Gynecologic Evaluation
A healthy lifestyle includes having regular gynecologic examinations and screening tests for disorders that can be prevented or treated effectively if detected early (see Section 1, Chapter 5). The main tests specific to women are the Papanicolaou (Pap) test or other similar tests to detect cancer of the cervix and mammography to detect breast cancer.
For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to menopause. The practitioner may be a gynecologist, an internist, a nurse-midwife, or a general, family, or nurse practitioner. During the gynecologic visit, a woman can ask this practitioner any questions she has about reproductive and sexual function and anatomy, including safe sex practices.
Gynecologic History
A gynecologic evaluation starts with a series of questions related to reproductive function, which usually focus on the reason for the visit to the doctor's office. The answers form the gynecologic history. A complete gynecologic history includes information about the age at which menstrual bleeding began (menarche); the frequency, regularity, and duration of menstrual periods; the amount of flow; and the dates of the last two menstrual periods. Questions about abnormal bleeding--too much, too little, or between menstrual periods--are included.
A doctor may ask about sexual activity to assess the possibility of gynecologic infections, injuries, and pregnancy. A woman is asked whether she uses or wants to use birth control and whether she is interested in counseling or other information. The number of pregnancies, dates that they occurred, outcomes, and complications are recorded.
The doctor asks the woman whether she has pain during menstrual periods, during intercourse, or under other circumstances. If the woman has pain, she is asked how severe it is and what provides relief. Questions are also asked about breast problems, such as pain, lumps, areas of tenderness or redness, and discharge from the nipples. The woman is asked whether she is examining her breasts, how often, and whether she needs any instruction on technique.
The doctor reviews the woman's history of past gynecologic disorders and usually obtains a medical and surgical history that includes all previous health problems. The doctor reviews all the drugs a woman is taking, including prescription and nonprescription drugs, illicit drugs, tobacco, and alcohol, because many of them affect gynecologic function. The woman is asked about mental, physical, or sexual abuse in the present and the past. Some questions about urination are asked to find out whether the woman has a urinary tract infection or has problems with leakage of urine (incontinence).
Gynecologic Examination
If a woman has any questions or fears about the gynecologic examination, she should talk with the doctor beforehand about her concerns. If any part of the examination causes pain, the woman should let the doctor know. A woman is usually asked to empty her bladder before the physical examination and may be asked to collect a urine sample for analysis.
A breast examination may be performed before or after the pelvic examination. With the woman sitting, the doctor inspects the breasts for irregularities, dimpling, tightened skin, lumps, and a discharge. The woman then sits or lies down, with her arms above her head, while the doctor feels (palpates) each breast with a flat hand and examines each armpit for enlarged lymph nodes. The doctor also feels the neck and the thyroid gland for lumps and abnormalities. While performing the examination, the doctor can review the technique for breast self-examination with the woman (see Section 22, Chapter 251).
The doctor gently feels the entire abdomen, looking for abnormal growths or enlarged organs, especially the liver and spleen. Although the woman may experience some discomfort when the doctor presses deeply, the examination should not be painful. To estimate the size of the liver and spleen, the doctor may tap with the fingers (percuss) and listen for differences in sound between hollow-sounding and dull-sounding areas. A stethoscope may be used to listen for the activity of the intestines and for any abnormal noises made by blood flowing through narrowed blood vessels.
During the pelvic examination, the woman lies on her back with her hips and knees bent and her buttocks moved to the edge of the examining table. Most examining tables have heel stirrups that help a woman maintain this position. If a woman wants to observe the pelvic examination, she should let the doctor know ahead of time. The doctor can provide a mirror as well as explanations or a diagram. First, the doctor inspects the external genital area and notes the distribution of hair and any abnormalities, discoloration, discharge, or inflammation. This examination may indicate that all is well or give clues to hormonal problems, cancer, infections, injury, or physical abuse.
The doctor spreads the tissues around the opening of the vagina (labia) and examines the opening. Using a speculum (a metal or plastic instrument that spreads the walls of the vagina apart), the doctor examines the deeper areas of the vagina and the cervix. The cervix is examined closely for signs of irritation or cancer. The doctor checks for a protrusion of the bladder, rectum, or intestine into the vagina (see Section 22, Chapter 249).
 See the figure Collecting Cervical Cells for a Pap Test.
For a Papanicolaou (Pap) test or another similar test, the doctor collects cells from the surface of the cervix with a plastic spatula similar to a tongue depressor. Then, a small bristle brush is used to obtain cells from the cervix. Usually, these tests feel scratchy or crampy, but they are not painful and take only a few seconds. The cells removed with the spatula or brush are placed on a glass slide and sprayed with a preservative or rinsed into a vial of liquid. The sample is sent to a laboratory, where it is examined under a microscope for abnormal cells, which may indicate cervical cancer. Such tests identify 80 to 85% of cervical cancers, even in their earliest stages. They can also detect changes in cells of the cervix that can lead to cancer. The changes can be treated, thus helping prevent cancer.
Pap and similar tests are most accurate if the woman is not having her period and does not douche or use vaginal creams for at least 24 hours before the examination. Most women should have such a test once a year. The first test is usually performed when a woman becomes sexually active or reaches age 18. If test results are normal for 3 consecutive years, the woman can discuss with her health care practitioner whether scheduling tests every 1, 2, or 3 years is appropriate.
If an infection is suspected, the doctor uses a swab to obtain a small amount of vaginal discharge from the vagina and cervix. The sample is sent to a laboratory for culture and evaluation. Tests for sexually transmitted diseases are not part of a routine examination. If a woman thinks she may have one of these diseases, she can request testing.
After removing the speculum, the doctor feels the vaginal wall to determine its strength and support. The doctor inserts the index and middle fingers of one gloved hand into the vagina and places the fingers of the other hand on the lower abdomen above the pubic bone. Between the two hands, the uterus can usually be felt as a pear-shaped, smooth, firm structure, and its position, size, consistency, and degree of tenderness (if any) can be determined. Then the doctor attempts to feel the ovaries by moving the hand on the abdomen more to the side and exerting slightly more pressure. More pressure is required because the ovaries are small and much more difficult to feel than the uterus. The woman may find this part of the examination to be slightly uncomfortable, but it should not be painful. The doctor determines how large the ovaries are and whether they are tender. The doctor also feels for growths or tender areas within the vagina.
Finally, the doctor performs a rectovaginal examination by inserting the index finger into the vagina and the middle finger into the rectum. In this way, the back wall of the vagina can be examined for abnormal growths or thickness. In addition, the doctor can examine the rectum for hemorrhoids, fissures, polyps, and lumps. A small sample of stool can be obtained with a gloved finger and tested for unseen (occult) blood. A woman may be given a take-home kit to test for occult blood in the stool.
Diagnostic Procedures
Occasionally, more extensive diagnostic procedures are needed.
Colposcopy
For colposcopy, a binocular magnifying lens (similar to that of a microscope) can be used to inspect the cervix for signs of cancer. The procedure is often performed after an abnormal Pap test result. A speculum is used to spread the walls of the vagina so that the cervix can be seen. Colposcopy is painless and requires no anesthetic. It takes 15 to 30 minutes to perform.
Biopsy
A biopsy consists of removing a small sample of tissue for examination under a microscope. This procedure is performed when a precancerous condition (a condition that is likely to eventually lead to cancer) or cancer is suspected. A biopsy of the vulva can usually be performed in the doctor's office with use of a local anesthetic. A biopsy of the cervix and vagina is usually performed during colposcopy. Colposcopy enables doctors to take tissue samples from the area that looks most abnormal. Usually, biopsy of the cervix or vagina does not require an anesthetic. Typically, this procedure feels like a pinch or a cramp.
For biopsy of the lining of the uterus (endometrial biopsy), a small metal or plastic tube is inserted through the cervix into the uterus. The tube is moved back and forth and around to dislodge and suction out tissue from the uterine lining. This procedure is usually performed to determine the cause of abnormal vaginal bleeding. Also, infertility specialists use this procedure to determine whether ovulation is occurring normally or whether the uterus is ready for implantation of embryos. An endometrial biopsy can be performed in a doctor's office and usually does not require an anesthetic. Typically, it feels like strong menstrual cramps.
Endocervical Curettage
Endocervical curettage consists of inserting a small, sharp instrument (curet) inside the cervix to obtain tissue. This tissue is examined under a microscope by a pathologist. It is performed when endometrial or cervical cancer is suspected or needs to be ruled out. This procedure is usually performed during colposcopy and usually does not require an anesthetic.
Loop Electrical Excision Procedure
In a loop electrical excision procedure (LEEP), a thin wire loop through which an electrical current can pass is used to remove a piece of tissue. This procedure may be performed after an abnormal Pap test result to evaluate the abnormality more accurately and to remove the abnormal tissue. LEEP requires an anesthetic (often a local one), takes about 5 to 10 minutes, and can be performed in a doctor's office. Afterward, a woman may feel mild discomfort and have a small amount of bleeding.
Dilation and Curettage
 See the figure D and C.
For dilation and curettage (D and C), the cervix is stretched open (dilated) with metal rods so that a small, sharp instrument (curet) can be inserted to remove tissue lining the uterus. This procedure may be used to identify abnormalities of the uterine lining if biopsy results are inconclusive or to treat women who have had an incomplete miscarriage. D and C is often performed in a hospital, and a general anesthetic may be used. However, most women do not have to stay overnight in the hospital.
Hysteroscopy
To view the interior of the uterus, doctors can insert a thin viewing tube (hysteroscope) through the vagina and cervix into the uterus. The tube is about ¼ inch in diameter and contains cables that transmit light. A biopsy, an electrocautery (heat), or a surgical instrument may be threaded through the tube. The site of abnormal bleeding or other abnormalities can usually be seen and can be sampled for a biopsy, sealed off using heat, or removed. This procedure may be performed in a doctor's office or in a hospital at the same time as a dilation and curettage.
Ultrasonography
Ultrasonography uses ultrasound waves, produced at a frequency too high to be heard. The ultrasound waves are emitted by a handheld device that is placed on the abdomen or inside the vagina. The waves reflect off internal structures, and the pattern of this reflection can be displayed on a monitor. In pregnant women, ultrasonography can help determine the condition and size of a fetus and can detect the presence of more than one fetus. It can often identify the sex of the fetus. Ultrasonography can also be used to monitor the fetus and to detect fetal abnormalities. It can be used to guide the placement of instruments during amniocentesis and chorionic villus sampling, which are used to detect genetic disorders in the fetus. Ultrasonography can detect an ectopic pregnancy, tumors, cysts, and other abnormalities in the pelvic organs. Ultrasonography is painless and has no known risks.
Sonohysterography
For sonohysterography, fluid is placed in the uterus through a thin tube (catheter) inserted through the vagina. Then ultrasonography is performed. The fluid fills and stretches (distends) the uterus so that abnormalities inside the uterus, such as polyps or fibroids, can be more easily detected. The procedure is performed in a doctor's office and may require a local anesthetic. A nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, may be taken 20 minutes before the procedure to help relieve the cramping that may occur.
Laparoscopy
To directly examine the uterus, fallopian tubes, or ovaries, doctors use a viewing tube called a laparoscope. The laparoscope is attached to a thin cable containing flexible plastic or glass rods that transmit light. The laparoscope is inserted into the abdominal cavity through a small incision just below the navel. A probe is inserted through the vagina and into the uterus. The probe enables doctors to manipulate the organs for better viewing. Carbon dioxide is pumped through the laparoscope to inflate the abdomen, so that organs in the abdomen and pelvis can be seen clearly. Laparoscopy is performed in a hospital and requires an anesthetic, usually a general anesthetic. An overnight stay in the hospital is usually not required. Laparoscopy may cause mild abdominal discomfort, but normal activities can usually be resumed in 1 or 2 days.
Often, laparoscopy is used to determine the cause of pelvic pain, infertility, and other gynecologic disorders. Instruments can be threaded through the laparoscope to perform some surgical procedures, such as biopsies, sterilization procedures, and removal of an ectopic pregnancy in a fallopian tube or an ovary.
Hysterosalpingography
For hysterosalpingography, x-rays are taken after a radiopaque dye, which can be seen on x-rays, is injected through the cervix to outline the interior of the uterus and fallopian tubes. The procedure is often used to help determine the cause of infertility. The procedure is performed in a place where x-rays can be taken, such as a hospital or the radiology suite of a doctor's office. Hysterosalpingography usually causes discomfort, such as cramps.
Mammography
For mammography, x-rays of the breasts are taken to detect abnormal areas (see Section 22, Chapter 251). A technician positions the woman's breast on top of an x-ray plate. An adjustable plastic cover is lowered on top of the breast, firmly compressing the breast. Thus, the breast is flattened so that the maximum amount of tissue can be imaged and examined. X-rays are aimed downward through the breast, producing an image on the x-ray plate. Two x-rays are taken of each breast in this position. Then plates may be placed vertically on either side of the breast, and x-rays are aimed from the side. This position produces a side view of the breast.
 See the figure Mammography: Screening for Breast Cancer.
Mammography is one of the best ways to detect breast cancer early. It is designed to detect the possibility of cancer at an early stage, years before it can be felt. All women aged 50 and older should have mammograms once a year to check for breast cancer. Many authorities recommend that women aged 40 to 49 have mammograms every 1 to 2 years.
The dose of radiation used is very low and is considered safe. This procedure may cause some discomfort, but the discomfort lasts only a few seconds. Mammography should be scheduled at a time during the menstrual period when the breasts are less likely to be tender. Deodorants should not be used on the day of the procedure, because they can affect it. The entire procedure takes about 15 minutes.
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