Examination of the female genitalia is typically performed when a patient presents with a specific concern, as part of the newborn examination, for the sexually active adolescent, or as part of an overall health visit. Examination of the anus and rectum ( Chapter 21 ) is often performed at the same time.
External Genitalia
- 1.
Inspect the pubic hair characteristics and distribution.
- 2.
Inspect and palpate the labia for:
- •
Symmetry of color
- •
Caking of discharge
- •
Inflammation
- •
Irritation or excoriation
- •
Swelling
- •
- 3.
Inspect the urethral meatus and vaginal opening for:
- •
Discharge
- •
Lesions or caruncles
- •
Polyps
- •
Fistulas
- •
- 4.
Milk the Skene glands.
- 5.
Palpate the Bartholin glands.
- 6.
Inspect and palpate the perineum for:
- •
Smoothness
- •
Tenderness, inflammation
- •
Fistulas
- •
Lesions or growths
- •
- 7.
Inspect for prolapse and urinary incontinence as the patient bears down.
- 8.
Inspect the perineal area and anus for:
- •
Skin characteristics
- •
Lesions
- •
Fissures or excoriation
- •
Inflammation
- •
Internal Genitalia Speculum Examination
- 1.
Insert the speculum along the path of least resistance
- 2.
Inspect the cervix for:
- •
Color
- •
Position
- •
Size
- •
Surface characteristics
- •
Discharge
- •
Size and shape of os
- •
- 3.
Collect necessary specimens
- 4.
Inspect vaginal walls for:
- •
Color
- •
Surface characteristics
- •
Secretions
- •
Bimanual Examination
- 1.
Insert the index and middle fingers of one hand into the vagina, and place the other hand on the abdominal midline.
- 2.
Palpate the vaginal walls for:
- •
Smoothness
- •
Tenderness
- •
Lesions (cysts, nodules, or masses)
- •
- 3.
Palpate the cervix for:
- •
Size, shape, and length
- •
Position
- •
Mobility
- •
- 4.
Palpate the uterus for:
- •
Location
- •
Position
- •
Size, shape, and contour
- •
Mobility
- •
Tenderness
- •
- 5.
Palpate the ovaries for:
- •
Size
- •
Shape
- •
Consistency
- •
Tenderness
- •
- 6.
Palpate adnexal areas for masses and tenderness.
Rectovaginal Examination
- 1.
Insert the index finger into the vagina and the middle finger into the anus.
- 2.
Assess sphincter tone.
- 3.
Palpate the rectovaginal septum for:
- •
Thickness
- •
Tone
- •
Nodules
- •
- 4.
Palpate the posterior aspect of the uterus
- 5.
Palpate the anterior and posterior rectal wall for:
- •
Masses, polyps, or nodules
- •
Strictures, other irregularities, tenderness
- •
- 6.
Note characteristics of feces when the gloved finger is removed.
Anatomy and Physiology
External Genitalia
The vulva, or external female genital organs, include the mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening ( Fig. 19.1 ). The symphysis pubis is covered by a pad of adipose tissue called the mons pubis or mons veneris, which in the postpubertal female is covered with coarse terminal hair. Extending downward and backward from the mons pubis are the labia majora, two folds of adipose tissue covered by skin. The labia majora vary in appearance depending on the amount of adipose tissue present. The outer surfaces of the labia majora are also covered with hair in the postpubertal female.
Lying inside and usually hidden by the labia majora are the labia minora, two hairless, flat, reddish folds. The labia minora meet at the anterior of the vulva, where each labium divides into two lamellae, the lower pair fusing to form the frenulum of the clitoris and the upper pair forming the prepuce. Tucked between the frenulum and the prepuce is the clitoris, a small bud of erectile tissue, the homolog of the penis and a primary center of sexual excitement. Posteriorly, the labia minora meet as two ridges that fuse to form the fourchette.
The labia minora enclose the area designated as the vestibule, which contains six openings: the urethra, the vagina, two ducts of Bartholin glands, and two ducts of Skene glands. The lower two-thirds of the urethra lie immediately above the anterior vaginal wall and terminate in the urethral meatus at the midline of the vestibule just above the vaginal opening and below the clitoris. Skene ducts drain a group of urethral glands and open onto the vestibule on each side of the urethra. The ductal openings may be visible.
The vaginal opening occupies the posterior portion of the vestibule and varies in size and shape. Surrounding the vaginal opening is the hymen, a connective tissue membrane that may be circular, crescentic, or fimbriated. After the hymen tears and becomes permanently divided, the edges either disappear or form hymenal tags. Bartholin glands, located posteriorly on each side of the vaginal orifice, open onto the sides of the vestibule in the groove between the labia minora and the hymen. The ductal openings are not usually visible. During sexual excitement, Bartholin glands secrete mucus into the introitus for lubrication.
The pelvic floor consists of a group of muscles that form a supportive sling for the pelvic contents. The muscle fibers insert at various points on the bony pelvis and form functional sphincters for the vagina, rectum, and urethra ( Fig. 19.2 ).
Internal Genitalia
The vagina is a musculomembranous tube that has transverse rugae (anatomic folds) during the reproductive phase of life. It inclines posteriorly at an angle of approximately 45 degrees with the vertical plane of the body ( Fig. 19.3 ). The anterior wall of the vagina is separated from the bladder and urethra by connective tissue called the vesicovaginal septum. The posterior vaginal wall is separated from the rectum by the rectovaginal septum. The anterior and posterior walls of the vagina lie in close proximity, with only a small space between them. The upper end of the vagina is a blind vault into which the uterine cervix projects. The pocket formed around the cervix is divided into the anterior, posterior, and lateral fornices. These are of clinical importance, as the internal pelvic organs can be palpated through their thin walls. The vagina carries menstrual flow from the uterus, serves as the terminal portion of the birth canal, and is the receptive organ for the penis during sexual intercourse. The anatomy of a neovagina created in a transgender woman differs from that of a natal vagina. It is a blind cuff, lacks a cervix and surrounding fornices, and may have a more posterior orientation.
The uterus sits in the pelvic cavity between the bladder and the rectum. It is an inverted, pear-shaped, muscular organ that is relatively mobile ( Fig. 19.4 ). The uterus is covered by the peritoneum and lined by the endometrium, which is shed during menstruation. The rectouterine cul-de-sac (pouch of Douglas) is a deep recess formed by the peritoneum as it covers the lower posterior wall of the uterus and upper portion of the vagina, separating it from the rectum. The uterus is flattened anteroposteriorly and usually inclines forward at a 45-degree angle, although it may be anteverted, anteflexed, retroverted, or retroflexed. In nulliparous patients the size is approximately 5.5 to 8 cm long, 3.5 to 4 cm wide, and 2 to 2.5 cm thick. The uterus of a parous patient may be larger by 2 to 3 cm in any of the dimensions. The uterus of a nulliparous patient weighs approximately 40 to 50 g ( Fig. 19.5 ), and that of a multiparous patient is 20 to 30 g heavier.
The uterus is divided anatomically into the corpus and cervix. The corpus consists of the fundus, which is the convex upper portion between the points of insertion of the fallopian tubes; the main portion or body; and the isthmus, which is the constricted lower portion adjacent to the cervix. The cervix extends from the isthmus into the vagina. The uterus opens into the vagina via the external cervical os.
The fallopian tubes and ovaries comprise the adnexa of the uterus. The fallopian tubes insert into the upper portion of the uterus and extend laterally to the ovaries. Each tube ranges from 8 to 14 cm long and is supported by a fold of the broad ligament called the mesosalpinx. The isthmus end of the fallopian tube opens into the uterine cavity. The fimbriated end opens into the pelvic cavity, with a projection that extends to the ovary and captures the ovum. Rhythmic contractions of the tubal musculature transport the ovum to the uterus.
The ovaries are a pair of oval organs resting in a slight depression on the lateral pelvic wall at the level of the anterosuperior iliac spine. The ovaries are approximately 3 cm long, 2 cm wide, and 1 cm thick in the adult patient during the reproductive years. Ovaries secrete estrogen and progesterone, hormones that have several functions, including controlling the menstrual cycle ( Fig. 19.6 and Table 19.1 ) and supporting pregnancy.
The internal genitalia are supported by four pairs of ligaments: the cardinal, uterosacral, round, and broad ligaments.
Bony Pelvis
The pelvis is formed from four bones: two innominate (each consisting of ilium, ischium, and pubis), the sacrum, and the coccyx ( Fig. 19.7 ). The bony pelvis is important in accommodating a growing fetus during pregnancy and in the birth process. The four pelvic joints—the symphysis pubis, the sacrococcygeal, and the two sacroiliac joints—usually have little movement.
The pelvis is divided into two parts. The shallow upper section is considered the false pelvis, which consists mainly of the flared-out iliac bones. The true pelvis is the lower curved bony canal, including the inlet, cavity, and outlet; the fetus must pass through these during birth. The upper border of the outlet is at the level of the ischial spines, which project into the pelvic cavity and serve as important landmarks during labor. The lower border of the outlet is bounded by the pubic arch and the ischial tuberosities ( Fig. 19.8 ).
Infants and Children
The vagina of the infant is a small narrow tube with fewer epithelial layers than those of the adult. The uterus is approximately 35 mm long, with the cervix constituting about two-thirds of the entire length of the organ. The ovaries are tiny and functionally immature. The labia minora are relatively avascular, thin, and pale. The labia majora are hairless and nonprominent. The hymen is a thin diaphragm just inside the introitus, usually with a crescent-shaped opening in the midline. The clitoris is small. External genitalia may be swollen at birth due to estrogen from the pregnant patient.
During childhood, the genitalia, except for the clitoris, grow incrementally at varying rates. Anatomic and functional development accelerate with the onset of puberty and the accompanying hormonal changes.
Adolescents
During puberty, the external genitalia increase in size and begin to assume adult proportions. The clitoris becomes more erectile and the labia minora more vascular. The labia majora and mons pubis become more prominent and begin to develop hair, often occurring simultaneously with breast development. Growth changes and secondary sex characteristic developments that occur during puberty are discussed in Chapter 8 .
If the hymen is intact, the vaginal opening is about 1 cm. The vagina lengthens, and the epithelial layers thicken. The vaginal secretions become acidic.
The uterus, ovaries, and fallopian tubes increase in size and weight. The uterine musculature and vascular supply increase. The endometrial lining thickens in preparation for the onset of menstruation (menarche). The average age at menarche in the United States is between 12 and 13 years ( Cabrera et al, 2014 ). Just before menarche, vaginal secretions increase.
Functional maturation of the reproductive organs is reached during puberty. Due to immaturity of the hypothalamic-pituitary-ovarian axis, irregular menstrual cycles are common during the early years after menarche as a result of anovulation.
Pregnant Patients
The high levels of estrogen and progesterone that are necessary to support pregnancy are responsible for uterine enlargement during the first trimester. After the third month, uterine enlargement is primarily the result of mechanical pressure of the growing fetus. As the uterus enlarges, the muscular walls strengthen and become more elastic. As the uterus becomes larger and more ovoid, it rises out of the pelvis; by 12 weeks of gestation, it reaches into the abdominal cavity. During the first months, the walls become thicker but then gradually thins to about 1.5 cm or less at term. Uterine weight at term, excluding the fetus and placenta, will usually have increased more than 10-fold and the capacity increases 500 to 1000 times that of the nonpregnant uterus. In the postpartum period the uterus involutes rapidly. Immediately after delivery the uterus is approximately the size of a 20-week pregnancy (at the level of the umbilicus). By the end of the first week, it is about the size of a 12-week pregnancy, palpable at the symphysis pubis.
Hormonal activity (relaxin and progesterone) is responsible for the softening of the pelvic cartilage and strengthening of the pelvic ligaments. As a consequence, the pelvic joints separate slightly, allowing some mobility; this results in the characteristic “waddle” gait. The symphysis pubis relaxes and increases in width, and there is marked mobility of the pelvis at term. The symphysis pubis returns to the prepregnancy state within 3 to 5 months postpartum. Protrusion of the abdomen as the uterus grows causes the pelvis to tilt forward, placing additional strain on the back and sacroiliac joints.
During pregnancy, an increase in uterine blood flow and lymph causes pelvic congestion and edema. As a result the uterus, cervix, and isthmus soften (Goodell sign) and the cervix takes on a bluish color (Chadwick sign). The cervical canal is obstructed by thick mucus soon after conception, protecting the infant from infection. When this plug dislodges at the beginning of labor, it produces a sign of labor called “bloody show.” The glands near the external os proliferate with eversion of the columnar endocervical glands. The softness and compressibility of the isthmus result in exaggerated uterine anteflexion during the first 3 months of pregnancy, causing the fundus to press on the urinary bladder.
Both the mucosa of the vaginal walls and the connective tissue thicken, and smooth muscle cells hypertrophy. These changes result in an increased length of the vaginal walls, so that at times they can be seen protruding from the vulvar opening. The papillae of the mucosa have a hobnailed appearance. The vaginal secretions increase and have an acidic pH due to an increase in lactic acid production by the vaginal epithelium. The increase in pH helps keep bacteria from multiplying in the vagina but also can cause Candida infection. Fig. 19.9 compares the changes that occur in a patient experiencing the first pregnancy with those in a patient who has experienced more than one pregnancy.
Older Adults
Concurrent with endocrine changes, ovarian function diminishes during a patient’s 40s, and menstrual periods begin to cease although fertility may continue. The median age of menopause in the United States is 51 years (range 41 to 59 years). Menopause is defined as 1 year with no menses (amenorrhea). Just as menarche in the adolescent is one aspect of puberty, similarly, cessation of menses is one aspect of this transitional phase of the life cycle. During this time, estrogen levels decrease, causing the labia and clitoris to become smaller. The labia majora also become flatter as body fat is lost. Pubic hair turns gray and is usually sparser. Both adrenal androgens and ovarian testosterone levels markedly decrease after menopause, which may account in part for decreases in libido and in muscle mass and strength.
The vaginal introitus gradually constricts. The vagina narrows, shortens, and loses its rugae, and the mucosa becomes thin, pale, and dry, which may result in pain with sexual intercourse (dyspareunia). The cervix becomes smaller and paler. The uterus decreases in size, and the endometrium thins.
The ovaries also decrease to approximately 1 to 2 cm. Follicles gradually disappear, and the surface of the ovary convolutes. Ovulation usually ceases about 1 to 2 years before menopause.
The ligaments and connective tissue of the pelvis sometimes lose their elasticity and tone, thus weakening the supportive sling for the pelvic contents. The vaginal walls may lose some of their structural integrity.
Menopause has systemic effects, which include an increase in body fat and intraabdominal deposition of body fat (tendency toward male pattern of body fat distribution). Levels of total and low-density lipoprotein cholesterol increase. Thermoregulation is altered, which produces the hot flashes associated with menopause.
Review of Related History
For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing on the physical examination and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations) as well as complementary and alternative therapies are relevant for each.
History of Present Illness
- •
Abnormal bleeding: postmenopausal bleeding, menstrual abnormalities (see Box 19.1 )
- •
Character: interval between periods, amount of flow and duration during menses, bleeding between periods; postmenopausal bleeding
- •
Change in flow: nature of change, number of pads or tampons saturated in 24 hours, presence of clots
- •
Temporal sequence: onset, duration, precipitating factors, course since onset
- •
Associated symptoms: pain, cramping, abdominal distention, pelvic fullness, change in bowel habits, weight loss or gain
- •
Medications; oral contraceptives; hormones; tamoxifen
Box 19.1
Abnormal Uterine Bleeding: Terminology
- •
Amenorrhea: absence of menstruation
- •
Polymenorrhea: shortened interval between periods—less than 19 to 21 days
- •
Oligomenorrhea: lengthened interval between periods—more than 35 days
- •
Hypermenorrhea: excessive flow during normal duration of regular periods
- •
Hypomenorrhea: decreased flow during normal duration of regular periods
- •
Menorrhagia: regular and normal interval between periods, excessive flow and duration
- •
Metrorrhagia: irregular interval between periods, excessive flow and duration
- •
Menometrorrhagia: irregular or excessive bleeding during periods and between periods
- •
- •
Pain
- •
Temporal sequence: date and time of onset, sudden versus gradual onset, course since onset, duration, recurrence
- •
Character: specific location, type, and intensity of pain
- •
Associated symptoms: vaginal discharge or bleeding, gastrointestinal symptoms, abdominal distention or tenderness, pelvic fullness
- •
Association with menstrual cycle: timing, location, duration, changes
- •
Relationship to body functions and activities: voiding, eating, defecation, flatus, exercise, walking up stairs, bending, stretching, sexual activity
- •
Aggravating or relieving factors
- •
Previous medical care for this problem
- •
Efforts to treat
- •
Medications: analgesics
- •
- •
Vaginal discharge
- •
Character: amount, color, odor, consistency, changes in characteristics
- •
Occurrence: acute or chronic
- •
Douching habits
- •
Clothing habits: use of underwear with noncotton crotch, tight pants or jeans
- •
Sexual history—see in personal and social history
- •
Presence of discharge or symptoms in sexual partner
- •
Use of spermicide or latex condoms
- •
Associated symptoms: itching; tender, inflamed, or bleeding external tissues; dyspareunia; dysuria or burning on urination; abdominal pain or cramping; pelvic fullness
- •
Efforts to treat: vaginal cream
- •
Medications: oral contraceptives, antibiotics, aromatase inhibitors, hormones
- •
- •
Premenstrual symptoms
- •
Symptoms: headaches, weight gain, edema, breast tenderness, irritability or mood changes
- •
Frequency
- •
Interference with activities of daily living
- •
Relief measures
- •
Aggravating factors
- •
Medications: analgesics, diuretics
- •
- •
Menopausal symptoms
- •
Age at menopause or currently experiencing
- •
Symptoms: menstrual changes, mood changes, tension, hot flashes, sleep disruption
- •
Postmenopausal uterine bleeding
- •
General feelings about menopause: self-image, effect on intimate relationships
- •
Mother’s experience with menopause
- •
Birth control measures during menopause
- •
Medications: hormones—dose and duration; serum estrogen receptor modulators
- •
Use of complementary or alternative therapy: soy, other natural estrogen products; black cohosh (used as an alternative to hormonal treatment for menopause)
- •
- •
Infertility
- •
Length of time attempting pregnancy, sexual activity practices, knowledge of fertile period in menstrual cycle, length of cycle
- •
Abnormalities of vagina, cervix, uterus, fallopian tubes, ovaries
- •
Contributing factors: stress, nutrition, chemical substances
- •
Partner factors (see Chapter 20 )
- •
Diagnostic evaluation to date
- •
- •
Urinary symptoms: dysuria, burning on urination, frequency, urgency
- •
Character: acute or chronic; frequency of occurrence; last episode; onset; course since onset; feel like bladder is empty or not after voiding; pain at start, throughout, or at cessation of urination
- •
Description of urine: color, presence of blood or particles, clear or cloudy
- •
Associated symptoms: vaginal discharge or bleeding, abdominal pain or cramping, abdominal distention, pelvic fullness or pressure, flank pain
- •
Medications: urinary tract analgesics, antispasmodics
- •
Past Medical History
- •
Gender identity: female, male, transgender man; transgender woman; sex assignment at birth
- •
Menstrual history
- •
Age at menarche and/or menopause
- •
Date of last normal menstrual period: first day of last cycle
- •
Number of days in cycle and regularity of cycle
- •
Character of flow: amount (number of pads or tampons used in 24 hours on heaviest days), duration, presence and size of clots
- •
Dysmenorrhea: characteristics, duration, frequency, relief measures
- •
Intermenstrual bleeding or spotting: amount, duration, frequency, timing in relation to phase of cycle
- •
Intermenstrual pain: severity, duration, timing; association with ovulation
- •
Premenstrual symptoms: see History of Present Illness
- •
- •
Obstetric history
- •
G: Gravidity (total number of pregnancies)
- •
T: number of Term pregnancies
- •
P: number of Preterm pregnancies
- •
A: number of Abortions, spontaneous or induced
- •
L: number of Living children
- •
Complications of pregnancy, delivery, abortion, or with fetus or neonate
- •
- •
Menopause history: see History of Present Illness
- •
Gynecologic history
- •
Date of last pelvic examination
- •
Prior Papanicolaou (Pap) smears, human papillomavirus (HPV) testing and results
- •
Prior abnormal Pap smears or HPV test—when, how treated, follow-up
- •
Sexually transmitted infections (STIs)
- •
Pelvic inflammatory disease
- •
Vaginal infections
- •
Recent and past gynecologic/genitourinary procedures or surgery—tubal ligation, hysterectomy, oophorectomy, laparoscopy, cryosurgery, conization, colposcopy, hysterectomy, vaginectomy, oophorectomy, orchiectomy, feminizing vaginoplasty, masculinizing phalloplasty, scrotoplasty, erectile implants, metoidioplasty (clitoral release/enlargement which may include urethral lengthening)
- •
Chronic diseases: diabetes, cancer of reproductive organs or related cancers (breast, colorectal)
- •
HPV infection: Human papillomavirus (HPV) infection is common, and only a small percentage of those infected with untreated HPV will develop cervical cancer. The “high-risk” types include HPV 16, HPV 18, HPV 31, HPV 33, and HPV 45, as well as some others.
HPV vaccination: protective factor; decreases risk of cervical cancer
Pap smear history: lack of regular screening for cervical cancer; transgender men are less likely to be current on cervical cancer screening
High parity: Patients with three or more full-term pregnancies have an increased risk of developing cervical cancer.
Young age at parity: Patients who were younger than 17 years when they had their first full-term pregnancy are more likely to develop cervical cancer later in life than those who were not pregnant until they were 25 years or older.
Cigarette smoking: doubles the risk; tobacco by-products have been found in the cervical mucus of patients who smoke.
HIV infection: increased susceptibility to HPV infections
Chlamydia infection: increases risk for cervical cancer
Diet: Diets low in fruits and vegetables may increase risk for cervical cancer; overweight patients are more likely to develop this cancer.
DES exposure: increased risk in patients exposed in utero to diethylstilbestrol (DES) (prescribed between 1940 and 1971to pregnant patients at high risk of miscarriages)
Oral contraceptives: Some evidence indicates that long-term use (more than 5 years) may slightly increase the risk of cervical cancer.
Low socioeconomic status: likely related to access to healthcare services, including cervical cancer screening and treatment of precancerous cervical disease
Age: Risk increases with age. Most ovarian cancers develop after menopause;
Inherited genetic mutation or syndromes: increased risk with known inherited mutation of the BRCA1 or BRCA2 or PTEN gene. Increased risk hereditary non polyposis colon cancer syndrome (HNPCC), Peutz-Jeghers syndrome, MUTYH-associated polyposis
Family history: one or more first-degree relatives (parent, sibling, child) with ovarian and/or breast cancer; strong family history of colon cancers; Ashkenazi Jewish descent; and a family history of breast and/or ovarian cancer
Obesity: Patients with a body mass index of at least 30 have a higher risk of developing ovarian cancer.
Reproductive history: Nulliparity or parity after age 35 years increases the risk.
Use of fertility drugs: increased risk in some studies, especially if pregnancy is not achieved
Personal history: increased risk with breast, endometrial, and/or colon cancers
Hormone replacement therapy: Increased risk in postmenopausal patients. The risk seems to be higher in patients taking estrogen alone (without progesterone) for at least 5 or 10 years.
Use of oral contraceptives: Protective use for 4 or more years is associated with an approximately 50% reduction in ovarian cancer risk in the general population.
Testosterone therapy: no evidence that transgender men taking testosterone have an increased risk
Diet: high-fat diet associated with higher rates of ovarian cancer in industrialized nations, but the link remains unproved
Total number of menstrual cycles: increased risk with more menstrual cycles during a patient’s lifetime (i.e., early menarche plus late menopause)
Infertility or nulliparity: During pregnancy, the hormonal balance shifts toward more progesterone. Therefore having many pregnancies reduces endometrial cancer risk, and nulliparity increases risk
Obesity: Having more fat tissue can increase a patient’s estrogen levels and therefore increase the endometrial cancer risk.
Tamoxifen: an antiestrogen drug that acts like an estrogen in the uterus increases risk
Estrogen replacement therapy (ERT): estrogen alone (without progestins) in patients with a uterus increases risk
Testosterone therapy: no evidence that transgender men taking testosterone have an increased risk
Ovarian diseases: Polycystic ovaries and some ovarian tumors such as granulosa–theca cell tumors cause an increase in estrogen relative to progestin. Some of these conditions lead to hysterectomy and oophorectomy, ending the risk for endometrial cancer.
Diet: diet high in animal fat
Diabetes: endometrial cancer more common in patients with both type 1 and type 2 diabetes
Age: Risk increases with age; 95% of endometrial cancers occur in patients 40 years of age or older.
Family history: history of endometrial, breast, ovarian, or colorectal cancers
Personal history: breast or ovarian cancer, or hereditary nonpolyposis colorectal cancer syndrome; known genetic mutation in BRCA1 or BRCA2
Prior pelvic radiation therapy: Radiation used to treat some other cancers can damage the DNA of cells, sometimes increasing the risk of developing a second type of cancer such as endometrial cancer.
Family History
- •
Diabetes
- •
Cancer of reproductive organs
- •
Pregnancies with multiple births (e.g., twins, triplets)
- •
Congenital anomalies
Personal and Social History
- •
Cleansing routines: use of sprays, powders, perfume, antiseptic soap, deodorants, or ointments
- •
Contraception history
- •
Current method: length of time used, effectiveness, consistency of use, side effects, satisfaction with method
- •
Previous methods: duration of use for each, side effects, and reasons for discontinuing each
- •
- •
Douching history: frequency—length of time since last douche; number of years douching, method, solution used, reason for douching
- •
Sexual history
- •
Current sexual activity: number of current and previous partners; number of their partners; gender
- •
Satisfaction with relationship(s), sexual pleasure achieved, frequency
- •
Problems: pain on penetration (entry or deep); decreased lubrication, lack of orgasm of partner(s), sexual preference
- •
Sexually transmitted infection (STI) history
- •
Use of barrier protection for STIs
- •
Prior STIs
- •
Partner testing for STIs
- •
- •
Sexual assault or abuse
- •
Screening for intimate partner violence (IPV) and domestic violence: see Chapter 1 .
- •
- •
Performance of genital self-examination (see Patient Safety: “Self-Examination to Detect STIs” )
- •
Use of recreational drugs
Genital self-examination (GSE) is recommended for anyone who is at risk for contracting a sexually transmitted infection (STI). This includes sexually active persons who have had more than one sexual partner or whose partner has had other partners. The purpose of GSE is to detect any signs or symptoms that might indicate the presence of an STI. Many people who have an STI do not know that they have one, and some STIs can remain undetected for years. GSE should become a regular part of routine self–healthcare practices.
You should explain and demonstrate the following procedure to your patient and give the opportunity to perform a GSE under your guidance. Emphasize handwashing before and afterward.
Instruct the patient to start by examining the area that the pubic hair covers. Patients may want to use a mirror and position it so that they can see their entire genital area. The pubic hair should then be spread apart with the fingers, and the patient should carefully look for any bumps, sores, or blisters on the skin. Bumps and blisters may be red or light-colored or resemble pimples. Also instruct the patient to look for warts, which may look similar to warts on other parts of the body. At first they may be small, bumpy spots; left untreated, however, they could develop a fleshy, cauliflower-like appearance (see Fig. 19.47 ).
Next, instruct the patient to spread the outer vaginal lips and look closely at the hood of the clitoris. The patient should gently pull the hood up to see the clitoris and again look for any bumps, blisters, sores, or warts. Then both sides of the inner vaginal lips should be examined for the same signs.
Have the patient move on to examine the area around the urinary and vaginal openings, looking for any bumps, blisters, sores, or warts (see Figs. 19.48 through 19.51 ). Some signs of STIs may be out of view—in the vagina or near the cervix. Therefore, if patients believe that they have come in contact with an STI, they should see their healthcare provider even if no signs or symptoms are discovered during self-examination.
Also educate patients about other symptoms associated with STIs—specifically, pain or burning on urination, pain in the pelvic area, bleeding between menstrual periods, or an itchy rash around the vagina. Some STIs may cause a vaginal discharge. Patients should try to be aware of what their normal discharge looks like. Discharge caused by an STI will be different from the usual; it may be yellow and thicker and have an odor.
Instruct patients to see a healthcare provider if they have any of the preceding signs or symptoms.
Infants and Children
Usually no special questions are required unless there is a specific concern from the parent, other adult, or child.
- •
Bleeding
- •
Character: onset, duration, precipitating factor if known, course since onset
- •
Age of mother at menarche
- •
Signs of breast development and pubic hair (thelarche and adrenarche)
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Suspicion about retained toilet tissue or insertion of foreign objects by child
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Suspicion about possible sexual abuse
- •
- •
Pain
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Character: type of pain, onset, course since onset, duration
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Specific location
- •
Associated symptoms: vaginal discharge or bleeding, urinary symptoms, gastrointestinal symptoms, child fearful of parent or other adults
- •
Contributory problems: use of bubble bath, irritating soaps, or detergents; suspicion about insertion of foreign objects by child or about possible sexual abuse
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Recent trauma (straddle injury)
- •
- •
Vaginal discharge
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Relationship to diapers: use of powder or lotions, how frequently diapers are changed
- •
Associated symptoms: pain, bleeding
- •
Contributory problems: use of bubble bath, irritating soaps, or detergents; suspicion about insertion of foreign objects by child or about possible sexual abuse
- •
- •
Masturbation ( Box 19.2 )
Box 19.2
Evaluation of Masturbation in Children
Masturbation is a common, healthy, self-discovery activity in children. Parents sometimes express concern about their child’s masturbation activity. The following guidelines can help you determine when such activity might be a cause for concern.
HEALTHY ACTIVITY
NEEDS FURTHER ASSESSMENT
Occasional
Frequent, compulsive excessive/obsessive
Discreet, private
No regard for privacy
Age-inappropriate public masturbation
Not preferred over other activity or play
Often preferred over other activity or play
Combined with other emotional and/or behavioral problems
No physical signs or symptoms
Produces genital discomfort, irritation, or physical signs
External stimulation of genitalia only
Involves penetration of the genital orifices; aggressive; includes bizarre practices or rituals
Adolescents
As the older child matures, you should ask the same questions that you ask adult patients. You should not assume that youthful age precludes sexual activity or any of the related concerns. While taking the history, it is necessary at some point to talk with the adolescent alone while the parent is out of the room to provide a confidential safe space for discussion of sensitive topics. Your questions should be posed in a gentle, matter-of-fact, and nonjudgmental manner.
Pregnant Patients
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Expected date of delivery (EDD) or weeks of gestation
- •
Previous obstetric history: GPTAL, prenatal complications, infertility treatment
- •
Previous birth history: length of gestation at birth, birth weight, fetal outcome, length of labor, fetal presentation, type of delivery, use of forceps, lacerations and/or episiotomy, complications (natal and postnatal)
- •
Previous menstrual history (see menstrual history under Past Medical History)
- •
Surgical history: prior uterine surgery and type of scar
- •
Family history: diabetes mellitus, multiple births, preeclampsia, genetic disorder
- •
Involuntary passage of fluid, which may result from rupture of membranes (ROM); determine onset, duration, color, odor, amount, and if still leaking
- •
Bleeding
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Character: onset, duration, precipitating factor if known (e.g., intercourse, trauma), course since onset, amount
- •
Associated symptoms
- •
- •
Pain: type (e.g., sharp or dull, intermittent or continuous), onset, location, duration
- •
Gastrointestinal symptoms: nausea, vomiting, heartburn
Older Adults
- •
Menopause history: see History of Present Illness
- •
Symptoms associated with age-related physiologic changes: itching, urinary symptoms, dyspareunia
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Changes in sexual desire or behavior in self or partner(s)
Examination and Findings
Equipment
- •
Lamp or light source
- •
Drapes
- •
Speculum
- •
Gloves
- •
Water-soluble lubricant
- •
Pap smear/HPV collection equipment
- •
Collection device: (wooden or plastic spatula, cervical brush or broom)
- •
Glass slides and cytologic fixative or fluid collection media
- •
- •
Other specimen collection equipment as needed:
- •
Cotton swabs
- •
Culture plates or media
- •
DNA tests for organisms
- •
Preparation
Although most patients express lack of enthusiasm in anticipation of a pelvic examination, most do not experience anxiety (see Clinical Pearl, “Anxiety” ). Explain in general terms what you are going to do. Maintain eye contact with the patient, both before and, as much as possible, during the examination. Patients from some cultural or ethnic groups may not return eye contact as a show of respect. Be sensitive to cultural variations in behavior. If the patient has not seen the equipment before, show it and explain its use.
The genital and pelvic examination is often anxiety-producing for transgender patients. The use of a gender-affirming approach during the examination, for example, use of correct name and pronouns, can help reduce anxiety. Patients who have undergone gender-affirming surgeries may have varying physical examination findings depending on the procedures performed.
Marked anxiety before an examination may be a sign that something is not quite right. Before beginning you should find out the source of the anxiety. It could be a bad experience either in a patient’s personal life (e.g., child abuse, sexual assault) or during a previous pelvic examination. It could be the lack of familiarly with what to expect during the examination; it could be worry about possible findings or their meaning. Do not assume you know—use your skills and ask. It is your job to minimize the patient’s apprehension and discomfort.
Assure the patient that you will explain what you are doing as the examination proceeds. Advise that you will be as gentle as possible, and to tell you about any discomfort.
Have the patient empty the bladder before the examination. Bimanual examination is uncomfortable for the patient if the bladder is full. A full bladder also makes it difficult to palpate the pelvic organs.
Make sure that the room temperature is comfortable. Do what you can to ensure privacy. The door should be securely closed and should be opened only with permission of both the patient and examiner. The examination table should be positioned so that the patient faces away from it during the examination. A drawn curtain can ensure that any door opening will not expose the patient. A chaperone is often required by practice or institutional policy and protects both the examiner and patient. Some patients may be reluctant to reveal confidential and sensitive information in the presence of an observer chaperone.
Positioning
Assist the patient into the lithotomy position on the examining table. (If a table with stirrups is not available or if the patient is unable to assume the lithotomy position, the examination can be performed in other positions.) Help the patient stabilize the feet in the stirrups, and slide the buttocks down to the edge of the examining table. If the patient is not positioned correctly, you will have difficulty with the speculum examination.
Draping and Gloving
The patient can be draped in such a way that allows minimal exposure. A good method is to cover the knees and symphysis, depressing the drape between the knees. This allows you to see the patient’s face (and the patient, yours) throughout the examination ( Fig. 19.10 ).
Once the patient is positioned and draped, make sure that any equipment is nearby and in easy reach. Arrange the examining lamp so that the external genitalia are clearly visible. Wash or sanitize your hands and put gloves on both hands (see Clinical Pearl, “Gloving” ).
Ask the patient to drop open the knees. Never try to separate the legs forcibly or even gently. The pelvic examination is an intrusive procedure, and you may need to wait a moment until the patient is ready. Tell the patient that you are going to begin, then start with a neutral touch on the lower thigh, moving your examining hand along the thigh without breaking contact to the external genitalia.
Once you have touched any part of the patient’s genital area, assume that your glove is “contaminated.” Do not touch any surfaces or instruments that will not be discarded or immediately disinfected until you remove or change your gloves. This includes lights, drawers, door handles, counter surfaces, examining table surfaces, fixative and specimen bottles and jars, computer or electronic device, and patient forms. Change gloves as often as you need to. Some healthcare providers prefer to double or triple glove at the beginning of an examination and then remove a glove when a clean hand is needed.
External Examination
Inspection and Palpation
Sit at the end of the examining table and inspect and palpate the external genitalia. Look at the hair distribution and notice the surface characteristics of the mons pubis and labia majora. The skin should be smooth and clean, and the hair should be free of nits or lice.
Labia Majora
The labia majora may be gaping or closed and may appear dry or moist. They are usually symmetric and may be either shriveled or full. The tissue should feel soft and homogeneous. Labial swelling, redness, or tenderness, particularly if unilateral, may be indicative of a Bartholin gland infection. Look for excoriation, rashes, or lesions, which suggest an infectious or inflammatory process. If any of these signs are present, ask if the patient has been scratching. Observe for discoloration, varicosities, obvious stretching, or signs of trauma or scarring.
Labia Minora
Separate the labia majora with the fingers of one hand, and inspect the labia minora. Use your other hand to palpate the labia minora between your thumb and second finger; then separate the labia minora and inspect and palpate the inside of the labia minora, clitoris, urethral orifice, vaginal introitus, and perineum ( Fig. 19.11 ).
The labia minora may appear symmetric or asymmetric, and the inner surface should be moist and dark pink. The tissue should feel soft, homogeneous, and without tenderness ( Fig. 19.12 ). Look for inflammation, irritation, excoriation, or caking of discharge in the tissue folds, which suggests vaginal infection or poor hygiene. Discoloration or tenderness may be the result of traumatic bruising. Ulcers or vesicles may be signs of an STI. Palpate for irregularities or nodules.
Clitoris
Inspect the clitoris for size. Generally, the clitoris is about 2 cm or less in length and 0.5 cm in diameter. Enlargement may be a sign of a masculinizing condition. Observe also for atrophy, inflammation, or adhesions.
Urethral Orifice
The urethral orifice appears as an irregular opening or slit. It may be close to or slightly within the vaginal introitus and is usually in the midline. Inspect for discharge, polyps, caruncles, and fistulas. A caruncle is a bright red polypoid growth that protrudes from the urethral meatus; most urethral caruncles cause no symptoms ( Fig. 19.13 ).
Signs of irritation, inflammation, or dilation suggest repeated urinary tract infections or insertion of foreign objects. Ask questions about any findings at a later time—not during the pelvic examination when the patient feels most vulnerable.
Vaginal Introitus
The vaginal introitus can be a thin vertical slit or a large orifice with irregular edges from hymenal remnants (myrtiform caruncles). The tissue should be moist. Look for swelling, discoloration, discharge, lesions, fistulas, or fissures.
Skene and Bartholin Glands
With the labia still separated, examine the Skene and Bartholin glands. Tell the patient you are going to insert one finger in the vagina and that she or he will feel you pressing forward with it. With your palm facing upward, insert the index finger of the examining hand into the vagina as far as the second joint of the finger. Exerting upward pressure, milk the Skene glands by moving the finger outward. Do this on both sides of the urethra, and then directly on the urethra ( Fig. 19.14 ). Look for discharge and note any tenderness. If a discharge occurs, note its color, consistency, and odor, and obtain a culture. Discharge from the Skene glands or urethra usually indicates an infection—most commonly, but not necessarily, gonococcal.
With your finger still in place, you can then locate the cervix and note the direction in which it points. This may help you locate the cervix when you insert the speculum.
Maintaining labial separation and with your finger still in the vaginal opening, tell the patient to expect pressure around the entrance to the vagina. Palpate the lateral tissue between your index finger and thumb. Palpate the entire area, paying particular attention to the posterolateral portion of the labia majora where the Bartholin glands are located. Note any swelling, tenderness, masses, heat, or fluctuation. Observe for discharge from the opening of the Bartholin gland duct. Palpate and observe bilaterally, because each gland is separate ( Fig. 19.15 ). Note the color, consistency, and odor of any discharge, and obtain a specimen for laboratory evaluation. Swelling that is painful, hot to the touch, and fluctuant is indicative of infection of the Bartholin gland. The infection is usually gonococcal or staphylococcal in origin and is filled with pus. A nontender mass is indicative of a Bartholin cyst, which is the result of chronic inflammation of the gland.
Muscle Tone
Test muscle tone if the patient has delivered children or has told you about signs of weak muscle tone (e.g., urinary incontinence or the sensation of something “falling out”). To test, ask the patient to squeeze the vaginal opening around your finger, explaining that you are testing muscle tone. Then ask the patient to bear down as you watch for urinary incontinence and uterine prolapse. Uterine prolapse is marked by protrusion of the cervix or uterus on straining.
Perineum
Inspect and palpate the perineum ( Fig. 19.16 ). The perineal surface should be smooth; episiotomy scarring may be evident in patients who have borne children. The tissue will feel thick and smooth in the nulliparous patient. It will be thinner and rigid in multiparous patients. In either case, it should not be tender. Look for inflammation, fistulas, lesions, or growths.
Anus
The anal surface is more darkly pigmented, and the skin may appear coarse. It should be free of scarring, lesions, inflammation, fissures, lumps, skin tags, or excoriation. If you touch the anus or perianal skin, be sure to change your gloves so that you do not introduce bacteria into the vagina during the internal examination.
Internal Examination
Preparation
It is essential that you become familiar with how the speculum operates before you begin the examination so that you do not inadvertently hurt the patient through mishandling of the instrument. Chapter 3 describes the proper use of the speculum. Become familiar with both the reusable stainless steel and the disposable plastic specula because their mechanisms of action are somewhat different.
Lubricate the speculum (and the gloved fingers) with water or a water-soluble lubricant. Most healthcare providers routinely lubricate with water only. An added advantage of using water as a lubricant is that a cold speculum can be warmed by rinsing in warm (but not hot) water. A speculum can also be warmed by holding it in your hand (if it is warm) or under the lamp for a few minutes.
Select the appropriate-size speculum (see Chapter 3 ) and hold it in your hand with the index finger over the top of the proximal end of the anterior blade and the other fingers around the handle. This position controls the blades as the speculum is inserted into the vagina.
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