3
History and examination
Introduction
In general, history and examination cannot be divided neatly into different specialties, and questions relating to obstetrics and gynaecology should form part of the assessment of any woman presenting to any specialty. There may be embarrassment and recrimination, for example, when a suspected appendicitis turns out to be a pelvic infection secondary to an unsuspected intrauterine contraceptive device. Similarly, not all problems presenting to obstetricians and gynaecologists are obstetrical or gynaecological in nature. It is therefore important to take a full history and perform an appropriate examination in all cases. The key points of gynaecological and obstetrical history and examination are emphasized below.
Gynaecological history
A gynaecological history should follow the usual model for history-taking, with questions about the presenting complaint, its history and associated problems. It should include a past medical history and information about prescription and non-prescription drugs used, and any known allergies. After questions about social circumstances and activities, and family history, the history is completed with a general systemic enquiry. However, during a gynaecological history, there are specific key areas to be expanded upon. These include menstrual, fertility, pelvic pain, urogynaecological and obstetrical histories.
Menstrual history
The pattern of bleeding
The simple phrase ‘tell me about your periods’ often elicits all the information required. The bleeding pattern of the menstrual cycle is expressed as a fraction, such that a cycle of 4/28 means the woman bleeds for 4 days every 28 days. A cycle of 4–10/21–42 means the woman bleeds for between 4 and 10 days every 21–42 days. Asking the shortest time between the start of successive periods, the longest time between periods, and the average time between periods helps determine the cycle characteristics.
Bleeding too little
Amenorrhoea is the absence of periods. Primary amenorrhoea is when someone has not started menstruating by the age of 16. Secondary amenorrhoea means that periods have been absent for longer than 6 months. Oligomenorrhoea means the periods are infrequent, with a cycle of 42 days or more.
The climacteric is the perimenopausal time when periods become less regular and are accompanied by increasing menopausal symptoms. The menopause is the time after the last ever period, and can only therefore be assessed retrospectively.
Irregular periods, oligomenorrhoea or amenorrhoea, suggest anovulation or irregular ovulation. Specific questions about weight, weight change, acne, greasy skin, hirsutism, flushes or galactorrhoea may help identify the nature of the ovarian dysfunction.
Bleeding too much
It is very difficult to find out how heavy someone’s periods are. If menstrual blood loss is accurately measured, an average of 35 ml of blood is lost each month. Heavy menstrual bleeding (previously known as menorrhagia) is defined as loss of more than 80 ml during regular menstruation. Some women will complain of very heavy periods with a normal blood loss, while others will not complain in the presence of heavy menstrual bleeding. Asking how often pads or tampons have to be changed and using pictorial charts can provide more objective information. Whether menstrual loss is excessive, however, is a largely subjective assessment.
Specific symptoms can indicate abnormally heavy menstruation. Although small pieces of tissue are normal, blood clots are not. ‘Flooding’ is when menstrual blood soaks through all protection. It is both abnormal and distressing. Symptoms of anaemia may also be present. A history of the menstrual cycle since menarche (the first period) can reveal changes in the bleeding pattern. However, an emphasis on the effect on lifestyle and treatments tried previously is particularly important.
Bleeding at the wrong time
It is important to ask specifically about bleeding, brown or bloody discharge between periods (intermenstrual bleeding, IMB), or after intercourse (post-coital bleeding, PCB). These symptoms can point to abnormalities of the cervix or uterine cavity. Postmenopausal bleeding (PMB) is defined as bleeding more than 1 year after the last period. Undiagnosed abnormal bleeding requires further investigation.
Fertility history
Last menstrual period (LMP)
This question is vital and should be followed with whether that period came at the expected time and was of normal character. As well as alerting to the possibility of pregnancy, the information is important because some investigations need to be performed at specific times of the menstrual cycle.
Contraception
It is useful to establish whether the woman is sexually active, perhaps with something like, ‘Are you currently in a physical sexual relationship?’ and then, ‘Are you using any contraception at present?’ A further discussion about fertility issues, unprotected intercourse and risk factors for certain diseases may be appropriate. A contraceptive history should include any problems with chosen contraceptives and why they were stopped. Questions may be followed-up with ‘Are you hoping for a pregnancy?’ if the situation is not clear.
If there are any infertility issues, their duration and the results of any investigation or treatment may be of relevance. If the woman is postmenopausal, enquiry should be made about past or current use of hormone replacement therapy and whether she has any symptoms attributable to the menopause.
Cervical smears
Cervical screening programmes vary in different countries but generally, women between the ages of 20–25 and 60–64 are invited to participate every 3–5 years. The date of the woman’s last smear should be noted, and when it was recommended that she have her next smear. Any previous abnormalities or vaccination should also be noted, and whether she has had any colposcopic investigation or treatment. If she is over 50, it may be relevant to discuss breast screening.
Pelvic pain history
Painful periods
Dysmenorrhoea is a common problem and its effects on lifestyle are important. The cramping pain of primary dysmenorrhoea is at its most intense just before and during the early stages of a period. Young women are particularly affected and the pain has usually been present from the time of the first period. It is not usually associated with structural abnormalities and may improve with age or after a pregnancy. Secondary dysmenorrhoea is when menstruation has not tended to be painful in the past, and is more likely to indicate pelvic pathology. In particular, progressive dysmenorrhoea, where the intensity of the pain increases throughout menstruation, may suggest endometriosis.
Pelvic pain
The relationship of pelvic pain to the menstrual cycle is important. Pain immediately prior to or during periods is more likely to be of gynaecological origin. ‘Mittelschmerz’ is a cramping pelvic pain that can be midline or unilateral. It occurs 2 weeks before a period and is caused by ovulation. Intermittent discomfort may suggest some scarring or ovarian pathology but it is more commonly non-gynaecological. It is vital to take a urinary and lower gastrointestinal history as urinary tract infection or irritable bowel syndrome may present with pelvic pain. Any pain is likely to be worse if the person is anxious, stressed or depressed. Chronic pelvic pain is particularly affected by psychosomatic factors, and recognizing this during history-taking is important.
Pain on intercourse
There are two main types of dyspareunia: superficial and deep. They can be differentiated by asking, ‘Is it painful just as he begins to enter or when he is deep inside?’ Deep dyspareunia is associated with pelvic pathology, such as scarring, adhesions, endometriosis or masses that restrict uterine mobility. Superficial dyspareunia can arise from local abnormalities at the introitus or from inadequate lubrication. It can also be due to a voluntary or involuntary contraction of the muscles of the pelvic floor referred to as ‘vaginismus’ (see Chapter 25).
Vaginal discharge
Discharge can be normal or be associated with cervical ectopy and, particularly if offensive or irritant, can indicate infection. It can also suggest neoplasia of the cervix or endometrium. Enquire about the duration, amount, colour, smell and relationship to cycle.
Urogynaecological history
Urinary incontinence
A good initial question to ask is, ‘Do you ever leak urine when you don’t intend to?’ If so, find out what provokes it, how it affects her lifestyle and what steps she takes to avoid it. ‘Do you ever not make it to the toilet in time?’ can help identify urge incontinence, as can a history of frequency and small volumes passed after desperation. Incontinence after exercise, coughing, laughing or straining can suggest stress incontinence. It can be difficult to differentiate stress incontinence and urge incontinence, however, as there is often a mixed picture.
Other urinary symptoms
Enquiry should be made about frequency and nocturia. If present, small volumes and an inability to interrupt the flow may suggest detrusor instability. If large volumes are passed, ask about thirst and fluid intake. A history of dysuria or haematuria may suggest bladder infection or pathology. ‘Strangury’ is the constant desire to pass urine and suggests urinary tract inflammation.
Prolapse
Prolapse may be associated with vaginal discomfort, a dragging sensation, the feeling of something ‘coming down’ and possibly backache. Although the uterus, anterior vaginal wall and posterior vaginal wall can prolapse, it is difficult to separate these by history. Bladder and bowel function should be explored, including a question about the need to digitally manipulate the vagina in order to be able to void.
Gynaecological examination
Signs of gynaecological disease are not limited to the pelvis. A full examination may reveal anaemia, pleural effusions, visual field defects or lymphadenopathy in gynaecological conditions. However, passing a speculum, taking a cervical smear and performing a bimanual pelvic examination are the key skills to acquire. A great deal of sensitivity is required in their use.
Passing a speculum
Preparation
The patient should empty her bladder and remove sanitary protection. The examination room should be quiet and have a private area for the patient to undress. It should contain an examination couch with a modesty sheet and good adjustable lighting. A female chaperone should always be present. The examination requires full explanation and verbal consent.
Stand on the right of the patient with gloves, speculum and lubricating gel immediately to hand. The patient should lie back, bend her knees, put her heels together and let her knees fall apart. The light should be adjusted to give a good view of the vulva and perineum and the modesty sheet should cover the patient’s abdomen and thighs.
Inspection
Inspect the hair distribution and vulval skin. Hair extending towards the umbilicus and onto the inner thighs can be associated with disorders of androgen excess, as can clitoromegaly. The vulva can be a site of chronic skin conditions such as eczema and psoriasis, specific conditions such as lichen sclerosis and warts, cysts of the Bartholin’s glands (see History box), and cancers. Ulceration may imply herpes, syphilis, trauma or malignancy.
Look at the perineum (Fig. 3.1) and gently part the labia to inspect the introitus. Perineal scars are usually secondary to tears or episiotomy during childbirth. A red papule around the urethral opening is usually a prolapsed area of urethral mucosa. A white, plaque-like discharge may suggest thrush, and pale skin with punctate red areas implies atrophic vaginitis. Asking the woman to cough may reveal demonstrable stress incontinence or the bulge of a prolapse.
Speculum examination
Disposable speculums tend to be all one size, but smaller and larger speculums are available if required. Ensure the speculum is warmed, working normally and lubricated with gel. Hold the speculum so that its blades are oriented in the same direction as the vaginal opening. Part the labia and slowly insert the speculum, rotating it gently until the blades are horizontal (Fig. 3.2).
If the patient is in the lithotomy position at the edge of the couch, the speculum can be turned downwards to avoid pressure on the clitoris. If the patient is lying on the couch itself, it is usually easier to rotate the speculum upwards. It should be inserted fully in a slightly posterior direction, before firmly, but gently, opening to visualize the cervix (Fig. 3.3). The speculum can be closed a little when the cervix pops into view.
