Office Gynecology
Gynecology history:
Chief complaint: What is the patient here for?
Menstrual history:
13 |
/28 |
/5 |
age of menarche |
# of days between cycles |
# of days menses last |
Abnormal uterine bleeding:
| Menorrhagia: |
Menstrual bleeding that is excessive in either amount or duration (=Hypermenorrhea)
- Prolonged: more than 7 days
- Excessive: more than 80 ml
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| Hypomenorrhea: |
Diminished menstrual flow, sometimes only spotting |
| Polymenorrhea: |
Episodes of vaginal bleeding more frequently than 21 days |
| Oligomenorrhea: |
Episodes of vaginal bleeding at intervals greater than 35 days |
| Metrorrhagia: |
Uterine bleeding between menstrual cycles |
| Menometrorrhagia: |
Uterine bleeding that is irregular in frequently and excessive in amount |
| Amenorrhea: |
Primary amenorrhea - no menses by age 16 ½
Secondary amenorrhea - no menses for 6 months after menses has been established. |
Pregnancy History:
| History: |
G |
P |
| |
# of pregnancies |
# of pregnancies
a woman has carried to viability |
examples:
G1P1: 1 pregnancy, 1 delivery
G2P1: 2 pregnancies, 1 delivery
- patient could be pregnant now
- patient could have had a pregnancy loss
(sp Ab, el Ab, ectopic pregnancy, preterm delivery or infant death)
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the above system is vague, so use this system:
G ___ P___ / ___/ ___
G = gravidity (number of pregnancies)
P = parity P___ /___ /___ /___
T P A L
T = Term Deliveries
P = Preterm deliveries
A = Abortions (includes elective, spontaneous, ectopics, molar pregnancies - anything < than 20 weeks)
L = Living
examples:
- G1P1001
- G2P2002
- G2P2001
- G3P2103
- G3P3004
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Pelvic Infections
Don’t ask: "Have you ever had any STD’s?"
Do ask: "Have you ever had gonorrhea, chlamydia, herpes, trichomonas, or syphilis?"
Don’t ask: "Have you ever had PID?"
Do ask: "Have you ever had an infection in your pelvis or your tubes?"
Urologic history
Ask about involuntary loss of urine.
Assess whether it is related to coughing or sneezing.
Pelvic pain
Important questions:
- Is the pain related to menses (dysmenorrhea)?
- Is there pain with intercourse (dyspareunia)?
superficial vs. deep penetration
Sexual history
Assess the risk of HIV by number or partners, history of STD’s, history of IVDA, contraceptive (condom) use.
Inquire whether a patient would like to be tested for HIV.
Remember that number of lifetime partners is a risk factor for cervical cancer.
Contraceptive history
History of previous (or present) IUD use is important.
Conceiving while on OCP’s is important.
- No know teratogenic effects to fetus.
- Dating of a pregnancy can be difficult.
Pap smear history
Ask if a patient has ever had an abnormal pap smear.
If yes, what treatment was done:
Has the patient had any paps done since? Result?
The remainder of the history includes:
PMH, PSH, Allergies, Medication, Social Hx, Family Hx, ROS.
- Especially important is whether there is a history of any gynecological or breast cancer in a first degree relative.
(Ovarian and breast cancer can be familial)
Physical examination:
General HEENT, Neck, Lungs, Heart, Abdomen, Extremities
Breast exam
Pelvic exam:
speculum (SSE = Sterile Speculum Exam)
- comment on appearance of external genitalia, vagina, and cervix
- comment on vaginal discharge (color, odor, consistency)
bimanual (SVE = Sterile Vaginal Exam)
- comment on uterus, size and position
- comment on adnexae / ovaries
** Remember: it is okay (and appropriate) to say and write "ovaries not palpated" rather than to say "adnexae normal"!!
ex: "Ovaries normal bilaterally, no adnexal masses."
"Ovaries not palpated, no adnexal masses palpated."
rectovagnial exam:
-change gloves before doing this part
-test for occult blood if appropriate (over age 35, history of bloody stools, melena, etc.) Be careful of testing someone who has vaginal bleeding.
Pap smear screening:
- Initial screening should begin at age 18 or when an individual becomes sexually active, whichever comes first.
- High risk women should have pap smears every year.
This includes individuals with a history of abnormal paps, history of HPV (human papilloma virus), tobacco use, early fist coitus, multiple partners.
- If a woman has 3 or more consecutive satisfactory normal annual pap smears, the interval can be increased between pap smears. (consensus recommendations in 1988 by ACOG, ACS, NCI, AMA, ANA, AAFP, AMWA)
- What about after hysterectomy?
How to perform a pap smear:
Have everything all ready that you will need. This includes: slides, labeled with the patient’s last name (do this before you do the pap smear, otherwise this can be unpleasant)
fixative
spatula
cytobrush or cotton swab
swabs for DNA probe, if needed (based on history)
lubricant
proper light
If testing for STI’s do the pap smear first, then tests for GC, Chlamydia.
Visualize the entire cervix.
If a heavy vaginal discharge is present, remove it carefully without disturbing the epithelium.
Obtain the portio (ectocervix) sample first, then obtain the endocervical sample. This will minimize the blood in the sample.
Small amounts of blood will not interfere with cytologic evaluation, but large amounts will. We do not perform pap smears during menses for this reason
Avoid contaminating the pap smear with lubricant - we always do a pap smear and all cultures before a bimanual examination.
Cytobrush vs. cotton swabs for the endocervical specimen:
- Either is appropriate in most cases.
- Cytobrush can increase the yield of obtaining endocervical cells by seven-fold. Use these if available.
- We avoid using the cytobrush in pregnant women because it creates more bleeding, and a pregnant women’s cervix is generally more friable.
Apply the specimen uniformly to the slide and fix rapidly. Hold fixative sprays at least 10 inches away to prevent dispersal and destruction of cells by the propellant.
What is an adequate sample?? Endocervical cells must be present!
Endometrial biopsy (EMB)
An office "D&C" used to evaluate the endometrial lining.
Used in a variety of situations such as in the investigation of infertility and abnormal uterine bleeding to rule out endometrial hyperplasia or carcinoma.
The accuracy of EMB in diagnosing malignancy is 90-98% when compared to subsequent findings at D&C or hysterectomy.
Remember to obtain an hCG test if the possibility of pregnancy exists of if this test is being done in the luteal phase of the menstrual cycle.
Contraindication: Pregnancy, acute pelvic or cervical infection.
Complications: Infection, uterine perforation (1-2 per 1000)
Ovarian cancer screening
- Most patients present at Stage 3 or 4.
- The best screening is a yearly exam!
- Role of CA125, pelvic ultrasound generally not for screening!
Mammogram
American Cancer Society recommendations:
Baseline mammogram: age 35-40 years
Every 1-2 years: age 40-49 years
Annually: after age 50
- Mammograms need to obtained sooner if you palpate a mass!
- If a mass is palpated and the mammogram is normal, this does not mean this patient is "okay" -- she likely needs a breast biopsy or other evaluation.
- If a patient has a suspicious mammogram, but a normal exam, this does not mean that this patient is okay -- she likely needs a needle-localized breast biopsy. A consultation is needed from an oncologist.
- Risk of breast cancer increases with age.
- Risk of breast cancer in America: 1 in 9 women!!
- Radiation to breast with mammogram: 0.1 rad
- Feig and Ehrlich (1990) have estimated the lifetime radiation risk or number of excess breast cancer cases that could be related to mammography of one million women -
The lifetime radiation risk of death, which is approximately 1-2 per million, is similar to:
- driving 220 miles by car
- riding a bike for 10 miles
- smoking 1.5 cigarettes
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