The gynecologic history and pelvic examination

INTRODUCTION — Assessment of the gynecologic history and the pelvic examination is part of the assessment of female patients in many clinical contexts. Clinician familiarity with the gynecologic evaluation can help reduce anxiety for both patients and health care professionals [1].

The gynecologic history and physical examination in adult females are reviewed here. The initial assessment of pregnant patients, evaluation of breast complaints, general approaches to patient interviewing as well as pelvic examination in children are discussed separately. (See "Prenatal care: Initial assessment" and "Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass" and "Gynecologic examination of the newborn and child".)

GYNECOLOGIC HISTORY

Overview — Individual patients vary tremendously in their knowledge of, and comfort with, their own bodies. While some may be quite open in disclosing their sexual, reproductive, and genital concerns, others will find such discussions embarrassing or socially inappropriate. Thus, it is essential that providers maintain a sensitive and nonjudgmental approach during this encounter.

The history should be obtained in a relaxed and private setting, and before the patient is asked to disrobe. The patient should be interviewed alone under most circumstances, unless there is a hearing or language barrier. Questioning should proceed from very straightforward, objective information to more delicate issues. The provider should evaluate and respond to the patient's comfort level and make every effort to remain supportive.

It is particularly important to avoid making assumptions about a patient's background; as an example, that a patient is sexually active or is heterosexual.

One should begin the history with an open-ended question that will elicit the patient's gynecologic concerns. Patients should be encouraged to describe the situation in their own words and without frequent interruptions. Maintaining eye contact, nodding, and brief clarification of important points convey the provider's attention to the patient's issues. The provider can then ask questions to proceed with the evaluation.

Basic history — The basic components of the gynecologic history are the following:

●Menstrual history (table 1) – The shorthand for menstrual history is age at menarche x cycle length x number of days of bleeding (eg, 13x28x5).

●Obstetric history (table 2) – The shorthand for obstetric history is gravida (number of pregnancies) para (number of term births; number of births from 20 to <37 weeks of gestation; number of failed or terminated pregnancies at <20 weeks; living children), eg, G2P2112. A delivery with multiple gestations counts as one birth (para = 1).

●Sexual history. (See 'Sexual function' below.)

●Type of contraception, past and current (if appropriate). Patients using hormonal contraception for treatment of another indication (eg, menorrhagia, pelvic pain) may deny the use of "contraception." Thus, all patients should be queried regarding use of hormonal medications. Patients should be advised that this question is not limited to prescription methods.

●Current symptoms or history of pelvic, vaginal, or vulvar infections – Vaginal discharge, vulvar or vaginal lesions, fever, pelvic pain, abnormal genital tract bleeding, prior sexually transmitted infections or pelvic inflammatory disease (diagnosis, frequency, and treatment).

●Cervical cytology (Pap test) history – Date and result of last test; diagnosis and follow-up of abnormal Pap smears.

●History of other gynecologic problems, such as ovarian cysts, uterine fibroids, infertility, endometriosis, or polycystic ovarian syndrome – Mode of diagnosis and treatment.

●Symptoms of pelvic organ prolapse or urinary or anal incontinence.

●History of gynecologic procedures (eg, endometrial biopsy, laparoscopy, hysterectomy) – Date, indication, complications.

●Screening for abuse (physical and emotional), including intimate partner violence. (See "Intimate partner violence: Diagnosis and screening".)

Specific questions are essential in order to obtain accurate information. As an example, some patients may not include miscarriages or abortions when asked about past pregnancies; therefore, the provider should specifically inquire about these events. Some patients will equate undergoing a pelvic examination with having a Pap test, and erroneously state that this test was recently performed [2]. Other patients may make inaccurate assumptions about whether their ovaries or cervix were removed with a hysterectomy. Therefore, written records of cervical cytology testing results, operative procedures, and pathology results should be obtained whenever possible.

A comprehensive gynecologic history includes a complete summary of the patient's medical, surgical, social, and family history. A review of symptoms is taken that focuses on the genitourinary areas (table 3).

Problem focused history — The most common gynecologic concerns relate to vaginal discharge, abnormal bleeding, pelvic pain, urinary problems, sexual dysfunction, and infertility. When a patient identifies one of these issues, detailed questioning can guide further evaluation and diagnosis.

Vaginal discharge — Many reproductive-age patients have daily vaginal discharge. Normal vaginal discharge is composed of mucoid endocervical secretions in combination with desquamated vaginal wall epithelium and normal bacteria. Physiologic discharge is typically clear, white, or light yellow in color. The volume of discharge varies considerably among patients and timing in the menstrual cycle. For patients who present with vaginal discharge, questions should be asked regarding the onset, duration, frequency, color, consistency, volume, and odor of the flow. Discharge that is malodorous, pruritic, copious, purulent, bloody, or accompanied by fever requires investigation. (See "Vaginitis in adults: Initial evaluation".)

Abnormal genital tract bleeding — Patients commonly present with a complaint of "vaginal bleeding." A complaint of vaginal bleeding most often represents uterine bleeding, but the source may be any part of the genital tract, or the urinary or gastrointestinal tracts (table 4). Pregnancy should be excluded in any patient of reproductive age with abnormal genital tract bleeding. (See "Causes of female genital tract bleeding".)

Pertinent data are the onset of a change in bleeding, and the amount, duration, and frequency of bleeding (table 5). In patients of reproductive age or in the menopausal transition, the use of a menstrual chart or electronic tracking application to document bleeding patterns is helpful in determining whether the changes are sufficiently abnormal to justify investigation (figure 1). Irregular bleeding occurs commonly during the menopausal transition and may be a symptom of serious underlying pathology.

Uterine bleeding is abnormal when it is associated with a change in the patient's normal menstrual pattern or it occurs after menopause. The average menstrual cycle lasts up to seven days and the amount of menstrual blood loss is 35 to 40 mL per cycle, but the range is wide [3,4]. Historically, heavy menstrual bleeding has been defined as menstrual blood loss greater than 80 mL [4]. As blood volume is difficult to measure, heavy menstrual bleeding is defined as "excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life" [5,6]. Prolonged menses are defined as longer than seven to nine days, depending on the patient's age [7,8]. Given the difficulty in quantifying actual blood loss, questions should focus on a significant change from baseline, bleeding at abnormal times during the cycle (intermenstrual or postcoital), and symptoms of anemia (such as new significant fatigue, orthostasis, or palpitations). (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

Menopause is defined by 12 months of amenorrhea after the final menstrual period. Postmenopausal bleeding refers to any uterine bleeding in a menopausal patient, though some light bleeding may occur when initiating or discontinuing a hormone replacement regimen. While menopause may occur in some patients in their 40s, other causes of amenorrhea and abnormal uterine bleeding should be considered, particularly for patients in their early 40s. While a change in the menstrual pattern is expected in the months or years prior to menopause, an increase in the amount or duration of bleeding during this time should be treated as pathologic and evaluated. (See "Approach to the patient with postmenopausal uterine bleeding" and "Evaluation and management of secondary amenorrhea".)

Pelvic pain — The characterization of pelvic pain should include the time of onset, duration, location, quality, and severity. The relationship of the pain to menstruation, physical activity, or sexual activity and alleviation of the pain with analgesics, hormonal contraceptives, or position change are useful components of the pain history. For example, pelvic pain provoked by activity or that radiates to the hips or back may reflect pelvic floor dysfunction. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis", section on 'Clinical presentation'.)

Associated gastrointestinal or urinary symptoms could point to a nongynecologic source of the pain. However, ovarian torsion is often accompanied by nausea and vomiting. (See "Ovarian and fallopian tube torsion", section on 'Clinical presentation'.)

Causes of pelvic pain are discussed in detail separately. (See "Causes of abdominal pain in adults" and "Chronic pelvic pain in nonpregnant adult females: Causes".)

Urinary incontinence and pelvic organ prolapse — Urinary incontinence occurs among patients of all ages and requires evaluation when the involuntary loss of urine is bothersome. Historical factors, such as leakage of urine with physical activity (exercise, lifting, coughing, sneezing) versus an overwhelming urge to void with leakage of urine before reaching a toilet, can help to differentiate stress incontinence from detrusor instability. A careful voiding and intake history will help the clinician determine the underlying cause. (See "Female urinary incontinence: Evaluation".)

Patients with pelvic organ prolapse may complain of a vaginal bulge, vaginal pressure, or the need to place a finger in the vagina to void or defecate. Such symptoms should be evaluated further with physical examination. It is important to ask about urinary and fecal incontinence as well as sexual dysfunction when evaluating prolapse symptoms and making treatment decisions. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

Sexual function — Many sexual problems result from and/or cause reproductive dysfunction and gynecologic problems. Sexual issues include prevention of sexually transmitted infections, contraception, sexual dysfunction (pain or difficult arousal or orgasm), and prevention and management of sexual assault.

Many patients are reluctant to express concerns regarding these matters but welcome the opportunity to discuss them when approached in an interested and compassionate manner. The importance of an assessment of sexual function was demonstrated in a questionnaire study of over 1000 females seen for a primary care visit; 98 percent reported one or more sexual concerns, but only 18 percent of clinicians asked about sexual health [9]. Patients who discussed their sexual concerns with their clinician found the discussion helpful. In another study, among 3000 patients with a sexual problem that caused personal distress, only 6 percent of those who sought medical advice scheduled a visit specifically for a sexual problem, and approximately 80 percent of the time, the patient, rather than the physician, initiated the conversation [10].

In addition to questions regarding basic gynecologic health, contraception and safe sex practices, all patients should be asked an open-ended question, such as: do you have any sexual concerns? This question also provides an opportunity to discuss sexual issues and pertinent sexual history.

A brief set of screening questions is adequate to determine whether a problem exists that requires further inquiry:

●Do you have sexual concerns?

●Are you currently having, or have you ever had, sexual relations?

●If not, when did you last engage in sexual activity?

●If so, with an individual of the same or different sex, or both?

●Have you recently had any new partners or sexual contacts?

●Do you protect yourself from pregnancy and sexually transmitted infections?

●Would you like to be screened for sexually transmitted infections?

●Do you need contraception or preconceptional counseling?

●Do you have difficulty with sexual arousal or enjoyment?

●Do you experience pain or vaginal dryness that limits sexual relations?

●Are you currently experiencing, or have you experienced, previous sexual abuse?

The patient's answers to these questions will guide the subsequent discussion and help the clinician provide care regarding safe sex, contraception, sexual dysfunction, or sexual abuse or assault. (See "Prevention of sexually transmitted infections" and "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation", section on 'Diagnostic evaluation' and "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Evaluation' and "Contraception: Counseling and selection".)

Infertility — Many patients become very concerned when they have not conceived a pregnancy after a few months of trying, while others have had years of unprotected, regular intercourse without recognizing that an underlying medical problem may exist. Infertility is defined as failure of a couple to conceive after 12 months of regular intercourse without use of contraception in females less than 35 years of age, and after six months of regular intercourse without use of contraception in females 35 years and older [11]. Before proceeding with an infertility evaluation, the provider should confirm that the couple is having regular, frequent intercourse during the middle of the menstrual cycle. Once the diagnosis is established, the infertility history should focus on three factors: ovulation, tubal and uterine problems, and male factors (table 6). (See "Female infertility: Evaluation".)

PELVIC EXAMINATION

Timing issues — Pelvic examination is indicated in any patient with genital or pelvic symptoms and in other patients for preventive care. (See 'Indications and frequency for examination' below.)

Age at initial examination — The American College of Obstetricians and Gynecologists (ACOG) recommends a first reproductive health visit between the ages of 13 and 15 years [12,13]. The scope of the examination in adolescents depends upon the individual needs of the patient. A reproductive health visit may be limited to age-appropriate education regarding reproductive health matters. A pelvic examination is not included unless indicated due to symptoms or specific patient concerns.

Prior to a first pelvic examination, the components and benefits of the examination should be explained. Every effort should be made to communicate with and reassure the patient, and the examination should be stopped if the patient is too anxious or uncomfortable. Education regarding the pelvic examination includes potential evaluation for sexually transmitted infections (STIs) and cervical cancer screening. Many patients erroneously equate a speculum examination with a Pap test and may incorrectly think that they have been screened for cervical cancer.

Indications and frequency for examination — Traditionally, an annual pelvic examination combined with a Pap test, often with screening for STIs, was standard practice in all adult females. In current practice, the goals and outcomes of a routine annual pelvic examination have been questioned [14,15]. As a result, most professional societies no longer recommend that every patient have a pelvic examination each year. Societies differ on whether pelvic examination should be performed in asymptomatic patients, unless it is necessary for a particular screening test (eg, Pap test).

There is consensus about the following indications for pelvic examination in nonpregnant patients:

●To evaluate gynecologic symptoms or concerns

●In asymptomatic patients:

•To perform a Pap test or testing for human papillomavirus (HPV). (See "Screening for cervical cancer in resource-rich settings".)

•To screen for STIs – Screening for female genital tract gonorrhea or chlamydia is typically performed with a cervical or vaginal swab during a pelvic examination. Alternatively, the patient may perform a self-collected vaginal swab or urine test. (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Asymptomatic patients' and "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Test performance'.)

•In some instances, patients request a pelvic examination. This may be because a routine check-up is desired.

The pelvic examination had been required historically as a prerequisite to obtain hormonal contraceptives. However, this is no longer part of current practice with the exception of intrauterine devices [13,16,17]. (See "Contraception: Counseling and selection".)

The question of the necessity of routine pelvic examination is part of a larger trend away from routine annual physical examinations. In addition, cervical cancer screening guidelines have changed, and many patients require screening only every three to five years. Also, some STI screening may be performed with methods that do not require a pelvic examination. (See "Overview of preventive care in adults", section on 'Periodic "check-up"' and "Screening for sexually transmitted infections", section on 'Screening methods' and "Screening for cervical cancer in resource-rich settings".)

In 2018, ACOG discontinued the recommendation for an annual routine pelvic examination and advised shared decision-making with the patient. They recommended that obstetrician-gynecologists and other gynecologic care providers counsel asymptomatic, nonpregnant patients about the benefits, harms, and lack of data regarding routine pelvic examinations. The patient and gynecologic care provider should then decide together if an examination will be performed [18]. They also advised that, regardless of whether a pelvic examination is performed, patients should see their obstetrician-gynecologist at least once a year for well-woman care [19]. We acknowledge that high-quality care can be provided by a variety of health care professionals with an interest in female health, including family practice and primary care physicians, nurse practitioners, physician assistants, and certified nurse-midwives. Ultimately, a patient should have the opportunity to form a comfortable relationship with the provider of their choice.

Other society recommendations include:

●The United States Preventive Services Task Force (USPSTF) advises that there is insufficient evidence to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult patients [20,21]. They state that this does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Pap test and screening for gonorrhea and chlamydia).

●The American College of Physicians (ACP) recommends against screening pelvic examinations in asymptomatic, nonpregnant patients [22]. This is based on the lack of evidence for a health or cancer screening benefit other than cervical cancer. They also cite anxiety, embarrassment, and overdiagnosis and overtreatment harms that can result from non-evidence-based screening.

●The American Academy of Family Physicians (AAFP) recommends against screening pelvic examinations in asymptomatic patients [23].

The benefits and harms of routine pelvic examination have not been fully investigated. The available studies of pelvic examination were not performed exclusively in asymptomatic patients [22]. Also, clinician factors have not been evaluated (specialty, frequency, and comfort level with performing pelvic examination). Patients who present to a gynecologist may differ from those who present to another clinician in terms of underlying pathology and goals and expectations of the visit. The varying guidelines from the USPSTF, ACP, and ACOG may reflect these differences.

Patients and clinicians should engage in shared decision-making regarding pelvic examination. Patients should be informed if a pelvic examination is recommended, and the examination should not be performed if a patient declines.

For patients who are anxious or uncomfortable before or during a pelvic examination, in our experience, modifications of pelvic examination technique (eg, varying the order of the steps of the examination, use of a single finger for bimanual examination rather than two, use of a narrow Pederson or pediatric speculum) and clinician explanation and reassurance are helpful.

Guidance regarding screening tests that may involve a pelvic examination include:

●Screening for sexually transmitted infections – Screening recommendations vary by age and risk factors (table 7) and are discussed in detail separately. (See "Screening for sexually transmitted infections".)

●Cervical cancer screening – In asymptomatic, immunocompetent patients, the age at which to initiate cervical cancer screening and which testing method (eg, Pap smear, primary HPV testing) is preferable is unclear and recommendations from expert groups vary (table 8). This is discussed in detail separately. (See "Screening for cervical cancer in resource-rich settings".)

●In terms of screening for genital tract cancers other than cervical cancer:

•There is no evidence that annual pelvic examination reduces mortality from ovarian cancer, while harms of screening (including unnecessary surgery) have been demonstrated [24-26]. Even pelvic examination under anesthesia has been shown to have limited sensitivity to detect adnexal masses [27]. (See "Screening for ovarian cancer" and "Pelvic examination under anesthesia".)

•Uterine cancer is not typically detected on pelvic examination, but rather presents with abnormal uterine bleeding. (See "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening".)

•There is no routine screening method for vulvar cancer and no data regarding use of pelvic examinations for screening. However, periodic examinations may provide some benefit. In our clinical experience, vulvar precancer and cancer are often asymptomatic and may be detected only on routine pelvic examination. This is particularly true for older patients (average age at diagnosis is 65 years), who may be less likely to notice a vulvar lesion or bring it to medical attention. Vulvar cancer is more likely to be diagnosed at an advanced stage in older patients [28,29]. There is no evidence that vulvar cancer screening should be performed more frequently than cervical cancer screening in asymptomatic patients with no history of vulvar disease, though it is also not clear that vulvar cancer screening should stop at age 65. Because there is no HPV screening test for the vulva and because some vulvar cancers are not HPV-related, vulvar cancer screening may need to continue after cervical cancer screening is discontinued. In our practice, we perform a careful inspection of the vulva each time that a patient presents for cervical cancer screening or for a pelvic examination for another indication. Any suspicious lesion should be biopsied. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment".)

In our practice, we perform a pelvic examination in all symptomatic patients. This requires taking a detailed history to elicit any new, unusual, or bothersome symptoms. A benefit of routine pelvic examination is that many patients have difficulty expressing concerns or symptoms related to their genital tract or sexual function. A pelvic mass, tenderness, or discharge may be noted on examination in patients who did not notice or were reluctant to discuss pelvic issues.

In asymptomatic patients, in addition to cervical cancer and STI screening, we recommend a pelvic examination in the following situations:

●If a gynecologic condition that may be asymptomatic is suspected by history or risk factors.

●If the patient desires a routine gynecologic check-up.

●For patients with a history of precancerous lesions of the cervix, vagina, or vulva.

●For patients who may have difficulty detecting a vulvar lesion (eg, older adults, limited vision or mobility).

●As part of ovarian cancer screening in high-risk patients (BRCA mutation, Lynch syndrome) who have not undergone risk-reducing bilateral salpingo-oophorectomy.

●As part of post-treatment surveillance following genital tract cancer, if appropriate for tumor site and treatment history.

●At the initial prenatal visit and as indicated during obstetric care.

When to discontinue examinations — ACOG advises the following regarding discontinuing the pelvic examination [13]:

●The decision to receive an internal examination can be left up to the patients if they are asymptomatic and have undergone a total hysterectomy and bilateral salpingo-oophorectomy for benign indications and have no history of vulvar intraepithelial neoplasia, cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cancer; are not infected with HIV; are not immunocompromised; and were not exposed to diethylstilbestrol in utero. Cytology testing is not recommended in this select population. Annual examination of the external genitalia should continue.

●It would be reasonable to stop performing pelvic examinations when a patient's age or other health issues reach a point where the patient would not choose to intervene on conditions detected during the routine examination, particularly if the patient is discontinuing other routine health care maintenance assessments. This conclusion can be documented after a process of shared and ongoing communication and decision-making between the patient and clinician.

Preparing for the examination

Patient consent — The clinician should request permission before starting a pelvic examination [30]. Written consent is not required, with the exception of examination under anesthesia. (See "Pelvic examination under anesthesia", section on 'Informed consent'.)

Adolescents may undergo a pelvic examination without their parents' or caregivers' knowledge or permission if the examination is performed in the context of testing or treatment for STIs or pregnancy. Laws vary by jurisdiction regarding confidential access to HIV testing, contraception, and abortion services. On the other hand, consent by a legal guardian is required for childhood examinations and adolescent pelvic examinations unrelated to sexual contact [31]. Permission from a legal guardian is required for a nonemergency pelvic examination of patients who cannot consent to their own health care. (See "Consent in adolescent health care".)

Chaperone — No universal guidelines exist regarding the use of a chaperone during the examination, though ACOG recommends a chaperone for all breast and pelvic examinations [32]. In our own practice, chaperones are present by protocol, and this is explained to our patients.

Surveys of both patients and providers demonstrate variable usage and preferences. Some patients who generally prefer female providers are open to a male provider if a chaperone is present [33,34]. Other patients may actively object to having a chaperone present [34], though an examiner is not obligated to an un-chaperoned examination at the patientꞌs insistence. Although charges of inappropriate conduct during a pelvic examination are rare, both male and female providers should consider utilizing a chaperone [35]. Any member of the health care team serving in this role must understand rules for patient privacy and confidentiality, and patients should be offered additional time without the chaperone to discuss private concerns [36].

Patient anxiety or refusal — Some patients have had difficult experiences with sexual abuse or assault or with prior pelvic examinations and may feel substantial anxiety regarding the examination. For such patients, the examination may be nearly unbearable, and may deter the patient from seeking appropriate health care. Such anxiety may manifest as tense and withdrawn body language, extreme discomfort with the examination, or refusal to have an examination at all.

It is widely recognized that a pelvic examination may be uncomfortable. In its summary of studies reporting on over 4000 patients, the ACP reported that approximately 35 percent may experience pain, discomfort, fear, embarrassment, or anxiety during a pelvic examination [22]. In one study, approximately 1000 patients in a variety of clinical settings were asked to explain the parts of the examination that were uncomfortable, the reasons for the discomfort, and to suggest ways the provider could have improved the process [37]. Physical discomfort (37 percent), embarrassment (20 percent), disliking the attitude of the examiner (7 percent), and experiencing problems during a previous examination (5 percent) were the major concerns reported. Techniques suggested to improve the examination process included explaining each step of the examination in advance, providing more information about the reproductive organs, warming the instruments, and increased gentleness. Other surveys have recommended that providers make an effort to maintain eye contact during the examination and give the patient choices (eg, asking permission prior to placing the speculum or performing a bimanual examination) where possible [38,39].

At first recognition of the patient's discomfort, the provider should stop the physical examination and address the patient's concerns. In some patients, performing the bimanual examination with one finger before the speculum examination is helpful in decreasing anxiety. In addition, a narrow speculum (narrow Pederson, Huffman, or pediatric) can be used to decrease discomfort.

If it becomes clear that the patient has been abused or is suffering from severe anxiety, the provider may need to delay the examination in order to elicit help from a therapist or social worker. Often by discussing the examination ahead of time and agreeing to stop uncomfortable procedures at the patient's request, the provider can give the patient some control over the situation, which may alleviate some anxiety regarding the examination. Importantly, the provider should never proceed in the setting of patient refusal and should abort an examination when asked to do so, no matter how medically necessary the provider perceives the examination.

Patient positioning — The pelvic examination is traditionally performed in the dorsal lithotomy position in order to allow optimal exposure of the internal and external genitalia and palpation of the pelvis. Unfortunately, laying the patient in a horizontal position does not allow eye contact between the provider and patient and may increase the patient's sense of vulnerability. Raising the patient's head to allow eye contact may be particularly important for patients who are hard of hearing. The horizontal position may also be physically difficult for patients with cardiorespiratory or musculoskeletal limitations. Elevating the head of the table 30 to 45 degrees makes it easier for the patient to relax, thereby facilitating bimanual examination.

Equipment — The basic equipment needed to perform a pelvic examination includes:

●An examining table with stirrups (or means for elevating the buttocks when stirrups aren't available [eg, the patient is on a stretcher or in bed]).

●Good light source (preferably cold light).

●Speculum of appropriate size (eg, Huffman speculum for patients without prior vaginal penetration).

●Materials to obtain cervical cytology and/or HPV, if needed.

●Materials to test for common infections – Chlamydia, gonorrhea, herpes simplex virus.

●Cotton swabs for obtaining samples of vaginal discharge.

●Materials for testing vaginal discharge, including pH indicator paper and dropper bottles of saline and potassium hydroxide, in settings where microscopes and trained providers are available.

●Large cotton swabs to absorb excess vaginal discharge or blood.

●Water soluble lubricant, disposable gloves, material to drape the patient.

Components of the examination — The pelvic examination traditionally includes the internal and external genitalia, and pelvic organs. Comprehensive examination also includes evaluation of some components of the urinary and gastrointestinal tracts, including the urethra, anus, and rectum. A more comprehensive examination, involving the abdomen, breast, and other sites, may be indicated to provide complete primary care or to evaluate gynecologic problems that involve other organ systems. (See "Evaluation of the adult with abdominal pain", section on 'Physical examination' and "Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass", section on 'Physical examination'.)

Abdomen — Examination of the abdomen should be performed using the standard techniques of inspection, auscultation, palpation, and percussion. The examiner should observe for abnormalities of skin color and intestinal peristalsis, hernias, organomegaly, masses, fluid collection, and tenderness.

External genitalia — The external genitalia are inspected and palpated (figure 2). The hair distribution, skin, labia minora and majora, perineal body, clitoris, urethral meatus, vestibule, and introitus (vaginal orifice) are evaluated for developmental abnormalities, skin lesions (eg, discoloration, ulcers, plaques, verrucous changes, excoriation), masses, and evidence of trauma or infection. In patients with vulvar pain, the vestibular epithelium should be touched with a dry cotton swab to identify the location of the pain. Visible vulvar lesions may need to be cultured or biopsied. (See "Vulvar lesions: Diagnostic evaluation" and "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers" and "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

Bartholin and paraurethral glands — The Bartholin gland (also called the greater vestibular gland) openings are located at the 4 and 8 o'clock positions just outside the hymenal. The glands are not palpable when healthy. (See "Bartholin gland masses".)

The paraurethral glands (also called the lesser vestibular glands), the largest of which are Skene's glands, are adjacent to the distal urethra; the gland ducts (paraurethral ducts) open into the urethra or just outside the urethral orifice [40]. If enlarged or tender, an attempt should be made to express exudate, which suggests infection.

Speculum examination — The vagina is first inspected using a speculum of appropriate size, lubricated with warm water or a water-soluble lubricant. Some lubricants may interfere with sampling for cervical cytology, and lubricants containing carbomers or carbopol polymers should be avoided [41]. (See "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing", section on 'Gel lubricants and other contaminants'.)

Atraumatic insertion is aided by assisting muscle relaxation at the opening of the vagina. This may be accomplished by advising patients to relax their legs to the sides and also by inserting a finger into the distal vagina and gently applying downward pressure. The speculum is then inserted and downward pressure applied. The speculum is advanced in a direction free of resistance and opened as the apex of the vagina is reached.

Vaginal lesions, anomalies, or atrophic mucosa are noted. If abnormal discharge is identified, the volume, color, consistency, and odor should be noted and a sample taken with a cotton swab. The pH of physiologic vaginal discharge is less than 4.5; an elevated pH may be due to infection (eg, bacterial vaginosis) or exogenous substances (eg, semen), and may be normally observed in menopausal patients. (See "Vaginal cancer", section on 'Diagnosis' and "Congenital anomalies of the hymen and vagina", section on 'Anomalies of the vagina' and "Vaginitis in adults: Initial evaluation" and "Vaginitis in adults: Initial evaluation", section on 'Physical examination'.)

The degree of vaginal wall relaxation and uterine prolapse is evaluated, if indicated, by removing the top blade of the speculum and using the posterior blade as a retractor. It is helpful to ask the patient to bear down to determine the degree of uterovaginal descensus. Additional testing can be performed in patients with complaints of urinary incontinence. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Approach to the examination'.)

Lesions or discharge of the cervix are noted. Cervical cultures and cervical cancer screening are performed, as appropriate. (See "Benign cervical lesions and congenital anomalies of the cervix" and "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing", section on 'How to obtain a sample' and "Screening for sexually transmitted infections" and "Screening for sexually transmitted infections", section on 'Screening recommendations'.)

Bimanual examination — The index and middle fingers of the dominant hand are normally used to examine the vagina, cervix, uterus, and pelvic floor, although some providers find that switching hands during the examination facilitates evaluation of the adnexa. Only a single finger can be inserted comfortably in patients with a narrow introitus. The abdominal hand should be used to sweep the pelvic organs downward, while the vaginal hand is simultaneously elevating them.

The uterus is assessed for size, shape, symmetry, mobility, position, and consistency. The uterine size and consistency vary according to reproductive status (parity, menopausal status (figure 3 and table 9)). The position, or axis, of the uterus is described by its variation in the anterior-posterior (sagittal) plane. There are several normal variations of uterine position (figure 4); the terms used to describe this are:

●Axial – The axis of the uterus is the same as the vaginal axis

●Version – Position of the entire uterus relative to the axis of the vagina (eg, anteverted, retroverted)

●Flexion – Position of the uterine fundus relative to the axis of the cervix (eg, anteflexed, retroflexed)

A uterus can be both verted and flexed in the same direction (eg, anteverted and anteflexed); it is less common for a uterus to be verted and flexed in opposing directions (eg, anteverted and retroflexed).

The adnexal areas are checked for the presence of appropriately sized, mobile ovaries (eg, approximately 2 by 3 cm), which are normally somewhat tender. Palpable ovaries in postmenopausal patients are not a "normal" finding (detectable in approximately 30 percent of postmenopausal patients [42,43]) and require investigation, although most are associated with benign or no disease [44-49].

The ability to palpate the ovaries during a clinical examination in the office depends upon several factors, including the patient's body habitus, the examiner's experience, the time taken to perform the examination, and the presence of other pelvic abnormalities. Ovaries can be difficult to palpate, even by experienced clinicians under ideal circumstances. In one series in which bimanual examination was performed under anesthesia before various gynecologic surgery procedures, ovaries were detected in 30 percent of patients ≥55 years of age versus 51 percent of patients under 55 years of age, in 9 percent of patients weighing over 200 pounds versus 55 percent of patients weighing under 200 pounds, and in 12 percent of patients with a uterine weight over 200 g versus 51 percent of patients with a uterine weight under 200 g [42]. Overall, the bimanual examination has a sensitivity of less than 60 percent, whether for detecting adnexal masses in general or for distinguishing benign from malignant masses [50].

When adnexal masses are detected, they should be described as to location, size, consistency, mobility, and degree of tenderness. (See "Approach to the patient with an adnexal mass", section on 'Diagnostic evaluation' and "Adnexal mass: Differential diagnosis".)

The pelvic floor muscles are evaluated by palpating the lateral sidewalls and upper vaginal fornices. Focal nodularity or tenderness can indicate sources of myofascial pelvic pain. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)

Rectovaginal examination — Another potential component of the gynecologic assessment is the rectovaginal examination. This allows optimal palpation of the posterior cul-de-sac and uterosacral ligaments, as well as the uterus and adnexa. Studies of rectovaginal examinations under anesthesia show poor sensitivity in detecting adnexal masses and uterosacral and posterior cul-de-sac disease [51,52]. There are no professional society guidelines regarding the use of the rectovaginal examination [36,53].

If a rectovaginal examination is performed, anorectal findings should be documented (eg, hemorrhoids, rectal mass). If indicated, stool on the examining glove can be tested for occult blood. However, a single sample does not suffice for colorectal cancer screening; screening is better accomplished by colonoscopy or, less preferably, home collection of stool samples. Screening for colorectal cancer is discussed in detail separately. (See "Screening for colorectal cancer: Strategies in patients at average risk".)

When performing the rectovaginal examination, using a lubricated examining glove and asking the patient to strain against the examiner's finger will usually allow the sphincter to relax and decrease discomfort. The same finger should not be used to examine both the vagina and rectum to avoid transmission of HPV [54] or contamination with blood, which may alter fecal occult blood testing, if performed.

SPECIAL CONSIDERATIONS

Examination of infants and children — The first genital inspection should be performed on the newborn. This will confirm patency of the anus and vagina, and help identify congenital anomalies and ambiguous genitalia. (See "Assessment of the newborn infant", section on 'Genitalia'.)

Young girls should undergo a focused genital examination when the patient or caregiver identifies a gynecologic symptom. (See "The pediatric physical examination: The perineum", section on 'Female genitourinary system' and "Gynecologic examination of the newborn and child", section on 'History and physical examination'.)

Examination of transgender or transitioning patients — Patients should be asked about their preferred name and gender pronouns.

The use of gender affirming hormonal or surgical therapies should be discussed as part of the patientꞌs history. If such therapies have been used, or if there is a history of ambiguous genitalia, then the patientꞌs anatomy (including their preferred terminology for their anatomy and if they have a preferred mean of being examined) should be discussed with the patient prior to the examination. The discussion may benefit from using drawings or diagrams.

The importance of cervical cancer screening should be discussed with transgender males or nonbinary persons with a cervix (see "Primary care of transgender individuals", section on 'Cervical cancer'). As with all patients, efforts should be made to minimize discomfort and potential trauma with the examination.

Additional considerations for care of transgender individuals are discussed in detail separately. (See "Primary care of transgender individuals".)

Examination of patients with limited mobility or obesity — In rare cases, the gynecologic examination may not be possible in the office setting. Examples include severe physical limitations, patient intolerance due to pain or anxiety, or examination of small children. In such cases, the examination may need to be performed with anxiolytic premedication, conscious sedation, or general anesthesia. (See "Pelvic examination under anesthesia" and "Gynecologic examination of the newborn and child", section on 'History and physical examination'.)

Suggestions for facilitating gynecologic examination of disabled patients are listed in the table (table 10).

Examination after hysterectomy — The indications for pelvic examination are the same for patients who have undergone hysterectomy as for other patients. The exception to this is that most patients who have undergone total hysterectomy (the cervix has been removed) do not require Pap tests. In the past, many clinicians performed vaginal Pap tests in this patient population. However, the risk of vaginal intraepithelial neoplasia (VaIN) or vaginal cancer is extremely low in patients who have undergone total hysterectomy for benign disease (excluding cervical intraepithelial neoplasia 2,3) and, for this reason, screening guidelines in the United States from the US Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), and the American College of Obstetricians and Gynecologists (ACOG) concur that these patients do not need posthysterectomy vaginal cytology. Vaginal cancer screening is advisable in patients with risk factors for vaginal cancer. (See "Cervical cancer screening: The cytology and human papillomavirus report", section on 'Vaginal cytology' and "Cervical intraepithelial neoplasia: Choosing excision versus ablation, and prognosis and follow-up after treatment", section on 'Type and duration of testing' and "Cervical intraepithelial neoplasia: Choosing excision versus ablation, and prognosis and follow-up after treatment", section on 'Potential candidates for hysterectomy'.)

ACOG guidelines state that some patients may choose to stop having pelvic examinations after total abdominal hysterectomy and bilateral salpingo-oophorectomy, if asymptomatic and if there are no other factors that increase the risk of pelvic disease [13]. We recommend ongoing periodic external genital examinations in this situation. (See 'When to discontinue examinations' above.)

Examination of patients following hysterectomy or other gynecologic surgery (eg, oophorectomy) is generally the same as for other patients, but the examination and documentation of the findings should reflect the patient's current anatomy. As an example, in a patient who has undergone a total hysterectomy, the examiner should note that the cervix is surgically absent and record the condition of the vaginal cuff (eg, well-healed). In some cases, patients are not certain of the details of their surgical procedure, including whether the cervix or one or both ovaries or tubes were conserved. The definitive documentation of this is in the operative note. If this is not available, the clinician can confirm the absence of the cervix on examination and the absence of the ovaries with pelvic imaging, if this information is needed for clinical reasons.

Patients who have had a total hysterectomy continue to be at risk of sexually transmitted infections of the urethra. Thus, patients at risk of, and/or with symptoms of, these infections should be tested for gonorrhea or chlamydia with urine testing. (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Diagnostic approach' and "Clinical manifestations and diagnosis of Chlamydia trachomatis infections".)

DOCUMENTATION — There are six critical elements of good record-keeping:

●Accuracy

●Objectivity

●Legibility

●Timeliness

●Comprehensiveness

●Absence of alterations

All entries should be dated, signed, and checked for accuracy. Documentation guidelines related to reimbursement are available from the Centers for Medicare & Medicaid Services [55].

When a paper medical record is used, a preprinted form is useful for documentation of the history and physical examination (figure 5A-B). In electronic medical records, if templates are used, care must be taken to ensure that the information is reviewed and is correct for the individual patient and encounter [56].

SUMMARY AND RECOMMENDATIONS

●Gynecologic history – The gynecologic history should be obtained in a relaxed and private setting, and before the patient is asked to disrobe. The patient should be interviewed alone under most circumstances. It is particularly important to avoid making assumptions about a patient's background (eg, that the patient is sexually active or heterosexual). (See 'Overview' above.)

●Problem focused history – The most common gynecologic concerns relate to vaginal discharge, abnormal bleeding (table 5), pain, urinary problems, breast disorders, sexual dysfunction, and infertility (table 6). When a patient identifies one of these issues, detailed questioning can guide further evaluation and diagnosis. (See 'Problem focused history' above.)

●Pelvic examination – The pelvic examination traditionally includes the external genitalia and internal pelvic organs. The abdomen and breasts are also commonly examined. The pelvic examination is traditionally performed in the dorsal lithotomy position in order to allow optimal exposure of the internal and external genitalia and palpation of the pelvis. (See 'Pelvic examination' above.)

●Age at initial examination – There is no defined age at which the first gynecologic examination is performed, as this depends upon the probability of identifying a gynecologic problem. Screening examinations generally begin when cervical cancer screening is initiated (table 8). (See 'Age at initial examination' above.)

●Indications and frequency – A gynecologic examination should be performed whenever a patient presents with pelvic symptoms. Asymptomatic patients should have an examination at least with every scheduled cervical cancer screening test. There is controversy as to whether an asymptomatic screening examination should take place yearly or periodically, and the preferred examination frequency should be decided by patients and their providers. (See 'Indications and frequency for examination' above.)

●Chaperones – No universal guidelines exist regarding the use of a chaperone during the examination, though the American College of Obstetricians and Gynecologists (ACOG) recommends a chaperone for breast and pelvic examinations. Although charges of inappropriate conduct during a pelvic examination are rare, both male and female providers should consider utilizing a chaperone. (See 'Equipment' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Donald Peter Goldstein, MD, who contributed to earlier versions of this topic review.