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Preventive healthcare includes having regular gynecologic examinations, even when no symptoms are present, and screening tests. Screening tests are done before people have any symptoms to check for disorders that can be prevented or treated effectively if recognized early (see  ). Women should have a gynecologic evaluation every year starting at about age 13 to 15. For all women who are sexually active, the evaluation should include a pelvic examination. For younger women who are not sexually active, this evaluation may not include a pelvic examination. Beginning about 3 years after first vaginal intercourse or at age 21, the pelvic examination should include cervical cytology testing (such as a Papanicolaou or Pap test) to detect precancerous changes of the cervix.
For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to menopause. The practitioner may be a gynecologist, an internist, a nurse-midwife, or a general, family, or nurse practitioner.
Gynecologic evaluation of young and teenage girls can sometimes be done by their pediatrician. However, if the pediatrician cannot set aside time for the girl to speak privately about personal concerns or is reluctant to provide gynecologic care, another health care practitioner should be found for this care.
The gynecologic visit is the time to ask the practitioner questions about reproductive and sexual function and anatomy, including safe sex practices, such as the use of condoms to minimize the risks of sexually transmitted infections.
Gynecologic History
A gynecologic evaluation starts with a series of questions related to menstruation and reproductive function. These questions usually focus on the reason for the visit to the doctor's office. The answers form the gynecologic history. A complete gynecologic history includes the following information:
Questions about abnormal bleeding—too much, too little, or between menstrual periods—are included.
A doctor usually asks about sexual activities to assess the risk of gynecologic infections, injuries, and pregnancy and to determine whether a woman has any sexual problems. A woman is asked whether she uses or wants to use birth control and whether she is interested in counseling or other information.
The doctor may ask the woman whether she has pain, cramps, or headaches during menstrual periods. She is asked whether she has pain during intercourse, in the middle of the menstrual cycle (which may indicate that the pain coincides with ovulation), or under other circumstances. If she has pain, she is asked how severe the pain is and what provides relief. The doctor also asks about breast problems, such as pain, lumps, areas of tenderness or redness, and discharge from the nipples. The woman is asked whether she examines her breasts, how often, and whether she needs any instruction on technique.
The doctor reviews the woman's history of past gynecologic disorders and usually obtains a general medical and surgical history that includes previous health problems. The doctor reviews all the drugs a woman is taking, including prescription and nonprescription drugs, illicit drugs, tobacco, and alcohol, because many of them affect gynecologic function. The woman is asked about mental, physical, or sexual abuse in the present and the past. Some questions about urination are asked to find out whether the woman has a urinary tract infection or has problems with leakage of urine (incontinence).
Gynecologic
Examination
If a woman has any questions or fears about the gynecologic examination, she should talk with the doctor beforehand about her concerns. If any part of the examination causes pain, the woman should let the doctor know. The woman should empty her bladder before the physical examination and may be asked to collect a urine sample for analysis.
The doctor usually feels the neck and the thyroid gland to check for lumps and abnormalities. An enlarged, overactive thyroid gland can cause menstrual abnormalities. The doctor examines the skin for signs of acne, excessive hairiness (hirsutism), spots, and growths.
A breast examination is typically done before the pelvic examination. With the woman sitting, the doctor inspects the breasts for irregularities, dimpling, tightened skin, lumps, and a discharge. The woman then sits or lies down, with her arms above her head, while the doctor feels (palpates) each breast with a flat hand and examines each armpit for enlarged lymph nodes and for lumps and abnormalities. While performing the examination, the doctor may review the technique for breast self-examination with the woman (see Breast Disorders:Cancer ).
The doctor may use a stethoscope to listen for activity of the intestine and to check for abnormal noises made by blood flowing through narrowed blood vessels. The doctor may tap areas of the abdomen with the fingers. The doctor gently feels the entire abdomen to check for abnormal growths or enlarged organs, especially the liver and spleen. Although the woman may experience some discomfort when the doctor presses deeply, the examination should not be painful.
During the pelvic examination, the woman lies on her back with her hips and knees bent and her buttocks moved to the edge of the examining table. Special pelvic examination tables have heel stirrups that help a woman maintain this position. If a woman wants to observe the pelvic examination, she should tell the doctor, who can provide a mirror. The doctor may explain the examination or review the findings before, during, or after the examination. For the examination, the doctor first inspects the external genital area and notes the distribution of hair and any abnormalities, discoloration, discharge, or inflammation. This examination may detect no abnormalities or may give clues to hormonal problems, cancer, infections, injury, or sexual abuse.
The doctor spreads the tissues around the opening of the vagina (labia) and examines the opening. Using a speculum (a metal or plastic instrument that spreads the walls of the vagina apart), the doctor examines the deeper areas of the vagina and the cervix. The cervix is examined closely for signs of irritation or cancer. The doctor may use a swab, brush, or small plastic spatula to obtain a sample for testing, usually a Papanicolaou (Pap) test or a variation of it. The doctor checks for protrusion of the bladder, rectum, or intestine into the vagina (see Pelvic Floor Disorders).
After removing the speculum, the doctor feels the vaginal wall to determine its strength and support. The doctor also feels for growths or tender areas within the vagina. After inserting the index and middle fingers of one gloved hand into the vagina, the doctor places the fingers of the other hand on the lower abdomen above the pubic bone. Between the two hands, the uterus can usually be felt as a pear-shaped, smooth, firm structure, and its position, size, consistency, and degree of tenderness (if any) can be determined. Then the doctor attempts to feel the ovaries by moving the hand on the abdomen more to the side and exerting slightly more pressure. More pressure is required because the ovaries are small and much more difficult to feel than the uterus. The woman may find this part of the examination to be slightly uncomfortable, but it should not be painful. The doctor determines how large the ovaries are and whether they are tender.
A rectovaginal examination may be done. The doctor inserts the index finger into the vagina and the middle finger into the rectum to examine, the back wall of the vagina for abnormal growths or thickness. In addition, the doctor can examine the rectum for hemorrhoids, fissures, polyps, and lumps. A small sample of stool can be obtained with a gloved finger and tested for unseen (occult) blood. A woman may be given a take-home kit to test for occult blood in the stool.
Screening Tests
Two important screening tests for women are cervical cytology testing (such as the Papanicolaou [Pap] test) to check for cancer of the cervix and mammography to check for breast cancer (see Breast Disorders: Screening). Women at risk of sexually transmitted diseases should be screened for these diseases. Other screening tests are done in pregnant women (see Normal Pregnancy: Medical Care).
Screening for
Cervical Cancer:
Cervical cytology testing (such as the Pap test) involves collecting a sample of cells from the cervix and examining them under a microscope. There are two types of cervical cytology: the conventional test and the liquid-based test. The clinician collects the sample by inserting a speculum into the vagina to spread the walls of the vagina apart and using a plastic spatula (similar to a tongue depressor) to remove some cells from the surface and opening of the cervix. Then, a small bristle brush is inserted into the passageway through the cervix (cervical canal) to obtain cells from the wall of the canal. The sample is then sent to a laboratory, where it is examined under a microscope for abnormal cells, which may indicate precancerous changes or, rarely, cervical cancer. Usually, the Pap test feels scratchy or crampy, but it is not painful and takes only a few seconds.
Pap tests identify 80 to 85% of cervical cancers, even very early-stage cancer. They can also detect changes in cervical cells that can lead to cancer (precancerous changes). These changes, called cervical intraepithelial neoplasia (CIN), can be treated, thus helping prevent cancer.
Pap tests are most accurate if the woman is not having her period and does not douche or use vaginal creams for at least 24 hours before the test. Experts recommend that women have the first test about 3 years after they begin having vaginal intercourse but no later than age 21. How often the test is needed depends mainly on the woman's age and the results of previous Pap tests:
Women who have had their uterus completely removed (total hysterectomy) and have not had any abnormal Pap test results do not need Pap tests.
Screening
for Sexually Transmitted Diseases:
Women at risk of sexually transmitted diseases should be screened yearly for these diseases, even if they have no symptoms. High-risk women include the following:
For most sexually transmitted diseases, the doctor uses a swab to obtain a small amount of cervical discharge from the cervix. The sample is sent to a laboratory for analysis. Women who think they may have one of these diseases can request screening. Testing for gonorrhea and chlamydial infection can also be performed on a urine specimen.
A doctor may consider screening women for the human papillomavirus (HPV) if they are 30 years old or older or if a Pap test detected questionable abnormalities that may result from HPV infection. HPV can cause genital warts or cervical cancer. A sample of vaginal discharge, obtained with a swab, is also used for this test. Normal results of a HPV test indicate that cervical cancer and precancerous conditions are highly unlikely. For women at high risk of HPV, the HPV test can be done at the same time as a Pap test. If results of a Pap test and an HPV test are normal in women older than 30, neither test needs to be repeated for at least 3 years.
Diagnostic Procedures
Occasionally, more extensive diagnostic procedures are needed.
Biopsy
A biopsy consists of removing a small sample of tissue for examination under a microscope. Biopsy of the vulva, vagina, cervix, or lining of the uterus can be done.
Cervix or Vagina:
A cervical biopsy is done when a condition likely to eventually lead to cancer (precancerous condition) or cancer is suspected, usually because a Pap test result was abnormal. A biopsy of the cervix or vagina is usually done during colposcopy. During colposcopy, doctors can identify the area that looks most abnormal and take tissue samples from it. Usually, biopsy of the cervix or vagina does not require an anesthetic, although this procedure typically feels like a sharp pinch or a cramp. Taking a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, 20 minutes before the procedure may help relieve any discomfort during the procedure.
Vulva:
A biopsy of the vulva can usually be done in the doctor's office and requires use of a local anesthetic.
Uterus:
For biopsy of the lining of the uterus (endometrial biopsy), a speculum is used to spread the walls of the vagina, and a small metal or plastic tube is inserted through the cervix into the uterus. The tube is used to suction tissue from the uterine lining. This procedure is usually done to determine the cause of abnormal vaginal bleeding. Also, infertility specialists use this procedure to determine whether ovulation is occurring normally and whether the uterus is ready for implantation of embryos. An endometrial biopsy can be done in a doctor's office and usually does not require an anesthetic. Typically, it feels like strong menstrual cramps. Taking a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, 20 minutes before the procedure may help relieve discomfort during the procedure.
Colposcopy
Colposcopy is often done if results of a Papanicolaou (Pap) test are abnormal. For colposcopy, a speculum is used to spread the walls of the vagina and a binocular magnifying lens (similar to that of a microscope) is used to inspect the cervix for signs of cancer. Often, a sample of tissue is removed for examination under a microscope (biopsy). Colposcopy alone (without biopsy) is painless and thus requires no anesthetic. The biopsy procedure is typically described as causing a crampy sensation and also does not require an anesthetic. The procedure usually takes 10 to 15 minutes.
Endocervical
Curettage
Endocervical curettage consists of inserting a small, sharp, scoop-shaped instrument (curet) into the passageway through the cervix (cervical canal) to obtain tissue. The curet is used to scrape a small amount of tissue from high inside the cervical canal. A cervical biopsy (to remove a smaller piece of tissue from the surface of the cervix) is typically done at the same time. The tissue samples are examined under a microscope by a pathologist.
Endocervical curettage is done when endometrial or cervical cancer is suspected or needs to be ruled out. Usually, it is done during colposcopy and does not require an anesthetic.
Dilation
and Curettage
For dilation and curettage (D and C), a speculum is used to spread the walls of the vagina. Then, metal rods are used to stretch open (dilate) the cervix so that a small, sharp, scoop-shaped instrument (curet) can be inserted to remove tissue from the lining of the uterus.
This procedure may be used to treat women who have had an incomplete (partial) miscarriage. D and C is sometimes used to identify abnormalities of the uterine lining when biopsy results are inconclusive, but it is no longer commonly used for this purpose because biopsies usually provide as much information and can be done in the doctor's office. D and C is often done in a hospital. Conscious sedation or a general anesthetic may be used. However, most women do not have to stay overnight in the hospital.
Hysterosalpingography
For hysterosalpingography, x-rays are taken after a radiopaque dye (which can be seen on x-rays) is injected through the cervix to outline the interior of the uterus and fallopian tubes.
The procedure is often used to help determine the cause of infertility or to confirm that a sterilization procedure to block the tubes is successful. The procedure is done in a place where x-rays can be taken, such as a hospital or the radiology suite of a doctor's office. Hysterosalpingography usually causes discomfort, such as cramps. Taking an NSAID, such as ibuprofen, 20 minutes before the procedure may help relieve discomfort.
Hysteroscopy
To view the interior of the uterus, doctors can insert a thin viewing tube (hysteroscope) through the vagina and cervix into the uterus. The tube is about ¼ inch in diameter and contains cables that transmit light. Instruments used for a biopsy, electrocautery (heat), or surgery may be threaded through the tube. The site of abnormal bleeding or other abnormalities can usually be seen and can be sampled for a biopsy, sealed off using heat, or removed. This procedure may be done in a doctor's office or in a hospital with a general anesthetic at the same time as a dilation and curettage.
Laparoscopy
To directly examine the uterus, fallopian tubes, or ovaries, doctors use a viewing tube called a laparoscope. The laparoscope is attached to a thin cable containing flexible plastic or glass rods that transmit light. The laparoscope is inserted into the abdominal cavity through a small incision just below the navel. A probe is inserted through the vagina and into the uterus. The probe enables doctors to manipulate the organs for better viewing. Carbon dioxide is pumped through the laparoscope to inflate the abdomen, so that organs in the abdomen and pelvis can be seen clearly.
Often, laparoscopy is used to determine the cause of pelvic pain, infertility, and other gynecologic disorders. Instruments can be threaded through the laparoscope to perform some surgical procedures, such as biopsies, sterilization procedures, and removal of an ectopic pregnancy in a fallopian tube. Additional incisions may be required if surgical procedures, such as removal of an ovarian cyst or the uterus (hysterectomy), are needed.
Laparoscopy is done in a hospital and requires an anesthetic, usually a general anesthetic. An overnight stay in the hospital is usually not required. Laparoscopy may cause abdominal pain, but normal activities can usually be resumed in 3 to 5 days, depending on the extent of the procedure that is performed through the laparoscope.
Loop
Electrical Excision Procedure
In a loop electrical excision procedure (LEEP), a thin wire loop that conducts an electrical current is used to remove a piece of tissue. Typically, this piece of tissue is larger than that obtained in a cervical biopsy.
This procedure may be done after an abnormal Pap test result to evaluate the abnormality more accurately or to remove the abnormal tissue. LEEP requires an anesthetic (often a local one), takes about 5 to 10 minutes, and can be done in a doctor's office. Afterward, women may feel mild to moderate discomfort and have a small amount of bleeding. Taking an NSAID, such as ibuprofen, 20 minutes before the procedure may help relieve discomfort during the procedure.
Sonohysterography
For sonohysterography, fluid is placed in the uterus through a thin tube (catheter) that is inserted through the vagina and then the cervix. Then ultrasonography is done. The fluid fills and stretches (distends) the uterus so that abnormalities inside the uterus, such as polyps or fibroids, can be more easily detected. The procedure is done in a doctor's office and may require a local anesthetic. Taking an NSAID, such as ibuprofen, 20 minutes before the procedure may help relieve discomfort.
Ultrasonography
Ultrasonography uses ultrasound waves, produced at a frequency too high to be heard. The ultrasound waves are emitted by a handheld device that is placed on the abdomen or inside the vagina. The waves reflect off internal structures, and the pattern of this reflection can be displayed on a monitor.
Ultrasonography can detect an ectopic pregnancy, tumors, cysts, and other abnormalities in the pelvic organs. It is commonly performed during pregnancy to determine the condition and size of the fetus, to monitor the fetus, or to guide the placement of instruments during amniocentesis or chorionic villus sampling (see Genetic Disorders Detection: Ultrasonography). Ultrasonography is painless and has no known risks.
Last full review/revision March 2007 by Paula J. Adams Hillard, MD
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