A great deal of gynecologic care is preventative and depends on population characteristics, risk profiles, epidemiology, and statistics for screening programs. Annual examinations may be recorded on data sheets containing “check-off” lists for preventive services. An example of this type of form is available at the American College of Obstetricians and Gynecologists (ACOG) website (http:// www.acog.com). Reminder systems for follow-up visits for Papanicolaou (Pap) smears and mammograms can help to integrate disease prevention and health maintenance into gynecologic practice. In addition, gynecologists play a major role in screening for domestic violence, depression, injury, and other psychosocial concerns as well as sexual dysfunction. Counseling practices for sexually transmitted diseases (STDs) human immunodeficiency virus (HIV), and human papillomavirus (HPV) infection has changed markedly over the past 2 decades.

In June 2006, the Food and Drug Administration (FDA) licensed the first HPV vaccine developed to prevent cervical cancer and other diseases in females caused by HPV infection. The quadrivalent vaccine labeled as Gardasil® protects against four HPV subtypes (6, 11, 16, 18). These types are responsible for approximately 70% of cervical cancers and 90% of genital warts. Indications at this time include the use of this vaccine in females ages 9 to 26 years. Ideally, it should be administered before the onset of sexual activity but may be useful afterward as well. The vaccine has been tested in over 11,000 women worldwide, with studies noting that there are no serious side effects. Clinical trials have
demonstrated close to 100% efficacy in preventing cervical, vulvar, and vaginal precancers as well as genital warts caused by the four HPV types. If the patient is already infected by one of the HPV types, the vaccine will not prevent disease from that type but will prevent against the remainder. Current studies suggest that the vaccine is effective for at least 5 years.

Additional preventative measures include genetic screening for some forms of breast and ovarian cancer, which could result in the assimilation of routine genetics into gynecologic office practice. In addition, postmenopausal women have a variety of preventive health needs including breast and cervical cancer screening and primary care such as cholesterol screening and smoking cessation. This health care interaction begins with the gynecologic history and follows up with physical examination, along with office diagnostic procedures.

Women who want to be actively involved in decisions regarding their gynecologic care usually expect physicians to use the history to obtain information concerning not only medical issues but also concerns regarding family history, cancer risk, sexual partners, or significant personal and social issues. The quality of the medical care provided by a physician, as well as the type of the relationship between the physician and patient, may be determined largely by the depth of the gynecologic history.

A comprehensive history and physical examination should be performed on each new patient. It is important to establish a database on each patient, along with a physician–patient relationship based on good communication. Scheduling should permit dedicated time for new patient bookings to allow sufficient time to obtain the information, perform an examination, provide the management plan, and allow for health education. Many preprinted history and physical examination forms exist, some of which may be obtained at the ACOG website, including the Women’s Health Record for initial and long-term follow up office care. Some physicians prefer to use patient-directed history forms, others use an assistant or nurse, and still others prefer to take the history personally. Multiple studies have documented that personally directed questioning is more productive than the use of patient questionnaires. Understanding the preventive medicine needs based on family history, patient history and lifestyle, and integrated functional medical investigations is important. The development of personal preventive programs impacts the ongoing health and wellness relationship.

Once a good database has been established, updates should include any changes in gynecologic or pregnancy history. Additional surgery, accidents, hospitalizations, new medications, or allergies should be added. Any changes in family history should be noted. This type of history taking, both for new and established patients, results in a well-organized, problem-oriented medical record. Besides obtaining the historical details, it is important to understand why the patient is seeking care in the gynecologist’s office. In addition to understanding and meeting patients’ needs, physicians must be prepared to do a medical evaluation in a physically and emotionally comfortable setting, making the visit as comfortable and informative as possible so that women leave the office calm and with their questions answered. This is achieved by an understanding attitude and an ability to listen.

Several things can be done when obtaining a history to reduce patients’ anxiety.

In this age of rapidly expanding medical knowledge and an emphasis on preventive health care, it is ironic that there is widespread dissatisfaction in physician–patient relationships. There is increasing evidence that a physician’s attitude influences not only patient compliance but also the ultimate effect of therapy. The first step in effective communication is establishing a good physician–patient relationship. Research in human relations has demonstrated that a rapport is most readily established if physicians possess and display certain qualities including empathy, respect, non-possessive warmth, genuineness, non-judgmental acceptance, kindness, and interest. These qualities are common to all effective counselors and can be learned by most clinicians. They reinforce these qualities by summarizing their understanding of patients’ problems in terms that patients can understand. The communication of warmth, kindness, and interest is, for the most part, non-verbal. Examples of nonverbal communication that convey these qualities include maintaining eye contact, having a relaxed open posture, facing the patient, leaning toward the patient, showing a facial expression consistent with the patient’s predominant emotion, and having a modulated, nonmechanical tone of voice.

The history provides information about the total patient and is perhaps the most important part of the gynecologic evaluation. In most cases, it provides the data to establish a tentative diagnosis before the physical examination. If the gynecologic history is sufficiently comprehensive, it should in many cases permit a physician to narrow the likely diagnoses. Like a hospital chart, the office chart is a legal and medical record. As such, it is subject to subpoena, and whatever is recorded in it may someday need to be defended in court. It should not contain extraneous or casually entered material, and the notes should be sufficiently complete that the case can be reconstructed readily.

The gynecologic history should include the following information:

The pelvic examination is one of the most commonly performed medical procedures and is considered a highly unpleasant experience by most women. Aspects of the pelvic examination, such as genital exposure, make it likely that women will have feelings of anxiety, vulnerability, apprehension, or fear. It is important that the gynecologist observes a woman’s behavior, which will communicate her feelings and possibly anxieties. A complete physical examination most commonly is performed at the first visit. In order to reduce anxiety, patients should be encouraged to give feedback to the physician during the examination, especially when the examination causes pain. Description of the examination, including which portions may include mild to moderate discomfort (such as the rectal examination), should be given to the patient beforehand. When the physician enters the room, the patient should be sitting up on the examination table with the examination gown completely covering her. During the physical examination, a female chaperone, either a nurse or medical assistant, must be present. This woman can assist the physician and also lend psychologic support to the patient. The patient should be asked to lie down and place her feet in the stirrups, and the physician should be at the level of the patient’s head, speaking to her when her position is changed. This dialog may include the physician asking the patient about her symptoms, location of any pain, or other pertinent questions. Studies evaluating anxiety in women with respect to pelvic examinations have found those who have had a less positive first experience have higher anxiety levels with their gynecologists.

A general impression should be recorded of patient’s nutritional state, distribution and proportion of body fat, texture and condition of skin and hair, presence of facial or excessive body hair, acne, abnormal nevi (>5 mm, asymmetric outline, variable pigmentation, and indistinct borders), and any specific physical features. The patient’s hair is examined for cleanliness, texture, and scalp health. The eye examination may include ophthalmoscopy to detect retinal aberrations. The patient’s nose, throat, and teeth also can be checked. Finally, the anterior cervical, posterior cervical, and supraclavicular nodes, as well as the thyroid gland, should be palpated.

Hypertension is the most common chronic disease in women over 50 years of age. Therefore, every woman, especially one over 50, should have her blood pressure measured with her annual gynecologic examination. Careful cardiac auscultation may be performed as part of the gynecologic examination. Mitral valve prolapse (MVP), the most common cardiac condition diagnosed by auscultation in asymptomatic women, can be problematic during surgery or pregnancy. From the back, a curvature of the vertebral column can be assessed by observation and palpation.