History taking and general physical examination
Taking a gynecological history requires a detailed clarification of reproductive function: age of sexual debut and first pregnancy, total number and outcomes of pregnancies (including childbirth, induced, spontaneous, or illegal abortions, as well as ectopic pregnancies and hydatidiform mole). It is essential to screen for contact bleeding after sexual intercourse and spotting after physical exertion or defecation.
General examination includes assessing body build (female, male, or eunuchoid type), searching for phenotypic features (pterygium colli, high-arched palate, retrognathia, short stature), and calculating the body mass index (BMI). A BMI exceeding 40 kg/m² indicates grade IV obesity.
Breast examination is performed while standing in two positions (arms lowered and arms behind the head), assessing the contours, symmetry, and condition of the nipple-areolar complex. If discharge is present, an imprint smear is taken on a glass slide:
- Bloody discharge is characteristic of an intraductal papilloma.
- Purulent discharge indicates mastitis.
- Milky discharge (galactorrhea) indicates hyperprolactinemia.
X-ray mammography is prescribed in the 1st phase of the cycle for women over 35 years of age (the method is contraindicated under 35, as well as during pregnancy and lactation; in young patients, ultrasound with color Doppler mapping is used instead).
Objective examination of the abdomen and pelvis
Abdominal examination is performed in the supine position. Palpation of the abdominal wall reveals its tension — a key symptom of peritoneal irritation in acute adnexitis or peritonitis. Percussion clarifies organ borders and the presence of free fluid, while auscultation is performed after laparotomy to diagnose intestinal paresis.
A gynecological examination in the gynaecological chair is performed with an emptied bladder and rectum:
- Inspection of external genitalia: evaluation of the gaping of the vulvar cleft and the straining test to detect prolapse of the vaginal walls and uterus.
- Speculum examination: performed only in sexually active women. It allows for visualization of the cervix, taking smears for flora and cytological examination, and performing a biopsy.
- Bimanual examination: performed strictly after removing the specula. Using vaginal fingers of one hand and the abdominal hand on the outside, the position, size, shape, consistency, mobility, and tenderness of the uterus and appendages are assessed.
- Rectovaginal examination: mandatory in postmenopause and in women over 40 years of age to assess the appendages, sphincter tone, and pelvic floor muscles.
Normal topography of internal genital organs
In a healthy sexually mature woman, the uterine fundus is directed upward and does not project beyond the plane of the pelvic inlet, while the external os is located at the level of the spinal plane.
The anatomical norm is the position of anteversion (anterior tilt of the uterus) and anteflexion (body and cervix form an obtuse angle opening anteriorly). The normal position of the organs is ensured by the intrinsic tone of the genital organs (depending on hormone levels and the state of the nervous system) and their anatomical relationship with adjacent organs (bladder, urethra, and rectum).
Functional diagnostic tests
To indirectly assess ovarian hormonal function and the nature of the menstrual cycle, a set of tests is used:
- «Pupil» sign: reflects cervical mucus secretion under the influence of estrogens. During ovulation, the os dilation is maximal (+++, up to 3 mm), whereas in the luteal phase, it decreases under the action of progesterone to (+).
- Mucus elasticity test: under the influence of estrogens, by the time of ovulation, the mucus thread taken with ring forceps stretches up to 12 mm.
- Karyopycnotic index (KPI): the percentage of cornified cells in a vaginal smear; reaches 60–80% during ovulation.
- Basal body temperature: in an ovulatory cycle, the curve is biphasic — after ovulation, the temperature rises by 0.5 °C and remains elevated for 12–14 days. A monophasic curve indicates anovulation.
- Endometrial biopsy histology: sampling material 2–3 days before menstruation reveals secretory changes in the endometrium, confirming ovulation (method accuracy up to 90%).
Remember the sequence of the vaginal examination — SPECULA before BIMANUAL: first, inspect the cervix with specula and take smears, and only after removing the specula perform bimanual palpation.
Class and exam questions
What are the contraindications to X-ray mammography?
X-ray mammography is contraindicated in women under 35 years of age, as well as during pregnancy and lactation. In these groups, ultrasound examination is preferred.
What does a biphasic basal body temperature curve indicate?
A biphasic chart with a sustained temperature rise of 0.5 °C in the second phase lasting 12–14 days indicates that ovulation has occurred and reflects adequate secretory activity of the corpus luteum.
What is the purpose of the straining test during the examination?
The straining test during visual inspection of the external genitalia allows for the timely identification of occult prolapse of the vaginal walls and uterus.
What else to study on this topic
- Indications and technique of ductography for nipple discharge
- Diagnosis of dysmorphic stigmata in the practice of an obstetrician-gynecologist
- Cytological evaluation of the KPI in various phases of the menstrual cycle
- Features of rectal and rectovaginal examination in women over 40 years of age
- Methods for laboratory verification of genital tract infections (bacterioscopy, PCR, culture method)
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