This document discusses the principles of gynecological history taking and examination. It outlines common gynecological symptoms and the components of a gynecological exam, including inspection of external genitalia, speculum and bimanual pelvic exam. The goal is to understand symptoms, perform a tactful history and exam, and formulate a differential diagnosis. Key aspects of history taking include menstrual, obstetric, medical and family histories. The exam involves inspection of breasts and external genitalia, speculum exam of the cervix and vagina, and bimanual palpation of the uterus, ovaries and adnexa.

1. Gynecology History taking
Principles of history taking
and pelvic examination of a
gynecological case

2. Learning Objectives
•Understand the Symptoms
•Tactful history taking
•Doing a Pelvic Examination
•Reaching a differential diagnosis

3. Gynecology
• It is the specialized branch of medicine dealing with the health related issues of
the female reproductive system.

4. Organs involved
•Uterus
•Vagina
•Ovaries
•breasts

5. GYNECOLOGICAL SYMPTOMS

6. Gynaecological Symptoms
• Amenorrhea. (cessation of menses)
• Discharge per vagina
• Bleeding per vagina
• Dysmenorrhea.(pelvic pain)
• Vulval complaints.(swelling, ulcers, lesions, pain)
• Pain in the lower abdomen.
• Swelling.
• Something coming out per vagina. (prolapse).
• Urinary complaints( retention, incontinence)
• Inability to conceive. (sub-fertility

7. Gynaecological symptoms
Amenorrhea:
• Primary: failure to get menses up to age of 16yrs in the presence of
normal growth and Secondary sexual characters(SSC).
& up to age of 14yrs in the absence of SSC.
• Secondary: Failure to get menses after at least one menses (menarche)

8. Bleeding per vagina
• ORIGIN: Uterine, cervical or vaginal,
• CHARACTER:
1) Menorrhagia
2) Polymenorrhoea
3) Oligomenorrhoea
• Regular / irregular
• Contact bleed (PCB), Heavy menstrual bleeding, Intermenstrual
bleed

9. Dysmenorrhea
• Primary/secondary and
•Dyspareunia:
• Deep / superficial
Vulval complaints
• Swelling( Bartholins cyst), Infective lesions. ( ulcers, pustules, papules, rash)
Pruritus vulvae.
Vaginal Discharge:
• Infective or Malignant and pre malignant conditions

10. •Abdominal swelling: That typically seem to arise from the pelvis.
•Something coming out per vagina.
•Urinary complaints
•Dysuria, frequency, urgency,
•Incontinence: SUI, Urge incontinence, Mixed and
continuous

11. Inability to conceive ( sub-fertility )
PCOS will have its own array of symptoms.
Climacteric & Menopausal symptoms: flushing, palpitations, anxiety, lack of sleep.
Symptoms of Malignancy: And that depends upon the organs involved and the extent of
spread.
Intersexuality and congenital anomalies will present with its own array of symptoms

12. HISTORY TAKING

13. History taking Policies /Tact
• Patience: In patient’s own words. Can ask specific questions later.
• Gentleness Speak softly and firmly, look into the eyes of the patient, you get
many clues, like: Fear, sadness, or anger
• Privacy and Confidentiality
• Empathetic approach ( and not sympathetic)
• Involvement of the family members.
With due Consent of the patient,

14. 1. Personal details
• NAME
• AGE
• MARITAL STATUS and Husband’s name,
• Consanguinity
• PARITY
• OCCUPATION
• SOCIO-ECONOMIC STATUS

15. 2. Menstrual history
• Age of onset of the first period.(menarche)
• Regularity and length of the cycle
• Duration of the period
• Amount of bleeding– excess is indicated by the passage of clots or
more number of pads used.
• Intermenstrual bleed, Contact bleed And Dysmenorrhea.
• Never forget to ask first day of LMP

16. 3. Obstetric history
Gravidity
Parity
Details of previous delivery & details of previous pregnancy loss:
1) Miscarriage (1st/2nd trimester)
2) IUFD
3) PTD
4) vaginal/ cesarean deliveries.

17. 4. Medical history
• Heart disease
• Hypertension
• Endocrine : DM and Thyroid
• Respiratory diseases
• Renal diseases
• Hepatic diseases
• Bleeding disorders and H/O BT
• Drug Allergy

18. • Also ask when was the last PAP Smear taken
• Any previous Surgical or Anesthetic complications

19. 5.Family history
• Especially of First degree relatives.
• Enquire about all relevant medical illness.
• Involve all systems (RS,CVS,CNS, GIT, Blood)
• Pay special emphasis on Malignancy of :
breast,
Ovary, and Colon,
• Ask for Chronic infective diseases
Eg, tuberculosis, HIV, etc

20. 6. Surgical History
Past Surgical History :
• general,
• obstetric and
• gynecological surgeries
Contraceptive use

21. 7.Personal history
•Diet, Sleep, Bowel habits,
•Sexual history,
•Substance abuse, alcohol, smoking, etc.
•H/O allergies or taking some medications since a long time.
•Childhood abuse and domestic violence

22. EXAMINATION

23. General examination
• Vital parameters (T,P,R, BP)
• Build, Nutrition, Stature,
• Pallor, jaundice, edema, cyanosis and icterus.
• Development of secondary sexual characters,
• Lymph nodes should be examined especially Inguinal and supra-clavicular.
• Teeth, gums and tonsils for any septic foci,
• Neck look for the thyroid glands and lymph nodes.
• CVS, RS and CNS examination to look for any abnormalities.

24. BREAST EXAMINATION
Should be included in your routine especially if your patient is above 30 years.
Why and How? Both Self examination and Clinical examination.
• Clinical examination: Includes visual inspection combined with palpation.
a) Inspection with the arms at her sides, then raised above her head and then
with hands pushing on the waist.
b) Palpation of the breast with the flat surface of your palms in a circular motion.
c) Palpation of the axillary nodes and the supra clavicular nodes.

25. Abdominal examination
•Inspection
•Auscultation
•Palpation
•Percussion. (compare with shifting dullness of ascites).

26. Shifting dullness

27. Pelvic examination
Includes:
• Inspection of the external genitalia
• Vaginal examination:
Inspection of the cervix and vaginal walls.
Palpation of the vagina and cervix by digital examination.
Bimanual examination of the pelvic organs.
• Rectal examination,
• Rectovaginal examination

28. Preparation
1) A female assistant should attend the exam.
2) Explain, Assure and take Consent of the patient.
3) Ask the patient to empty her bladder before the examination
(except in the case of SUI).
4) Position: a) Dorsal position,
b) lithotomy position, &
c) Sim’s lateral position.
NOTE: Take care to properly drape, elevate her head slightly by a pillow, and tell her
to keep her hands on the chest or on the sides, and not over the head, why?

29. Preparation 2
• Explain in advance, each step of the examination and tell her
what she may feel.
• Adjust the light over the perineal area.
• Wear gloves throughout the examination and try to keep your
hand warm.
• Watch her face (whenever possible)when you are examining her.
• Be as gentle as possible.

30. Inspection and External examination
• Assess the sexual maturity of an adolescent female
(by pubic hair and breast development, using Tanner’s staging).
• Inspection of the patient’s external genitalia:
You can seat comfortably and inspect the :
1) Mon’s Pubis
2) Labia majora and
3) Perineum.(For any scars and the length).

32. Inspection
•Separate the labia minora by the thumb and index
fingers of the right hand and inspect the following:
• 1) Labia Minora,
• 2) the clitoris,
• 3) the urethral meatus,
• 4) the vaginal opening or introitus

33. Inspection
Note for any inflammation, ulceration, discharge, swelling or nodules.
• If there is any lesion we are supposed to palpate it to feel for the consistency,
margins and to elicit any tenderness.
• If there is history of labial swelling , check whether it is a Bartholin’s gland
swelling by inserting your index finger into the vagina near the posterior end of
the introitus. Check using thumb and index fingers on each sides.
• Check for any discharge exuding out from the duct opening of the gland.

34. Bartholin gland cyst

35. urethra
If symptoms s/o urethritis or inflammation of the urethra
or the para-urethral glands:
• Insert your index finger into the vagina and milk the urethra
gently from inside outwards. &
• Note for any discharge & tenderness.

36. Stress test
Ask the patient to strain down and cough and inspect for:
• A) Stress incontinence.(leakage of urine)
• B) Vaginal prolapse.
• C) Uterine prolapse

37. Speculum examination
• Use sterile instruments
• You can use Cusco’s/ Sim’s speculum.
• Insertion of speculum
• Do examination of Cervix.
• Do examination of vagina during removal of the speculum.

38. Internal examination
1) lubricate your hands with an antiseptic solution like savlon or Betadine,
but only water if you are planning to take a swab for C/S.
2) From a standing position , spread the labia minora by your left hand and then
insert your index and middle fingers of your right hand slowly and gently into
the vagina,
2) The thumb should be abducted, your ring finger and little finger flexed into your
palm. Pressing inwards on the perineum with your flexed fingers usually do not
cause any discomfort to the patient.

39. Internal examination
• 4) note any nodularity or tenderness of the vaginal wall, including the
region of the urethra and bladder anteriorly.
• 5) Palpate the Cervix, note the position, size, shape, consistency,
regularity, mobility, masses, tenderness and opening of external
cervical canal. Palpate the fornices around the cervix. ( normally the
cervix can be moved a little bit without causing much pain)

40. Palpation of uterus
• Place your other hand on the abdomen about midway between the umbilicus
and the symphysis pubis.
• While you elevate the cervix and uterus with your pelvic hand, press your
abdominal hand in and down, trying to grasp the uterus between your two hands.
• Note its size, shape, consistency and mobility and identify any tenderness or
masses.
• Normally the uterus is retroverted, pear shaped, firm, and mobile.

42. Uterine palpation
• If you cannot feel the uterus with either of these manoeuvers, it may be
tipped posteriorly.(retroverted).
• Slide your fingers into the posterior fornix and feel for the uterus
pushing against your fingertips.
• An obese or poorly relaxed abdominal wall prevents you from feeling
the uterus properly even if it is located anteriorly (anteverted).

43. Ovarian and adnexal palpation
• Place your abdominal hand on the right lower quadrant, your pelvic hand in the
right lateral fornix. Press your abdominal hand gently in and down, trying to push
the adnexal structures towards your pelvic hand, at the same time push by your
pelvic hand backward and upward as far as possible.
• By moving your hands slightly, slide the adnexal structures between your fingers,
if possible, and note their size, shape, consistency, mobility and tenderness.
• Repeat all of the above on the left side

44. Ovary
Note : normal ovaries are somewhat tender and you can
palpate them only if the female is very thin and relaxed,
otherwise it is almost impossible to palpate the ovaries

46. Assessing the strength of the pelvic muscles
• Withdraw your two fingers slightly, just clear of the cervix,
and spread them to touch the sides of the vaginal walls.
Ask the patient to squeeze her muscles around them as hard
and as long as she can.
• A squeeze that compresses your fingers snuggly, moves them
upward and inward, and lasts for 3 seconds or more is full- strength.
• Cervical excitation test: Tenderness on cervical movement.

47. Withdrawal
• Withdraw your pelvic hand gradually, look for presence of blood or
discharge.
• After your examination wipe off the external genitalia and anus or
offer the patient some tissue so that she can do it herself.
• In case of virgins (and also in case of very old ladies)
do a per rectal examination instead of PV.
• Lastly, do not forget to test for hernias

48. Combined Recto vaginal palpation

49. Normal findings
• Labia’s are apposed and covers the vestibule
• Ant and Post walls of the Vagina are apposed
• The Perineum is at least 5cm long
• No swelling of Bartholin /Skene glands
• No e/o Clitoromegaly
• Adult pattern of hair distribution.
• Vagina and Cervix are clean and without any lesion or discharge.

50. Normal findings
• Uterus is normal size (size of a large lemon)
• It is uniform with smooth contours and it is non tender
• The adnexa ( tubes and ovaries) are neither tender nor enlarged.
• Patient might feel like passing urine at the time of bimanual
examination.
• There is some discomfort but normally the examination is painless
• When coughing /straining no prolapse nor any passage of urine per
urethra or vagina.

51. Summary
Common Gynecological
symptoms
Examination
Formulate a differential
diagnosis
Techniques of history taking

52. .
Source : Beckman & Ling : Gynecology