CHAPTER 11

The Gynecological Exam

Gynecology is the study of human femaleness. A gynecologist is a physician who cares for and treats women with a focus on reproduction and the reproductive organs. A related field is obstetrics, the study of women and childbirth. An obstetrician is a physician concerned with caring for and treating women in connection with childbirth. Doctors who specialize in the female reproductive area train in both gynecology and obstetrics.

Many women are apprehensive about having a gynecological exam. The exam can make the patient feel exposed, vulnerable, and embarrassed. However, doctors are taught gentle and compassionate skills to make the exam the best possible experience for the patient. These skills include conducting the examination in a sensitive but straightforward manner. This involves listening to the patient attentively and answering questions she may have, explaining the procedures to her, and educating the woman about her body (this may include letting the woman view the pelvic examination with a mirror whenever deemed appropriate). Women should take active steps to learn about their bodies and enter into a partnership with their gynecologist, where both assume responsibility for the woman's health.

The Gynecological Examination:

A gynecological examination is performed on a woman with the focus on evaluation of her reproductive organs. Doctors encourage women to have a gynecological exam each year beyond the age of 18 and for the rest of their lives. One reason for this is that a complete gynecological exam can detect more than half of all cancers that affect women today. These are cancers of the breast, cervix, ovary, bladder, rectum, endometrium, and vulva.

A woman should have her first gynecological exam around the age of 18 or when she becomes sexually active, whichever comes first. The time when a girl has her first menstrual period, usually occurring between the ages of 11-17, is called menarche. The time when a woman stops having menstrual periods is called menopause and occurs between the ages of 45-50. Although it is an important examination for any woman, the gynecological exam is most important for women who are sexually active.

The gynecological exam consists of two parts: the patient's history and the physical examination. While obtaining a history, a physician may ask specific questions concerning previous pregnancies, contraception, and past gynecological history. The physical should include a total examination with special attention paid to the breasts and reproductive organs by pelvic examination.

Examination of the Breasts:
First, the breasts are inspected by the physician while the patient is sitting upright. The appearance and texture of the breasts are evaluated in this part of the examination. With the patient's arms at her sides, the physician looks for changes in the appearance of the patient's breasts, noting bumps, flattenings, or unequal shapes. Any change in breast appearance may be indicative of an underlying tumor. Tumors can be cancerous (malignant) or non-cancerous (benign). Next, the nipples are examined. A deviated (or crooked) nipple may indicate a tumor growing underneath it that is forcing the skin to pull it from its normal shape. Tumors come in many different sizes and irregular shapes.

Following observation of the breasts, the physician thoroughly palpates (or feels) the breasts. Palpation is performed with the patient lying on her back with her hands behind her head. Palpation is carried out to note any changes in the way the breasts feel from the previous exam. A lump, an area of thickening, or an area of tenderness are all things that can be discovered upon palpation. The physician also checks the nipples for any discharge by gently squeezing them. A breast discharge may be indicative of cancer, infection, or other problems. If the patient does not know how to perform breast self-examination, the physician should instruct the patient how to do so. [ Figures 11A, 11B ]

Mammography:
Mammography is the use of X-rays to examine the breasts. This procedure is invaluable because it can detect a tumor before there are any clinical signs and symptoms and before there has been time for cancer cells to spread to other parts of the body. Once a malignant tumor has had time to spread, it is difficult to completely cure the patient of cancer. Early detection of a (malignant) tumor through mammography can offer treatment early on and cure the patient of cancer 90% of the time. Malignant tumors are treated with chemotherapy, radiation, or surgery, depending on the size and extent of spread. Experts disagree on when women should have their first mammograms. Usually, routine mammograms are not recommended before the age of 40.

The External Pelvic Exam:
The pelvic exam is carried out gently by the physician. [ Figure 11C ] The doctor inspects and palpates the lower abdomen. The physician is looking for any enlargements, tenderness, masses, hernias (protrusions under the skin), or incisions. The amount of pubic, facial, and underarm hair and its distribution is also noted. A small or large amount of hair can be an indicator of a hormonal imbalance.

The pelvic exam is performed with the woman lying on her back on a special table with stirrups (foot holders) at one end. She is placed in the lithotomy position which means that her heels are placed in the stirrups with her buttocks extending past the end of the table. This position relaxes the abdominal muscles and straightens the lower region of the spine (called the lumbar region).

The external genitalia are next inspected and palpated. [ Figure 11D ] This external portion of a woman's genitals are collectively referred to as the vulva. This area is carefully examined for warts, irritation, tumors, scarring, or sores. Next, the labia minora and labia majora are separated to examine the hymen, urethral opening, and opening to the vagina. The size of the clitoris and the development of the labia minora and majora are also noted.

The Internal Pelvic Exam:
The internal examination begins with the insertion of an instrument called the speculum into the vagina which is used to separate and hold apart the walls of the vagina. [ Figures 11E and 11F ] When inserting the speculum, the physician makes sure it is warm and lubricated with water. With a bright light aiding the physician's sight, the cervix (entrance to the uterus) is inspected. The area is examined for ulcerations, cysts, bleeding, enlargements, or menstrual discharge. The positioning of the cervix is also noted. For instance, if the cervix points toward the bladder, then the uterus will be bent backward and will point toward the lower spinal chord or sacrum. This condition is called retroversion.

The Pap Test:
This test, named after Dr. George Papanicolaou, is good for detecting early stages in the development of cervical cancers. With the speculum in place, the doctor gently scrapes some cells from the cervix and vagina with a swab. These cells are examined for the purpose of detecting cancerous cells. Cancerous and precancerous cells appear different from normal cells. This test for early detection of cancer has been very useful in reducing the death rate due to cancer of the cervix by 50 percent.

Following the pap test the speculum is removed slowly while the physician inspects the vaginal walls for vaginitis (inflammation of the vagina), discharges, cysts, or other lesions that may have been missed because of the presence of the speculum. Other cervical or vaginal tests may be conducted during the exam, such as obtaining a specimen of a discharge to determine the cause of an infection.

The Bimanual Examination:
Using both hands for this procedure the doctor is able to examine the cervix, uterus, ovaries, fallopian tubes, and bladder. With the index and middle fingers of the left hand inserted into the vagina and the other hand placed on the abdomen, the doctor first identifies the cervix and then the uterus. [ Figure 11G ] The uterus is ordinarily pear-shaped, firm, smooth, moveable, and not tender. The physician now tries to identify the ovaries and fallopian tubes. The normal fallopian tube cannot be felt as a distinct structure, and the woman may feel a bit of pain as it is being palpated. The ovaries are more easily palpated, although in heavier patients it may be more difficult. The entire region is felt for masses and tenderness. If a mass is felt, its characteristics and location are carefully noted. The bimanual exam also includes palpation of the bladder. Again the doctor feels for abnormal shape, masses, or tenderness.

The Rectovaginal Exam:
With the index finger in the vagina and the middle finger in the rectum, the physician can feel more accurately the posterior surface of the uterus, cervical ligaments (tough bands of tissue that hold the cervix in place), the ovaries, and the side walls of the pelvis. The shape of the rectum is noted as the physician removes the finger. Feces that adhere to the gloves are examined for mucous or blood. Thus, this procedure may also detect rectal disorders. The pelvic examination should be gentle and careful. Tightened and anxious muscles make the examination unnecessarily uncomfortable. A woman who can relax while she is examined is likely to find that the whole experience was not as uncomfortable as she might have anticipated.

Chapter 12