Office Gynecology

PGI Leiza Joy Tabora

History and Physical Examination
The first contact a physician has with a
patient is critical
The physician will gain patient’s
confidence and establish rapport by
nonjudgmental manner in which he or
she collects these data.
The OB-GYNE should assume the role
of her primary physician.
 Non Verbal Clues
Look at her even before speaking
Five general impressions can be
transmitted both by facial expression
and by posture:
– Happiness
– Apathy
– Fear
– Anger
– Sadness
History Outline
Important Points of Sexual History
History Outline
History Outline
 Complete Physical Examination
Allows to
gather information about the patient
to teach the patient information she
should know about herself and her body.
The chaperone, a third party, usually a
woman, serves a variety of purposes:
-support to the patient during uncomfortable
or potentially embarrassing portions of the
examination
Complete Physical Examination
may help the physician to carry out
procedure
offers the physician protection from
having his or her intentions
misunderstood by a naive or suspicious
individual.
Complete Physical Examination

1. General evaluation of appearance

and posture
2. Eyes, ears, nose, and throat
• Fundoscopic examination should be
performed at least annually.
• evidence of upper lip or chin hair may
indicate increased androgen activity
3. Neck-examine the thyroid gland,
palpate for evidence of adenopathy
 Complete Physical Examination

4. Chest -inspected , percussed and

auscultated bilaterally
5. Heart- palpated, percussed and
auscultated
-evidence of vascular bruits especially in
elderly
6. Breast examination
 Complete Physical Examination

Factors are associated with a high-

quality breast examination:
longer duration
thorough coverage of the breast
 a consistent exam pattern
use of variable pressure with the finger
pads
use of the three middle fingers.
 Clinical Breast Examination Elements

1.    Examination of each breast with the patient

sitting with arms raised, and with the patient
supine   
2.    Attention to the entire breast mound from
midsternum to the posterior axillary line and
from the costal margin to the clavicle   
3.    Inspection and palpation to assess:   
– Skin flattening or dimpling   
– Skin erythema   
– Skin edema  
–   Nipple retraction   
 Clinical Breast Examination Elements

– Nipple eczema    -Nipple discharge   

– Breast fixation   
– Tissue thickening   
– Palpable masses  

4.    Evaluation for axillary and supraclavicular

lymphadenopathy
Physical Examination of the Abdomen

1. Inspection
• Symmetry, scars, protuberance, or
discoloration of the skin
• Striations-may suggest previous
pregnancies or adrenal gland hyperactivity
• The hair pattern
– female escutcheon-inverted triangle
– male escutcheon-hair growth between the area of
the mons pubis and the umbilicus
– diamond pattern-may indicate excessive
androgen activity in the patient
Physical Examination of the Abdomen
Physical Examination of the Abdomen

2. Palpation
• Organomegaly (liver, spleen, kidneys, and
uterus)
• Adnexal masses
• Fluid wave
• Rigidity of the abdomen
• Direct and Rebound tenderness
Physical Examination of the Abdomen

3. Percussion
• differentiate fluid waves
• outline solid organs and masses
4. Auscultation
• listen for bowel sounds
 Physical Examination

• Groins
– adenopathy and inguinal hernias.
– femoral pulses
• Legs
– varicose veins, edema, and other lesions
– pedal pulses
Pelvic Examination
• Patient lying supine on the examining
table with her legs in stirrups, with or
without draped
• The physician should be sure the
patient is as relaxed
• Describe the procedure and allow the
patient to prepare herself.
Normal Female Perineum
 Inspection
• The quality and pattern of the hair
– Areas of alopecia may imply a skin
abnormality.
– Body lice
• Skin of the perineum
– redness, excoriation, discoloration, or loss
of pigment, vesicles, ulcerations, pustules,
warty growths, or neoplastic growths,
pigmented nevi or other pigmented lesions
– Skin scars
 Inspection
• Clitoris -size and shape (normally 1 to
1.5 cm in length.
• Labia majora or minora –evidence of
trauma related to coitus, accidental
injury, or childbearing.
• Introitus
– hymen is intact, imperforate, or open
– perineum gapes or remains closed in the
usual lithotomy position
 Inspection
• Perineal body
• Perianal area
– evidence of hemorrhoids, sphincter injury,
warts, and other lesions
 Palpation
• With the second and fourth fingers of the gloved
hand separating the labia minora, the urethra is
inspected and the length of the urethra is palpated
and “milked” with the middle finger.
– Irregularities and inflammation of Skene's glands
(periurethral glands), pus or mucus expressed, or
a suburethral diverticulum
• Palpate the area of the posterior third of the labia
majora, placing the index finger inside the introitus
and the thumb on the outside of the labium
– enlargements or cysts of Bartholin's glands are
noted. This exercise should be performed on each
side
• With the gloved hand holding the labia
apart, the opening of the vagina should
be inspected
– cystocele or a cystourethrocele
– rectocele
– prolapse of the uterus.
– enterocele
Cystocoele
Rectocoele
Enterocoele
• An evidence for relaxation of the pelvic supports
• graded 1+ to 4+ (1+ being a minimum bulge and 4+
being a bulge through the introitus)
• A prolapse of the cervix and uterus
• stage I - minimum descent of the cervix into the
vaginal canal,
• stage II -descent of the cervix to the introitus
• stage III -prolapse of the cervix or uterus through
the introitus (total descensus, total procedentia) (
 Speculum Examination
Graves speculum-three sizes:
– Small-which is used in young children,
• women who have undergone tight perineal repair
• aged patient who has undergone severe involution
– Medium-used for most women
– Large-useful in large or obese, grand multiparas
Pederson speculum-same length as Graves
speculum but narrower
– for women who have not become active sexually,
have never been pregnant, or have not used
tampons
– women who have undergone operations that have
narrowed the vaginal diameter
 Speculum Examination
1. The speculum should be warmed, then
touched to the patient's leg.
2. Insert by placing the transverse diameter of
the blades in the anteroposterior position
and guiding the blades through the
introitus in a downward motion with the tips
pointing toward the rectum. The procedure
may be facilitated by placing two fingers
into the introitus and pressing down.
 Speculum Examination
3. Once the blades are inserted, the speculum
should be turned so that the transverse axis
of the blades is in the transverse axis of the
vagina. The blades should be inserted to
their full length and then opened so that the
physician may inspect for the position of the
cervix
• the speculum should be opened and the
introitus widened so that the cervix can be
adequately inspected and a Pap smear taken.
 Speculum Examination
• The vaginal canal is inspected during the insertion
of the speculum or on its removal.
– evidence of erythema or lesions
– SALINE SMEAR-fluid discharge should be
evaluated on slides prepared by placing one drop
of vaginal secretion in one drop of sodium
chloride solution
– KOH-A drop of potassium hydroxide is placed on
another slide, and a drop of vaginal secretion is
placed within this.
• causes lysis of the epithelial cells and
trichomonads but leaves intact the mycelium of
Candida.
 Speculum Examination
• Cervix - should be pink, shiny, and clear.
– Nulliparous-round
– Parous-fishmouth
– Stellate-healed cervical lacerations
• Transformation zone -the junction of squamous and
columnar epithelium
– barely visible inside the external os.
– nabothian cysts
– eversion of the external os
– ectropion
• Any lesions of the cervix should be noted and,
where appropriate, a biopsy should be performed.
 Papanicolaou Smear
• vaginal and cervical cytology is
valuable as a screening tool for cervical
neoplasm
• the use of the Pap smear in screening
programs reduced the incidence of
invasive cervical cancer by 50%.
 Papanicolaou Smear
• Initial screening should begin at age 21 or 3 years after
the individual becomes sexually active.
• Screening interval may be extended from the usual 1
year to 3 years in certain low-risk individuals after age
30.
• High-risk women, those with a history of early sexual
activity and multiple partners, should be screened
annually.
• Patients with later exposure to coitus who have only one
sexual partner and who have had three successive
negative annual smears may be considered low risk and
should be screened every 2 to 3 years at the discretion
of the physician.
 Papanicolaou Smear
• Major objective is to sample exfoliated
cells from the endocervical canal and
to scrape the transitional zone.
 Papanicolaou Smear
• 1.    Remove the excess mucus,
the endocervical canal is
sampled with either a cotton-
tipped applicator or a
cytobrush, which is placed into
the canal and rotated
– The material is smeared
thinly on a microscope slide
by rotation of the swab or
brush on the glass surface
and labeled endocervix and
fixed immediately either by
use of a spray fixative or by
immersion of the slide into a
fixative
 Papanicolaou Smear
2.    With an Ayres spatula or
some variation thereof, the
entire transformation zone
is scraped and the sample
smeared thinly on a
second slide, which is
immediately fixed.
-vaginal pool sample may be
taken with the reverse side
of the Ayres spatula and
smeared on a third slide or
on a second portion of the
slide containing the
transformation zone
material
 Liquid-based monolayer cytology

• This technique is based on placing the sample

into a vial containing a liquid medium that
preserves the cells primarily ethanol.
• Sure-Path (TriPath Imaging)
• Thin-Prep (Cytyc Corp).
• Advantages:
– Suitable for high-risk HPV
testing
– may reduced unsatisfactory specimens from 4.1% to
2.6%.
2001 Bethesda System
 Bimanual Examination
• Allows the physician to palpate the uterus
and the adnexa.
• The lubricated index and middle fingers of
the dominant hand are placed within the
vagina, and the thumb is folded under so as
not to cause the patient distress in the area
of the mons pubis, clitoris, and pubic
symphysis.
• The fingers are inserted deeply into the
vagina so that they rest beneath the cervix in
the posterior fornix.
 Bimanual Examination
• The opposite hand is placed on the patient's
abdomen above the pubic symphysis. The
flat of the fingers are used for palpation.
• The physician then elevates the uterus by
pressing up on the cervix and delivering the
uterus to the abdominal hand so that the
uterus may be placed between the two
hands, thereby identifying its position, size,
shape, consistency, and mobility.
 Bimanual Examination
• Uterus-size, shape, irregularities, consistency
• Adnexa-size, mobility and consistency
– the first two fingers of the right hand are then moved
into the right vaginal fornix as deeply as they can be
inserted.
– The abdominal hand is placed just medial to the
anterior superior iliac spine on the right
– The two hands are brought as close together as
possible, and with a sliding motion from the area of the
anterior superior iliac spine to the introitus, the fingers
are swept downward, allowing for the adnexa to be
palpated between them.
 Rectovaginal Examination
• After completing the vaginal portion of the
bimanual examination, the middle finger is
relubricated with a water-soluble lubricant and
placed into the rectum.
• The index finger is reinserted into the vagina,
the rectovaginal septum is palpated between the
two fingers, and any thickness or mass is noted
• Identify the uterosacral ligaments, note for
thickening or beadiness that may imply an
inflammatory reaction or endometriosis.
 Rectal Examination
• The rectum is palpated in all
dimensions with the rectal examining
finger.
• Note the tone of the anal sphincter and
any other anal abnormalities, such as
hemorrhoids, fissures, or masses.
• Occult blood is no longer
recommended for office screening.
 Examination of Pediatric and
Adolescent Patient
• All newborns should undergo a genital examination
to determine whether they have normal external
genitalia and a vagina present
• Young child
– it is important to put the child at ease
– allow the child to touch and look at all the instruments
that will be used.
– Discuss the exam with the child and her parent or
guardian prior to beginning
– Palpation of the breasts and Tanner and abdominal
exam, should be performed.
 Examination of Pediatric Patient
• A child should never be forced into a gynecologic exam
• If an examination needs to be performed immediately, it
may be done under anesthesia to minimize
traumatization
Different positions are used to help visualize the pediatric
vagina:
1. frog-leg position
2. knee-to-chest position.
3. lithotomy position using stirrups or by straddling the
caregiver's legs-older children.
• A speculum is not used in the pediatric patient unless
the child is very cooperative and can tolerate the exam.
Examination of Pediatric Patient
 Examination of Adolescent Patient
• A careful history with special attention to sexual activity
and any gynecologic problems should be addressed.
• The exam of the adolescent should include a breast
exam and Tanner staging.
• The pelvic exam should be discussed with the patient
prior to beginning the exam.
• A Huffman speculum is designed to allow for easy
inspection of the cervix in adolescents and is thinner
than Pederson speculums
• Patients who have never been sexually active and who
have a tight hymenal ring should undergo a one-finger
bimanual exam or rectal examination may have to be
done instead
Minor Diagnostic Procedures
• Pap Smear
• Saline Smear
• KOH
• Gram Staining
 Colposcopy
• almost always the first step in the evaluation
of women with abnormal cytology results
• Colposcope -is a low-power binocular
microscope that is mounted on a stand with
a powerful light source that is focused 30 cm
beyond the front objective.
– magnification is from approximately 3× to 15×
– The instrument is placed just outside the vagina
after a speculum has been inserted and the
cervix brought into view
 Colposcopy
• Punctation-capillaries perpendicular to the
surface
• Vessels in mosaic pattern-
neovascularization
• White epithelium-piling of cell with
increased N:C
• Leukoplakia-normal white areas of the
cervix prior to application of acetic acid
Acetic Acid Wash test
•Diluted acetic acid, 3% to 5%, is
then applied to the cervix, and
after approximately 30 seconds,
the cervix is again examined.
•Abnormal cells have increased
amount of protein , coagulated by
acetic acid (acetowhite
epithelium)
Schiller’s Test-
Lugol's iodine solution is applied
to the cervix under direct vision.
Normal cervical mucosa contains
glycogen and stains brown,
whereas abnormal areas, such as
early cervical cancer, do not take
up the stain.
 Colposcopy
• Transformation Zone (TZ)
– the area that lies between normal
columnar epithelium and mature
squamous epithelium.
– vast majority of cases of squamous
neoplasia of the cervix begin in this
anatomic area, probably because it is an
area of rapid cell turnover.
 Colposcopy
• Cervical biopsy
– If a lesion is seen, one or more biopsy specimens
should be taken to confirm the diagnosis
– it is important to maintain a sharp cutting edge on
the biopsy instruments as the cervix has pain
fibers that respond to stretch.
– If bleeding occurs, the base of the biopsy site
can be touched with Monsel's solution or a silver
nitrate stick.
– Cervical biopsy specimens are very small, usually
only approximately 4 × 5 mm.
– The sites heal within a few days
 Cryosurgery
• Used in ablation of benign and premalignant
lesions of cervix, vagina and vulva
• a probe is selected that will cover the entire lesion
• N2O is used as the refrigerant.
• The probe is applied to the cervix and the system
is activated.
• The cervix will freeze quickly, but the probe must
remain in place until the ice ball that forms extends
to at least 5 mm beyond the edge of the
instrument.
• The refrigerant is then turned off, and the probe
allowed to thaw and separate from the cervix.
 Endometrial Sampling
• most frequently performed to evaluate
dysfunctional uterine bleeding
• done to investigate abnormal bleeding
associated with increasing use of
hormonal replacement therapy in
postmenopausal women.
• standard diagnostic test to confirm a
chronic uterine infection
 Endometrial Sampling
Contraindications to endometrial biopsy:
– Profuse bleeding
– Should not be performed more than 14 to
16 days after ovulation because of the
possibility of interfering with an early
pregnancy.
 Endometrial Sampling
– most frequent problem in performing
endometrial sampling is cervical stenosis
or spasm
– The major complication is uterine
perforation
 Hysterosalpingography
• a radiographic imaging technique in which the
uterine cavity and the lumina of the fallopian tubes
are visualized by injecting contrast material through
the cervical canal.
• a safe and rapid means of investigating abnormalities
in the endometrial cavity and fallopian tubes
• leading indications are primary and secondary
infertility
• Gives evidence of endometrial irregularities, tubal
patency, tubal mobility, and sometimes peritubal
disease
 Hysterosalpingography
• Uterine cavity
abnormalities
• Congenital
müllerian
anomalies, such
as bicornuate,
septate,
arcuate, and T-
shaped uteri
Saline Infusion Sonohysterography

• Uses ultrasound
• Uterine cavity is filled with the saline solution
• Used to delineate the architecture of the
endometrial cavity
• Improves sonographic detection of
endometrial pathology, such as polyps,
hyperplasia, cancer, leiomyomas, and
adhesions.
Thank You!
Thank You!