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Gynecologic History and Physical exam

Gynecologic History and Physical exam. Jonathan Tankel FRCSC FACOG Dept of Obstetrics and Gynecology & Student Health Service, U of A jtankel@ualberta.ca. Gynecolgic History. Remember: This may be the women’s only contact with the health care system

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Gynecologic History and Physical exam

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  1. Gynecologic History and Physical exam Jonathan Tankel FRCSC FACOG Dept of Obstetrics and Gynecology & Student Health Service, U of A jtankel@ualberta.ca

  2. Gynecolgic History • Remember: • This may be the women’s only contact with the health care system • Women vary in their knowledge and comfort level • Sensitivity, non –judgmental • Best to do history prior to patient undressing • Avoid assumptions re sexual activity/orientation • Start with less sensitive questions and work “up” • May very depending on whether routine or problem specific visit

  3. Basic Gynecologic History:Menstrual (28 +/- 7 days) • Main complaint • Menstrual History: • Menarche, regular/irregular – cycle length, “heavy” intermenstrual bleeding, dysmenorrhea • Last period (LMP) and last normal period (LNMP) • Cyclical Molimina/PMS • Postmenopausal: LMP, Hormones (HRT), Bleeding (PMB), Vasomotor symptoms, symptoms of atrophy

  4. Gynecologic History:Sexual • 43% women report some form of sexual dysfunction • Patient will often not offer history unless asked “thought it normal, too embarrassed • Are you sexually active? If not prior? When? • Men, women or both? • Penetrative or not? • Satisfied – frequency and quality? Pain? • Any recent new partner or contacts?

  5. Gynecologic HistoryObstetrical • Number of pregnancies G (gestation),P (birht), PT,T, A • Miscarriages, terminations, ectopic’s • Assisted reproduction • Pregnancies • Date • Type of delivery (Vaginal , Operative: C-section, vacuum, forceps) • Maternal complications ( eg HPT,DM) • Fetal complications (eg IUGR, anomalies, stillbirth) • Current health of kids

  6. Gynecologic History:Contraception • Type, past and current • Side effects • Compliance??? • 48% Pregnancies unplanned in N. America!

  7. Gynecologic History:PAP test • Date of last • History of abnormal’s and follow - up • New guidelines; • 1st up after 3 years of “intimate” sexual activity AND age 21 (nobody should be doing one until they are 21 except under very unusual circumstances) • After 3 normal pap’s AT LEAST 1 year apart in 5 years, every 3 years.

  8. Gynecologic History:Procedures • Type : (eg Endometrial biopsy, laparoscopy, hysteroscopy, D+C) • Date • Diagnosis • Complications .

  9. Gynecologic historyOther gynecologic problems • Infertility – how long, investigations, treatment • Ovarian cysts, type, treatment • Endometriosis • Infections: pelvic, vaginal, vulva • Diagnosis, frequency, treatment • Polycystic Ovary Syndrome (PCOS: 5-10% women)

  10. Other Gynecologic problems cont. • Pelvic pain: acute vs. chronic, location, onset, relation ship to menses, GI, UT, MSK • Urologic – Incontinence, frequency, urge • Prolapse • Vulvovaginal symptoms: discharge, dryness, pain, lesions

  11. Gynecologic History:Must include the rest! • Medical • Surgical • Social • Habits • Medications • Allergies • Family REMEMBER THE WOMAN FOR THE PAP WITH THE MELANOMA! • .

  12. GYNECOLOGIC EXAMINATION • 1st exam depends on history • Newborns • Young girls only if issue suggested • Adolescents/young adults: DON’T need exam to screen for STi (Urine for CT/GC • DO NOT EXAM for Contraception (Guys don’t need testicular exam before using condoms?!)

  13. Gyne. exam • Explain, use pictures to explain if possible • Offer mirror • Educational • Participate • Position: • Dorsal lithotomy traditional • Elevate 30-90 deg better • Comfort, eye contact • PROPER DRAPING

  14. Gyne. Exam continued

  15. Gyne exam continued • Explain in detail • 1 study 1000 women: • Discomfort 37% • Embarrassed 20% • Dislike examiner 7% • Prior problems 5% • MAINTAIN EYE CONTACT • Consent • Often presumed • Best to consent • See SOGC guidelines re exam under GA • Anxiety • Recognize • Reassure • Agree to stop if pain • Patient control

  16. Gyne exam contEquipment • Chaperone: NO universal guidelines, ideal, always offer, both male and female physicians at risk • Light, multiple sizes speculum, Pap “stuff”, swabs for Sti, large cotton swabs, pH paper (good for bacterial vaginosis, +4.5), gloves, lubricant, KOH, drapes

  17. Gyne exam:Breast • Breast : Annual exam recommended over 40 (ACOG) • Breast exam younger women controversial as is Breast self exam (higher chance benign lesions) • Inspect: Supine and sitting, hands above head and on hips • Observe: Contour, symmetry, skin, erythema • Palpate using pads of fingers systematically

  18. Gyne ExamAbdomen • Standard technique: • Inspect ( Mass seen?), skin changes, hernias • Palpate: tenderness, masses, hernias, organomegaly, inguinal nodes • Auscultate • Percussion

  19. Gyne exam:External Genitalia • Inspect: • Hair, skin (IMPORTANT!), labia minora and majora, clitoris, introitas, urethra, perineal body, Bartholin’s and periurethral glands • VESTIBULAR EPITHILIUM touched with dry q-tip to assess for pain (Vestibulodynia or provoked localized vulvodynia)

  20. Gyne examVAGINA • Speculum: • Plastic or Metal • Water or lubricant • Insert straight pointing down • Avoid vestibule if pain! (Can apply downward pressure if not – I don’t!) • Discharge: pH • Ulcerations, cysts, whitening, condylomata • PAP

  21. Gyne exam:Vagina cont

  22. Gyne exam:Vagina cont

  23. Gyne exam continued • PAP testing • See new guideline • Spatula then brush OR “1” device with 5 rotations • Evaluate vag wall relaxation and prolapse by removing top speculum and using bottom ½ • May need to have patient stand

  24. Gyne exam continued:Cervix

  25. Gyne exam:Cervix continued Polyps lead to bleeding, usually are removed

  26. Gyne exam cont:Bimanual • Palpation of Vagina, cervix, uterus, adnexa, cul de sac • If pain syndrome, START with single digit in vagina ONLY • Usually index and middle finger dominant hand OR only index finger • ONLY 60% sensitivity!

  27. Gyne exam:Bimanual continued • Uterus: Assess for size, shape, mobility, position, consistency • Version: Position of uterus relative to axis of vagina. Eg. Anteverted, reteroverted • Flexion: Position of uterine fundus relative to the axis of the cervix eg; anteflexed, reteroflexed. • Adnexa: Prominence, size of ovaries, usually tender, should NOT be palpable post menopause. Difficult even with experience • Obesity a limiting factor • Nodularity post cul de sac, tenderness • Motion tenderness: NOT SPECIFIC

  28. Gyne exam:Rectovaginal exam • Allows palpation of post cul de sac (Douglas) & Uterosacral ligaments (and uterus/adnexa) • POOR sensitivity and PPV (poor predictive value) • Not routine, do in high suspicion endometriosis, older (? > 50) • Also assesses rectal lesions, Occult blood, hemorrhoids, sphincter

  29. Gyne exam:Documentation • 6 elements of good record keeping: • Accuracy • Objectivity • Legibility • Timeliness • Comprehensiveness • Absence of alterations

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