Gynecological Exam and Investigations.pptPresentation Transcript
Dr. Shamanthakamani Narendran M.D. (Pead), Ph.D. (Yoga Science) The Gynecological Visit and Exam
The medical specialty concerned with diseases of the female genital tract, as well as endocrinology and reproductive physiology of the female is a gynecologist gyn-, gyne-, gyneco-, gyno- means FEMALE
Gynecology is health care for women. It helps to take good care of sexual and reproductive health.
Routine gynecological care
Prevents illness and discomfort
Allows for early detection of cancers of the breast and cervix — when they are more curable
Detects sexually transmitted infections and other conditions before they cause serious damage
Promotes healthy pregnancy and childbirth
Good gynecological care is the key to good health
Staying healthy is important.
young or old,
married or single,
sexually active or not, or
History of abnormal pap test results
History of sexual health problems
Mother or sister who developed breast cancer before menopause
Sexually related illness
Sexually transmitted infection or a sex partner with an infection
Visit clinician if any
Abnormal or unexplained change in vaginal bleeding or discharge
Concerns about the sexual or reproductive health
Changes in size or shape of the breast
Growths or thickening of the breast or armpit
Increased pain or discomfort before the periods
Newly retracted nipples or bleeding or discharge from the nipple
Pain, swelling, or tenderness of the vulva or vagina
Puckering, dimpling, or other changes in the skin of the breast
Severe pelvic or lower abdominal pain
Sores, lumps, or itching of the vulva or vagina
Unusual vaginal or pelvic pain
Medical History Before examine, patient will be asked to fill out a questionnaire. It will include some of these questions:
When was the last period?
How often do patient have periods?
How long do they last?
Having any bleeding problems between periods?
Do patient feel any pain when having sex?
Is there any bleeding after sex?
Do patient have any unusual genital pain, itching, or discharge?
Do patient have any other medical conditions?
What medical problems do other members of patient’s family have?
Using birth control?
Do patient suspect she is pregnant?
Trying to become pregnant?
What method do patient use to prevent sexually transmitted infections?
Patient will be asked about history of allergies, illnesses, pregnancy, risks for sexually transmitted infections, and surgery; may be asked about lifestyle, like smoking, drinking alcohol or use other drugs; finally may also be asked if she is having problems on holding urine.
The Breast Exam Patient will change into an examination gown or be covered with a drape sheet. Some clinicians provide both. Clinician will examine the breasts for lumps, thickening, irregularities, and discharge. Many talk about the health history during the breast exam.
Breast lumps are often discovered by a woman or her sex partner. Changes noticed in the breasts since last exam, if any. Should become familiar with the way breasts normally look and feel. That way patient will be more likely to notice any changes.
Some women use breast self-exams (BSEs) to get to know their breasts. The best time for a BSE is one week after the period, when breasts are not swollen or tender. Lumps are also noticed during day-to-day activities such as showering or sex play. Most lumps are not cancerous. But report anything unusual to the clinician as soon as possible.
Four-Step Breast Self-Exam Stand up and place one hand behind head. Hold the fingers of the other hand flat. Gently touch every part of the breast below the raised arm. Feel for lumps, bumps, or thickening. Now do the other breast. Stand in front of a mirror. Place hands on hips. Inspect each breast for changes in size, shape, and form. Do it again with arms raised above the head In front of the mirror
Lie back with a pillow or folded towel under right shoulder. Place right hand behind the head. Examine every part of the breast with the fingers of the left hand held flat. Gently press in small circles. Start at the top outermost edge and spiral in to the nipple. Feel for lumps, bumps, or thickening. Now do the other breast. Be sure to follow a consistent pattern. On the bed
Use one of the following patterns: Do not miss any part of the breast.
Rest the arm on a firm surface like the top of a bookshelf. Examine the underarm. Feel for lumps, bumps, or thickening in the same way. Now do the other underarm.
Breast cancer is a leading cause of death among women.
As of today little is known about the prevention of breast cancer.
Therefore, much rests on early detection, when the cancer can be cured completely.
An ideal screening test should detect cancer or the pre-cancerous condition at a stage when treatment can affect outcome.
The rate of false positive and negative results should be low.
The test should not cause morbidity, should be reproducible, inexpensive, and suitable for large sections of the population.
The best test would be the one that detects abnormal cells before they turn malignant.
Mammography has long been used as a screening test for breast cancer.
It involves taking an X-ray of the breast.
It is widely accepted that screening mammography leads to early detection of breast cancer.
LIMITATIONS OF MAMMOGRAPHY
Since mammography cannot separate normal gland tissue from tumours, it is more effective when gland tissue diminishes with age.
Many women retain glandular tissue even as they mature and this camouflages tumours until they are large.
Young women have more glandular tissue, which interferes with detection of small cancers.
BENEFITS OF MAMMOGRAPHY
Apart from early detection of breast cancer, there are other potential benefits of mammography screening.
The amount of dense parenchymal tissue can affect the validity of cancer screening, it is also a marker of breast cancer risk.
It has been found in a case control study that women with extremely dense breast tissue are at an elevated risk of developing breast cancer than those with extremely fatty breast tissue.
The knowledge that breast density is a marker of breast cancer risk can be used to minimize the risk.
EFFECT ON INCIDENCE OF SURGERY
Incidence of surgery - tumorectomy and mastectomy - has increased dramatically since the beginning of clinical use of mammography.
Screening identifies some slow growing tumours that are not likely to grow bigger in the woman's remaining lifetime.
These can be followed by mammography or treated aggressively, thus increasing the incidence of surgery.
Improvement in mammography has resulted in the test's ability to detect a higher number of Ductal Carcinoma in Situ (DCIS).
Currently, most of the DCIS are diagnosed by mammography, since there is usually no lump that can be detected by touch.
These may not always develop into invasive cancer, but since these lesions are often diffuse, women are treated with bilateral mastectomy.
PAPANICOLAOU SMEAR TEST A Pap smear is a test – doctor does to check for signs of cancer of the cervix. The cervix is part of the uterus (womb). During a Pap smear, doctor takes a sample of cells from the cervix to be tested.
THE PELVIC EXAM
After the breasts have been examined, patient will be asked to place the feet in the footrests at the end of the table. Some tables have knee rests instead of footrests.
Slide hips down to the edge of the table. Let the knees spread wide apart, and relax as much as possible.
If buttocks and abdominal and vaginal muscles are relaxed, patient will be more comfortable, and the exam will be more complete.
Can cover lower abdomen and thighs with the drape sheet to feel less exposed and more comfortable during the procedure.
How to feel less tense during exam
Breathe slowly and deeply with mouth open.
Let the stomach muscles go soft.
Relax the shoulders.
Relax the muscles between the legs.
Ask the clinician to describe what's being done as it's happening.
Sexual Abuse and Other Concerns
Some women are very anxious about having a pelvic exam because of difficult experiences that may include sexual abuse. Patient may have more pelvic pain, fear, and discomfort during pelvic exam if
Been sexually abused in the past
Heard alarming stories about GYN exams
Had other negative sexual experiences
Remember that the exam is not emotional or sexual for clinician. Talk with the clinician about
Any pelvic pain
Experience of abuse
Talking with clinician about the experience will help
tailor the exam to special needs
help feel as comfortable as possible
understand how physical and emotional health may be affected
It is also okay to have a trusted friend or relative during the exam.
Usually, the exam lasts just a few minutes.
There are four steps:
The External Genital Exam
The Speculum Exam
The Bimanual Exam
The Rectovaginal Exam
Step 1. The External Genital Exam
The clinician visually examines the soft folds of the vulva and the opening of the vagina to check for signs of irritation, discharge, cysts, genital warts, or other conditions.
Step 2. The Speculum Exam
The clinician inserts a metal or plastic speculum into the vagina.
When opened, it separates the walls of the vagina, which normally are closed and touch each other, so that the cervix can be seen.
Feels some degree of pressure or mild discomfort when the speculum is inserted and opened.
Will likely feel more discomfort if tensed or if vagina or pelvic organs are infected.
The position of the cervix or uterus may affect the comfort as well.
May feel the chill of the metal, if a metal speculum is used
Most clinicians lubricate the speculum and warm it to body temperature for more comfort.
Talk with clinician about any feeling of discomfort.
Once the speculum is in place, the clinician checks for any irritation, growth, or abnormal discharge from the cervix.
Tests for gonorrhea, human papilloma virus, chlamydia, or other sexually transmitted infections may be taken by collecting cervical mucus on a cotton swab.
These tests may not be done unless asked for testing or having a concern about infections.
Be sure to talk with clinician if any symptoms or concerns about the partner(s).
Usually a small spatula or tiny brush is used to gently collect cells from the cervix for a Pap test.
The cells are tested for abnormalities — the presence of precancerous or cancerous cells.
May have some staining or bleeding after the sample is taken.
As the clinician removes the speculum, the vaginal walls that were covered by it are also checked for irritation, injury, and any other problems.
Pap tests can detect
the presence of abnormal cells in the cervix
infections and inflammations of the cervix
symptoms of STDs (With the exception of trichomoniasis, Pap tests cannot identify specific STDs, but they may detect symptoms.)
thinning of the vaginal lining from lack of estrogen commonly related to menopause
The cell sample will be sent to a laboratory. The results will be sent back to the clinician within few weeks. Pap tests need to be repeated if there is too much blood present for an accurate reading or if there are not enough cells to be examined.
Interpreting Pap Tests
Cytologists and clinicians are very careful about interpreting
Pap tests and recommending follow-up care.
They don't want to overlook any abnormality.
They are also aware that failure to detect early cancers can lead to serious and even deadly consequences.
Their caution may lead them to request re-doing the Pap test, or doing other tests.
In some cases, the cytologist is unsure about whether or not there are precancerous changes.
In such a case, clinician will recommend repeat testing or other tests to be more sure.
As with mammography, fewer cancers are overlooked with these precautions.
But having more tests done can lead to more anxiety, as well as expense.
It is reassuring that these precautions improve the chance of finding abnormal cell changes as early as possible.
If any abnormal results, clinician will advise a follow-up care:
If noncancerous abnormalities and infections are found, be sure to complete the prescribed treatment and repeat the tests as advised.
If cancerous growths are found
Discuss the options with clinician.
See another provider or specialist.
If early precancerous or suspicious growths are found, will need careful follow-up and may also be advised to
Repeat the Pap test in a few weeks or have them at more frequent intervals.
Have other tests.
Have a colposcopy and biopsy.
Have growths removed with cryotherapy, laser surgery, or electrocautery.
Most abnormalities that are detected are not cancer.
Early treatment of precancerous growths can prevent cancer from developing.
Follow-up examinations are necessary if an abnormal condition is found.
Step 3. The Bimanual Exam
Wearing an examination glove, the clinician inserts one or two lubricated fingers into the vagina.
The other hand presses down on the lower abdomen.
The clinician can then feel the internal organs of the pelvis between the two fingers in the vagina and the fingers on the abdomen.
The clinician examines the internal organs with both hands to check for
Size, shape, and position of the uterus
An enlarged uterus, which could indicate a pregnancy or fibroids
Tenderness or pain, which might indicate infection
Swelling of the fallopian tubes
Enlarged ovaries, cysts, or tumors
The bimanual part of the exam causes a sensation of pressure.
May find it somewhat uncomfortable. Deep breathing through the mouth helps.
If feeling pain, tell the clinician.
Step 4. Rectovaginal Exam
Many clinicians complete the bimanual exam by inserting a gloved finger into the rectum to check the condition of muscles that separate the vagina and rectum.
They also check for possible tumors located behind the uterus, on the lower wall of the vagina, and in the rectum.
Some clinicians insert one finger in the anus and another in the vagina for a more thorough examination of the tissue in between.
During this procedure, she may feel as though she need to have a bowel movement.
This is normal and lasts only a few seconds.
Blood Pressure . It's important to have blood pressure measured on a regular basis –having high blood pressure and not having any symptoms. Detecting and treating high blood pressure can reduce the risk of problems such as heart attack and stroke.
Weight . Rising or falling weight can give important clues to overall health. Should discuss any significant change with clinician.
Other areas the clinician may examine include the abdomen, the thyroid gland in the neck, the heart, and the lungs.
A blood test may be necessary to check for anemia.
Be sure to point out to clinician any abnormality in the body that has seen or felt.
After the Exam
This is a time for further consultation with clinician.
Will discuss the results of the exam, arrange for any follow-up or consultation that may be needed, and ask any further questions if any.
This is another opportunity to discuss the concerns about sex and sexuality, birth control, pregnancy, abortion, sexually transmitted infections, problems holding the urine, inherited disorders, infertility, cancer signals, changes in the breasts, and menopause.
Don't let embarrassment become a health risk. Speak up.
If the lab tests indicate anything unusual, will be contacted when the results are completed.
Pregnancy test results are usually ready during visit.
Other test results may take a few days or weeks. Clinician will tell how long to wait.
Be sure clinician has current address and phone number.
Remember — for good health
Eat properly — get plenty of folic acid and vitamins C and D.
Drink when thirsty.
Get enough sleep.
Avoid taking health risks with mind and body.
Have periodic GYN visits and exams.
Take advantage of immunizations that are available
Good health is a matter of teamwork — patient and the clinician working together and maintaining good communication.
Uterine fibroids are among the most common tumors in women.
These noncancerous growths of the uterus may appear during childbearing years. Also called fibromyomas, leiomyomas or myomas, uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer.
Most of the time, uterine fibroids aren't harmful.
As many as three out of four women have uterine fibroids, but most are unaware of them as they often cause no signs or symptoms.
Doctor may discover them incidentally during a pelvic exam or prenatal ultrasound.
Fibroids cause problems for about one in four women, most frequently during their 30s or 40s.
Fibroids can require emergency treatment if they cause sudden, sharp pelvic pain, but this is rare.
In general, fibroids cause no problems and seldom require treatment.
Medical therapy and surgical procedures can
shrink or remove
fibroids if they cause
discomfort or troublesome
SIGNS AND SYMPTOMS When signs and symptoms of uterine fibroids are present, the most common include:
Heavy menstrual bleeding
Prolonged menstrual periods or bleeding between periods
Pelvic pressure or pain
Urinary incontinence, frequent urination or urine retention
Backache or leg pains
Rarely, a fibroid can cause acute pain when it outgrows its blood supply.
Deprived of nutrients, the fibroid begins to die.
Byproducts from a degenerating fibroid can seep into surrounding tissue, causing pain and fever.
A fibroid that hangs by a stalk inside or outside the uterus (pedunculated fibroid) can trigger pain by turning on its stalk.
Fibroid location influences signs and symptoms.
Fibroids that grow into the inner cavity of the uterus (submucosal fibroids) are thought primarily responsible for prolonged, heavy menstrual bleeding.
Fibroids that project to the outside of the uterus (subserosal fibroids) can press on bladder or ureters, causing to experience urinary symptoms.
If fibroids bulge from the back of uterus, they can press either on rectum, causing constipation, or on spinal nerves, causing backache.
Uterine fibroids develop from the smooth muscular tissue of the uterus (myometrium).
A single cell reproduces repeatedly, eventually creating a pale, firm, rubbery mass distinct from neighboring tissue.
Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus.
They can be single or multiple, in extreme cases expanding the uterus so much that it reaches the rib cage.
Genetic alterations . Many fibroids contain alterations in genes that code for uterine muscle cells.
Hormones . Estrogen and progesterone, two reproductive hormones produced by the ovaries that stimulate development of the uterine lining in preparation for a possible pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and estrogen receptors than do normal uterine muscle cells.
Other chemicals . Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
There are few known risk factors for uterine fibroids, other than being a woman of reproductive age.
Heredity probably plays a role. If mother or sister had fibroids – increased risk of also developing them.
Black women are more likely to have fibroids than are women of other racial groups.
In addition, black women have fibroids at younger ages, and they're also likely to have more or larger fibroids.
Research examining other potential risk factors has been inconclusive.
Although some studies have suggested that obese women are at higher risk of fibroids, other studies have not shown a link.
In addition, limited studies once suggested that women who take oral contraceptives and athletic women may have a lower risk of fibroids, but later research failed to establish this connection.
Researchers have also looked at whether pregnancy and giving birth may have a protective effect, but results remain unclear.
SCREENING AND DIAGNOSIS
Adenomyosis . In this condition, glands normally located in the uterine lining penetrate the muscular wall of uterus. Pain results when displaced glandular tissue develops during menstrual cycle and then attempts to slough off during menstruation. Abnormal bleeding results when the tissue builds up and blood seeps from the muscle. Treatment is surgery or hormonal therapy.
Hormonal dysfunction . Abnormal hormone signals that accompany lack of ovulation can cause heavy bleeding and a thickened uterine lining.
Uterine (endometrial) polyps . These growths, usually noncancerous (benign), extend from the lining of uterus. They may cause heavy menstrual bleeding, spotting after menstrual period or spotting not related to menstruation.
Hysterosonography . This diagnostic technique uses an ultrasound probe to obtain images of the uterine cavity.
Hysterosalpingography . This technique uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images.
Hysteroscopy . Doctor inserts a small, lighted telescope called a hysteroscope through the cervix into the uterus. The tube releases a gas or liquid to expand uterus, allowing doctor to examine the walls of uterus and the openings of fallopian tubes. A hysteroscopy can be performed in doctor's office.
Other imaging techniques that may be necessary to diagnose fibroids include computerized tomography (CT) and magnetic resonance imaging (MRI). Doctor may order an MRI to diagnose adenomyosis.
Uterine artery embolism
Focused ultrasound surgery
Tubal sterilization is surgery to block a woman’s fallopian tubes.
Tubal sterilization is a permanent form of birth control.
After this procedure, eggs cannot move from the ovary through the tubes (a woman has two fallopian tubes), and eventually to the uterus.
Also, sperm cannot reach the egg in the fallopian tube after it is released by the ovary. Thus, pregnancy is prevented.
Sterilization won't make less feminine. It doesn't cause weight gain or facial hair.
It won't decrease sexual pleasure or cause menopause.
It's important to know that sterilization won't protect against STDs.
This procedure is also called tubal ligation
While under anesthesia, one or two small incisions (cuts) are made in the abdomen (usually near the navel), and a device similar to a small telescope on a flexible tube (called a laparoscope) is inserted.
Using instruments that are inserted through the laparoscope, the tubes (fallopian tubes) are coagulated (burned), sealed shut with cautery, or a small clip is placed on the tube. The skin incision is then closed with a few stitches, usually feeling well enough to go home from the outpatient surgery center in a few hours.
Will sterilization hurt?
Given anesthetics before the procedure.
The four types are general (makes sleep), regional (makes numb from the waist down), local (acts only where applied) and IV sedation (makes calm).
The choice of anesthetic will depend on the health and the type of sterilization being done.
When a local anesthetic is injected or regional anesthesia is given, may feel brief discomfort.
The pain is relieved with pain medicines and sedatives.
Will be awake, but sleepy. Will feel little or no discomfort during the procedure.
General anesthesia is painless, but it can put at risk of serious problems.
Feeling after the operation depends on general health, the type of procedure and tolerance to pain.
May feel tired and have slight stomach or shoulder pain.
May feel dizzy, nauseated, bloated or gassy.
Most of these symptoms last 1 to 3 days.
Contact doctor right away if develops a fever, bleed from an incision, have severe stomach pain that won't stop or have fainting spells.
Can go back to work after sterilization depending on general health, attitude, job and the type of sterilization.
Recovery is usually complete in a couple of days. May want to take it easy for 1 week or so. Avoid heavy lifting for about 1 week.
Will still have a period.
As women get older, their periods change.
How often period occurs, how long it lasts and the amount of bleeding will vary.
Near menopause (usually in late 40s to 50s), can expect to have irregular cycles.
This happens whether or not had a tubal sterilization procedure.
Don't have sex until feel comfortable about it. It usually takes about a week after surgery.
Will have to wait at least 4 weeks if a sterilization is done shortly after childbirth.
As with any surgery, there is always a risk when given general anesthesia.
May have a bad reaction to the medication used.
Surgery itself may present problems with bleeding or infection.
There is still a chance in become pregnant after tubal sterilization.
About 1 in 200 women become pregnant who have their tubes tied.
This may be caused by an incomplete closure of the tubes.
If pregnancy occurs after the procedure –increased risk for an ectopic pregnancy in which the pregnancy develops in the fallopian tubes. This is a dangerous situation.
Because the procedure is performed by tiny instruments inserted into abdomen, may have injury to other organs in the body.
FEMALE STERILIZATION TECHNIQUE Pomeroy method Laparoscopic cauterization Laparoscopic banding, clamping or clipping Spring Clips Filschie clip