3A Skills: How to conduct a gynaecological history and examination

Contents

• Objectives
• Taking a gynaecological history
• General examination of the patient
• Speculum examination
• Bimanual examination
• Taking a Pap smear
• Doing a pregnancy test

Objectives

When you have completed this section you should be able to:

• Take an adequate gynaecological history
• Perform a gynaecological examination including passing a speculum
• Take a Pap smear
• Do a pregnancy test

Taking a gynaecological history

The purpose of taking a gynaecological history is to find out more about the woman’s presenting complaint and to assess past and present gynaecological problems. It is also an opportunity to assist a woman in talking about her reproductive health, to educate her about reproductive health risks and how to reduce them, and to support her in taking responsibility for her health.

A. Current complaint

The first step is to find out why she has come to see the nurse or doctor. Important questions to ask are:

• What is her current complaint?
• How long has she been experiencing it?
• What is the severity or frequency of the condition?
• How is it affecting her life (such as her ability to work or sleep)?
• Has she noticed any other related symptoms?
• Has she received any investigations or treatment for her complaint?

B. Gynaecological history

The following questions are part of a routine gynaecological history:

• When was her last menstrual period? Does she have a normal regular cycle, bleeding once a month with a period that is not too heavy or painful?
• Does she have any abnormal vaginal discharge?
• Does she know what a Pap smear is? Has she ever had one? If so, when? What was the result? If she does not know what a Pap smear is, use the opportunity to educate her.
• Has she ever been tested for HIV infection? If yes, when? What was the result?
• Has she had surgery for any gynaecological or abdominal problem?
• Is she in a stable relationship? Is she sexually active? Is she happy in her relationship? Remember that gender-based violence and sexual abuse is extremely common in South Africa and that many women will not speak about it unless asked, and even then they may remain silent. Have a low threshold of suspicion. If you do ask about abuse ask in a private setting and sensitive manner.
• If sexually active, is she experiencing any problems with intercourse? Is she using contraception or is she trying to conceive? Ask about what method of contraception she is using and if she is compliant with the method. Ask how long she has been trying to fall pregnant. If she has been trying for over a year she is suffering from couple infertility.

C. Past obstetric history

Even if a woman is not pregnant she should briefly be asked how many times she has been pregnant and what the outcome of each pregnancy was. Ask about the mode of delivery.

D. Medical history

A woman should be asked about any significant illnesses, admissions to hospital or operations which she may have had. Asking about allergies and medication often brings to light a problem which the patient may have forgotten, or thought not to be of significance.

E. Social history

The social history is very important as it may have a big influence on a woman’s health. Poor social circumstances can increase the risk of many conditions including unwanted pregnancy, sexual abuse and late detection of cancers. Poor lifestyle such as poor diet, obesity, or substance abuse (smoking, alcohol, drugs) is also associated with many general health and reproductive health problems. Difficult social circumstances may prevent women from attending appointments or from being fully compliant with medical interventions.

General examination of the patient

The examination of a woman, including the gynaecological examination, should be conducted in a private area and in a respectful, sensitive manner. The nature of the examination should be explained to her and why the examination is important. Always preserve her dignity and provide suitable cover such as a gown or blanket. Ideally you should have a chaperone (someone else with you) when performing a gynaecological examination, especially if a male doctor or nurse does the examination.

A woman has the right to decline the examination, but the implications need to be carefully explained to her. She should never be forced to have an examination, nor should a natural degree of discomfort be used by the health worker as an excuse not to conduct an examination. A vaginal examination in a woman who is menstruating should only be postponed if you can be confident that the bleeding is not part of her problem (she may have cervical cancer or a miscarriage). You also need to be confident that she will come back for follow up in order to have another examination in the near future.

F. Routine observations

The following should be assessed:

1. Height, measured in centimetre (cm): This does not require special equipment. A tape measure stuck to the wall, or a wall marked at centimetre intervals is adequate. The patient should not wear shoes when her height is measured.
2. Weight, measured in kilograms (kg): The patient should only wear light clothing while her weight (mass) is being measured. The scale should be periodically checked for accuracy, and if necessary re-calibrated.
3. General appearance:
   • Is the patient thin or overweight?
   • Is there evidence of recent weight loss?
   • The presence of pallor, oedema, jaundice and rash should be specifically looked for.

G. Examination of the thyroid gland

This can be difficult when the patient has a short, thick neck, or when she is obese. Look for an obviously enlarged thyroid gland (a goitre). She should be referred for further investigation when there is obvious enlargement of the thyroid, the thyroid feels nodular or a single nodule can be felt.

H. Examination of the breasts

The patient must be undressed from her neck to her waist in order for the breasts to be examined properly. The breasts should be examined with the patient both sitting and lying on her back, with her hands above her head.

1. Look: There may be obvious gross abnormalities. Particularly look for any distortion of the breasts or nipples. Check and ask about any discharge from the nipples. Note any eczema or red, flaky skin.
2. Feel: Feel for lumps, using the flat hand rather than the fingers. Also feel for lumps in both the axillae. Use the opportunity to show her how to regularly examine her own breasts.

I. Examination of the lymph nodes.

When the thyroid is examined, the neck should also be thoroughly examined for enlarged lymph nodes. The areas above the clavicles and behind the ears must be palpated. The axillae and inguinal areas should also be examined for enlarged lymph nodes.

Patients with HIV infection usually have painless, enlarged lymph nodes in all these areas.

J. Examination of the chest.

The patient must be undressed from her neck to her waist. Look for any of the following signs:

• Any deformities or scars.
• Any abnormality of the spine.
• Any difficulty breathing (dyspnoea).

K. Examination of the cardiovascular system

1. Pulse: The rate is important. A rapid heart rate is almost always an indication that the patient is anxious or ill.
2. Blood pressure: It is important to always measure the blood pressure correctly.

L. Examination of the abdomen

1. Look for abdominal distension or a lump.
2. Feel the abdomen for pain, tenderness, or any lump or swelling. Assess if the woman has guarding (which mean she tenses her abdominal muscles to prevent you from probing more deeply) or rebound tenderness (which means she experiences acute, sharp pain once you quickly withdraw your hand after pushing down on the abdomen). Guarding and rebound tenderness are a sign of peritonitis which is usually associated with intra-abdominal infection or bleeding.

Speculum examination

The aim of a speculum examination is to examine the vagina and cervix. It also provides an opportunity to take a Pap smear.

M. Method of performing a speculum examination

Ask the patient to lie on her back and bend her knees. Her hands should rest next to her sides as this helps to relax the abdomen. Make sure that she is appropriately covered. Always explain what you are doing.

Look at the vulva for any discharge or blood coming from the vagina. Check for any lesions, ulcers or swellings.

Lubricate the bivalve speculum. Close the valves and turn it 90 degrees into a vertical position. Part the labia gently and ask the patient to bear down. Gently insert the closed speculum aiming slightly posterior towards the woman’s sacrum. Advance the speculum and then turn it into the horizontal position. Make sure that the handles of the speculum do not hurt the patient. Gently open the valves and look for the cervix. See if the cervix looks healthy or if you notice any discharge, blood, ulcers, or tumors.

When gently withdrawing the speculum inspect the vaginal walls and look for any abnormality like inflammation or ulcerations.

Bimanual examination

N. Method of performing a bimanual vaginal examination

For a bimanual examination gently introduce your gloved and lubricated right index finger into the vagina by gently pushing down posteriorly and then add your middle finger. Advance your fingers until you can feel the cervix. Feel the cervix for any irregularity or lumps. Move it from side to side to assess whether this causes any discomfort. Use your left hand to feel the abdomen at the same time. Feel for the size of the uterus between your 2 hands and assess whether it feels mobile, enlarged, irregular or tender. Also check if you can feel any masses or tenderness next to the uterus.

Note

Pain on moving the cervix during bimanual examination is called cervical excitation tenderness and is usually a sign of intra-abdominal sepsis or bleeding. Uterine enlargement is measured in weeks of gestation, even if the woman is not pregnant. For example, an enlarged uterus due to fibroids may be documented as ‘16 weeks’ (if it is midway between the symphysis pubis and the umbilicus) or ‘20 weeks’ (if it reaches the umbilicus). Masses or tenderness on either side of the uterus usually indicates pathology of the adnexae (ovaries and tubes).

Taking a Pap smear

O. Indications for a Pap smear

The indications for a Pap smear are:

• Asymptomatic women should have 3 Pap smears in 10-year intervals starting at the age of 30
• Asymptomatic HIV-positive women should have a Pap smear at least every year
• Women who present with a gynaecological complaint or condition which puts them at risk of cervical cancer must have a Pap smear as part of the clinical examination. This includes women who have:
  • Post-coital bleeding
  • Post-menopausal bleeding
  • Irregular bleeding
  • Abnormal or blood-stained discharge
  • A sexually transmitted infection

Note

Obvious cervical cancer cannot be diagnosed on a Pap smear but requires a biopsy and histology. Therefore any suspicious looking lesion on the cervix, such as an ulcer or a tumor, must be biopsied.

P. Preparation for a Pap smear

Explain to the patient what you will be doing and why. You will need:

• A vaginal speculum
• A glass slide used for microscopic examination
• A wooden Ayre’s spatula or a cytobrush
• A fixative spray
• A cytology request form

Get all items ready. Label the glass slide with the patient’s name and hospital or clinic number.

Q. How to take a Pap smear

Pass the speculum as described above. Look for the cervix and inspect it carefully for any abnormality. If using a wooden spatula introduce the long arm of the spatula gently into the external os of the cervix (the central opening of the cervix) and rotate it by 360 degrees. Remove the spatula and gently wipe it across the glass slide. Fix the slide immediately after making the smear with a fixative spray. If using a cytobrush insert the brush gently into the external os then swirl it around and remove it. Gently roll the brush across the slide, then fix the slide with the fixative spray.

Complete the cytology request form and send the slide plus form in a safe package (to avoid breaking of the slide during transport) to the laboratory.

R. Informing the patient of the result of a Pap smear

It is very important to bring the patient back for follow up so she can be informed of her result of the Pap smear. Make sure she understands how important it is for her to get the result. Each year many Pap smears are taken in South Africa without women getting their result. This is a problem because these women are at risk of developing cervical cancer and resources are wasted in the process.

Doing a pregnancy test

S. Indications for a pregnancy test

This test is usually done when a patient has missed 1 or more menstrual periods and when, on clinical examination, one is uncertain whether or not she is pregnant.

The test is based on the detection of human Chorionic Gonadotrophin (hCG) in the patient’s urine.

The earliest that the test can be expected to be positive is 10 days after conception. The test will be positive by the time a pregnant woman first misses her period. If the test is negative and the woman is not having her period yet, the test should be repeated after 48 hours.

Note

Pregnancy tests which use reagent strips, are very accurate and become positive when the hCG concentration in the urine reaches 20 mIU/ml.

T. Storage of the pregnancy test ‘kit’

The test which is described in this book is the U-TEST β-hCG STRIP FOIL. If another pregnancy test is used, the method of doing the test and reading the results must be carefully studied in the instruction booklet. All these kits can be stored at room temperature. However do not expose to direct sunlight, moisture or heat.

U. Method of performing a pregnancy test

The patient should bring a fresh urine specimen.

1. Open the foil wrapper and remove the test strip.
2. Hold the blue end of the test strip so that the blue arrow points downwards. Dip the test strip into the urine, as far as the point of the arrow, for 5 seconds.
3. Place the test strip on a flat surface and read after 30 seconds. The result is not reliable if the test strip is read more than 10 minutes after it was dipped into the urine.

V. Reading the result of the pregnancy test

1. Negative if only the control band nearest the upper blue part of the test strip becomes pink
2. Positive if 2 pink bands are visible. Between the control band and the blue part of the test strip another pink band is seen in a positive test
3. Uncertain if no pink bands are seen. Either the test was not performed correctly or the test strip is damaged. Repeat the test with another test strip.