Gynaecology History and Examination

This should be handled with sensitivity and preservation of dignity for the patient. A chaperone should be available and offered.

Presenting complaint

Allow the patient to tell you her problem. She may need prompting over more delicate issues especially if you are a man. A feeling of "something coming down below" may be a prolapse.

• Menstrual history:
  • Last menstrual period - date of first day of bleeding (LMP)
  • Cycle length and frequency e.g. 5/28, 5 days of bleeding every 28 days
  • How heavy is the bleeding? Number of tampons per day/clots/flooding/double protection
  • Any inter-menstrual bleeding (IMB)
  • Any postcoital bleeding (PCB)
  • Age of menarche/menopause
  • Any postmenopausal bleeding (PMB)
• Discharge:
  • Colour
  • Amount
  • Smell
  • Itchiness
  • Duration
  • Rash
  • Any symptoms in partner
• Pain:
  • Duration, type, alleviating or aggravating factors, radiation
  • Any relation to cycle (mid-cycle or period related)
  • Any possibility of pregnancy (ectopic)
  • Bowel problems
  • Dyspareunia - superficial or deep
• Urinary symptoms:
  • Leakage
  • Cloudiness
  • Haematuria
  • Hesitancy
  • Dysuria
  • Frequency
  • Stranguary
  • Stress or urge incontinence
• Obstetric history:
  • No. of children, details of pregnancy, labour and delivery, birth weights
  • Any problems with the babies?
  • Miscarriages/terminations
  • Any postnatal problems e.g. depression
  • Conception difficulties/subfertility
• Contraception:
  • Contraceptive history
  • Any recent unprotected intercourse
  • Reliability of method and user
  • Potential contraindications to different methods e.g. combined pill
  • Permanent or temporary method required
• Sex/relationships:
  • Sexually active?
  • Sexual orientation
  • Relationship difficulties - ask open ended questions e.g. "How are things between you?"
• Infection:
  • Any past history of pelvic inflammatory disease
  • Was it adequately treated, including contact tracing
  • Any known contact with STD
  • Asses the risk of HIV and hepatitis
• General health:
  • Smoking/alcohol/drugs (esp IV usage)
  • Note any other health symptoms or concerns e.g. arthritis, physical mobility problems, any breast symptoms such as breast tenderness, discharges, lumps, history of breast cancer etc. acne, hirsutism, abnormal weight gain or loss etc.
• Gynaecological operations
• Date and result of last cervical smear

Allow privacy to undress, offer a chaperone for the examination, and record its offer in notes (together with whether offer was taken up or declined). Always use a chaperone if requested and especially if your sixth sense tells you to. Provide a blanket or other clean cover. Explain what you are doing and why before you do it rather than as you do it.

• General appearance:
  • Paleness
  • Jaundice
  • Smoke stained fingers
  • Obesity
  • Extreme thinness
  • Swollen abdomen
  • Ankle swelling
  • Look for pyrexia, shock, swelling
• Blood pressure, breast examination (if appropriate)
• Abdomen palpation feeling for:
  • Peritonitis
  • Abnormal lumps including enlarged uterus, liver, spleen, nodes in groin and umbilicus
  • Ascites, distended veins - peritoneal secondaries can show with an umbilical secondary
  • Percuss the bladder if palpably enlarged, or indicated from history

Vaginal examination

• Usually done with the patient on her back.
• Look at the vulva for any abnormalities of skin texture, lumps, excoriation, lichenification and whitening.
• Choose the appropriate sized speculum - usually Cusco's bivalve speculum - for the patient.
• Warm the speculum before use.
• Part the labia with your hand from above and introduce the speculum at a slight tilt to the vertical and twist it gently to the horizontal.
• Point the speculum downwards, at about 45 degrees, open making sure that the handle is not impinging on the clitoris.
• Look at the vaginal mucosa and locate cervix.
• Take a vaginal swab if discharge.
• Check for retained tampon.
• Look for warts/herpes (the rash may give symptoms for a week or so before the vesicles appear).
• If no cervix visualised:
  • Try partially withdrawing and try again.
  • Perform bimanual examination to establish position of cervix.
  • Ask patient to hold onto her knees or put hands under sacrum to tilt the pelvis. A pillow could also be used.
  • If still no luck try on a different occasion.

• Ideally this should take place mid-cycle.
• Visualise cervix, clear excess mucus/discharge.
• Make a full 360 degree sweep of the cervix /- endocervical brush (whichever is most likely to sample the transformation zone).
• If there is an obviously abnormal area on the cervix, note the position on form/notes and include the area in your smear sweep.
• Take care not to pinch the vaginal wall or even the cervix when withdrawing the speculum.
• Fix the slide immediately as drying before fixing spoils the smear.
• Remember to note your findings.
• Tell patient how long to leave it before checking up results.
• Mention possibility of needing to redo smear or examine more closely (colposcopy).
• Many practices now use liquid based cytology for preserving and transporting smears. This has reduced the rate of inadequate smears. Training is provided locally.

Bimanual examination

• Use your left hand to palpate abdomen and right for internal (if examining from right).
• Feel for any abnormalities of the vagina.
• Feel the cervix for areas of roughness, hardness, lumps.
• Assess uterine position, size, mobility, lumpiness, tenderness.
• Feel the adnexae bimanually for any swelling or tenderness.

Urinary incontinence

Confirmation of leakage can be done by asking patient to cough whilst holding a tissue over urethral opening either lying or standing with feet slightly apart.
However if there is a history of urinary incontinence then refer for urodynamics.

Prolapse

• Vaginal examination needs to be performed with a Sims speculum in the left lateral position looking for a cystocoele or rectocoele.
• Assistant can hold leg at 30 degrees (useful if patient is obese).
• Need to have a good light and look for uterine or vaginal prolapse whilst withdrawing the Sims speculum.