1. GYNAECOLOGICAL HISTORY AND EXAMINATION

2. LECTURE OVERVIEW Taking a gynaecological history ABCD(I)F
Abdominal/ pelvic pain
Bleeding
Contraception
Discharge and itch
(E) Incontinence and prolapse
Fertility
Performing a gynaecological examination
Abdominal palpation
Speculum examination of vulva/ vagina/cervix
Bimanual palpation of uterus and adnexae
Approach to common gynaecological symtoms

3. GYNAECOLOGICAL HISTORY
Age
Past medical, surgical, gynaecological history
Medications
Allergies
Family History
Social History

4. GYNAECOLOGICAL HISTORY
Past Obstetric History
Have you ever been pregnant before?
Spontaneous abortions, terminations of pregnancy, ongoing pregnancies, living children
What happened in those pregnancies?
Spontaneous, duration of pregnancy, type of labour and delivery, outcome, complications

5. GYNAECOLOGICAL HISTORY
Abdominal pelvic pain
Bleeding
Contraception
Discharge (itch)
Incontinence and prolapse
Fertility
Screening history

6. (1) PELVIC PAIN What causes pain? Ovulation Dysmenorrhoea
ovarian cysts, particularly if complicated
(THINRIM) torsion, haemorrhage, infection, necrosis, rupture, malignant change
endometriosis
infection
PID, tubo-ovarian abscess
complication of pregnancy
miscarriage, ectopic pregnancy

7. (1) PELVIC PAIN Pain with periods (dysmenorrhoea)
Pain with sex (dyspareunia)
Pain at other times
Site of pain, radiation
sudden or gradual
associated symptoms
fever, discharge
LNMP

8. (2) BLEEDING Menstrual history menarche
cycle length and regularity (5/28)
midcycle bleeding/pain/mucus change
excessively heavy or painful
LNMP
Abnormal bleeding
Abnormal menstrual bleeding
Abnormal non menstrual bleeding
intermenstrual bleeding, post coital bleeding, postmenopausal bleeding

9. (2) BLEEDING What causes abnormal menstrual bleeding?
‘Dysfunctional bleeding’ (ie abnormal menstrual bleeding in response to reproductive hormones)
ovulatory
anovulatory
Uterine pathology which increases surface area of endometrium
polyps
fibroids
Coagulopathy

10. (2) BLEEDING What causes non-menstrual bleeding? Post coital bleeding
cervical lesion (polyp, cervicitis, cancer)
Intermenstrual bleeding
midcycle bleeding
cervical/ uterine malignancy
Postmenopausal bleeding
endometrial hyperplasia
atrophic endometrium

11. (3) DISCHARGE AND ITCH What causes discharge? physiological discharge
tubal infection (PID)/ malignancy
uterine infection/malignancy
cervical infection/malignancy
vaginal infection (vaginitis, vaginosis)
vulval infection/ malignancy
Physiological discharge + bacterial vaginosis and vaginitis + UGT infection = 95% of presentations with discharge

12. (3) DISCHARGE AND ITCH Nature of discharge amount
colour (bloody, offensive, yellow, brown)
offensive
relationship to period
Associated symptoms
vulval burning and itch, urinary frequency

13. (4) CONTRACEPTION AND FERTILITY
Type of contraception, side-effects, compliance, complications including breakthrough pregnancies
Fertility
number of pregnancies
time taken to get pregnant
Infertility
duration
sexual history
history of anovulation, tubal disease or surgery, male factor

14. (5) PROLAPSE AND INCONTINENCE
Vulval lump, dragging pain or pressure
Incontinence
urinary
stress
urgency
faecal incontinence or soiling
flatus incontinence

16. GNAECOLOGICAL EXAMINATION
Explain examination
Allow patient privacy to change
Chaperone
Ensure patient is draped, and room is warm and comfortable

17. GNAECOLOGICAL EXAMINATION
General examination
H&N, breasts, cardiorespiratory, abdominal, periphery
Abdominal palpation
Inspection external genitalia
Speculum examination vagina/cervix
Bimanual palpation of uterus and adnexae

18. Inspection Hair distribution Vulval skin
Look at the perineum for scars/tears
Gently part labia – inspect urethra
Look for discharge, prolapse, ulcers, warts
Hair extending towards umbilicus and onto inner thigh can be associated with disorders of androgen excess and clitoromegaly.
Vulva can be a site of chronic skin conditions such as eczema, psoriasis, Lichen sclerosis and warts, cysts of the Bartholin’s gland and cancers. Ulceration may imply herpes, syphilis, trauma or malignancy.
Perineal scars maybe secondary to childbirth.

19. Pelvic Examination Empty bladder! Vaginal Cervix Uterus Adnexa Rectal
Wash hands, gloves, warm vaginal speculum with warm water, obtain specimens as needed (Pap smear, cultures)
Vaginal
Lesions, discharge
Cervix
Cervical excitation, os open/closed,
Polyps, erosions, etc...
Uterus
Size, shape, regularity, tenderness, position, mobility
Adnexa
Masses, tenderness, ovaries
Rectal
Mass, tenderness, blood

20. Insertion Use lubricant and warm speculum if possible
Hold speculum in dominant hand
Part labia with nondominant hand
Slowly insert and open speculum blades to visualize the cervix.

21. Visualisation of Cervix
Inspect for:
Discharge
Warts
Tumours
Size of cervical os
Bleeding

23. Taking a cervical smear
Following insertion of bivalve speculum
Equipment prepared before examination begins:
gloves
Aylesbury spatula
Confirm name, DOB, hosp number etc
Label frosted end of slide
Fixative agent
Position equipment

24. Taking a Cervical smear
Rest point of spatula within the os and rotate clockwise 360° then rotate 360° anti- clockwise.
Exert light pressure (pencil).
Ensure contact with cervix throughout.

25. Concluding Cervical Smear
REMOVE the speculum!
Ensure patient comfort/safety
Spread both sides of the spatula onto the slide.
Perform similar procedure for cytobrush
Spray fixative immediately onto the labelled slide surface

26. Bimanual Examination Separate labia with gloved left hand
Slowly insert index finger and middle finger into vagina then palpate cervix
Left hand then palpates uterus and adnexa abdominally

29. Univalve Speculum Positioning
Position patient in the left lateral position
Left leg extended
Right Knee drawn up to chest
Hold back anterior vaginal wall with lubricated speculum

30. Hx of presenting complaint Past Obstetric Hx (gravity, parity)
Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.
Age
Hx of presenting complaint
Past Obstetric Hx (gravity, parity)
Past gynae Hx
PMHx, PSHx, PGHx
Medications, Allergies
FHx, SHx

31. Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.
History of bleeding
menstrual cycle; ? ovulating
amount
LNMP
contraception
sinister features: post coital, intermenstrual, post menopausal bleeding
associated symptoms
pain, symptoms of anaemia
Remainder of gynae history
discharge, prolapse, incontinence, POHx, fertility, PAP, breasts

32. Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.
O/Ex:
general examination
pallor
abdominal palpation
?enlarged or tender uterus
speculum examination
blood coming from os
normal vagina and cervix
Bimanual examination
size of uterus
adnexal pathology

33. Ix will depend on Hx and Ex, but may involve:
Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.
Ix will depend on Hx and Ex, but may involve:
hCG
PAP smear
FBE
Fe studies
Coagulation profile
Ultrasound
Endometrial sampling
Hysteroscopy, D&C

34. SUMMARY How to take a ‘general’ gynaecological history (A,B,C,D,I/P,F)
Reproductive screening
How to take a ‘targetted’ history of a specific presenting complaint such as bleeding, pain, discharge, prolapse and incontinence, infertility
3 parts of gynaecological examination
abdominal palpation
speculum examination
bimanual examination
Combining history and examination features to come up with a differential diagnosis, and plan investigations