• Clinical science

Diagnostic procedures in gynecology

Abstract

A complete gynecological examination includes inspection of the vagina with the aid of a speculum and, if needed, colposcopy and bimanual palpation. Speculum examination is also used to facilitate obtaining smears for cytological and microbiological studies. Depending on the clinical presentation, other laboratory diagnostics and imaging procedures may be indicated. MRI scans and/or ultrasounds of the breast, for example, may supplement standard screening tests such as mammography. Unexplained pelvic symptoms may require transvaginal ultrasonography or more invasive diagnostic procedures such as endometrial sampling and hysteroscopic or laparoscopic examination.

Speculum examination

  • Insertion of a speculum device facilitates the inspection of the vaginal wall and ectocervix
  • Evaluate the quality of vaginal discharge to determine whether a smear should be acquired

Speculum examination is virtually never indicated in preadolescent patients! If absolutely necessary (e.g., vaginal bleeding, trauma, abuse), it is usually performed under general anesthesia!

References:[1]

Colposcopy

  • Colposcope: a type of microscope used to acquire a magnified view of the ectocervix or vaginal wall
  • Allows for assessment of the ectocervix under magnification (6–40 x)
    • Application of acetic acid or iodine facilitates the colposcopic detection of precancerous and cancerous lesions
    • Colposcopy-directed cervical smears and biopsies
    • Surgical procedures under colposcopic guidance

Benign lesions

Abnormal findings

References:[2][3][4][5]

Vaginal smear

Finding Diagnosis
Pseudomycelia and/or yeast cells Vaginal candidiasis
Motile flagellated protozoa Trichomoniasis
Clue cells and whiff test (adding KOH to vaginal smear elicits a fishy odor) Bacterial vaginosis
  • Gram staining when gonorrhea is suspected → gram-negative, intracellular diplococci
  • Estimate pH levels
    • Normal pH: 4–4.5
    • pH > 4.5 → suspect bacterial infections (other causes of increased vaginal pH include menstruation, amniotic fluid, and sexual intercourse)
  • Bacterial culture and sensitivity analysis if bacterial infections due to an unknown pathogen are suspected
  • PCR and/or serological tests; (e.g., suspected chlamydial infections, HPV typing)
  • For cervical smear see Papanicolaou test

References:[6][7][8]

Laboratory tests

Depending on the clinical presentation, other laboratory tests may be indicated:

Always perform a pregnancy test if a woman of child-bearing age presents with lower abdominal pain!References:[9][10]

Ultrasound

Transabdominal ultrasound

  • An abdominal ultrasound is the easiest method of assessing the uterus, ovaries, and adnexal structures.
  • Assessment of:
    • Urogenital tract
    • Assessment of fetal development (see ultrasonography during pregnancy)
    • Pelvic organs

Transvaginal ultrasound

  • Ovaries: : Performed to diagnose ovarian cysts, tumors, and follicular maturation
  • Uterus
    • Myometrium (e.g., to diagnose leiomyomas)
    • Endometrium
      • Echogenic layer in the long axis view of the uterus (referred to as the endometrial stripe)
      • Endometrial thickness varies with the menstrual cycle
      • Postmenopausal women with an endometrial thickness greater than 8 mm should undergo a follow-up ultrasound after 1–3 months
      • Postmenopausal women with an endometrial thickness greater than 10 mm should undergo hysteroscopy and endometrial curettage to rule out endometrial carcinoma.
  • Assessment of fetal development during the first trimester
  • Measurement of cervical length in cases of cervical incompetence

Breast ultrasound

Breast ultrasound can be used to assess breast lesions which were detected by palpation, mammography, and/or breast MRI scans. Ultrasound can also be used to assess the axilla for lymph node involvement if there is suspicion for breast cancer.

References:[11]

Additional diagnostics

Hysteroscopy

References:[12]

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  • 2. Feltmate CM, Feldman S, Goff B, Falk SJ. Colposcopy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/colposcopy. Last updated September 26, 2016. Accessed July 3, 2017.
  • 3. McNeeley SG. Cervical Polyps. https://www.msdmanuals.com/professional/gynecology-and-obstetrics/benign-gynecologic-lesions/cervical-polyps. Updated March 1, 2017. Accessed April 17, 2018.
  • 4. Weerakkody Y et al. Nabothian Cyst. https://radiopaedia.org/articles/nabothian-cyst. Updated January 1, 2018. Accessed April 17, 2018.
  • 5. Kleppa E, Holmen SD, Lillebø K, et al. Cervical ectopy: associations with sexually transmitted infections and HIV. A cross-sectional study of high school students in rural South Africa. Sex Transm Infect. 2014; 91(2): pp. 124–129. doi: 10.1136/sextrans-2014-051674.
  • 6. Hainer BL, Gibson MV. Vaginitis: diagnosis and treatment. Am Fam Physician. 2011; 83(7): pp. 807–815. url: https://www.aafp.org/afp/2011/0401/p807.html.
  • 7. Reichert RA. Diagnostic Gynecologic and Obstetric Pathology. Lippincott Williams & Wilkins; 2012.
  • 8. Pfenninger JL, Fowler GC. Pfenninger and Fowler's Procedures for Primary Care. Elsevier Health Sciences; 2010.
  • 9. Chourin S, Georgescu D, Gray C, et al. Value of CA 15-3 determination in the initial management of breast cancer patients. Ann Oncol. 2009; 20(5): pp. 962–964. doi: 10.1093/annonc/mdp061.
  • 10. Gadducci A, Cosio S, Carpi A, Nicolini A, Genazzani AR. Serum tumor markers in the management of ovarian, endometrial and cervical cancer. Biomed Pharmacother. 2004; 58(1): pp. 24–38. pmid: 14739059.
  • 11. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2004; 24(5): pp. 558–565. doi: 10.1002/uog.1704.
  • 12. Bradley LD. Overview of Hysteroscopy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-hysteroscopy. Last updated November 6, 2017. Accessed April 17, 2018.
last updated 11/19/2018
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