Clinical Clerk Arbado, Pearl Joy

RIC: Dr. Angela Saldajeno

Consultant: Dr. Donna Alindong
 OFFICE GYNECOLOGY
annual well-woman visit
can attend to current
gynecologic concerns
promote disease
prevention
assess risks for potential
disease
provide the indicated
physical examination or
tests
 OFFICE GYNECOLOGY
first visit generally involves taking a:
complete history
performing a complete physical examination
ordering appropriate screening or laboratory
tests
GYNECOLOGIC HISTORY
GYNECOLOGIC HISTORY
PERTINENT GYNECOLOGIC HISTORY
menstrual history
MIDAS
last menstrual period
characteristics of the menstrual flow
color, the amount of flow, and accompanying
symptoms, such as cramping, nausea,
headache, or diarrhea
postmenopausal woman
the age at last menses
history of hormone replacement therapy
postmenopausal bleeding
PERTINENT GYNECOLOGIC HISTORY
previous pregnancies
deliveries
year of birth
gestational age at delivery
type of delivery
infant birth weight
complications
PERTINENT GYNECOLOGIC HISTORY
history of vaginal and pelvic infections
types of infection
treatment received
complications
risk factors for human immunodeficiency virus (HIV)
infection
intravenous drug abuse or coitus with drug
abusers or bisexual men
PERTINENT GYNECOLOGIC HISTORY
Pap smear screening history
date of the last Pap smear
frequency of screening
any abnormal tests and the treatment.
human papilloma virus (HPV) vaccination status
should be determined
PERTINENT
GYNECOLOGIC
HISTORY
PERTINENT GYNECOLOGIC HISTORY
contraceptive history
methods used
length of time
effectiveness
complications
PERTINENT GYNECOLOGIC HISTORY
gynecologic surgical procedures
office procedures
endometrial biopsies
vulvar, vaginal, or cervical biopsies
minor or major procedures
laparoscopy or laparotomy
dates, types of procedures, diagnoses, and
significant complications
In cases where pertinent, past records, particularly
operative and pathology reports, should be sought.
PERTINENT GYNECOLOGIC HISTORY
PERTINENT GYNECOLOGIC HISTORY
Symptoms of pelvic pain or discomfort
location
timing
quality
radiation to other body areas
intensity
duration
GENERAL HEALTH HISTORY
significant health problems that she has had during
her lifetime
including all hospitalizations and operative
procedures
FAMILY
HISTORY
NUTRITIONAL AND DIETARY ASSESSMENT
Assessment of folic acid is important in reproductive-
aged women.
Asking about fruits and vegetables as well as
calcium-containing foods should be standard.
 GENERAL EVALUATION
American College of Obstetricians and Gynecologists
(ACOG) reaffirmed its recommendation that the
annual examination include obtaining:
vital signs
body mass index (BMI)
palpating the abdomen
palpating inguinal lymph nodes
overall assessment of the patient’s health
 PHYSICAL EXAMINATION
general evaluation of the patient’s appearance and
affect
weight, height, and blood pressure
body mass index (BMI)
thyroid gland should be palpated for irregularities or
increase in size (goiter).
patient’s neck should be palpated for evidence of
adenopathy along the supraclavicular and posterior
auricular chains.
GENERAL EVALUATION
 BREAST EXAM
ACOG, American Cancer Society (ACS), and National
Comprehensive Cancer Network (NCCN) all
recommend CBE
every 1 to 3 years for women ages 20 to 39 and
yearly thereafter
A careful breast examination should be carried out in
a systematic fashion.
BREAST
EXAM
 ABDOMINAL EXAM
inspected for symmetry, scars, masses, distension,
and visible organomegaly.
The hair pattern should be noted.
 ABDOMINAL EXAM
auscultation for bowel sounds
abdominal percussion
abdomen should be palpated for
organomegaly
adnexal masses
groin should be palpated for adenopathy and
inguinal hernias.
 PELVIC EXAM
ACOG continues to recommend that the pelvic exam,
including an external genital evaluation, speculum
exam, and bimanual exam, be performed yearly in
adult women
 PELVIC EXAM
pelvic examination is conducted with
patient lying supine on the examining table with her
legs in stirrups and a sheet draped across her.
The physician should be sure the patient is as relaxed
as possible and should take a few minutes to
describe the procedure and allow the patient to
prepare herself.
Suggesting that the patient allow her legs to fall wide
apart and concentrate on relaxing her abdominal
muscles may be helpful.
 PELVIC EXAM
INSPECTION
vulva and introitus
quality and pattern of the hair on the mons and
the labia majora
evidence of body lice (pediculosis)
skin of the vulva/perineum is inspected for
erythema, excoriation, discoloration, or loss of
pigment and for the presence of vesicles,
ulcerations, pustules, warty growths, or
neoplastic growths.
pigmented nevi or other pigmented lesions
Skin scars denoting previous episiotomy or other
laceration
 PELVIC EXAM
vulva
specific structures of the vulva should be
systematically evaluated
clitoris should be noted and its size and shape .
introitus should be observed closely
Whether the hymen is intact, imperforate, or open
whether the perineum gapes or remains closed in the
usual lithotomy position should be noted.
PELVIC
EXAM
PELVIC EXAM: PALPATION
labia minora are gently separated
urethra is inspected and the length of the urethra is
palpated and “milked” with the middle finger
Any pus expressed from the urethra should be
submitted for Gram stain and cultured, because it is
occasionally found to contain gonococci.
PELVIC EXAM: PALPATION
area of the posterior third of the labia majora is
palpated by placing the index finger inside the
introitus and the thumb on the outside of the labium
enlargements or cysts of Bartholin glands are noted.
this exam should be performed on each side.
SPECULUM
EXAMINATION
Grave and the Pederson specula.
Pederson speculum is narrower
and may be more appropriate for
virginal or nulligravid women
women with a history of sexual
abuse
vaginal pain or dyspareunia
postmenopausal women
Each is available in several sizes
corresponding to length of the
blades (small, medium, large, extra
large)
 SPECULUM EXAMINATION
speculum is then inserted by placing the transverse diameter of
the blades in the anteroposterior position and guiding the blades
through the introitus in a downward motion with the tips pointing
toward the rectum.
Once the blades are inserted, the speculum should be turned so
that the transverse axis of the blades is in the transverse axis of
the vagina.
The blades should be inserted to their full length and then
opened so that the physician may inspect for the position of the
cervix.
Once the blades are inserted and the cervix is visualized, the
speculum should be opened and the introitus widened so that
the cervix can be adequately inspected and any indicated
specimens obtained.
 SPECULUM EXAMINATION
inspects the vagina and cervix
vaginal canal is inspected during the insertion of the speculum
and upon its removal
vaginal epithelium should be noted for evidence of erythema or
lesions.
Vaginal lesions, such as areas of adenosis, clear cystic structures
(Gartner cysts), or inclusion cysts on the lines of scars or
episiotomy incisions, should be noted.
Any concerning fluid discharge is collected for wet mount and
potential culture.
 SPECULUM EXAMINATION
Saline wet mount
allows for visualization of normal vaginal epithelial cells as
any abnormal findings such as motile trichomonads, clue cells
(vaginal epithelial cells studded with adherent coccobacilli,
indicative of bacterial vaginosis), or polymorphonuclear
leukocytes (indicative of inflammation).
potassium hydroxide wet mount
includes the whiff-amine test, which, if positive for a distinct
fishy odor, may indicate bacterial vaginosis
inspection of the slide may reveal hyphae and budding yeast,
indicative of Candida vaginitis.
 SPECULUM EXAMINATION
gold standard is nucleic acid amplification testing (NAAT) of the
urine or vaginal/cervical discharge, rather than a culture.
Yearly chlamydia testing is recommended for all sexually active
women up to age 25
 SPECULUM EXAMINATION
cervix should be pink and without lesions
nulliparous individual
external os should be round.
parous
external os takes on a slitlike appearance
cervical lacerations
healed stellate lacerations may be noted
 SPECULUM EXAMINATION
Any lesions of the cervix should be noted and, where appropriate,
a biopsy should be performed.
In a patient with acute herpes simplex, vesicles or ulcers may be
noted.
In a patient infected with human papillomavirus, warts
(condylomata acuminata) on the cervix may also be observed.
 PAPANICOLAOU SMEAR
incidence of invasive cervical cancer has been reduced by 50%.
initial screening should begin at age 21 regardless of sexual
activity.
For women ages 21 through 29, screening should occur every 3
years.
Women ages 30 to 65 can either have co-testing (Pap plus high-
risk human papillomavirus [HPV] testing) or just a routine Pap test.
Repeat co-testing occurs every 5 years, whereas Pap testing
alone continues on an every 3-year basis.
Pap smear screening is no longer recommended in women after
age 65, if she has had normal adequate testing over the past 10
years and she has not been treated for high-grade dysplasia
within the past 20 years.
PAPANICOLAOU SMEAR
PAPANICOLAOU SMEAR
PAPANICOLAOU SMEAR
BIMANUAL EXAMINATION
RECTOVAGINAL
EXAMINATION
OFFICE GYNECOLOGY
PROCEDURES
 CERVICAL CANCER
Cervical cancer is the most common gynecologic cancer in
women worldwide.
Most of these cancers stem from infection with the human
papillomavirus (HPV)
develops in a younger population.
screening for this neoplasia typically begins in young adulthood.
Most early cancers are asymptomatic.
Thus, diagnosis usually follows histologic evaluation of biopsies
taken during colposcopic examination or from a grossly
abnormal cervix.
This cancer is staged clinically, and this in turn directs treatment.
early-stage disease is effectively eradicated surgically.
advanced disease, chemoradiation is primarily selected.
 CERVICAL BIOPSY
Histologic evaluation of cervical biopsy is the primary tool to
diagnose cervical cancer.
Pap testing has only a 53- to 80-percent sensitivity for detecting
high-grade lesions on any given single test
Pap testing alone for evaluation of a suspicious lesion is
discouraged.
Instead, these lesions are directly biopsied with Tischler biopsy
forceps or a Kevorkian curette
CERVICAL BIOPSY
CERVICAL BIOPSY
 COLPOSCOPY
outpatient procedure examines the lower anogenital tract with a
binocular microscope affixed to a stand
requires skills that encompass colposcopic terminology, lesion
identification and grading, and biopsy techniques.
primary goal is to identify invasive or preinvasive neoplastic
lesions for directed biopsy and subsequent management.
It remains the gold standard evaluation of patients with
abnormal cervical cytology.
 COLPOSCOPY
colposcope contains a stereoscopic lens or digital imaging
system that has magnification settings ranging from 3- to 20-fold.
Its stand allows positioning, and a high-intensity light provides
illumination. A green (red-free) light filter adds contrast to aid
vascular pattern evaluations
COLPOSCOPY
COLPOSCOPY
 CERVICAL CRYOTHERAPY
Used to safely and effectively ablate the cervix transformation
zone and CIN lesion
This method uses compressed gas to create extremely cold
temperatures that necrose cervical epithelium.
Cryoprobe, an interfacing tip made of silver or copper, allows
contact with and conduction of extreme cold across the cervix
surface.
When nitric oxide gas is used, probe temperatures can reach –
65°C. Cell death occurs at –20°C
 CERVICAL CRYOTHERAPY
Cryotherapy typically requires a tank of refrigerant gas plus a
cryogun, connecting tubing, pressure gauge, and cryoprobe.
Nitric oxide and carbon dioxide are frequently used refrigerant
gases.
Gas moves through connecting tubing, into the barrel of the
cryogun, and then to the cryoprobe tip.
Circumferential grooves at the cryoprobe base allow it to be
screwed securely to the end of the cryogun.
 CERVICAL CRYOTHERAPY

1 Analgesia and Patient

Positioning.
may be performed in an office setting
requires no significant analgesia
standard dorsal lithotomy position
3
First Thaw.
After the first freeze, the trigger is
released.
removed from the cervix
surface of the cervix is allowed to
thaw during the following 5
vaginal speculum is placed. minutes.
No vaginal cleansing prep is required.
The appropriate-sized cryoprobe is

3
attached onto the end of the cryogun

2
barrel. Second Cycle
Iceball Formation. freezing cycle is repeated for an
additional 3 minutes.
probe is then pressed firmly against At completion of the second cycle,
the cervix the cryoprobe and speculum are
cryogun trigger is squeezed removed.
frost begins to cover the probe
The trigger is held for 3 minutes as
the iceball extends past the outer
margin of the cryoprobe
CERVICAL CRYOTHERAPY
 ENDOMETRIAL BIOPSY
Indications
In women with AUB, sampling and histologic evaluation of the
endometrium may identify infection or neoplastic lesions such
as endometrial hyperplasia or cancer.
 ENDOMETRIAL BIOPSY
Sampling Methods
Initial office techniques used metal curettes.
Endometrial samples that are removed with these curettes
show significant positive correlation with histologic results
obtained from hysterectomy specimens
Prior to performing endometrial biopsy, pregnancy is
excluded in women of reproductive age.
With Pipelle insertion, patients frequently note cramping,
which can be allayed by a preprocedural NSAID.
Slow transcervical intrauterine instillation of 5 mL of 2-percent
lidocaine using an 18-gauge angiocatheter can lower
perceived pain scores
ENDOMETRIAL BIOPSY
A
Pipelle is inserted through the cervical os and
directed to the uterine fundus.

B
stilette of the Pipelle is retracted to create
suction within the cylinder.

C
Pipelle is withdrawn to the level of the internal
cervical os and advanced back to the fundus.
The Pipelle is gently turned during its advance
and retraction to allow thorough sampling of all
endometrial surfaces.
 ENDOMETRIAL BIOPSY
limitations to endometrial sampling with the Pipelle device

1 tissue sample that is inadequate for histologic evaluation

such as from endometrial atrophy, or an inability to pass the
catheter into the endometrial cavity

2 cancer-detection failure rate of 0.9 percent

3 associated with a greater percentage of false-negative results

with focal pathology such as endometrial polyps.
 SALINE INFUSION SONOGRAPHY
simple, minimally invasive, and effective sonographic procedure
can be used to evaluate the myometrium, endometrium, and
endometrial cavity
SIS typically permits superior detection of intracavitary masses
and differentiation of lesions as being endometrial, submucous,
or intramural
 CARBON DIOXIDE LASER CERVICAL
ABLATION
carbon dioxide (CO2 ) laser produces a beam of infrared light
that produces heat at its focal point sufficient to boil intracellular
water and vaporize tissue.
used for cases in which the entire transformation zone can be
seen with satisfactory colposcopy.
CARBON DIOXIDE LASER CERVICAL
ABLATION
CARBON DIOXIDE LASER CERVICAL ABLATION

1 3
Analgesia and Patient
Ablation
Positioning four dots are ablated at 12, 3, 6,
Most procedures are performed as an and 9 o’clock positions on the
outpatient procedure in the office or perimeter of the cervix to surround
emergency room. the entire lesion
local analgesia combined with a Once encircled, the area is ablated
vasoconstrictor is sufficient to a depth of 5 to 7 mm

4
standard dorsal lithotomy position
matte-surfaced speculum is inserted Endocervical Eversion
smoke evacuation tubing is attached to a
port on the speculum. tissue immediately surrounding the
Lugol solution is applied. endocervix is ablated less deeply.

2 5
Laser Settings Hemostasis
power density (PD) of 600 to 1200 W/cm2 defocused laser beam and a lower
in a continuous wave mode. Average PD = power setting in a super pulse
100 × W / D2 wave mode will coagulate vessels
and aid hemostasis.
Bleeding present at the end of
surgery may also be controlled with
an application of Monsel paste.
Bartholin Gland Duct Incision and Drainage
are vulvar masses encountered routinely in office gynecology
Bartholin duct cysts
1 to 4 cm in diameter: frequently asymptomatic
larger cysts: vaginal pressure or dyspareunia
Gland duct abscesses
rapid unilateral vulvar enlargement
significant pain
fluctuant mass is found on:
one side of the introitus, external to the hymenal ring
lower aspects of the vulva
Bartholin Gland Duct Incision and Drainage
goal of Bartholin gland duct I & D is to empty the cystic cavity
and create a new accessory epithelialized tract for gland
drainage
Word catheter is used
Bartholin Gland Duct Incision and Drainage

1 3
Analgesia and Patient
Word Catheter Placement
Positioning deflated Word catheter tip is
Most procedures are performed as an placed into the empty cyst cavity
outpatient procedure in the office syringe is used to inject 2 to 3 mL
or emergency room. of sterile saline through the
standard dorsal lithotomy position catheter hub to inflate the balloon.
ipsilateral labial skin is cleaned with
a povidone-iodine solution
Local analgesia: lidocaine solution.

2 Drainage
incision is made atop the cyst, is
placed just outside and parallel to
the hymen at 5 or 7 o’clock
(depending on the side involved),
and is positioned medial to Hart line.
Mucus drained from a Bartholin cyst
cavity is explored with a small cotton
swab tip to open potential pus or
mucus loculations
Bartholin Gland Duct Incision and Drainage
 WIDE LOCAL EXCISION
It removes the preinvasive lesion, offers a tissue specimen for
exclusion of invasive disease and evaluation of surgical margins,
and compared with simple vulvectomy, lowers patient morbidity.
 WIDE LOCAL EXCISION

1 3
Analgesia and Patient Incision
Positioning elliptical incision is preferred
Adson forceps or skin hooks can
smaller labial or perineal lesions may elevate and retract the skin margin
easily be excised using local away from the incision line.
analgesia in an office setting Dissection beneath the lesion
standard dorsal lithotomy position begins at the incision periphery and
progresses toward the center of
the proposed excision area and
then to the opposite incision

2
margin.
Lesion Identification
area of excision should be well
demarcated
colposcopic examination following
application of 3- to 5-percent acetic
4 Margin Undermining
surgeon may need to sharply
undermine the skin at the wound
margins with fine scissors to mobilize
the skin and immediate underlying
subcutaneous tissue
acid to the vulva will aid

5
identification of lesion margins
Most recommend a 5-mm Wound Closure
circumferential surgical margin edges of the skin are then
surrounding the lesion reapproximated with interrupted
stitches using 3-0 or 4-0 gauge
delayed-absorbable sutures
WIDE LOCAL EXCISION
Thank you!