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Consultado el 13 de julio de 2016

The gynecologic history and pelvic examination

Author
Daniela A Carusi, MD, MSc
Section Editor
Robert L Barbieri, MD
Deputy Editor
Sandy J Falk, MD, FACOG
Contributor disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2016. | This topic last updated: Apr 04, 2016.

INTRODUCTION — 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 [1].

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".)

GYNECOLOGIC HISTORY

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.

One should begin the history with an open-ended question that will elicit the woman's gynecologic concerns. She
should be encouraged to describe the situation in her own words and without frequent interruptions. Maintaining
eye contact, nodding, and brief clarification of important points convey the provider's attention to the woman's
issues. The provider can then ask questions to proceed with the evaluation. (See "A patient-centered view of the
clinician-patient relationship".)

Basic history — The basic components of the gynecologic history are the following:

●Menstrual history (table 1) – the shorthand for menstrual history is age at menarche x cycle length x
number of days of bleeding (eg, 13x28x5)
●Obstetric history (table 2) – the shorthand for obstetric history is gravida (number of pregnancies) para
(number of term births; number of births from 20 to <37 weeks of gestation; number of failed or terminated
pregnancies at <20 weeks; living children) (eg, G2P112)
 ●Sexual history (See 'Sexual function' below.)
●Type of contraception, past and current (if appropriate)
●Current symptoms or history of pelvic, vaginal, or vulvar infections – vaginal discharge, vulvar or vaginal
lesions, fever, pelvic pain, abnormal genital tract bleeding, prior sexually transmitted infections or pelvic
inflammatory disease (diagnosis, frequency, and treatment)
●Cervical cytology (Pap test) history – date and result of last test; diagnosis and follow-up of abnormal Pap
smears
●History of other gynecologic problems, such as ovarian cysts, uterine fibroids, infertility, endometriosis, or
polycystic ovarian syndrome - mode of diagnosis and treatment
●Symptoms of pelvic organ prolapse or urinary or anal incontinence
●History of gynecologic procedures (eg, endometrial biopsy, laparoscopy, hysterectomy) – date, indication,
complications
●Screening for intimate partner violence. (See "Intimate partner violence: Diagnosis and screening".)

Specific questions are essential in order to obtain accurate information. As an example, some patients may not
include miscarriages or abortions when asked about past pregnancies; therefore, the provider should specifically
inquire about these events. Some patients will equate undergoing a pelvic examination with having a Pap test,
and erroneously state that this test was recently performed [2]. Other patients may make inaccurate
assumptions about whether their ovaries or cervix were removed with a hysterectomy. Therefore, written records
of cervical cytology testing results, operative procedures, and pathology results should be obtained whenever
possible.

A comprehensive gynecologic history includes a complete summary of the woman's medical, surgical, social,
and family history. A review of symptoms is taken that focuses on the genitourinary areas (table 3).

Problem focused history — The most common gynecologic concerns relate to vaginal discharge, abnormal
bleeding, pelvic pain, urinary problems, sexual dysfunction, and infertility. When a patient identifies one of these
issues, detailed questioning can guide further evaluation and diagnosis.

Vaginal discharge — Many reproductive age women have daily vaginal discharge. Normal vaginal discharge is
composed of mucoid endocervical secretions in combination with desquamated vaginal wall epithelium and
normal bacteria. Physiologic discharge is typically clear, white, or light yellow in color. The volume of discharge
varies considerably among women and timing in the menstrual cycle. For women who present with vaginal
discharge, questions should be asked regarding the onset, duration, frequency, color, consistency, volume, and
odor of the flow. Discharge that is malodorous, pruritic, copious, purulent, bloody, or accompanied by fever
requires investigation. (See "Approach to women with symptoms of vaginitis".)

Abnormal genital tract bleeding — Women commonly present with a complaint of “vaginal bleeding.” A
complaint of vaginal bleeding most often represents uterine bleeding, but the source may be any part of the
genital tract, or the urinary or gastrointestinal tracts (table 4). Pregnancy should be excluded in any woman of
reproductive age with abnormal genital tract bleeding. (See "Differential diagnosis of genital tract bleeding in
women".)

Pertinent data are the onset of a change in bleeding, amount, duration, and frequency of bleeding (table 5). In
women of reproductive age or in the menopausal transition, the use of a menstrual chart to document bleeding
patterns is helpful in determining whether the changes are sufficiently abnormal to justify investigation (figure 1).
Irregular bleeding occurs commonly during the menopausal transition and may be a symptom of serious
underlying pathology.
Uterine bleeding is abnormal when it is associated with a change in the woman's normal menstrual pattern or it
occurs after menopause. The average menstrual cycle lasts up to seven days and the amount of menstrual
blood loss is 35 to 40 mL per cycle, but the range is wide [3,4]. Menorrhagia is defined as menstrual blood loss
greater than 80 mL. However, the term menorrhagia is applied variably to ovulatory or anovulatory uterine
bleeding [5]. Prolonged menses are defined as longer than seven days. Given the difficulty in quantifying actual
blood loss, questions should focus on a significant change from baseline, bleeding at abnormal times during the
cycle (intermenstrual or postcoital), and symptoms of anemia (such as new significant fatigue, orthostasis, or
palpitations). (See "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women".)

Menopause is defined by 12 months of amenorrhea after the final menstrual period. Postmenopausal bleeding
refers to any uterine bleeding in a menopausal woman (other than the expected cyclic bleeding that occurs in
women taking sequential postmenopausal hormone therapy). While menopause may occur in some women in
their 40s, other causes of amenorrhea and abnormal uterine bleeding should be considered, particularly for
patients in their early 40s. While a change in the menstrual pattern is expected in the months or years prior to
menopause, an increase in the amount or duration of bleeding during this time should be treated as pathologic
and evaluated. (See "Postmenopausal uterine bleeding" and"Evaluation and management of secondary
amenorrhea".)

Pelvic pain — The characterization of pelvic pain should include the time of onset, duration, location, quality,
and severity. The relationship of the pain to menstruation, physical activity, or sexual activity and alleviation of
the pain with analgesics, hormonal contraceptives, or position change are useful components of the pain history.
Associated gastrointestinal or urinary symptoms could point to a nongynecologic source of the pain. However,
ovarian torsion is often accompanied by nausea and vomiting. (See "Causes of abdominal pain in
adults" and "Causes of chronic pelvic pain in women".)

Urinary incontinence and pelvic organ prolapse — Urinary incontinence occurs among women of all ages
and requires evaluation when the involuntary loss of urine is bothersome. Historical factors, such as leakage of
urine with physical activity (exercise, lifting, coughing, sneezing) versus an overwhelming urge to void with
leakage of urine before reaching a toilet, can help to differentiate stress incontinence from detrusor instability. A
careful voiding and intake history will help the clinician determine the underlying cause. (See "Evaluation of
women with urinary incontinence".)

Women with pelvic organ prolapse may complain of a vaginal bulge, vaginal pressure, or the need to place a
finger in the vagina to void or defecate. Such symptoms should be evaluated further with physical examination. It
is important to ask about urinary and fecal incontinence as well as sexual dysfunction when evaluating prolapse
symptoms and making treatment decisions. (See "Pelvic organ prolapse in women: An overview of the
epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

Sexual function — Many sexual problems result from and/or cause reproductive dysfunction and gynecologic
problems. Sexual issues include prevention of sexually transmitted infections, contraception, sexual dysfunction,
and prevention and management of sexual assault.

Many women are reluctant to express concerns regarding these matters, but welcome the opportunity to discuss
them when approached in an interested and compassionate manner. The importance of an assessment of
sexual function was demonstrated in a questionnaire study of over 1000 women seen for a primary care visit; 98
percent reported one or more sexual concerns, but only 18 percent of clinicians asked about sexual health [6].
Women who discussed their sexual concerns with their clinician found the discussion helpful. In another study,
among 3000 women with a sexual problem that caused personal distress, only 6 percent of those who sought
medical advice scheduled a visit specifically for a sexual problem, and about 80 percent of the time, the woman,
rather than the physician, initiated the conversation [7].
In addition to questions regarding basic gynecologic health, contraception and safe sex practices, all women
should be asked an open-ended question, such as: do you have any sexual concerns? This question also
provides an opportunity to discuss sexual issues and pertinent sexual history.

A brief set of screening questions is adequate to determine whether a problem exists that requires further
inquiry:

●Do you have sexual concerns?

●Are you currently having or have you ever had sexual relations?
●If not, when did you last engage in sexual activity?
●If so, with men or women or both?
●Have you recently had any new partners or sexual contacts?
●Do you protect yourself from pregnancy and sexually transmitted infections?
●Would you like to be screened for sexually transmitted infections?
●Do you need contraception or preconceptional counseling?
●Are you currently experiencing or have you experienced previous sexual abuse?

The patient’s answers to these questions will guide the subsequent discussion and help the clinician provide
care regarding safe sex, contraception, sexual dysfunction, or sexual abuse or assault. (See "Prevention of
sexually transmitted infections" and "Sexual dysfunction in women: Epidemiology, risk factors, and evaluation",
section on 'Diagnostic evaluation' and "Evaluation and management of adult sexual assault victims", section on
'Evaluation' and "Contraceptive counseling and selection".)

Infertility — Many women become very concerned when they have not conceived a pregnancy after a few
months of trying, while others have had years of unprotected, regular intercourse without recognizing that an
underlying medical problem may exist. Infertility is defined as failure of a couple to conceive after 12 months of
regular intercourse without use of contraception in women less than 35 years of age, and after six months of
regular intercourse without use of contraception in women 35 years and older [8]. Before proceeding with an
infertility evaluation, the provider should confirm that the couple is having regular, frequent intercourse during the
middle of the menstrual cycle. Once the diagnosis is established, the infertility history should focus on three
factors: ovulation, tubal and uterine problems, and male factors (table 6). (See "Evaluation of female infertility".)

PELVIC EXAMINATION

Timing issues — Pelvic examination is indicated in any patient with genital or pelvic symptoms and in other
patients for preventive care. (See'Indications and frequency for examination' below.)

Age at initial examination — The American College of Obstetricians and Gynecologists (ACOG) recommends
a first reproductive health visit between the ages of 13 and 15 years [9-11]. The scope of the examination in
adolescents depends upon the individual needs of the patient. A reproductive health visit may be limited to age-
appropriate education regarding reproductive health matters. A pelvic examination is not included unless
indicated due to symptoms or specific patient concerns.

Prior to a first pelvic examination, the components and benefits of the examination should be explained. Every
effort should be made to communicate with and reassure the patient, and the exam should be stopped if the
patient is too anxious or uncomfortable. Education regarding the pelvic examination includes potential testing for
sexually transmitted infections and cervical cancer screening. Many women erroneously equate a speculum
examination with a Pap test, and may incorrectly think that they have been screened for cervical cancer.

Indications and frequency for examination — Routine pelvic examinations in asymptomatic women are
controversial [12]. The pelvic examination is performed to evaluate genital tract symptoms (eg, pain, bleeding,
discharge). Traditionally, it has also been performed in asymptomatic women as part of a yearly examination
combined with a Pap test, and often combined with screening for sexually transmitted infections (STIs).

Practice patterns and guidelines for periodic examinations have changed. General physical examinations are no
longer performed annually for most patients. Cervical cancer screening guidelines have changed, and many
women require screening only every three to five years. Some methods of screening for genital gonorrheal or
chlamydial infection do not require a pelvic examination. (See "Screening for cervical cancer", section on
'Routine screening recommendations' and "Preventive care in adults: Strategies for prioritization and delivery",
section on 'Periodic "check-up"' and "Screening for sexually transmitted infections", section on 'General
principles'.)

ACOG states regarding pelvic examinations in asymptomatic adolescents and women [10,11,13]: Pelvic
examinations should be performed only when indicated by the medical history for patients younger than 21
years. For women ≥21 years-old, an annual pelvic examination seems logical, but also lacks data to support a
specific time frame or frequency of such examinations. The decision whether or not to perform a complete pelvic
examination at the time of the periodic health examination for the asymptomatic patient should be a shared
decision after a discussion between the patient and her healthcare provider. They note that physical examination
findings may elicit functional problems. Arguments in favor of ACOG's stance include the recognition of
functional problems (such as sexual dysfunction and incontinence) that may not have been elicited in the patient
history. Additionally, while no data exist to support the pelvic examination for non-cervical cancer screening,
studies of cancers other than cervical and ovarian have yet to be performed [14].

The American College of Physicians (ACP) guidelines advise against performing screening pelvic examinations
in asymptomatic, nonpregnant, adult women [15]. They base this on the lack of evidence for a health or cancer
screening benefit other than cervical cancer. They also cite anxiety, embarrassment, and overdiagnosis and
overtreatment harms that can result from non-evidence-based screening.

Cervical cancer screening is initiated at age 21 years based upon current guidelines (table 7). Annual screening
for cervical cancer is no longer recommended for all women; the frequency depends upon age, prior history of
cervical abnormalities, cervical cytology, immune system status, and human papilloma virus testing.
(See "Screening for cervical cancer".)

The United States Centers for Disease Control and Prevention (CDC) advises annual screening of sexually
active adolescents and women ≤25 years for gonorrheal and chlamydial infection [16]. STI screening is also
advised for pregnant women and for sexually active women older than 25 years with risk factors (eg, a new sex
partner in prior 60 days, more than one sex partner, inconsistent condom use, unmarried, or history of STI).
(See "Screening for sexually transmitted infections".)

Testing for genital gonorrheal or chlamydial infection may be performed with an endocervical or vaginal swab or
a urine specimen. Endocervical and vaginal swabs have comparable sensitivity, but vaginal swabs do not
require a speculum examination and can be obtained by the patient if less invasive testing is preferred. Although
urine specimens are also acceptable for women, the sensitivity of testing appears to be lower compared with
vaginal samples. (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and
adolescents", section on 'Diagnostic techniques' and "Clinical manifestations and diagnosis of Chlamydia
trachomatis infections".)

A pelvic examination with speculum and bimanual examination is often performed at the time of cervical cancer
or STI screening. However, the extent of the examination may vary depending upon the clinical context and
desires of the patient.

In terms of screening for genital tract cancers other than cervical cancer:
 ●There is no evidence that annual pelvic examination reduces mortality from ovarian cancer [17-19]. Even
pelvic examination under anesthesia has been shown to have limited sensitivity to detect adnexal masses
[20]. (See "Screening for ovarian cancer" and "Pelvic examination under anesthesia".)
●Uterine cancer is not typically detected on pelvic examination, but rather presents with abnormal uterine
bleeding. (See "Endometrial carcinoma: Clinical features and diagnosis".)
●There is no routine screening method for vulvar cancer and no data regarding use of pelvic examinations
for screening. However, periodic examinations may provide some benefit. In our clinical experience, vulvar
precancer and cancer are often asymptomatic and may be detected only on routine pelvic examination.
This is particularly true for older women (average age at diagnosis is 65 years), who may be less likely to
notice a vulvar lesion or bring it to medical attention. Vulvar cancer is more likely to be diagnosed at an
advanced stage in older women [21,22]. In our practice, we perform a careful inspection of the vulva each
time that a patient presents for cervical cancer screening or for a pelvic examination for another indication.
Any suspicious lesion should be biopsied. (See "Vulvar cancer: Clinical manifestations, diagnosis, and
pathology".)

The pelvic examination had been required historically as a prerequisite to obtain hormonal contraceptives.
However, this is no longer part of current practice [23,24]. (See "Contraceptive counseling and selection".)

In some instances, patients request a pelvic examination. This may be because a routine check-up is desired. In
addition, many patients have difficulty expressing concerns or symptoms related to their genital tract or sexual
function.

The potential adverse effects of pelvic examination are anxiety, discomfort, and false positive findings that result
in further testing. The available studies were not performed exclusively in asymptomatic women [15]. Also,
clinician factors have not been evaluated (specialty, frequency and comfort level with performing pelvic
examination). Patients who present to a gynecologist may differ from those who present to another clinician in
terms of underlying pathology and goals and expectations of the visit. The varying guidelines from the ACP and
ACOG may reflect these differences.

For women who are anxious or uncomfortable before or during a pelvic examination, in our experience,
modifications of pelvic examination technique (eg, varying the order of the steps of the examination, use of a
single finger for bimanual examination rather than two, use of a narrow Pederson or pediatric speculum) and
clinician explanation and reassurance are helpful.

In our practice, we perform a pelvic examination in all symptomatic women. This requires taking a detailed
history to elicit any new, unusual, or bothersome symptoms. In asymptomatic women, we recommend a pelvic
examination in the following situations:

●If a gynecologic condition that may be asymptomatic is suspected by history or risk factors
●If the patient desires a routine gynecologic check-up
●At the initial prenatal visit and as indicated during obstetric care
●At the time of cervical cancer screening
●For women with a history of precancerous lesions of the cervix, vagina, or vulva
●For women who may have difficulty detecting a vulvar lesion (eg, elderly, limited vision or mobility)
●As part of ovarian cancer screening in high-risk women (BRCA mutation, Lynch syndrome) who have not
undergone risk-reducing bilateral salpingo-oophorectomy, as the positive predictive value of a positive
finding will be higher in this group
●As part of post-treatment surveillance following genital tract cancer, if appropriate for tumor site and
treatment history
Patients and clinicians should engage in shared decision-making regarding pelvic examination. Patients should
be informed if a pelvic examination is planned, and the examination should not be performed if a patient
declines.

When to discontinue examinations — ACOG advises continued pelvic examinations until a women’s age or
other health issues are such that she would not choose to intervene on conditions detected during the routine
examination [10].

Preparing for the examination

Patient consent — The clinician should request permission before starting a pelvic examination [25]. Written
consent is not required, with the exception of examination under anesthesia. (See "Pelvic examination under
anesthesia", section on 'Informed consent'.)

Adolescents may undergo a pelvic examination without their parents' knowledge or permission if the examination
is performed in the context of testing or treatment for sexually transmitted infections. Laws vary by jurisdiction
regarding confidential access to human immunodeficiency virus testing, contraception, and abortion services. On
the other hand, parental consent is required for childhood examinations, adolescent pelvic examinations, and
pelvic examinations unrelated to sexual contact [26]. Permission from a legal guardian is required for a
nonemergent pelvic examination of a patient who cannot consent to her own healthcare. (See "Consent in
adolescent health care".)

Chaperone — No universal guidelines exist regarding the use of a chaperone during the examination. Surveys
of both patients and providers demonstrate variable usage and preferences. Some patients who generally prefer
female providers are open to a male provider if a chaperone is present [27,28]. Other patients may actively
object to having a chaperone present [28]. Although charges of inappropriate conduct during a pelvic
examination are rare, both male and female providers should consider utilizing a chaperone [29]. Any member of
the healthcare team serving in this role must understand rules for patient privacy and confidentiality, and patients
should be offered additional time without the chaperone to discuss private concerns [30].

Patient anxiety or refusal — Some women have had difficult experiences with sexual abuse or assault or with
prior pelvic examinations, and may feel substantial anxiety regarding the examination. For such patients, the
examination may be nearly unbearable, and may deter the patient from seeking appropriate healthcare. Such
anxiety may manifest as tense and withdrawn body language, extreme discomfort with the examination, or
refusal to have an examination at all.

It is widely recognized that a pelvic examination may be uncomfortable. In its summary of studies reporting on
over 4000 women, the American College of Physicians reported that approximately 35 percent may experience
pain, discomfort, fear, embarrassment, or anxiety during a pelvic exam [15]. In one study, approximately 1000
women in a variety of clinical settings were asked to explain the parts of the examination that were
uncomfortable, the reasons for the discomfort, and to suggest ways the provider could have improved the
process [31]. Physical discomfort (37 percent), embarrassment (20 percent), disliking the attitude of the
examiner (7 percent), and experiencing problems during a previous examination (5 percent) were the major
concerns reported. Techniques suggested to improve the examination process included explaining each step of
the examination in advance, providing more information about the reproductive organs, warming the
instruments, and increased gentleness. Other surveys have recommended that providers make an effort to
maintain eye contact during the examination and give the patient choices where possible [32,33].

At first recognition of the patient's discomfort, the provider should stop the physical examination and address the
patient's concerns. In some women, performing the bimanual examination with one finger before the speculum
examination is helpful in decreasing anxiety. In addition, a narrow speculum (narrow Pederson, Huffman, or
pediatric) can be used to decrease discomfort.

If it becomes clear that the patient has been abused or is suffering from severe anxiety, the provider may need
to delay the examination in order to elicit help from a therapist or social worker. Often by discussing the
examination ahead of time and agreeing to stop uncomfortable procedures at the patient's request, the provider
can give the woman some control over the situation, which may alleviate some of her anxiety regarding the
examination. Importantly, the provider should never proceed in the setting of patient refusal, no matter how
medically necessary he or she perceives the examination.

Patient positioning — The pelvic examination is traditionally performed in the dorsal lithotomy position in order
to allow optimal exposure of the internal and external genitalia and palpation of the pelvis. Unfortunately, laying
the patient in a horizontal position does not allow eye contact between the provider and patient, and may
increase her sense of vulnerability. This may also be a physically difficult position for women with
cardiorespiratory or musculoskeletal limitations. Elevating the head of the table 30 to 45 degrees makes it easier
for the woman to relax, thereby facilitating bimanual examination.

Equipment — The basic equipment needed to perform a pelvic examination includes:

●An examining table with stirrups (or means for elevating the buttocks when stirrups aren't available [eg,
the patient is on a stretcher or in bed])
●Good light source (preferably cold light)
●Speculum of appropriate size (eg, Huffman speculum for virginal patients)
●Materials to obtain cervical cytology
●Materials to test for common infections – chlamydia, gonorrhea, herpes simplex virus
●Cotton swabs for obtaining samples of vaginal discharge
●pH indicator paper
●Dropper bottles of saline and potassium hydroxide for performing wet preps
●Large cotton swabs to absorb excess vaginal discharge or blood
●Test kits for fecal occult blood
●Water soluble lubricant, disposable gloves, material to drape the patient

Components of the examination — The pelvic examination traditionally includes the internal and external
genitalia, and pelvic organs. Comprehensive examination also includes evaluation of some components of the
urinary and gastrointestinal tracts, including the urethra, anus, and rectum. A more comprehensive examination,
involving the abdomen, breast, and other sites, may be indicated to provide complete primary care or to evaluate
gynecologic problems that involve other organ systems. (See "Evaluation of the adult with abdominal pain",
section on 'Physical examination' and "Clinical manifestations and diagnosis of a palpable breast mass", section
on 'Physical examination'.)

Abdomen — Examination of the abdomen should be performed using the standard techniques of inspection,
auscultation, palpation, and percussion. The examiner should observe for abnormalities of skin color and
intestinal peristalsis, hernias, organomegaly, masses, fluid collection, and tenderness.

External genitalia — The external genitalia are inspected and palpated (figure 2). The hair distribution, skin,
labia minora and majora, perineal body, clitoris, urethral meatus, vestibule, and introitus are evaluated for
developmental abnormalities, skin lesions (eg, discoloration, ulcers, plaques, verrucous changes, excoriation),
masses, and evidence of trauma or infection. In patients with vulvar pain, the vestibular epithelium should be
touched with a dry cotton swab to identify the location of the pain. Visible vulvar lesions may need to be cultured
or biopsied. (See"Vulvar lesions: Diagnostic evaluation" and "Vulvar lesions: Differential diagnosis based on
morphology" and "Clinical manifestations and diagnosis of localized vulvar pain syndrome (formerly vulvodynia,
vestibulodynia, vulvar vestibulitis, or focal vulvitis)".)

Bartholin and paraurethral glands — The Bartholin gland openings are located at the 4 and 8 o'clock positions
just outside the hymenal ring. The glands are not palpable when healthy. (See "Bartholin gland masses:
Diagnosis and management".)

The paraurethral glands, the largest of which are Skene's glands, are adjacent to the distal urethra; the gland
ducts open into the urethra or just outside the urethral orifice. If enlarged or tender, an attempt should be made
to express exudate, which suggests infection.

Speculum examination — The vagina is first inspected using a speculum of appropriate size, lubricated with
warm water or a water soluble lubricant. Lubricants do not appear to interfere with sampling for cervical cytology.
(See "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing",
section on 'Gel lubricants and other contaminants'.)

Atraumatic insertion is aided by assisting muscle relaxation at the opening of the vagina. This may be
accomplished by advising the patient to relax her legs to the sides and also by inserting a finger into the distal
vagina and gently applying downward pressure. The speculum is then inserted and downward pressure applied.
The speculum is advanced in a direction free of resistance and opened as the apex of the vagina is reached.

Vaginal lesions, anomalies, or atrophic mucosa are noted. If abnormal discharge is identified, the volume, color,
consistency, and odor should be noted and a sample taken with a cotton swab. The pH of physiologic vaginal
discharge is less than 4.5; an elevated pH may be due to infection (eg, bacterial vaginosis) or exogenous
substances (eg, semen). (See "Vaginal cancer", section on 'Diagnosis' and "Diagnosis and management of
congenital anomalies of the vagina", section on 'Anomalies of the vagina' and "Approach to women with
symptoms of vaginitis" and "Approach to women with symptoms of vaginitis", section on 'Physical examination'.)

The degree of vaginal wall relaxation and uterine prolapse is evaluated, if indicated, by removing the top blade of
the speculum and using the posterior blade as a retractor. It is helpful to ask the patient to bear down to
determine the degree of uterovaginal descensus. Additional testing can be performed in patients with complaints
of urinary incontinence. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Approach to
the examination'.)

Lesions or discharge of the cervix are noted. Cervical cultures and cervical cancer screening are performed, as
appropriate. (See "Congenital cervical anomalies and benign cervical lesions" and "Cervical cancer screening
tests: Techniques for cervical cytology and human papillomavirus testing", section on 'How to obtain a
sample' and "Screening for sexually transmitted infections" and "Screening for sexually transmitted infections",
section on 'Screening recommendations'.)

Bimanual examination — The index and middle fingers of the dominant hand are normally used to examine the
vagina and uterus, although some providers find that switching hands during the examination facilitates
evaluation of the adnexa. Only a single finger can be inserted comfortably in patients with a narrow introitus or
small vaginal orifice. The abdominal hand should be used to sweep the pelvic organs downward, while the
vaginal hand is simultaneously elevating them.

The uterus is assessed for size, shape, symmetry, mobility, position, and consistency. The uterine size and
consistency vary according to reproductive status (parity, menopausal status) (figure 3) (table 8). The position, or
axis, of the uterus is described by its variation in the anterior-posterior (sagittal) plane. There are several normal
variations of uterine position (figure 4); the terms used to describe this are:

●Axial — the axis of the uterus is the same as the vaginal axis
 ●Version — position of the entire uterus relative to the axis of the vagina; eg, anteverted, retroverted
●Flexion — position of the uterine fundus relative to the axis of the cervix; eg, anteflexed, retroflexed

A uterus can be both verted and flexed in the same direction (eg, anteverted and anteflexed); it is rare for a
uterus to be verted and flexed in opposing directions (eg, anteverted and retroflexed).

The adnexal areas are checked for the presence of appropriately sized, mobile ovaries (eg, about 2 by 3 cm),
which are normally somewhat tender. Palpable ovaries in postmenopausal women are not a "normal" finding
(detectable in about 30 percent of postmenopausal women [34,35]) and require investigation, although most are
associated with benign or no disease [36-41].

The ability to palpate the ovaries during a clinical examination in the office depends upon several factors,
including the patient's body habitus, the examiner's experience, the time taken to perform the examination, and
the presence of other pelvic abnormalities. Ovaries can be difficult to palpate, even by experienced clinicians
under ideal circumstances. In one series in which bimanual examination was performed under anesthesia before
various gynecological surgery procedures, ovaries were detected in 30 percent of women ≥55 years of age
versus 51 percent of women under 55 years of age, in 9 percent of women weighing over 200 pounds versus 55
percent of women weighing under 200 pounds, and in 12 percent of women with a uterine weight over 200 g
versus 51 percent of women with a uterine weight under 200 g [34]. Overall, the bimanual examination has a
sensitivity of less than 60 percent, whether for detecting adnexal masses in general or for distinguishing benign
from malignant masses [42].

When adnexal masses are detected, they should be described as to location, size, consistency, mobility, and
degree of tenderness. (See"Approach to the patient with an adnexal mass" and "Differential diagnosis of the
adnexal mass".)

Rectovaginal examination — Another potential component of the gynecologic assessment is the rectovaginal
examination. This allows optimal palpation of the posterior cul-de-sac and uterosacral ligaments, as well as the
uterus and adnexa. Studies of rectovaginal examinations under anesthesia show poor sensitivity in detecting
adnexal masses and uterosacral and posterior cul-de-sac disease [43,44]. There are no professional society
guidelines regarding the use of the rectovaginal examination [30,45].

If a rectovaginal examination is performed, anorectal findings should be documented (eg, hemorrhoids, rectal
mass). If indicated, stool on the examining glove can be tested for occult blood. However, a single sample does
not suffice for colorectal cancer screening; screening is better accomplished by home collection of stool
samples. Screening for colorectal cancer is discussed in detail separately. (See "Screening for colorectal cancer:
Strategies in patients at average risk", section on 'Tests used for screening'.)

When performing the rectovaginal examination, using a lubricated examining glove and asking the patient to
strain against the examiner's finger will usually allow the sphincter to relax and decrease discomfort. The same
finger should not be used to examine both the vagina and rectum to avoid transmission of HPV [46] or
contamination with blood, which may alter fecal occult blood testing, if performed.

SPECIAL CONSIDERATIONS

Examination of infants and children — The first genital inspection should be performed on the newborn. This
will confirm patency of the anus and vagina, and help identify congenital anomalies and ambiguous genitalia.
(See "Assessment of the newborn infant", section on 'Genitalia'.)

Young girls should undergo a focused genital examination when the patient or parent identifies a gynecologic
symptom. (See "The pediatric physical examination: The perineum", section on 'Females' and "Gynecologic
examination of the newborn and child", section on 'History and physical examination'.)
Examination of women with limited mobility or obesity — In rare cases, the gynecologic examination may
not be possible in the office setting. Examples include severe physical limitations, patient intolerance due to pain
or anxiety, or examination of small children. In such cases, the examination may need to be performed with
conscious sedation or general anesthesia. (See "Pelvic examination under anesthesia" and"Gynecologic
examination of the newborn and child", section on 'History and physical examination'.)

Suggestions for facilitating gynecologic examination of disabled women are listed in the table (table 9).

Examination after hysterectomy — The indications for pelvic examination are the same for women who have
undergone hysterectomy as for other women. The exception to this is that most women who have undergone
total hysterectomy (the cervix has been removed) do not require Pap tests. In the past, many clinicians
performed vaginal Pap tests in this patient population. However, the risk of vaginal intraepithelial neoplasia
(VAIN) or vaginal cancer is extremely low in women who have undergone total hysterectomy for benign disease
(excluding CIN 2,3) and, for this reason, screening guidelines in the United States from the US Preventive
Services Task Force (USPSTF), the American Cancer Society (ACS), and the American College of Obstetricians
and Gynecologists (ACOG) concur that these women do not need post-hysterectomy vaginal cytology. Vaginal
cancer screening is advisable in women with risk factors for vaginal cancer. (See "Screening for cervical cancer",
section on 'Prior hysterectomy' and "Cervical and vaginal cytology: Interpretation of results (Pap test report)",
section on 'Vaginal cytology' and "Cervical intraepithelial neoplasia: Treatment and follow-up", section on
'Posthysterectomy' and "Cervical intraepithelial neoplasia: Treatment and follow-up", section on 'Hysterectomy'.)

ACOG guidelines state that the decision for having a screening pelvic examination may be left to the patient if
she has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for benign indications, has no
history of vulvar or cervical neoplasia, is HIV-negative, is not immunocompromised, and was not exposed to
diethylstilbestrol [11].

Examination of women following hysterectomy or other gynecologic surgery (eg, oophorectomy) is generally the
same as for other women, but the examination and documentation of the findings should reflect the patient’s
current anatomy. As an example, in a patient who has undergone a total hysterectomy, the examiner should
note that the cervix is surgically absent and record the condition of the vaginal cuff (eg, well-healed). In some
cases, women are not certain of the details of their surgical procedure, including whether the cervix or one or
both ovaries or tubes were conserved. The definitive documentation of this is in the operative note. If this is not
available, the clinician can confirm the absence of the cervix on examination and the absence of the ovaries with
pelvic imaging, if this information is needed for clinical reasons.

Women who have had a total hysterectomy continue to be at risk of sexually transmitted infections of the
urethra. Thus, women at risk of, and/orwith symptoms of, these infections should be tested for gonorrhea or
chlamydia with urine testing. (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in
adults and adolescents", section on 'Diagnostic approach' and "Clinical manifestations and diagnosis of
Chlamydia trachomatis infections".)

DOCUMENTATION — There are six critical elements of good record-keeping:

●Accuracy
●Objectivity
●Legibility
●Timeliness
●Comprehensiveness
●Absence of alterations
 All entries should be dated, signed, and checked for accuracy. Documentation guidelines related to
reimbursement are available from the Centers for Medicare & Medicaid Services [47].

When a paper medical record is used, a preprinted form is useful for documentation of the history and physical
examination (figure 5A-B). In electronic medical records, if templates are used, care must be taken to ensure
that the information is reviewed and is correct for the individual patient and encounter [48].

SUMMARY AND RECOMMENDATIONS

●The gynecologic history should be obtained in a private setting, before the patient is asked to disrobe.
She should be interviewed alone under most circumstances. It is particularly important to avoid making
assumptions about a woman's background (as an example, that she is sexually active or heterosexual).
(See 'Overview' above.)
●The most common gynecologic concerns relate to vaginal discharge, abnormal bleeding, pain, urinary
problems, breast disorders, sexual dysfunction, and infertility. When a patient identifies one of these
issues, detailed questioning can guide further evaluation and diagnosis. (See 'Problem focused
history' above.)
●The pelvic examination traditionally includes the internal and external genitalia, pelvic organs. The
abdomen and breasts are also commonly examined. The pelvic examination is traditionally performed in
the dorsal lithotomy position in order to allow optimal exposure of the internal and external genitalia and
palpation of the pelvis. (See 'Pelvic examination' above.)
●There is no defined age at which the first gynecologic examination is performed, as this depends upon the
probability of identifying a gynecologic problem. (See 'Age at initial examination' above.)
●No universal guidelines exist regarding the use of a chaperone during the examination. Although charges
of inappropriate conduct during a pelvic examination are rare, both male and female providers should
consider utilizing a chaperone. (See 'Equipment' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Donald Peter Goldstein,
MD, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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