# Obstetrics and Gynecology/Gynecological Examination

The Gynecological Examination must always follow a comprehensive history as it is the history which guides the physician's examination. It must be performed with a chaperone. There are 3 aspects to the Gynecological Examination:
* General Approach
* Inspection
* Palpation
* Conclusion of the examination

## General Approach

Most women are anxious about seeing their gynecologist, especially the very old and the very young. The physician's approach must optimise trust and confidence in the patient from the outset. After taking a history, explain to the patient that you would like to perform an internal examination. It is essential that the patient understands fully what the examination is going to entail and it is equally important to ask the patient for verbal consent to the procedure. It is wise to explain what you are about to do during the procedure as well.
The examination should be performed with enough exposure to allow adequate inspection, but try as much as possible to maintain the patient's dignity throughout by allowing uninteresting parts of the body unexposed. If possible, allow the patient to undress herself behind a curtain. The examination should be performed with the patient in the supine position with her legs in stirrups.

## Inspection

Inspection of the area must be thorough, but swift. Items of interest include:
* Pubic hair distribution - Pubic hair can be absent or reduced in conditions that cause adrenal insufficiency such as hypopituitarism, Turner's Syndrome, Alopecia and Delayed Puberty.
* Presence of scars - Stretch marks would indicate previous parity, surgical scars may be present
* Presence of ulcers - There may be evidence of the herpes simplex virus
* Presence of warts - These are caused by Human Papilloma Virus which is a risk factor for cervical cancer
* Evidence of trauma - Trauma may be a result of recent delivery, which will appear in the history, or by sexual assault, which may not!!
* Presence of swelling - Look for swelling of Bartholin's glands
Once these areas have been swiftly addressed, it is time to assess stress incontinence and genital prolapse. This can be done by asking the patient to cough and "bear down" respectively.
The physician can now move on and inspect the cervix of the patient using a speculum. There are many steps in this procedure:
* Choosing the size of the speculum - Too large a speculum may hurt the patient and too small a speculum may make visualizing the cervix difficult
* Warming and lubricating the speculum - It is important to make the speculum examination as comfortable as possible or the woman may tense her pelvic muscles making the examination unnecessarily difficult.
* Warning the Patient - This should be done verbally and by touching the groin with the speculum
* Insertion of the speculum - The closed speculum should be inserted with the handle in the horizontal position and rotated 90 degress in any direction before it is opened and then locked in position.
* Inspection of the cervix - Colour, contours and position of the cervix. Examine the os and note the position, appearance and presence of discharge.
* Optional Smear testing - A smear test can be performed by gently inserting the point of the speculum into the os and rotating it 720 degrees in either direction.
* Removal of the speculum - Removal of the speculum involves simultaneous withdrawal and closure of the speculum to avoid nipping the cervix or vaginal walls.

## Palpation

Palpation begins at the labia in which Bartholin's glands are palpated with the index finger and thumb of the dominant hand. These glands are located in the 5 and 7 O'Clock positions and are palpated for any presence of swelling.
The next step is the bimanual examination. This involves the insertion of the index and middle fingers of the dominant gloved and lubricated hand into the patient's vagina and placin the palm of the other hand on the patient's lower abdomen wih the aim of palpating the major structures of the female reproductive system. A systematic approach is essential and should strictly follow this structure:
* Palpation of the Posterior Fornix - the uterus should be lifted up towards the non-dominant hand. Its position, size, shape, consistency, and mobility should all be noted.
* Palpation of the Adnexae - Both hands should be brought together and moved in a slow-sliding motion as if warming the hands
* Palpation of the Rectovaginal Septa - The dominant hand should be brought anteriorly to meet the non-dominant hand to assess a retroverted uterus.

## Conclusion of the Examination

The moment the examination is over, it is essential to inform the patient that the examination is over and that she can now get dressed before you talk to her again. When the patient is sitting comfortably opposite the physician, the examination is summarised and any findings are clearly explained to the patient. If further investigation is required it is important to explain why these procedures are necessary. The patient should be reassured and thanked for her co-operation.