APPROACH TO GYNAECOLOGY

PATIENT

DR HALIMATUN MANSOR

SPECIALIST

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

HSNZ

APPROACH TO GYNAECOLOGY PATIENT Gynaecology history and examination

are a modification of a standardized history taking design for

elucidation of the presenting problems,concluding provisional and differential

diagnosisPlanned for further management

HISTORY Depending on the presenting complaint

Age of menarche/menopauseMarital status- infertilityLNMPLength of menstruation and cycleFrequency and regularity of cycleMenstrual loss , presence of clots and

floodingDuration of dysmenorrhea and relation to

period

HISTORY Abnormal bleeding

IntermenstrualPostcoitalPostmenopausal

Abnormal PV dischargeColor, pruritus, offensive odour

HISTORY Sexual history

DyspereuniaContraceptionPrevious STD

Hormonal therapyOral / injectableHRT

HISTORY Menopausal symptoms

Pain Onset, duration , nature , siteRelation to menstrual cycle

Symptoms of prolapse, unconfortable lumps in vagina

HISTORY Urinary problems

Incontinence, (stress or urge)Frequency, nocturia or dysuria

Other systemic review

Past obstetric and gynaecology history Past medical and surgical history

HISTORY Social history Smoking, alcohol consumption Drug history

PHYSICAL EXAMINATION Always begin with

InspectionPalpationPurcussion Auscaltation

Genaral examination Specific examination

GENITAL EXAMINATION Inspection of genitalia and urethral

meatus Evidence of estrogen deficiency,

prolapse or abnormal masses Presence of abnormal bleeding or

discharge

GENITAL EXAMINATION Speculum Examination

Inspection of vagina and cervixTaking of cervical cytology or microbiology

swab

Assess uterovaginal prolapse and incontinance

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Candidiasis Strawberry cervix: Trichomonas

Bacteria vaginosisHerpes Simplex

Actinomyces infection

Atrophic cervicitis

Stage IV Complete eversion

GENITAL EXAMINATION Perform bimanual examination

Assess uterine size, shape, ante/retroverted, mobility of uterus

Tenderness- cervical motion, POD, adnexasPresence of abnormal masses at POD or

adnexaUterosacral ligament- presence of noduleThickness of the rectovaginal space

Imperforate hymen

FURTHER MANAGEMENTDifferential diagnosisRevise/Prioritise diagnosisInvestigationsTreatment / Management

COMMON PROCEDURES IN GYNAECOLGY Ultrasound PAP Smear for cervical screening Colposcopy procedure

http://en.wikipedia.org/wiki/Image:Nucal_thickness_11_weeks.JPG

1. PAP SMEAR SCREENING Cheap Acceptable Good sensitivity and specificity Achieved of screening must be 70-80%

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PAP SMEAR

Cervical Biopsy

Exfoliative cytology test cells collected are from normally shedding epithelium .

collected using spatulas or brushes.Specimen is fixed, stained and studied for morphology under microscope.

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HISTORY Initially using vaginal pool smears to

study hormonal status .

Found cancer cells on a slide containing a specimen from a woman's uterus.

Dr. George Papanicolaou reported the usefulness of the technique for detecting neoplastic cervical cells in 1941.

late 1940s to early 1950s, Pap smear became widely used as a screening technique.

Dr. George Nicholas Papanicolaou

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CONVENTIONAL PAP SMEAR

1. Approximately 80% of cells sample containing important diagnostic imformation is removed with sampling devices.

2. False negative rate at least 20% (mainly due to sampling error).

3. Sampling is a factor in up to 90% of false negative pap smear.

( JosephMG. Diagn Cytopathol 1991;7(5):477)

4.Up to 40% of all Pap smears are compromised by blood, mucus and inflammation. (Davey DD.Arch Pathol Lab Med 1992;116:90)

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INADEQUATE SMEARS Sampling

Scanty cells

Blood, mucous, pus

Mainly endocervical cells *

Preparation Too thick due to poor spreading

Air drying artifact

2.VISUAL INSPECTION TEST

VIA : Visual inspection with acetic acid.

VILI : Visual inspection with Lugol’s iodine.

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COLPOSCOPY A tool for screening as well as treatment

of cervical pathology especially at preinvasive and early stage

Need training and practice Available

smooth featureless covering of the cervix

Low grade lesion in a satellite pattern