- Clinical science
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.
- 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
- The amount of vaginal discharge varies by individual and by the stage of the menstrual cycle
Signs that vaginal discharge may be pathologic
- Malodorous (e.g., fishy)
- Abnormal consistency (e.g., frothy, curd-like)
- Bloody, brown, yellow, green, or gray color
- Symptoms indicating pathologic discharge
- Physiologic leukorrhea
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!
- 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)
- No further evaluation necessary
- Cervical ectopy: a state in which the squamous cell epithelium of the ectocervix is replaced by columnar cell epithelium of the endocervix under the physiological influence of estrogen (e.g., pregnancy, certain oral contraceptives). Cervical ectopy is seen on colposcopy as a sharply demarcated bright red area with papillary structures.
- Transformation zone: : the area between the non-keratinized squamous epithelium of the ectocervix and the columnar epithelium of the endocervix; . The transformation zone is a common site for infections and dysplastic changes.
- Nabothian cysts: retention cysts that arise in the transformation zone . These cysts have no pathological significance.
Cervical polyps: hyperplastic cervical epithelium
- Clinical features: vaginal bleeding
- Malignant degeneration is rare
- Treatment: surgical resection; of the polyp and cauterization of the polyp's pedicle to prevent recurrence
- Require further evaluation
- White lesions under acetic acid application:
- White membrane that cannot be scraped off:
- Punctate lesions or coarse mosaic pattern:
- Atypical vessels:
- Normal findings: cylindrical Lactobacilli (Doderlein's bacilli)
- Pathological findings:
|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
Depending on the clinical presentation, other laboratory tests may be indicated:
- Inflammatory parameters if adnexitis, mastitis, and/or endometritis are suspected
- Pregnancy test
- Hormone levels for work-up of infertility
- Renal function tests and urinalysis if urinary symptoms are present
- Serum transaminase (AST, ALT) and alkaline phosphatase (ALP) levels, If liver or bone metastases are suspected
- Tumor markers
- An abdominal ultrasound is the easiest method of assessing the uterus, ovaries, and adnexal structures.
- Assessment of:
- Urogenital tract
- Assessment of fetal development (see
- Pelvic organs
- Ovaries: : Performed to diagnose ovarian cysts, tumors, and follicular maturation
- Myometrium (e.g., to diagnose leiomyomas)
- 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 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 .
- A fiberoptic scope is introduced transcervically into the uterus to diagnose and/or treat uterine pathologies.
- Commonly done as part of the work-up for abnormal uterine bleeding.
- Hysteroscopy can be combined with diagnostic/therapeutic uterine curettage.