Key points
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Strive to become a culturally sensitive and aware physician with a nonjudgmental approach to women regardless of race or ethnicity, age, faith, disabilities, profession, sexual orientation/identity, or activities.
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Goals of preventive medicine include maintaining good health and function and promoting high-quality longevity.
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A complete gynecologic evaluation should always include a review of menstruation, sexuality, contraception, pregnancies, gynecologic infections, gynecologic procedures, and any history of physical, emotional, or sexual abuse.
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The specific examination components of the annual well-woman visit are based on patient age, health concerns, and risk factors. Whether to perform breast or pelvic examinations is a joint decision between individual providers and their patients.
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Screenings, such as Papanicolaou smears, mammography, and sexually transmitted infection testing, should be in accordance with national recommendations.
The first contact a physician has with a patient is critical. It allows an initial bond of trust to be developed on which the future relationship may be built. The patient will share sensitive medical, reproductive, and psychosocial information. The physician will gain her confidence and establish rapport by the understanding and nonjudgmental manner in which he or she collects these data. Today’s obstetrician/gynecologist (OB/GYN) will care for women from around the globe with varying cultural, social, and religious beliefs and values. Women will be of differing socioeconomic status, may have physical or mental disabilities, and may identify as lesbian, bisexual, transgender, or queer. Open communication, with an awareness of and sensitivity to the vast diversity of our patient population, will help create a collaborative environment in which to explore health issues.
The annual well-woman visit is a crucial part of general medical care. The purpose of this visit includes the following:
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Discussing healthy lifestyle and minimizing health risks
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Promoting preventive health practices
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Performing or providing age-specific screening, evaluation and counseling, and immunizations
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Taking a comprehensive history and vital signs (including body mass index [BMI])
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Performing indicated physical examinations
This chapter focuses on the appropriate manner that an OB/GYN should use to conduct a history and physical examination and discusses the appropriate ingredients of ongoing health maintenance.
Direct observations before speaking to the patient (nonverbal clues)
When meeting a patient, it is important to look at her even before speaking. Differing cultural backgrounds and belief systems may greatly affect the transfer of information and challenge effective communication. Addressing each patient by the patient’s preferred pronoun, she, he, or they, is crucial to demonstrate respect and understanding of each individual patient’s identity. The general demeanor of the patient should be evaluated. Many new patients are apprehensive about meeting a new physician and the potential for a pelvic examination. This apprehension may create barriers to an open and positive first encounter.
By observing nonverbal clues, such as eye contact, posture, facial expressions, and tone of voice, the physician can determine the appropriate approach for conducting the interview. The act of greeting the patient by name, making eye contact, and shaking hands is a formal but friendly start to the visit.
Four qualities have been recognized as potentially important in caring communication skills: comfort, acceptance, responsiveness, and empathy. Despite the busy demands of clinical practice, effective communication skills enhance patient satisfaction and patient safety and decrease the likelihood of medical liability litigation. Box 7.1 lists some components of effective physician communication.
Be culturally sensitive.
Establish rapport.
Listen and respond to the woman’s concerns (empathy).
Be nonjudgmental.
Include both verbal and nonverbal communication.
Engage the woman in discussion and treatment options (partnership).
Convey comfort in discussing sensitive topics.
Abandon stereotypes.
Check for understanding of your explanations.
Show support by helping the woman to overcome barriers to care and compliance with treatment.
Essence of the gynecologic history
Chief complaint
The patient should be encouraged to tell the physician why she has sought care. The chief complaint is a concise statement describing the woman’s concerns in her words. Questions such as “What is the nature of the concern that brought you to me?” or “How may I help you?” are appropriate.
History of the present illness
The patient should be able to present her concern as she sees it, in her own words. During the interview the physician should ideally face the patient with direct eye contact and acknowledge important points of the history. This approach allows the physician to be involved in the problem and demonstrates a degree of caring to the patient. Now that electronic medical records (EMRs) are almost universally used, the ability to sit and just listen to the patient and provide that direct eye contact can be challenging because providers are often documenting while the patient is sharing her story. When the patient has completed the history of the present illness (HPI) or a review of her overall health, pertinent open-ended questions should be asked with respect to specific points. This process allows the physician to develop a more detailed database. Directed questions may be asked where pertinent to clarify points. A general outline for a gynecologic and general history is given in Box 7.2 .
- I.
Observation—nonverbal clues
- II.
Chief complaint
- III.
History of gynecologic issues/concerns(s)
- A.
Menstrual history
- B.
Pregnancy history
- C.
Vaginal and pelvic infections
- D.
Gynecologic surgical procedures
- E.
Urologic history
- F.
Pelvic pain
- G.
Vaginal bleeding
- H.
Sexual orientation, activity, concerns
- I.
Contraceptive status
- A.
- IV.
Significant health issues
- A.
Systemic illnesses
- B.
Surgical procedures
- C.
Other hospitalizations
- A.
- V.
Medications, habits, and allergies
- A.
Medications
- B.
Allergies
- C.
Smoking history
- D.
Alcohol usage
- E.
Illicit drug usage
- A.
- VI.
Family history
- A.
Illnesses and causes of death of close family
- B.
Congenital malformations, mental retardation, and reproductive loss
- A.
- VII.
Occupational and avocational history
- VIII.
Social history, including current safety and any history abuse (physical, verbal, emotional, sexual)
- IX.
Review of systems
- A.
Constitutional
- B.
Head, eyes, ears, nose, mouth, throat
- C.
Cardiovascular
- D.
Respiratory
- E.
Gastrointestinal
- F.
Genitourinary
- G.
Musculoskeletal
- H.
Skin
- I.
Neurologic
- J.
Psychiatric—often using a depression questionnaire, such as the Patient Health Questionnaire (PHQ) 2 or PHQ-9
- K.
Endocrine
- L.
Hematologic
- M.
Allergic/immunologic
- A.
Pertinent gynecologic history
A pertinent gynecologic history can be divided into several parts. These include menstrual history, pregnancy history, history of gynecologic infections; history of cervical cancer screenings, history of contraceptive use, history of gynecologic surgical procedures, sexual history, and history of pelvic pain.
Menstrual history
A menstrual history should include the following:
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Age of menarche
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Interval between cycles
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Number of days bleeding
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Regularity of menstrual cycles.
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Intermenstrual or unexpected vaginal bleeding
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Date of last menstrual period
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Characteristics of the menstrual flow: the amount of flow, any clots, any accompanying symptoms, such as cramping, nausea, headache, or diarrhea
In general, menstruation that occurs monthly (range: 21 to 35 days), lasts 4 to 7 days, is bright red, and is often accompanied by cramping on the day preceding and the first day of the period is characteristic of an ovulatory cycle. Menstruation that is irregular, often dark colored, painless, and often short or very long may indicate lack of ovulation. Often adolescents or premenopausal women have anovulatory cycles with resultant irregular menstruation. For the postmenopausal woman, the age at last menses, history of hormone replacement therapy, and any postmenopausal bleeding should be noted.
Pregnancy history
A pregnancy history should include the following:
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Chemical pregnancies
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Abortions: miscarriages and terminations and method of resolution (medical or surgical)
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Molar or ectopic pregnancies and how they were managed (medically and/or surgically)
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Live births:
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Year of birth
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Gestational age at delivery
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Type of delivery
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Infant birth weight
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Complications of pregnancy or delivery
- •
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Infertility
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Future family planning goals
Gynecologic infections
A history of gynecologic infections should include the following:
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Specific infections, treatment received, and any complications
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Risk factors for infections such as human immunodeficiency virus (HIV) and hepatitis C:
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Intravenous (IV) drug use or coitus with IV drug users
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Unprotected sex
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Sex with bisexual men
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Being a commercial sex worker
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History of blood transfusion between 1978 to 1985
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Sexual activity with partner with known HIV or hepatitis C infection
The 2013 U.S. Preventive Services Task Force (USPSTF) report states with “high certainty that the net benefit of screening for HIV infection in adolescents, adults and pregnant women is substantial” ( ). Part of this rationale stems from the fact that 20% to 25% of individuals living with HIV infection are unaware they are infected ( Table 7.1 ).
| CDC, 2006 | ACP, 2009 | IDSA, 2009 | AAP, 2011 | AAFP, 2013 | USPSTF, 2013 | ACOG, 2014 |
|---|---|---|---|---|---|---|
| Initial screening age 13-64, regardless of risks | Initial screening age 13-64, regardless of risks | Screen all sexually active adults | Adolescents screened once by age 16-18 | Screen all individuals aged 18-65 | Initial screening age 15-65; however, optimum frequency of repeat screening unable to be determined | All women aged 13-64 screened at least once and annually based on risk factors |
Cervical cancer screening
The physician should obtain a Papanicolaou (Pap) test screening history:
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Date of last Pap test
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Result of last Pap test, including if human papilloma virus (HPV) was concurrently checked (cotest)
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Frequency of screening
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Any abnormal tests and subsequent follow-up or treatment
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HPV vaccination status
Contraception
Contraceptive history should be investigated:
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Specific methods used
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Duration of use
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Effectiveness of contraceptive method
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Complications or significant side effects
Gynecologic surgical procedures
All gynecologic procedure should be noted, including office procedures, such as endometrial, vulvar, vaginal, or cervical biopsies, and their results. For any minor or major surgeries, such as laparoscopy or laparotomy, the following data should be collected:
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Dates
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Specific types of procedures
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Specific diagnoses, pathology reports
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Results of the surgery (e.g., resolution of pain or heavy bleeding)
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Significant complications
In cases where pertinent, operative and pathology reports should be obtained.
Sexual history
A complete sexual history should be obtained ( Box 7.3 ), and specific problems should be evaluated. The history should include whether the patient is currently sexually active or has been in the past. Patients should be asked if they have one or more current partners and if they have sex with men, women, or both. The provider should also inquire about any sexual dysfunction such as dyspareunia or anorgasmia.
- 1.
Sexual activity (presence of)
- 2.
Types of relationships
- 3.
Individual(s) involved
- 4.
Satisfaction? Orgasmic? Desire/interest?
- 5.
Dyspareunia
- 6.
Sexual dysfunction
- a.
Patient
- b.
Partner
- a.
Pelvic pain
Any current pelvic pain should be discussed fully. Six common questions should be asked about the pain:
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Location
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Timing
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Quality, such as throbbing, burning, or colicky
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Radiation to other body areas
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Intensity on a scale of 1 to 10, with 10 being the worse pain imaginable
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Duration of symptoms
Additional questions about what causes the pain to worsen or subside, the context of the pain symptoms, and associated triggers, signs, and symptoms may be helpful. The pain should be described, noting the presence or absence of a relationship to the menstrual cycle and its association with other events, such as coitus or bleeding and bladder and bowel symptoms.
General health history
The woman should be asked to list any significant health problems that she has had during her lifetime, including all hospitalizations and operative procedures. It is reasonable for the physician to ask about specific illnesses, such as diabetes, hypertension, or heart disease, that seem likely based on what is known about the woman or about her family history. Many physicians use a history checklist of the most common conditions.
All medications, including over-the-counter drugs and complementary and alternative medicines, being used and reasons for doing so should be noted. In addition, a careful review of medication allergies or reactions is essential.
A history of smoking should be obtained in detail, including amount, length of time she has smoked, and attempts at smoking cessation. She should be questioned about the use of illicit drugs, including heroin, methamphetamines, and cocaine, as well as prescription opioids. Any affirmative answers should be followed by specific questions concerning length of use, types of drugs used, and side effects that may have been noticed. Her use of alcohol should be detailed carefully, including the number of drinks per day and any history of binge drinking or previous therapy for alcoholism. Vaping and marijuana use should be assessed.
Family history
A detailed family history of first- and second-degree relatives (parents, siblings, children, aunts, uncles, and grandparents) should be taken and a family tree constructed if relevant ( Fig. 7.1 ). Serious illnesses or causes of death for each individual should be noted. If the patient desires fertility now or in the future, an inquiry should be made about any congenital malformations, mental retardation, or pregnancy loss in either the patient’s or her spouse’s family. Such information may offer clues to hereditarily determined causes of reproductive problems.
Occupational and social history
The patient should be asked to detail her occupation. A nonjudgmental way to approach this could be to ask if she is currently working outside the home. It is very important to determine whether she is currently exercising, what type of activity she engages in, and the frequency of exercise.
Additional information that may be relevant include hobbies and other avocations that may affect health or reproductive capacity, where and with whom the woman lives, other individuals in the household, areas of the world where the woman has lived or traveled, and unusual experiences that may affect her health. The physician should discuss possible stressors in the patient’s life, such as her relationship with her partner and other family members, her satisfaction or dissatisfaction with her job, and other social problems that she may be experiencing.
Safety issues
The patient should be questioned about safety. She should be asked about the use of seat belts and helmets where applicable. She should be asked whether there are firearms in her household and, if so, whether appropriate safety precautions are taken. A question about intimate partner violence is crucial and can be asked in a nonthreatening manner, such as “Has anyone threatened or physically hurt you?” Sexual violence is a widespread problem, and as more is being learned about prevention, providers should be knowledgeable about resources ( ).
Nutritional and dietary assessment
It is important to inquire about dietary choices that our patients make. Assessment of folic acid is important in reproductive-aged women. Asking about fruits and vegetables, as well as calcium-containing foods should be standard. Vegetarians and vegans may need additional discussion about adequate protein and vitamin and mineral intake. A referral to a certified nutritionist may be a valuable addition to routine preventive health care.
Review of systems
A complete review of systems (ROS) should be obtained and documented. (See Box 7.2 for comprehensive ROS and some relevant examples.)
Components of the physical examination
The scope of services and examination provided by an OB/GYN in the ambulatory setting vary from practice to practice. In 2018 the American College of Obstetricians and Gynecologists (ACOG) recommended that the annual well-woman visit include obtaining a comprehensive history and vital signs, including body mass index (BMI) ( ). However, they stated that the physical examination may not be required at a well-woman visit and that engaging patients in shared decision making is key in determining which, if any, examinations to perform. The extent to which additional examinations are performed is based on many factors, such as age, patient concerns, family history, and whether the patient has a primary care provider whom she also sees for routine and concern-driven care. Not all women will require a clinical breast or pelvic examination at each yearly visit. Significant controversy exists regarding recommendations for screening breast and pelvic examinations. Refer to Tables 7.2 through 7.4 for contemporary recommendations from national organizations such as the American College of Physicians and USPSTF.
| Age (Years) | |||
|---|---|---|---|
| 19-39 | 40-64 | 65+ | |
| Vital signs | Ht, Wt, BMI, BP | Ht, Wt, BMI, BP | Ht, Wt, BMI, BP |
| Chlamydia/gonorrhea | <26 and sexually active, yearly | As indicated | As indicated |
| Diabetes testing | As indicated based on personal or family history | 45+, every 3 years | Every 3 years |
| Lipids | If indicated | 45+, every 5 years | Every 5 years |
| Thyroid-stimulating hormone | If indicated | 50+, every 5 years | Every 5 years |
| Bone mineral density | If indicated | Every 2+ years | |
| Immunizations | HPV, Tdap once, TD q 10 years; influenza yearly | Tdap once, TD q 10 years; influenza yearly; herpes zoster twice (50+) | Influenza yearly; Tdap once, TD every 10 years; pneumococcus once |
| Organization | Recommendations |
|---|---|
| USPSTF, 2009 | Insufficient evidence to recommend screening BE |
| ACS, 2015 | No screening BE for average risk women of any age |
| AAFP, 2016 | Current evidence is insufficient to assess the benefits and harms of clinical breast examination for women aged 40+ years |
| NCCN, 2016 | Recommends BE: age 25-39, every 1-3 years; age 40+, yearly |
| ACOG, 2017 | Recommends BE: age 25-39, every 1-3 years; age 40+, yearly |
| Organization | Recommendations |
|---|---|
| ACP, 2014 | Recommends against screening PE in asymptomatic, nonpregnant, adult women |
| SGO, 2016 | Offer PE to every woman, in context of a balanced discussion of risks/benefits |
| USPSTF, 2017 | Insufficient evidence to recommend screening PE for asymptomatic, nonpregnant women |
| AAFP, 2017 | Recommends against screening PE in asymptomatic women |
| ACOG, 2018 | No evidence supports or refutes the annual PE, speculum, bimanual exam for low-risk, asymptomatic patients. Discussion: benefits, harms, lack of data. Shared decision making. |
Physical examination
The patient should disrobe completely and cover herself with a hospital gown that ensures warmth and modesty. During each step of the examination she should be allowed to maintain personal control by being offered options whenever possible. These options begin with the presence or absence of a chaperone. The chaperone, a third party, usually a woman, serves a variety of purposes. She may offer warmth, compassion, and support to the patient during uncomfortable or potentially embarrassing portions of the examination. She may help the physician to carry out procedures and in some cases act as a witness to the doctor-patient interaction. Although the presence of a chaperone is not imperative in every physician-patient relationship, one should be immediately available for any encounter ( ).
The examination should begin with a general evaluation of the patient’s appearance and affect. Her weight, height, and blood pressure should be taken initially. A BMI should be calculated and is an important “vital sign” to track over time. Most EMRs will automatically calculate BMI when height and weight data are entered. Postmenopausal women should have their height measured routinely to document evidence of osteoporosis, which causes loss of height from vertebral compression fractures. Some institutions require pain scale reporting at each visit and consider it a fourth vital sign.
Most gynecologists will not perform a comprehensive screening head, eye, ears, neck, and throat (HEENT) examination. The American Academy of Ophthalmology (AAO) recommends that adults with no signs or risk factors for eye disease should receive a baseline comprehensive eye evaluation at age 40 and then every 2 to 4 years until age 55; every 1 to 3 years through age 64: and yearly to every other year for individuals 65 years old or older ( ).
If indicated, the thyroid gland should be palpated for irregularities or increase in size (goiter). Discrete areas of enlargement, hardness, and tenderness should be described, and the patient’s neck should be palpated for evidence of adenopathy along the supraclavicular and posterior auricular chains.
In a comprehensive preventive health examination, both the chest and cardiac systems should be evaluated. Whether this is necessary in an annual well-woman visit for a healthy woman is at the discretion of the provider. A nongynecologic primary care provider or subspecialist will primarily care for women with medical conditions such as hypertension or diabetes. If performing, the components of the chest and cardiac examination include the following:
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Inspection for symmetry of movement of the diaphragm
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Respiratory effort
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Palpation
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Percussion
- •
Auscultation (heart sounds and rhythm, neck auscultation for vascular bruits in older women)
- •
Peripheral pulses
Breast examination
A systematic approach is indicated if performing a clinical screening breast examination. For a summary of a detailed clinical breast examination, refer to Box 7.4 . Research has shown that the following factors are associated with a high-quality breast examination: longer duration, thorough coverage of the breast, a consistent examination pattern, use of variable pressure with the finger pads, and use of the three middle fingers. ACOG, the American Cancer Society (ACS), and the National Comprehensive Cancer Network (NCCN) all recommend the teaching of breast self-awareness. Women are no longer instructed to examine their own breasts monthly but rather if they feel or see any concerning symptom or abnormality such as redness, pain, skin changes, or a mass.
