1. THE GYNAECOLOGICAL
Jasleen Kaur Luthra
2. Made By:
Jasleen kaur luthra
3. Gynecological History Taking
Gynecological history taking involves a series of
methodical questioning of a gynecological patient
with the aim of developing a diagnosis or a
differential diagnosis on which further management of
the patient can be arranged. This further treatment
may involve examination of the patient, further
investigative testing or treatment of a diagnosed
There is a basic structure for all gynecological
histories but this can differ slightly depending on the
When taking any history in medicine it is essential to
understand what the presenting complaint means and
what the possible causes (differential diagnosis) of the
presenting complaint may be.
4. BIODATA OF PATIENT
5. Presenting complaint
“What is the problem that brought you to the
Best to record this in the patient’s own
“Were you referred by your doctor or did you
self‐refer yourself to the hospital/clinic?”
6. History of presenting
Pain - Uterine; colicky pain felt in sacrum and groins
Ovarian; Iliac fossa with radiation down anterior aspect of
the thigh to the knee
• Site - Localized/general/symmetrical, abdominal or pelvic
• Onset (sudden or gradual), duration and evolution over time
• Character and Severity
• Relieving/Precipitating/Exacerbating factors - Help to date
(Exercise, posture, external stimuli)
Associated features e.g. bowel or urinary symptoms, peritonitis,
Effects - Impact on life, functional capacity, disability, hygiene,
Spread - Radiation
7. Menstrual History
Menarche and menopause
1st day of last menstrual period
Length of bleeding (days)
Bleeding between periods
Bleeding after intercourse
Any post menopausal bleeding *Nature of
8. Past Obstetric History
Gravidity and Parity
Dates of deliveries
Length of pregnancies
Induction of labor/Spontaneous
Weight of babies
Sex of babies
Complications before, during and
9. • Past Medical History
• Operations (particularly pelvic or abdominal) and
• Identify presence of diabetes, epilepsy,
thromboembolism, UTIs, STIs and other chronic
conditions (e.g. thyroid disease, cardiac disease,
asthma, connective tissue disorders).
•Non-prescribed medications/herbal remedies
•Any known drug allergies .
10. Sexual history
Frequency of sexual intercourse
Type of contraception used?
Any complaints before ,during and after sexual
Dyspareunia –superficial or deep?
ƒ“Are your parents still alive?” “Do they suffer from
any illness?” – if dead “What was the cause of
“Do you have any brothers or sisters?” – if yes –
“What is their state of health?”
“Is there any family related disease in your family
that you are aware of?” –diabetes,
11. Social History
Sleep *Appetite *Micturition *Defecation
*Weight loss or gain *Addiction
The patient’s bladder must be empty-the
exception being a case of stress incontinence.
A female attendant (nurse or relative of the
patient)should be present by a side.
To examine a married or unmarried,a consent
from the parent or guardian is required.
Lower bowel (rectum and pelvic colon) should
preferably be empty.
A light source should be available.
14. POSITIONS OF THE PATIENT
15. 1. DORSAL
The patient is commonly
examined in dorsal position
with knees flexed.
The physician usually stands
on the right side.
This position gives better view
of the external genitalia and
the bimanual pelvic
examination can be effectively
16. 2. SIMS’ POSITION
A semi- prone position with
buttocks on edge of the bed.
Patient’s right knee and thigh
drawn well up to the chest.
Lower left leg semi extended.
Left arm is placed along patient
back and chest inclined forward
so that patient rest upon it.
Lateral or sims’ position is ideal
for inspecting any lesion in
anterior vaginal wall as the
vagina balloons with air as soon
as the introitus is opened by a
17. 3. LITHOTOMY POSITION
Lithotomy position is
ideal for examination
18. • EXAMINATION OF LABIAL SWELLING(BARTHOLIN’S
19. SPECULUM EXAMINATION
Speculum examination should preferably be done
prior to bimanual examination.
1. Cervical scrape cytology and endocervical
sampling can be taken as screening in the
2. Cervical or vaginal discharge can be taken for
3. The cervical lesion may bleed during bimanual
examination which makes the lesion difficult
20. TYPES OF SPECULUM
21. 2. SIMS’
22. USES OF CUSCO’S SPECULUM
In dorsal position,cusco speculum is
It allows satisfactory inspection of the
cervix, taking of a pap smear,
collection of vaginal discharge from
the posterion fornix for hanging drop
smear and colposcopic examination.
23. USES OF SIM’S SPECULUM
SIMS’ SPECULUM IS ADVANTAGEOUS IN
CASES OF GENITAL PROLAPSE.
ANTERIOR VAGINAL WALL IS TO BE
VISUALISED BY SIMS’ SPECULUM.
IN LATERAL POSITION SIMS’ SPECULUM
HAS GOT ADVANTAGES.
25. RECTAL OR RECTOABDOMINAL
26. SAGITTAL VIEW OF RECTOABDOMINAL BIMANUAL
EXAMINATION SHOWING PALPATION OF UTERUS
IN PREPUBERTAL CHILD
Children or in adult virgins
Painful vaginal examination
Carcinoma cervix-to note the parametrial
involvement (base of the broad ligament and
the uterosacral ligament can only be felt
rectally) or involvement of rectum.
Patients having rectal complaints
To diagnose rectocele and differentiate it from
To corroborate the findings felt in the pouch of
douglas by bimanual vaginal examination.
28. RECTOVAGINAL EXAMINATION
The procedure consists of introducing the index
finger in the vagina and the middle finger in the
This examination helps to determine whether
the lesion is in the bowel or between the rectum
This is of special help to differentiate a growth
arising from the ovary or rectum.
30. CERVICAL AND
31. MATERIALS REQUIRED FOR PAP SMEAR
32. WHAT IS PAP SMEAR?
A Pap smear is a microscopic
examination of cells scraped from
the opening of the cervix. The cervix
is the lower part of the uterus
(womb) that opens at the top of the
It is a screening test for cervical
CERVICAL CANCER SCREENING.
WITHIN 5 YEARS OF BECOMING SEXUALLY
ACTUALLY IN HIGH RISK GROUPS SUCH AS
PATIENTS WITH RECURRENT STD’S AND HIV.
POST COITAL BLEEDING
34. Procedure of pap smear
35. 1. The Ayres spatula is placed in the cervical os and rotated
360 deg to sample the entire ectocerivx. This specimen is
then smeared on a glass slide. When cervical ectopy is
present, the red endocervical lining extends to the
ectocervix, and an additional circumferential scraping at
this transition is sometimes necessary to ensure that the
squamocolumnar junction is sampled.
2. The cytobrush is next inserted into the cervical os and
rotated 360 degree. The brush is then rolled onto the
slide, ensuring that the entire circumference of the brush
makes contact with the slide.
3.The slide must be immediately sprayed with fixative to
prevent desiccation of the cells, which begins to occur in
as quickly as 15 sec.
4. If desired, a separate cervical specimen may be obtained
and placed in specific transport medium for HPV testing.
36. COLLECTION OF SMEAR
38. ABNORMAL CERVICAL CELLS UNDER THE MICROSCOPE
39. Why is pap smear necessary?
Early changes in the cervix may be
the first warning signs that a problem
Early changes of cervix are treatable.
90% of cases can be prevented from
progressing to cancer of cervix.
Half of the new cases diagnosed each
year are women of age 50 or more.
40. How often should I have a
Regular pap smear every 2 yrs is
very effective in detecting
abnormalities that may lead to
cancer of cervix.
If you had treatment on the
cervix with laser or loop then you
require pap smears every 6
months until you have normal
42. WHAT IS COLPOSCOPY ?
Colposcopy is a procedure that uses
an instrument with a magnifying lens
and a light, called a colposcope, to
examine the cervix and vagina for
abnormalities. The colposcope
magnifies the image many times,
thus allowing the health care provider
to see the tissues on the cervix and
vaginal walls more clearly.
Patient is placed in lithotomy position.
The cervix is visualised using a cusco’s
Colposcopic examination of the cervix and
vagina is done using low magnification (6-16
Cervix is then cleared of any mucous discharge
using a swab soaked with normal saline.
Next, the cervix is wiped gently with 3% acetic
acid and examination repeated. Acetic acid
causes coagulation of nuclear protein which is
high in CIN. This prevents transmission of light
through the epithelium which is visible as white
44. INDICATIONS FOR
Epithelial cell abnormalities
detected by cervical cytology.
Suspicious cervical lesions.
Vulvar or vaginal neoplasia.
Sexual partner of patients with
genital tract neoplasia.
Unexplained vaginal bleeding.
Post coital bleeding.
45. COLPOSCOPIC TERMINOLOGY
The squamo-columnar junction
The squamous metaplasia
The transformation zone
The adequate colposcopy
46. The Squamocolumnar Junction
found on the
leading edge of
47. Squamous Metaplasia
columnar cells by
•Stimulated by an
48. TRANSFORMATION ZONE
49. Adequate Colposcopy
Hysterosalpingography is the radiographic
demonstration of the female reproductive tract with
a contrast medium. The radiographic procedure best
demonstrates the uterine cavity and the patency
(degree of openness) of the uterine tubes. The
uterine cavity is outlined by injection of contrast
medium throughout the cervix. The shape and
contour of the uterine cavity are assessed to detect
any uterine pathologic process. As the contrast
agent fills the uterine cavity, the patency of the
uterine tubes can be demonstrated as the contrast
flows through the tubes and spills into the peritoneal
To note the tubal patency in the investigation of
infertility or following tuboplasty operation
To detect uterine malformation in recurrent
To diagnose cervical incompetency.
To diagnose the translocated IUD whether lying
inside or outside the uterine cavity.
To diagnose uterine synechiae.
To confirm diagnosis of secondary abdominal
53. Major Equipment
The major equipment required for an HSG is a radiographic fluoroscope
room. Newer equipment may provide digital fluoroscopy capabilities.
Ideally, the table should have the capability to tilt the patient to a
Trendelenburg position if needed. If available, gynecologic stirrups should
be attached to the table to assist the patient in the lithotomy position.
54. Accessory and Optional Equipment
Routinely, a sterile, disposable HSG tray is used The general contents of the
tray include a vaginal speculum, basin, cotton balls, medicine cup, sterile
gauze, sterile drapes, sponge-holding forceps, 10 ml syringes, 16 and 18
gauge needles, extension tubing, and lubricating jelly. In addition to the HSG
tray, sterile gloves, an antiseptic solution, a cannula or balloon catheter, and
contrast media are necessary
55. Contrast Media
Two categories of radiopaque (positive) iodinated contrast media
have been used in HSG. Water-soluble iodinated contrast media,
such as Omnipaque 300, is preferred. It is absorbed easily by the
patient, does not leave a residue within the reproductive tract,
and provides adequate visualization. This medium does, however,
cause pain when injected within the uterine cavity, and the pain
may persist for several hours after the procedure.
In the past, oil-based contrast media that allowed for maximal
visualization of uterine structures was used. However, it has a
very slow absorption rate and persists in the body cavities for an
extended time. It also introduces the risk that an oil embolus that
could reach the lungs may form.
The amount of contrast medium to be introduced into the
reproductive tract is variable, depending on radiologist
preference. On average, approximately 5 ml is necessary to fill
the uterine cavity, and an additional 5 ml is needed to
demonstrate uterine tube patency.
The operation is done in radiology department
and without anaesthesia.
Patient is to empty her bladder.
She is placed in dorsal position with the
buttocks on the edge.
Internal examination is done.
Posterior vaginal speculum is introduced; the
anterior lip of the cervix is held by allis forceps
and an uterine sound is passed.
57. Hysterosalpingographic cannula is fitted with a
syringe containing radio-opaque dye- either water
soluble contrast medium, meglumine diatrizoate
(Renografin 60) or a low viscosity oil based dye,
ethiodized oil (Ethidol). The dye is introduced
slowly. About 5-10 ml of the solution is introduced.
The passage of the dye into the interior may be
observed by using a x-ray image intensifier and a
video display unit.
The speculum and the allis forceps are removed but
not the cannula.
2 radiographic views are taken.the first one to show
the filling of uterine cavity and the other at the
completion of the procedure(after10-15 mins)
showing tubal findings. The tubal patency is
evidenced by peritoneal spillage.
Apart from the inherent complications of the
uterine sound(uterine perforation)
haemorrhage, HSG has got the following
Peritoneal irritation and pelvic pain
Intravasation of dye within the venous or
lymphatic channels(common in tubercular
Flaring up of pelvic infection(1-3%).
59. CONTRAINDICATIONS TO
Women known to have hydrosalpinges
Presence of adnexal mass(PID).
Pelvic tenderness on bimanual examination
60. ENDOMETRIAL BIOPSY
The endometrial biopsy is
a medical procedure that
involves taking a tissue
sample of the lining of the
uterus. The tissue
evaluation which aids the
physician in forming a
61. Abnormal uterine
Evaluation of patient
with one year of
(combined with US
and neg HCG).
Abnormal Pap smear
with atypical cells
Cancer screening (e.g.,
found on US
Acute cervical or vaginal infections
Non-sterile Tray (Examination for Uterine
Absorbent pad to place beneath the patient on
the examination table
Formalin container (for endometrial sample) with
the patient's name and the date recorded on the
20 percent benzocaine (Hurricaine) spray with the
extended application nozzle *
64. Sterile Tray for the Procedure
Sterile vaginal speculum
Sterile metal basin containing sterile cotton balls
soaked in povidone-iodine solution
Endometrial suction catheter
Ring forceps (for wiping the cervix with the
Sterile 4 x 4 gauze (to wipe off gloves or
The patient is asked to lie on the table with her feet in the
stirrups for a pelvic examination. She may or may not be
given localized anesthesia.
A speculum will be inserted into the vagina to spread the
walls of the vagina apart to expose the cervix.The cervix
will then be cleansed with an antiseptic solution.
A tenaculum, a type of forceps, will hold the cervix steady
for the biopsy.
The biopsy curette will be inserted into the uterine fundus
and with a scraping and rotating motion some tissue will
The removed tissue will be placed in formalin or equivalent
The tissue will be sent to a laboratory, where it will be
processed and tested. It will then be read microscopically
by a pathologist who will provide a histologic diagnosis.
66. Endometrial suction
(A) The catheter tip is
inserted into the uterus
fundus or until resistance is
(B) Once the catheter is in
the uterus cavity, the
internal piston is fully
(C) A 360-degree twisting
motion is used as the
catheter is moved between
the uterus fundus and the
67. CERVICAL BIOPSY
A cervical biopsy is the removal of tissue
from the cervix, the lower third of the uterus
to be analyzed for cellular abnormalities,
precancerous conditions, or cervical cancer.
The cervix is a canal from the uterus into
the vagina, which leads to the outside of the
68. TYPES OF CERVICAL BIOPSYThere are several types of cervical biopsies. In addition to removing
tissue for testing, some of these procedures may be used to
completely remove areas of abnormal tissue and may also be used
for treatment of precancerous lesions.
Types of cervical biopsies include:
Punch Biopsy: A surgical procedure to remove a small piece of
tissue from the cervix. One or more punch biopsies may be
performed on different areas of the cervix.
Cone Biopsy or Conization: A surgical procedure that uses a laser or
scalpel to remove a large cone-shaped piece of tissue from the
Endocervical Curettage (ECC): A surgical procedure in which a narrow
instrument called a curette is used to scrape the lining of the
endocervical canal, an area that cannot be seen from the outside of
69. CONE BIOPSY (CONISATION)
Conisation is done as diagnostic and therapeutic
purpose in CIN. Cases of CIN suitable for
1.Unsatisfactory colposcopic findings. The entire
margins of the lesion are not visualised.
2.Inconsistent findings-colpascopic, cytology ,and
3.When biopsy cannot rule out invasive cancer from
CIS or microinvasion.
4.Positive endocervical curettage.
70. PRINCIPLE STEPS(COLD
The operation is done under general anaesthesia.
Blood loss is minimised with prior haemostatic
sutures at 3 and 9o’clock positions on the cervix by
lighting descending cervical branches.
The cone is cut so as to keep the apex below the
After the cone is removed, a margin suture is
placed at 12 0’clock position for identification of
Routine endocervical curette above the apex of the
cone is performed and uterine curettage is done,if
71. Cone margins are repaired by haemostatic
The excised cervical tissue is sent for
histological examination. If the margins of cone
are involved in neoplasia ,hysterectomy should
be seriously considered either within 48 hrs or
at a later date to prevent infection.
Cervical stenosis leading to haematometra
Diminished cervical mucuc
Cervical incompetence leadind to adverse
Midtrimester abortion or preterm labour.
Culdocentesis is the transvaginal aspiration of
peritoneal fluid from the cul-de-sac or pouch of
1.In suspected disturbed ectopic pregnancy or
other causes producing haemoperitoneum
2.In suspected cases of pelvic abscess.
The procedure is done under sedation.
The patient is put in lithotomy position.
Vagina is cleaned with Betadine.
A posteror vaginal speculum is inserted.
A 18 gauge spinal needle fitted with a syringe is
inserted at point 1cm below the cervicovaginal
junction in the posterior fornix.
After inserting the needle to a depth of about
2cm,suction is applied as the needle is is
If unclotted blood is obtained,the diagnosis of
intraperitoneal bleeding is established.
75. Endoscopy in obstetrics and
gynaecology has many branches:
It is a technique which allows viewing (Diagnostic)
and surgical maneuvers (Therapeutic) to be
performed in abdominal organs through a surgical
incision of < 1cm with help of pneumoperitoneum
1. Verres needle:
used to inflate air to
the peritoneal cavity
there is the thinnest
79. 2. Electronic laparoflator:
Used to insufflate through the verres needle.
Maintains constant intra-abdominal pressure without
exceeding the safety limit.
Some types have heating system to prevent lowering the
patient body temperature.
80. 3. Trocars:
Permit access to the
intraperitoneal cavity in
which other instruments
The trocar used should
be adapted to the
diameter of the telescope
81. 4. Telescope:
There are different sizes each with a
They are used to visualize the
82. 5. Camera
6. Light source.
83. 7. Forceps and scissors
There are two types:
They can be either
8. Bipolar elecrtosurgey.
9. Unipolar electrosurgery.
11. Ultrasound system.
12. Suction and irrigation system.
14. Laparoscopic bag.
15. Tissue morcellator: used to
remove large specimens like myomas
or an entire uterus in small pieces.
16. Uterine manipulator: used to
mobilize or stabilize the uterus and
1. Preparation of the patient:
Inform the patient about the
therapeutic benefits and
potential risks (informed
Intestinal preparation: Simple
intestinal emptying, for better
viewing and preventing
Place the patient in the
86. 2. Creation of pneumoperitoneum:
a. The abdominal wall is lifted by hand or by grasping forceps
b. Pnemoperitoneum is created by verres needle introduced
to the umbilical area (less subcutaneous and preperitoneul
c. The needle is inserted in an oblique angle toward the
d. The negative pressure will allow the underlying structures
to fall away.
e. After making sure that the needle is in correct position, air
flow can be increased to 2.5 liters per minute till a pressure
87. 3. Trocar introduction
a. Once the intra-
reaches 15 mmHg the
main trocar is
removal of veress
b. The position of the
trocar must be verified
by inserting the
viewing the pelvic
88. 4. Viewing the peritoneal cavity:
A. The omentum, bowel and bifurcation of pelvic vessels should
be evaluated to avoid injuries caused during the introduction
of Verres needle or trocar.
B. The site of introduction of other
trocars should be verified by finger
palpation and transillumination of
abdominal wall to avoid injury to
C. Identify if there is any bleeding
89. After the procedure
CO2 gas must be
to reduce post-operative
In operative procedures:
- 1 or 2 bottles of Ringer’s
lactate are used to wash
the peritoneal cavity after
- Leave 500/1000 cc of
ringer’s lactate to reduce
the incidence of post
Used as a diagnostic tool
Infertility: status of the fallopian
tube (morphology and
functionality) and any
pathological condition e.g.
Ovarian cysts or tumors.
PID: tubal abscess or adhesions.
Endometriosis: define the sites
of implants and endometrial
91. As a therapeutic tool
- Management of ovarian cyst by:
- Ovarian cystectomy.
- Ovarian drilling of the cortex and
stroma to decrease androgens in the ovaries
- Correcting ovarian torsion.
- As a treatment of endometriosis
- By removal of the endometrial
cauterization of endometrial spots
93. Management of infertility:
- Treat the cause
Myomectomy for fibroids: used for
subserosal and intramural fibroids
only, not used for submucosal
Management of PID: by draining
tubal abscess and adhesiolysis.
94. MANAGEMENT OF ECTOPIC
Used to preserve the
tubes for desired
Done if the patient is
If size < 5 cm
Location must be
Contralateral tube either
normal or absent.
1. Generalized peritonitis
2. Hypovolemic shock
3. Severe cardiac disease
4. Hemoglobin less than 7
5. Uterine size > 12 wks.
6. Multiple previous
7. Extreme body weight
- Extraperitonel emphysema due to failure of
introducing verres needle correctly into the
peritoneal cavity and not checking the negative
pressure on the machine.
- Gas may extend to the mediastinum and
compromise cardiac function
- Pneumoomentum: and put the patient on the
- Injury to abdominal organs
- GI: if the intestine is distended or adherent to
the abdominal wall (prevented by good
intestinal preparation) and putting the patient
on the telendelenburg position.
- Bladder injury: prevented by emptying the
It is a technique which allows viewing and
surgical maneuvers to be performed in the
It has many advantages that made it wide
spread and fundamental diagnostic method in
daily gynecological practice
media of the
2. Light source.
source gives the
101. 3. Camera Equipment
flexible: high cost and
fragile cannot be
rigid: gives different
direction of the view.-
0°, 12°, 30° (bes for
102. 5. Hysteroscope:
There are 2 types of hysteroscopes:
1. Preparation of the patient:
Detailed history and complete physical examination
It is preferable to do the procedure in the first part of the
menstrual cycle, because there is less mucus (better
viewing) and no chance of encountering early pregnancy
Patient is placed in lithotomy position
Accurate bimanual examination to asses the uterine
(position, morphology, volume).
Clean cervix with antiseptics
Cervical forceps is placed on the front labia
Light source & CO2 gas supply are connected to
Insert hysteroscope into the cervical canal, which
dilates from the gas pressure.
Used as a diagnostic tool:
- Abnormal uterine bleeding caused by:
- submucous and intramural myoma.
- endometrial polyps.
- endometrial atrophy.
- Endometrial tumors.
- Infertility related to:
- Intrauterine adhesions (Asherman’s
- Submucous fibroids.
- Endometrial polyps.
- Uterine malformation (it cannot differentiate
between sepatate and bicorneate uterus)<- this
can be done by laparoscopy
106. Used as a therapeutic tool
Endometrial ablation (using laser):
Abnormal uterine bleeding but we should role out
cancerous or pre cancerous cause of bleeding.
Also used in patients with high risk for hysterectomy or
the patient does not want to do the
surgery.steroscopic Surgeries and Correct
uterine malformation like septate uterus by
resection of the septum. (bicorneate uterus is
corrected by laparotomy using metroplasty).
Myomectomy: The main indication for
hysteroscopic myomectomy is AUB caused by
submucous myomas in infertile patients
107. Uterine anomaly
108. Intrauterine Adhesions
109. Endometrial carcinoma
Current or recent pelvic infection.
Current vaginitis, cervicitis and
Recent uterine perforation.
- Distension media:
- Fluid overload
pulmonary oedema, cerebral oedema
- Intraoperative complications:
- Uterine perforation (<1%)
- Hemorrhage either from:
- Tenaculum used to hold the cervix.
- Thermal damage.
– Evaluation of CIN
– Biopsy target
– Vaginal and vulval examination
– DES exposure
– Acetic acid
– Schiller’s iodine
– Outpatient treatment of CIN e.g. Laser
In salpingoscopy, a firm telescope is inserted
through the abdominal ostium of the uterine
tube so that the tubal mucosa can be visualised
by distending the lumen with saline infusion.
The telescope is to be introduced through
Salpingoscopy allows study of the physiology
and anatomy of the tubal epithelium and
permits more accurate selection of patients for
IVF rather than tubal surgery.
Shaw’s textbook of gynaecology(15th edition)
Textbook of gynaecology –by D.C DUTTA (5th
Jasleen kaur luthra
NHMC, New Delhi.