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Accurate diagnosis and treatment of gynecologic disease begins with obtaining a complete history and physical examination. A thorough history should include the following:

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  • First day of the most recent menstrual cycle.
  • Current genital tract symptoms.
  • Age at first menses (menarche).
  • Interval from starting one menses to the next (cycle length).
  • Duration and amount of menstrual flow.
  • Presence or absence of irregular or unexplained bleeding.
  • Symptoms associated with each menstrual cycle such as cramping before or during menses.
  • Other genital tract symptoms such as urinary or fecal incontinence, prolapse, dyspareunia, discharge, or pruritus.
  • Sexual history, including assessment of risk factors such as knowledge of safe sex practices, age of first intercourse (coitarche), number and gender of partners, and presence of any history of abuse.
  • Number of pregnancies and subsequent outcome, including term delivery, mode of delivery, preterm delivery, miscarriage, or abortion.
  • Contraceptive use, including type, duration.
  • History of sexually transmitted disease such as infection with human papillomavirus, gonorrhea, or chlamydia.
  • Adequacy of cervical cancer screening with Pap tests, including date of most recent screen and any prior history of abnormal screens.
  • History of any gynecologic surgery, including type, date, and indication.
  • Age of menopause.
  • Presence of postmenopausal bleeding, regardless of amount of flow.
  • Hormone therapy of any type, including oral contraceptives, postmenopausal estrogen replacement therapy, hormone therapy of breast cancer, and so on.
  • Family history of pertinent cancer sites, including ovarian cancer, endometrial cancer, breast cancer, and colorectal cancer. Determine the age at time of cancer diagnosis and relationship of the affected individual to the patient.
  • Determine the ethnicity of the patient regarding potential for hereditary diseases.

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Perform a complete pelvic examination. Inspect external genitalia, including vulva and urethra, for development, symmetry, and visible lesions. Place a vaginal speculum to inspect the vagina and cervix for symmetry or visible lesions, and perform Pap test, cultures, or wet mount tests as indicated to evaluate symptoms or update screening. Bimanual examination is then performed with careful compression of pelvic viscera between the examiner’s hand on the abdominal wall and the finger(s) in the vagina. The process is repeated with the rectovaginal examination whereby one finger is placed in the vagina and one is inserted into the rectum. The rectovaginal examination allows the examiner to feel higher into the pelvis and may improve the ability to feel the cardinal and uterosacral ligaments, cul-de-sac peritoneum, ovaries, rectocele, and sphincter integrity. The rectovaginal examination is particularly important for assessing pelvic masses or malignancies, rectocele, and fecal incontinence.

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Development of the reproductive tract in the female fetus results from fusion and differentiation of the müllerian ducts and the urogenital sinus. Fusion defects may result in duplication, malformation, or absence of genital tract structures. The most common defects are imperforate hymen, presence of longitudinal or transverse septae within the vagina, congenital absence of the vagina, and duplication defects of the uterus (see Figure 39–1). The etiology of most of these congenital defects is idiopathic, but ...

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