax her legs and hips and breathe deeply.
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 lower part of the uterus). The cervix is examined closely for signs of irritation or cervical cancer. The doctor may use a small plastic brush to obtain a sample for testing, usually a Papanicolaou (Pap) test or a variation of it (to screen for cervical cancer). The doctor checks for protrusion of the bladder, rectum, or intestine into the vagina (called pelvic floor disorders).
After removing the speculum from the vagina, the doctor inserts the index and middle fingers of one gloved hand into the vagina and feels the vaginal wall to determine its strength and support. The doctor also feels for growths or tender areas within the vagina.
With the fingers still in the vagina, the doctor then places the fingers of the other hand on the lower abdomen above the pubic bone (called a bimanual examination). 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 rectal 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. The woman may be given a take-home kit to test for occult blood in the stool.