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Questions and Answers
What does LMP stand for and why is it important in patient history?
Last Menstrual Period
Which of the following are common complaints that would warrant a gynecological exam? (Select all that apply)
Consent is required before starting a pelvic examination.
True
The basic equipment needed to perform a pelvic exam includes an examining table with __________.
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What areas should be inspected during the external exam of the genitalia?
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What structures are evaluated during a bimanual exam?
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What are some common external genitalia abnormalities that may be observed?
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It is important to explain the speculum exam procedure to the patient before starting.
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How should the speculum be inserted during the exam?
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What can be the position of a normal uterus?
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What is a cystocele?
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What may be the cause of pain on palpation/movement of the cervix?
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After menopause, the ovaries may no longer be palpable. (True/False)
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What defines a cystourethrocele?
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Urethral caruncle mainly occurs in young women.
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Increased frequency, increased flow, or bleeding between periods may have systemic causes or may be ______.
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Match the following diseases with their descriptions:
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Mucopurulent ______ usually produces purulent yellow drainage from the cervical os due to infections like chlamydia trachomatis, Neisseria gonorrhoeae, or herpes infection.
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Match the following types of masses with their characteristics:
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Study Notes
Breast and Pelvic Exam
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History Taking:
- Setting: quiet, private, well-lit room with patient dressed, and intimidating instruments covered.
- Be welcoming and minimize family members' presence.
- Interpreter if necessary.
- Allow patient to change privately and use the bathroom after history taking.
OB/GYN History and ROS Components
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Pap Smear History:
- Date and results of most recent Pap smear.
- Prior abnormal results, including evaluation, treatment, and follow-up.
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Infections and STDs:
- Vaginal, pelvic infections.
- Sexually transmitted diseases (STDs).
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Contraceptive History:
- Dates, methods, complications, and reasons for changes.
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Sexual History:
- Sexual activity, types of relationships, satisfaction, and dysfunction.
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Infertility History:
- Evaluation, treatment, and outcome.
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Urinary or Fecal Incontinence:
- Evaluation, treatment, and outcome.
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Abdominal or Pelvic Symptoms:
- Pain, bloating, bowel, bladder, weight gain or loss, vaginal discharge, irregular bleeding, and dyspareunia.
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Abdominal or Gynecologic Surgery:
- Tubal ligation, dilation and curettage, termination of pregnancy, laparoscopy, hysterectomy, and pelvic reconstruction.
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History of Assault or Domestic Violence:
- Breast disorder or surgery.
Obstetrics History
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Duration and Year of Pregnancy:
- Weight of baby, gender, type of delivery, and current condition of the baby.
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Complications:
- Termination of pregnancy, gestational age, type of procedure, and associated medical conditions.
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Spontaneous Abortions:
- Gestational age, need for uterine instrumentation, and complications.
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Ectopic Pregnancies:
- Location of pregnancy and treatment.
Common Terms
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Gravity (G):
- Number of pregnancies, including present pregnancy.
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Parity (P):
- Pregnancy outcome of prior pregnancies.
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Nulligravida:
- Never been pregnant and not currently pregnant.
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Primipara:
- Delivered one baby beyond 20 weeks.
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Parturient:
- Currently in labor.
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Puerpera:
- Has recently given birth.
Summary of History/Example Questions
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Menstrual History:
- Age at menarche and menopause.
- Last menstrual period (LMP).
- Frequency, duration, and quantity of menses.
- Premenstrual symptoms or pain with menses.
- Vaginal discharge or discomfort.
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Sexual History:
- Engagement in sexual activity.
- Number of sexual partners.
- Pain with sexual activity.
- Level of sexual satisfaction.
- History of sexually transmitted infections (STIs).
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Contraception:
- Method used in the past or currently.
- Method to protect against STIs.
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Pap Smear Screening:
- Last Pap smear and frequency of exams.
- Prior abnormal Pap smears.
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Breast Cancer Screening:
- Mammogram screening done.
- Frequency and results.
- Prior abnormal mammograms.
Gynecologic Exam
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ACOG Recommendations:
- Discontinued recommendation for annual routine pelvic examination.
- Shared decision-making with the patient.
- Counseling asymptomatic, nonpregnant women about benefits, harms, and lack of data.
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Complaints Warranting a Gynecological Exam:
- STI testing or screening.
- Screening exams in females above 21.
- Pain, discharge, pregnancy, or postpartum.
- Infection, itching, swelling, bleeding, or menstrual abnormalities.
- Sexual development abnormalities, sexual or physical trauma, or neurological conditions.
- Incontinence or pelvic floor disorders.
Consent
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Patient Consent:
- Request permission before starting a pelvic examination.
- Written consent is not required, except for examination under anesthesia.
- Lack of consent is a contraindication for the exam.
Clinical Pearls
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Allow Adequate Time:
- Be prepared to answer questions.
- Ensure patients have a sense of control during the exam.
- Thoroughly explain the procedure.
- Allow the patient to participate in decision-making.
- Reassure the patient that the exam can be discontinued at any point.
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Talk to the Patient During the Exam:
- Explain what is coming next.
- Comment on findings.
- Maintain eye contact.
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Good Habits:
- Warming instruments and being gentle during the exam.
Equipment
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Basic Equipment:
- Examining table with stirrups.
- Good light source.
- Speculum of appropriate size.
- Materials for obtaining cervical cytology.
- Materials for testing common infections.
- Cotton swabs for obtaining samples of vaginal discharge.
- pH indicator paper.
- Dropper bottles of saline and potassium hydroxide.
- Large cotton swabs to absorb excess vaginal discharge or blood.
- Water-soluble lubricant, disposable gloves, and material to drape the patient.
Gynecologic Exam Steps
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1. Observation and Visual Inspection:
- External genitalia.
- Identify external structures (mons pubis, labia, clitoris, urethral opening, vaginal opening, Bartholin glands, perineum, anus).
- Evaluate for developmental abnormalities, skin lesions, masses, and evidence of trauma or infection.
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2. Speculum Exam:
- Inspect the cervix (color, position, surface characteristics, any ulcerations, nodules, masses, bleeding, discharge).
- Inspect the vagina (masses, lesions, or abnormal discharge or bleeding).
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3. Bimanual Exam:
- Palpate the cervix (position, shape, consistency, mobility, tenderness).
- Palpate the uterus (size, shape, consistency, mobility, and tenderness or masses).
- Palpate the ovaries (size, shape, consistency, mobility, and tenderness).
- Assess the pelvic floor muscles (strength and tenderness).
Rectovaginal Exam (if Indicated)
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Tips for a Successful Exam:
- Patient: avoid intercourse, douching, or using vaginal suppositories for 24 to 48 hours before the exam.
- Patient: empty the bladder before the exam.
- Patient: lie supine, with head and shoulders elevated, and arms at the sides or folded across the chest.
- Examiner: obtains permission, selects a chaperone, and explains each step of the exam.
- Examiner: drapes the patient, avoids unexpected movements, and chooses the correct speculum size.
- Examiner: warms the speculum, monitors the patient's comfort, and uses excellent technique.
- Examiner: positions the patient, arranges the sheet, and asks the patient to position their legs.
- Examiner: uses verbal cues to assist the patient in positioning their legs.
External Exam–Common Abnormalities
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Mucosal Appearance:
- Thin, reflecting atrophy, or decreased lubrication.
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Discharge:
- Normal: small to moderate amount, without strong odor.
- Abnormal: HSV infection, ulcers, masses, skin or mucosal findings.
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Ulcers, Masses, or Skin Lesions:
- Typically genital or perianal area.
- Can be isolated or have a cauliflower-like appearance.
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Speculum Exam:
- Gain comfort with the speculum prior to using it with a patient.
- Show it to the patient, describe the process, and continue to explain the steps.
- Use a water-soluble lubricant, and warm the metal specula with water.
- Insert the speculum sideways, apply steady downward pressure, and open the bills while observing through the opening.
- If the cervix is not visible, close the bills, withdraw the speculum, reposition, and open again.### Gynecological Examination
- A gentle painting motion is used to avoid destroying cells when collecting a Pap smear.
- A cotton-tipped applicator moistened with saline is recommended for pregnant women instead of an endocervical brush.
Gonorrhea and Chlamydia Testing
- Testing methods include PCR amplification of urine or cervical discharge samples and nucleic acid amplification testing (NAAT).
Herpes Testing
- Culture or PCR and typing are used to diagnose herpes.
Removing the Speculum
- Care should be taken to avoid discomfort when removing the speculum.
- Steps to remove the speculum include:
- Pulling the speculum back to clear the cervix.
- Closing the speculum halfway.
- Observing the vaginal walls for any abnormalities.
- Closing the bills and taking pressure off the thumb piece before fully removing the speculum.
Bimanual Exam
- Explain the exam to the patient before proceeding.
- Use a lubricated finger to gently move the cervix and note any pain or discomfort.
- Palpate the uterus, noting its size, shape, consistency, mobility, and any pain caused by manipulation.
- Use the other hand to palpate the lower abdomen and note the position of the uterus.
- Check for any adnexal masses or tenderness.
Rectovaginal Examination
- This exam allows for optimal palpation of the posterior cul-de-sac and uterosacral ligaments.
- It is used to screen for colorectal cancer, detect endometriosis, and evaluate symptoms in the rectal area.
- Use a lubricated examining glove and ask the patient to bear down to relax the sphincter and decrease discomfort.
Concluding the Exam
- Provide the patient with privacy to clean up and get dressed.
- Return to answer questions, review findings, and discuss next steps.
Expected Lifespan Variations
- Ovarian function usually starts to diminish in a woman's 40s, and menstrual periods cease between ages 45 and 52.
- Physical changes associated with menopause include:
- Sparse and gray pubic hair.
- Smaller labia and clitoris.
- Narrowing and shortening of the vagina.
- Thinning of the vaginal mucosa.
- Decrease in size of the uterus and ovaries.
Tanner Staging
- A system used to document and track the development and sequence of secondary sex characteristics in children.
- Stages:
- Stage 1: Preadolescent, no sexual hair.
- Stage 2: Sparse, pigmented, long, straight hair.
- Stage 3: Darker, coarser, curlier hair.
- Stage 4: Adult, but decreased distribution.
- Stage 5: Adult in quantity and type, with spread to medial thighs.
History "Red Flags" and Disease-Related Findings
- Dates of previous periods may indicate possible pregnancy or menstrual irregularities.
- Abnormal bleeding patterns, such as excessive flow, bright red color, or presence of "clots," may indicate underlying conditions.
- Postmenopausal bleeding raises the question of endometrial cancer.
- Other causes of secondary amenorrhea include low body weight, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction.
Pelvic Exam "Red Flags" and Disease-Related Findings
- Delayed puberty may be due to familial or chronic illness.
- Excoriations or itchy, small, red macules or papules suggest pediculosis pubis.
- Clitormegaly, imperforate hymen, and sexual dysfunctions may be identified during the exam.
Diseases
- Epidermoid cyst: a small, firm, round cystic nodule in the labia.
- Venereal wart: warty lesions on the labia and within the vestibule.
- Genital herpes: shallow, small, painful ulcers on red bases.
- Syphilitic chancre: a firm, painless ulcer.
- Carcinoma of the vulva: an ulcerated or raised red vulvar lesion in an elderly woman.
- Bacterial vaginosis: a gray or white, thin, homogeneous discharge with a malodorous odor.
Bacterial Infections
- Trichomonal vaginitis: a yellowish-green or gray discharge, often profuse and malodorous.
- Candidal vaginitis: a white and curdy discharge, often thick and not malodorous.
- Bacterial vaginosis: a gray or white, thin, homogeneous discharge with a malodorous odor.
Other Conditions
- Cystocele: a bulge of the upper 2/3s of the anterior vaginal wall, together with the bladder above it.
- Cystourethrocele: a bulge of the entire anterior vaginal wall, together with the bladder and urethra.
- Urethral caruncle: a small, red, benign tumor visible at the posterior part of the urethral meatus.
- Prolapse of the urethral mucosa: a swollen red ring around the urethral meatus.
- Bartholin's gland infection: a tense, hot, very tender abscess.
- Rectocele: a herniation of the rectum into the posterior wall of the vagina.
- Mucopurulent cervicitis: a purulent yellow drainage from the cervical os.
- Carcinoma of the cervix: a growth that begins in an area of metaplasia.
- Myomas of the uterus: benign uterine tumors that may be single or multiple.
- Prolapse of the uterus: a weakness of the supporting structures of the pelvic floor, often associated with a cystocele and rectocele.### Pelvic Inflammatory Disease (PID)
- PID is often a result of sexually transmitted infections of the fallopian tubes (salpingitis) or the tubes and ovaries (salpingo-oophoritis)
- Caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and other organisms
- Acute disease is associated with: • Very tender, bilateral adnexal masses • Pain and muscle spasm making it impossible to delineate them • Pain upon movement of the cervix
- If left untreated, a tubo-ovarian abscess and infertility may ensue
- Infection of the fallopian tubes and ovaries may occur after: • Delivery of a baby • Gynecologic surgery
Speculum Types
- Graves Speculum: • Wider, higher, and curved on the sides • Suitable for parous women with loose vaginal walls • Available in pediatric sizes for virginal adults or young children
- Pederson Speculum: • Flat and narrow blades with minimal curvature on the sides • Suitable for nulliparous women and menopausal women with atrophic vaginas • Available in pediatric sizes for virginal adults or young children
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Description
Learn about the setting and procedures for conducting a breast and pelvic exam, including creating a comfortable environment for the patient and taking a thorough history.
