Comprehensive Evaluation of the Female

Dr. Debby Pacquing Songco

November 3, 2011

Lecture Objectives
Young and Adult Gynecologic History and Physical
Examination
Doing the PAP Smear
Strategies for Health Maintenance and Disease Prevention
Immunizing Women
The Gynecologic History
*Obstetrician/Gynecologist- primary physician for women, thus should have a
complete history

History

Complete There could be other medical problems, not only

gynaecologic.
General then focus on gynecologic (Go from general
point of view then focus on the gynecologic problem.)
*A obstetrician/gynecologist serves as the primary physician for
females, so assume that this is the first consult. Questions may not be
related to the gynaecologic problem. Problems may be headache or
back ache. It similar to an internal medicine history taking and physical
examination.
The Gynecologic History Outline (from the book, Comprehensive
Gynecology)
I. Observation The minute a patient comes in the clinic, dont see
the patient as a person but look into clues. Ask yourself hat could you
be dealing with. This could help in making a diagnosis, what does the
patient have, or reason for coming to the clinic. Example is a 24-yearold patient who comes in frightened and shy. She may be pregnant, or
seeking for second opinion after being diagnosed with cancer.
This may be useful in gauging how to approach the patient. Patients
may come from different social strata. A patient from Barangay Tatalon
may have different values and beliefs from someone from Ayala,
Alabang. Deal with them appropriately. This is part of rapport and trust
building.
*Do not forget to introduce yourself to the patient.

II. Chief Complaint What seems to be the problem?

Common Problems:
Discharge (Most common)
Irregular menses
Amenorrhea
Vaginal itching
Abdominal mass/enlargement
Sexual dysfunction
Infertility
*Encompasses a lot of things

III. History of Gynecologic Problems

*MOGS (Menstrual, Obstetric, Gynecologic, Sexual/Constrceptive)
can be used as an outline

A. Menstrual History
B. Pregnancy History
C. Vaginal and Pelvic Infections
D. Gynecologic Procedures
E. Urologic History
A. Menstrual History
Ask for LMP(first day of last menstrual period, always qualify)
Regardless of the flow, the first sign of menses is the first
day.
Also ask about previous menstrual period
Go back to the last even if it is irregular. Make the patient
remember.
Some patients really dont remember.
Some monitor it regularly.

Most common response would be regular monthly or

irregular.

*Irregular menses, hirsutism suspect PCOS

Know the length or duration of menstruation.

Usually normal is not more than 7 days, 3-7 days.
2 days is considered oligomenorrheic.
Quantify the flow
Know this by the number of pads used. For elderly, ask for
number of pasador/ clothe pads. Some use tampons. Take
note of this.
Is there pain during menses? Quantify and qualify pain.
Dysmennorhea
Does it limit you from walking? Is it tolerable? If it is tolerable, usually
on the first day, then it is not really dysmenorrhea but the usual
cramping. But if the patient has to file a leave from work due to sever
pain, or take pain relievers to go through he day, then this may be
telling you that the patient has chronic pelvic pain or the patient may
have endometriosis.
Expound further. Is pain still present even when there is no
menstruation? If is confined during the menstrual cycle, then it may not
be a pelvic infection which may also cause chronic pelvic pain.
B. Pregnancy History (Obstetric Hx)
OB Score GP TPAL
Gravidity
Parity multiparous or nulliparous
Full term
Preterm
Abortion
Livebirths
Example: A 28-year-old currently pregnant at 7 weeks AOG, had 2
miscarriages in the past, had 2 deliveries; 1 at 34 weeks and 1 at term,
and both are alive and now are in preschool. She was also operated on
for ectopic pregnancy, what is the Obstetric Score?
G6P2 (1132)
Then enumerate:
G1 - 1908. Order. type of delivery. Sex. Complications, etc.
**If the patient had the preterm, delivered as twins, then just add 1 in
the livebirth, G6P2 (1133).
Obstetrical Score
Describe each pregnancy in detail.
Date, order, type of delivery, birth weight, condition at birth,
complications related to delivery/pregnancy.
*RPL Recurrent Pregnancy Loss - A patient with multiple
miscarriages that may have a small chance of being able to have a
livebirth. Patients with this condition are considered high risk.
*will give you idea if high risk, the use of contraception, same/different father;
make you prepare for hemorrhage or possible complications

C. Vaginal/ Pelvic Infections

Vaginal Discharge ask patient about the color of discharge.
Is it yellowish? Or greenish discharge? gonorrhea. Vaginal
discharge could be from frotty, whitish, greyish.
*Foul smelling discharge after sexual contact (emanating)- bacterial
vaginosis.
* STD- sexual contact with lesions (lesions also present on
partner) Frothy trichomonas
*highly pruritic, with excoriations, cheese like discharge fungal
*Previously treated with Doxycycline and Ceftriaxone - Gonorrhea

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Lesions

Gynecologic/ Surgical Procedures

Dilatation and Curretage ask for results of D&C
Vaginal Repairs episiorraphy, episiotomy, perineorraphy
Myomectomy- Patients who had been operated on myomas
and now is pregnant. What does that tell you? Depending on
what type of myomectomy. Patient may be high risk so may
need CS. You have to get operative technique
Cystectomy/Oophorectomy- Patient comes in 24 year old,
had cystectomy before and complains of ammenorhea for 1
year- negative pregnancy test, PE unremarkable, FSH
elevated Probable diagnosis: Premature ovarian failure due
to complication of cystectomy (POF)
*if bilateral oophorectomy - menopause
Hysterectomy- ask patient why he/she had hysterectomy.
Important for monitoring
Approach: Open, Laparascopic, Hysteroscopy

Chest Exam
Breast
Tanner Staging
*Prepubertal (Tanner 1); Adult (Tanner 5) Important to take note
on adolescents
Primary amenorrhea never had menses
*Big breast, no hair, blind vagina history of androgen insensitivity
(male person that becomes a female looking)
*Turners Syndrome- primary amenorrhea, 411(very short)

Urologic History

Frequency
Leaking (Pag tumatawa po kayo, nagleleak po ba? Are you able to
reach the bathroom? common among perimenopausal women,
menopause women)

Young patient complaining of leaks- probable congenital

problem with the pelvic floor or prone to relaxation
Pelvic Pain very important
Dysmennorrhea
Chronic Pelvic Pain- Pelvic inflammatory disease (PID)
Other than cyclic pain- PID or endometriosis

Vaginal Bleeding
Ask for duration, how many pads are being consumed
Heavy Menstrual Bleeding- intermenstrual cycle,
menstruation twice a month
Pattern
Duration bleeding with menses; bleeding even after
menses

*Submucus myoma- heavy bleeding within menses

*Intermenstrual spotting polyps
*Twice a month menses - anovulation

Flow

Sexual Status
Quantify and Qualify
Partner/s ask how many partners
Sexual Preference- patient complains of infertility but might
not be in a heterosexual type of relationship. Sexual
preference is very important.
Sexual Dysfunction patient usually volunteers this
information
Information regarding the partner- career, age, previous
relationship of the partner, is he polygamous? Lesions? etc..
Contraceptive history
Ask for Type of contraceptive, duration, and reason for
discontinuation
COC
POP
IUDs
Injectibles
Patches
Other data
Past Health History
Medical- medications, allergies
Family- history of cancer, endocrine problems, congenital
malformations
Social History if patient is on the pill, patient should not be
smoking
Smoking with pill use may cause thromboembolism

Alcohol Drinking
Drug Use- some drugs would interfere with oral contraceptive
pills or can put you to infertility problem
Work
Educational Attainment
Review of Systems
Physical Examination
General Evaluation
- Is the patient normal for BMI, morbidly obese,
overweight, undernourished
Ask for endocrine problems which may cause
amenorrhea
Thyroid disorders - Very important ; TS4,TSH, and
prolactin must be assessed after a pregnancy test

Clinical Breast Examination

*never forget to drape the patient since these are sensitive areas of
a woman; inform the patient of the procedure you are about to do
*Raise arms and place underneath the head circular (inner to
outer) or parallel lines; also palpate for the Tail of Spence- breast
upto the axilla; use tips of fingers/pads of fingers

Self Breast Exam always teach women how to perform proper

SBE

Heart Evaluation
Menopause period
Turners Syndrome- on their 20s; prone to aortic coarctations
Abdominal Exam
Inspection- enlarged abdomen (not pregnant), probably a
mass, cyst
Auscultation- bruits, hypo/hyperactive bowel sounds
Palpation
Percussion
The Pelvic Examination
Be gentle
Explain the procedure
Drape the patient properly
Proper positioning; supine with legs on the stirrups (adult woman)
Do it stepwise
1. External Examination- distribution of hair, masses, discharges,
bleeding, if orifices open or not (septum, imperforate hymen),
protruding mass pelvic organ prolapse, cystocoeles bulging out
2. Palpation- Masses on the labia, bartholins cyst (mass on posterior
fourchette), express paraurethral glands which may secrete pus
urethritis/gonococcal)
3. Speculum Exam Ask for history
Assess for lesions, warts, discharges, and cervix
Nulligravid but with sexual contact-smaller speculum
Graves speculum- more rounded, shorter, and has wider
blade
Penderson speculum- narrower and longer
How to insert the speculum
Place your gloved index and middle fingers at or just inside
the introitus, exert downward pressure on the perineum
With your other hand, gently insert the speculum at a 45
downward angle. When inserting the speculum,(towards
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the posterior side of the vaginal canal) make sure that the
blades are closed and held at an oblique angle
Remove your fingers from the introitus, and rotate the
blades of the speculum horizontally while maintaining
downward pressure with the speculum
When the blades are fully inserted, open the blades and
rotate the speculum (A-P position) until the cervix comes
into view.
Push in the speculum towards the posterior side of vaginal
canal
Lock the blades into the open position using the
thumbscrew.
Well lubricated or with warm water

Do TSH screening starting age 50 and at 65 years old it should

be done at least 3-5 years
Immunizing Women

Advisory Committee for Immunization Practices (ACIP)

An international committee that holds annual
conventions in the hope to be able to come up with adult
immunization schedule

Pediatric and Adolescent Gynecology

*In doing papsmear- no lubrication just water because it will

become an artifact; just use water

*Prepare Ayres spatula, cotton pledgets, cervical broom/brushes
before doing cervical exam

Speculum exam
Vaginal canal- lesions
Cervix is it smooth? Parous? Nulliparous
Discharges:
**Normal- clear, sometimes minimally whitish and not on the
walls (not foul smelling)
Strawberry cervix -- trichomonas

Ayres spatula or brush better yield

Plaslights and Ethyl alcohol 95% to fixate the specimen
Obtain 3 specimen:
1. Get the specimen in the endocervical canal and rotate the brush
360, put smear on one side of the slide
2. Next is the ectocervix, another pledget and put smear on the other
side again
3. Last specimen is the vaginal walls
Using Ayres spatula one rotation 360 you get both cells from
endocervix and ectocervix
4. Bimanual Exam- inserting both your middle finger and your second
digit into the vaginal canal in order for you to be able to palpate the
uterus. Sweep thru the right or left if there are masses (usually non
dominant hand on the abdomen)
5. Rectovaginal Exam- Insert middle finger on the rectum and the
second digit on the vagina. Eg.Endometriosis/nodularities in the
uterosacral (DO NOT do this before doing bimanual exam)

Different from adult approach

Needs good timing approach
Different examining room
o It should be inviting, comfortable with toys and
important is to build trust with the patient
History is based on the mothers history or the caregiver
(difficult to obtain)
Starts with inspection and ends with rectal exam
No Internal Exam (IE)
Has speculum exam unless needed

Points to remember
Make sure that the patient is re-assured and that
the patient has the sense of control
Know the growth and development, Tanner staging, complete
P.E
Position
Not the supine but litothomy
Frog leg position- gives you the initial view of your genitalia
and vaginal canal (child may sit on the mothers lap)
Knee chest- complete view
Adolescent may do lithotomy if she is big enough
Lateral traction method hymenal rings
Otoscope doubt of foreign body/discharges to magnify view
May also use nasal speculum
Rectal exam use little finger to palpate for masses

Transers: Robby, Mara, Garen

Checker: Ren

6. Rectal Exam
The Annual Visit to the Gynecologist
GOAL: Prevention
For menopausal women/sexually active
Screening for Illnesses
Wellness
Shift in Terminologies - Before it was APE (Annual Physical Exam),
now it is AHM (Annual Health Maintenance)
*New recommendation
Papsmear at the age of 21 and once every 2 years.
For women above 30 years old you can do it once every 3
years.
Unless the patient is high-risk(multiple partners, sexual workers,
history of cervical CA)
*For premenopausal or menopausal women consider
Mammogram
Lipid profile
Colorectal screenings
TSH- Usually premenopausal women has hypothyroidism.
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