The Gynecologic History and Examination
Noelle C. Bowdler and Marygrace Elson
Table Of Contents
Noelle C. Bowdler, MD
Marygrace Elson, MD
THE GYNECOLOGIC HISTORY|
THE GYNECOLOGIC EXAMINATION
Taking a history is the initial step in the physician-patient encounter. This provides a basis for emphasizing aspects of the subsequent physical examination, and for initial decisions about diagnostic testing and treatment. The information gained during the physical examination helps the clinician to narrow the list of possible diagnoses to explain a patient’s symptoms, and to refine plans for additional testing and treatment. This chapter outlines the components of a basic gynecologic history and gynecologic examination.
|THE GYNECOLOGIC HISTORY|
Because a discussion of reproductive issues may be difficult for some women, it is important to obtain the history in a relaxed and private setting. The patient should be clothed, particularly if she is meeting the physician for the first time. Ordinarily, the patient should be interviewed alone. Exceptions may be made for children, adolescents, and mentally impaired women, or if the patient specifically requests the presence of a caretaker, friend, or family member. However, even in these circumstances, it is desirable for the patient to have some time to speak with the clinician privately.
The manner of address should be formal using the title Mrs., Ms., Miss, or Dr. with the patient’s surname, unless the patient requests otherwise.
In some settings, it may be appropriate for nursing staff to be involved with history taking. The nurse may be perceived as less threatening than the physician, and may be able to take the history in a less hurried manner.1 The physician can verify the history and focus on areas of concern. Alternatively, it may be helpful to ask the patient to complete a self-history form on paper or by computer prior to speaking with the physician. This allows the physician to devote time to addressing positive responses, and ensures that important questions are not missed. Using a crossover study design, Hasley2 showed that responses to a computer-based questionnaire designed to update a patient’s gynecologic history were equivalent to those obtained during a personal interview.
In order to increase a patient’s level of comfort during the interview, questions should be asked in an open-ended and nonjudgmental way. Assumptions should not be made about aspects of the patient’s background such as sexual orientation. At the conclusion of the interview, patients should be asked whether there are concerns that they would like to discuss that were not addressed previously in the interview.
While the focus of the history may vary depending on whether the patient is being seen for evaluation of a gynecologic problem or for an annual gynecologic examination, the gynecologic history must include an evaluation of the patient’s overall health. An outline of a comprehensive gynecologic screening history is shown in Table 1. Aspects of the comprehensive history include:
|THE GYNECOLOGIC EXAMINATION|
The gynecologic examination includes examination of the breasts, abdomen, and pelvic organs. However, many women see their gynecologist as their primary health care provider, and will seek a complete physical examination when they come into the office for their gynecologic evaluation. In addition, many gynecologic problems have symptoms that involve other organ systems. Consequently, the gynecologist must be prepared to perform a general physical examination competently.
Timing and Frequency of Examinations
Genital examinations are often part of routine well-baby and well-child pediatric care. A genital examination should be performed if a child has a symptom in the genital area (e.g., vulvar itching) or there any concerns about a developmental problem (e.g., early development of secondary sexual characteristics).
Adolescents often benefit from a visit to a primary care provider to discuss any health care concerns they may have, and to ensure that appropriate preventive primary care is administered (e.g., immunizations, blood pressure checks, and general physical examinations, as well as counseling regarding smoking and safety habits). This visit will hopefully pave the way for a relaxed relationship between the adolescent and the provider when it is time for the first pelvic examination. A pelvic examination is recommended at age 18 or with onset of sexual activity, whichever occurs earlier.
Hormonal contraception can be provided safely based on a careful review of a patient’s medical history and measurement of the patient’s blood pressure. Unless the patient has symptoms, the pelvic and breast examinations and screening for cervical neoplasia and sexually transmitted diseases can wait until a subsequent visit. Especially in the adolescent population it is important to not always require tests and procedures prior to an initial prescription for hormonal contraception. These patients may be reluctant to undergo examination, and an unintended pregnancy may result, with all of its inherent risks.6
The recommended interval for examinations during the reproductive years varies with a woman’s health and risk status. Women should undergo annual cytologic screening for cervical intraepithelial neoplasia for at least 3 years. Thereafter, cervical smears can be obtained every 3 years in the selected low-risk patient. Women at risk for cervical intraepithelial neoplasia should continue to have annual cervical cytologic screening. Screening may be discontinued at age 65 if there is no history of abnormal smears or HPV, or at any age after hysterectomy for benign disease if the patient has not previously had abnormal cervical cytology. Whether or not a smear for cervical cytology is performed, many women benefit from annual well-woman examinations that include assessments of height, weight, and blood pressure, as well as examinations of the thyroid and breasts, and the other components of the pelvic examination. Women receiving contraceptive hormone therapy should be assessed at least annually.7
Women’s Experiences and Gynecologic Examinations
Women are often apprehensive about undergoing a pelvic examination. A previous examination that was not a good experience contributes to even more anxiety. Women feel vulnerable and exposed during this examination. The positioning necessary for the examination creates a significant imbalance of power in the patient/provider interaction, and carries sexual connotations for many women. The practitioner may unintentionally use words or actions that the patient may find threatening or offensive. The provider may feel that the interaction was satisfactory, but the patient may feel completely the opposite. On the other hand, if a woman is at ease with the examination experience, she is more likely to spontaneously contribute information that may prove valuable in her evaluation.
Patients will have a more positive experience if they feel that adequate time was allowed for their visit and that the practitioner was prepared to answer questions. Most patients indicate that they are more comfortable if the provider talks to them during the examination. Silence can cause the patient to think that something is wrong. If the provider explains what is coming next, maintains eye contact as much as possible, and comments on findings, the patient is more likely to feel relaxed and safe. Some women will feel more at ease if they are allowed to view their own anatomy by using a hand-held mirror during the examination. Warming instruments and trying to be as gentle as possible during the examination are good habits. Some women desire an attendant to be present during their examination but many prefer not. Ideally a woman is empowered to choose whether a chaperone is present during her examination. There are situations where the provider must have a chaperone present for examinations due to liability or security concerns. If so, this should be explained to the patient.8
The examiner should be conscious of patient behaviors that suggest anxiety during the examination. These include holding hands, covering or shutting the eyes, placing hands on shoulders, hands covering the pelvis, placing hands on legs, or hands holding the table. Such behaviors signal the need for a more careful or respectful approach. The examiner may suggest techniques to promote relaxation, such as slow exhalation, and may provide more information about what is coming next in the examination and what the patient may feel. The provider should endeavor to individualize the consultation and examination style so that it meets the needs of the patient.9
The pelvic examination is usually performed with the patient lying supine on an office examination table with the knees flexed, and with the feet in supporting stirrups. Some examination tables have supports that fit behind the knees instead. Electric examination tables are available, with which the patient’s head can be lowered from a seated position; these can be advantageous for the elderly or for patients with mobility problems. The patient’s head is often elevated with a pillow, or by slightly elevating the head of the examining table. This allows better eye contact between the practitioner and the patient and may help the patient to relax.
In order to perform a pelvic examination the practitioner should have a good light source, non-sterile gloves, a speculum of proper size, and water-soluble lubricant. A variety of the most commonly used specula, materials with which to obtain cervical cytologic samples, fixative, large cotton-tipped swabs, and a test kit for occult blood in stool should be immediately available in the examination room. Swabs and transport media for cervical cultures, test tubes, and normal saline for wet mounts, and pH paper should also be on hand.
Performance of the Gynecologic Examination
The breast examination is included in a routine gynecologic examination. The technique for breast examination is outlined in another chapter. The health care provider should instruct the patient about how to undertake a breast self-examination.
EXAMINATION OF THE ABDOMEN.
Examination of the abdomen is likewise included in the general gynecologic examination. The abdomen should be examined utilizing the standard techniques of inspection, auscultation, percussion, and palpation. The contour of the abdomen and appearance of the skin should be noted. Auscultation aids in the assessment of intestinal peristalsis (bowel sounds) and in the detection of abdominal bruits. Percussion is utilized to determine the size of abdominal and pelvic structures such as the liver and masses, as well as any abdominal fluid collection such as ascites. Percussion is also useful for assessing abdominal and pelvic tenderness. Finally, palpation is performed to assess for tenderness, organ enlargement, and masses.
If tenderness is noted, the examiner should assess for involuntary guarding and rebound tenderness. In addition, it may be helpful to ask the patient to raise her head from the examination table so as to flex the rectus abdominus muscles. Tenderness localized to the abdominal wall will typically worsen with this maneuver.
There can be a tendency to focus on insertion of the speculum for obtaining cytology specimens. The examiner should always remember to inspect the external genitalia first for normalcy of appearance and hair distribution. Any lesions or developmental abnormalities are noted. Hormonal abnormalities may cause changes in the external genitalia, such as clitoromegaly. States accompanied by low levels of estrogen are associated with atrophy of the mucosae. The skin should be inspected and palpated for superficial and subcutaneous lesions.
The Bartholin’s (greater vestibular) gland openings are located at approximately the 5 and 7 o’clock positions, just lateral and posterior to the vaginal orifice. They may be visible, but the normal Bartholin’s gland is not palpable. The Skene’s (paraurethral) glands are likewise not palpable in the healthy state. The urethra is inspected for the presence of caruncle and other findings.
Vagina and Cervix.
The vagina is inspected with the use of a speculum. There are many different sizes of specula varying both in length and width. The largest size that is comfortable allows the best visualization. The examiner should be ready to switch to a narrower or shorter speculum if the patient is uncomfortable with the size selected.
Speculum insertion is more comfortable if the instrument is warmed. The speculum can be moistened with warm water, which does not interfere with the results of cultures, cytology, or wet mount. Lubricants can alter the results of these studies, and should only be used if none of these studies will be undertaken. The examiner may exert gentle downward (posterior) pressure at the introitus with one or two fingers before inserting the speculum. The speculum blades can be inserted at an oblique to horizontal angle but should never be inserted vertically so as to avoid the sensitive suburethral area. Utilizing steady posterior pressure, the blades are advanced to the vaginal apex. The speculum can then be gently opened to expose the cervix. Sometimes a gentle rocking motion will allow the cervix to come into view.
The vagina and cervix are inspected for lesions. The vagina is also inspected for the presence or absence of rugae to assess the level of estrogen present. The examiner assesses any vaginal discharge that is present for normalcy in appearance, color, consistency, and odor. Physiologic vaginal discharge is scant in amount, flocculent, and white. The pH of the normal vagina is less than 4.2. Normal cervical mucus is clear.
Samples are taken for cervical or vaginal cytology. Cervical cytology should include a sample from the ectocervix taken with a spatula and a sample from the endocervical canal taken with a brush. Cervical cytology should be fixed immediately after obtaining the sample in order to avoid air-drying artifact. In the absence of a cervix, a spatula can be used to obtain a smear from the vaginal cuff.
If indicated, samples are then obtained for cervical cultures and vaginal wet mount. Swabs used to collect samples for cervical cultures should be left in the endocervical canal for 15 to 30 seconds. A swab of vaginal sidewall secretions is placed in normal saline for direct microscopic examination (wet mount) to evaluate for vaginitis. The pH of vaginal secretions can be assessed with pH paper.
The vagina is inspected for lesions as the speculum is withdrawn, again with care to avoid anterior discomfort.
If indicated, the examiner now proceeds to evaluate vaginal wall relaxation and uterine prolapse. This can be done by removing the anterior blade of the speculum and using the posterior blade as a retractor, or by using one’s hand as the posterior retractor. The integrity of the vaginal walls is examined throughout 360 degrees, and at the apex. The patient may be asked to increase intra-abdominal pressure with the Valsalva maneuver to accentuate the findings. Examination can also be performed with the patient standing to better assess the integrity of pelvic support when the patient is upright.
Typically, the bimanual examination is performed with the aid of lubricating jelly. The examiner usually places two fingers in the vagina and uses the opposite hand to palpate the lower abdomen. Sometimes only a single digit is placed in the vagina for patient comfort. The examiner palpates the vagina, cervix, uterus, adnexa, and surrounding structures by elevating structures with the vaginal hand and palpating in a downward fashion with the abdominal hand. Tenderness with lateral movement of the cervix (cervical motion tenderness) is assessed, as well as the size, mobility, position and contour of the uterus. The adnexa are palpated. Any masses that are appreciated are assessed for size, location, mobility, tenderness, and contour. The posterior cul-de-sac and utero-sacral ligaments are checked for nodularity and masses.
Some believe that a rectal examination is an important element of every gynecologic examination. Others feel that it is only necessary in the age group for whom fecal occult blood testing is recommended for routine preventative health care (annually beginning at age 50). A reasonable middle-ground approach involves including a rectovaginal examination when the bimanual examination alone has been insufficient to fully assess the pelvic anatomy, when one suspects endometriosis or a pelvic mass, or if there are symptoms attributable to the rectal area.
Gloves should be changed prior to the rectal examination. This prevents contamination of the sample for occult blood. The examiner inserts an index finger into the vagina, and utilizing lubricant, inserts the middle finger into the rectum. The examiner palpates the rectovaginal septum and again places the opposite hand on the patient’s lower abdomen to palpate the previously assessed structures. The uterosacral ligaments may be palpated more easily with the rectovaginal examination than the bimanual examination. The rectum is assessed for masses. On withdrawing the rectal finger, a sample of stool can be checked for occult blood.
1. Moore TR, Rhomberg A: A longitudinal approach to women’s health care. In Moore TR, Reiter RC, Rebar RW, Baker VV (eds): Gynecology and Obstetrics. A Longitudinal Approach. p. 22, New York, Churchill Livingstone, 1993