History and Examination in Gynecology

HISTORY



includes ID, CC, HPI, PMH, Meds, Allergies, etc...

Obstetrical History
Gravida__ Para__ SAB__ TAB__ L__
year, hospital, outcome, mode of delivery, sex, gestational age,
weight, complications

Menstrual History
LNMP, LMP
age menarche, menopause
cycle length, duration, regularity
flow
associated symptoms
• pain, PMS
abnormal menstrual bleeding
• intermenstrual, post-coital


Sexual History
age when first sexually active
number and sex of partners
history of sexual assault or abuse

Contraceptive History
present and past contraception modalities
reasons for discontinuing
compliance
complications/failure/side-effects

Gynecological Infections
STDs, PID (herpes, chlamydia, gonorrhea, etc...)
vaginitis, vulvitis
lesions
include treatments, complications, etc...

Gynecological Procedures
last Pap smear
• history of abnormal Pap
• follow-up and treatments

gynecological or abdominal surgery
previous ectopic pregnancies


PHYSICAL EXAMINATION


height, weight, BP
breast exam
abdominal exam
pelvic exam including
• observation of external genitalia
• speculum exam +/– smears and swabs
• bimanual exam
• cervix size, consistency, os, and tenderness
• uterus size, consistency, contour, position, shape,
mobility, and other masses
• adnexal mass, tenderness
• rectovaginal exam
• rectal exam


INVESTIGATIONS
Bloodwork
CBC
• evaluation of abnormal uterine bleeding, preoperative investigation
ßhCG
• investigation of possible pregnancy or ectopic pregnancy,
work-up for GTN
• monitored after the medical management of ectopic and in
GTN to assess for cure and recurrences
LH, FSH, TSH, PRL
• amenorrhea, menstrual irregularities, menopause, infertility, etc...
Notes APPROACH TO THE PATIENT . . . CONT.



Imaging

ultrasound
• transvaginal ultrasound provides enhanced details of structures located
near the apex of the vagina; i.e. intrauterine and adnexal structures
• may be used for
• acute or chronic pelvic pain
• rule in or out ectopic pregnancy, intrauterine pregnancy
• assess uterine, adnexal, ovarian masses (i.e. solid or cystic)
• uterine thickness
• follicle monitoring during assisted reproduction

hysterosalpingography
• an x-ray is taken after contrast is introduced through the
cervix into the uterus
• contrast flows through the tubes and into the peritoneal
cavity if the tubes are patent
• used for evaluation of size, shape, configuration of uterus,
tubal patency or obstruction

sonohystography
• saline infusion into endometrial cavity under ultrasound
visualization expands endometrium, allowing visualization
of uterus and fallopian tubes
• useful for investigation of abnormal uterine bleeding,
uncertain endometrial findings on vaginal U/S, infertility,
congenital/acquired uterine abnormalities (i.e. uterus
didelphys, uni/bicornate, arcuate uterus)
• easily done, minimal cost, extremely well-tolerated,
sensitive and specific
• more accurate than hysterosalpingography and frequently
avoids need for hysteroscopy
Genital Tract Biopsy


vulvar biopsy
• under local anesthetic
• Keye’s biopsy or punch biopsy
• hemostasis achieved with local pressure, Monsel solution or
silver nitrate

vaginal and cervical biopsy
• punch biopsy or biopsy forceps
• generally no anesthetic used
• hemostasis with Monsel solution

endometrial biopsy
• in the office using an endometrial suction curette (Pipelle)
• hollow tube guided through the cervix used to
aspirate fragments of endometrium (well-tolerated)
• a more invasive procedure using cervical dilatation and curettage
may be done in the office

Colposcopy
diagnostic use
• provides a magnified view of the surface structures of the
vulva, vagina and cervix
• special green filters allow better visualization of vessels
• application of 1% acetic acid wash dehydrates cells and
reveals white areas of increased nuclear density (abnormal)
or areas with epithelial changes
• biopsy of visible lesions or those revealed with the acetic acid
wash allows early identification of dysplasia and neoplasia

therapeutic use
• cryotherapy
• tissue destruction by freezing
• for dysplastic changes, genital warts
• laser
• cervical conization
• encompasses the cervical transformation zone and
into the endocervical canal
• methods include cold knife, laser excision, or electrocautery



DIFFERENTIAL DIAGNOSIS OF COMMON GYNECOLOGICAL COMPLAINTS


VAGINAL DISCHARGE

Physiological
normal vaginal discharge (midcycle)
increased estrogen states, e.g. pregnancy, BCP
Infectious
candida vulvovaginitis (Candida albicans)
trichomonas vaginitis (Trichomonas vaginalis)
bacterial vaginosis (Gardnerella vaginalis)
chlamydia
gonorrhea
bartholinitis or Bartholin abscess
PID
Neoplastic
VAIN
vaginal squamous cell ca
invasive cervical ca
fallopian tube ca
Other
allergic/irritative vaginitis
foreign body
atrophic vaginitis
enterovaginal fistulae


VAGINAL/VULVAR PRURITUS
Infectious
Candida vulvovaginitis
Trichomonas vaginitis
Herpes genitalis (HSV)
Other
postmenopausal vaginitis or atrophic vaginitis
chemical vaginitis
hyperplastic dystrophy
lichen sclerosis
vulvar ca


GENITAL ULCERATION
Infectious
painful
• herpes genitalis (HSV)
• chancroid (Hemophilis ducreyi)
painless
• syphilis (Treponema pallidum)
• granuloma inguinale
(Calymmatobacterium granulomatis)
• lymphogranuloma venereum
(C. trachomatis - serotypes L1-L3)
Malignant
vulvar ca

Other
trauma
foreign body
Bechet disease (autoimmune disease resulting in oral and genital
ulcerations with associated superficial ocular lesions)



INGUINAL LYMPHADENOPATHY
Infectious
HSV
syphilis
chancroid
granuloma inguinale (D. granulomatis)
Malignant
vulvar ca
vaginal ca
anal ca
lymphoma


PELVIC MASS
Uterus, Asymmetrical
leiomyomata
leiomyosarcoma
Uterus, Symmetrical
pregnancy
adenomyosis
endometrial ca
Adnexal, Ovarian
corpus luteum cyst
follicular cyst
theca lutein cyst
endometrioma
inflammatory cyst (tubo-ovarian abscess)
luteoma of pregnancy
polycystic ovary
benign neoplasms
• dermoid cyst (most common)
malignant neoplasms
• granulosa cell tumour (most common)
Adnexal, Non-ovarian

gynecological
• ectopic pregnancy
• pelvic adhesions
• paratubal cysts
• pyosalpinx/hydrosalpinx
• leiomyomata or fibroids
• primary fallopian tube neoplasms

gastrointestinal
• appendiceal abscess
• diverticular abscess
• diverticulosis, diverticulitis
• carcinoma of rectum/colon

genitourinary
• distended bladder
• pelvic kidney
• carcinoma of the bladder


DYSPAREUNIA

atrophic vaginitis
chemical vaginitis
lichen sclerosis
Candida vulvovaginitis
Trichomonas vaginitis
acute or chronic PID
endometriosis
fibroids
adenomyosis
congenital abnormalities of vagina
• e.g. septate vagina
retroverted, retroflexed uterus may cause dyspareunia
ovarian cysts/tumours
symptomatic retroverted uterus
psychological trauma
vaginismus
vulvodynia


PELVIC PAIN
Acute Pelvic Pain
gynecological causes
• ectopic pregnancy
• abortion - missed, septic, etc...
• ruptured ovarian cyst
• torsion of ovary or tube
• hemorrhage into ovarian cyst, neoplasm
• degeneration of fibroid
• torsion of pedunculated fibroid
• acute PID
• mittelschmertz (ovulation pain as follicle ruptures into
peritoneal space)


non-gynecological causes
• appendicitis
• UTI - cystitis, pyelonephritis
• renal colic
• mesenteric adenitis
• diverticulitis
• inflammatory bowel disease


Chronic Pelvic Pain
refers to pain of greater than 6 months duration

gynecological causes of CPP
• chronic PID
• endometriosis
• adenomyosis
• invasive cervical ca (late)
• leiomyomata
• uterine prolapse
• adhesions
• cyclic pelvic pain
• primary dysmenorrhea
• secondary dysmenorrhea
• ovarian remnant syndrome
• pelvic congestion syndrome
• ovarian cyst

non-gynecological causes
• referred pain
• urinary retention
• urethral syndrome
• penetrating neoplasms of GI tract
• irritable bowel syndrome
• partial bowel obstruction
• inflammatory bowel disease
• diverticulitis
• hernia formation
• nerve entrapment
• constipation
• psychological trauma
• 20% of CPP is due to history of previous sexual
abuse/assault


ABNORMAL UTERINE BLEEDING
abnormal vaginal bleeding
pregnant not pregnant
first trimester 2nd and 3rd
• see obstetric section
normal pregnancy abnormal pregnancy
• implantation bleed
• abortion intrauterine extrauterine
• trophoblastic • ectopic



Approach to Abnormal Vaginal Bleeding
Gynecological Causes

increased bleeding with menses
• polyps
• adenomyosis
• leiomyomata
• endometriosis
• IUD


bleeding following a missed period
• ectopic pregnancy
• abortion - missed, threatened, inevitable, incomplete, or complete
• implantation bleed
• trophoblastic disease
• placental polyp

irregular bleeding
• dysfunctional uterine bleeding
• polycystic ovarian disease
• vulvovaginitis
• PID
• benign or malignant tumours of vulva, vagina, cervix, or uterus
• ovarian malignancy
• anovulation (e.g. stress amenorrhea)
• oral contraceptive use
• polyps


postmenopausal bleeding
• endometrial ca until proven otherwise
• atrophic vaginitis (most common cause)
• ovarian malignancy
• benign or malignant tumours of vulva, vagina or cervix
• withdrawal from exogenous estrogens
• atrophic endometrium
• endometrial/endocervical polyps
• endometrial hyperplasia
• trauma
• polyps
• lichen sclerosis
common causes vary according to age group
adolescent
• anovulatory
• exogenous hormone use
• coagulopathy
reproductive
• anovulatory
• exogenous hormone use
• fibroids
• cervical and endometrial polyp
• thyroid dysfunction
premenopause
• anovulatory
• fibroid
• cervical and endometrial polyp
• thyroid dysfunction
post menopausal
• endometrial cancer until proven
otherwise
• other endometrial lesion
• exogenous hormone use
• atrophic vaginitis
• other tumour (vulvar, vaginal,
cervix)