Transcript gynaecological history and examination

GYNAECOLOGICAL HISTORY AND
EXAMINATION
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
GYNAECOLOGICAL HISTORY
 Age
 Past medical, surgical, gynaecological history
 Medications
 Allergies
 Family History
 Social History
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
GYNAECOLOGICAL HISTORY
 Gynaecological History
 Abdominal pelvic pain
 Bleeding
 Contraception
 Discharge (itch)
 Incontinence and prolapse
 Fertility
 Screening history
(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
(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
(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
(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
(2) BLEEDING
 What causes non-menstrual bleeding?
 Post coital bleeding
 cervical lesion (polyp, cervicitis, cancer)
 Intermenstrual bleeding
 midcycle bleeding
 cervical/ uterine malignancy
 Postmenopausal bleeding
 cervical/ uterine malignancy
 endometrial hyperplasia
 atrophic endometrium
(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
(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
(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
(5) PROLAPSE AND INCONTINENCE
 Vulval lump, dragging pain or pressure
 Incontinence
 urinary
 stress
 urgency
 faecal incontinence or soiling
 flatus incontinence
GNAECOLOGICAL EXAMINATION
 Explain examination
 Allow patient privacy to change
 Chaperone
 Ensure patient is draped, and room is warm and comfortable
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
Inspection
 Hair distribution
 Vulval skin
 Look at the perineum for
scars/tears
 Gently part labia – inspect
urethra
 Look for discharge,
prolapse, ulcers, warts
Pelvic Examination
 Empty bladder!
 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
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.
Visualisation of Cervix
 Inspect for:
• Discharge
• Warts
• Tumours
• Size of cervical os
• Bleeding
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
Taking a Cervical smear
 Rest point of spatula
within the os and rotate
clockwise 360° then
rotate 360° anticlockwise.
 Exert light pressure
(pencil).
 Ensure contact with
cervix throughout.
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
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
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
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
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
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
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
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