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📋 Lesson 11: Medical Investigations in Gynecological Patients

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1. Introduction

• Age (pubescence → adolescence → reproductive years → peri/postmenopause)
• Reproductive status (cycling, pregnant, postpartum, menopausal)
• Reproductive goals (desire to conceive or avoid pregnancy)

💡 Key principle: The history is the most powerful first tool — in most cases it points you toward the correct diagnosis and tells you which investigations to order. Never skip a thorough history.

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2. Patient History

Identifying Data

Chief Complaint

• Ask open-ended: "What kind of problem are you having?" or "How can I help you?"
• Let the patient tell her story — cutting her off can miss important clues

Present Illness

• For each complaint, obtain:
  • What exactly is it? Where is it?
  • When did it start? Sudden vs. gradual onset?
  • Is it getting better or worse?
  • Duration when symptoms occur
  • Relationship to other events (menses, intercourse, medications)

Past History

• Contraception use and type
• Medications and habits (smoking, alcohol)
• Previous medical and surgical history
• Allergies
• Obstetric, gynecological, sexual, and social history

Family History

• Familial heart disease, hypertension, diabetes
• Breast, ovarian, or other cancers (BRCA gene risk assessment!)
• Genetic illnesses

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3. Physical Examination

💡 The examination environment should be comfortable and non-threatening. A female chaperone/assistant should be present, and the physician should explain each step — especially during pelvic examination. This improves patient cooperation and is medico-legally important.

General Examination

• Vital signs, weight, height, BMI
• Heart rate, respiratory rate, blood pressure
• Look for systemic signs: pallor (anemia from heavy bleeding), hirsutism (PCOS), thyroid enlargement, etc.

Abdominal Examination

• Auscultation first, then palpation (standard order, especially if bowel sounds matter)
• Look for tenderness, masses, organomegaly
• Suprapubic palpation to identify uterus or bladder enlargement

Pelvic Examination

• Inspect pubic hair → folliculitis or pubic lice
• Inspect clitoris, labia, vestibular (Bartholin's) glands → enlargement, cysts, abscess
• Check perianal region for lesions

Vaginal / Speculum Examination

• Visualize the vagina and cervix
• Note discharge (color, consistency, odor), erosions, polyps, lesions

Bimanual Examination

• Two fingers inside vagina + opposite hand on lower abdomen
• Assess uterus: position, size, shape, mobility, consistency, tenderness
• Assess adnexae (ovaries & tubes): tenderness = PID, masses = cyst/tumor

Rectovaginal Examination (mandatory after age 40)

• Middle finger in rectum, index finger in vagina
• Feels for posterior masses, rectal wall involvement
• Tender nodules on uterosacral ligaments = classic sign of endometriosis
• Also used to stage gynecologic cancers

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4. Diagnostic Office Procedures

A. Tests for Vaginal Infection

• Normal vaginal pH = 3.8–4.5 (acidic, maintained by Lactobacillus)
• pH 4–5 → Fungal (Candida) infection
• pH 5.5–7 → Bacterial vaginosis (BV) or Trichomonas

• 1 drop vaginal discharge + 1 drop warm normal saline + coverslip
• Look for:
  • Motile trichomonads → Trichomonas vaginalis
  • Branching/segmented mycelia → Candida albicans
  • Clue cells (epithelial cells plastered edge-to-edge with coccobacilli) → Bacterial vaginosis

💡 Clue cells are pathognomonic of BV. The slide should be examined while still warm or trichomonads lose motility.

• 1 drop discharge + 1 drop KOH
• KOH dissolves human epithelial cells, leaving fungal elements (hyphae/mycelia) visible
• "Whiff test": fishy amine odor on adding KOH → strongly suggests BV

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B. Fern Test (Ferning / Spinnbarkeit Test) for Ovulation

• Cervical mucus is spread on a dry glass slide and allowed to air-dry
• Under microscope:
  • Fern-like (arborization) pattern = high estrogen, NO progesterone → pre-ovulation (ovulation hasn't happened yet)
  • No ferning = progesterone present → ovulation has occurred (luteal phase)
• Useful for timing of ovulation / detecting anovulation in infertility workup

💡 Think of it this way: estrogen makes cervical mucus watery and "fernable." After ovulation, progesterone makes it thick and kills the fern pattern.

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C. Schiller / Acetic Acid Test for Neoplasia

• Used when cervical or vaginal cancer/precancer is suspected
• Two agents used:
  1. Lugol's iodine solution → stains glycogen-rich normal squamous epithelium mahogany brown
  2. Acetic acid (3–5%) → causes abnormal/dysplastic cells to turn acetowhite (white)
• Any area that does NOT stain with iodine (or stains white with acetic acid) = abnormal → needs biopsy
• Abnormal areas = scar tissue, neoplasia, columnar epithelium

💡 Colposcopy is more accurate, but this test can be done with basic equipment. The principle: normal cells have glycogen (iodine-positive), cancer cells don't.

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D. Biopsy

💡 Endometrial biopsy (EMB) with the Pipelle is an office procedure — no operating room needed. It causes cramping similar to menstrual cramps. In postmenopausal bleeding, it is the first-line investigation to rule out endometrial cancer.

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5. Diagnostic Laboratory Procedures

Routine Tests

• Glucose screening (diabetes risk in gynecology: PCOS, metabolic syndrome)
• Lipid profile
• Urinalysis
• Thyroid panel (hypothyroidism → menstrual irregularities, infertility)

Cultures

• Urine culture → UTIs
• Urethral & cervical cultures → STIs (gonorrhea, chlamydia)
• Vaginal cultures

Specific STI Tests

Other

• Group B Streptococcus (GBS): screening swab at 35–37 weeks gestation (lower vagina → anus)
• Pregnancy test: urine or serum β-hCG

💡 NAAT for chlamydia/gonorrhea has replaced older culture methods because it's more sensitive and can be done on urine, vaginal swabs, or cervical swabs.

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6. Papanicolaou (Pap) Smear

• Purpose: Screening for cervical cancer and precancerous lesions (CIN — Cervical Intraepithelial Neoplasia)
• Sensitivity: ~95% for cervical carcinoma; ~50% for endometrial polyps/hyperplasia/cancer
• Frequency: Every 2–3 years after 3 consecutive normal results

Technique

1. Patient must not douche for ≥24 hours before; should not be menstruating
2. Speculum lubricated with water only (lubricating gel interferes with cytology)
3. Ectocervix: Plastic/wooden spatula rotated 360° at the squamocolumnar junction (transformation zone)
4. Endocervix: Cotton-tipped swab or cytobrush rotated 360° inside the cervical os
5. Specimens placed on slide separately or mixed
6. Preservative applied immediately — air drying ruins the sample

💡 The squamocolumnar junction (transformation zone) is where most cervical cancers arise, which is why sampling here is critical. The Pap smear is a screening test — a positive result always requires follow-up (colposcopy ± biopsy) for definitive diagnosis.

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7. Colposcopy

• A binocular microscope for direct, magnified visualization of the cervix
• Magnification: up to 60x (clinically most common: 13.5x)
• Can be fitted with a camera for photo documentation
• Allows visualization of:
  • Cellular dysplasia
  • Vascular abnormalities (abnormal vascular patterns like punctation, mosaic, atypical vessels)
  • Tissue abnormalities not visible to the naked eye
• Stains (acetic acid, Lugol's iodine) used to enhance visualization
• Guides targeted biopsy → replaced the need for "blind" random cervical biopsies

💡 Colposcopy indication: Abnormal Pap smear, persistent HPV high-risk, visible cervical lesion. Think of it as the "bridge" between Pap smear (screening) and biopsy (diagnosis).

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8. Hysteroscopy

• Visual examination of the uterine cavity using a fiberoptic hysteroscope

Distention Media

• Liquid: Normal saline, glycine, dextran 70
• Gas: CO₂ insufflation

💡 Distention is needed to open the collapsed uterine cavity for visualization.

Anesthesia

• IV sedation + paracervical block usually sufficient (can be done in office)

Applications (Diagnostic + Therapeutic)

• Abnormal uterine bleeding
• Resection of uterine synechiae (Asherman's syndrome) and septa
• Removal of polyps and IUDs
• Resection of submucous (intracavitary) fibroids
• Endometrial ablation (destruction of endometrium to treat heavy bleeding)

Failures

• Cervical stenosis
• Inadequate uterine distention
• Excessive bleeding or mucus

Complications

• Uterine perforation (most commonly at the fundus)
• Bleeding
• Infection
• Fluid/gas embolism from intravascular extravasation

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9. Culdocentesis

• Passage of a needle into the cul-de-sac (pouch of Douglas — the peritoneal space behind the uterus and in front of the rectum) through the posterior vaginal fornix

Interpretation of Fluid

⚠️ Culdocentesis is now rarely performed because transvaginal ultrasound can detect even small amounts of free fluid in the pouch of Douglas non-invasively. But it is still tested and important to know conceptually.

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10. Radiographic / Imaging Procedures

A. Plain Film (X-ray)

• Detects calcified lesions, dermoid cyst ring/teeth
• Shows displaced bowel loops from pelvic masses

B. Hysterography (HSG — Hysterosalpingography)

• Contrast medium instilled via cervical cannula → fluoroscopy
• Assesses:
  • Tubal patency (contrast spills from fimbriated ends = patent; no spill = blocked)
  • Uterine cavity abnormalities: congenital malformations (bicornuate/septate uterus), submucous fibroids, endometrial polyps
• Key use: Infertility workup

C. Sonohysterography (SIS — Saline Infusion Sonography)

• Uterine cavity filled with saline while ultrasound is simultaneously performed
• Better than HSG for intrauterine lesions (polyps, fibroids)
• No radiation exposure

D. Angiography

• Radiographic contrast to visualize blood vessels
• Uses in gynecology:
  • Locate source of pelvic hemorrhage (postoperative or cancer-related)
  • Uterine artery embolization (UAE) → to treat acute bleeding or shrink uterine fibroids

E. CT Scan (Computed Tomography)

• High-resolution 2D cross-sectional images
• With contrast → differentiates bowel/urinary organs from reproductive organs
• Best for:
  • Retroperitoneal lymphadenopathy (cancer staging)
  • Depth of myometrial invasion in endometrial carcinoma
  • Pelvic abscesses not found on ultrasound
  • Pelvic thrombophlebitis

💡 CT involves ionizing radiation, so it's not first-line in young women if ultrasound/MRI can answer the question.

F. MRI (Magnetic Resonance Imaging)

• Uses radiofrequency waves + magnetic field (no ionizing radiation)
• Advantages:
  • No harmful radiation
  • Excellent soft tissue differentiation (can distinguish fibroids from adenomyosis, cancer from inflammation)
  • Best for staging pelvic cancers
• Disadvantages:
  • Expensive
  • Poor at showing calcifications
  • Not suitable for patients with metal implants (pacemakers, certain clips)
• Main gynecologic use: Staging and follow-up of cervical, endometrial, and ovarian cancers

G. Ultrasonography

• First-line imaging in gynecology — simple, painless, no radiation
• Especially useful in:
  • Children (avoids pelvic exam)
  • Virginal women
  • Uncooperative patients
• Transabdominal: Requires full bladder (acts as acoustic window, elevates uterus out of pelvis)
• Transvaginal (TVS): Better resolution of uterus and ovaries (closer probe proximity)
• Diagnoses:
  • Normal early pregnancy
  • Ectopic pregnancy
  • Incomplete/missed abortion
  • Ovarian cysts, fibroids, ovarian torsion
  • Ovarian teratoma (dermoid cyst — echogenic fat)

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Quick Summary Table

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📝 Exam tip: The investigation hierarchy in gynecology is: History → Examination → Office tests (Pap/biopsy) → Lab → Ultrasound → Advanced imaging (CT/MRI). Each step refines the diagnosis.