Gynecological Examination
• In gynecology, the patient is examined in the lithotomy or Simms position. It starts with the inspection of the external genitals. The labium majus is opened , Changes in the odor and color of the urethral orifice and the condition of the Bartholin's and Skene's glands are evaluated
• Inspection of the vagina is done by means of a speculum. Cervical examination is continued with inspection. Cervical appearance is different in women who have never given birth (nulliparous) or who have given birth (multiparous. In multiparous women, the external orifice of the cervical canal shows horizontal striping. If this line extends to the lateral fornixes, it is called an Emmet tear. Emmet tear causes chronic cervical infection and leukorrhea.
• Cervicovaginal smear should be taken before palpation.
• The cervix, which is a very hard tissue on palpation, is 2-4 cm long and is normally not painful when mobilized.
• The next step in the examination is the evaluation of the uterus. The size, position, location, mobility of the uterus and whether it is painful are determined.
• Uterine size is expressed by gestational week. When the uterus reaches the symphysis pubis level, it is 12 weeks of gestation, 20 weeks when it reaches the navel level, and 36 weeks when it reaches the xiphoid.
• On the other hand, the position of the uterus is tried to be determined by bimanual examination. The bending of its corpus over the cervix is called anteflexion. The bending of the corpus and cervix on the long axis of the vagina is called anteversion. In 30% of women, the uterus is retroverted (retroversio-flexio uteri). Low back pain is the most common symptom in severely retroverted uteruses.
• Adnexa; It is the term used for tuba uterina, ovary and peritoneal folds associated with these structures. The presence, consistency, size, mobility, and presence of pain of any palpable mass in this region must be determined.
Diagnostic Procedures in Gynecology
Cervicovaginal Smear (Papanicolaou Smear)
• It is a screening test and it is never sufficient for diagnosis alone.
• The main uses of smear in gynecology are:
Genital malignancy screening (especially cervical cancer)
Hormonal assessment; It is taken from the vaginal lateral wall and evaluated by the maturation index (the ratio of cells belonging to different layers).
Cervical smear screening program:
<21 years; No scan
21-29 years old; Screening with cytology every 3 years
30-65 years old; Cytology every 5 years + HPV DNA (co-test), cytology every 3 years or high-risk HPV DNA every 5 years
>65 years; Screening is discontinued if 3 consecutive cytology or 2 co-tests are negative in the last 10 years (no history of HGSIL, in situ adenocarcinoma or cancer)
However, annual follow-up should be continued in women with HIV positivity, immunosuppressants, those with DES exposure, and those with a history of CIN2 or higher cervical intraepithelial lesions.
Conditions that cause an abnormal Pap smear result
invasive cervical cancer
Cervical intraepithelial neoplasia
Atrophic changes
Flat condyloma
Inflammation (especially trichomoniasis and chronic cervicitis)
Post-damage regenerative changes (metaplasia)
Vaginal cancer
Vulvar cancer
Upper genital tract cancer (endometrium, tuba and ovarian cancer)
Previously received radiotherapy
Spinnbarkeit Test
It is a test that determines the elasticity of cervical mucus
Fern Test
It is used to determine whether there is ovulation. Cervical mucus is spread on a dry clean slide, dried and examined under a microscope:
o The fern appearance shows the effect of estrogen (in favor of anovulation when seen in the luteal phase)
o The absence of fern appearance shows the effect of progesterone (ovulation)
culdocentesis
It is the aspiration of the material by entering the Douglas cavity through a needle from the posterior fornix.
Vulvar Biopsy
If lesion is seen, biopsy is performed directly from the lesion. If there is no lesion, but if there are symptoms, 3% acetic acid is applied to the vulva and biobsy is taken with colposcopy.
Vaginal Biopsy
If a lesion is seen, a biopsy is taken directly from the lesion. If there is no lesion but there are symptoms, Lugol's solution is applied to the vagina and a biopsy is taken from the areas that do not hold dye, under the guidance of a colposcope.
colposcopy
It is the primary technique in the evaluation of abnormal cervical cytology. colposcope; It is a microscope for examining the cervix by magnifying 6-40 times.
Colposcopy indications
1. Abnormal cervical cytology or high-risk HPV positivity
2. Clinically suspicious cervical appearance
3. Unexplained intermenstrual or postcoital bleeding
4. Vulvar or vaginal neoplasia
5. DES exposure in utero
• Following the application of physiological saline and acetic acid (3-5%), nuclear swelling occurs in the atypical epithelium, while the atypical epithelium appears opaque or white, while in the normal epithelium the acid cannot pass under the glycogen and appears pink. After the procedure, a sharp line is formed between the normal epithelium and the atypical epithelium.
Abnormal colposcopic findings
1. Acetowhite epithelium (application of acetic acid coagulates proteins in the cell)
2. Leukoplakia (abnormal white keratin layer that forms on the surface of the epithelium) (HPV)
3. Punctuation (dilated capillaries terminating at the surface) (LSIL)
4. Mosaic appearance (blocks of acetowhite epithelium and capillaries surrounding them) (HSIL)
5. Atypical vascularization (invasive cervical cancer)
• Some colposcopists complete the examination by applying iodine (Lugol's solution) to the cervix and vagina (Schiller test). Normally mature, glycogen-rich squamous cells retain iodine and turn brown; cylindrical epithelium, immature metaplastic squamous cell epithelium, preinvasive and invasive cancer cells do not uptake iodine and remain white (Schiller +, iodine -) . Absolute biopsy should be taken from these areas.
Colposcopic findings suggestive of invasion
1. Atypical vascularization (invasive cervical cancer)
2. Irregular surface contour with loss of surface epithelium
3. Color tone change
• The most common cause of cervical leukoplakia is HPV.
Cervical Biopsy and Endocervical Canal Curettage
• If a lesion is seen in the ectocervix, biopsy is taken directly from the lesion. In cases without lesions, bivopsy can be taken with colposcopy.
Loop Electrosurgical Excision Procedure (Leep/Lletz)
• Excision of the cervix using low-voltage alternating current. Since a part of the cervical canal is removed, fertility may be affected in the future. Its complications are rarer than other surgical interventions and consist of cervical stenosis.
conization
• It is the reading of a cone-shaped piece of cervical tissue with the help of a scalpel. It is an intervention aimed at both diagnosis and treatment, especially to determine the depth of invasion in cervical carcinoma.
Conization Complications:
1. Bleeding (most common)
2.Sepsis
3.Servial stenosis
4. Cervical insufficiency
5.Ureter injury
Endometrial Biopsy
• Biopsy can be taken from the endometrium with a thin plastic cannula (pipele biopsy) or with the aid of a curette (probe curettage). Cervical dilatation before the procedure and then endometrial curettage is called dilatation curettage.
Hysterosalpingography (HSG)
• In the 7-12 days of the period : aradiopaque substance is injected into the cervical canal to determine the uterus, tubas and the distribution of the administered substance in the peritoneal cavity.
• HSG provides indirect visualization of endometrial cavity borders, submucous fibroids, masses pressing from the from outside, and uterotubal junction obstructions or distortion secondary to peritubal adhesions.
• HSG is not withdrawn during menstruation and prophylactic doxycycline 100 mg 2x1 dose should be started one day before withdrawal in high-risk women.
• Water-soluble contrast agents are absorbed in a shorter time than Fat-soluble ones and do not carry the risk of extravasation or lipid embolism due to lipid granuloma formation.
• While Fat-based contrast agents cause less uterine cramps, they provide better resolution in tubal structure and higher spontaneous pregnancies are obtained after the procedure.
HSG Contraindications
1. Acute pelvic infection
2. Active uterine bleeding
3. Pregnancy
4. Iodine allergy
HSG Complications
1. Pelvic infection (most common)
2. Cervical laceration
3.Uterine perforation
4.Hemorrhage
5. Vasovagal reaction
6. Allergic reaction to the contrast material
7.Pelvic pain
Hysteroscopy (H/S)
• Provides diagnostic imaging of endometrial surfaces with an optical tool. Simultaneously, operative intervention can be performed. The gold standard method for the evaluation of the endometrial cavity is hysteroscopy.
Hysteroscopy Indications
A. Indications for diagnostic hysteroscopy
1. Unexplained uterine bleeding
2. Selected infertility cases; in cases of abnormal HSG and unexplained infertility
3. Habitual abortion
B. Indications for operative hysteroscopy
1. Endometrial polyp removal
2. Submucous miyoma resection
3. Endometrial ablation
4. Opening of intrauterine synechiae
5. Cutting the uterine septum
6. Foreign body removal
7. Tubal sterilization
Hysteroscopy Contraindications
Absolute Contraindications
1. Pelvic Inflammatory Disease, tuboovarian abscess
2. Uterine perforation
3. Sensitivity to anesthesia and augmenting agents
Relative Contraindications
1. Heavy bleeding to distort the image
2. Known presence of genital cancer
Hysteroscopy Complications
1. Anesthesia-induced complications
2. Perforation
3. Bleeding
4. Thermal injury; bowel and ureteral injuries
5. Connected to the distension medium; CO, embolism, electrolyte imbalances, pulmonary edema
6. Infection
Laparoscopy (L/S)
The endometrial surface cannot be evaluated by laparoscopy. It is the gold standard diagnostic method in the evaluation of internal genital organs, peritoneum, tubal passage, and in endometriosis and adhesions. In addition, subserous fibroids with torsioned stalks are also an indication for laparoscopy.
Laparoscopy Complications
1. Anesthesia complications
2. CO2 embolism
3. Cardiovascular complications (due to hypercarbia and acidemia)
4. Gastric reflux
5. Extraperitoneal insufflation
6. Electrocautery complications
7. Hemorrhagic complications
8. GIS injuries
9. Urological injuries (Most common with electrocautery.)
10. Neurological injuries
11. Incisional hernia and wound dehiscence
12. Infection
• In laparoscopy; the most frequently injured main vessel during the main trocar insertion from the umbilical port; right common iliac artery and aorta. During the placement of lateral trocars, the inferior epigastric artery, which is the branch of the external iliac artery, is most frequently injured.
• There is a risk of injury to the iliohypogastric nerve when placing lateral trocars in laparoscopy.
Sonohysterography (Hysterosonography) S.H.G
• Ultrasonography is performed during saline infusion into the endometrial cavity. It is useful for imaging endometrial polyps, submucosal fibroids, and endometrial synechia.
• Its sensitivity is lower than hysteroscopy in the diagnosis of congenital uterine anomaly.
Magnetic Resonance (MR) Imaging
• It is a 100% sensitive and specific diagnostic method in the diagnosis of congenital uterine anomalies. It is especially useful in the diagnosis of rudimentary uterine horn.
• It can be used as a second-line investigation method in the following situations:
Localization of uterine fibroids and their relationship with the endometrial cavity (most sensitive test)
Preoperative evaluation and staging of endometrial cancer
Diagnosis of adenomyosis
Evaluation of adnexal and ovarian pathology