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The reproductive system


Breast

Anatomy and physiology

The adult breast lies over the pectoralis major and serratus anterior muscles; it extends from the lateral border of the sternum into the lower axilla as the tail of Spence. The centre of the breast is the nipple, which is composed mostly of smooth muscle fibres. The areola is the pigmented skin around the nipple that contains numerous Montgomery glands. The breast is divided into four quadrants by two invisible lines running horizontally and vertically through the nipple ( Fig. 11.1 ). Accessory breast tissue ( Fig. 11.2 ) is usually found in the axilla, whilst accessory nipples are most commonly seen just inferior to a normal breast or above the groins.

Fig. 11.1, Adult right breast.

Fig. 11.2, Accessory breast tissue in the axilla.

The breast is composed of mammary glands, which are modified sweat glands surrounded by connective tissue stroma ( Fig. 11.3 ). The mammary glands consist of 15–20 duct and lobular units that open individually onto the nipple-areolar complex. The connective tissue stroma has a fibrous and a fatty component. The fibrous bands, called the suspensory ligaments of Cooper, anchor the breast tissue to the dermis and underlying pectoral fascia and separate the secretory lobules of the breast. The fibrous stroma maintains the shape of the breast, while the fatty component contributes to the breast volume. Advancing age, body weight fluctuations and hormonal changes during puberty, menstruation, pregnancy and lactation can alter the consistency and density of the breast, resulting in changes to breast shape and volume.

Fig. 11.3, Cross-section of the female breast.

Four groups of lymph nodes drain each breast: supraclavicular, infraclavicular, internal mammary and axillary. More than 75% of the lymphatic drainage of the breast is to the ipsilateral axillary lymph nodes.

The history

Breast symptoms affect all ages. Most patients present with a single breast complaint, but it is not uncommon for patients to have multiple breast concerns. The most common presenting symptoms are breast lumps, breast pain and changes to the skin and nipples. Malignancy is more common as patients get older. An older patient who presents with a painless breast lump with skin dimpling and nipple inversion would raise suspicion of malignancy. On the other hand, a red, painful, swollen breast lump in a patient who is breastfeeding would suggest lactational mastitis.

For each presenting symptom, it is important to establish the duration and progression of the symptom and any association with the menstrual cycle.

In addition, ask about previous breast investigations, breast surgeries, breast cancer diagnoses and treatments. Document any exposure to exogenous oestrogen, especially the use of hormonal replacement therapy. Previous mantle field radiation for the treatment of lymphoma is also relevant.

Family history of cancer, especially breast and ovarian cancer, should be established. Be specific about the degree of relatives affected and their age at diagnosis.

Common presenting symptoms

Breast pain (mastalgia)

Ask if the pain varies during the menstrual cycle (if relevant) and establish the site, duration, severity and characteristics of the pain.

Breast pain associated with the menstrual cycle (cyclical mastalgia) is commonest among young women. Non-cyclical mastalgia may suggest a non-breast origin, for example, the chest wall. Ask about the association of pain with arm movements and the presence of underlying shoulder pathologies to distinguish a non-breast cause.

Breast lump

A breast lump is the commonest reason for referral to a breast clinic. Many patients describe lumpiness or nodularity rather than a discrete mass. Patients may also present with an axillary lump. The general approach to history taking is the same for all these scenarios.

Ask:

  • Is it a single lump or multiple lumps?

  • When was it first noticed?

  • Has it changed in size?

  • Is there any relation to the menstrual cycle?

Establish:

  • Any association with other symptoms, such as skin dimpling or nipple retraction?

  • Any recent trauma to the breast?

In addition, for an axillary lump, establish:

  • Any recent systemic illness?

  • Any previous history of skin malignancy?

The commonest causes of an axillary lump are lymph nodes, skin lesions such as cysts, and accessory breast tissue.

Breast volume and shape changes

Patients may report a change in the size or shape of their breasts. To quantify breast volume changes, it is best to ask the patient if they have recently changed their bra size. In addition, ask if the changes are:

  • unilateral or bilateral,

  • recent or longstanding

Breast cancer surgery or treatment, especially radiotherapy, are likely to cause scarring that results in breast skin colour, texture, shape and volume changes ( Fig. 11.4 ).

Fig. 11.4, Breast volume and shape changes to right breast following lumpectomy (scar at upper outer quadrant) and radiotherapy (tattoo indicated by arrow ). Radiotherapy has also resulted in right breast skin thickening and hyperpigmentation

Breast implant surgery is increasingly common, and changes to breast volume and shape may be a consequence of implant changes, such as capsular contracture or implant rupture.

Skin changes

  • Ask about skin colour and textural changes and their site, duration and progression. Common descriptions of skin changes used by patients include rash, dimpling, puckering and thickening. It is essential to understand what they are referring to and establish any association with other symptoms.

    • Rash can be a sign of infection. It is important to establish if the patient has been treated with antibiotics and if the rash has responded to them. If not, further investigation is necessary, as it may be a sign of inflammatory breast cancer ( Fig. 11.5 ).

      Fig. 11.5, Inflammatory breast cancer: patchy erythema, flattened nipple, peau d’orange of right breast.

    • ‘Orange peel appearance’ or ‘peau d’orange’ describes thickened and dimpled breast skin ( Fig. 11.6 ). It is a sign of breast lymphoedema and may be a consequence of infection or malignancy.

      Fig. 11.6, Peau d’orange of the breast.

Nipple changes

Patients may report changes to the nipple, or these may be noted on examination. Common nipple complaints are: pain, discharge, inversion and nipple and/or areola skin changes.

  • Nipple pain: establish the duration, severity and characteristics of the pain.

  • Nipple discharge: establish if unilateral or bilateral and if spontaneous or provoked by massage. Ascertain the frequency, quantity (from single or multiple ducts) and the colour (white, yellow, green or blood-stained) of the discharge. Nipple discharge can be part of the ageing process (e.g. duct ectasia). Galactorrhoea, which is bilateral milky discharge not associated with pregnancy or breastfeeding, can be drug-induced or secondary to hyperprolactinaemia. A persistent, blood-stained ( Fig.11.7 ), spontaneous, single duct nipple discharge should be investigated in order to exclude malignancy.

    Fig. 11.7, Single duct, blood-stained nipple discharge.

  • Nipple and areola skin changes: may be skin colour changes, irritation or ulceration. Dermatitis of the nipple-areola complex can be part of a generalised skin condition; however, if it fails to respond to conservative treatments, Paget’s disease of the nipple and skin malignancy should be excluded.

  • Nipple inversion: retraction of the nipple is common. Establish its duration, whether it is correctible or not, and any associated symptoms. Malignant nipple retraction is unlikely to be correctable and often presents with other signs of malignancy.

Gynaecomastia

Gynaecomastia is the enlargement of the male breast and is usually, but not always, bilateral. It can be due to physiological, pharmacological or pathological causes, often when there is relative oestrogen excess or testosterone insufficiency ( Box 11.1 ).

11.1
Causes of gynaecomastia

Physiological

  • Neonatal, puberty and old age

Pharmacological

  • Prescription: cimetidine, digoxin, diazepam, spironolactone, Angiotension Converting Enzyme (ACE) inhibitor

  • Recreational: cannabis, marijuana, alcohol, anabolic steroids

Pathological

  • Cirrhosis, thyrotoxicosis, hypogonadism, Klinefelter’s syndrome, testicular and adrenal tumours

The physical examination

Breast examination should be conducted in a well-illuminated room, on an examination bed, in the presence of a chaperone, whose name should be recorded. Ask your patient to undress to the waist and explain that you will be examining them sitting up as well as lying down.

Examination sequence

  • Ask the patient to sit with hands relaxed by their side ( Fig.11.8A ).

    Fig. 11.8, Positions for inspecting the breasts.

  • Look for:

    • breast asymmetry: shape/contour and volume differences

    • breast skin colour and textural variation

    • nipple-areola complex changes: spontaneous discharge, skin ulceration, nipple retraction.

    • Operative scars and tattoos from previous chest wall radiotherapy

    • chest asymmetry (see Chapter 5 )

  • Ask the patient to press their hands firmly on their hips to contract the pectoral muscles (see Fig. 11.8B ), raise their arms above their head (see Fig. 11.8C ) and then lean forward (see Fig. 11.8D ).

  • Look for any breast abnormality that becomes more visible with arm movements and note its association with the overlying skin, adjacent nipple-areola complex and underlying pectoral muscles.

  • Ask the patient to lie supine, head on one pillow with their hand under their head on the side to be examined ( Fig.11.9 ).

    Fig. 11.9, Position for palpation of the right breast.

  • Use both hands to palpate the breast and feel for abnormality under your fingertips. Avoid pressing too firmly as breasts can be very tender.

  • Examine each quadrant of the breast from the outside towards the nipple, including under the nipple ( Fig. 11.10 ).

    Fig. 11.10, Clinical examination of the breast.

  • Examine the axillary tail between your finger and thumb.

  • Gently squeeze the nipple between your index finger and thumb to determine if a discharge is present, either from a single or multiple ducts, and whether blood is present (either frankly or on urine dipstick testing).

  • Palpate any breast abnormality. Assess its site, size, contour, texture and any fixation to the overlying skin, nipple-areolar complex or underlying muscle ( Fig 11.11 ). Compare examination findings between the two breasts ( Box 11.2 ).

    Fig. 11.11, Malignancy in the upper outer quadrant of left breast: painless, solid, irregular mass, fixed to the overlying skin.

    11.2
    Summary of examination findings in commonly presented breast conditions

    Conditions Examination findings Commonly affect
    Fibroadenoma

    • Extremely mobile, discrete, rubbery lump

    • Solitary or multiples in one or both breasts

    • Young women <35 years

    Breast cyst

    • Firm, discrete, smooth lump

    • Solitary or in clusters

    • Perimenopausal women

    Lactational mastitis

    • Pain, localised erythema and swollen breast

    • Usually a history of cracked nipple

    • Breastfeeding women

    Non-lactational mastitis

    • Peri-areolar infection: peri-areolar erythema and a mass or abscess

    • Peri-areolar fistula

    • Young female smokers

    Malignancy

    • Painless, solid, irregular mass, which can be fixed to surrounding tissues, leading to other skin and nipple changes (see Fig. 11.11 )

    • Women >50 years

  • Palpate the regional lymph nodes. The axilla and supraclavicular fossa are best examined with the patient in a sitting position.

    • Support the full weight of the patient’s arm at the wrist with your ipsilateral arm, place your contralateral hand high into the axilla and move it upwards over the chest to the apex. Compress the contents of the axilla against the chest wall. Define the characteristics of any mass (see Box 3.8 in the 14th edition).

    • Palpate the neck for the supraclavicular lymph nodes from behind (see Chapter 9 ).

Investigations

Any breast abnormality, especially a breast lump, should be assessed by triple assessment: a combination of clinical, radiological and pathological examination.

Radiological examination options include mammography ( Fig. 11.12 ) and ultrasonography ( Fig. 11.13 ). Digital breast tomosynthesis ( Fig.11.14 ) is sometimes used as an adjunct to standard mammography. Mammography is offered to women aged 40 or over, often in conjunction with ultrasonography, to detect malignancy. For women under 40, ultrasound is often the only imaging required. High breast density in younger women decreases the sensitivity of mammography for the detection of cancer. However, if there is a strong clinical and ultrasonographic suspicion of malignancy, then mammography is performed. Digital breast tomosynthesis increases cancer detection by increasing visibility between overlapped dense breast tissue. Breast MRI is the most sensitive technique for the detection of breast cancer; in selected cases, it can be used to evaluate the extent of cancer and for screening. It is also useful in assessing breast implant integrity.

Fig. 11.12, Digital mammogram.

Fig. 11.13, Ultrasound of a breast cyst.

Fig. 11.14, Digital breast tomosynthesis.

The pathological examination involves a biopsy ( Box 11.3 ). Image-guided biopsy improves diagnostic accuracy.

11.3
Fine-needle aspiration vs core biopsy

Fine-needle aspiration Core biopsy
Material examined Cells Tissue
Indications Aspiration of cysts
Lymph node assessment
Sampling an area where core biopsy is technically not possible		 Breast lump assessment
Lymph node assessment
Advantages and disadvantages Unable to distinguish between non-invasive and invasive cancer
Molecular markers difficult to obtain		 Can differentiate between non-invasive and invasive cancer
Enables tumour grade and molecular markers assessment

Female reproductive system

Anatomy and physiology

The female reproductive organs are situated within the bony pelvis ( Fig. 11.15 ). They cannot normally be felt on abdominal palpation. A vaginal examination is required for their routine assessment.

Fig. 11.15, Pelvis and pelvic organs.

The vulva ( Fig. 11.16 ) consists of fat pads, called labia majora, covered with hair. The labia minora are hairless skin flaps at each side of the vulval vestibule, which contains the urethral opening and the vaginal orifice. The clitoris is situated anteriorly where the labia minora meet and is usually obscured by the prepuce. Posteriorly the labia meet at the fourchette, and the perineum is the fibromuscular region posteriorly that separates it from the anus.

Fig. 11.16, External female genitalia.

The vagina is a rugged tube 10–15 cm in length. There is an irregular mucosal ring two centimetres into the vagina that represents the remnants of the hymen (see Fig. 11.16 ). Bulging into the top of the vagina is the grape-sized fibrous uterine cervix, with the external cervical os on its surface ( Fig. 11.17 ). The fornices are the areas of the top of the vagina next to the cervix ( Fig. 11.18 ).

Fig. 11.17, Section through the pear-shaped, muscular uterus.

Fig. 11.18, Sagittal and coronal sections of the uterus.

The uterus is a muscular pear-shaped structure, about the size of a large plum, situated in the midline and usually tilted anteriorly over the bladder ( Fig. 11.19 ). Its internal cavity is lined by endometrium that proliferates, secretes and breaks down during the menstrual cycle. The Fallopian tubes run laterally from the uterine fundus towards the ovaries (see Fig. 11.17 ). Their distal finger-like fimbriae collect the oocyte after ovulation.

Fig. 11.19, Lateral view of the female internal genitalia.

The ovaries are about the size of a walnut and sit behind and above the uterus close to the pelvic sidewall. At mid-cycle, one ovary will have developed a fluid-filled preovulatory follicle measuring around 2 cm in diameter. The female reproductive tract is in close proximity to the bladder, ureter and lower gastrointestinal tract (see Fig. 11.19 ).

The history

Identify the patient’s main symptoms, how these developed, their day-to-day impact, how they cope and their ideas, concerns and expectations of the encounter. Document any previous investigations and management. Check the history, even if an asymptomatic patient has come for a routine cervical smear.

Take a gynaecological history by asking about:

  • (in pre- or perimenopausal patients) last menstrual period (LMP) and whether it was normal; always consider that these patients might be pregnant

  • past and present contraceptive use

  • plans for fertility

  • previous cervical smears, when taken, and any treatment required for abnormalities

  • prior abdominal surgery, pelvic infection or sexually transmitted disease

  • prior pregnancies and their outcomes

  • current or previous hormone replacement therapy

  • other medication with potential gynaecological effects (see later).

Common presenting symptoms

Abnormal vaginal bleeding

If patients present with heavy periods, ask about:

  • flooding: whether menstrual blood soaks through protection, increased requirements for sanitary protection

  • passing of blood clots.

Menstruation normally occurs monthly from the menarche (average age 12) until the menopause (average age 51). Menstrual bleeding for 3–6 days normally occurs every 22–35 days (average 28). A menstrual cycle with bleeding for 4–5 days every 25–29 days is recorded as 4–5/25–29. Heavy menstrual bleeding (HMB, previously called menorrhagia) affects 20% of menstruating patients over 35 and is defined as >80 mL blood loss during a period (average 35 mL). As this is not quantified in routine practice, HMB is subjective. Anaemia implies heavy bleeding.

Unexpected bleeding suggests endometrial or cervical pathology. Ask when the bleeding occurs:

  • between periods (intermenstrual bleeding, IMB)

  • after intercourse (postcoital, PCB)

  • more than 1 year after menopause (postmenopausal bleeding, PMB).

Approximately 4% of postmenopausal patients experience bleeding, which must be investigated as 10% have endometrial cancer.

Lack of periods (amenorrhoea) in the absence of pregnancy implies ovarian dysfunction and affects 5–7% of females in their reproductive years. Distinguish between:

  • Primary amenorrhoea: periods have not started by age 16. Both ovarian function and the structure of the reproductive tract should be investigated.

  • Secondary amenorrhoea: there have been no periods for ≥6 months, but there was previous menstruation.

  • Oligomenorrhoea: the menstrual cycle is longer than 35 days.

Thirty percent of patients experience vaginal bleeding in early pregnancy. Establish if this is associated with lower abdominal pain. Although the pregnancy may continue normally, bleeding is associated with miscarriage and ectopic pregnancy. Further investigation is required, particularly if the bleeding is associated with lower abdominal pain.

Lower abdominal pain

Lower abdominal pain may arise from the reproductive organs or the urinary or gastrointestinal tract or be musculoskeletal or neurological in origin (p. 108). Psychological and social factors may also contribute to the experience of pain.

To differentiate between the possible causes of lower abdominal pain, ask about:

  • site of the pain (unilateral, bilateral or midline)

  • onset (sudden or gradual, cyclical/related to menstruation or not).

Ovarian pain is often unilateral and can be physiological ( Mittelschmertz is discomfort associated with ovulation). Ovarian cyst accidents involving torsion (twisting on the vascular pedicle causing acute ischaemia), haemorrhage or rupture can lead to acute severe pain.

Primary dysmenorrhoea is pain arising from intense uterine contractions just before and during peak menstruation. Secondary or progressive dysmenorrhoea, due to underlying pathology such as endometriosis or chronic infection, often manifests as pain that lasts beyond the normal menstrual cycle. Infection, pelvic adhesions and endometriosis can cause generalised pain ( Box 11.4 ).

11.4
Characteristics of pelvic pain

Uterine pain Ovarian pain Adhesions or pelvic infection Endometriosis
S ite Midline Left or right iliac fossa Generalised lower abdomen; more on one side Variable
O nset Builds up before period Sudden, intermittent Builds up, acute on chronic Builds up, sudden
C haracter Cramping Gripping Shooting, gripping Shooting, cramping
R adiation Lower back and upper thighs Groin; if free fluid, to shoulder – –
A ssociated symptoms Bleeding from vagina Known cyst, pregnancy, irregular cycle Discharge, fever, past surgery Infertility
T iming With menstruation May be cyclical Acute, may be cyclical Builds up during period
E xacerbating factors – Positional Movement, examination Intercourse, cyclical
S everity Variable in spasms Intense Intense in waves Variable

Dyspareunia is pain during intercourse. Ask if it is felt around the vaginal entrance (superficial) or within the pelvis (deep). Pain due to an involuntary spasm of muscles at the vaginal entrance (vaginismus) may make intercourse impossible. Persistent deep dyspareunia suggests underlying pelvic pathology. Dyspareunia can be due to vaginal dryness following menopause.

Iliac fossa pain in early pregnancy is commonly associated with a corpus luteum cyst of the ovary but may indicate a tubal ectopic pregnancy. Ruptured ectopic pregnancy results in generalised abdominal pain, peritonism, haemodynamic instability and referred pain in the shoulder.

Abdominal distension and bloating

Pelvic masses can cause non-specific symptoms like abdominal distension, bloating or urinary frequency due to pressure on the bladder. They may also be asymptomatic and picked up during routine abdominal or vaginal examination. Uterine masses include pregnancy and benign leiomyoma tumours (fibroids). Large ovarian cysts can also be midline, and malignant ovarian cysts are associated with ascites.

Vaginal discharge

Discharge may be normal and variable during the menstrual cycle. Prior to ovulation, it is clear, abundant and stretches like egg white; after ovulation, it is thicker, does not stretch and is less abundant. Abnormal vaginal discharge occurs with infection. Ask about:

  • consistency

  • colour

  • odour

  • associated itch, pain or dysuria.

The most common non-sexually transmitted infection (caused by Candida species) gives a thick, white, curdy discharge often associated with marked vulval itching. Bacterial vaginosis is a common, non-sexually acquired infection caused by multiple bacteria, particularly Gardnerella vaginalis , producing a watery, fishy-smelling discharge. The pH of normal vaginal secretions is usually <4.5, but in bacterial vaginosis, it is >5. Sexually transmitted infections (STIs) can cause discharge, vulval ulceration or pain, dysuria, lower abdominal pain and general malaise. They may also be asymptomatic.

Urinary incontinence

Inappropriate and involuntary voiding of urine is severe in 10% of cases, and its prevalence increases with age.

Stress incontinence occurs on exertion, coughing, laughing or sneezing and is associated with pelvic floor weakness.

Urge incontinence is an overwhelming desire to urinate when the bladder is not full due to detrusor muscle dysfunction.

Prolapse

In 30% of patients, the pelvic contents bulge into the vagina ( Fig. 11.20 ). They feel something ‘coming down’, particularly when standing or straining. Uterine prolapse is associated with previous childbirth and is classified as:

  • Grade 1: halfway to the hymen.

  • Grade 2: at the hymen.

  • Grade 3: beyond the hymen.

  • Grade 4 (procidentia): external to the vagina ( Fig. 11.21 ).

    Fig. 11.21, External prolapse of the uterus.

Fig. 11.20, Anterior vaginal wall prolapse.

The top of the vagina (vault) can also prolapse after a previous hysterectomy. More commonly, the bulge relates to the vaginal wall. A cystocoele is a bulge on the anterior wall containing the bladder (see Fig. 11.20 ), and a rectocoele is a bulge on the posterior wall containing the rectum. An enterocoele is a bulge of the distal wall posteriorly containing the small bowel and peritoneum.

Drug history

Tamoxifen has oestrogenic effects in postmenopausal patients, antibiotics can cause vaginal candidiasis, antipsychotic drugs can cause hyperprolactinaemia, and antiepileptic or antituberculous drugs may reduce the effectiveness of oral contraceptives.

Family and social history

Family and social history, including smoking status and lifestyle, may also have an impact on gynaecological conditions. For example, obesity is associated with an increased risk of gynaecological malignancy.

Sexual history

Sometimes a sexual history is required, but people often find it difficult to talk about sexual matters. It is important for you to be at ease and ask questions in a straightforward manner. Explain why you need to enquire, use clear, unambiguous questions ( Box 11.5 ) and be non-judgemental. The sexual partners of patients with STIs should be informed and treated to prevent further transmission and reinfection of the treated person. Confidentiality is paramount, so do not give information to a third party. Do not perform a pelvic examination on someone who has not been sexually active.

11.5
Taking a sexual history

  • Are you currently in a sexual relationship?

  • How long have you been with your partner?

  • Have you had any (other) sexual partners in the last 12 months?

  • How many were male? How many were female?

  • When did you last have sex with:

    • Your partner?

    • Anyone else?

  • Do you use barrier contraception–sometimes, always or never?

  • Have you ever had a sexually transmitted infection?

  • Are you concerned about any sexual issues?

The physical examination

A vaginal examination is required to perform a routine cervical smear. Otherwise, the focus of gynaecological examination is to detect abnormalities that could explain the symptoms or alter treatment options (e.g. body mass index (BMI) and blood pressure assessment affect the use of the contraceptive pill). Signs of gynaecological disease are not limited to the pelvis, and a general, as well as a pelvic, examination is required ( Box 11.6 ). You should offer a chaperone and record this in the records. The examination area should be private, with appropriate equipment and an adjustable light source available. The patient should have an empty bladder and remove their clothing from the waist down, along with any sanitary protection. Give them privacy to do this.

11.6
Focus of the gynaecological examination
PCOS, Polycystic ovary syndrome; PMB, postmenopausal bleeding; STI, sexually transmitted infection.

Clinical feature General examination Pelvic examination
Abnormal bleeding Anaemia
Underweight (hypogonadotrophic hypogonadism)
Galactorrhoea, visual field defects (hyperprolactinaemia)
Hirsutism, obesity, acanthosis nigricans (PCOS)		 Enlarged uterus (fibroids, pregnancy)
Abnormal cervix
Open cervical os (miscarriage)
Vaginal atrophy (most common cause of PMB)
Pain Abdominal tenderness Uterine excitation (acute infection or peritonism)
Fixed uterus (adhesions or endometriosis)
Adnexal mass (ovarian cyst)
Vaginal discharge Rash (associated with some STIs) Clear from cervix (chlamydia)
Purulent from cervix (gonorrhoea)
Frothy with strawberry cervix (trichomoniasis)
Urinary incontinence Obesity, chronic respiratory signs (stress incontinence)
Neurological signs (urge incontinence)		 Demonstrable stress incontinence
Uterine or vaginal wall prolapse
Abdominal distension or bloating Ascites, weight loss, lymphadenopathy, hepatomegaly (malignancy)
Pleural effusion (some malignant or benign ovarian cysts)		 Pelvic mass (uterine, ovarian or indiscriminate)
Fixed uterus and adnexae
Abnormal vulva (skin disease or malignancy)

Passing a speculum

Explain what you are going to do and why it is necessary, and obtain verbal consent. Use a vaginal speculum to see the cervix and the vaginal walls, carry out a cervical smear and take swabs if required. Specula are metal or plastic and come in various sizes and lengths. Metal specula may be sterilised and reused; plastic specula are always disposable. A metal speculum is cold, so warm it under the hot tap. Most patients find a speculum examination mildly uncomfortable, so always use a small amount of lubricating gel on the tip of each blade. Clean your hands and put on medical gloves. Ask the patient to lie on their back on the couch, covered with a modesty sheet to the waist, with their knees bent and apart ( Fig. 11.22 ).

Examination sequence ( , )

  • Look at the perineum for any deficiency associated with childbirth; note abnormal hair distribution and clitoromegaly (associated with hyperandrogenism). Note any skin abnormalities, discharge or swellings of the vulva, such as the Bartholin’s glands on each side of the fourchette ( Fig. 11.23 ).

    Fig. 11.23, Bartholin’s abscess.

  • Ask the patient to cough while you look for any prolapse or incontinence.

  • Gently part the labia using your left hand ( Fig. 11.24 ). With your right hand, gently insert a lightly lubricated bivalve speculum ( Figs 11.25–11.26A ), with the blades vertical, fully into the vagina, rotating the speculum through 90 degrees so that the handles point anteriorly and the blades are now horizontal (see Fig. 11.26B ). Someone who has been pregnant may need a larger or longer speculum or a bolster under the sacrum if the cervix is very posterior. If they find the examination difficult, ask them to try to insert the speculum themself.

    Fig. 11.24, Inspection of the vulva.

    Fig. 11.25, Bivalve speculum.

    Fig. 11.26, Bivalve speculum examination.

  • Slowly open the blades and see the cervix between them. If you cannot see it, reinsert the speculum at a more downward angle, as the cervix may be behind the posterior blade. Note any discharge or vaginal or cervical abnormalities.

  • Open the blades a little during the initial removal of the speculum to avoid catching and pulling on the cervix.

To assess prolapse ( )

  • Ask the patient to lie on their left side and bring their knees up to their chest.

  • Use a univalve Sims speculum, placing a small amount of lubricating jelly on the blade.

  • Insert the blade to hold back the posterior wall.

  • Ask them to cough while you look for uterine descent and the bulge of a cystocoele ( Fig. 11.27 ).

    Fig. 11.27, Examination in the left lateral position using a Sims speculum.

  • Repeat, using the speculum to hold back the anterior vaginal wall to see a rectocoele or enterocoele.

Fig. 11.22, Position for pelvic examination.

Taking a cervical smear

There are two ways of taking a smear:

  • using liquid-based cytology

  • using a microscope slide.

Liquid-based cytology is increasingly common, as it allows for efficient processing and gives fewer inadequate smears. Many screening services now test these for human papilloma virus (HPV) rather than performing routine cytology.

Examination sequence ( )

  • Always label the cytological medium or slide and ask the questions required to fill in the request form before starting the examination to avoid mixing specimens.

  • Clearly visualise the entire cervix.

Liquid-based cytology

  • Insert the centre of the plastic broom into the cervical os.

  • Rotate the broom 5 times through 360 degrees ( Fig. 11.28A ).

    Fig. 11.28, Taking a cervical smear.

  • Push the broom 10 times against the bottom of the specimen container.

  • Twirl 5 times through 360 degrees to dislodge the sample.

  • Firmly close the lid.

Conventional smear

  • Insert the longer blade of the spatula into the cervical os.

  • Rotate the spatula through 360 degrees (see Fig. 11.28B ).

  • Spread once across the glass slide.

  • Place the slide immediately into fixative (methylated spirits) for 3–4 minutes.

  • Remove it and leave it to dry in the air.

Bimanual examination

Examination sequence ( )

  • Apply gloves and lubricate your right index and middle finger with gel.

  • Gently insert them into the vagina and feel for the firm cervix. The uterus is usually anteverted ( Fig. 11.29A ), and you can feel its firmness anterior to the cervix. If the uterus is retroverted and lying over the bowel (15%; Fig. 11.29B ), you will feel the firmness posterior to the cervix.

    Fig. 11.29, Coronal section.

  • Push your fingers into the posterior fornix and lift the uterus while pushing on the abdomen with your left hand.

  • Place your left hand above the umbilicus and bring it down, palpating the uterus between both hands and note its size, regularity and any discomfort ( Fig. 11.30 ).

    Fig. 11.30, Bimanual examination of the uterus.

  • Move your vaginal fingers into the anterior fornix and palpate the anterior surface of the uterus, holding it in position with your abdominal hand.

  • Move your fingers to the lateral fornix and, with your left hand above and lateral to the umbilicus, bring it down to assess any adnexal masses between your hands on each side ( Fig. 11.31 ).

    Fig. 11.31, Palpating an adnexal mass.

  • If urinary leakage occurs when the patient coughs, try lifting the anterior vaginal wall with your fingers and ask them to cough again. This stops genuine stress incontinence.

The normal cervix os may be a slit after childbirth. The vaginal squamous epithelium and the endocervical columnar epithelium meet on the cervix. The position of this squamocolumnar junction varies considerably, so the cervix can look very different in individual people. If the transition zone is on the cervix, this is called an ectopy and looks red and friable; there may be small cysts called Nabothian follicles. The normal uterus should feel regular and be mobile and the size of a plum. The Fallopian tubes cannot be felt, and normal ovaries are palpable only in the very slim.

Vulval changes include specific skin diseases, infections such as herpes or thrush, and malignancy. Visual abnormalities of the cervix such as ulceration or bleeding suggest cervical pathology, including polyps or malignancy. Tender nodules in the posterior fornix suggest endometriosis, and both endometriosis and pelvic adhesions cause fixation of the uterus. Acute pain when touching the cervix (cervical excitation) suggests an acute pelvic condition such as infection, cyst accident or tubal rupture.

Fibroids can cause uterine irregularity and enlargement. The size is related to that of the uterus in pregnancy. A tangerine-sized uterus is 6 weeks, an apple at 8 weeks, an orange at 10 weeks and a grapefruit at 12 weeks. After 12 weeks, the uterus can be palpated suprapubically on abdominal palpation. A large midline mass may be ovarian or uterine. Push the mass upwards with your left hand and feel the cervix with your right hand; if the mass moves without the cervix, this suggests it is ovarian.

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