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General Gynecologic Evaluation Gynecologic evaluation may be necessary to assess a specific problem such as pelvic pain, vaginal bleeding, or vaginal discharge. Women also need routine gynecologic evaluations, which may be provided by a gynecologist, an internist, or a family practitioner; evaluations are recommended every year for all women who are sexually active or > 18 yr. Many women expect their gynecologist to provide general as well as gynecologic health care. Obstetric evaluation focuses on issues related to pregnancy. Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. History Gynecologic history consists of the problem prompting the visit; menstrual, obstetric, and sexual history; and history of gynecologic symptoms, disorders, and treatments. Menstrual history includes age at menarche, number of days of menses, length and regularity of the interval between cycles, start date of the last menstrual period (LMP), dates of the preceding period (previous menstrual period, or PMP), color and volume of flow, and any symptoms that occur with menses (eg, cramping, loose stools). Usually, menstrual fluid is medium or dark red, and flow lasts for 5 (± 2) days, with 21 to 35 days between menses; average blood loss is 30 mL (range, 13 to 80 mL), with the most bleeding on the 2nd day. A saturated pad or tampon absorbs 5 to 15 mL. Cramping is common on the day before and on the 1st day of menses. Vaginal bleeding that is painless, scant, and dark, is abnormally brief or prolonged, or occurs at irregular intervals suggests absence of ovulation (anovulation). A complete obstetric history includes dates and outcomes of all pregnancies and previous ectopic or molar pregnancies. Sexual history includes frequency of sexual activity, number and sex of partners, use of contraception, participation in unsafe sex, and effects of sexual activity (eg, pleasure, orgasm, dyspareunia). The examiner should be professional and nonjudgmental. The patient is asked about any symptoms present: for pelvic pain, its location, duration, character, quality, and triggering and relieving factors; for abnormal vaginal bleeding, its quantity, duration, and relation to the menstrual cycle. Patients of reproductive age are asked about symptoms of pregnancy (eg, morning sickness, breast tenderness, delayed menses). Screening for domestic violence should be routine. Methods include self-administered questionnaires and a directed interview by a staff member or physician. In patients who do not admit to experiencing abuse, findings that suggest past abuse include inconsistent explanations for injuries, delay in seeking treatment for injuries, unusual somatic complaints, psychiatric symptoms, frequent emergency department visits, head and neck injuries, and having given birth to a low-birth-weight infant. Physical Examination The examiner should explain the examination, which includes breasts, abdomen, and pelvis, to the patient. For the pelvic examination, the patient lies supine on an examination table with her legs in stirrups and is usually draped. A chaperone may be required. The pubic area and hair are inspected for lesions, folliculitis, and lice. The perineum is inspected for redness, swelling, excoriations, abnormal pigmentation, and lesions (eg, ulcers, pustules, nodules, warts, tumors). Structural abnormalities due to congenital malformations or female genital mutilation are noted. A vaginal opening that is < 3 cm may indicate infibulation, a severe form of genital mutilation. Next, the introitus is palpated between the thumb and index finger for cysts or abscesses in Bartholin's glands. While spreading the labia and asking the patient to bear down, the examiner checks the vaginal opening for signs of pelvic relaxation: an anterior bulge (suggesting cystocele), a posterior bulge (suggesting rectocele), and displacement of the cervix toward the introitus (suggesting prolapsed uterus). Before speculum and bimanual examination, the patient is asked to relax her legs and hips and breathe deeply. If a Papanicolaou (Pap) test or cervical culture is planned, the speculum is rinsed with warm water; if not, it is lubricated. Then, it is inserted with the handle horizontal (blades vertical) while widening the vagina by pressing 2 fingers on the posterior vaginal wall. The speculum is fully inserted, then rotated so that the handle is down, and opened, pulling back as needed to visualize the cervix. Normally, the cervix is pink and shiny, without discharge. A specimen for the Pap test is taken from the endocervix and external cervix with a brush and plastic spatula; both are rinsed in a liquid, producing a cell suspension to be analyzed for cancerous cells and human papillomavirus. Specimens for detection of sexually transmitted diseases (STDs) are taken from the endocervix. The speculum is withdrawn, taking care not to pinch the labia with the speculum blades. For the bimanual examination, the index and middle fingers of the dominant hand are inserted to just below the cervix. The other hand is placed just above the pubic symphysis and gently presses down to determine the size, position, and consistency of the uterus and, if possible, the ovaries. Normally, the uterus is about 6 cm by 4 cm and tilts anteriorly (anteversion), but it may tilt posteriorly (retroversion) to various degrees. The uterus also may be bent at an angle anteriorly or posteriorly (anteflexion and retroflexion, respectively). The uterus is movable and smooth; irregularity suggests uterine fibroids (leiomyomas). Normally, the ovaries are about 2 cm by 3 cm in young women and not palpable in postmenopausal women. With ovarian palpation, mild nausea and tenderness are normal. Significant pain when the cervix is gently moved from side to side (cervical motion tenderness) suggests pelvic inflammation. After bimanual palpation, the examiner palpates the rectovaginal septum by inserting the index finger in the vagina and the middle finger in the rectum. For children, the examination should be adjusted according to their psychosexual development and is usually limited to inspection of the external genitals. Young children can be examined on their mother's lap. Older children can be examined in the knee-chest position or on their side with one knee drawn up to their chest. Vaginal discharge can be collected, examined, and cultured. Sometimes a small catheter attached to a syringe of saline is used to obtain washings from the vagina. If cervical examination is required, a fiberoptic vaginoscope, pediatric cystoscope, or flexible hysteroscope with saline lavage should be used. In children, pelvic masses may be noted during palpation of the abdomen. Testing Most women who are of reproductive age and have gynecologic symptoms are tested for pregnancy (see Approach to the Pregnant Woman and Prenatal Care: Ultrasonography). Urine assays of the β subunit of human chorionic gonadotropin (β-hCG) are specific and highly sensitive; they become positive within about 1 wk of conception. Serum assays are specific and even more sensitive. Specimens of cervical cells taken for the Pap test are examined for signs of cervical cancer; the examination may also detect uterine cancer and human papillomavirus. Pap tests are done routinely for most of a woman's life. Microscopic examination of vaginal secretions helps identify vaginal infections (eg, trichomoniasis, bacterial vaginosis, yeast infection. Culture or molecular methods (eg, PCR) are used to analyze specimens for specific STD organisms (eg, Neisseria gonorrhoeae , Chlamydia trachomatis) if patients have symptoms or risk factors; in some practices, such analysis is always done. Bedside inspection of a cervical mucus specimen by a trained examiner can provide information about the menstrual cycle and hormone states; this information may help in assessment of menstrual dysfunction, infertility, suspected endocrine disorders, and time of ovulation. The specimen is placed on a slide, allowed to dry, and assessed for degree of microscopic crystallization (ferning), which reflects levels of circulating estrogens. Just before ovulation, cervical mucus is clear and copious with abundant ferning because estrogen levels are high. Just after ovulation, cervical mucus is thick and ferns little. Pituitary and hypothalamic hormones and ovarian hormones may also be measured. Imaging of suspected masses and other lesions usually involves ultrasonography, which may be done in the office; both transvaginal and transabdominal probes are used. MRI is highly specific but expensive. CT is usually less desirable because it is somewhat less accurate and involves significant radiation exposure and often radiopaque agent. Laparoscopy detects structural abnormalities too small to be detected by imaging, as well as abnormalities on the surfaces of internal organs (eg, endometriosis, inflammation, scarring); it is also used to sample tissue. Culdocentesis, now rarely used, is needle puncture of the posterior vaginal fornix to obtain fluid from the cul-de-sac (which is posterior to the uterus) for culture and for tests to detect blood from a ruptured ectopic pregnancy or ovarian cyst. Endometrial aspiration is done if women > 35 have unexplained vaginal bleeding. A thin, flexible, plastic cannula is inserted through the cervix (often dilation is not required) to the level of the internal cervical os. Suction is applied to the device, which is turned and moved up and down a few times to sample different parts of the endometrial cavity. Sometimes the uterus must be stabilized with a cervical tenaculum.
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