gynaecological history and examination. lecture overview taking a gynaecological history abcd(i)f...
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LECTURE OVERVIEW Taking a gynaecological history ABCD(I)F
Abdominal/ pelvic painBleedingContraceptionDischarge and itch(E) Incontinence and prolapseFertility
Performing a gynaecological examinationAbdominal palpationSpeculum examination of vulva/ vagina/cervixBimanual palpation of uterus and adnexae
Approach to common gynaecological symtoms
GYNAECOLOGICAL HISTORYAgePast medical, surgical, gynaecological
historyMedicationsAllergiesFamily HistorySocial History
GYNAECOLOGICAL HISTORYPast Obstetric History
Have you ever been pregnant before?Spontaneous abortions, terminations of pregnancy,
ongoing pregnancies, living childrenWhat happened in those pregnancies?
Spontaneous, duration of pregnancy, type of labour and delivery, outcome, complications
GYNAECOLOGICAL HISTORYGynaecological History
Abdominal pelvic painBleedingContraceptionDischarge (itch)Incontinence and prolapse FertilityScreening history
(1) PELVIC PAINWhat causes pain?
OvulationDysmenorrhoeaovarian cysts, particularly if complicated
(THINRIM) torsion, haemorrhage, infection, necrosis, rupture, malignant change
endometriosis infection
PID, tubo-ovarian abscesscomplication of pregnancy
miscarriage, ectopic pregnancy
(1) PELVIC PAINPain with periods (dysmenorrhoea)Pain with sex (dyspareunia)Pain at other times
Site of pain, radiation sudden or gradualassociated symptoms
fever, dischargeLNMP
(2) BLEEDINGMenstrual history
menarchecycle length and regularity (5/28)midcycle bleeding/pain/mucus changeexcessively heavy or painfulLNMP
Abnormal bleedingAbnormal menstrual bleedingAbnormal 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)
ovulatoryanovulatory
Uterine pathology which increases surface area of endometrium
polypsfibroids
Coagulopathy
(2) BLEEDINGWhat causes non-menstrual
bleeding?
Post coital bleedingcervical lesion (polyp, cervicitis, cancer)
Intermenstrual bleedingmidcycle bleedingcervical/ uterine malignancy
Postmenopausal bleedingcervical/ uterine malignancyendometrial hyperplasiaatrophic endometrium
(3) DISCHARGE AND ITCHWhat causes discharge?
physiological dischargetubal infection (PID)/ malignancyuterine infection/malignancycervical infection/malignancyvaginal infection (vaginitis, vaginosis)vulval infection/ malignancy
Physiological discharge + bacterial vaginosis and vaginitis + UGT infection = 95% of presentations with discharge
(3) DISCHARGE AND ITCHNature of discharge
amountcolour (bloody, offensive, yellow, brown)offensiverelationship to period
Associated symptomsvulval burning and itch, urinary frequency
(4) CONTRACEPTION AND FERTILITYType of contraception, side-effects,
compliance, complications including breakthrough pregnancies
Fertilitynumber of pregnanciestime taken to get pregnant
Infertilitydurationsexual historyhistory of anovulation, tubal disease or
surgery, male factor
(5) PROLAPSE AND INCONTINENCE Vulval lump, dragging pain or pressure
Incontinenceurinary
stressurgency
faecal incontinence or soilingflatus incontinence
GNAECOLOGICAL EXAMINATIONExplain examinationAllow patient privacy to changeChaperoneEnsure patient is draped, and room is warm
and comfortable
GNAECOLOGICAL EXAMINATIONGeneral examination
H&N, breasts, cardiorespiratory, abdominal, periphery
Abdominal palpationInspection external genitaliaSpeculum examination vagina/cervixBimanual palpation of uterus and adnexae
Inspection
Hair distributionVulval skinLook 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
CervixCervical excitation, os
open/closed,Polyps, erosions, etc...
UterusSize, 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.
Taking a cervical smearFollowing insertion of bivalve speculumEquipment prepared before examination
begins:glovesAylesbury spatulaConfirm name, DOB, hosp number etcLabel frosted end of slideFixative agentPosition equipment
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.
Concluding Cervical Smear
REMOVE the speculum!Ensure patient comfort/safetySpread both sides of the spatula onto the
slide.Perform similar procedure for cytobrushSpray 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 extendedRight Knee drawn
up to chestHold back anterior
vaginal wall with lubricated speculum
Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.
AgeHx of presenting complaintPast Obstetric Hx (gravity, parity)Past gynae HxPMHx, PSHx, PGHxMedications, AllergiesFHx, SHx
Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding. History of bleeding
menstrual cycle; ? ovulatingamountLNMPcontraceptionsinister features: post coital, intermenstrual, post
menopausal bleedingassociated 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 examinationpallorabdominal palpation
?enlarged or tender uterusspeculum examination
blood coming from osnormal vagina and cervix
Bimanual examinationsize of uterusadnexal pathology
Dear Dr, Thank you for seeing Mary Smith who has problematic vaginal bleeding.
Ix will depend on Hx and Ex, but may involve:hCGPAP smearFBEFe studiesCoagulation profileUltrasoundEndometrial samplingHysteroscopy, 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 examinationabdominal palpationspeculum examinationbimanual examination
Combining history and examination features to come up with a differential diagnosis, and plan investigations
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