Art & science | advanced practice
Gynaecological assessment
and history taking
Anthony Summers describes how nurse practitioners
should undertake pelvic examinations, and
outlines significant signs and symptoms
Correspondence
anthony_summers@health.qld.gov.au Abstract
Anthony Summers is a nurse Nurse practitioners (NPs) rarely undertake
practitioner at Redlands Hospital,
Queensland, Australia
gynaecological histories or female genital examinations
yet, by doing so, they can broaden their scope of
Date of submission practice. This article discusses what NPs should
May 3 2013
ask women about their gynaecological histories and
Date of acceptance how to undertake pelvic examinations, and reviews
July 10 2013 common gynaecological symptoms. Further articles
Peer review
will cover different aspects of the pelvic examination
This article has been subject and potential differential diagnoses.
to double-blind review and
has been checked using
antiplagiarism software
Keywords
Gynaecological history, pelvic examination, obstetrics
Author guidelines
www.emergencynurse.co.uk
TAKING GYNAECOLOGICAL histories and
undertaking physical examinations can be
challenging tasks for nurse practitioner (NPs).
They and the patients concerned may be
embarrassed during the processes, and patients
may have unrealistic expectations about the
examinations. Some patients know less about how
their bodies function, are less comfortable about
revealing parts of their bodies and are less willing
to discuss their sexual histories than other patients,
while some may think that discussing these topics
with men socially or culturally inappropriate (Carusi
and Goldstein 2013).
The aim of this article is to provide NPs with
the necessary skills and knowledge to take
gynaecological histories and undertake physical
examinations of adult women, here defined
as women aged over 18 years. The article will
allow them to approach such situations without
embarrassment and thereby reassure their patients
that they are being treated professionally.
Many women are anxious or embarrassed
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about their gynaecological histories, and the
prospect of physical examination. This anxiety and
embarrassment can be more pronounced if they
have had bad or no experiences of such procedures,
or they have histories of trauma or injury
(Huber et al 2009). The confident manner in which
NPs approach such patients and explain everything
before proceeding can go a long way to alleviating
such fears and concerns.
The presence of chaperones can also help to
ensure patients feel comfortable (Bates et al 2011)
and some chaperones can help with examinations.
In the UK, the Nursing and Midwifery Council
(NMC) (2012) states that patients have the right to
request chaperones when undergoing procedures
or examinations, and most female patients prefer
to have chaperones present when examiners are
male (Fiddes et al 2003, Shawn and Upshur 2008).
There are no guidelines advocating that there
should always be chaperones present, however, and
no evidence that their presence makes litigation
less likely. In addition, their presence during history
taking can make patients feel embarrassed about
revealing their sexual or gynaecological histories to
other people. It is therefore recommended that male
examiners use chaperones routinely, that female
examiners ask patients if they would like chaperones
to be present and that individual patient preferences
are documented (Bates et al 2011). Each emergency
department (ED) should have guidelines about
chaperoning patients.
Gynaecological history
Before examination, patient histories should be
taken to discover important information about
patients and their presenting problems (Bridge
2011). Histories should be taken in private areas
EMERGENCY NURSE
because it is likely that many sensitive issues will be
discussed. Nurse practitioners should avoid making
assumptions about patients’ backgrounds and
remain sensitive and non-judgemental throughout
the history taking process (Carusi and Goldstein
2013). History taking should begin with general
open-ended questions to allow patients to express
what they are concerned about in their own words.
Nurse practitioners can then ask specific questions
about signs and symptoms. The areas covered when
taking a gynaecological history include:
Menstrual history How this is taken depends on the
age of the women concerned.
■■ For all women: the age of menarche, any history
of menstrual irregularity, heavy bleeding,
irregularity or dysmenorrhoea, length of cycle
including the characteristics of bleeding and
any other associated signs and symptoms
(Matteson et al 2011).
■■ For women of reproductive age and in
menopausal transition: the date of their last
period as measured by the first day of bleeding
or spotting, the date of their previous period,
the length of their current cycle, the number of
days of menses, the occurrence of postcoital
bleeding, the occurrence of premenstrual
signs or symptoms (Carusi and Goldstein
2013). Irregularity in a menstrual cycle among
premenopausal women should prompt NPs to
consider that they are pregnant.
■■ For postmenopausal women: age of last menses;
history of hormone therapy; the occurrence
of postmenopausal bleeding, a risk factor for
endometrial cancer (Bickley 2003).
Obstetric history This includes pregnancies,
miscarriages, terminations or ectopic pregnancies,
as well as attempts at assisted reproduction such as
in vitro fertilisation.
■■ For each pregnancy: date of delivery, gestational
age, mode of delivery, maternal complications
and fetal complications; delivery complications;
neonatal problems and current health of the child
(Carusi and Goldstein 2013).
■■ Sexual history: sexually transmitted diseases
that can affect the gynaecological system
(Coverdale et al 2011).
■■ Use of contraceptive pills without condoms,
and the associated risk of sexually
transmitted infection.
■■ Current signs and symptoms.
■■ History of pelvic, vaginal or vulva infections, the
most common sign and symptoms of which being
vaginal discharge or itching (Bickley 2003).
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■■ Papanicolaou, or pap, test history. This includes
whether the patient has had one recently, whether
the results were normal or abnormal and what
follow up was needed.
■■ History of gynaecological problems, of which the
presenting conditions may be exacerbations.
■■ Vaginal prolapse: whether the patient feels a
lump in her vagina or has problems defecating or
passing urine.
■■ History of gynaecological procedures, such as a
hysterectomy or oophrectomy, and the reasons
why these were performed.
■■ Screening for intimate-partner violence to
discover whether the symptoms are caused by
abuse or violence. Signs and symptoms can
include: dysmenorrhea, urinary tract infections,
changes in menstrual cycle, vaginal infections,
pelvic pain independent of menstrual bleeding
and adnexitis, or inflammation of the ovaries or
fallopian tubes (Mark et al 2008).
Symptoms
When good gynaecological histories have been taken,
histories of signs and symptoms should be obtained.
The most common gynaecological problems among
patients attending EDs are vaginal discharge,
abnormal bleeding, pelvic pain and urinary
problems. Other potential complaints include sexual
dysfunction and infertility, but these are rare in
people who attend EDs.
Vaginal discharge There are many causes of vaginal
discharge. These may or may not be related to
sexually transmitted infection (Box 1, page 35).
Most adult women have some vaginal discharge,
which is produced as part of a process that keeps
the vagina healthy. Fluids secreted by the cervix and
vagina leave the vagina daily, along with sloughed
off epithelial cells, non-pathological bacteria and
mucus. The amount of discharge varies in response
to changes in circulating oestrogen levels (Robb-
Niholson 2009) but an increase in the usual amount
of vaginal discharge may be due to vulvovaginal
candidiasis, bacterial vaginosis, trichomoniasis,
or infection involving Chlamydia trachomatis or
Neisseria gonorrhoeae (French et al 2004). It should
be noted, however, that no infective cause is found
in up to 34 per cent of patients with an increase in
vaginal discharge (French et al 2004).
When taking a history from someone with vaginal
discharge, it is important to establish timing, colour,
consistency, smell and presence of itch, because
these details can help NPs distinguish between
infections (Spence and Melville 2007). For example,
Chlamydia infection and gonorrhoea produce
 Art & science | advanced practice
purulent vaginal discharge (Spence and Melville
2007), while Trichomonas infection often results
in a frothy, yellowy-green, fishy smelling discharge
(Summers 2011).
Uterine bleeding There are many potential causes
for abnormal uterine bleeding (Box 2) and the
first to be considered, and excluded if necessary,
is pregnancy (Cirlli and Cipot 2012). If a patient
is pregnant with vaginal bleeding, she should be
referred to an obstetrician because a threat to the
viability of the pregnancy may be indicated and
specialist investigation may be required.
Bleeding associated with a change in menstrual
cycle or that occurs after menopause is classed
as abnormal (Carusi and Goldstein 2013). Normal
menses last up to seven days with an average blood
loss of between 35 and 40ml. Menorrhagia, defined
as blood loss of more than 80ml, is a common
health problem and occurs in about 10 per cent
of all women and 22 per cent of women aged over
35 (Jensen et al 2012).
Menopause is said to have occurred after
12 months of amenorrhea and usually occurs
between the ages of 40 and 58 (Dillaway and Burton
2011). Postmenopausal bleeding therefore occurs at
any stage after 12 months of amenorrhea.
Pain Musculoskeletal, gynaecological, urological,
gastrointestinal or neurological conditions can
all cause pain in the pelvic region (Apte et al
2012). Gynaecological conditions account for up
to two thirds of cases of pelvic pain in women
(Apte et al 2012) and, of these, endometriosis
accounts for half (Garry 2006). Associated
gastrointestinal or urinary signs and symptoms
point to other causes, including constipation,
irritable bowel disease, urinary tract infection, and
musculoskeletal or psychiatric causes (Damle and
Gomez-Lobo 2011).
Prolapse In describing pelvic organ, or vaginal,
prolapse women often report discomfort or
pressure, a weakness in muscle or connective
tissue, vaginal bulging or visibility of vaginal walls,
or urinary or bowel-related signs or symptoms
(Pakbaz et al 2011). They may also report a need to
place a finger into the vagina to help them defecate
or pass urine (Carusi and Goldstein 2013). Up
to 50 per cent of parous women may experience
a form of pelvic organ prolapse at some point
(Maher et al 2013).
Pelvic examination
Pelvic examinations in EDs are controversial because
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there is rarely enough space or time available to
undertake them privately and thoroughly, which
means that women are likely to require second
examinations soon afterwards.
The competence of the individuals performing
the examinations should be considered and, where
possible, patients should be referred to specialists
who perform the examinations regularly rather
than emergency care team members who perform
them infrequently. Pelvic examinations should be
undertaken in the ED only when appropriate, for
example to confirm a diagnosis of cervicitis.
If patients are likely to require admission, or if
firm diagnoses are unlikely to be made, they should
be referred to the most appropriate specialists,
usually gynaecologists, for examination so that
subtle abnormalities are not missed. Staff in EDs
are called on to make these examinations more than
other non‑gynaecological staff, however, and should
proficient at them (Close et al 2001).
Before undertaking examinations, NPs should
prepare all the equipment they need so that patients
are not left in embarrassing or compromising
positions while, for example, they or the patients’
chaperones leave to find equipment they have
forgotten. The equipment needed to undertake
vaginal or pelvic examinations includes:
■■ An appropriate examination table, ideally
with stirrups or with a means to elevate the
patient’s buttocks.
■■ A good light source to see clearly what is
being examined.
■■ Specula in a range of sizes. There are no
guidelines about the size or make of speculum
that should be used with individual patients.
Wide specula cause the most discomfort but
narrower ones can restrict visibility (Bates et al
2011). Nurse practitioners should be familiar with
the different specula in their EDs and understand
how each of them can suit their needs.
■■ Swabs to collect samples from the vagina.
This equipment should be available even if the
patient undergoing examination has no history
of discharge.
■■ Large cotton swabs to absorb vaginal discharge or
blood, to allow a good view of the cervix.
■■ Water soluble lubricant, gloves and material to
drape the patient.
If the patient is pregnant or has recently given birth,
the due date of delivery, gestational age of the
fetus, mode of delivery and complications, maternal
and fetal complications, neonatal problems, and
health of the child should be recorded (Carusi and
Goldstein 2013).
Before undertaking examinations, NPs should
EMERGENCY NURSE
Box 1 Common causes of vaginal discharge
Non-infective causes
■■ Physiological, such as an increase in normal
vaginal secretions.
■■ Cervical ectopy.
■■ Presence of foreign bodies such as retained tampons.
■■ Vulval dermatitis.
Non-sexually transmitted infections
■■ Bacterial vaginosis.
■■ Candidal infections.
Sexually transmitted infections
■■ Chlamydia.
■■ Gonorrhoea.
■■ Trichomonas.
(Spence and Melville 2007)
explain what they are going to examine and
everything they intend to do. Verbal consent for
examinations should be obtained before they
begin and patients should be told that, if they
are uncomfortable, the examinations will be
stopped. Written consent is usually required only
for examinations of patients under anaesthesia.
Patients should be told they can be accompanied
by chaperones and, if they choose to have them,
examinations should not start until suitable
chaperones are present.
Usually, patients are asked to pass urine
before examinations because a full bladder causes
discomfort during bimanual examination and
interferes with the palpation of structures. It also
pulls the uterus superiorly, making localisation of
the cervix difficult (Bates et al 2011).
Pelvic examinations include that of the external
genitalia, and of the Bartholin’s and paraurethral
glands. They also include speculum examination of
the vagina walls and the cervix, bimanual examination
to palpate the ovaries and rectovaginal examination.
They should be undertaken after examinations of
other parts of the body have been undertaken, when
patients are more likely to be at ease.
External genitalia When patients are comfortable,
NPs should examine the external genitalia, including
the mons pubis, labia, perineum, labia minora,
clitoris, urethral meatus and vaginal opening.
Excoriations or the presence of itchy, small, red
maculopapules in the mons pubis suggest pubic lice,
and the base of the pubic hairs should be examined
to see if lice are present (Bickley 2003). Inflammation,
ulceration, discharge, swelling or nodules on the
labia, perineum or around the vagina opening should
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be noted because they can help confirm diagnosis
(Talley and O’Connor 2006). If lesions are present,
they should be palpated to determine if they are
painful and swabs taken for culture.
Bartholin’s and paraurethral glands Bartholin’s
glands are located in the labia minora, at the 4 and
8 o’clock positions, with the clitoris area being the
12 o’clock position. Their function is to secrete
mucus through the Bartholin’s ducts to lubricate
the vagina. Unless the ducts are obstructed or
there is infection, the glands are rarely palpable
(Mercado et al 2013).
The paraurethral, or Skene’s (Gittes 2002), glands
are glandular tissue proximal to the two ducts, the
openings of which can be seen next to the urethral
meatus. If the glands are enlarged or tender, an
attempt should be made to express exudates, which
indicate infection (Carusi and Goldstein 2013).
Speculum examination The speculum should be
inserted into the vagina with the aid of warm water
or water-based lubricant. Gentle downward pressure
with a finger inserted into the vagina can help with
this process. The speculum is advanced to a depth
of around 4cm, and the blades are opened to help
identify the cervix. The blades should be opened
enough to encircle the cervix before being locked in
place (Edelman et al 2007).
Vaginal wall lesions, anomalies or atrophic
mucosa should be noted. If discharge is present,
the volume, colour, consistency and odour should
be noted, and swabs taken (Carusi and Goldstein
2013). Lesions or discharge around the cervix
should be recorded and swabs taken (Carusi and
Goldstein 2013). If patients require pap smears,
they should be taken before any other tests (Royal
College of Nursing (RCN) 2013). Non-specialist ED
staff should not take pap smear samples, however,
because diagnoses may be wrong if they are
taken incorrectly.
Box 2 Common causes of uterine bleeding
■■ Pregnancy.
■■ Structural problems, such as atrioventricular
malformation, polyps, fibroids, endometriosis and
hyperplasia.
■■ Coagulopathies such as von Willebrand’s disease.
■■ Polycystic ovary syndrome.
■■ Intrauterine or oral contraceptives.
■■ Medications such as antiepileptics and
antipsychotics.
■■ Endometritis.
(Cirlli and Cipot 2012)
 Art & science | advanced practice

After the cervix has been examined, the speculum
should be removed carefully, ensuring that neither
the vaginal walls nor cervix are trapped in the
closing blades. As the speculum is removed, the
vagina is examined for foreign bodies, signs of
infection or cysts (RCN 2013).
Bimanual examination Bimanual examination
has long been considered an essential part of
pelvic examination because it is suggested that
it provides accurate assessment of the uterus,
fallopian tubes and ovaries (Padilla et al 2005).
Its use is controversial, however, especially for
the detection of ovarian masses, with the use of
transvaginal ultrasonography being the preferred
method of examination for symptomatic women
(Westhoff et al 2011).
The procedure is carried out by inserting gloved,
lubricated index and middle fingers into the vagina,
while placing the other hand on the abdomen and
pressing towards the inserted fingers (RCN 2013).
As the fingers are inserted, the vaginal tone and
wall support are assessed for protrusions, prolapse
and foreign bodies.
After palpating along the vagina walls, the cervix
is palpated, again with notice of its position, shape,
consistency, uniformity, mobility and tenderness;
also the fornices around the cervix are palpated
(Bickley 2003). Pain on movement of the cervix and
adnexal tenderness suggest pelvic inflammatory
disease (Bickley 2003).
To palpate the uterus, the hand on the abdomen
should press down midway between the umbilicus
and the symphysis pubis, and the fingers of the
other hand should elevate the cervix, until the
uterus between can be grasped between both hands.
The size and shape of the uterus vary according to
reproductive status, with enlargement, for example,
suggesting pregnancy, or malignant or benign
tumours (Bickley 2003). The position of the uterus
can be described as:
■■ Axial, wherein its axis is the same as the
vaginal axis.
■■ Inversion, wherein the entire uterus relative to
the axis of the vagina is, for example, anteverted
or retroverted.
■■ Inflexion, wherein the position of the uterine
fundus relative to the axis of the cervix is, for
example, anteflexed or retroflexed (Carusi and
Goldstein 2013).
Finally, the adnexal areas are palpated to examine
the ovaries, which are usually mobile and tender,

References
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Chronic female pelvic pain: part 1. Clinical
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The challenging pelvic examination. Journal
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Bickley L (2003) Bates’ Guide to Physical
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Bridge S (2011) A competency history: an
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Close R, Sachs CJ, Dyne P (2001) Reliability
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Coverdale J, Balon R, Roberts L (2011)
Teaching sexual history-taking: a systematic
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Damle L, Gomez-Lobo V (2011)
Pelvic pain in adolescents. Journal of
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Davisson L, Clark K, Powers R et al (2006) The
rectovaginal examination: physician attitudes
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Dillaway H, Burton J (2011) ÔNot done
yet?!Õ Women discuss the ‘end’ of
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Edelman A, Anerderson J, Lai S et al (2007)
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Fiddes P, Scott A, Fletcher J et al (2003)
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French L, Horton J, Matousek M (2004)
Abnormal vaginal discharge: using office
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Garry D (2006) Diagnosis of endometriosis and
pelvic pain. Fertility and Sterility. 86, 5, 1307-1309.
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Huber J, Pukall C, Boyer S et al (2009)
‘Just relax’: physicians’ experiences with
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36 September 2013 | Volume 21 | Number 5 EMERGENCY NURSE

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and measure about 2 by 3cm (Carusi and Goldstein
2013). Most women will be diagnosed with benign
disease processes or no disease. It should be noted
that palpation of adnexal masses can be difficult
for inexperienced examiners and, if diagnoses are
likely to be based on this procedure, referral to a
gynaecological specialist is prudent. Palpation of
ovaries in postmenopausal women is not a normal
practice (McDonald and Modesitt 2006).
Rectovaginal examination Rectovaginal examination
is used to evaluate the posterior portion of the
pelvis and the rectovaginal septum. The examination
may be uncomfortable for patients, however,
because the index finger is inserted into the vagina
while the middle finger of the other hand is inserted
into the rectum. This allows for palpation of the
posterior cul-de-sac and uterosacral ligaments. Its
use for the detection of cul-de-sac pathology is
debatable (Davisson et al 2006) and, because of its
lax sensitivity or specificity for abnormal findings,
is rarely performed.
Conclusion
Taking gynaecological histories and examining
patients can be daunting for NPs and patients. Nurse
practitioners need the confidence and skill to put
patients at their ease so that they experience as
little trauma as possible. Cultural sensitivities must
be acknowledged and respected, and NPs should
ask patients if they object to undergoing pelvic
examinations, and whether they would prefer a male
or female examiner.
Before examining patients, comprehensive
histories should be taken to ensure that physical
examinations are focused. Nurse practitioners need
to be confident also in asking questions because
this gives patients the confidence to answer them
truthfully. Examinations must also be approached
confidently, so that patients are confident that they
are being treated professionally.
This article focuses on the taking of gynaecological
histories and examination of adult women. It does
not cover the taking of sexual histories, or caring
for adolescents or women with special needs. These
two categories of patient often require a different Online archive
approach to examination. Questions asked of women
For related information, visit
with special needs may have to be simplified to
our online archive and search
ensure that they are understood. A discussion of their using the keywords
needs has been omitted, therefore, to allow NPs to
focus on the patients they are most likely to see and Conflict of interest
to gain confidence in their management. None declared

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