THE METHODS OF MEDICAL

INVESTIGATIONS IN A GYNECOLOGICAL

PATIENT

Intoduction

The health care of women encompasses all aspects of medical science and therapeutics.

The special medical needs and concerns of women vary with the patient's age, reproductive status, and desire to reproduce.

For the proper evaluation, diagnosis and treatment of a gynecological patient, it is necessary for the physician to use variety of methods of medical investigation.

The foremost step in investigation of a gynecological patient is to get a proper history, which in most of the cases helps to make a differential diagnosis and indicates which medical investigation should be done for making an accurate diagnosis.

Patient History

The patient history should include general information about the patient and her goals in seeking care. The history of the present problem, past medical history, family history, medications used, allergies, social history, and review of systems should be concise but thorough.

The developmental history, menstrual history, sexual history, and obstetric history obviously assume central importance for the gynecologic or obstetric visit.

One should avoid cutting off the patient's story, because doing so may obscure important clues or other problems that may have contributed to the reasons for the visit.

The following outline can be used in obtaining a history from a gynecological patient:

Identifying data:Age : The problems and the approach to them vary at different stages in a woman's life (pubescence, adolescence, childbearing years, and premenopausal and postmenopausal years).Last Normal Menstrual Period : A missed period, irregularity of periods, erratic bleeding, or other abnormalities may all imply certain events that are more easily diagnosed when the date of onset of the LNMP is established.Gravidity and Parity : A convenient symbol for recording the reproductive history is a 4-digit code denoting the number of term pregnancies, premature deliveries, abortions, and living children (TPAL).

Chief Complaints:The chief complaint usually is best elicited by asking "What kind of problem are you having?" or "How can I help you?"

Present Illness:Each of the problems the patient describes must be obtained in detail, what exactly the problem is, where exactly the problem is occurring, the date and time of onset, whether the symptoms are abating or getting worse, the duration of the symptoms when they do occur, and how these symptoms are related to or influence other events in her life.

Past History:About Contaception, medications and habits, previous medical or surgical histories, allergies, obstetrics, gynecological, sexual and social histories.

Family History:Health state of immediate relatives, familial heart disease, hypertension, diabetes, breast or ovarian or other cancers, genetic illnesses.

Physical Examination The physical examination is most useful if it is conducted in an environment that is aesthetically pleasing to the patient.

A physician may have a female assistant remain in the examining room to assist when necessary.

It is highly recommended that the physician explain the steps and acts that will be taken, especially during the pelvic examination.

General Examination: Vital Signs, Weight, Height, heart rate, breathing, etc.

Abdominal Examination: Auscaltation, then palpation for any tenderness or enlargement, Suprapubic palpation for identifying Uterine, ovary or bladder enlargement. Then Percussion.

Pelvic Examination: The pubic hair should be inspected for folliculitis or pubic lice. For dermatitis, glans clitoridis, and palpate the vestibular or bartholin’s glands for enlargement. And for perianal lesions.

Vaginal Examination: The vagina and cervix can be inspected using the Speculum for discharge, color, erosion and lesions.

Bimanual Examination: The uterus and adnexal structures should be outlined between the 2 fingers of the hand in the vagina and the flat of the opposite hand, which is placed upon the lower abdominal wall . Gentle palpation and manipulation of the structures will delineate position, size, shape, mobility, consistency, and tenderness of the pelvic structures.

Rectovaginal Examination: Should always be performed, especially after age 40 years, after Bimanual Exam. The well-lubricated middle finger of the examining hand should be inserted gently into the rectum to feel for tenderness, masses, or irregularities. if the finger in the rectum can palpate tender nodules along the uterosacral ligaments—endometriosis may be present.

Bimanual Examination

Rectovaginal Examination

Diagnostic Off ice Procedures

Test for Vaginal Infection:If abnormal vaginal discharge is present, a sample of vaginal discharge should be scrutinized. The vaginal discharge can also be tested for the vaginal pH. An acidic pH of 4–5 is consistent with fungal infection, whereas an alkaline pH of 5.5–7 suggests infections such as bacterial vaginosis and Trichomonas.

Saline (Plain Slide) : the physician mixes on a slide 1 drop of vaginal discharge with 1 drop of normal saline warmed to approximately body temperature. The slide should have a coverslip. If the smear is examined while it is still warm, actively motile trichomonads usually can be seen. Also can be used to see mycelia of the fungus Candida albicans, which appear as segmented and branching filaments and bacterial vaginosis by looking for "clue cells," epithelial cells covered from edge to edge by short coccobacilli-type bacteria.

Potassium Hydroxide : to the slide add 1 drop of Potassium Hydroxide. Visualization of the mycelia of a fungus causing vaginal infection, if the discharge has a "fishy" odor is strongly suggestive of bacterial vaginosis,

Fern Test for OvulationThe fern test can determine the presence or absence of ovulation or the time of ovulation. When cervical mucus is spread upon a clean, dry slide and allowed to dry in air, it may or may not assume a frond like pattern when viewed under the microscope.The fern frond pattern indicates an estrogenic effect on the mucus without the influence of progesterone; thus, a non-frondlike pattern can be interpreted as showing that ovulation has occurred.

Schiller or Acetic acid Test for Neoplasia Although colposcopy is more accurate, the Schiller or Acetic acid test can be performed when cancer or precancerous changes of the cervix or vaginal mucosa are suspected. The suspect area is painted with Lugol's (strong iodine) solution or Acetic acid, interacts and marks the glycogen-rich epithelial cells of the cervix. Any portion of the epithelium that does not accept the dye is abnormal because of the presence of scar tissue, neoplasia and precursors, and columnar epithelium. Biopsy of samples taken from this area should be performed if there is any suspicion of cancer.

Acet ic Acid Staining Iodine Staining

BiopsyVulva and Vagina: A 1–2% aqueous solution of a standard local anesthetic solution can be injected around a small suspicious area and a sample obtained with a skin punch or sharp scalpel. Bleeding usually can be controlled by pressure or by Monsel's solution, but occasionally suturing is necessary.

Cervix: Colposcopically directed biopsy is the method of choice for the diagnosis of cervical lesions, either suspected on visualization or indicated after an abnormal Pap smear. Colposcopically directed biopsy is the method of choice for the diagnosis of cervical lesions, either suspected on visualization or indicated after an abnormal Pap smear. A "4-quadrant" biopsy sample can be taken at 12, 3, 6, and 9 o'clock positions if colposcopy is not available. A Schiller test often may more quickly direct the physician to the area that should be biopsied.

Endometrium: helpful in the diagnosis of ovarian dysfunction(Infertility), irregular uterine bleeding, test for carcinoma of the uterine corpus. Performed with flexible disposable cannulas, such as the Pipelle. The procedure causes cramping, advised to take a pain medication such as ibuprofen 1 hour prior to the procedure

Diagnostic Laboratory Procedures

Routine procedures : CBC Panel, Glucose Screening, Lipid Profile, Urinalysis, Thyroid Panel.

Cultures: Urine culture for UTIs, Urethral and Cervical for STD infections, Vaginal.

Specific Tests: Herpes Virus by culture, HPV and subtypes by PCR test, Chlamydia and Gonnorrheal infection by Nucleic Acid amplification testing, HIV by blood test,

Other Specific Tests: May be indicated for some of the less common venereal diseases, eg, lymphogranuloma venereum and hepatitis B and C. A screening test for streptococcus B carrier is advocated at 35–37 weeks' gestation. A 1-step culture swab from the lower vagina, followed by the anus, is recommended.

Pregnancy Test

Papanicolaou Smear of Cervix An important part of the gynecologic examination.

For the average woman who has had 3 normal Pap smears, a Pap test every 2 or 3 years is adequate.

Is a screening test only, positive tests are an indication for further diagnostic procedures.

Diagnosis of carcinoma of the cervix in approximately 95% of cases and endometrial polyps, hyperplasia, and cancers in 50% of cases.

Alternatives to the traditional Pap smear are being evaluated in an attempt to decrease the false-negative and false-positive Pap smear results.

Technique of PAP smear: The patient should not have douched for at least 24 hours before the examination and should not be menstruating.

The speculum is placed in the vagina after it has been lubricated with water only.

With the cervix exposed, a specially designed plastic or wooden spatula is applied to the cervix and rotated 360 degrees to abrade the surface slightly and to pick up cells from the squamocolumnar area of the cervical os.

Next, a cotton-tipped applicator or a small brush is inserted into the endocervix and rotated 360 degrees.

These 2 specimens can be mixed or placed on the slide separately according to the preference of the examiner.

A preservative is applied immediately to prevent air drying, which would compromise the interpretation. The slide is sent to the laboratory.

ColposcopyThe colposcope is a binocular microscope used for direct visualization of the cervix.

Magnification as high as 60x is available, but the most popular instrument in clinical use has 13.5x magnification.

Some colposcopes are equipped with a camera for single or serial photographic recording of pathologic conditions.

The colposcopist is able to see areas of cellular dysplasia and vascular or tissue abnormalities not visible otherwise, which makes possible the selection of areas most propitious for biopsy.

Stains and other chemical agents are also used to improve visualization.

The colposcope has reduced the need to perform blind cervical biopsies .

A Colposcope

A Colposcopic image, cervix stained with acetic acid.

Hysteroscopy Hysteroscopy is the visual examination of the uterine cavity through a fiberoptic instrument, the hysteroscope.

The uterine cavity is inflated with a solution such as saline, glycine, or dextran, or by carbon dioxide insufflation.

Intravenous sedation and paracervical block often are adequate for hysteroscopy .

Applications include evaluation for abnormal uterine bleeding, resection of uterine synechiae and septa, removal of polyps and intrauterine devices (IUDs), resection of submucous myomas, and endometrial ablation. Failure of Hysterocopy due to cervical stenosis, inadequate distention of the uterine cavity, bleeding, or excessive mucus secretion.

Complications include perforation, bleeding, and infection. Perforation of the uterus usually occurs at the fundus

Intravascular extravasation of fluid or gas from hysteroscopy often not significant, but has been associated with severe consequences such as hyponatremia, air embolism, cerebral edema, and even death.

A normal Uterus in Hysteroscopy Hysteroscopic view of a uterine septum

Hysteroscopic view with Fibroids

Hysteroscopic view with Endometrial Polyps

Culdocentesis

The passage of a needle into the cul-de-sac—culdocentesis—in order to obtain fluid from the pouch of Douglas.

The type of fluid obtained indicates the type of intraperitoneal lesion. Bloody - a ruptured ectopic pregnancy, Pus - Acute Salpingitis, or Ascitic Fluid - Malignant cells in cancer.

Less performed due to improvement in Ultrasonography

Radiographic Diagnostic Procedures

The "flat film" shows calcified lesions, teeth, or a ring of a dermoid cyst and indicates other pelvic masses by shadows or displaced intestinal loops.

Hysterography : The uterine cavity and the lumens of the oviducts can be outlined by instillation of contrast medium through the cervix, followed by fluoroscopic observations or film.To diagnose tubal patency or occlusion, the medium is instilled through a cervical cannula. Filling of the uterine cavity , spreading of the medium through the tubes are watched via a fluoroscope, If no occlusion is present, the medium will reach the fimbriated end of the tube and spill into the pelvis—evidence of tubal patency.Reveals abnormality of the uterus like congenital malformation, submucous myomas, or endometrial polyps.

Sonohysterography: The uterine cavity is filled with fluid while ultrasound is used to delineate the architecture of the endometrial cavity and detect a spillage through the fallopian tubes. Easier to diagnose intrauterine abnormalities, such as polyps or fibroids, and tubal patency.

Normal Hysterography on top.Second image – a patient who underwent bi lateral salpingo-oophorectomy.

Sonohysterography with a Polyp

Angiography:Angiography is the use of radiographic contrast medium to visualize the blood vascular system.By demonstrating the vascular pattern of an area, tumors or other abnormalities can be delineated.Delineate continued bleeding from pelvic vessels postoperatively, to visualize bleeding from infiltration by cancer in cancer patients, or to embolize the uterine arteries in order to decrease acute bleeding and/or reduce the size of uterine myomas.

Computed Tomography:Is a diagnostic imaging technique that provides high-resolution 2-dimensional images.Contrast media used to outline the gastrointestinal and urinary systems helping to differentiate these organ systems from the pelvic reproductive organs.Most useful in accurately diagnosing retroperitoneal lymphadenopathy associated with malignancies.To determine the depth of myometrial invasion in endometrial carcinoma as well as extrauterine spread.For locating pelvic abscesses that cannot be located by ultrasonography.Pelvic thrombophlebitis often can be diagnosed by CT scan and also common abnormalities such as ovarian cysts and myomas are easily diagnosed.

CT scan of the pelvis showing a large f ibroid uterus with 3 calc if ied f ibroids in the body of the uterus Anteroposter ior digital

subtraction pelvic angiogram, arrows showing active hemorrhage

Magnetic Resonance ImagingThe technique is based on the body absorbing radio waves from the machine. Advantages of MRI – uses nonionized radiation that has no adverse or harmful effects on the body, ability to differentiate among various types of tissue, including inflammatory masses, cancers, and abnormal tissue metabolism.Disadvantages are mainly its high cost and its poor demonstration of calcifications.Main use in gynecology is staging and follow-up of pelvic cancers.

Ultrasonography:Ultrasonography is a simple and painless procedure, freedom from any radiation hazard.Especially helpful in patients in whom an adequate pelvic examination may be difficult, such as in children, virginal women, and uncooperative patients.The abdominal scan is performed with bladder full, which elevates uterus out of pelvis.Normal early pregnancy can be diagnosed, as can pathologic pregnancies such as incomplete and missed abortions and hydatidiform moles.Congenital malformations such as a bicornuate uterus or vaginal agenesis are sometimes detected.Useful in the diagnosis of pelvic masses. Myomas can be diagnosed without too much difficulty , Ovarian cysts, Pelvic Abscesses, for visualizing ectopic pregnancies.

14-year-old g ir l with ovarian torsion. Axial T1 MRI 

A Normal Ovary in Ultrasonography

An Ultrasonography image with Ovarian Teratoma

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