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PERTINENT HISTORY & PHYSICAL EXAM FOR GYNECOLOGIC DISEASES

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

  • 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 or bleeding between periods

  • Symptoms associated with each menstrual cycle such as cramping, nausea, or mood symptoms before or during menses

  • Other genital tract symptoms such as urinary or fecal incontinence, vaginal bulge, dyspareunia, discharge, or pruritus

  • Sexual history, including assessment of risk factors such as knowledge of safe sex practices, age at first intercourse (coitarche), number and gender of partners, and any history of assault or abuse

  • Number of pregnancies and subsequent outcome of each, including term delivery or preterm delivery, (and mode of each delivery), miscarriage, or abortion, and number of living children

  • Contraceptive use including type, duration, compliance, and side effects

  • History of sexually transmitted diseases such as infection with human papillomavirus (HPV), gonorrhea, chlamydia, herpes, HIV, or syphilis

  • Adequacy of cervical cancer screening with Pap tests and HPV testing if appropriate, 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 if applicable

  • Presence of postmenopausal bleeding, regardless of amount of flow

  • Hormone therapy of any type including oral contraceptives, postmenopausal estrogen replacement therapy, or hormone therapy for breast cancer

  • Family history of pertinent cancers including ovarian cancer, endometrial cancer, breast cancer, and colorectal cancer, including the age at diagnosis and relationship of the affected individual to the patient

  • Ethnicity of the patient regarding potential for hereditary diseases

Perform a complete pelvic examination. Inspect external genitalia including the vulva and urethra for development, symmetry, and visible lesions. Place a vaginal speculum to inspect the vagina and cervix for symmetry and visible lesions, and perform Pap test, cultures, or wet mount 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 exam allows the examiner to feel higher into the pelvis and improves the ability to feel the cardinal and uterosacral ligaments, cul-de-sac peritoneum, ovaries, rectocele, and sphincter integrity. The rectovaginal exam is particularly important for assessing pelvic masses or malignancies, rectocele, and fecal incontinence.

EMBRYOLOGY & ANATOMY

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. ...

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