ivestigation in gyno pt

1. THE METHODS OF
MEDICAL
INVESTIGATIONS IN A
GYNECOLOGICAL
PATIENT

2. Intoduction
 The health care of women encompasses all aspects of medical science and
therapeutics.
 The special medical needs and concerns of women vary with the
patient's age, reproductive status, and desire to reproduce.
 For the proper evaluation, diagnosis and treatment of a gynecological
patient, it is necessary for the physician to use variety of methods of
medical investigation.
The foremost step in investigation of a gynecological patient is to get a
proper history, which in most of the cases helps to make a differential
diagnosis and indicates which medical investigation should be done for
making an accurate diagnosis.

3. Patient History
The patient history should include general information about the patient
and her goals in seeking care. The history of the present problem, past medical
history, family history, medications used, allergies, social history, and review
of systems should be concise but thorough.
The developmental history, menstrual history, sexual history, and obstetric
history obviously assume central importance for the gynecologic or obstetric
visit.
One should avoid cutting off the patient's story, because doing so may
obscure important clues or other problems that may have contributed to the
reasons for the visit.

4. The following outline can be used in obtaining a history from a gynecological
patient:
Identifying data:
Age : The problems and the approach to them vary at different stages in a woman's
life (pubescence, adolescence, childbearing years, and premenopausal and
postmenopausal years).
Last Normal Menstrual Period : A missed period, irregularity of periods, erratic
bleeding, or other abnormalities may all imply certain events that are more easily
diagnosed when the date of onset of the LNMP is established.
Gravidity and Parity : A convenient symbol for recording the reproductive history is
a 4-digit code denoting the number of term pregnancies, premature deliveries,
abortions, and living children (TPAL).
Chief Complaints:
The chief complaint usually is best elicited by asking "What kind of problem are you
having?" or "How can I help you?"

5. Present Illness:
Each of the problems the patient describes must be obtained in detail,
what exactly the problem is, where exactly the problem is occurring, the date and time
of onset, whether the symptoms are abating or getting worse, the duration of the
symptoms when they do occur, and how these symptoms are related to or influence
other events in her life.
Past History:
About Contaception, medications and habits, previous medical or
surgical histories, allergies, obstetrics, gynecological, sexual and social
histories.
Family History:
Health state of immediate relatives, familial heart disease, hypertension,
diabetes, breast or ovarian or other cancers, genetic illnesses.

6. Physical Examination
 The physical examination is most useful if it is conducted in an
environment that is aesthetically pleasing to the patient.
A physician may have a female assistant remain in the examining room to
assist when necessary.
It is highly recommended that the physician explain the steps and acts
that will be taken, especially during the pelvic examination.
General Examination: Vital Signs, Weight, Height, heart rate,
breathing, etc.
Abdominal Examination: Auscaltation, then palpation for any
tenderness or enlargement, Suprapubic palpation for identifying
Uterine, ovary or bladder enlargement. Then Percussion.

7. Pelvic Examination: The pubic hair should be inspected for folliculitis or pubic lice.
For dermatitis, glans clitoridis, and palpate the vestibular or bartholin’s glands for
enlargement. And for perianal lesions.
Vaginal Examination: The vagina and cervix can be inspected using the Speculum for
discharge, color, erosion and lesions.
Bimanual Examination: The uterus and adnexal structures should be outlined between
the 2 fingers of the hand in the vagina and the flat of the opposite hand, which is placed
upon the lower abdominal wall . Gentle palpation and manipulation of the structures
will delineate position, size, shape, mobility, consistency, and tenderness of the pelvic
structures.
Rectovaginal Examination: Should always be performed, especially after age 40 years,
after Bimanual Exam. The well-lubricated middle finger of the examining hand should
be inserted gently into the rectum to feel for tenderness, masses, or irregularities. if the
finger in the rectum can palpate tender nodules along the uterosacral ligaments—
endometriosis may be present.

8. Bimanual Examination
Rectovaginal Examination

9. Diagnostic Office Procedures
Test for Vaginal Infection:
If abnormal vaginal discharge is present, a sample of vaginal discharge should be
scrutinized. The vaginal discharge can also be tested for the vaginal pH. An acidic pH
of 4–5 is consistent with fungal infection, whereas an alkaline pH of 5.5–7 suggests
infections such as bacterial vaginosis and Trichomonas.
Saline (Plain Slide) : the physician mixes on a slide 1 drop of vaginal discharge with 1
drop of normal saline warmed to approximately body temperature. The slide should
have a coverslip. If the smear is examined while it is still warm, actively motile
trichomonads usually can be seen. Also can be used to see mycelia of the fungus
Candida albicans, which appear as segmented and branching filaments and bacterial
vaginosis by looking for "clue cells," epithelial cells covered from edge to edge by short
coccobacilli-type bacteria.
Potassium Hydroxide : to the slide add 1 drop of Potassium Hydroxide. Visualization
of the mycelia of a fungus causing vaginal infection, if the discharge has a "fishy" odor
is strongly suggestive of bacterial vaginosis,

10. Fern Test for Ovulation
The fern test can determine the presence or absence of ovulation or the time of
ovulation.
When cervical mucus is spread upon a clean, dry slide and allowed to dry in air, it
may or may not assume a frond like pattern when viewed under the microscope.
The fern frond pattern indicates an estrogenic effect on the mucus without the
influence of progesterone; thus, a non-frondlike pattern can be interpreted as showing
that ovulation has occurred.

11. Schiller or Acetic acid Test for Neoplasia
 Although colposcopy is more accurate, the Schiller or Acetic acid test can be performed
when cancer or precancerous changes of the cervix or vaginal mucosa are suspected.
The suspect area is painted with Lugol's (strong iodine) solution or Acetic acid, interacts
and marks the glycogen-rich epithelial cells of the cervix. Any portion of the epithelium
that does not accept the dye is abnormal because of the presence of scar tissue, neoplasia
and precursors, and columnar epithelium.
 Biopsy of samples taken from this area should be performed if there is any suspicion of
cancer.
Acetic Acid Staining Iodine Staining

12. Biopsy
Vulva and Vagina: A 1–2% aqueous solution of a standard local anesthetic solution
can be injected around a small suspicious area and a sample obtained with a skin punch
or sharp scalpel. Bleeding usually can be controlled by pressure or by Monsel's solution,
but occasionally suturing is necessary.
Cervix: Colposcopically directed biopsy is the method of choice for the diagnosis of
cervical lesions, either suspected on visualization or indicated after an abnormal Pap
smear. Colposcopically directed biopsy is the method of choice for the diagnosis of cervical
lesions, either suspected on visualization or indicated after an abnormal Pap smear. A "4-
quadrant" biopsy sample can be taken at 12, 3, 6, and 9 o'clock positions if colposcopy is
not available. A Schiller test often may more quickly direct the physician to the area that
should be biopsied.
 Endometrium: helpful in the diagnosis of ovarian dysfunction(Infertility), irregular
uterine bleeding, test for carcinoma of the uterine corpus. Performed with flexible
disposable cannulas, such as the Pipelle. The procedure causes cramping, advised to take
a pain medication such as ibuprofen 1 hour prior to the procedure

13. Diagnostic Laboratory Procedures
 Routine procedures : CBC Panel, Glucose Screening, Lipid Profile, Urinalysis, Thyroid
Panel.
Cultures: Urine culture for UTIs, Urethral and Cervical for STD infections, Vaginal.
Specific Tests: Herpes Virus by culture, HPV and subtypes by PCR test, Chlamydia and
Gonnorrheal infection by Nucleic Acid amplification testing, HIV by blood test,
Other Specific Tests: May be indicated for some of the less common venereal diseases,
eg, lymphogranuloma venereum and hepatitis B and C. A screening test for streptococcus B
carrier is advocated at 35–37 weeks' gestation. A 1-step culture swab from the lower vagina,
followed by the anus, is recommended.
Pregnancy Test

14. Papanicolaou Smear of Cervix
 An important part of the gynecologic examination.
 For the average woman who has had 3 normal Pap smears, a Pap test
every 2 or 3 years is adequate.
Is a screening test only, positive tests are an indication for further
diagnostic procedures.
 Diagnosis of carcinoma of the cervix in approximately 95% of cases and
endometrial polyps, hyperplasia, and cancers in 50% of cases.
Alternatives to the traditional Pap smear are being evaluated in an
attempt to decrease the false-negative and false-positive Pap smear results.

15.  Technique of PAP smear:
 The patient should not have douched for at least 24 hours before the examination
and should not be menstruating.
The speculum is placed in the vagina after it has been lubricated with water only.
With the cervix exposed, a specially designed plastic or wooden spatula is applied to
the cervix and rotated 360 degrees to abrade the surface slightly and to pick up cells
from the squamocolumnar area of the cervical os.
Next, a cotton-tipped applicator or a small brush is inserted into the endocervix and
rotated 360 degrees.
These 2 specimens can be mixed or placed on the slide separately according to the
preference of the examiner.
A preservative is applied immediately to prevent air drying, which would compromise
the interpretation. The slide is sent to the laboratory.

16. Colposcopy
The colposcope is a binocular microscope used for direct visualization of the cervix.
Magnification as high as 60x is available, but the most popular instrument in clinical use
has 13.5x magnification.
Some colposcopes are equipped with a camera for single or serial photographic recording of
pathologic conditions.
The colposcopist is able to see areas of cellular dysplasia and vascular or tissue
abnormalities not visible otherwise, which makes possible the selection of areas most
propitious for biopsy.
Stains and other chemical agents are also used to improve visualization.
The colposcope has reduced the need to perform blind cervical biopsies .

17. A Colposcope
A Colposcopic image, cervix
stained with acetic acid.

18. Hysteroscopy
 Hysteroscopy is the visual examination of the uterine cavity through a fiberoptic
instrument, the hysteroscope.
 The uterine cavity is inflated with a solution such as saline, glycine, or dextran, or by
carbon dioxide insufflation.
 Intravenous sedation and paracervical block often are adequate for hysteroscopy .
 Applications include evaluation for abnormal uterine bleeding, resection of uterine
synechiae and septa, removal of polyps and intrauterine devices (IUDs), resection of
submucous myomas, and endometrial ablation. Failure of Hysterocopy due to cervical
stenosis, inadequate distention of the uterine cavity, bleeding, or excessive mucus secretion.
 Complications include perforation, bleeding, and infection. Perforation of the uterus
usually occurs at the fundus
Intravascular extravasation of fluid or gas from hysteroscopy often not significant, but
has been associated with severe consequences such as hyponatremia, air embolism, cerebral
edema, and even death.

19. A normal Uterus in Hysteroscopy Hysteroscopic view of a uterine
septum
Hysteroscopic view with Hysteroscopic view with

20. Culdocentesis
 The passage of a needle into the cul-de-sac—culdocentesis—in order to
obtain fluid from the pouch of Douglas.
 The type of fluid obtained indicates the type of intraperitoneal lesion.
Bloody - a ruptured ectopic pregnancy, Pus - Acute Salpingitis, or Ascitic
Fluid - Malignant cells in cancer.
Less performed due to improvement in Ultrasonography

21. Radiographic Diagnostic Procedures
 The "flat film" shows calcified lesions, teeth, or a ring of a dermoid cyst and
indicates other pelvic masses by shadows or displaced intestinal loops.
 Hysterography :
The uterine cavity and the lumens of the oviducts can be outlined by instillation of
contrast medium through the cervix, followed by fluoroscopic observations or film.
To diagnose tubal patency or occlusion, the medium is instilled through a cervical
cannula. Filling of the uterine cavity , spreading of the medium through the tubes are
watched via a fluoroscope, If no occlusion is present, the medium will reach the
fimbriated end of the tube and spill into the pelvis—evidence of tubal patency.
Reveals abnormality of the uterus like congenital malformation, submucous myomas, or
endometrial polyps.
Sonohysterography:
The uterine cavity is filled with fluid while ultrasound is used to delineate the
architecture of the endometrial cavity and detect a spillage through the fallopian tubes.
Easier to diagnose intrauterine abnormalities, such as polyps or fibroids, and tubal
patency.

22. Normal Hysterography on top.
Second image – a patient who
underwent bilateral salpingo-
oophorectomy.
Sonohysterography with a Polyp

23. Angiography:
Angiography is the use of radiographic contrast medium to visualize the blood vascular
system.
By demonstrating the vascular pattern of an area, tumors or other abnormalities can be
delineated.
Delineate continued bleeding from pelvic vessels postoperatively, to visualize bleeding
from infiltration by cancer in cancer patients, or to embolize the uterine arteries in order to
decrease acute bleeding and/or reduce the size of uterine myomas.
Computed Tomography:
Is a diagnostic imaging technique that provides high-resolution 2-dimensional images.
Contrast media used to outline the gastrointestinal and urinary systems helping to
differentiate these organ systems from the pelvic reproductive organs.
Most useful in accurately diagnosing retroperitoneal lymphadenopathy associated with
malignancies.
To determine the depth of myometrial invasion in endometrial carcinoma as well as
extrauterine spread.
For locating pelvic abscesses that cannot be located by ultrasonography.
Pelvic thrombophlebitis often can be diagnosed by CT scan and also common abnormalities
such as ovarian cysts and myomas are easily diagnosed.

24. CT scan of the pelvis showing
a large fibroid uterus with 3
calcified fibroids in the body
of the uterus Anteroposterior digital
subtraction pelvic angiogram,
arrows showing active hemorrhage

25. Magnetic Resonance Imaging
The technique is based on the body absorbing radio waves from the machine.
Advantages of MRI – uses nonionized radiation that has no adverse or harmful effects
on the body, ability to differentiate among various types of tissue, including inflammatory
masses, cancers, and abnormal tissue metabolism.
Disadvantages are mainly its high cost and its poor demonstration of calcifications.
Main use in gynecology is staging and follow-up of pelvic cancers.
Ultrasonography:
Ultrasonography is a simple and painless procedure, freedom from any radiation hazard.
Especially helpful in patients in whom an adequate pelvic examination may be difficult,
such as in children, virginal women, and uncooperative patients.
The abdominal scan is performed with bladder full, which elevates uterus out of pelvis.
Normal early pregnancy can be diagnosed, as can pathologic pregnancies such as
incomplete and missed abortions and hydatidiform moles.
Congenital malformations such as a bicornuate uterus or vaginal agenesis are sometimes
detected.
Useful in the diagnosis of pelvic masses. Myomas can be diagnosed without too much
difficulty , Ovarian cysts, Pelvic Abscesses, for visualizing ectopic pregnancies.

26. 14-year-old girl with ovarian
torsion. Axial T1 MRI
A Normal Ovary in
Ultrasonography
An Ultrasonography image with
Ovarian Teratoma

27. THANK YOU