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History and Examination

History and Examination of Gynaecology

Chapter - 1
Patient

The interaction of the patient with a physician can often be an anxiety-producing event,
particularly so in the practice of Gynaecology because of the sensitive nature of the
problems that need to be discussed.
Three ethical principles must be integrated into the care and nature of services offered
to every patient.
1. Respect: Today, counselling forms an important aspect of consultation.
Remember that the patient has the right to make decisions about her health
care. It is not ethically or morally right to enforce the physician's opinion on the
patient. This will safeguard against any charge of negligence if a medico legal
problem arises at a later date.
2. Beneficence: The medical attendant must be vigilant to ensure that the
therapeutic advice rendered to the patient should be in 'good faith'. It should be
aimed at benefiting her.
3. Justice: History and physical examination constitute the fundamental tools on
which rest the tentative diagnosis, the tests to be undertaken and the treatment
to be recommended.
History
Careful history and physical examination form the basis of patient evaluation, clinical
diagnosis and management.
History begins with the recording of the basic information about the patient as shown in
the sample proforma.
 History and Examination of Gynaecology Patient 29

History: Gynaecological Case Record Form

Registration No:
Name in full:
Address:
Tel. No: Name and contact of next of kin:
Insurance details:
Demographic data:
Age: Marital status: Parity: Occupation:
Chief complaints:
Origin, duration and progress:
Past history:
Medical illnesses:
Surgical illnesses: Allergy to drugs and previous blood transfusion:
Personal history:
Diet:
History of blood transfusion in the past:
Bowels and micturition:
Habits/addictions:
Medications:
Allergies:
Marital history:
Sexual intercourse:
Dyspareunia:
Contraceptives used:
Sexual disorders: vaginal discharge:
Family history:
Diabetes: Hypertension: Allergies: Tuberculosis:
Genetic disorders:
Carcinoma: Multiple births: Others:
30 History and Examination of Gynaecology Patient

Menstrual history:
Age at menarche:
Past menstrual cycles:
Present menstrual cycles:
Date of the last menstrual period:
Obstetric history:
Full-term deliveries:
Preterm deliveries: No. Outcome:
Abortions: No. Outcome:
Number of living children: Interventions with details:
Date of last delivery:

Present Illness
The clinician must record the patient's complaints in the sequence in which they occurred,
noting their duration, their aggravating and relieving factors and their relation to
menstruation, micturition and defaecation.
Past and Personal History
Past medical and surgical problems may have a bearing on the present complaints. For
example, pruritus vulva may be due to genital candidiasis, and history of sexually
transmitted disease (STD) may have a direct bearing on future infertility. History of
pelvic inflammatory disease (PID) or puerperal sepsis may be associated with menstrual
disturbances, lower abdominal pain, congestive dysmenorrhoea and infertility.
Tuberculosis may lead to oligomenorrhoea and infertility. History of endocrinopathy
may affect her sexual functions. Previous abdominal surgery such as caesarean section,
removal of the appendix, excision for ovarian cyst, etc. may lead to pelvic adhesions,
which may be the cause of abdominal pain, backache, retroverted fixed uterus, infertility
and menstrual disturbances.
Family History
Certain problems run in families, e.g. menstrual patterns tend to be similar amongst
members of the family. Premature menopause, menorrhagia and dysmenorrhoea may
occur in more than one member in a family. Similarly, female members of some families
are more prone to cancer of the ovary, uterus and breast. Diabetes, hypertension,
thyroid disorders, allergic diathesis and functional disorders are often familial in nature.
Genetic and hereditary disorders affect more than one member in the family, e.g.
thalassaemia. Tuberculosis may affect many in the family.
 History and Examination of Gynaecology Patient 31

Marital and Sexual History

Note the details of her marital life, such as the frequency of coitus, dyspareunia, frigidity,
achievement of orgasm, libido, use of contraceptives and the method used. Relevance
of dyspareunia to infertility should be noted.
Menstrual History
The term menorrhagia denotes excessive blood loss (increase in duration of bleeding /
heavier blood flow) with out any change in the cycle length. The term menorrhagia is
now replaced by 'abnormal uterine bleeding' (AUB). The term polymenorrhoea or
epimenorrhoea refers to frequent menstrual cycles as a result of shortening of the
cycle length. Sometimes women suffer from a menstrual disorder characterized by
shorter duration of the cycles coupled with heavier flow or prolongation in the duration
of the flow; this condition is termed as polymenorrhagia.
The severity of AUB can be assessed by taking into account the number of sanitary
pads required per day, history of passing blood clots, presence of anaemia and evaluating
for the presence of accompanying symptoms such as fatigue, palpitation, dizziness,
breathlessness on exertion and the presence of pallor. Menorrhagia and polymenorrhagia
are frequently present in women with myomas, adenomyosis and PID in women wearing
intrauterine contraceptive devices (IUCDs) and also due to hormonal imbalance causing
dysfunctional uterine bleeding (DUB) in perimenopausal women. Oligomenorrhoea is
the term used to describe infrequent menses. In this condition, the cycle length is prolonged
without affecting the duration and amount of flow. Hypomenorrhoea refers to the
condition in which the cycle length remains unaltered, however the duration of bleeding
or the amount of blood loss, or both are substantially reduced. When complete cessation
of menstruation occurs, the condition is described as amenorrhoea.
The problems of oligomenorrhoea and hypomenorrhoea are encountered in conditions
such as polycystic ovarian disease (PCOD), hyperprolactinaemia and genital tuberculosis,
in women on oral contraceptive pills, in association with certain neoplasms of the pituitary
or ovary, in functional hypothalamic disorders and in psychiatric disorders. Drugs may
occasionally be implicated. Amenorrhoea is physiological during pregnancy, lactation,
prior to puberty and after menopause. Metrorrhagia means the occurrence of
intermenstrual bleed¬ing, and it may occur in association with ovulation. However, it is
commonly associated with the presence of neoplasms such as uterine polyps, carcinoma
cervix and uterine and lower genital tract malignancy, vascular erosions, using intrauterine
devices or in oral pill users. However, this symptom calls for thorough investigation
because of a possible malignant cause. Genital tract neoplasms such as submucous
polyps and genital malignancies may present with continuous bleeding. Postmenopausal
bleeding is often related to genital malignancy in 30-40%; hence, this symptom should
not be treated lightly, it should be evaluated carefully and all efforts made to exclude
32 History and Examination of Gynaecology Patient

such a possibility. Postcoital bleeding often suggests cervical lesion. i.e. erosion. polyp
and cancer.
The presence of dysmenorrhoea and dyspareunia may have organic cause in the pelvis.
i.e. endometriosis, fibroid and PID. Vaginal discharge is common in lower genital tract
infections.
Obstetric History
Record the details of every conception and its ultimate outcome, the number of living
children, the age of the youngest child and the details of any obstetric complications
encountered. e.g. puerperal or postabortal sepsis. postpartum haemorrhage (PPH),
obstetrical interventions, soft tissue injuries such as cervical tear, an incompetent cervical
os and repeated abortions, genital fistulae, com-plete perineal tear and genital prolapse,
stress urinary incontinence and chronic backache. Medical termination of pregnancy
and spontaneous abortions should also be enquired into. Abdominal pain: Abdominal
pain is a complaint in pelvic tuberculosis, PID and endometriosis. Acute lower abdominal
pain occurs in ectopic pregnancy, torsion or rupture of an ovarian cyst and chocolate
cyst.
Physical Examination
Physical examination includes general examination, systemic examination and
gynaecological examination with a female attendant present to assist the patient and
reassure her, particularly so when the attending clinician is a male doctor.
General Examination
General examination includes data mentioned in the proforma. Pallor of the mucous
membranes, the tongue and conjunctivae together with pale appearance of the skin and
nails is highly suggestive of anaemia fullness of the neck is suggestive of a thyroid
enlargement and enlarged lymph nodes are indicative of chronic infection, tuberculosis
or metastasis following malignancy. Bilateral oedema of the feet may be found in women
with large abdominal tumours, and unilateral non pitting oedema is highly suggestive of
malignant growth involving the lymphatics. Breast examination should be included in
general examination. Hirsutism is a feature of PCOD. Breast secretion is noted in
hyperprolactinaemia an important feature in amenorrhoea.
Systemic Examination
All gynae patients must be examined as a whole. This includes the examination of the
cardiovascular and respiratory systems. Presence of any neurological symptoms calls
for a detailed neurological evaluation.
 History and Examination of Gynaecology Patient 33

PHYSICAL EXAMINATION
1. General examination:
Height in cm: weight (in KG), gait : appearance:
Build: Weight nutritionalstatus: odema of the feet:
Pallor:
Lymphadenopathy:
Stigmata of disease: Breasts, thyroid, hirsutism
Vital parameters:
Respiratory rate:
2. Systemic examination:
Cardiovascular system:
Respiratory system:
Liver palpation in malignancy
3. Gynaecological examination:
Abdomen:
Inspection:
Shape: umbilicus: movement with breathing:
Scars:
Palpation: lump:
Tenderness:
Rigidity and guarding:
Palpable lump: Ascites due to tuberculosis, ovarian malignancy and Meig syndrome
Auscultation:
Peristalsis: Bruit:
Pelvic examination:
External genitalia:
Appearance:
Discharges:
Scars:
34 History and Examination of Gynaecology Patient

Lymphadenopathy:
Temperature:
Blood pressure:
Pulse rate:
Umbilicus:
Lump:
Movement with breathing:
Perineum:
Bimanual examination:
Cervix:
Uterus:
Fornices:
Speculum examination:
Cervix:
Vagina:
Pap smear:
Vaginal discharge:
Rectal examination if necessary:
4.Clinical diagnosis:
Provisional diagnosis : Final:
Abdominal Examination
Inspection
Many gynaecological tumours arising out of the pelvis grow upwards into the abdominal
cavity. They cause enlargement of the abdomen, particularly the lower abdomen below
the umbilicus, and their upper and lateral margins are often apparent on inspection.
However, very large tumours can give rise to a diffuse enlargement of the entire abdomen.
Eversion of the umbilicus can occur as a result of raised intra-abdominal pressure and
is observed with large tumours, ascites and pregnancy. The mobility of the abdominal
wall with breathing should be observed carefully. In case of an intra-abdominal tumour,
the abdominal wall moves over the tumour during breathing so that its upper margin is
apparently altered. In case of pelvic peritonitis, the movements of the lower abdomen
below the umbilicus are often restricted. The presence of striae is seen in parous women,
pregnant women, in obese subjects and in women harbouring large tumours.
 History and Examination of Gynaecology Patient 35

Palpation
With the clinician standing on the right side of the patient, it is desirable to palpate for
the liver, spleen and kidneys with the right hand, and to use the sensitive ulnar border of
the left hand from above downwards to palpate swellings arising from the pelvis. The
upper and lateral margins of such swellings can be felt, but the lower border cannot be
reached. Myomas feel firm and have a smooth surface, unless they are multiple, when
they present a bossed surface. Ovarian neoplasms often feel cystic, and may be fluctuant.
The upper margin of these swellings is often well felt, unless the swelling is too large.
The pregnant uterus feels soft and is known to harden intermittently during Braxton
Hicks contractions; this is characteristic of pregnancy. The full bladder bulges in the
lower abdomen and feels tense and tender. Extreme tenderness on palpation below the
umbilicus is suggestive of peritoneal irritation, seen in women with ectopic pregnancy,
PID, twisted ovarian cyst, a ruptured corpus luteum haematoma or red degeneration in
a fibroid often associated with pregnancy. In women with an acute surgical condition,
guarding in the lower abdomen and rigidity on attempting deep palpation are noted.
Percussion
Uterine myomas and ovarian cysts are dull to percussion, but the flanks are resonant.
Dullness in the flanks and shifting dullness indicate the presence of free fluid in the
peritoneal cavity. Ascites may be associated with tuberculous peritonitis, malignancy or
pseudo-Meig's syndrome.
Auscultation
This reveals peristaltic bowel sounds, fetal heart sounds in pregnancy, souffle in vascular
neoplasms and pregnant uterus. Hyperperistalsis may indicate bowel obstruction; feeble
or absent peristalsis indicates ileus, calling for aggressive attention. Return of peristaltic
sounds following pelvic surgery is a welcome sign of recovery and an indication to start
oral feeds.
Gynaecological Examination
Most prefer dorsal position, so that bimanual examination of the pelvic organs can be
conducted following abdominal examination without changing the position. Some may
prefer left lateral (Sims' position). Verbal consent should be obtained for bimanual
examination.
External Examination
It is a good practice to inspect the external genitalia under a good light. Notice the
distribution of pubic hair. Normal pubic hair is distributed in an inverted triangle, with
the base centred over the mons pubis. Extension of the hair line upwards in the midline
along the linea nigra up to the umbilicus is seen in about 25% of women, especially in
women who are hirsute or mildly androgenic as in PCOD. With the patient in lithotomy
and her thighs well parted, note the various structures of the vulva. Look for the presence
36 History and Examination of Gynaecology Patient

of any discharge or blood. Ask the patient to bear down and observe for any protrusion
due to polyp or genital descent
such as cystocele, rectocele, uterine descent or procidentia Separate the labia wide
apart and examine the fourchette to see whether it is intact or reveals an old healed
tear.
Speculum Examination
Speculum examination should ideally precede bimanual vaginal examination especially
when the Papanicolaou (Pap) smear and vaginal smear need to be taken.
A bivalve self-retaining speculum such as the Cusco's speculum is ideal for an office
examination. It allows satisfactory inspection of the cervix, taking of a Pap smear,
collection of the vaginal discharge from the posterior fornix for hanging drop/KOH
smear and colposcopic examination. The Sims' vaginal speculum with an anterior vaginal
wall retractor can be used for the above examination. It permits an assessment of
vaginal wall for cystocele and rectocele
Bimanual Examination
After separating the labia with the thumb and index fingers of the left hand, two fingers
of the right hand (index and forefinger), after lubrication re gradually introduced beyond
the introitus to reach up to the fornices. If the fingers
encounter the anterior lip of the cervix first, it denotes the cervix is pointing downwards
and back towards the posterior vaginal wall, and that the uterus is in the anteverted
position, conversely when the posterior lip of the cervix is
encountered first, it is indicative of a retroverted uterus. The clinician next observes the
consistency of the cervix: it is soft during pregnancy and firm in the non pregnant state.
Observe whether the movements of the cervix during the
examination cause pain; this is seen in an ectopic pregnancy, as also in women with
acute salpingo-oophoritis. The examining fingers now lift up the fornices and thereby
elevate the uterus towards the left hand, which is placed over the lower abdomen and
brought behind it. The uterus can thus be brought within reach of the abdominal hand
and palpated for position, size, shape, mobility, tenderness and presence of any uterine
pathology, e.g. fibroids.
In case of the retroverted uterus. It will be felt through the posterior fornix. Thereafter,
the clinician directs the tips of the examining fingers in the vagina into each of the
lateral fornices and by lifting it up towards the abdominal hand, attempts to feel for
masses in the lateral part of the pelvis between the two examining hands. Should this
reveal the presence of a swelling separate from the uterus, then the presence of some
adnexal pathology is confirmed. The common swellings identified include ovarian cyst
or neoplasm, a paraovarian cyst, e.g. fimbrial cyst, tubo-ovarian masses, hydrosalpinx,
 History and Examination of Gynaecology Patient 37

and swelling in chronic ectopic pregnancy. The appendages are normally not palpable
unless they are swollen and enlarged. The ovary is not easily palpable; however, when
palpated, it evinces a peculiar painful sensation that makes the patient to wince. Next in
turn is the palpation of the posterior fornix. This enables the palpation of the contents of
the pouch of Douglas. The most common swelling is the loaded rectum, particularly if
she is constipated. Others in order of diminishing frequency include a retroverted uterus,
ovaries prolapsed into the pouch of Douglas, uterine fibroid, ovarian neoplasm, chocolate
cyst of the ovary, endometriotic nodules, pelvic inflammatory masses resulting from the
adhesions of tuba-ovarian masses to the posterior surface of the uterus and the floor of
the pouch of Douglas, pelvic abscess pointing in the posterior pouch and pelvic
haematocele commonly associated with a ruptured ectopic pregnancy. To recognize
the uterus from the adnexal mass, push the cervix upwards, and if this is transmitted to
the swelling it is the uterus. Alternately, pushing down the uterus causes the cervix to
move down. Adnexal mass does not move with cervical or uterine movement.
Rectal Examination
In virgins, a vaginal examination is avoided. Instead a well lubricated finger inserted
into the rectum can be used for a bimanual assessment of the pelvic structures. Today,
practically all gynaecologists prefer ultrasonic scanning to rectal
examination, which, apart from being unpleasant, is not that accurate. A rectal
examination is a very useful additional examination whenever there is any palpable
pathology in the pouch of Douglas. It often allows the ovaries to be more easily identified.
In parametritis and endometriosis, the uterosacral ligaments are often thickened, nodular
and tender. It confirms the swelling to be anterior to the rectum, and if the rectum is
adherent to that swelling. This is important in case of carcinoma of the cervix to determine
the extent of its posterior spread. A rectal examination is mandatory in women having
rectal symptoms. This should begin by inspecting the anus in a good light, when lesions
such as fissures, fistula-in-ano, polyps and piles may come to light. Introduction of a
well-lubricated proctoscope to inspect the rectum and anal canal helps to complete the
examination. Ultrasound today has reduced the importance of rectal examination except
in cancer cervix and pelvic endometriosis.

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