Gynecological Exam & Patient History

• Female Genitalia: Bates Chapter 21

Instructional Objectives

• Understanding female genitalia anatomy and physiology is important.
• It is important to obtain a thorough patient history regarding changes in menstruation, vaginal bleeding/discharge, or vulvovaginal lesions.
• Understanding risk factors for cervical cancer, STDs, and HIV is important.
• Describing the principles of the pelvic examination is important.

Helpful Definitions

• Menarche refers to the onset of menses.
• Dysmenorrhea is characterized by pain with menses, often with bearing down, aching, or cramping in the lower abdomen or pelvis.
• Premenstrual syndrome (PMS) is a cluster of emotional, behavioral, and physical symptoms that occur 5 days before menses for three consecutive cycles.
• Abnormal uterine bleeding occurs between menses and includes infrequent, excessive, prolonged, or postmenopausal bleeding.
• Menopause is defined as the absence of menses for 12 consecutive months, usually occurring between the ages of 48 and 55 years.
• Postmenopausal bleeding is any bleeding that occurs after menopause.
• Menorrhagia is periods where the bleeding is quite heavy, or the duration is longer than usual.
• Metrorrhagia is bleeding or spotting in between menstruation.
• Menometrorrhagia is a combination of menorrhagia and metrorrhagia.
• Polymenorrhea is having less than 21-day intervals between menses.
• Oligomenorrhea is infrequent bleeding.
• Amenorrhea is the absence of menses.
• Gravidity refers to the number of times a woman has been pregnant.
• Primigravida refers to a woman who is currently pregnant or has been pregnant once.
• Multigravida is a woman who has been pregnant more than once.
• Nulligravida is a woman who has never been pregnant.
• Parity refers to the number of times a woman has given birth to a baby of viable age (≥24 weeks) regardless of birth outcome.
• Primipara (Primip) is a woman who is pregnant for the first time (and has made it beyond viable age) or has given birth to only 1 child.
• Multipara (Multip) is a woman who has given birth 2 or more times.
• Nullipara (Nullip) is a woman who has never given birth or who has never had a pregnancy progress beyond viability.
• Miscarriage (spontaneous abortion) - fetal demise before the 20th week of gestation.

History: Chief Complaint (CC)

• Yearly well-woman visits are important for preventative care.
• Inquiring about menarche and menstruation provides important information about reproductive health.
• Premenstrual syndrome (PMS) presents with a range of symptoms including depression, angry outbursts, irritability, anxiety, and confusion.
• PMS also presents with crying spells, sleep disturbance, poor concentration, social withdrawal, bloating, weight gain, swelling of hands and feet, and generalized aches/pains.
• The criteria to be diagnosed with PMS is the symptoms must be present in the 5 days prior to menses for at least three consecutive cycles, and cessation of symptoms/signs within 4 days after onset of menses, and interfere daily activities.
• Amenorrhea: Primary is absence of ever initiating periods. Secondary is the cessation of periods after they have been established.
• Abnormal bleeding can manifest as menorrhagia, metrorrhagia, and menometrorrhagia.
• Also, abnormal bleeding can present as polymenorrhea, oligomenorrhea, and post coital bleeding.
• Dysmenorrhea is abnormal when interfering with ADLs.
• Primary dysmenorrhea is an increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline.
• Secondary Dysmenorrhea: Endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease (PID), and endometrial polyps.
• Also, chief complaints include menopause, postmenopausal bleeding, pelvic pain (acute and chronic), and vulvovaginal symptoms.
• Other chief complaints include STIs, sexual health, pregnancy, and urinary symptoms (dysuria, frequency, urgency, incontinence).

History

• HPI: Use OLDCARTS to gather details about the present illness.
• It is important to note pertinent positives/negatives during the HPI.
• PMH: reproductive health history/STI's are important to assess impact on fertility, risk for ectopic pregnancy, and the best contraceptive to prescribe.
• History of UTIs, glomerulonephritis, previous urinary catheterization/dilation, spina bifida (risk factor for recurrent UTI), trauma/spinal cord injury are important.
• Medications and forms of birth control, and surgical history are included when gathering patient history.

Reproductive Health History

• Includes Onset of Menarche and Last Normal Menstrual Period
• Includes Obstetric History: # of Pregnancies, Losses/Abortions, Delivery History
• Includes Gynecological History: Ovarian cyst, Endometriosis, Infertility/treatments, Fibroids, Salpingitis, Tubo-ovarian
• Includes Sexual History
• Includes Screenings: Last pap smear, Last mammogram

Reproductive Health History/Sexual History: The 5 "Ps+"

• Partners includes genders of sexual partners, recent sexual intercourse, # of partners in the last 6 months, 5 years, and lifetime, any new partners in the last 6 months
• Practices includes Types of sex (oral, vaginal, anal, etc).
• Protection from STIs includes Use of condoms.
• Past history of STIs includes what kind of STI, when did they have it, what treatment, last screening
• Pregnancy Plans includes any plans or desire to have (more) children and discussing concerns, birth control, etc.
• Plus encompasses an assessment of trauma, violence, sexual satisfaction, sexual health concerns/problems, and support for sexual orientation and gender identify (SOGI)

Reproductive Health History/OB History

• Gravidity and Parity can be documented succinctly as G and P.
• A G2P2 has had two pregnancies and two deliveries after 24 weeks.
• A G2P0 has had two pregnancies, neither of which survived to a gestational age of 24 weeks.
• Parity can be broken down even further G,P(TPAL)
• G= Gravidity - # of pregnancies
• P= Parity
• T= Term- # of term pregnancies/deliveries
• 37-40 weeks
• P= Premature- # of premature pregnancies/deliveries
• 20-36 weeks
• A= Abortions/miscarriages
• Elective abortions and spontaneous abortions
• L= Living children
• If a woman with two spontaneous losses prior to 20 weeks gestation, 3 living children who were delivered at term, and currently pregnant = G6P3023
• For twins it’s important to note that for gravidity, it's about number of pregnancies, not number of babies.

History

• FH: History of renal disease, Polycystic Kidney dz, Renal failure, Cancer
• SH: Sexual history
• ROS: General, Skin, Pulm, Cardiac, GI, GU

Physical Exam

• Includes vital signs, general, skin, pulm, cardiac, and GI
• Rectal exam when indicated
• GU and Pelvic exam

Before preparing for the exam

• Determine if patient is younger than 21 years old.
• Pelvic exams on patients under 21 years old should only occur if indicated by the medical history.
• NO EVIDENCE SUPPORTS THE ROUTINE INTERNAL EXAMINATION OF THE HEALTHY, ASYMPTOMATIC PATIENT BEFORE AGE 21 YEARS.
• Male examiners should be accompanied by female chaperones, and female examiners should be accompanied by a chaperone as well.

Tips for Successful Female Genitalia Exam

• Examiner obtains permission and selects chaperone
• Examiner explains each step of the examination in advance
• Examiner drapes the patient from midabdomen to knees and depresses the drape between the knees to provide eye contact with patient
• Examiner avoids unexpected or sudden movements and chooses a speculum that is the correct size, as well as, warms the speculum with tap water
• Examiner monitors the comfort of the examination by watching the patient's face and obtaining verbal feedback
• Examiner uses excellent but gentle technique, especially when inserting the speculum (see p. 699)
• Patient avoids intercourse, douching, or use of vaginal suppositories for 24 to 48 hours before examination
• Patient empties bladder before the physical exam
• Patient lies supine, with head and shoulders elevated, and arms at her sides or folded across the chest to enhance eye contact and reduce tightening of abdominal muscles

Prep for the Pelvic Exam

• Assemble equipment, which includes Moveable light source, Gloves, Vaginal speculum of appropriate size, Water-soluble lubricant, Pap smear equipment (if indicated), Specimen/culture equipment (if

Make Sure The Patient is Comfortable

• Assist the patient into lithotomy position
• May be warmer and feel less exposed with socks on
• Patient slides all the way down the exam table until her buttocks extend slightly beyond the edge with the hips flexed, abducted, and externally rotated
• Head is supported with a pillow

Touching the Patient

• Give the patient power by your words such as, "This is the speculum I will use", "We will begin the examination now with your permission", and "You will feel the back of my hand"

GU Female Exam

• Involves inspection (and palpation if indicated) of the external genitalia
• Inspect Mons pubis, labia majora and perineum, labia minora, clitoris, urethral meatus, and Also, Anus

External Exam inspection of:

• Inspect: pubic hair pattern/distribution
• Labia majora: color, symmetry, moisture, scarring, inflammation, swelling.
• Palpate Labia majora for tenderness
• Labia minora: symmetry, moisture, inflammation, discharge, excoriations, lesions
• Palpate Labia minora for tenderness
• Clitoris: Size, atrophy, inflammation, adhesions
• Urinary meatus: Discharge, polyps, caruncles, inflammation
• Vaginal introitus: Moisture, swelling, discoloration, discharge, lesions, fissures
• Skene and Bartholin glands: inspect the discharge and swelling while palpate the bartholin glands for tenderness

Bartholin Glands Exam

• Palpate each side at approximate the 4-o'clock and 8-o'clock position between your finger and thumb
• Check for swelling or tenderness
• Note any discharge exuding from the duct opening of the gland and culture if present

Speculum Examination

• Understand mechanics of the speculum and make sure it's in good working order.
• Preferably lubricate with warm water but only use sparingly because can prevent accurate pap/culture results so use with caution!

Internal Exam-Speculum Exam

• Advise patient they you will now place the speculum in the vagina
• Place 1-2 fingers in the posterior introitus and press downward
• If needed, locate the position of the cervix with your fingers to guide the direction of the speculum
• With speculum closed, insert at an oblique angle and gradually rotate to horizontal position
• Insert at a 30-degree downward angle towards the cervix
• Gradually open the speculum, bring cervix into view, and lock
• If having difficulty finding the cervix, withdraw slightly and reposition on a different slope
• If discharge obscures the view, wipe away gently with a large cotton swab
• Note the color and symmetry of the cervix
• Note the surface characteristics: Smooth, ectropion, Nabothian cysts, polyps, erythema
• Note the shape of the os
• Note the presence of any discharge and odor, consistency
• Obtain pap smear and cultures if indicated
• Withdraw the speculum just until it clears the cervix, then inspect the vaginal walls- Inspect for color, surface characteristics, lesions, secretions, or bleeding
• Have the patient bear down, and check for bulging in the vaginal wall or incontinence
• Ensuring the speculum has cleared the cervix, close the speculum and remove slowly at the same oblique angle

Papanicolaou (Pap) Smear

• Once the cervix is clearly visualized: Obtain one specimen from the endocervix and another from the ectocervix
• If indicated/consented: Then take cultures from the cervical os
• TAKE CUTURES LAST!!!

GU Female Exam (Bimanual Examination)

• Lubricate index and middle fingers
• Inform patient you will insert fingers
• Insert fingers exerting pressure posteriorly, with the thumb abducted and 4th and 5th fingers flexed into the palm
• Note any lesions or tenderness in the vaginal wall, including the region of the urethra and bladder anteriorly .Palpate the cervix, noting the size, contour/consistency, and assess for cervical motion tenderness
• Palpate the uterus by placing your other hand on the lower abdomen just above the symphysis pubis while you elevate the cervix and uterus with your pelvic hand. Press the abdominal hand in and down, capturing the uterus between your two hands
• Note its position, size, shape, contour/consistency, any masses present, mobility and identify any tenderness.
• Palpate each ovary by placing your abdominal hand on the right lower quadrant and your pelvic hand in the right lateral fornix, pushing your abdominal hand in and down.
• Try to identify the right ovary or any adjacent adnexal masses
• Note the size, shape, consistency, mobility, and tenderness
• Repeat on left side
• DRE (Verbalize only that you will perform)- Note the sphincter tone and any scarring, fissures, lesions, rectal wall masses, polyps, tenderness, uterus position/size/tenderness, stool color, and presence of any blood.

Special Techniques

• Milking the urethra assists to evaluate possible urethritis or inflammation of the paraurethral glands, insert your index finger into the vagina and milk the urethra gently outward from the inside
• Note any discharge from the urethral meatus and if discharge is present, culture it

Common Abnormalities: Vulvar/Vaginal Lesions

• Herpes simplex presents with vesicles/ulcers
• Syphilis
• Cancer
• Bartholin cysts
• HPV presents with warts

Common Abnormalities Presenting as Vaginal Pruritus/Pain

• Candidiasis
• Trichomoniasis
• Herpes simplex with Vesicles

Common Abnormalities Presenting with Vaginal Discharge

• Urethritis/cervicitis
• Chlamydia/GC with Mucopurulent discharge
• Bacterial Vaginosis with Homogeneous white discharge which coats t+clue cells and Fishy odor, "whiff” test
• Candidiasis with White clumped discharge
• Trichomoniasis-Yellow/green, often malodorous discharge with vulvar itching as well as Motile flagellated organisms

Urethrocele

• When a prolapsed urethra protrudes into the anterior vaginal wall

Cystocele

• A bulge of the upper two-thirds of the anterior vaginal wall due to a prolapsed bladder

Cystourethrocele

• When the entire anterior vaginal wall, together with the bladder and urethra, produces the bulge.

Rectocele

• Herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.

Urethral abnormalities

• Caruncle-Small red benign tumor visible at the posterior urethral meatus is Most common in in postmenopausal women and Typically asymptomatic but it is Important to avo with carcinoma of the

Cervical abnormalities presenting as Mucopurulent discharge

• Mucopurulent cervicitis produces purulent yellow drainage from the cervical os, usually from C. trachomatis, N. gonorrhoeae, or herpes infection.

Carcinoma of the cervix

• Earliest stages-cannot be distinguished from a normal cervix.
• Later stages-an extensive, irregular, cauliflower-like growth may develop.
• Early frequent intercourse, multiple partners, smoking, and infection with human papillomavirus increase the risk for cervical cancer.

Fetal exposure to DES

• Daughters of women who took DES during pregnancy are at greatly increased risk for several abnormalities such as Columnar epithelium that covers most or all of the cervix, Vaginal adenosis (i.e extension of this epithelium to the vaginal wall), A circular collar or ridge of tissue, between the cervix and vagina,Rare carcinoma of the upper vagina.
• Nabothian cysts (AKA Mucinous retention cysts)

Uterine abnormalities

• Fibroids (Myomas): Very common, benign tumors that Vary in number and size.
• Can be firm, irregular nodules
• Prolapse: Weakness of supporting structures of the pelvic floor that is defined in 3-degrees.
• 1st degree-cervix is still well within the vagina
• 2nd degree-cervix is at the introitus
• 3rd degree-cervix and vagina are outside the introitus

Adnexal masses and other causes of pelvic pain includes:

• Ovarian cancer
• Ovarian cysts/tumors that Cysts can be transient or suggestive of PCOS. PCOS-Requires 2/3 factors to be present for diagnosis:
• Androgen excess
• Ovulatory dysfunction
• Polycystic ovaries on U/S
• Ectopic pregnancy, PID, Dysmenorrhea, Endometriosis

Renal Conditions includes?

• UTI and Pyelonephritis, Nephrolithiasis presenting as Gross hematuria, Glomerulonephritis that has Previous history of streptococcal infection with Microscopic hematuria.
• Nephrotic syndrome which presents as Facial edema/increased bp/> 3grams of protein in 24hours

Documentation sample

• "External genitalia without erythema, lesions, or masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses. Stool brown and negative for fecal blood."
• Another Sample: "External genitalia without erythema or lesions. Vaginal mucosa and cervix coated with white homogenous discharge with mild fishy odor. After swabbing cervix, no discharge visible in the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and negative for fecal blood."

Screen for average-risk women for cervical cancer

• Start screening at 21 years old
• From ages 21-65 screen cytology every 3 years OR
• Ages 30-65 screen with cytology plus HPV testing (for high-risk or oncogenic HPV types) every 5 years; HPV testing alone (age 25 or 30)
• Age >65 yrs, assuming three consecutive negative results on cytology or two consecutive negative results on cytology plus HPV testing within 10 yrs before cessation of screening, with the most recent test performed within 5 yrs

Questions cover gravidity/parity, medical history, review of systems, physical exam components, pelvic exam guidelines, speculum use, and cervical cultures. Focuses on best practices for gynecological assessments and patient care.