 • The consultation should be performed in a private

environment and in a sensitive fashion

 • The examiner should introduce him/herself and explain
what is about to happen and why.
 there should be no more than one other person in the room.
 be aware of the different attitudes to various women’s health
issues in a religious and
 culturally diverse population and sensitivity should always be
shown.
 Enough time should be allowed for the patient to express
herself and the doctor’s manner should be one of interest
and understanding
 • The examiner should be familiar with the history
template and use it regularly to avoid omissions.
 Listening to the patient tell her story
 Generating a hypothesis
 Testing the hypothesis
▪ By interrogation
▪ 50 %
▪ By examination
▪ 10%
▪ By selective testing
▪ 40%
 If at first you don’t succeed...
 Go back and listen to the patient
 Reproductive tract dysfunction
 Dysmenorrhoea
 Dysfunctional uterine bleeding
 Functional ovarian cysts
 Endometriosis

 Pregnancy
 Miscarriage
 Ectopic
 Pregnancy-related disease
 Reproductive Tract Infections
 Vaginitis
 Pelvic inflammatory disease

 Reproductive Tract Cancer

 Cervix
 Uterus - endometrium
 Ovaries

 Benign tumours
 Fibroids
 Polyps of cervix and endometrium
 Ovarian

 Uterovaginal Prolapse
 Urinary dysfunction
 Anorectal dysfunction
 Psychosexual
 Pelvic Pain
 Dyspareunia/ Vaginismus
 Sexual Assault
 Libido
 Homosexuality (not usually a problem for the gynaecologist)

 Iatrogenic
 Arising from contraception/HRT
 Arising from other drugs

 Other Diseases
 With pelvic manifestations
 Infertility
 Male
 General history
 History of the presenting complain
 Menstrual history
 Pelvic pain
 Vaginal discharge
 Cervical screening
 Contraceptive history
 Sexual history
 Menopause
 Past gynecological History
 Previous obstetric history
 Past medical history
 Other systems
 Drug history
 Bladder and Bowel function
 Summery
 Menarche
 Cycle
 Usually expressed as days bleeding/cycle length
 Regular or not
 Last menstrual period (LMP)
 Intermenstrual bleeding (IMB)
 Postcoital bleeding (PCB)
 Postmenopausal bleeding (PMB)
 Menstrual pain
 How often do your periods come
 From the beginning of one period to the beginning of the next
 What do you mean by regular
 Do they “come early” or do they “come late”
 How much early, how late
 Do you get any bleeding between your periods
 When does it occur in the cycle
 Do you know of anything that brings this on
 Does your period start as a full flow
 When was your last normal period
 First day of the last period
 Not the date of the missed period
 For how long do you have a period
 How many heavy days
 How many light days
 What do you call heavy
 How many pads or tampons
 How often do you change
 Do you change at night
 How often
 How many nights
 Do you pass clots
 How big
 How often
 Do your periods interfere with your life
Used loosely means excessive menstrual loss...
 Escapes from normal menstrual protection

 Large clots – frequently

 Changing at night more than once

 Lasts longer than 7 days “full flow”

 Interferes with normal life or duties

 Causes iron deficiency (anaemia)

 Other causes excluded
 Menorrhagia
 Excessive menstrual loss at regular intervals

 Metrorrhagia
 Frequent and irregular menstrual loss

 Polymenorrhoea
 Regular cycles at <21 days

 Oligomenorrhoea
 Infrequent menstruation (>35 days)

 Intermenstrual Bleeding
 Bleeding between menstrual periods
 Requires careful questioning
 Do you get pain with your periods
 Is this the same as its always been
 If changing with time how and when

 Which is the worse day for pain

 What do you do for the pain
 Analgesia used. How many tablets Does it help
 Does the pain interfere with your life. Your sleep
 Describe the pain
 Nature and location. Aggravating factors

 Pain with intercourse

 Frequency
 Nature and location
 Choose your words carefully, sometimes with preamble
 How long have you been in your current relationship
 Is sexual intercourse occurring
 Have you ever been in a relationship
 When was the last relationship

 How many partners have you had in (period of time)

 or before your current relationship

 What does you or your partner do to avoid pregnancy

 Does your partner travel
 or spend nights away from home
 or have other sexual partners
 Any other serious illnesses. Any operations
 Any gynaecological operations
 on your tubes, ovaries or uterus
 Any vaginal surgery
 Any curettes or keyhole surgery
 Any treatment to the cervix for pre cancer changes
 What was done in those operations
 What were you told after

 Do you have regular Pap tests

 When was the last or where was it done
 What was the result
 Has there ever been any abnormality
 How many have you had in (period of time)
 Have you ever been treated for inflammation of the pelvis,
tubes or for a sexually transmitted disease?
 Did you have any trouble getting pregnant?
 Any infertility treatment(s)

 Number of pregnancies (G) and births (P)

 Gravida = number of pregnancies
 Para = births after 20w (and twins =1)
 T= termination of pregnancy
 A= miscarriage E=ectopic

 Birthweights and mode of delivery

 Spontaneous or assisted vaginal birth
 Birth trauma

 Pregnancy complications
 Are you on any drugs or medications
 Any hormones
 The pill, injections or implants
 Patches or hormone creams
 Vaginal pessaries or creams
 Details of the drug, dose and dates can be very important

 Any vitamins, minerals , supplements or

herbal remedies?

 Do you smoke?
 Do you get up at night to pass urine
 Do you have to get there in a hurry
 Ever wet before you get there
 How long can you hold on during the day
 Do you ever wet
 If you cough or sneeze
 A little or a lot
 Do you have any difficulty emptying your bladder
 or getting started
 Do you have good stream
 Any bladder infections
 Any difficulty getting your bowels emptied
 What happens when you strain
 Can you control your wind
 How about a loose bowel motion?
 The most important calculation is the number of
months that the woman has been exposed to the
possibility of pregnancy but has not conceived
 This may not be the same as the couple’s view of how long they
have been “trying”
 Take a careful “contraceptive history”

 Other useful questions

 Have you ever been pregnant
 Have you ever fathered a pregnancy (in any other relationship
or tried)
 How often is intercourse occurring
 Any (intercourse) problems?
 Important information about the patient can be obtained on
watching them walk into the examination room.
 patient’s consent and with appropriate privacy and
sensitivity. Ideally, a chaperone should be present
throughout the examination.
 general examination
 The thyroid gland
 The chest and breasts
 general neurological assessment
 The patient should empty her bladder before the abdominal
examination.
 The patient should be comfortable and lying semi-
recumbent with a sheet covering her from the waist down,
but the area from the xiphisternum to the symphysis pubis
should be left exposed .
 examine the women from her right hand side.
 Abdominal examination comprises
 inspection.
 palpation.
 percussion .
 auscultation.
 contour of the abdomen , There may be an obvious
distension or mass.
 surgical scars,
 dilated veins
 striae gravidarum (stretch marks).
 examine the umbilicus for laparoscopy scars
 Pfannenstiel scars (used for Caesarean,
hysterectomy, etc.).
 asked The patient to raise her head or cough and
any hernias or divarication of the rectus muscles will
be evident
 First, asked if the patient has any abdominal pain –
the area should not be examined until the end of
palpation.
 use the right hand examining the left lower
quadrant and proceeding in a total of four steps .
 masses,the liver, spleen and kidneys. If a mass is
present but one can palpate below it, then it is more
likely to be an abdominal mass rather than a pelvic
mass.
 look for signs of peritonism, i.e. guarding and
rebound tenderness.
 inguinal hernias and lymph nodes.
Percussion is particularly useful if free fluid is
suspected. In the recumbent position, ascitic fluid will
settle down into a horseshoe shape and dullness is
the flanks can be demonstrated.As the patient
moves over to her side, the dullness will move to her
lowermost side. This is known as ‘shifting dullness’.
A fluid thrill can also be elicited.
Anenlarged bladder due to urinary retention will also
be dull to percussion and this should be
demonstrated to the examiner .
 patient’s verbal consent should be obtained a
 female chaperone should be present for any
intimate examination.
 Unless the patient’s complaint is of urinary
incontinence, it is preferable for the patient to
empty her bladder before the examination. If a urine
infection is suspected, a midstream sample should
be collected at this point.
 the examiner should wear gloves .
 There are three components to the pelvic
examination.
 The external genitalia and surrounding skin,
including the peri-anal area, are first inspected under
a good light with the patient in the dorsal position,
 the hips flexed and abducted and knees flexed. The
 left lateral position can also be used.
 Thepatient is asked to strain down to enable
detection of any prolapse and also to cough, as this
may show the sign of stress incontinence.
 A speculum is an instrument which is inserted into
the vagina to obtain a clearer view of part of the
vagina. There are two principal types. The bi-valve or
Cusco’s speculum which holds back the anterior and
posterior walls of the vagina and allows visualization
of the cervix when opened out. It has a retaining
screw that can be tightened to allow the speculum to
stay in place while a procedure or sample is taken
from the cervix, e.g. smear or swab.
 A Sim’s speculum is used in the left lateral position.
This is useful for examination of prolapse as it allows
inspection of the vaginal walls.
 performed to assess the pelvic organs. It requires practice.
 use the left hand to part the labia and expose the vestibule
 insert one or two fingers of the right hand into the vagina.
The fingers are passed upwards and backwards to reach the
cervix.
 The cervix is palpated and any irregularity, hardness or
tenderness noted.
 The left hand is now placed on the abdomen below the
umbilicus and pressed down into the pelvis to palpate the
fundus of the uterus.
 The size, shape, position, mobility, consistency and
tenderness are noted. The normal uterus is pearshaped and
about 9 cm in length. It is usually anterior (antiverted) or
posterior (retroverted) and freely mobile and non-tender.
 The tips of the fingers are then placed into each
lateral fornix to palpate the adenexae (tubes and
ovaries) on each side. The fingers are pushed
backwards and upwards, while at the same
time pushing down in the corresponding area with
the fingers of the abdominal hand . It is unusual to be
able to feel normal ovaries. Any swelling or
tenderness is noted,
 The posterior fornix should also be palpated to
identify the uterosacral ligaments which may be
tender or scarred in women with endometriosis
 A rectal examination can be used as an alternative to
 a vaginal examination in children and in adults who
 have never had sex. It is less sensitive than a vaginal
 examination and can be quite uncomfortable, but it
 will help pick up a pelvic mass. In some situations,
 a rectal examination can also be useful as well as
 a vaginal examination to differentiate between
 an enterocele and a rectocele or to palpate the
 uterosacral ligaments more thoroughly. Occasionally,
 a rectovaginal examination (index finger in the vagina
 and middle finger in the rectum) may be useful to
 identify a lesion in the rectovaginal septum.
 the patient should be given the opportunity to
dress in privacy
 come back into the consultation room and discuss
the findings.
 You should now give a summary of the whole case
and formulate a differential diagnosis.
 determine the appropriate further investigations.
 Swabs and smears should be taken at the time of
the examination and a midstream specimen
 of urine (MSU) when the patient empties her
 bladder before the examination