Gynaecological History and Examination
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Direct answer
Gynaecological history and examination means taking a structured menstrual, obstetric, sexual and contraceptive history, then combining speculum inspection with bimanual palpation of the uterus and adnexa. The menstrual history centres on cycle length, bleeding duration and volume, and intermenstrual or postcoital bleeding. Findings are interpreted together, because no single examination finding is diagnostic on its own.
What you must remember
- Menstrual history: Record menarche, last menstrual period, cycle length (normally about 21 to 35 days) and bleeding duration (usually up to about seven days).
- Bleeding volume: Heavy menstrual bleeding is classically defined as loss above 80 mL per cycle, which the pictorial blood assessment chart estimates indirectly.
- PALM-COEIN: Structural causes are polyp, adenomyosis, leiomyoma and malignancy or hyperplasia; non-structural causes are coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified.
- Sexual and contraceptive history: Ask about partners, sexually transmitted infections, contraceptive use and cervical screening; postcoital or intermenstrual bleeding needs cervical assessment.
- Speculum examination: Inspect the vulva, vagina and cervix for discharge, ectropion, polyps, ulcers or friable lesions, and take cervical samples when due.
- Bimanual examination: Assess uterine size, position, mobility and tenderness, and palpate both adnexa with the second hand on the abdomen.
- Unmarried women: Avoid speculum examination unless essential; use rectal examination or ultrasound, with consent and a chaperone.
Reading the pelvic examination
A 28-year-old with pelvic pain and heavy periods is examined in a fixed sequence. The table links common examination findings to the differential the examiner should hold. The examination begins with inspection of the external genitalia and abdomen before any internal assessment.
| Examination finding | Differential to consider |
|---|---|
| Bulky, firm, irregular uterus | Fibroids; malignancy must be excluded if the uterus is hard or enlarging quickly |
| Diffusely enlarged, tender uterus | Adenomyosis |
| Tender, fixed, retroverted uterus with nodular uterosacral ligaments | Endometriosis |
| Cervical motion and adnexal tenderness with discharge | Pelvic inflammatory disease |
| Hard, fixed, irregular adnexal mass | Ovarian malignancy until proved otherwise |
Examination findings are rarely diagnostic alone, so they are checked against ultrasound, blood tests and the history. Documentation should record the size, consistency, mobility and tenderness of each organ examined, so that later examinations can be compared.
A normal examination does not exclude pathology, so imaging is ordered when the history and examination disagree. The examiner also notes whether pain, a full bladder or anxiety limited the findings, because those limits affect how confidently the result can be read.
Where the exam tries to catch you
Viva questions usually test the examination sequence and the consent step.
- Trap: Performing a speculum examination on a virgin to look for a cervical cause. Correct: Rectal examination or ultrasound is used instead, since speculum examination is avoided unless essential.
- Trap: Calling a cervical polyp or ectropion malignant on sight. Correct: Ectropion is common and benign, but a friable or ulcerated lesion needs biopsy rather than reassurance.
- Trap: Reading a uniformly enlarged, tender uterus as fibroids. Correct: Fibroids are firm and irregular, while a diffusely enlarged, tender uterus suggests adenomyosis.
Frequently asked questions
What is the normal menstrual cycle length used in gynaecological history?
A normal menstrual cycle lasts about 21 to 35 days in adults, and bleeding typically lasts up to about seven days. Cycles or bleeding outside these ranges need further evaluation.
What does PALM-COEIN classify in abnormal uterine bleeding?
PALM-COEIN classifies abnormal uterine bleeding into structural causes, namely polyp, adenomyosis, leiomyoma and malignancy or hyperplasia, and non-structural causes, namely coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified.
How is an unmarried patient examined when a pelvic assessment is needed?
An unmarried patient is usually examined with a rectal examination or transabdominal or transrectal ultrasound rather than a speculum examination, unless one is essential. Consent and a chaperone are needed at every step.
What does a tender, fixed uterus with nodular uterosacral ligaments suggest?
Tenderness, fixity of the uterus and nodular uterosacral ligaments suggest endometriosis, particularly deep infiltrating disease. Ultrasound or MRI and laparoscopy are used to confirm it.
What does bimanual examination assess in the uterus?
Bimanual examination assesses the uterus for size, position, mobility, consistency and tenderness, and it also palpates the adnexa. Precise documentation of these findings allows later examinations to be compared.