Examination of a gynecological patient and the diagnostic procedures
1. Salahaldin Safadi
2. Aidarbek kyzy Aidanek
(1. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.
2. Teacher, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
Abstract
Background
The gynecological consultation is one of the few clinical encounters in which history, inspection, invasive palpation, and highly intimate imaging are performed within minutes. Errors of omission—failure to ask about menstrual calendar apps, to inspect the perineum in an obese woman, or to consider endometrial sampling in a 28-year-old with obesity and breakthrough bleeding—carry disproportionate downstream harm. Updated epidemiological and medico-legal data are therefore essential.
Methods
A structured scoping review (January 2019 – December 2024) was undertaken using PubMed, EMBASE, Cochrane, WHO IRIS, and grey literature. Eligible articles described (i) accuracy, safety, or patient-experience metrics of gynecological history-taking, abdominal, pelvic, speculum, or bimanual examination; (ii) performance characteristics of bedside, imaging, or laboratory diagnostics; (iii) clinical algorithms for common presenting complaints—abnormal uterine bleeding (AUB), pelvic pain, infertility, vulvovaginal symptoms, post-menopausal bleeding; (iv) medico-legal and cultural dimensions. Global Burden of Disease (GBD) 2023 supplied epidemiological data for gynecological disorders (2019-2023). Where randomised trials were scarce, prospective cohorts and high-quality audit studies were integrated.
Results
A systematic menstrual history captured by validated apps (e.g., Flo, Clue) detected 92 % of cycle anomalies versus 64 % with unstructured recall. Sensitivity of abdominal palpation for masses > 8 cm was 82 %; sensitivity of digital examination for levator ani tenderness was 88 %. Speculum examination using warm water instead of gel reduced pain scores (VAS) by 1.4 cm. Endometrial sampling in an outpatient setting achieved ≥ 1.5 mm tissue in 96 % of cases with a 0.8 % vasovagal reaction rate. Trans-vaginal ultrasound (TVUS) correctly localised 97 % of intrauterine devices, identified 94 % of endometrial polyps ≥ 5 mm, and predicted deep endometriosis with 89 % sensitivity when performed by accredited sonologists. Saline-infused sonography (SIS) added marginal benefit (Δ sensitivity +4 %) at double the cost. MRI was superior for adenomyosis (sensitivity 94 % vs TVUS 68 %). Human papillomavirus (HPV) primary screening every 5 years yielded 96 % sensitivity for CIN3+; self-collection reached 92 % sensitivity with higher acceptance (89 % vs 72 % clinician-collected). GBD 2023 attributes 4.7 million DALYs to delayed gynecological diagnosis; incidence of missed endometrial cancer in women < 50 rose 18 % since 2019. Discomfort, embarrassment, and cultural taboos remain the commonest barriers; trauma-informed care improved follow-up attendance from 64 % to 87 %.
Conclusion
Modern gynecological examination is a precision instrument when history is digital, hands are warmed, and ultrasound probe is wielded by accredited eyes. Yet epidemiological signals warn of rising missed diagnoses in young and obese women. A three-pronged strategy—mandated menstrual-app documentation, universal endometrial sampling for AUB in BMI ≥ 30, and accredited TVUS within primary care—could avert 60 % of attributable DALYs. Without such measures, the speculum will remain a symbol of fear rather than the diagnostic ally it should be.
Introduction
Few clinical encounters evoke as much anticipation, anxiety, or embarrassment as the gynecological consultation. The patient is asked to expose the most intimate anatomy, to recount bleeding patterns that WhatsApp chats may know more accurately than she does, and to trust that a metal or plastic speculum will not reproduce past trauma. The clinician, meanwhile, balances the need for thoroughness against time pressure, the risk of missing a rare cancer, and the legal shadow of every cervical cytology slide that could be reviewed years later in a courtroom.
The stakes have risen. Obesity now complicates half of reproductive-age encounters, making bimanual examination technically difficult and endometrial cancer detectable at 28 instead of 68. Viral sexually transmitted infections (STIs) surge among women who have never seen a speculum because “monogamy” felt safe. Endometriosis remains undiagnosed for an average of 7.5 years, and 121 million unintended pregnancies each year testify to unasked questions about contraceptive satisfaction.
Yet the examination itself has changed little since the days of Sims and Marx. Warm hands, good lighting, and a chaperone remain the mantra, but smartphones now track menstrual blood loss to the millilitre, point-of-care HPV assays return results in 45 minutes, and saline-infused sonography can be performed with a catheter costing less than a takeaway coffee. The gap between what is possible and what is practised widens daily.
This article synthesises contemporary evidence on gynecological history, physical examination, and diagnostic procedures within the Introduction-Methods-Results-And-Discussion (IMRAD) framework. It explicitly embeds epidemiological trends for 2019-2023, incorporates patient-experience metrics, and addresses cultural, medico-legal, and technological dimensions that traditional reviews relegate to small print. The goal is to equip clinicians with an evidence-based, obesity-aware, trauma-informed roadmap that transforms the speculum from an instrument of fear into the diagnostic ally it was meant to be.
Methods
Search strategy and eligibility
A systematic scoping review was conducted (January 2019 – December 2024) adhering to PRISMA-ScR. Electronic databases (PubMed, EMBASE, Cochrane Library, WHO IRIS, LILACS, ClinicalTrials.gov) were searched using: ("gynecological examination" OR "pelvic examination" OR "speculum examination" OR "bimanual examination") AND ("accuracy" OR "sensitivity" OR "specificity" OR "patient experience" OR "pain" OR "cultural barriers") AND ("diagnostic procedure" OR "ultrasound" OR "endometrial sampling" OR "colposcopy" OR "HPV screening") AND ("2019/01/01"[Date - Publication] : "2024/12/31"[Date - Publication]). Grey literature included WHO cervical cancer screening guidelines 2021, ACOG committee opinions 2023, RCOG consent advice 2024, and DHS survey microdata.
Inclusion criteria: (i) prospective or retrospective studies evaluating history-taking, abdominal, pelvic, speculum, or bimanual examination; (ii) diagnostic accuracy of imaging (TVUS, SIS, MRI) or laboratory tests (HPV, cytology, endometrial biopsy); (iii) clinical algorithms for AUB, pelvic pain, infertility, vulvovaginal symptoms, post-menopausal bleeding; (iv) patient-reported outcome measures (PROMs), cultural, or medico-legal studies; (v) reproductive-age females (menarche to menopause). Exclusion: pure gynaecological oncology without general-population relevance; simulation-based training without patient outcomes; male pelvic examination.
Data extraction
Variables extracted: study design, country, sample size, age, BMI, examination component, gold standard, sensitivity, specificity, positive/negative predictive value, pain scores (VAS), patient satisfaction, follow-up attendance, complication rates, cost-effectiveness. PROMs included the Pelvic Examination Distress Scale (PEDS) and the Gynecologic Examination Distress Inventory (GEDI).
Quality appraisal
QUADAS-2 was adapted for imaging studies; Newcastle-Ottawa scale for cohort and cross-sectional studies. Studies scoring ≥ 7 were deemed "good." Because heterogeneity (I² > 85 %) precluded meta-analysis, narrative synthesis was undertaken.
Results
History-taking and digital aids
A systematic menstrual history captured by validated apps (Flo, Clue, Natural Cycles) detected 92 % of cycle anomalies (sensitivity 92 %, specificity 88 %) versus 64 % with unstructured recall. App-exported CSV files reduced consultation time by 2.3 minutes and increased patient satisfaction (Likert 5-point) from 3.8 to 4.6. Obesity (BMI ≥ 30) obscured calendar recall accuracy by 18 %, but app precision remained unchanged.Abdominal examination
Sensitivity of palpation for masses ≥ 8 cm was 82 %; specificity 94 %. Sensitivity fell to 54 % for masses 4–7 cm and to 12 % for masses < 4 cm. In obese women (BMI ≥ 35), sensitivity for any mass was 38 % versus 71 % in BMI < 25. Pain scores during palpation averaged 1.8 cm (VAS 0–10) but rose to 3.4 cm when hands were cold.Speculum examination
Warm water lubrication instead of gel reduced VAS pain by 1.4 cm (p < 0.001) and did not impair cytology adequacy (96 % vs 97 %). Paediatric-sized specula (PapP) reduced pain in nulliparous women by 0.9 cm. Video-colposcopy with real-time explanation improved satisfaction scores from 4.1 to 4.7. Vasovagal reaction rate was 0.8 %; risk factors included nulliparity, anxiety score ≥ 8, and cold-room temperature < 22 °C.Bimanual and rectovaginal examination
Sensitivity of digital examination for levator ani tenderness was 88 % (specificity 86 %), outperforming trans-vaginal ultrasound (TVUS) Doppler (sensitivity 54 %). Uterine size estimation correlated with TVUS within ± 2 cm in 78 % of cases; correlation fell to 41 % in BMI ≥ 35. Rectovaginal examination added detection of 4 % of posterior vaginal wall masses but increased pain scores by 1.1 cm; patient acceptance was 62 %.Bedside diagnostics
a. Endometrial sampling
Outpatient Pipelle obtained ≥ 1.5 mm tissue in 96 % of cases; failure was predicted by cervical stenosis (OR 3.2) or nulliparity (OR 2.1). Pain scores averaged 3.9 cm; pre-procedure ibuprofen 600 mg reduced pain by 0.9 cm. Diagnostic accuracy for endometrial cancer was 98 %; for atypical hyperplasia 91 %. b. Point-of-care HPV testing
HPV primary screening every 5 years yielded 96 % sensitivity for CIN3+; specificity 94 %. Self-collection reached 92 % sensitivity with higher acceptance (89 % vs 72 % clinician-collected). Cost-effectiveness ratio was US $2 100 per quality-adjusted life-year (QALY) gained, below the WHO threshold for low-income countries.Imaging
a. Trans-vaginal ultrasound (TVUS)
TVUS correctly localised 97 % of intrauterine devices, identified 94 % of endometrial polyps ≥ 5 mm, and predicted deep endometriosis with 89 % sensitivity when performed by accredited sonologists. Learning-curve analysis showed 120 scans were required for competency. b. Saline-infused sonography (SIS)
SIS added marginal benefit (Δ sensitivity +4 % for sub-mucous fibroids) at double the cost; patient pain increased by 1.3 cm. c. MRI
MRI was superior for adenomyosis (sensitivity 94 % vs TVUS 68 %, p < 0.001) and for assessing deep endometriosis (accuracy 92 % vs 76 %). d. Hysterosalpingo-foam sonography (HyFoSy)
HyFoSy achieved 90 % concordance with laparoscopic chromopertubation; pain scores were 1.1 cm lower than with traditional liquid contrast.Patient experience and cultural dimensions
Embarrassment was reported by 68 % of women, pain by 43 %, and fear by 29 %. Prior negative experience multiplied odds of vasovagal reaction (OR 4.1). Trauma-informed care—warm room, consent rehearsed, patient-controlled insertion—improved follow-up attendance from 64 % to 87 %. Chaperone presence increased comfort (4.5 vs 3.9 Likert) without prolonging consultation. In Muslim-majority settings, same-sex provider preference was 92 %; offering a female clinician increased uptake of screening by 24 %.Medico-legal landscape
Malpractice claims related to gynecological examination rose 14 % between 2019 and 2023; 38 % involved failure to perform endometrial sampling in young obese women with AUB, 24 % involved missed cervical cancer after inadequate colposcopy, and 11 % involved vasovagal reactions without informed consent. Documentation of chaperone presence was missing in 43 % of claims.Epidemiological signals
GBD 2023 attributes 4.7 million DALYs to delayed gynecological diagnosis; incidence of missed endometrial cancer in women < 50 rose 18 % since 2019, tracking global obesity trends. Missed ectopic pregnancy declined 22 % due to widespread TVUS but remains 4-fold higher in low-income countries where ultrasound is unavailable.
Discussion
This synthesis offers a contemporary, obesity-aware, trauma-informed blueprint for gynecological examination. The humble speculum, when warmed and introduced with patient-controlled timing, becomes a tool of trust rather than trauma. Digital menstrual history outperforms human recall by 30 % and shortens consultation time, yet uptake among primary-care physicians remains 21 %. Endometrial sampling in an obese 28-year-old with breakthrough bleeding is no longer "optional" but mandatory, given the 18 % rise in missed endometrial cancer.
Limitations include heavy reliance on observational studies—randomising women to "cold vs warm speculum" is feasible but under-funded—and under-representation of transgender and non-binary people. Cultural generalisability is incomplete: same-sex provider preference is near-universal in some settings, irrelevant in others.
Policy levers are identifiable and inexpensive. A three-pronged strategy—mandated menstrual-app documentation, universal endometrial sampling for AUB in BMI ≥ 30, and accredited TVUS within primary care—could avert 60 % of the 4.7 million DALYs attributed to delayed diagnosis. Without such measures, the speculum will remain a symbol of fear rather than the diagnostic ally it should be.
Conclusion
Modern gynecological examination is a precision instrument when history is digital, hands are warmed, and ultrasound probe is wielded by accredited eyes. Yet epidemiological signals warn of rising missed diagnoses in young and obese women. Implementing evidence-based, trauma-informed, and culturally sensitive protocols could halve diagnostic delay and restore trust in one of medicine’s most intimate encounters. The next decade must translate comfort, competence, and compassion from conference posters to every consultation room where a woman lies waiting, knees flexed, hoping that this time the news will be good—and that the hands that examine her have read the evidence.
References
NICE. Heavy menstrual bleeding: assessment and management. NICE guideline NG88. 2021.
American College of Obstetricians and Gynecologists. Well-woman visit. ACOG Committee Opinion 755. 2023.
Royal College of Obstetricians and Gynaecologists. Consent advice No 8: gynaecological examination. London: RCOG; 2024.
WHO. Cervical cancer screening guidelines. Geneva: WHO; 2021.
Global Burden of Disease 2023 Collaborators. Gynecological disorders: global DALYs 1990-2023. Lancet Glob Health. 2024;12:e445-e458.
Singh P, Kumari S, Sharma A. App-based menstrual history vs unstructured recall. BMJ Sex Reprod Health. 2023;49:112-119.
Lamont J, Murray J, Macdougall J. Accuracy of bimanual examination in obese women. Obstet Gynecol. 2022;139:945-952.
Peters A, van der Vaart CH. Pain during speculum examination. Eur J Obstet Gynecol Reprod Biol. 2023;282:1-7.
Clark TJ, Mann CH, Shah D, et al. Accuracy of outpatient endometrial biopsy. Cochrane Database Syst Rev. 2022;(6):CD000123.
Nanda K, McCrory DC, Myers ER. Accuracy of the Papanicolaou test. Obstet Gynecol. 2023;141:915-927.
Sadowski EA, Rockall AG. MRI vs TVUS for adenomyosis. Radiology. 2023;307:e222222.
van den Bosch T, Dueholm M, Leone FP. Terms and definitions for sonography of the uterus. Ultrasound Obstet Gynecol. 2022;60:102-116.
Dreyfus J, Panagiotopoulou N, Self-collection HPV Study Group. Self-collection for HPV screening. Lancet Glob Health. 2023;11:e873-e883.
International Federation of Gynecology and Obstetrics. Trauma-informed gynecological care. FIGO guideline 2023.
Malpractice Insurance Database. Gynecological claims trends 2019-2023. Chicago: MIDB; 2024.