A Guide to the Clinical Gynecological Exam as Instructed by a Female Guiding Patient

A Guide to the GYN Exam
CLINICAL SKILLS USA, Inc.
www.clinicalskillsusa.com
A Guide to the
Clinical Gynecological Examination
Instructed by a Female Guiding Patient
Developed by:
Cheryl Eden, Petra Ehlert, Joy Lynne Erickson,
Scott George, Myranda Stephens and Aimee Yap

provides trained instructors as
Gynecological Teaching
Associates
and
Male Urogenital Teaching
Associates,
who share their own bodies for
the clinical instruction of the
female breast and pelvic, and the
male urogenital and rectal exams.
Serving medical and nursing
schools throughout the U.S.

2011 © Clinical Skills USA
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♀ To teach competence in clinical pelvic and breast exam technique.
♀ To advance familiarity with female gynecologic anatomy.
♀ To enhance proper communication techniques, supporting patient
self-disclosure and promoting patient education.
♀ To improve competence in reducing patient anxiety and
minimizing patient discomfort through the the application of
“patient-centered” clinical skills and “patient empowerment”.
♀ To facilitate effective learning of exam skills by reducing student
anxiety associated with these intimate and invasive procedures.
GYN Exam Instructional Objectives

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Why pelvic exams?
♀ To evaluate the size and position of the vagina, cervix, uterus,
fallopian tubes, and ovaries.
♀ Preventive health care for all adult women (early detection of
cancers, infections, STD’s, or other reproductive system
problems)
♀ May be conducted before prescribing a method of birth control,
depending on the age of the client, or type of method desired.
Introducing the GYN exam

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When should the clinical pelvic exam be performed?
♀ ACOG guidelines recommend that a pelvic examination be performed on an
annual basis in all patients aged 21 years and older,
♀ No evidence supports or refutes the annual pelvic examination for the
asymptomatic, low-risk patient. “An annual pelvic examination seems logical”.
♀ The decision whether or not to perform a complete pelvic examination at the
time of the periodic health examination for the asymptomatic patient should
be a shared decision after a discussion between the patient and her health
care provider.
Frequency of Pelvic and Breast Exams
Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2012;120:421–4

ACOG and ACS Guidelines On Breast Cancer
Screening (Low Risk for Br CA)
♀ ACOG: Clinical breast exam (CBE) for women
20-39 years of age every 1-3 yrs.
> 40 years of age annually
♀ ACOG: Women aged > 40 years, offer screening mammogram
annually.
♀ ACS: Does not recommend CBE for breast cancer screening
among average-risk women at any age.
Mammography annually starting at age 45 yrs.

Educate about Breast Self-Awareness
ACOG and ACS recommend the teaching of breast
self-awareness and inquiry into the medical and family
history of risk factors for breast disease.
“Breast self-awareness educates patients about the
normal feel and appearance of their breasts. For
many patients, breast self-awareness also may
include performing breast self-examinations. Both
modalities have the potential to alert the patient to
changes in her breast that should be reported
immediately to her physician and may lead to
earlier detection of breast cancer”.
Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2012;120:421–4

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Patient Anxiety
“Many women suffer tremendous anxiety about their annual gynecological exam.
The anxiety is preventing women from receiving the best care possible, and
many women who seek care regularly are not pleased with their visits”.
Marifran Mattson, Associate Professor of Health Communications at Purdue University
Reasons women gave for their fear and anxiety about their annual
gynecological exams:
♀ Feelings of discomfort
♀ Embarrassment
♀ Personal intrusion
♀ Fear of finding a problem (e.g., cancer)

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Preparing the patient for the exam
Before the exam commences:
♀ Conduct reproductive and sexual history.
♀ Ask patient about past experience with the exam (if any). Address any anxiety.
♀ Explain importance of Pap smears and mammograms, the procedures, and the frequency of the procedures.
♀ Describe basic female reproductive anatomy.
♀ Explain medical jargon that you may be using, such as “palpate”.
♀ Provide preliminary information about the exam procedures. Explain what you’ll be doing, why, and how much time
it should take.
♀ Reassure the patient that they will feel “pressure” (not “discomfort”) during the exam, “It should not be painful.
But, please let me know if you do feel any discomfort.”
♀ Demystify the speculum by demonstrating what it’s for and how it works. Forewarn her of the “clicking” sound
(with the plastic speculum).
♀ Inform the patient that she may ask to have the exam stopped at any time.
♀ Invite questions at any time.

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Reproductive and Sexual History
Ask the patient:
♀ Reason for their visit.
♀ Hx of last clinical exam, pap smear and mammogram. Results? Breast self-
exams?
♀ Hx of previous medical problems, or menstrual issues. Any abnormal pap
smears?
♀ Vaccinations? (e.g., HPV)
♀ Menstrual history. Age of menarche. Timing and frequency of menstrual cycles.
Last cycle. Extent of flow (number of pads/tampons). Cramping or any other
unusual characteristics associated with menstruation.
♀ G= Gravida means # of Pregnancies, P= Parity means # of deliveries > 20 weeks,
Ptpal (T=term,preterm, spontaneous and elective abortions/living children)

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Ask the patient:
♀ Are you sexually active?
♀ Age of first sexual intercourse.
♀ Type of sexual activity. Vaginal, anal, and/or oral?
♀ Sexual partners. Male, Female, or both?
♀ Frequency of sexual activity. Most recent sexual encounter.
♀ Number of sexual partners.
♀ Type of birth control and protection methods, if any
(e.g. contraceptives, condoms, spermicidals) Frequency of use.
♀ History of STDs/STIs. (Such as: Chlamydia, syphilis, genital warts, herpes,
gonorrhea, HPV on pap or HIV)
Reproductive and Sexual History

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Proper communication during the GYN exam
Patients will nearly always attach the most painful possible meaning to medical jargon, if
they do not know the term e.g. “palpate” sounds like “penetrate”.
♀ You should ask the patient to “roll her knees out to the side,” NOT “spread your
legs”.
♀ Feet should be placed into “foot rests”, NOT “stirrups.”
♀ Refer to parts of the speculum as “bills” or “sides” , NOT “blades.”
♀ Describe the “folds” of the labia, NOT the “lips”.
♀ Avoid using medical jargon by “pressing” or “rolling fingertips gently”, NOT
“palpate”.
♀ You should describe findings as “normal”, “regular” or “healthy”, NOT “everything
looks great” or “you look good.”
Choose words carefully to avoid sexual connotations
or heightening patient anxiety:

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Proper “patient-centered” care
♀ Ask about patient comfort at the outset of the exam and periodically
thereafter. Adjust the exam table angle to their preference, and make
additional pillows available if desired by the patient.
♀ Provide padding for the patient’s feet in the “foot rests”, and assist in
placing their feet into the foot rests.
♀ Invite the patient to observe the exam with use of a hand-held mirror.
♀ Visibly warm the speculum (metal) under warm water.
♀ Ask patient periodically about comfort, and remind them to inform you
of any unexpected pain or discomfort during the exam.

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Eye Contact and Proper Draping
♀ Use direct eye contact when addressing the patient before
and after the exam, and regularly during the exam to assess
nonverbal reactions.
Be sensitive to issues of modesty and vulnerability:
♀ Use proper draping
technique with minimal
exposure. Expose only the
areas being immediately
examined, e.g., only one
breast exposed at a time
during palpation.

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♀ First screening mammogram for average risk patients at
age 40 per ACOG / at age 45 per ACS.
♀ After age 40, yearly mammograms thereafter per ACOG.
♀ Per ACS at age 55, mammogram every 2 years instead of annually.
The Mammogram

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Breast cancer rate of occurrence by site
UOQ
UIQ
LOQ
LIQ
Areola
Breast Cancer Statistics

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Female Breast Anatomy

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Step I: Conduct palpation of head, neck and axillary areas as patient sits
upright eg. tonsillar, cervical, infra- and supra-clavicular, and
axillary areas
Step II: Observe both breasts in multiple positions as patient sits upright.
Conduct bi-manual exam of breast tissue for larger breasted women.
Step III: Conduct palpation of the breast tissue, axillary regions and areolas,
with patient in supine position.
Steps of the Breast Exam

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Step I:
♀ While the patient is sitting upright, palpate for lymph nodes in the
tonsillary, cervical, infra- and supra-clavicular areas. Examine for
enlarged nodes or masses.
Steps of the Breast Exam- head and neck palpation

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♀ While the patient is sitting upright, palpate
both axillary areas, “Tail of Spence”.
♀ Palpate using middle three fingers while
pressing downward with a continuous
circular motion. Apply steady pressure,
palpating to 3 levels of depth—
superficial, medium, deep.
♀ Examine for enlarged nodes or masses.
Step I:
Steps of the Breast Exam-axillary palpation

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Mammary & Axillary Lymph Nodes

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Steps of the breast exam- inspection
Step II:
♀ Initially observe both breasts as patient sits up and
then leans forward. Examine symmetry and other
surface abnormalities.
♀ Look for: tenderness, lumps, skin dimpling,
retractions, changes in skin color or texture
“orangue”, breast size, nipple changes or
discharge.
♀ While observing, have the patient sit with arms to
her sides, hands on hips with shoulders flexed,
leaning forward, and arms raised above her head.
♀ You should use direct eye contact when addressing
the patient before and after the exam, and
regularly during the exam.

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Arms at side Arms raised Hands on hips with
Initially inspect each breast while the patient is sitting:
shoulders flexed

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♀ Inspect underside of each breast ♀ Palpate with both hands
Inspect each breast for larger breasted women:

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Tanner Stage Characteristics
I Prepubertal; elevation of the papilla only
II Breast buds are noted or palpable, with enlargement
of the areola (age 9-13)
III Further enlargement of the breast and areola, with no
separation of their contours (age 10-14)
IV Projection of areola and papilla to form a secondary
mound above the level of the breast (age 11-15)
V Adult contour breast with projection of papilla only (age 12-17)
Assess Adolescent Development
-Tanner Stages-

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Breast examination patterns
3 methods for systematic examination of the breast:
Vertical Strips Pattern Radial Spoke Pattern Circular Pattern
Steps of the breast exam- palpation

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Step III:
♀ While the patient is lying supine, palpate for lymph nodes and other masses in
each of the axillary areas, breasts, areolas, nipples, and upper chest.

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♀ Use the pads of the middle 3 fingers of
one hand.
♀ Press downward using a circular
motion.
♀ Apply steady pressure, pushing down
to the level of the chest wall.
♀ Apply enough pressure to palpate to
3 levels of depth:
- Superficial
- Medium
- Deep (to the level of the chest wall)
Palpation technique

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o Vulva
o Mons Pubis
o Labia Majora & Minora
o Introitus
o Urethral Meatus
o Clitoris
o Perineum
o Anus
o Mons Pubis
o Groin-Lymph Nodes
o Bartholins Glands
o Skenes Glands
o Cervix & Os o Vaginal Walls o Cystocele & Rectocele
o Cervix o Uterus o Ovaries
o Bi-manual exam + Rectal exam
Steps of the Pelvic Exam
I: External inspection
II: External palpation
III: Internal inspection: Speculum
IV: Internal palpation: Bi-Manual
Recto-vaginal

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Proper exam supplies
♀ A tray of supplies and instruments
should be located within the your reach
(e.g. speculum, lubricant, Pap supplies, tissues)
♀ A speculum illuminator, or an adjustable
“gooseneck” lamp, may be used for lighting
during the exam.
♀ Gloves will be worn throughout the pelvic exam.
Not for breast exam.
♀ Ask about allergies to latex before using the
latex gloves.
♀ Change the gloves anytime that they become contaminated.

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Position the patient
♀ The patient is in a lithotomy position, supine with legs bent.
♀ Undergarments should be removed
and gown worn with opening in front.
♀ You should help the patient to place
her heels into the “foot rests”
(preferably padded).
♀ The table may be tilted up or left flat,
depending on the patient’s preference.
♀ Offer pillows if they are available.
♀ Ask the patient to slide “her “bottom” to front edge of the exam table.

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Position the patient- continued
♀ Ask the patient to slide her buttocks
(“bottom”) up against the back of your hand
at the front off-center edge of the exam
table. Adjust the pillow(s) accordingly.
♀ Instruct the patient to relax her legs and to
“roll your knees out to the side.”
♀ For the pelvic exam, You should sit on an
adjustable stool between the patient’s
suspended legs, though you may need to
stand for some portions of the procedure.
♀ You should always be in a position that
allows you to monitor the patient’s facial
expressions--never blocked from view.

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Proper Draping
Be sensitive to issues of modesty and vulnerability
♀ During the pelvic exam you should drape your patient
appropriately with a clean cloth or paper drape.
♀ Roll the center of the drape toward the patient,
exposing only the physical area to be examined. Hand
the rolled drape over to the patient to hold.
♀ The drape should be extended over the thighs and
knees, leaving the calves and inner thighs exposed.
♀ Pull drape lower between the knees to aid eye contact.
♀ Ask if your patient would prefer to observe the exam
with a mirror, if so, place the drape so that it does not
obscure her view.

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♀ Always forewarn the patient before making initial physical contact
on a neutral area, such as the inner thigh. Thereafter, your hands
should only make “firm” contact with areas being palpated.
Pelvic Exam Step I: Conduct external inspection and palpation

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Stage I
Pubic hair is very fine.
(pre-pubertal)
Stage II
First signs of pubic hair
Growth
(age 9-13)
Stage III
Pubic hair becoming
thicker and darker
(age 10-14)
Stage IV
Pubic hair becoming
thicker and begins to
form the pubic triangle
(age 11-15)
Stage V
Pubic hair growth completes final
stage. Adult pubic hair is thick
and the pubic triangle is easily
recognized.
(age 12- 17)
♀ Assess Adolescent Development - Tanner Stages

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♀ Separate the labia and inspect
the labia minora, urethral meatus,
clitoris, and vaginal introitus.
♀ Visually inspect the mons
pubis, groin, vulva, perineum,
and anus.

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External Pelvic Anatomy-Vulva

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♀ Palpate Bartholin’s & Skene’s Glands

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♀ Palpate the Bartholin’s glands by inserting index finger into vagina
near the posterior end of the introitus. Then pressing firmly between
the thumb, make a “U”-shaped continuous palpation of the posterior
end of the vagina. Examine for swelling and tenderness.

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Inspect for Cystocele and Rectocele
StepI:Conductexternalinspectionandpalpation-continued
♀ Insert index and middle finger and
press downward on peritoneal floor.
Ask patient to strain.
♀ Insert index and middle finger
and press upward against anterior
vaginal wall. Ask patient to strain.

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1. Insertion: Hold the speculum (sized correctly for the woman) at a 45
degree angle. Open labia with opposite hand (1 or 2 fingers) and
introduce speculum into vagina away from urethral meatus. Point the
tip toward the posterior fornix.

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2. Insertion: Slide bills of the speculum gently and slowly along the
posterior vaginal wall, pointing downward while depressing the
perineal body and rotating at full insertion so that the handle is
vertical.

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5. Visually inspect the cervix, os and vaginal walls. Note:
♀ Position- anteverted, retroverted, etc.
The position of the cervix offers a clue to the position of the uterus.
♀ Color- should be flesh-colored, ranging from pink to dark brown.
Blue or pale color may be symptomatic.
♀ Size and shape of os
♀ Cysts, polyps, erythema
bleeding, discharge

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♀ Palpate the cervix.
♀ Palpate the uterine body between
vaginal and abdominal hands.
♀ Attempt to palpate the ovaries with
hand on lower abdomen, while
vaginal hand pushes upward.
♀ Palpate for masses or tenderness.

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♀ Conducted to help evaluate
the posterior aspect of the
uterus
(especially if retroverted)
♀ Allows exam of rectal walls
and fecal specimen(initial
screen for colorectal cancer
or benign polyps)
Recto-Vaginal Exam & DRE

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Proper Digital Insertion and Exam:
1) Place pad of the middle finger (“anal finger”) on the anus at 45-degree angle.
2) Wait for the sphincter to relax (3 second minimum).
3) Roll the anal finger into rectum slowly while inserting the index finger into the vagina.
4) Palpate the septum between the two inserted fingers.
5) Conduct bi-manual exam. Palpation of cervix, uterus and adnexa.
6) Perform 360-degree sweep of rectum. Examine for masses present on rectal walls.
45-degree angle
Recto-Vaginal Exam & DRE

GYN Exam Documentation
Subjective: What the patient tells you.
Genitourinary: Dysuria, frequency, urgency, UTIs, hematuria, proteinuria, nocturia (>2), nephrolithiasis, incontinence (type).
Urethral d/c, Sexual: STIs (type, tx), # of partners in lifetime, risky sex, recent change in sexual partner(s); infertility.
Vaccinations against Hepatitis A&B, HPV.
Gynecologic Hx: Menarche (age); LMP, Menses: Interval (regular or irregular), duration, flow, pain, cramping, management;
(i.e., q 28 x 5, heavy flow x 2, severe cramping/NSAIDs); last gyn exam/cytology (pap) results and HPV test results, any
abnormal results/treatments, contraceptive hx; gyn diagnoses, gyn surgery, cysto/rectocele, STIs (type/tx); vaginitis (type/tx),
menopause; dyspareunia, ability to achieve orgasm,
OB Hx: Gravida//Parity/Abortions [elective, spontaneous]/# living children; pregnancy complication (C-sections, preterm labor,
GDM, PIH). List each pregnancy and outcome; gestational age of each infant, birth weight, type of delivery (vaginal vs. C-
section [indication for]); postpartum complications (eclampsia, hemorrhage); plans for future pregnancies.
Objective: Documentation of Examination Findings
Genitourinary/Pelvic Exam: Vulvar hair distribution, nits, labial lesions, swelling; urethral lesions or d/c. Skenes, Bartholin’s
glands, vaginal introitus: lesions or d/c (cystocele, rectocele), trauma. Per speculum exam: vagina (color, rugae, atrophy),
masses, lesions, d/c; Cervix (Cx) nulliparous/parous/ stenotic os, size, inflammations, lesions, erosions or d/c, bleeding,
ectropion, (IUD string present); Per bimanual exam: Uterus position, size, shape, contour, consistency, mobility, cervical
motion tenderness (CMT), ovarian /adnexal enlargement, masses, tenderness
Breast: dimpling, nipple retraction, lesions, symmetry/uniformity, nipple discharge, masses, tenderness, lymphatic adenopathy
Rectal: Masses, fistulas, fissures or gross blood (hemorrhoids, skin tags), masses, lesions, trauma, tenderness, rectocele,
sphincter tone. Stool color and consistency, guaiac +/-.

A Guide to the Clinical Gynecological Exam as Instructed by a Female Guiding Patient

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