The gynecological items in the physical examination are so embarrassing, can I not do them?

In the new year, have you done your annual physical examination last year?

Which part of the physical examination is the most terrifying?

Gynecological examinations definitely have a place

"Trouble", "Shame", "Embarrassment", "Pain"

A lot of negative words make many women

Choose "Don't go if you can avoid it"

However, the gynecological examination in the hospital is to check the health of the female reproductive system, including the examination of the cervix, uterus, ovaries, breasts and other organs. Regular gynecological examinations are very important and can help to detect and prevent gynecological diseases at an early stage. Today we will talk in detail about what gynecological examinations are and what to do if the results are abnormal.

1 What are the differences between the projects done by single and married people?

Women generally start to have sexual initiation at the age of 10-14, gradually enter puberty, and the reproductive system including ovaries and uterus begins to develop, generally mature at the age of 18. Relevant gynecological examinations should be carried out before and after marriage, but before the start of sexual life, in order to protect the integrity of the hymen, vaginal examinations are generally avoided, and relevant examinations such as relevant interviews, physical examinations, and ultrasound can be carried out.

After sexual intercourse begins, in addition to the above examinations, further screening for related diseases, such as transvaginal ultrasound, is performed to further evaluate the uterus and appendages. At the same time, cervical cancer screening is also performed through cervical cytology (Pap smear and liquid-based ultrathin cell test) and HPV testing after sexual intercourse begins.

2 What does each item check? What is the purpose of the inspection?

General gynecological examinations include medical interviews, physical examinations, sex hormone level testing, cervical cytology (Pap smear and liquid-based ultra-thin cell testing) examinations (TCT) and HPV testing, pelvic floor ultrasound, breast ultrasound and other related methods.

(1) Medical consultation

The doctor will ask the patient about his physiological cycle, menstruation, sexual life, etc. to understand the patient's health status and possible problems. The patient needs to pay attention to the time of his last menstrual period, menstrual cycle, menstrual cramps, menstrual volume, etc. to assist the doctor in evaluating the patient's condition. Since the gonads are the most sensitive endocrine system in the body, when there is a problem with the body, women often experience changes in menstruation. Patients need to record their own conditions to detect related problems as early as possible.

Figure 1 Schematic diagram of the menstrual cycle (the horizontal axis is the menstrual cycle, and the size of the red square represents the amount of bleeding; A is normal; B is amenorrhea; C is menorrhagia; D is irregular uterine bleeding) [1]

(2) Physical examination

The doctor will perform visual inspection and palpation of the vulva, vagina, cervix and other parts to check for abnormalities, such as lumps, ulcers, etc. Because the gynecological reproductive system is located in the pelvic cavity, it is difficult to touch the uterus and other organs by abdominal palpation under normal circumstances. If necessary, the doctor will use "bimanual examination" or "trimanual examination" to evaluate the position, size, shape, texture, etc. of the patient's cervix, uterus and other organs through the vagina and rectum.

Figure 2 Schematic diagram of bimanual examination of the uterus[1]

Figure 3 Schematic diagram of bimanual examination accessories[1]

Figure 4 Schematic diagram of triple diagnosis[1]

(3) Sex hormone level testing

The patient's reproductive system function status is assessed by testing the levels of hormones such as estrogen and progesterone. As the menstrual cycle changes, the hormone levels also change accordingly. Generally, the patient's sex hormone basal level is 2-3 days after the onset of menstruation, which is often used as a reference for gynecological hormone levels. At the same time, the anti-Mullerian hormone (AMH) level can be used to assess the patient's ovarian reserve to assist the patient in preparing for pregnancy.

Figure 5 Schematic diagram of hormone and endometrial changes during the menstrual cycle [2]

(4) Cervical cytology (Pap smear and liquid-based ultra-thin cell test) examination (TCT) and HPV testing

By removing the cell tissue on the surface of the cervix and then observing the morphology and structure of these cells under a microscope, cervical precancerous lesions and cervical cancer can be screened. At the same time, human papillomavirus (HPV) gene testing can be performed to evaluate the condition of the cervix and effectively screen for precancerous lesions and high-risk groups for cervical cancer, including high-risk human papillomavirus (HPV) testing, cervical cytology (traditional Pap or liquid-based cytology) and combined screening of the two. The WHO generally recommends that women over 30 years old undergo cervical cancer screening as early as possible regardless of whether they have started sexual life. The United States recommends even earlier, recommending 21 years old as the initial screening time. Although routine annual cervical cancer screening is not recommended, it is generally recommended to perform cytology or cytology and HPV combined examinations every 3 to 5 years. In special circumstances, further colposcopy is required.

Figure 6 Schematic diagram of traditional sampling method for Pap test [1]

(5) Pelvic floor ultrasound and breast ultrasound

Ultrasound technology is used to examine the uterus, ovaries, fallopian tubes, breasts and other organs in the pelvic cavity, including whether there are lumps, cysts or other abnormalities. Clinical examinations include transabdominal ultrasound, and patients need to drink water and hold urine before the examination to fully expose the uterus to the examination field of view; transvaginal ultrasound is mostly used for women who have started sexual life and do not need to hold urine, but patients who are resistant to transvaginal examinations need to inform the doctor in advance; transperineal ultrasound is mostly used to evaluate the lower vagina and other lesions in the pelvic floor.

At the same time, ultrasound can be used to examine the thickness of the endometrium to assess the patient's fertility and menstrual cycle.

3 What should I do if the test results are abnormal? What should I pay attention to in daily life?

When the results of a gynecological examination are abnormal, it does not necessarily mean that there is a serious problem, but further evaluation and treatment are required. The specific response measures will vary depending on the abnormal situation, which may include regular follow-up observation, further examination (such as biopsy), drug treatment or surgical treatment.

However, when patients experience or combine the following conditions, it is recommended that patients seek medical attention from a gynecologist or gynecological endocrinologist in a timely manner to rule out related diseases and eliminate the problem as early as possible.

(1) Irregular vaginal bleeding

Irregular vaginal bleeding is also called dysfunctional uterine bleeding, which includes amenorrhea, menorrhagia, irregular uterine bleeding and postmenopausal bleeding. When patients experience changes in their menstrual cycle, excessive or insufficient menstrual flow, they should seek medical attention in a timely manner and undergo targeted examinations. Communicate with the doctor about menstruation in a timely manner, such as how many sanitary napkins you use during your menstrual period, to assist the doctor in assessing the amount of menstruation.

(2) Dysmenorrhea

Dysmenorrhea is also known as menstrual pain. Patients need to pay attention to observe whether it is related to cramps caused by uterine contractions after menarche, whether it occurs after several years of periodic or painless menstruation, to assist doctors in determining whether it is primary dysmenorrhea or secondary dysmenorrhea. The pain is usually located in the lower abdomen and lumbosacral region, and may even radiate to the legs. Some patients may experience symptoms such as syncope, nausea, and vomiting.

(3) Mass or space-occupying

Whether it is a mass or lesion that can be felt by oneself on the external genitalia, or a mass or lesion detected by ultrasound or other imaging methods, patients should pay enough attention to it, as it is often related to sexually transmitted diseases, tumors and infections. Patients need to go to the gynecology department for evaluation and treatment in time to avoid delay in the disease.

(4) Abnormal vaginal discharge

Abnormal vaginal discharge is commonly known as "abnormal vaginal discharge", which is often related to vaginal diseases caused by vaginal infection or dysbacteriosis, generally including Trichomonas vaginitis, bacterial vaginosis and vulvar candidiasis. Patients need to pay attention to whether their vaginal discharge has changed in color, such as gray-yellow, yellow-green, etc., and whether the vaginal discharge has a fishy smell or other foul odor, and the shape of the discharge, such as cheesy or purulent changes, in order to accurately describe their own conditions and assist doctors in diagnosis.

(5) Vaginal itching

Vaginal itching is often related to vaginal infection, and may also be complicated by diabetes, vulvar leukoplakia and other conditions. Patients need to pay attention to whether the degree of itching affects normal life and its duration to assist doctors.

(6) Abdominal pain

Abdominal pain can be divided into acute or chronic. Spontaneous abortion, ectopic pregnancy, uterine perforation and other conditions can cause severe acute abdominal pain in patients, which can even cause death. Patients can also pay attention to whether there are symptoms such as frequent urination, urgency, and pain when urinating to assist doctors in ruling out urinary tract infections. At the same time, corpus luteum rupture caused by intense sexual activity is also common in clinical practice. Patients or their families should describe it as accurately as possible to detect the cause and diagnose and treat it early.

(7) Pain during sexual intercourse

Pain during intercourse and bleeding during intercourse are often related to inflammation of the reproductive system or related tumors. Although some sensitive patients may experience psychogenic pain and anxiety, they should seek medical attention in time when pain during intercourse and bleeding during intercourse occur to detect related problems early.

(8) Changes in hair distribution

When the patient has endocrine disorders and an imbalance in androgen levels, there are often changes in hair distribution, such as excessive hair growth on the upper lip, face, earlobes, etc., especially in the line between the navel and the upper lip under the nose. If severe hair growth occurs, abnormal androgen metabolism should be considered and the patient should see a gynecological endocrinologist in a timely manner.

(9) Changes in urination habits

When the intra-abdominal pressure increases, the patient will experience involuntary urinary incontinence, such as when bending over or sneezing. This is often related to impaired pelvic floor function. It is common in postpartum women and elderly women. In addition to seeking medical treatment in time, patients can also perform Kegel exercises more often to enhance pelvic floor function.

(10) Infertility

Infertility is usually defined as the situation where pregnancy has not occurred within 1 year without taking contraceptive measures and having regular sex. When this happens, patients do not need to be overly anxious and are advised to seek medical attention in a timely manner. The doctor will evaluate the patient's endocrine metabolism and ovarian reserve, and test the patency of the fallopian tubes through hysterosalpingography. With the development of assisted reproductive technology, more and more infertile patients are giving birth to babies through assisted reproductive technology. Of course, early marriage and childbearing within childbearing age is still the best solution to such problems.

In real life, people don’t talk about gynecological diseases like they talk about colds. However, gynecological diseases are not far away from women. From minor gynecological symptoms such as irregular menstruation to uterine diseases that affect fertility, all of them affect women’s health.

Gynecological examination is just a normal physical examination. As a woman, there is no need to feel ashamed of it. Clarifying the purpose of the examination and better understanding your own situation can help doctors to examine and diagnose female patients to the greatest extent, and carry out relevant prevention and treatment as soon as possible.

I hope we can all embrace our bodies warmly and bravely.

References:

[1] Mark H. Swartz. Textbook of Physical Diagnosis (7th Edition) [M]. USA: Elsevier, 2015: 500-532.

[2] Xie Xing, Kong Beihua, Duan Tao. Obstetrics and Gynecology (9th Edition)[M]. Beijing: People's Medical Publishing House, 2018: 238-246.

[3] UPTODATE [DB]. http://www.uptodate.com/

[4] Chinese Association of Preventive Medicine Tumor Prevention and Control Committee, Chinese Medical Doctor Association Obstetricians and Gynecologists Branch Colposcopy and Cervical Lesions Committee, Chinese Eugenics Association Colposcopy and Cervical Pathology Branch, etc. Chinese Expert Consensus on Human Papillomavirus Nucleic Acid Detection for Cervical Cancer Screening (2022). [J]. Chinese Medical Journal, 2023, 103(16):1184-1195.

[5] Hu Shangying, Zhao Xuelian, Zhang Yong, et al. Interpretation of "Prevention of cervical cancer: WHO guidelines for screening and treatment of cervical precancerous lesions (Second Edition)". [J]. Chinese Medical Journal, 2021, 101(34): 2653-2657. DOI:10.3760/cma.j.cn112137-20210719-01609

Written by: Du Boran Beijing Obstetrics and Gynecology Hospital, Capital Medical University