The term ‘gynaecology’ describes the study of diseases of the female genital tract and reproductive system. There is a continuum between gynaecology and obstetrics so that the division is somewhat arbitrary. Complications of early pregnancy (less than 20 weeks) such as miscarriage and ectopic pregnancy are generally considered under the title of gynaecology.
After studying this chapter you should be able to:
Knowledge criteria
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Recognize the logical sequence of eliciting a history and physical signs in gynaecology
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Describe pathophysiological basis of symptoms and physical signs in obstetrics and gynaecology
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List the relevant investigations used in the management of common conditions in gynaecology
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Clinical competencies
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Elicit a history from a gynaecology patient
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Perform an abdominal examination in women in the non-pregnant state and in early pregnancy (under 20 weeks) and recognize normal findings and common abnormalities
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Perform a vaginal examination (bimanual, bivalve speculum) and recognize normal findings and common abnormalities
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Recognize the acutely unwell patient in gynaecology (pain, bleeding, hypovolaemia, peritonitis)
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Perform, interpret and explain the following relevant investigations: genital swabs (high vaginal swab, endocervical swab), cervical smear
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Summarize and integrate the history, examination and investigation results; formulate a management plan in a clear and logical way and make a clear record in the case notes
Professional skills and attitudes
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Conduct an intimate examination in keeping with professional guidelines, e.g. Royal College of Obstetricians and Gynaecologists and the General Medical Council
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Appreciate the need for a chaperone
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Demonstrate an awareness of the importance of empathy
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Acknowledge and respect cultural diversity
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Demonstrate an awareness of the interaction of social factors with the patient’s illness
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Maintain patient confidentiality
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Provide explanations to patients in language they can understand
History
When taking a history, start by introducing yourself and explaining who you are. Details of the patient’s name, age and occupation should always be recorded at the beginning of a consultation. The age of the patient will influence the likely diagnosis for a number of presenting problems. Occupation may be relevant both to the level of understanding that can be assumed and the impact of different gynaecological problems on the patient’s life. The history should be comprehensive, but not intrusive in a manner that is not relevant to the patient’s problem. For example, whilst it is essential to obtain a detailed sexual history from a young woman presenting with a genital tract infection, it would be both irrelevant and distressing to ask the same questions of an 80-year-old widow with a prolapse. The history must, therefore, be geared to the presenting symptom.
Ten percent of patients presenting to gynaecological services have psychiatric morbidity, and there is a significant association between adverse life events, depression and gynaecological symptoms. Remember: the presenting symptom may not always be related to the main anxiety of the patient and that some time and patience may be required to uncover the various problems that bring the patient to seek medical advice.
The presenting complaint
The patient should be asked to describe the nature of her problem, and a simple statement of the presenting symptoms should be made in the case notes. A great deal can be learnt by using the actual words employed by the patient. It is important to ascertain the timescale of the problem and, where appropriate, the circumstances surrounding the onset of symptoms and their relationship to the menstrual cycle. It is also important to discover the degree of disability experienced for any given symptom. In many situations reassurance that there is no serious underlying pathology will provide sufficient ‘treatment’ because the actual disability may be minimal.
More detailed questions will depend on the nature of the presenting complaint. Disorders of menstruation are the commonest reason for gynaecological referral and a full menstrual history should be taken from all women of reproductive age (see below). Another common presenting symptom is abdominal pain, and the history must include details of the time of onset, the distribution and radiation of the pain and the relationship to the periods.
If vaginal discharge is the presenting symptom the colour, odour and relationship to the periods should be noted. It may also be associated with vulval pruritus, particularly in the presence of specific infections. The presence of an abdominal mass may be noted by the patient or may be detected during the course of a routine examination. Symptoms may also result from pressure of the mass on adjacent pelvic organs, such as the bladder and bowel.
Vaginal and uterine prolapse are associated with symptoms of a mass protruding through the vaginal introitus or difficulties with micturition and defecation. Common urinary symptoms include frequency of micturition, pain or dysuria, incontinence and the passage of blood in the urine (haematuria).
Where appropriate, a sexual history should include reference to the coital frequency, the occurrence of pain during intercourse ( dyspareunia ) and functional details relating to libido, sexual satisfaction and sexual problems (see Chapter 19 ).
Menstrual history
The first question that should be asked in relation to the menstrual history is the date of the last menstrual period.
The time of onset of the first period, the menarche, commonly occurs at 12 years of age and can be considered to be abnormally delayed over 16 years or abnormally early at 9 years. The absence of menstruation in a girl with otherwise normal development by the age of 16 is known as primary amenorrhoea . The term should be distinguished from the pubarche , which is the onset of the first signs of sexual maturation. Characteristically, the development of breasts and nipple enlargement predates the onset of menstruation by approximately 2 years (see Chapter 16 ).
Failure to check the date of the last period may lead to serious errors in subsequent management.
The length of the menstrual cycle is the time between the first day of one period and the first day of the following period. Whilst there is usually an interval of 28 days, the cycle length may vary between 21 and 42 days in normal women and may only be significant where there is a change in menstrual pattern. It is important to be sure that the patient does not describe the time between the last day of one period and the first day of the next period, as this may give a false impression of the frequency of menstruation.
Absence of menstruation for more than 6 months in a woman who has previously had periods is known as secondary amenorrhoea . Oligomenorrhoea is the occurrence of 5 or fewer menstrual periods over 12 months.
The amount and duration of the bleeding may change with age but may also provide a useful indication of a disease process. Normal menstruation lasts from 4 to 7 days, and normal blood loss varies between 30 and 80 mL. A change in pattern is often more noticeable and significant than the actual time and volume of loss. In practical terms, excessive menstrual loss is best assessed on the history of the number of pads or tampons used during a period and the presence or absence of clots.
Abnormal uterine bleeding (AUB) is any bleeding disturbance that occurs between menstrual periods or is excessive or prolonged. Intermenstrual bleeding is any bleeding that occurs between clearly defined cyclical, regular menses. Postcoital bleeding is non-menstrual bleeding that occurs during or after sexual intercourse. The term h eavy menstrual bleeding (HMB) is now used to describe any excessive or prolonged menstrual bleeding irrespective of whether the cycle is regular ( menorrhagia) or irregular (metorrhagia) .
The cessation of periods at the end of menstrual life is known as the menopause and bleeding which occurs more than 12 months after this is described as postmenopausal bleeding. A history of irregular vaginal bleeding or blood loss that occurs after coitus or between periods should be noted.
Previous gynaecological history
A detailed history of any previous gynaecological problems and treatments must be recorded. It is also important, where possible, to obtain any records of previous gynaecological surgery. Many women are uncertain of the precise nature of their operations. The amount of detail needed about previous pregnancies will depend on the presenting problem. In most cases the number of previous pregnancies and their outcome (miscarriage, ectopic or delivery after 20 weeks) is all that is required.
For all women of reproductive age who are sexually active it is essential to ask about contraception. This is important not only to determine the possibility of pregnancy, but because the method of contraception used may itself be relevant to the presenting complaint, e.g. irregular bleeding may occur on the contraceptive pill or when an intrauterine device is present. For women over the age of 18 years in Australia or 25 years in the UK ask about the date and result of the last cervical smear.
Previous medical history
This description should take particular account of any history of chronic lung disease and disorders of the cardiovascular system, as these are highly relevant where any surgical procedure is likely to be necessary. A record of all current medications (including non-prescription and alternative treatments) and any known drug allergies should be made. If she is planning a pregnancy in the near future check if she is taking folic acid supplements.
Family and social history
A social history is important with all problems but is particularly relevant where the presenting difficulties relate to abortion or sterilization. For example, a 15-year-old female requesting a termination of pregnancy may be put under substantial pressure by her parents to have an abortion and yet may not really be happy about following this course of action. Ask about smoking, alcohol and other recreational drug use.
Examination
A general examination should always be performed at the first consultation, including assessment of pulse, blood pressure and temperature. Careful note should be taken of any signs of anaemia. The distribution of facial and body hair is often important, as hirsutism may be a presenting symptom of various endocrine disorders. Body weight and height should also be recorded.
The intimate nature of gynaecological examination makes it especially important to ensure that every effort is made to ensure privacy and that the examination is not interrupted by phone calls, bleeps or messages about other patients. The examination should ideally take place in a separate area to the consultation. The patient should be allowed to undress in privacy and if necessary empty her bladder first. After undressing there should be no undue delay prior to examination. Before starting the examination explain what will be involved in vaginal examination and verbal consent should be obtained and documented. The woman should be informed that she can ask for the examination to be stopped at any stage. A chaperone should generally be present irrespective of the gender of the gynaecologist.
Breast examination
Breast examination should be performed if there are symptoms or at the first consultation in women over the age of 45 years. The presence of the secretion of milk at times not associated with pregnancy, known as, galactorrhoea may indicate abnormal endocrine status. Systematic palpation with the flat of the hand should be undertaken to exclude the presence of any lumps in the breast or axillae ( Fig. 15.1 ).
