Gynaecological examination and history

Gynaecological consultations should be handled with sensitivity and preservation of dignity for the patient. If the patient has come with someone (partner, friend, parent etc) then make sure to also see them alone. If they do not speak English, it is best to arrange a professional interpreter rather than allowing a relative, friend or partner to translate. If there is no professional interpreter available, consider seeing them again when you can get one.

Always consider the possibility of pregnancy.

Gynaecological history

Presenting complaint

Allow the patient to tell you their problem. They may need sensitive prompting over more delicate issues.

Direct questioning will then depend on the complaint but the following list includes issues which may need to be covered.

Menstrual history

• Last menstrual period (LMP) - date of first day of bleeding.

• Cycle length, regularity or irregularity and frequency - eg, 5/28, five 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), postcoital bleeding (PCB) or postmenopausal bleeding (PMB) - for the latter, note whether or not the patient is taking hormone replacement therapy and if so whether there have been any recent changes in the regime.

• Age of menarche/menopause.

Vaginal discharge

• Presence or absence of vaginal discharge.

  • Colour.

  • Amount.

  • Smell.

  • Itchiness.

  • Duration.

  • Timing within menstrual cycle.

  • Rash.

• Does their partner have symptoms?

Pain or discomfort

• Duration, type, alleviating or aggravating factors, radiation.

• Any relation to menstrual cycle (mid-cycle or period-related).

• Any possibility of pregnancy - remember to consider ectopic pregnancy.

• Bowel symptoms.

• Any feeling of 'something coming down below' - may be a prolapse.

• Dyspareunia - superficial or deep.

Urinary symptoms

• Leakage.

• Cloudiness.

• Haematuria.

• Hesitancy.

• Dysuria.

• Frequency.

• Strangury (slow, painful urination, caused by muscular spasms of the urethra and bladder).

• Stress or urge incontinence.

Obstetric history

• Number of children, details of pregnancy, labour and delivery, birth weights, complications.

• Miscarriages/terminations.

• Any postnatal problems - eg, depression.

• Conception difficulties/subfertility.

Contraception

• History of contraception used (previously and now).

• Any recent unprotected intercourse.

• Reliability of method and user.

• Potential contra-indications to different methods - eg, combined pill.

• Permanent or temporary method required.

Sexual history

• The key to taking a sexual history is to be matter of fact. If the clinician is embarrassed, the patient will be too.

• Whether sexually active.

• Sexual orientation - avoid heteronormativity, which is the assumption that someone is heterosexual. You could ask 'do you have sex with men, women or both' or if they mention a sexual partner could say 'is that a man or a woman'.

• Number of partners in the last three months, whether sex was with condoms or condomless, any sexually transmitted infection (STI) screens.

• Relationship difficulties. Ask open-ended questions - eg, "How are things between you?"

Past gynaecological history

• Infection:

  • Any past history of pelvic inflammatory disease (PID).

  • Whether it was adequately treated, including contact tracing.

  • Any known contact with sexually transmitted infections.

  • Assessment of the risk of HIV and hepatitis B.

• Gynaecological operations.

• Smear history - date and result of last cervical smear, previous abnormalities.

General health

• Smoking/alcohol/drugs (especially intravenous usage).

• Presence of other relevant symptoms such as:

  • Breast symptoms (such as tenderness, discharge, lumps).

  • Acne.

  • Hirsutism.

  • Weight changes.

• Other health symptoms or concerns.

In keeping with General Medical Council (GMC) guidance for intimate examinations, you should:¹

• 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 their dignity. For example, allow privacy to undress and dress. Provide a cover (eg, a few squares of couch roll) for them to use if they wish.

General examination

• General appearance:

  • Pallor or signs of anaemia.

  • Jaundice.

  • Smoke-stained fingers.

  • Obesity.

  • Extreme thinness.

  • Swollen abdomen.

  • Ankle swelling.

  • Pyrexia.

• Blood pressure.

• Palpation of the abdomen - feeling for:

  • Peritonitis.

  • Abnormal lumps including enlarged uterus, liver, spleen, nodes in the groin.

  • Ascites.

  • Umbilical abnormalities.

  • Bladder. Percuss the bladder if palpably enlarged or if indicated from history.

Bimanual examination

• Doing a bimanual examination before a speculum will help you to feel how far back the cervix is and therefore to choose the correct length of speculum.

• Do not perform a vaginal examination in primary care if there is any suspicion of an ectopic - you could rupture it.

• Use your left hand to palpate abdomen and your right inside the vagina (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.

Speculum examination

• Usually done with the patient lying on their 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.

• If the presentation is of urinary incontinence, 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.

• Look for atrophic changes (if menopausal).

• Choose an appropriately sized speculum for the patient.

• 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. Take a cervical smear if it is due.

• 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.

Examining for prolapse

• Ask them to bear down to look for descent of the vaginal walls or uterus. It may be necessary to ask them to stand up to visualise any prolapse.

• Assess ability to use pelvic floor musculature by asking them to squeeze on your examining finger in the vagina.

• Vaginal examination with a Lucy* speculum in the left lateral position is helpful in looking for a cystocele or rectocele. Look for uterine or vaginal prolapse whilst withdrawing the Lucy speculum.

*'Lucy speculum' is a proposed new name for what was previously called a Sims speculum; it is named after one of his victims. In light of the revelations about Marion Sims' experiments on enslaved African American women, who could not consent, it is now considered inappropriate for an instrument to be named after him. ²³