The gynecologic history and pelvic examination
- Daniela A Carusi, MD, MSc
Daniela A Carusi, MD, MSc
- Assistant Professor of Obstetrics & Gynecology
- Harvard Medical School
Assessment of the gynecologic history and the pelvic examination is part of the assessment of female patients in many clinical contexts. Clinician familiarity with the gynecologic evaluation can help reduce anxiety for both patients and healthcare professionals .
The gynecologic history and physical examination in adult women are reviewed here. The initial assessment of pregnant women, evaluation of breast complaints, general approaches to patient interviewing as well as pelvic examination in children are discussed separately. (See "Initial prenatal assessment and first-trimester prenatal care" and "Clinical manifestations and diagnosis of a palpable breast mass" and "Approach to the patient" and "Gynecologic examination of the newborn and child".)
Overview — Individual women vary tremendously in their knowledge of, and comfort with, their own bodies. While some may be quite open in disclosing their sexual, reproductive, and genital concerns, others will find such discussions embarrassing or socially inappropriate. Thus, it is essential that providers maintain a sensitive and nonjudgmental approach during this encounter.
The history should be obtained in a relaxed and private setting, before the patient is asked to disrobe. She should be interviewed alone under most circumstances, unless there is a hearing or language barrier. Questioning should proceed from very straightforward, objective information to more delicate issues. The provider should evaluate and respond to the patient's comfort level and make every effort to remain supportive.
It is particularly important to avoid making assumptions about a woman's background; as an example, that she is sexually active or is heterosexual.
- Carr SE, Carmody D. Outcomes of teaching medical students core skills for women's health: the pelvic examination educational program. Am J Obstet Gynecol 2004; 190:1382.
- Lyons MS, Lindsell CJ, Trott AT. Emergency department pelvic examination and Pap testing: addressing patient misperceptions. Acad Emerg Med 2004; 11:405.
- Cole SK, Billewicz WZ, Thomson AM. Sources of variation in menstrual blood loss. J Obstet Gynaecol Br Commonw 1971; 78:933.
- Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss--a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966; 45:320.
- Woolcock JG, Critchley HO, Munro MG, et al. Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding. Fertil Steril 2008; 90:2269.
- Nusbaum MR, Helton MR, Ray N. The changing nature of women's sexual health concerns through the midlife years. Maturitas 2004; 49:283.
- Shifren JL, Johannes CB, Monz BU, et al. Help-seeking behavior of women with self-reported distressing sexual problems. J Womens Health (Larchmt) 2009; 18:461.
- Practice Committee of tAmerican Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss. Fertil Steril 2008; 90:S60.
- Committee opinion no. 460: the initial reproductive health visit. Obstet Gynecol 2010; 116:240.
- American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 483: Primary and preventive care: periodic assessments. Obstet Gynecol 2011; 117:1008.
- Committee on Gynecologic Practice. Committee opinion No. 534: well-woman visit. Obstet Gynecol 2012; 120:421.
- Stormo AR, Hawkins NA, Cooper CP, Saraiya M. The pelvic examination as a screening tool: practices of US physicians. Arch Intern Med 2011; 171:2053.
- http://www.acog.org/About-ACOG/News-Room/College-Statements-and-Advisories/2014/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations (Accessed on July 01, 2014).
- Burns RB, Potter JE, Ricciotti HA, Reynolds EE. Screening Pelvic Examinations in Adult Women: Grand Rounds Discussion From the Beth Israel Deaconess Medical Center. Ann Intern Med 2015; 163:537.
- Qaseem A, Humphrey LL, Harris R, et al. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:67.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- http://consensus.nih.gov/1994/1994OvarianCancer096html.htm (Accessed on November 03, 2010).
- http://www.uspreventiveservicestaskforce.org/uspstf/uspsovar.htm (Accessed on November 03, 2010).
- Buys SS, Partridge E, Black A, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA 2011; 305:2295.
- Padilla LA, Radosevich DM, Milad MP. Limitations of the pelvic examination for evaluation of the female pelvic organs. Int J Gynaecol Obstet 2005; 88:84.
- Rauh-Hain JA, Clemmer J, Clark RM, et al. Management and outcomes for elderly women with vulvar cancer over time. BJOG 2014; 121:719.
- Lai J, Elleray R, Nordin A, et al. Vulval cancer incidence, mortality and survival in England: age-related trends. BJOG 2014; 121:728.
- Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA 2001; 285:2232.
- Harper C, Balistreri E, Boggess J, et al. Provision of hormonal contraceptives without a mandatory pelvic examination: the first stop demonstration project. Fam Plann Perspect 2001; 33:13.
- Gupta S, Hogan R, Kirkman RJ. Experience of the first pelvic examination. Eur J Contracept Reprod Health Care 2001; 6:34.
- http://www.guttmacher.org/statecenter/spibs/ (Accessed on February 09, 2011).
- Ekeroma A, Harillal M. Women's choice in the gender and ethnicity of her obstetrician and gynaecologist. Aust N Z J Obstet Gynaecol 2003; 43:354.
- Patton DD, Bodtke S, Horner RD. Patient perceptions of the need for chaperones during pelvic exams. Fam Med 1990; 22:215.
- Committee on Ethics, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 373: Sexual misconduct. Obstet Gynecol 2007; 110:441.
- American College of Obstetricians and Gynecologists. Guidelines for women’s health care, 4th, Washington, DC 2014. p.100.
- Petravage JB, Reynolds LJ, Gardner HJ, Reading JC. Attitudes of women toward the gynecologic examination. J Fam Pract 1979; 9:1039.
- Broadmore J, Carr-Gregg M, Hutton JD. Vaginal examinations: women's experiences and preferences. N Z Med J 1986; 99:8.
- Hilden M, Sidenius K, Langhoff-Roos J, et al. Women's experiences of the gynecologic examination: factors associated with discomfort. Acta Obstet Gynecol Scand 2003; 82:1030.
- Ueland FR, Depriest PD, Desimone CP, et al. The accuracy of examination under anesthesia and transvaginal sonography in evaluating ovarian size. Gynecol Oncol 2005; 99:400.
- Granberg S, Wikland M. A comparison between ultrasound and gynecologic examination for detection of enlarged ovaries in a group of women at risk for ovarian carcinoma. J Ultrasound Med 1988; 7:59.
- Oyelese Y, Kueck AS, Barter JF, Zalud I. Asymptomatic postmenopausal simple ovarian cyst. Obstet Gynecol Surv 2002; 57:803.
- McDonald JM, Modesitt SC. The incidental postmenopausal adnexal mass. Clin Obstet Gynecol 2006; 49:506.
- Rulin MC, Preston AL. Adnexal masses in postmenopausal women. Obstet Gynecol 1987; 70:578.
- Barber HR, Graber EA. The PMPO syndrome (postmenopausal palpable ovary syndrome). CA Cancer J Clin 1972; 22:357.
- Miller RC, Nash JD, Weiser EB, Hoskins WJ. The postmenopausal palpable ovary syndrome. A retrospective review with histopathologic correlates. J Reprod Med 1991; 36:568.
- Flynt JR, Gallup DG. The postmenopausal palpable ovary syndrome: a fourteen-year review. Mil Med 1981; 146:686.
- Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006.
- Dragisic KG, Padilla LA, Milad MP. The accuracy of the rectovaginal examination in detecting cul-de-sac disease in patients under general anaesthesia. Hum Reprod 2003; 18:1712.
- Davisson L, Clark K, Powers R, Hobbs G. The rectovaginal examination: physician attitudes and practice patterns. South Med J 2006; 99:212.
- AHRQ. The Guide to Clinical Preventive Services. www.preventiveservices.ahrq.gov/#uspstf (Accessed on November 29, 2007).
- Hurd WW. Rectovaginal examinations and human papillomavirus: can we decrease the risk of colorectal infection? Am J Obstet Gynecol 2008; 198:260.e1.
- http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp (Accessed on December 21, 2010).
- Committee opinion no. 472: Patient safety and the electronic health record. Obstet Gynecol 2010; 116:1245.
- GYNECOLOGIC HISTORY
- Basic history
- Problem focused history
- - Vaginal discharge
- - Abnormal genital tract bleeding
- - Pelvic pain
- - Urinary incontinence and pelvic organ prolapse
- - Sexual function
- - Infertility
- PELVIC EXAMINATION
- Timing issues
- - Age at initial examination
- - Indications and frequency for examination
- - When to discontinue examinations
- Preparing for the examination
- - Patient consent
- - Chaperone
- - Patient anxiety or refusal
- - Patient positioning
- - Equipment
- Components of the examination
- - Abdomen
- - External genitalia
- - Bartholin and paraurethral glands
- - Speculum examination
- - Bimanual examination
- - Rectovaginal examination
- SPECIAL CONSIDERATIONS
- Examination of infants and children
- Examination of women with limited mobility or obesity
- Examination after hysterectomy
- SUMMARY AND RECOMMENDATIONS