IMLE Preparatory Course

Lecture 51
Obstetrics and Gynecology

The Gynecological Exam

 The Menstrual Cycle
 Follicular phase (days 1–13 – varies!): Typically lasts
about 13 days but may vary. ↑ FSH → growth of
follicles → ↑ estrogen production.
 Results in the development of straight glands and thin
secretions of the uterine lining (proliferative phase).
Which of the following is a test for ovarian reserve?

a. FSH level one cycle day3

b. Estradiol level on cycle day 6
c. Progesterone level following ovulation
d. LH level before ovulation
e. Inhibin A level
Which of the following is a test for ovarian reserve?

a. FSH level on cycle day 3

b. Estradiol level on cycle day 6
c. Progesterone level following ovulation
d. LH level before ovulation
e. Inhibin A level
 The Menstrual Cycle

 Ovulation (day 14): LH and FSH spike results in

rupture of the ovarian follicle and release of a mature
ovum.
 Ruptured follicular cells involute and create the corpus
luteum.
 The Menstrual Cycle

 Luteal phase (days 15–28): This phase is the length of

time (14 days – don’t varie!) that the corpus luteum can
survive without further LH stimulation.
 Menstruation

 The corpus luteum produces estrogen and

progesterone, allowing the endometrial lining to

develop thick endometrial glands with thick
secretions (secretory phase).

 In the absence of implantation, the corpus luteum

cannot be sustained, and the endometrial lining sloughs

off.
what is the main hormone that effects the cervical mucosa
after ovulation

a-progesteron
b-estrogen
c-cortisol
d-LH
e-FSH
what is the main hormone that effects the cervical mucosa
after ovulation

a-progesteron
b-estrogen
c-cortisol
d-LH
e-FSH
 Menarch and Normal Development

 Breast development (thelarche) precedes menarche and usually

begins between the ages of 8 and 11.

 Menarche usually occurs between the ages of 10 and 16.

 Essentials for an Adequate
Examination - Relaxation
 Patient should be given an opportunity to empty her
bladder prior to the exam- Routine UA specimen may be
obtained at this time

 Explain what is to take place during the exam

 Drape her appropriately, cover extending at least over her

knees

 Arms should be at her side or folded across her chest.

 Essentials for an Adequate
Examination
 Examiner's hands should be warmed, also warm the
speculum before the exam

 Have eye to eye contact with the patient during the exam

 Explain in advance each step in the examination, avoiding

any sudden or unexpected movements
 Correct Examining Position of the
Patient
 The Lithotomy Position / or Semi-Sitting Lithotomy Position
 Lying in supine position
 Thighs flexed and abducted
 Feet resting in stirrups
 Buttocks extended slightly beyond edge of exam
table
 Head supported with a pillow
Pelvic Viscera and Perineum
 Sequence of a Pelvic Examination
 Inspect the client's external genitalia
 Perineal area must be well illuminated
 Both hands are gloved to prevent the
spread of infection
 Perineum is sensitive and tender, warn
the client by touching the neighboring
thigh first before advancing to the
perineum.
 Sequence of a Pelvic Examination
 Mons pubis--note quantity and
distribution of hair growt

 Labia--usually plump and well-

formed in adult female

 Perineum--slightly darker than

the skin of the rest of the body.
Mucous membranes appear dark
pink and moist
 Sequence of a Pelvic Examination
 Separate the labia and inspect the labia minora:
 Labia minora
 Clitoris
 Urethral orifice
 Hymen
 Vaginal orifice
 Sequence of a Pelvic Examination

 Note abnormalities such as:

 Bulges and swelling of
vulva and vagina
 Enlarged clitoris
 Syphilitic chancres
 Sebaceous cyst

Primary Syphilis
 Sequence of a Pelvic Examination
 Skene's glands
 Near the urethra
 Suspect inflammation; check for urethral discharge (Most
likely Gonorrhea)

 Insert index finger with palm facing you into the

vagina up to the 2d joint. Apply pressure upwards
and milk the Skene's gland by moving your fingers
outward
 Do this on both sides and note COCA on any
discharge. Obtain specimen for culture.
 Change glove if discharge is found.
 Sequence of a Pelvic Examination
 If there is history or appearance of labial
swelling check Bartholin's glands
 Insert index finger up to first knuckle
 With your index finger and thumb, palpate
the posterolateral area of the labia majora
noting any:
 Swelling
 Tenderness
 Masses
 Heat or discharge
 Sequence of a Pelvic Examination
 Assess the support of the vaginal outlet:
 With the labia separated by middle and index
finger
 Ask patient to strain down
 Note any bulging of the vaginal walls
(cystocele and rectocele).
 Inspect the anus at this time, note presence of
lesions and hemorrhoids
 Speculum Examination of Internal
Genitalia
 Select a speculum of appropriate size,
lubricate and warm with warm water
(Commercially prepared lubricants
interfere with pap smear studies)
 Small--not sexually active female
 Medium--sexually active
 Large--women who have had children

 Medium to large speculum may be used if

female has had children.
 Speculum Examination of Internal
Genitalia
 Hold speculum in right hand
 Place two fingers just inside or at the
introitus and gently press down, this will
help guide the speculum into the vagina
opening
 The speculum has to be closed
 Insert closed speculum obliquely into
vagina at a 45 degree angle rotating 50
degrees counterclockwise
 Speculum Examination of Internal
Genitalia
 Avoid trauma to the urethra
 Care is taken to avoid pulling pubic hair
or pinching the labia
 Maintaining downward pressure, open
blades slowly after full insertion and
position the speculum so that the cervix
can be visualized
 When the cervix is in full view, the blades
are locked in the open position
 Examination/Collection Specimen of
the Cervix
 Inspect the cervix
 Color should be uniformly pink
 Erythema around os:
 Ectropion--expressed columnar epithelium
 Erosion--term has been used to describe
both the exposed columnar epithelium and
the erythema seen with cervicitis
 Pale--anemia
 Bluish--Chadwick's sign, presumptive sign of
pregnancy.
 Examination/Collection Specimen of
the Cervix
 Inspect the cervix
 Lesions/cysts:
 Nabothian cyst- endocervical retention cysts usually
secondary to cervical infection/inflammation
 Friable, granular, red or white patchy areas--be
suspicious of dysplasia, needs to be evaluated with
colposcopy
 Ulcerative lesions- may be herpetic, do viral culture
of lesions and refer for colposcopy
 Polyps- soft, friable mass protruding through os,
may bleed if traumatized, refer for
evaluation/removal
How do nabothian cysts occur?

(A) Wolffian duct remnants

(B) blockage of crypts in the uterine cervix
(C) squamous cell debris that causes cervical irritation
(D) carcinoma
(E) paramesonephric remnants
How do nabothian cysts occur?

(A) Wolffian duct remnants

(B) blockage of crypts in the uterine cervix
(C) squamous cell debris that causes cervical irritation
(D) carcinoma
(E) paramesonephric remnants
Nulliparous cervix
Multiparous cervix
Everted cervix
Nabothian cysts
(Retention cysts)
 Examination/Collection Specimen of
the Cervix
 Inspect the cervix

 Discharge:
 Endocervical vs. from vaginal vault
 Physiological discharge--odorless,
colorless
 Culture any discharge.

 Os:
 Nulliparous--small, round, oval
 Parous/multiparous--linear,
irregular, stellate
 Examination/Collection Specimen of
the Cervix
 Obtain specimens
 Chlamydia culture--most prevalent STD
 GC culture--gram stain not reliable, done for screening, must
do Thayer-Martin for confirmation
 PAP smear for cytology--sites of collection:
 Endocervical brush--all patients
 Endocervical scrape with spatula--all patients
 Posterior fornix--all
 Vaginal cuff and area of former posterior fornix for post-
hysterectomy patient.
 Examination/Collection Specimen of
the Cervix
 Obtain specimens
 Wet mount of normal saline:
 WBCs--evidence of infection/inflammatory process
 Flagellated trichomonads--trichomonas
 Granulated epithelial cells,"clue cells"—Gardnerella

 KOH prep--budding yeast--candidiasis + "whiff" (fishy odor)--

Gardnerella
 Viral cultures of suspected lesions
 Others:
 STS (RPR/VDRL)--if suspected STDs
 Beta HCG--if pregnancy suspected.
 Examination/Collection Specimen of
the Cervix
 Obtain specimens

 Collect during routine PAP

smear/pelvic exam:
 Wet mount if suspicious discharge
 KOH prep if suspicious discharge
 Thayer-Martin of Transgrow cultures
 Chlamydia cultures
 Inspection of the Vagina
 Withdraw the speculum slowly while observing the
vaginal wall

 Close blades as the speculum emerges from the

introitus

 Inspect vaginal mucosa as the speculum is

withdrawn
Bimanual Examination
Perform a Bimanual Examination
 From a standing position, introduce the index
finger and middle finger of your gloved hand into
the vagina

 Exert pressure posteriorly

 Your thumb should be adducted with the ring

finger and little finger into your palm to avoid
touching the clitoris.
 Perform a Bimanual Examination
 Palpate the vaginal walls as you insert your fingers
for tenderness, cysts, nodules, masses or growths

 Identify the cervix, noting the following:

 Position--anterior or posterior
 Shape--pear-shaped
 Consistency--firm or soft
 Regularity
 Mobility--move from side to side 1-2 cm in each
direction
 Tenderness
 Perform a Bimanual Examination
 Palpate the fornix around the cervix

 The os should admit your fingertip 0.5 cm

 Place your free hand on the patient's

abdomen midway between the umbilicus
and symphysis pubis and press downward
toward the pelvic hand
 Perform a Bimanual Examination
 Many vaginal orifices will readily admit a single
examining finger.
 The technique can be modified so that the index
finger alone is used.
 Special small speculum or nasal speculum may make
inspection possible also.
 When the orifice is even smaller, a fairly good
bimanual examination can be performed with one
finger in the rectum.
 Perform a Bimanual Examination
 Your pelvic hand should be kept in a
straight line with your forearm and
inward pressure exerted on the perineum
by your flexed fingers.

 Support and stabilize your arm by resting

your elbow either on your hip or on your
knee which is elevated by placing your
foot on a stool
 (Bimanual Examination) Identify the
Uterus Noting the Following:
 Size--uterine enlargement suggests
pregnancy, benign or malignant tumors.
The uterus should be 5.5-8.0 cm long

 Shape--pear-shaped

 Consistency--firm or soft.
 (Bimanual Examination) Identify the
Uterus Noting the Following:
 Mobility--should be mobile in the antero-
postero plane and deviation to the left or right
is indicative of adhesions, pelvic masses of
pregnancy

 Tenderness--suggests PID process or ruptured

tubal pregnancy

 Masses.
 (Bimanual Examination) Identify Right
Ovary and Masses in the Adnexa
 Place your abdominal hand on the right lower
quadrant

 Place your pelvic hand in the right lateral fornix

 Maneuver your abdominal hand downward

 Use your pelvic hand for palpation.

 (Bimanual Examination) Identify Right
Ovary and Masses in the Adnexa
 Felt with the vaginal hand. The ovary has
the size and consistency of a shelled
oyster

 Note the size, shape, consistency, mobility

and tenderness of any palpable organs or
masses
(Bimanual Examination) Identify Right
Ovary and Masses in the Adnexa
 Repeat the procedure on the left side

 The normal ovary is somewhat tender

when palpated

 Withdraw Fingers from Vagina and

Change Gloves
 Techniques of a Rectovaginal
Examination

 The rectovaginal exam allows the

examiner to reach higher into the pelvis

 The rectovaginal exam is usually

performed after the bimanual
examination.
 Techniques of a Rectovaginal
Examination
 Client is instructed to bear down as though she
as having a bowel movement, caution her, she
will feel as though she must pass a bowel
movement

 As the anal sphincter relaxes, insert your

fingertip of the second finger gently into the
anal canal and the 1st finger into the vagina.

 Sphincter tone is palpated

 Techniques of a Rectovaginal
Examination
 Palpate the anorectal junction.

 Tell the woman to bear down, palpate the

anterior rectal wall and check for sphincter
tone.

 A loose sphincter may be present due to

neurologic deficit or 3d degree perineal
laceration after childbirth
 Techniques of a Rectovaginal
Examination
 Palpate the rectovaginal septum for tone and
thickness

 With your vaginal finger in the posterior fornix,

perform a bimanual exam and palpate the bottom
of the uterus and adnexa completely.

 Withdraw your fingers and evaluate the posterior

rectal wall.