History and Examination

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Chapter 5 History and Examination

Taking the history

The key to any consultation is taking an accurate and complete history. This is relevant in all medical disciplines and particularly in gynaecology. Do not assume that the referral letter contains all the relevant information. It is important to ask what the main problem is – it may be hidden away among a list of relatively unimportant or misleading complaints.

Women may find discussing gynaecological symptoms difficult and require

Privacy	Time	Sympathy
The consultation should be held in a room with adequate facilities and privacy. Permission should be sought for any students who are present	The patient should be allowed to tell her own story before any attempt is made to elicit specific symptoms	The doctor’s manner must be one of interest and understanding

Gynaecological history follows the standard principles of medical history taking but there are a number of other issues that are relevant to gynaecology.

Standard history taking	Additional features relevant to gynaecology
Age	Parity
Presenting complaint	Obstetric history
Past medical history	Contraception and fertility requirements
Medication history	Smear history
Allergies	Menstrual history – this will often be part of the presenting complaint
Social history
Family history
Systemic enquiry

Parity and obstetric history

The first number refers to the number of pregnancies beyond 24 weeks. This cut off largely relates to the gestation of potential viability although any liveborn infant before 24 weeks would also be counted among this number. The second number refers to pregnancies of less than 24 weeks. In practical terms, the easiest way to ask about this is to ask if the woman has any children and then ask if she has had any other pregnancies. Pregnancies in this category are likely to be miscarriages, terminations or ectopic pregnancies. It is important to be sensitive about the terminology when discussing pregnancy loss. The term ‘abortion’ is out dated and should not be used when discussing miscarriage.

Details of the mode of delivery of any children are always important in gynaecology, but other factors such as perineal trauma and postnatal infection are also relevant.

Contraceptive and fertility requirements

This information will be relevant to many gynaecological issues as potential treatments may affect fertility, and many contraceptive treatments will have a useful effect; for example, the combined oral contraceptive pill and menstrual loss and dysmenorrhoea. Infertility may also be the presenting complaint.

Smear history

Women should be asked when their last cervical smear was performed and if the result was normal. Any abnormal smears and colposcopy history should be noted. Within the UK, routine smears are generally performed by primary care, but cervical cytology may be required for symptomatic women.

Menstrual history

At the very minimum, the last menstrual period (LMP) should be recorded. For premenopausal women, the length of a menstrual period and frequency of period should be recorded. This is conveniently expressed as a numerical fraction. Thus, 5/28 means the cycle lasts for 5 days and occurs every 28 days. Make sure that you obtain the number of days from the start of one period to the start of the next. Irregular cycle may produce fractions such as 5–10/21–35.

Useful definitions

Menarche – first menstrual period.

Menopause – date of final menstrual period. This can only be defined with certainty after a year has elapsed since the final menstrual period. It is also useful to ask about menopausal symptoms and hormone replacement therapy (HRT) use. The classic menopausal symptom is vasomotor flushes, but a myriad of other symptoms can also be experienced (see Chapter 18 The Menopause).

Perimenopause – the years of transition where irregular cycles occur. For most women, this lasts for 4 years before the final menstrual period occurs.

Menorrhagia – heavy periods. This is one of the commonest reasons that women are referred to gynaecology. You should ask for how long and how often bleeding occurs. The passage of clots and flooding through sanitary protection are signs that the menstrual flow is excessive. It can also be useful to ask about frequency of changing sanitary protection and whether ‘double’ protection is required, that is, having to wear a sanitary towel and tampon at the same time.

Abnormal Bleeding

Postcoital bleeding – bleeding occurring after intercourse.

Intermenstrual bleeding – bleeding between periods.

Postmenopausal bleeding – bleeding more than one year since LMP.

Irregular Bleeding

Primary amenorrhoea – failure to menstruate by age 16.

Secondary amenorrhoea – no menstruation for 6 months after periods are established.

Oligoamenorrhoea – infrequent, erratic periods.

Remember that anovulatory cycles occur at the extremes of menstrual life. It is therefore physiological to have erratic infrequent periods in the first few years after menarche and in the perimenopause.

Pelvic pain

This may or may not be related to the menstrual cycle. Premenstrual pain may represent endometriosis. Dysmenorrhoea refers to painful menses, usually of a crampy nature. This is usually central low abdominal cramp but can be referred to the thighs and lower back.

Primary dysmenorrhoea – periods have been painful since established menstruation has occurred.

Secondary dysmenorrhoea – periods have become painful. This is thought to be more likely to be associated with pelvic pathology.

Mittelshmertz – mid-cycle pain related to ovulation.

Areas of referred pain duringmenstruation

There are a number of other organ systems that can be responsible for pelvic pain. The most likely sources within the pelvis are the gastrointestinal and urinary tracts. It is important to ask about these systems when assessing for a source of pain. For example, acute right iliac fossa pain could represent an ovarian cyst accident or appendicitis among other diagnoses. Classically, appendicitis will also present with anorexia.

The nature and pattern of pain will also be useful. Bladder pain is central and low, but renal pain will radiate to the loins.

The severity of pain can be judged to some extent by the patient’s behaviour. Pain that causes a woman to take time off work or wakes her from sleep is likely to be caused by an underlying pathology. Pain that causes nausea and vomiting is important. Associated symptoms such as fainting, shoulder tip or pain with defecation imply potential intra-abdominal blood loss, and ectopic pregnancy should be strongly considered.

Tubal pregnancy

Dyspareunia – Pain or exacerbation of underlying pain during sexual intercourse is an important symptom. Deep dyspareunia implies pathology of the upper genital tract. Patient will describe the pain as ‘deep inside’ during intercourse. Superficial dyspareunia is more likely to represent a vaginal cause. Superficial causes of dyspareunia include causes such as local infections, that is, Candida or scarring from episiotomy or vaginal tears during childbirth. Vaginismus is also a common cause of dyspareunia, where the vaginal muscles tense during attempted penetration. It can affect tampon insertion and smear taking and can usually be demonstrated with vaginal examination. It may be present in women with entirely healthy vaginal tissues, but understandably women who experience dyspareunia for any reason can tense up because of anticipation of pain so the presence of vaginismus does not exclude pelvic pathology. A careful one finger vaginal examination to identify if there are any specific areas of tenderness can be useful if the patient will not tolerate a speculum or two-finger bimanual.

Other Gynaecolgical Symptoms

Premenstrual symptoms

Many women experience premenstrual mood disturbance. A range of other physical symptoms occur, including breast tenderness, bloating and headaches. Ideally, women should keep a diary of these symptoms to explore the relationship to their menstrual cycle.

Vaginal discharge

Women who complain of a vaginal discharge should be asked about the colour, odour and any associated vaginal irritation or systemic upset. It can also be useful to determine any relationship to the menstrual cycle as the discharge may be physiological in nature.

Vaginal prolapse

Women with prolapse present with a sensation of something coming down within the vagina. They may also experience backache and a dragging sensation.

Urinary symptoms

Women are frequently referred to gynaecology with the complaint of urinary incontinence. This may or may not be associated with vaginal prolapse. Other urinary symptoms should be considered.

Urinary incontinence can be ‘stress’ incontinence, where the woman leaks when she coughs or exercises or it can be urge incontinence where the woman complains of a sudden sensation of urinary urgency and is incontinent before she makes it to the toilet. The latter symptom is often associated with urinary frequency and nocturia. In practice, many women complain of a mixed pattern of symptoms.

Gynaecological examination

General Principles

The majority of women have varying degrees of anxiety about vaginal examination. Examination is usually more informative in a relaxed patient and a number of simple measures can be used to make the patient feel at ease.

Women should be given an appropriate area to change in privacy. A sheet should be provided to allow the woman to cover herself. A chaperone should be present for any intimate examination. This should apply for both male and female practitioners. The chaperone provides two purposes, firstly as a source of support and distraction for the patient but also to provide evidence that no improper behaviour has taken place. Formal consent should be given for any intimate examination by a student including under anaesthesia.

An explanation of the purpose of the examination should be given to the woman and permission sought to perform the examination. Simple terms should be used to explain the likely sensations experienced. The examination should be thorough but gentle. The patient should feel confident that you will stop the examination if she wishes.

Abdominal examination

This must never be omitted, whatever be the patient’s complaint. Many gynaecological tumours form large swellings, which leave the pelvis altogether, and an undisclosed pregnancy may be present. Always examine the upper abdomen. Be certain that the bladder is empty. Ask the patient to tell you if you are hurting her.

Ovarian cysts often have long pedicles. This ovarian cyst is completely abdominal, and would not be palpable on bimanual pelvic examination.

The characteristic swelling of the 16-week pregnancy may not be seen but can always be felt by pressing with the flat of the hand. The bladder must not be full.

An enlarged uterus may be missed if bimanual examination is performed without an abdominal examination.

All the classical techniques of inspection, palpation, percussion and auscultation are advised, but the most important is gentle palpation with the flat of the hand to detect solid or semi-solid tumours.

The examiner must bear in mind the various intra-abdominal structures which may give rise to swellings.

The hypochondria should be examined to exclude liver and spleen enlargement or gallbladder tenderness, before palpating the lower abdomen.

An attempt to palpate the kidneys should be made. Tenderness may be elicited in the loin, suggesting urinary tract infection.

Inspection may show the characteristic shape of a large ovarian cyst. The outline is rounded and uniform, the skin is stretched and a fluid thrill may be elicited.

If ascites is present (and this means that the cyst is probably malignant), the outline tends to be cylindrical, with some flattening at the top. The umbilicus is everted, and the percussion note is dull in the flanks but tympanitic above because of the upward floating of the intestines.

If the patient is turned on her side, and the percussion is repeated after about 30 s, the dull and tympanitic areas are reversed – ‘shifting dullness’.

Unfortunately, obesity is an increasing problem, and abdominal examination can be particularly challenging. With an ‘abdominal apron’ of fat, the symphysis pubis may be mistaken for a hard lower abdominal mass on palpation. Investigation techniques can also be technically difficult. Abdominal ultrasound is significantly limited by abdominal fat, but transvaginal scanning will be useful.

Examination of the vulva

The dorsal position is most convenient for patient and doctor although examination in a lateral position is useful to assess vaginal prolapse. During palpation, visual inspection of the labia, clitoris, anus and surrounding skin should be performed. Raised or ulcerated areas should raise the question of vulval malignancy. There are specific skin conditions that affect the vulva, including lichen sclerosus, which often presents with itchy white patches and labial fusion. Common benign lesions include sebaceous cysts. Excoriation suggests an underlying irritation.

1. A single finger presses on the perineum, avoiding the sensitive vestibule, and accustoming the patient to the examiner’s touch.

2. Urethral meatus and vestibule are exposed. Pressure from the finger will squeeze any pus from the peri-urethral glands.

3. Bartholin’s gland is palpated (on both sides). It is difficult to feel the normal gland.

4. If there is room, a second finger is inserted and the perineal floor is palpated by stretching.

Bimanual pelvic examination

This technique needs practice. The external hand is the more important and supplies more information. It is customary to use two fingers in the vagina, but an adequate outpatient examination may be made with only one finger. Very little information is gained if the patient finds the examination painful. In a virgin or a child, vaginal examination should not be performed, unless there are exceptional circumstances, and examination under anaesthesia should be considered.

Pelvic models are available, with interchangeable uterine and adnexal components to simulate normal and pathological conditions, for practice examination.

1. The vagina and cervix are palpated and any hardness or irregularity noted.

2. The whole uterus is identified, and size, shape, position, mobility and tenderness are noted.

3. The lateral pelvis is palpated and any swelling noted. Normal adnexa are difficult to feel, unless the ovary contains a corpus luteum.

4. Sometimes rectovaginal examination is helpful, particularly if the rectovaginal septum is to be examined, for example, in assessment of extent of malignant disease.

Speculum examination

The bi-valve speculum is the most useful (Cusco’s pattern is shown here). It is made of either steel or Perspex (disposable) and is designed to open after insertion so that the cervix and vagina can be visualised. Versions with a screw or ratchet are available to hold the device open so that cytological smear or bacteriological swab can be taken as required.

1. The speculum is applied to the vulva at an angle of 45° from the vertical. This allows the easiest insertion.

2. When fully inserted, it is gently opened out and held in position with the cervix between the blades. A good light is needed for inspection. Care is required when removing the speculum to ensure that the blades have not caught the cervix or vagina and that the blades have not been held open by the ratchet or screw.

SIMS’ SPECULUM (the duckbill speculum) is designed to hold back the posterior vaginal wall so that air enters the vagina because of negative intra-abdominal pressure, and the anterior wall and cervix are exposed.

In this picture, the patient is in Sims’ position (semi-prone) which is useful if the anterior wall is to be studied (e.g. if fistula is suspected).