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Assessment of gynaecological problems should be handled with sensitivity and preservation of dignity for the patient.
Always consider the possibility of pregnancy when presented with abnormal bleeding or pain.
Allow the patient to tell you her problem. She may need sensitive prompting over more delicate issues, especially if you are a man.
Direct questioning will then depend on the complaint but the following list includes issues which may need to be covered.
- Last menstrual period (LMP) - date of first day of bleeding.
- Cycle length and frequency - eg, 5/28, 5 days of bleeding every 28 days.
- Heaviness of bleeding. (Number of tampons per day/clots/flooding/need for double protection.)
- Presence or absence of intermenstrual bleeding (IMB).
- Presence or absence of postcoital bleeding (PCB).
- Age of menarche/menopause.
- Presence or absence of postmenopausal bleeding (PMB).
- Presence or absence.
- Timing within menstrual cycle.
- Any symptoms in a partner.
Pain or discomfort
- Duration, type, alleviating or aggravating factors, radiation.
- Any relation to menstrual cycle (mid-cycle or period-related).
- Any possibility of pregnancy. (Consider ectopic.)
- Bowel problems.
- Any feeling of "something coming down below" - may be a prolapse.
- Dyspareunia - superficial or deep.
- Stress or urge incontinence.
- Number of children, details of pregnancy, labour and delivery, birth weights, complications.
- Any postnatal problems - eg, depression.
- Conception difficulties/subfertility.
- Contraceptive history.
- Any recent unprotected intercourse.
- Reliability of method and user.
- Potential contra-indications to different methods - eg, combined pill.
- Permanent or temporary method required.
- Whether sexually active.
- Sexual orientation.
- Relationship difficulties - ask open-ended questions - eg, "How are things between you?"
Past gynaecological history
- Any past history of pelvic inflammatory disease.
- Whether it was adequately treated, including contact tracing.
- Any known contact with sexually transmitted infections.
- Assessment of the risk of HIV and hepatitis.
- Gynaecological operations.
- Smear history - date and result of last cervical smear, previous abnormalities.
- Smoking/alcohol/drugs (especially intravenous usage).
- Presence of other relevant symptoms such as:
- Breast symptoms (such as tenderness, discharge, lumps).
- Weight changes.
- Other health symptoms or concerns - eg, arthritis or physical mobility problems.
In keeping with General Medical Council (GMC) guidance for intimate examinations, you should:
- Explain why the examination is necessary and what it will involve. Do this before you start, rather than as you do it.
- Obtain permission for the examination and record this.
- Offer a chaperone and record this discussion and the outcome.
- Respect the woman's dignity. For example, allow privacy to undress. Provide a cover (eg, a few squares of couch roll) for the woman to use if she wishes.
- General appearance:
- Pallor or signs of anaemia.
- Smoke-stained fingers.
- Extreme thinness.
- Swollen abdomen.
- Ankle swelling.
- Blood pressure.
- Palpation of the abdomen - feeling for:
- Abnormal lumps including enlarged uterus, liver, spleen, nodes in the groin.
- Umbilical abnormalities.
- Bladder. Percuss the bladder if palpably enlarged or if indicated from history.
- Usually done with the patient lying on her back.
- Use a good examination light positioned over your shoulder.
- Look at the vulva for any abnormalities of skin texture, lumps, rashes, vesicles, excoriation, lichenification and whitening.
- Look for atrophic changes (in menopausal women).
- Choose an appropriately sized speculum - usually Cusco's bivalve speculum - for the patient.
- Warm the speculum before use. (Usually with warm water, as lubrication jelly may interfere with swab or smear results.)
- 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°; open, making sure that the handle is not impinging on the clitoris.
- Look at the vaginal mucosa and locate the cervix.
- Note any discharge. Take a vaginal swab if there is discharge present. Consider a cervical swab for chlamydia.
- Check for any retained tampon.
- If no cervix visualised:
- Try partially withdrawing and try again.
- Perform a bimanual examination to establish the position of the cervix.
- Ask the patient to hold on to her knees or put hands under the sacrum to tilt the pelvis. A pillow could also be used.
- The left lateral position may be more successful.
- If you are still unsuccessful, try on a different occasion.
- Use your left hand to palpate abdomen and your right for internal (if examining from the right).
- Feel for any abnormalities of the vagina.
- Feel the cervix for areas of roughness, hardness, lumps. Note any cervical excitation.
- Assess the uterine position, size, mobility, lumpiness, tenderness.
- Feel the adnexae bimanually for any swelling or tenderness.
NB: an ectopic pregnancy can be ruptured by bimanual examination, so be gentle.
- Within the pelvis (size of an orange) = 8 weeks.
- Suprapubic = 12 weeks.
- Mid-suprapubic umbilicus = 16 weeks.
- To umbilicus = 20 weeks.
- To xiphisternum = 36 weeks.
Confirmation of leakage can be done by asking the patient to cough whilst holding a tissue over the urethral opening, either lying or standing with the feet slightly apart.
- Ask the woman to bear down to look for descent of the vaginal walls or uterus. It may be necessary to ask her to stand up to visualise any prolapse.
- Assess ability to use pelvic floor musculature by asking her to squeeze on your examining finger in the vagina.
- Vaginal examination with a Sims' speculum in the left lateral position is helpful in looking for a cystocele or rectocele. Look for uterine or vaginal prolapse whilst withdrawing the Sims' speculum.
Taking a smear
- Smears are indicated for screening purposes. Most laboratories will not process them if taken earlier than at the recommended interval. Therefore, they are not part of most gynaecological examinations.
- Ideally, smears should be done mid-cycle.
- Liquid-based cytology (LBC) is now the method of choice.
- A brush is used rather than a spatula, which is rotated against the squamocolumnar junction (usually in the cervical canal). Two systems for LBC are in use. Both systems use brushes which look similar. In one, the head of the brush that contains the cells is broken off into a pot that contains special preservative liquid. The brush head is sent to the laboratory in the pot (this is the SurePath® brand method). In the other system, the brush is rinsed in the preservative to wash the cells into the pot. The brush is then discarded (this is the ThinPrep® brand).
- LBC is now used nationally. It has significantly reduced numbers of inadequate smears, as the liquid is spun and treated to remove other cells such as pus or blood. Numbers of inadequate smears dropped from over 9% to 2.8% when LBC was introduced.
- Older methods include the Papanicolaou (Pap) smear test which uses a brush or the Ayre spatula to sample the ectocervix, by rotating it twice through 360°. In both these methods, the material obtained is smeared on to a microscope slide, which is then sprayed with or immersed in a fixative solution prior to transporting to the laboratory.
Further reading and references
Wood LN, Anger JT; Urinary incontinence in women. BMJ. 2014 Sep 15349:g4531. doi: 10.1136/bmj.g4531.
Osayande AS, Mehulic S; Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014 Mar 189(5):341-6.
Nappi RE, Palacios S; Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric. 2014 Feb17(1):3-9. doi: 10.3109/13697137.2013.871696.
Genital examination in women; Royal College of Nursing (RCN), 2013
The initial management of chronic pelvic pain; Royal College of Obstetricians and Gynaecologists (May 2012)
Good Medical Practice (2013); General Medical Council
Guidance on the use of liquid-based cytology for cervical screening; NICE Technology Appraisals, Oct 2003
Cervical screening across the UK; UK Screening Portal