Gyne History Review

Jonathan Tankel

jtankel@ualberta.ca

*REVIEW THESE SLIDES AS A REFRESHER WHILE WAITING FOR YOUR TURN WITH STANDARDIZED PATIENT*

Gynecologic 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 vary depending on whether routine or problem specific visit

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Basic Gynecologic History:�Menstrual

• 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

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?

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Gynecologic History�Obstetrical

• Number of pregnancies G,P,T,PT, L, SB, , A(SA, TA), EC
• 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

Gynecologic History:�Contraception

• Type, past and current
• Side effects
• Compliance???

• 48% Pregnancies unplanned in N. America!

Gynecologic History:�PAP test

• Date of last
• History of abnormal’s and follow - up
• New guidelines;
• Average risk women:
• Start screening 3 years AFTER onset of intimate sexual activity OR age 25 whichever comes LATER, then every 3 years

Gynecologic History:�Procedures

• Type : (eg Endometrial biopsy, laparoscopy, hysteroscopy, D+C)
• Date
• Diagnosis
• Complications

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Gynecologic history�Other 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)

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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

Gynecologic History:�Must include the rest!

• Medical
• Surgical
• Social
• Habits
• Medications
• Allergies
• Family

REMEMBER THE WOMAN FOR THE PAP WITH THE MELANOMA!

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Pelvic Exam Review

*REVIEW THESE SLIDES AS A REFRESHER WHILE WAITING FOR YOUR TURN WITH THE PELVIC MODEL*

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GYNECOLOGIC EXAMINATION

• 1^st 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?!)

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

Gyne. Exam continued

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

Gyne exam cont�Equipment

• 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, gloves, lubricant, KOH, drapes

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

Gyne Exam�Abdomen

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

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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)

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Gyne exam�VAGINA

• 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

Gyne exam:�Vagina cont

Gyne exam:�Vagina cont

Gyne exam continued

• PAP testing
• See new guideline
• Spatula then brush OR “1” device with 5 rotations
• Use Cytobrush+ other!!!
• Evaluate vag wall relaxation and prolapse by removing top speculum and using bottom ½
• May need to have patient stand

Gyne exam continued:�Cervix

Gyne exam:�Cervix continued

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!

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

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Gyne exam:�Rectovaginal exam

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

Gyne exam:�Documentation

• 6 elements of good record keeping:
• Accuracy
• Objectivity
• Legibility
• Timeliness
• Comprehensiveness
• Absence of alterations