INTRODUCTION TO GYNECOLOGICAL ASSESSMENTS 2025

​This course covers the essential components of women's healthcare, including detailed patient history, physical/pelvic examination techniques (speculum and bimanual), and the latest diagnostic tools like ultrasound and simulation training. It focuses on early detection of gynecological conditions and patient-centered care.

1. GYNECOLOGICAL ASSESSMENT 2025

2. Across life span, women experience multiple events associated with reproductive development such as menarche , menstruation , pregnancy, labour , post partum, and menopause .

3. ct Compared to developmental events in male reproduction, the developmental events in female reproduction induce more drastic physiological alterations e.g. during menstrual bleeding, physiological changes in pregnancy, breast feeding, menopause, hormone fluctuations, these produce more significant psychological changes and more complex psychosocial consequences for women .

4. ct Although most women adapt well to these reproductive events, under certain conditions, they may develop an increased vulnerability for psychological maladjustment. Psychological problems, in turn, might exacerbate physiological symptoms associated with reproductive conditions e.g. the influence of stress on menstrual cycle disorders.

5. ct Female reproductive health is closely associated with psychological, psychosocial, psychosexual, psychobiological, behavioral, and developmental psychological aspects. Consequently , gynecological and obstetric issues must be approached in a bio psychosocial framework of health and illness that encompasses women's development and experiences across life span.

6. ct Women's bodies, sexuality, and reproduction, are inevitably influenced by social constructions of gender and gender appropriate behavior. Gynecological consultation, which frequently includes an internal examination, may be seen to recreate a stereotypical heterosexual relationship in which the female is powerless, passive, and dependent e.g after a diagnosis of ca cervix.

7. WOMEN WITH SPECIAL NEEDS G ynecological practice focuses primarily upon heterosexual activity, and therefore may regulate aspects of women's sexuality and reproduction, for example, access to abortion care, fertility treatments, and surgical treatments e.g hysterectomy and oophorectomy .

8. Adolescents, teenagers and children have unique characteristics e.g lack of access to health care, under developed reproductive systems, lack of support from parents, teachers and society. This is because they are considered to be young, healthy and free from gynecological problems. Elderly women are neglected by spouses, family, society whenever they develop gynecological problems. Societies where GBV is practiced e.g FGm

9. Ct Little attention has been paid to the gynecological health needs of lesbian women, who are assumed to experience fewer gynecological problems than heterosexual or bisexual women. It important to note that care should be given across all spheres. LGBTQ should also be given the appropriate care.

10. Patients with gynecological disorders require a lot of understanding because of the emotional and the physical considerations that govern the situation. R espect and confidentiality of the patient's problems and sharing of any information obtained should be only with those directly involved professionally with the care of the patient. Explaining the procedure in detail is important to gain cooperation 10 SUPPORT IN GYNECOLOGICAL ASSESSMENT

11. ct A number of women prefer to be attended with their partner, close family member or a friend provided that the patient herself consents to, there is no reason to exclude them from the initial consultation, but this should be limited to one person. In some instances, the additional person may be required to be a key part of the consultation incase there is a language or comprehension difficulty or decision making. At some point the consultation or examination should be with the woman alone, to facilitate the answering of any specific queries more openly .

12. ct Body language and other non verbal cues should be noted and the physical exam or history conducted in the absence of the accompanying person. Allow enough time for the patient to express herself and the Nurse/doctor’s manner should be one of interest and understanding, while guiding her with appropriate questioning.

13. ct A history that is taken with sensitivity will often encourage the patient to reveal more details that may be relevant to future management. Use lay terms where possible, care should be taken to avoid medicalized language as much as possible . Correct diagnosis and prompt management is key.

14. ct Women with gynecological conditions take time before deciding on whether to visit a health care facility or not. Routine screening and check ups should be encouraged for all WRA. Medical cover scheme Financial freedom for WRA Integration of RH services as a one stop shop Encourage partner support

15. F actors influencing the WRA (women of reproductive age) health seeking behavior Education level Type of disease e.g cervical cancer, STI Financial ability Environmental factors -locality Accessibility to the health care facility Stigma Availability of cheap/alternative remedies

16. Ct Age Parity Traditions Availability of local remedies/herbals Attitude of the hospital staff Lack of partner support Religious beliefs

17. COMPONENTS OF GYNAECOLOGICAL CARE H istory taking Physical exam I nvestigations Interventions/Treatment Referral and Networking Rehabilitation Home based care Palliative care

18. History Taking The gynecological consultation should ideally be held in a closed room with adequate facilities and privacy . Some women will feel anxious or apprehensive about the forthcoming consultation, so it is important that the Nurse or doctor establishes initial rapport with the patient and puts them at ease. The practitioner should introduce themselves by name and status, and should check the patient’s details. Ideally, there should be no more than one other person in the room, but any student or attending nurse should be introduced by name and their role briefly explained.

19. History taking Ct 1 General Name, age and occupation. A brief statement of the general nature and duration of the main complaints -use the patient’s own words rather than medical terms at this stage e.g miscarriage instead of abortion .

20. 2. History of presenting complaint This session should focus on the presenting complaint e.g. menstrual problems, pain, subfertility, urinary incontinence, etc

21. 3 Menstrual history This will be explored in all patients except menopausal women: usual duration of each period and length of full cycle first day of the LMP P attern of bleeding regular or irregular and length of cycle Amount of blood loss patients will have different ideas as to what constitutes a ‘ heavy period/flow’

22. ct Last menstrual period ( LMP) note the date of last menstrual bleed Amenorrhea: - note absence of menses for in WRA in the absence of pregnancy, FP, menarche, hysterectomy etc. Note any hormonal control of the menstrual cycle and hormonal disorders. FP use :- type, duration of use, side effects Oligomenorrhea - : Infrequent menstrual bleeds more than 35 days apart

23. Dysmenorrhea :- Painful menstrual bleeding; Primary dysmenorrhea – during adolescent when one attains ovulatory cycles has no justifiable cause, can be mild to severe. Secondary dysmenorrhea - which is due to a pelvic pathology, can occur before or after delivery, primary dysmenorrhea improves after delivery, but incase there is a pelvic pathology, the cramps get worse with subsequent deliveries. Menorrhagia :- also called heavy menstrual bleeding (HMB), Abnormal uterine bleeding (AUB)

24. Take note of Post coital bleeding (PCB)/ intermenstrual bleeding (IMB ) . Dyspareunia - Painful intercourse, superficial or deep, Benign conditions of the vulva and vagina, psychosexual disorders and female genital tract conditions. Incontinence - Involuntary loss of urine, stress, urge or mixed. Urogynaecology and pelvic floor problems Prolapse - Feeling of something coming down in the vagina (protrusion).

25. 4. Cervical cancer elimination strategies Latest VIA, PaP smear, HPV vaccine, HPV test, Rx for Cx Ca.(90:70:90) This will be explored in all patients: • date of last Pap smear, its outcome and any previous abnormalities, colposcopy or treatments.

26. 5 Sexual and contraceptive history present partner(s ) sexual orientation sexual satisfaction any surgeries on sexual organs, gender changes/transformation. Any childhood sexual abuse FGM contraceptive method or needs.

27. 6 Other gynecological symptoms A brief exploration of the complaints should follow. • any irregular bleeding • any pelvic pain • any problems with fertility • any problems with continence • any dyspareunia or sexual difficulty • any vaginal discharge • menopausal history and use of Hormone Replacement Therapy (HRT).

28. 7. Previous gynecological history This section should include any previous gynecological treatments or surgery. Previous obstetric history: • number of children with ages and birth weights , mode of delivery and any complications • number of miscarriages and gestation at which they occurred. • any terminations of pregnancy with record of gestational age and any complications.

29. Ct 8 Previous medical/surgical history • any serious illnesses or operations with dates. 9 Medication and allergies • allergies: including to what and the reaction; • current/previous medications tried . 10. Family history Significant autoimmune diseases, related cancers eg breast and ovarian, thrombophilias

30. 11. Systems enquiry • appetite, weight loss, weight gain; • bowel function (if urogynecological complaint, more detail may be required); • bladder function (if urogynecological complaint e.g incontinence. 12. Herbal medications and other traditional methods of treatment sought

31. Physical Exam Important information about the patient can be obtained by watching them walk into the examination room. Poor mobility may affect decisions regarding surgery or future management. The general outlook of the patient should be noted including the facial expression, mood .

32. ct Any examination should always be carried out with the appropriate privacy patient’s consent observe sensitivity. Closed and locked the door

33. Ct It is good practice to perform a general examination, non performance of a PE will lead to delay in the righ diagnosis, actual treatment and management including referral. S pecial emphasis to include examining:- the hands and mucous membranes for evidence of anemia . The supraclavicular area should be palpated for the presence of nodes, particularly on the left side in cases of abdominal malignancy The thyroid gland should be palpated .

34. ct The breasts should be examined as part of routine care and exam. A more detailed breast exam should be conducted incase the history is suggestive of a breast problem. Teach on SBE(self breast exam). Pelvic examination; this is particularly relevant if there is a suspected ovarian mass. Blood pressure and body mass index (BMI) should be recorded as this will be relevant in medical and surgical management

35. Abdominal examination The patient should empty her bladder before the abdominal examination for comfort . If urine infection or a pregnancy is suspected, a sample should be tested. Abdominal examination comprises: inspection , palpation , percussion auscultation

36. Speculum exam A sterile speculum is inserted into the vagina to obtain a clearer view of part of the vagina or pelvic organs. Excessive lubrication should be avoided and if a smear is being taken, lubrication with anything other than water should be avoided as it may interfere with the analysis, swabbing the vulva with antiseptics also. Microbiology swabs are taken from the vaginal fornices . Endocervical swabs for chlamydia are taken from the endocervical canal.

37. Bimanual examination This is usually performed after the speculum examination and is performed to assess the pelvic organs. It is customary to use the left hand to part the labia and expose the vestibule and then insert one or two fingers of the right hand into the vagina. The fingers are passed upwards and backwards to reach the cervix. The cervix is palpated and any irregularity, hardness or tenderness noted.

38. The left hand is placed on the abdomen above the pubic symphysis and pressed down into the pelvis to palpate the fundus of the uterus. The size, shape, position, mobility, consistency and tenderness are noted. .

39. The normal uterus is pear-shaped and about 9 cm in length. It is usually anteverted with the angle of the axis falling forward. The tips of the fingers are then placed into each lateral fornix to palpate the adenexae (tubes and ovaries ) on each side.

40. The fingers are pushed backwards and upwards, while at the same time pushing down in the corresponding area with the fingers of the abdominal hand. It is unusual to be able to feel normal ovaries. Any swelling or tenderness is noted. The posterior fornix should also be palpated to identify the uterosacral ligaments, which may be tender or scarred in women with endometriosis

41. Rectal examination In some situations, a rectal examination with specific additional consent can be useful in addition to a vaginal examination to differentiate between an enterocele and a rectocele or to palpate the uterosacral ligaments more thoroughly . Occasionally , a rectovaginal examination (index finger in the vagina and middle finger in the rectum) may be useful to identify a lesion in the rectovaginal septum.

42. A rectal examination can be used as an alternative to a vaginal examination in children and in adults who have never had sex, if ultrasound is not available as an investigation. It is less sensitive than a vaginal examination and can be quite uncomfortable, but it will help pick up a pelvic mass.

43. ct FGM may be encountered in some women The presence and type must be recorded. Some cases of FGM can make vaginal examination impossible. The presence of FGM scar must be recorded. It’s advisable to have a female colleague if one is a male

44. Investigations Once the examination is complete, the patient should be given the opportunity to dress in privacy. Sample collection can be conveniently taken during the PE process e.g Pap smear, endometrial biopsy. Imaging Ultrasound imaging of the uterus and adnexa is part of the investigations of nearly all gynecological problems, perhaps with the exception of contraception and sexual health screening in asymptomatic women.

45. Pelvic ultrasound using a transvaginal ultrasound scan (TVUSS) is performed for adult women and is the investigation of choice for most problems. The probe is cleaned and covered with a probe cover (or commonly a latex-free condom), containing ultrasound gel on the inside and outside. The probe is inserted into the vagina while the images are viewed on a screen.

46. The presence of pain and the correlation with images can be useful diagnostically. The resolution of TVUSS is high, particularly if the organ lies close to the probe, and the depth of images visible is around 12 cm. Excellent images of the uterus and adnexa, including the internal architecture of the myometrium, endometrium, Fallopian tubes when abnormal and ovaries are achievable as well as images of early intrauterine pregnancies.

47. ct For women who haven’t been sexually active, children and teenagers and some elderly women, an abdominal ultrasound is more appropriate. In some women with a large pelvic mass both types of ultrasound may be utilized. More expensive tests such as MRI are usually not needed in gynaecology . Increasingly , 3D ultrasound is used to diagnose uterine and adnexal abnormalities.

48. Instillation of saline through the cervix (saline instillation sonography - SIS) allows distension of the cavity of the uterus to enable the detection of abnormalities such as endometrial polyps and submucosal fibroids. An MRI , although expensive, may be requested to distinguish fibroid change from adenomysosis and to delineate ovarian cysts and assess malignancy. It can also be used to identify structural abnormalities in the genital tract. Increasingly , expert 3D TVUSS is used as a cheaper alternative.

49. When a malignancy has been identified a CT scan may be indicated to determine the stage of the disease . HSG to rule out blocked fallopian tubes. Other Investigations include: Biopsy for histopathology, cytology Blood tests HVS urine Pus for culture and sensitivity

50. Radiology examination for breast conditions M ammography-is a test of choice for screening early breast ca in every early stages when lumps are not palpable by hand. It is fast and accurate. C hest x-ray-taken to determine the frequency of metastasis to the lungs. CT scan- to locate metastases to the bones,brain . MRI

51. Cytology examination : Cytology exam of nipple discharge or cyst. Breast biopsy can be done through: F ine needle aspirate(FNA). -involves aspiration of cells from the abnormal area using a fine needle. -done following detection of breast lump or abnormalities.

52. ct A spirate specimen is taken for microscopic examination(cytology) to confirm/ rule out breast ca. If the results CBE (clinical breast exam) ,mammography, and FNA are combined the accuracy of diagnosis reaches 100% . This is triple test assessment .

53. NB: Investigations are taken depending on the condition being managed. Brainstorming session What investigations (both lab and radiological) are performed for a client with Infertility Ca cervix Pelvic pain Erectile dysfunction ?

54. ASS IGNMENT: HAND WRITTEN WORK ONLY 1. Distinguish primary dysmenorrhea from secondary dysmenorrhea and their management 2. Prepare a NCP for a woman with breast Ca. 5 Actual and 2 risk Dx . 3. Describe the palliative care modalities for a 32year old male post penile amputation due to penile cancer. 4. Explain the management of infertility in males

55. CHEERS