CLINICAL TOPICS -

GYNECOLOGY
DoCC D
2021

UConn School of Medicine

 Common chief complaints or problems that warrant GYN
evaluation

 Symptoms related to the GU tract:

 Abnormal menstrual bleeding or pattern
 Abnormal vaginal discharge
 Amenorrhea evaluation
 Perineal, vaginal, or pelvic pain
 Sexual dysfunction or symptoms
 Bulges, fullness, lumps or other ‘lesions’ noted by patient
 Rashes or other symptoms (pruritis, etc)
 Lower (or mid) abdominal pain; pelvic pain
 Evaluation after assault or suspected assault
 Some endocrine problems or situations
 Recurrent UTIs
 Screening examinations for neoplasia (cervical, uterine, ovarian,
e.g.)
 As part of pregnancy evaluation and prenatal care
 The GYN Review of Systems
(the most common questions)

 Change in menstrual pattern

 Abnormal bleeding
Inter-menstrual
Change in amount of bleeding
Post/with intercourse
Postmenopausal
 Vaginal discharge
 Rashes, lumps, or sores in vaginal area
 Pain (pelvic area, genital, and with intercourse)

(other symptoms that might be considered either GYN or

ENDOCRINE include hot flashes, sexual dysfunction, loss of
libido)

Take Home Point: You should know the GYN ROS questions and when
to use them
 ***Please note the importance of considering GYN/PELVIC evaluation in
women/girls with abdominal pain, even in the absence of GYN
complaints.***

This would be particularly important in lower abdominal pain and

mid-abdominal pain. Certainly the higher up on the abdomen the
pain, the less likely it is from a pelvic-gyn source, but keep an
open mind.

Take Home Point: A Gyn Review of systems and possibly even a Pelvic Exam is
important to consider in the evaluation of Abdominal Pain.
 The slides that follow take you through the pelvic exam in the
general order that it is done, with pictures (drawings and/or
photos) of some examples of the types of abnormal findings that
you might see:

• External inspection
• Superficial vaginal exam
• Speculum exam for cervix and deeper vaginal vault
• Bimanual palpation (uterus, adnexa)
• ‘Recto-vaginal’ septum exam not discussed here (see
video
 The first part of the Pelvic Exam – External Inspection
(Inspecting the external vagina and surrounding skin areas)
Anatomic structures/areas:
• Labia majora
• Labia minora
• Urethra
• Clitoris
• Anus
• Perineum (area between vagina and anus in general)

Grouping of vesicles on skin of vulva

or peri-vaginally: HSV (herpes)

These can also become infected – called

Bartholin Gland abscesses in that instance.
Candidiasis – ‘yeast infection’ of skin –
Other lesions seen on EXTERNAL INSPECTION is not uncommon in the inguinal/genital/
include neoplasms (including carcinomas), other perineal area. There is intense redness,
infections (HSV, warts, candidiasis), sclerosis of skin, along with ‘satellite’ papules near edges
other skin conditions of the rash
Next -The external (or ‘superficial’) Vaginal Exam
Prior to the Speculum Exam, more inspection
Now, inspecting superficial area of the vaginal vault

Example of a common problem: A Cystocele – a bulging or

prolapsing of part of the the bladder into the vaginal vault

Symptoms of ‘bulging’ or protrusions into the vagina

might be due to a cystocele (also consider rectoceles,
urethroceles, abscesses, and uterine prolapse).

On inspection, even prior to inserting the speculum,

you may see tissue bulging into the introitus.

Having the patient Valsalva usually increases

the bulging
 The Speculum Exam – inspecting the Vaginal Vault and the
Cervix

Some ‘vaginal’ secretions (‘scant’) pooling This, however, is actual Cervical Discharge –
at bottom of vaginal vault. This could be visualized coming directly from the
normal secretions or sometimes ‘vaginitis’ VS. cervical os.

This is not ‘cervical discharge’, however. This type of discharge is more likely to be
There appears to be no discharge from caused by cervicitis, often due to infection
the actual cervical os. ….

Take Home Point: Distinguish true cervical

discharge from vaginal discharge or secretions
if possible.
 Cervix Findings on Examination

Note that the cervical os takes on a different shape

after having delivered children (Right sided picture).

Benign cysts on the cervix. Not

uncommon (Nabothian cysts)

Schematic picture of the appearance of

various degrees of Cervical neoplasia.
Colposcopy Procedure….and appearance of Cervix with
varying stages of CIN (cervical intraepithelial neoplasia)

The ability to get a magnified view of the cervix

and perform targeted/directed biopsies -- Colposcopy
Normal vs. Abnormal PAP Smear Cells
(Look at size and appearance of nuclei, arrangement of cells, etc)
 The BIMANUAL EXAM
Use of both hands for palpation of and applying pressure to various anatomic structures

1. The vaginal hand can apply cervical motion to test for tenderness. It also can check the adnexa and push the uterus
upward toward the abdominal hand for sizing and masses

2. The abdominal hand can feel for the uterus, for sizing and masses. It also puts pressure in a ‘sweeping’ manner on
the adnexae, so that they can be palpated by the vaginal hand.
 What is Pelvic Inflammatory Disease?
How is it diagnosed?
Take Home Point: PID is an infection of the ‘upper tracts’ of the GYN
structures (uterus, tubes, e.g) and can cause severe illness, scarring,
fertility issues, etc. This is a ‘do not miss’ diagnosis for abdominal
pain, abnormal discharge, fevers, etc.

Note these
major
criteria
 The Bimanual Exam
Uterine Fibroids

Often you will feel these masses or firm lumps with the abdominal hand,
especially as you push the uterus up a bit with the vaginal hand.
 The Bimanual Exam (cont.)
Fibroids
(Explanation of types, by anatomic location. Ultrasound of a fibroid – “FIB” – on R)

Fibroids – Ultrasound appearance

 The Bimanual Exam – Palpating
the Adnexa

Ovarian Cancer – Risk Assessment

These would be detected on the

bimanual exam, with the vaginal Also, remember that BRCA mutations significantly
fingers directed laterally from increase risk of Ovarian (and Breast) Cancers
the uterus. As diagram shows,
the uterine fingers gently push
upward, while the abdominal
ones push downward.
Take Home Point: Ovarian Cancer is very difficult to diagnose
at early stages due to anatomic and other factors. Know the
risk factors for this…though even these are nonspecific mostly
 Ectopic Pregnancy
(When the fertilized egg implants at a location outside of the uterus)
(A ‘Do not miss’ Diagnosis)

Common symptoms include

• Abdominal pain
• Abnormal bleeding
• Amenorrhea
• Lower back pain
• Syncope or hypotension

Note that some women may not be

aware of pregnancy yet, so we
cannot rely on a documented hx
of known current pregnancy.

Also note that the above symptoms

are relatively nonspecific, and
overlap with many other conditions,
as well as with some pregnancy
symptoms or other pregnancy
complications.

Take Home Point: Sometimes an ectopic All of this leads to the conclusion
that ECTOPIC PREGNANCY can
pregnancy dx is fairly clear and obvious; be a very tricky clinical syndrome
other times it can be subtle initially. Know and diagnosis. Being aware of
the major risk factors and clinical features. the risk factors (see table) for this
is essential.
Have a high ‘index of suspicion’ for this.
Laparoscopic View of Ectopic Pregnancy in adnexa