OB/GYN: history and physical examination

The process of taking a history and performing a physical examination (H&P) in OB/GYN patients presents unique challenges. Because of the intimate aspect of an OB/GYN examination, it is important to establish trust and a private and relaxing setting for the patient. This article provides an overview of the possible content of the H&P of the OB/GYN patient. Depending on the patient's symptoms, additional and/or more targeted questions may also be relevant. See the “Medical history” and “Physical examination” articles for more information on general clinical examination.

General principles

• A key difference in OB/GYN history taking is the focus on the menstrual/menopausal history and sexual history.
• Patients may be hesitant to disclose certain aspects of their gynecologic history because of the sensitive nature of the topic. In some cases, it may be due to cultural differences or even a history of abuse.
• Be empathetic and try to create a comfortable environment for each of your patients, since it will encourage them to discuss matters more openly with you.
• If you feel that the patient is uncomfortable talking about their gynecologic history, start with a social or family history in order to establish rapport with the patient.

Gynecologic history

Chief concern and history of present illness

• Begin with a brief summary of the patient's age, parity, date of last menstrual period (LMP), and any current concerns the patient may have.
• Common chief concerns in gynecology
  • Vaginal bleeding should be evaluated based on the following:
    • Amount (e.g., spotting, heavy flow)
    • Relation to menstrual cycle/menopause/sexual contact (e.g, intermenstrual, postmenopausal, postcoital)
  • Vaginal discharge should be evaluated based on the following:
    • Color (e.g., bloody, brown, yellow, green, or gray)
    • Consistency (e.g., frothy, curd-like)
    • Amount
    • Smell (e.g., fishy)
  • Pruritic and/or erythematous vagina
  • Abdominal or pelvic pain, that can be described using the SOCRATES mnemonic:
    • Site
    • Onset
    • Character
    • Radiation
    • Associations
    • Time course
    • Exacerbating and relieving factors
    • Severity

To evaluate abdominal/pelvic pain, use the SOCRATES mnemonic: Site, Onset, Character, Radiation, Associations, Time course, Exacerbating and relieving factors, Severity.

Menstrual history

• Age at menarche
• Date of last menstrual period (LMP)
• Duration, regularity, flow and associated symptoms (e.g., dysmenorrhea, mittelschmerz)
• History of intermenstrual vaginal bleeding

Menopausal history (if applicable)

• Age at onset
• History of postmenopausal vaginal bleeding
• Associated symptoms (e.g., vasomotor symptoms)
• History of hormone replacement therapy

Past gynecologic history

• Previous gynecologic problems (including diseases of the breast)
• Previous gynecologic/pelvic surgeries (e.g., cervical conization, hysterectomy)
• History of sexually transmitted infections and/or pelvic inflammatory disorder
• Time and results of previous screening/diagnostic tests (e.g., Pap smear, mammography)

Past obstetric history

• See “Obstetric history” below for more information.

Sexual history

• Opening the discussion
  • Discussing a patient's health is often a sensitive matter. It is important to encourage the patient to be as descriptive as possible while remaining sensitive to the fact that they are sharing very private details of their life. Always remain empathetic and open to discussion.
  • If the patient seems hesitant, explain to them that this information is vital for forming an overall picture of their health and that it is as important as other aspects of their physical and mental health.
• Current/past sexual partners
  • Discussing the patient's current/past sexual partners is an important part of taking a patient's sexual history.
  • The following questions can be used:
    • “Are you currently sexually active? If no, have you ever been sexually active?”
    • “In recent months, how many sex partners have you had? In the past 12 months, how many sex partners have you had?”
    • “Are your sex partners men, women, or both?”: If a patient answers “both,” repeat the first two questions for each specific gender.
• Current/past sex practices
  • It is necessary to ask about the patient's sexual practices to understand their risk for sexually transmitted infections (STIs), the need for testing, and to guide a discussion regarding risk-reduction strategies.
  • Example: “I am going to ask you a few questions to better understand if you are at risk for STIs. What kind of sexual contact do you usually engage in (genital/oral/anal)?”
• Current/past contraception methods use
  • This part of sexual history is particularly important since the use of barrier contraceptive methods can significantly reduce one's risk of STIs. Therefore, collecting this information can be very helpful in terms of assessing one's risk of developing an STI.
  • Example: “Do you and your partner(s) use any contraceptive methods or practice any form of birth control?”
    • If no, ask them why not.
    • If yes, ask them which method of contraception they use and with what frequency.
  • If the patient is sexually active, be sure to ask them if they are trying to conceive. If so, ask (how long they've been trying and) if they are experiencing any difficulties.
  • Always give the patient the chance to ask questions about their sexual health including different types of contraception, their indications, contraindications, as well as the potential for STI transmission , and the benefit of using barrier contraceptive methods as an STI prophylaxis method.
• History of STIs
  • A history of STIs should cover the patient's previous diagnoses and/or treatments of STIs, the presence of recurrent symptoms, as well as past STI testing results.
  • The following questions can be used:
    • “Have you ever been diagnosed with an STI? When? How were you treated?”
    • “Have you ever been tested for HIV, or other STIs? Would you like to be tested?”
    • “Has your current partner or any former partner ever been diagnosed or treated for an STI? Were you tested for the same STI(s)? If yes, when were you tested? What was the diagnosis? How was it treated?”
• History of postcoital vaginal bleeding
• History of sexual dysfunction (e.g., dyspareunia, low libido)
• History of sexual abuse

The 5 Ps of a sexual history include Partners, Practices, Protection from STIs, Past history of STIs, and Prevention of pregnancy.

Medications and allergies

• Prescribed drugs
• Over-the-counter drugs
• Herbal remedies
• Allergies to drugs or environmental factors and reaction to each allergen

Family history

• Cancers of the reproductive system in the family (e.g., breast cancer and ovarian cancer with BRCA1/2 gene mutations)
• Endocrine disorders (e.g., diabetes mellitus, hypertension)

Social history

• Relationship status
• Socioeconomic status
• Occupation
• Drug and alcohol use

Review of systems

• See “Medical history” for more information on the complete review of systems.
• In the OB/GYN examination, a particular emphasis should be placed on the:
  • Urogenital system (e.g., dysuria, hesitancy, urgency, incontinence, change in bowel habits, rectal bleeding)
  • Abdomen (e.g., abdominal/pelvic pain)
  • Breasts
• For post/perimenopausal woman, it is important to ask about menopausal symptoms (e.g., hot flashes/night sweats, vaginal dryness, abnormal bleeding, irritability, depression, mood changes).

If you feel that the patient is not comfortable talking about their gynecologic history, start with social/family history in order to establish rapport with the patient.

Obstetric history

Obstetric history taking varies based on the setting (normal prenatal checkup vs. patient presenting with a concern).

Past obstetric history (GTPAL system)

• Gravida: number of times the patient has conceived
• Term pregnancies (≥ 37 weeks of gestation)
  • Mode of delivery (e.g., normal spontaneous vaginal delivery/NSVD)
  • Birth weight/gender of the baby
  • Maternal/fetal perinatal complications
  • Use of assisted reproductive therapies
• Preterm pregnancies (< 37 weeks of gestation)
• Abortions (elective or spontaneous before 20 weeks gestation )
• Living children or live births
• See “Clinical tasks” in the “Obstetrics and gynecology clerkship” article for more information on the GTPAL system.

GTPAL is an acronym used by doctors and nurses to sum up the obstetric history of a woman: Gravida, Term births, Preterm births, Abortions, Living children.

Current pregnancy

• Gestational age and expected day of delivery
• Beginning of prenatal care (e.g, use of folate, regular OB/GYN visits)
• History of teratogenic drug use
• History of maternal infectious diseases and immunization; See “Congenital TORCH infections” for more information.
• Prenatal diagnostic results (e.g., previous ultrasound findings)
• History of vaginal bleeding or fluid leakage during the current pregnancy
• Presence and frequency of fetal movement and uterine contractions
• Any other presenting complaints; See “Clinical signs of early pregnancy” in the “Pregnancy” article.

If the mother is not aware of previous perinatal complications, try asking her how soon she went home with the baby after the delivery.

Preliminary considerations

Because of the sensitive nature of this physical examination, patients are often anxious, which can further complicate the exam itself. It is important to make sure the patient feels comfortable prior to proceeding.

• Always begin by explaining the procedure, the tools being used (e.g., speculum), why the examination is being done, and what you are looking for.
• Ask the patient how they feel and give them a chance to clarify any concerns they have with you.
• Let the patient know that they are still in control throughout the process. Assure them that you will not proceed if they are in pain or distress. Asking questions such as, “Is this painful in any way?” or “Are you alright with me proceeding?” will give the patient the feeling that they can stop the process if needed and help them relax.
• Explain what a chaperone is and whether the patient would like to have one present during their examination.
• See “Physical examination” and “Diagnostic procedures in gynecology” articles for more information.

Instruments and equipment

• Gynecologic exam: gloves, lubricant, vaginal speculum, cervicovaginal swab, paper towels
• Obstetric exam: measuring tape, Pinard stethoscope or doppler transducer, ultrasound gel, paper towels

Breast examination ^[1][2]

Preparation

• Before proceeding to breast examination, ask the patient what part of the menstrual cycle they are currently in.
• Ask the patient about any specific concerns (e.g., detected mass during breast self-examination).
• After explaining the details of the procedure and obtaining the patient's verbal consent, invite the patient to get undressed.
• The patient should be sitting upright during the examination.

Breast inspection

• Evaluate the breasts' symmetry and shape (e.g., swelling, breast masses).
• Check for any changes in skin color or texture (e.g., redness, peau d'orange, mamillary eczema, ulcerations).
• Evaluate the presence of nipple discharge.

Breast palpation

• The dominant hand should be used for palpation while the other hand provides support.
• A thorough tactile evaluation can be achieved with the following:
  • Circular movements starting at the nipple and moving towards the periphery or vice-versa
  • Vertical palpation of linear segments
  • Palpation of each of the four breast quadrants
• Apply light pressure at first to scan for superficial changes and then proceed to deeper palpation of each of the breasts.
• Gently squeeze the sides of the nipple to detect the presence of any discharge.

Even though breast self-examination is not the most accurate tool for breast cancer screening, it still remains an important tool for breast health promotion and disease prevention in women ^[3].

Lymph node palpation

• The palpation of the regional lymph nodes should be performed in the following three positions:
  • The patient lets their arms hang loosely at their sides.
  • The patient rests their hands on the hips.
  • The patient crosses their arms behind the head.
• The following lymph nodes should be evaluated for size, tenderness, mobility, and firmness:
  • Axillary nodes (most common site of lymphatic spread from breast cancer)
  • Infraclavicular and supraclavicular nodes

Pelvic exam ^[4]

Preparation

• After explaining the details of the procedure and obtaining the patient's verbal consent, ask the patient to empty their bladder.
• Allow the patient to remove all clothes and underwear below the waist in privacy, and provide sheets for cover if necessary.
• Ask the patient to lay back in the lithotomy position on the examination chair.
• Ensure that all the equipment and instruments used during the procedure are warmed.

External genital exam

• Check the vulva for any abnormalities (e.g., swelling, irritation, ulcers, warts).
• Examine the skin for the presence of scars, discoloration, and hair distribution.
• Inspect the vaginal introitus for discharge or swelling.
• Ask the patient to perform the Valsalva maneuver and examine the vaginal introitus for organ prolapse or urinary incontinence.
• Palpate the labia majora for any masses or tenderness.

Bimanual pelvic exam

• Lubricate the index and middle fingers of one hand and slowly insert them into the vaginal canal.
• Use the other hand to simultaneously palpate the abdomen.
• This procedure allows for palpation of both the uterus and adnexa (e.g., their localization, size, tenderness during manipulation, presence of masses).

Rectovaginal pelvic exam ^[5]

• Lubricate the index and middle fingers of one hand and slowly insert them into the vaginal canal and rectum respectively.
• Use the other hand to push the uterus posteriorly by pressing on the anterior abdominal wall.
• This procedure allows for the palpation of the rectovaginal septum, cul-de-sac tenderness, or masses.
• The rectovaginal exam is usually reserved for patients with suspected pelvic masses (e.g., colorectal cancer).

Sterile speculum exam ^[6]

• Before proceeding to the speculum exam, remind the patient about the procedure and ensure they are comfortable before beginning.
• Choose the appropriately sized speculum and lubricate it. ^[7]
• Separate the labia majora with the index and middle fingers and gently introduce the speculum inside the vaginal canal with the blades facing down and the handle pointing to the side.
• After fully advancing the speculum, carefully rotate it to 90° so that the blades are in a horizontal position, with the handle pointing down.
• Only after the speculum has been placed in its final position, remove the fingers and slowly open the speculum.
• Lock the screws on the speculum after getting a good visualization of the cervix.
• Inspect the cervix and the cervical os for the following:
  • Position (e.g., anteriorly displaced cervix in a patient with a retroverted uterus)
  • Color (e.g., ectocervical reddening due to the development of cervical ectropion )
  • Abnormal discharge (e.g., mucopurulent discharge in gonococcal cervicitis)
  • Erosions and ulcerations (e.g., HSV infection)
  • Hemorrhages (e.g., strawberry cervix in trichomoniasis)
  • Cervical masses (e.g., polyps, cervical cancer)
• Take a cervical swab/Pap smear if necessary.
• Loosen the screws, close the speculum partially , and slowly return it to its original position at insertion (i.e., with the blades facing down and the handle pointing to the side). ^[7]
• Carefully extract the speculum and inspect the vaginal introitus.

If the view of the cervix is obscured during a speculum exam by prolapse of the vaginal walls, a condom with the tip cut off may be rolled over the speculum to help keep them retracted while the speculum is open. ^[7]

After the procedure

• Inform the patient that the procedure is over and allow them to get dressed in privacy.
• Provide paper towels to the patient if needed.
• Dispose of the used equipment and wash your hands.
• Summarize and discuss the results of the exam with the patient.

Ask the patient to empty their bladder before proceeding to the pelvic exam.

Do not open the speculum until it has been fully inserted in the vaginal canal and placed in its final position. Do not extract the speculum in its fully open position.

See “Prenatal care” and “Childbirth” for more information.