GYNAECOLOGICAL HISTORY AND EXAMINATION

LECTURE OVERVIEW Taking a gynaecological history ABCD(I)F

Abdominal/ pelvic painBleedingContraceptionDischarge and itch(E) Incontinence and prolapseFertility

Performing a gynaecological examinationAbdominal palpationSpeculum examination of vulva/ vagina/cervixBimanual palpation of uterus and adnexae

Approach to common gynaecological symtoms

GYNAECOLOGICAL HISTORYAgePast medical, surgical, gynaecological

historyMedicationsAllergiesFamily HistorySocial History

GYNAECOLOGICAL HISTORYPast Obstetric History

Have you ever been pregnant before?Spontaneous abortions, terminations of pregnancy,

ongoing pregnancies, living childrenWhat happened in those pregnancies?

Spontaneous, duration of pregnancy, type of labour and delivery, outcome, complications

GYNAECOLOGICAL HISTORYGynaecological History

Abdominal pelvic painBleedingContraceptionDischarge (itch)Incontinence and prolapse FertilityScreening history

(1) PELVIC PAINWhat causes pain?

OvulationDysmenorrhoeaovarian cysts, particularly if complicated

(THINRIM) torsion, haemorrhage, infection, necrosis, rupture, malignant change

endometriosis infection

PID, tubo-ovarian abscesscomplication of pregnancy

miscarriage, ectopic pregnancy

(1) PELVIC PAINPain with periods (dysmenorrhoea)Pain with sex (dyspareunia)Pain at other times

Site of pain, radiation sudden or gradualassociated symptoms

fever, dischargeLNMP

(2) BLEEDINGMenstrual history

menarchecycle length and regularity (5/28)midcycle bleeding/pain/mucus changeexcessively heavy or painfulLNMP

Abnormal bleedingAbnormal menstrual bleedingAbnormal non menstrual bleeding

intermenstrual bleeding, post coital bleeding, postmenopausal bleeding

(2) BLEEDING

What causes abnormal menstrual bleeding?

‘Dysfunctional bleeding’ (ie abnormal menstrual bleeding in response to reproductive hormones)

ovulatoryanovulatory

Uterine pathology which increases surface area of endometrium

polypsfibroids

Coagulopathy

(2) BLEEDINGWhat causes non-menstrual

bleeding?

Post coital bleedingcervical lesion (polyp, cervicitis, cancer)

Intermenstrual bleedingmidcycle bleedingcervical/ uterine malignancy

Postmenopausal bleedingcervical/ uterine malignancyendometrial hyperplasiaatrophic endometrium

(3) DISCHARGE AND ITCHWhat causes discharge?

physiological dischargetubal infection (PID)/ malignancyuterine infection/malignancycervical infection/malignancyvaginal infection (vaginitis, vaginosis)vulval infection/ malignancy

Physiological discharge + bacterial vaginosis and vaginitis + UGT infection = 95% of presentations with discharge

(3) DISCHARGE AND ITCHNature of discharge

amountcolour (bloody, offensive, yellow, brown)offensiverelationship to period

Associated symptomsvulval burning and itch, urinary frequency

(4) CONTRACEPTION AND FERTILITYType of contraception, side-effects,

compliance, complications including breakthrough pregnancies

Fertilitynumber of pregnanciestime taken to get pregnant

Infertilitydurationsexual historyhistory of anovulation, tubal disease or

surgery, male factor

(5) PROLAPSE AND INCONTINENCE Vulval lump, dragging pain or pressure

Incontinenceurinary

stressurgency

faecal incontinence or soilingflatus incontinence

GNAECOLOGICAL EXAMINATIONExplain examinationAllow patient privacy to changeChaperoneEnsure patient is draped, and room is warm

and comfortable

GNAECOLOGICAL EXAMINATIONGeneral examination

H&N, breasts, cardiorespiratory, abdominal, periphery

Abdominal palpationInspection external genitaliaSpeculum examination vagina/cervixBimanual palpation of uterus and adnexae

Inspection

Hair distributionVulval skinLook at the

perineum for scars/tears

Gently part labia – inspect urethra

Look for discharge, prolapse, ulcers, warts

Pelvic Examination Empty bladder!

Wash hands, gloves, warm vaginal speculum with warm water, obtain specimens as needed (Pap smear, cultures)

Vaginal Lesions, discharge

CervixCervical excitation, os

open/closed,Polyps, erosions, etc...

UterusSize, shape, regularity,

tenderness, position, mobility Adnexa

Masses, tenderness, ovaries Rectal

Mass, tenderness, blood

Insertion

• Use lubricant and warm speculum if possible

• Hold speculum in dominant hand

• Part labia with nondominant hand

• Slowly insert and open speculum blades to visualize the cervix.

Visualisation of Cervix

Inspect for:• Discharge• Warts• Tumours• Size of cervical os• Bleeding

Taking a cervical smearFollowing insertion of bivalve speculumEquipment prepared before examination

begins:glovesAylesbury spatulaConfirm name, DOB, hosp number etcLabel frosted end of slideFixative agentPosition equipment

Taking a Cervical smear

Rest point of spatula within the os and rotate clockwise 360° then rotate 360° anti-clockwise.

Exert light pressure (pencil).

Ensure contact with cervix throughout.

Concluding Cervical Smear

REMOVE the speculum!Ensure patient comfort/safetySpread both sides of the spatula onto the

slide.Perform similar procedure for cytobrushSpray fixative immediately onto the

labelled slide surface

Bimanual Examination

Separate labia with gloved left hand

Slowly insert index finger and middle finger into vagina then palpate cervix

Left hand then palpates uterus and adnexa abdominally

Univalve Speculum Positioning

Position patient in the left lateral position

Left leg extendedRight Knee drawn

up to chestHold back anterior

vaginal wall with lubricated speculum

Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.

AgeHx of presenting complaintPast Obstetric Hx (gravity, parity)Past gynae HxPMHx, PSHx, PGHxMedications, AllergiesFHx, SHx

Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding. History of bleeding

menstrual cycle; ? ovulatingamountLNMPcontraceptionsinister features: post coital, intermenstrual, post

menopausal bleedingassociated symptoms

pain, symptoms of anaemia Remainder of gynae history

discharge, prolapse, incontinence, POHx, fertility, PAP, breasts

Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.

O/Ex:general examinationpallorabdominal palpation

?enlarged or tender uterusspeculum examination

blood coming from osnormal vagina and cervix

Bimanual examinationsize of uterusadnexal pathology

Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.

Ix will depend on Hx and Ex, but may involve:hCGPAP smearFBEFe studiesCoagulation profileUltrasoundEndometrial samplingHysteroscopy, D&C

SUMMARY How to take a ‘general’ gynaecological history

(A,B,C,D,I/P,F) Reproductive screening How to take a ‘targetted’ history of a specific presenting

complaint such as bleeding, pain, discharge, prolapse and incontinence, infertility

3 parts of gynaecological examinationabdominal palpationspeculum examinationbimanual examination

Combining history and examination features to come up with a differential diagnosis, and plan investigations