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Questions and Answers
What does LMP stand for and why is it important in patient history?
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)
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.
Consent is required before starting a pelvic examination.
True
The basic equipment needed to perform a pelvic exam includes an examining table with __________.
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?
What areas should be inspected during the external exam of the genitalia?
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What structures are evaluated during a bimanual exam?
What structures are evaluated during a bimanual exam?
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What are some common external genitalia abnormalities that may be observed?
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.
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?
How should the speculum be inserted during the exam?
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What can be the position of a normal uterus?
What can be the position of a normal uterus?
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What is a cystocele?
What is a cystocele?
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What may be the cause of pain on palpation/movement of the cervix?
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)
After menopause, the ovaries may no longer be palpable. (True/False)
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What defines a cystourethrocele?
What defines a cystourethrocele?
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Urethral caruncle mainly occurs in young women.
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 ______.
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:
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.
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:
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.
