EVALUATION OF A

BIMANUAL PELVIC EXAM

SCREENING FOR SEXUALLY

TRANSMITTED INFECTION
PAP SMEAR
COLPOSCOPY
ULTRASOUND
HYSTEROSALPINGOGRAM
SONOHYSTEROSALPINGOGRAM

GYNECOLOGIC PROCEDURES

GYNECOLOGIC PATIENT

FRANCIENE F. PAALAN-VASQUEZ, MD, FPOGS

DIAGNOSTIC PROCEDURES

SCREENING FOR SEXUALLY

TRANSMITTED INFECTION

CULDOCENTESIS
BIOPSY
HYSTEROSCOPY
FRACTIONAL D&C
LAPAROSCOPY
LEEP

Women at risk of sexually transmitted

diseases should be screened yearly
for these diseases, even if they have
no symptoms.

GRAM STAINING

HIGH RISK WOMEN

Sexually active women aged 25 and younger

Women who are just beginning sexual activity

Women who have several sex partners

Women whose partner has had several sex partners

Women who have had a sexually transmitted disease

Women who do not consistently use a barrier
contraceptive (such as a condom) and are not in a
mutually monogamous relationship or are unsure if
the relationship is mutually monogamous

Pregnant women

Women who have a vaginal discharge

HPV SCREENING

PAP SMEAR
(PAPANICOLAU SMEAR)

DIAGNOSTIC PROCEDURES

For most sexually transmitted diseases,

the doctor uses a swab to obtain a small
amount of cervical discharge from the
cervix. The sample is sent to a
laboratory for analysis.
Testing for gonorrhea and chlamydial
infection can also be performed on a
urine specimen.

A doctor may consider screening women for the

human papillomavirus (HPV) if they are 30
years old or older or if a Pap test detected
questionable abnormalities that may result
from HPV infection.
HPV can cause genital warts or cervical cancer.
A sample of vaginal discharge, obtained with a
swab, is also used for this test.

Normal results of a HPV test indicate that

cervical cancer and precancerous
conditions are highly unlikely.
For women at high risk of HPV, the HPV
test can be done at the same time as a
Pap test.
If results of a Pap test and an HPV test are
normal in women older than 30, neither
test needs to be repeated for at least 3
years.

PAP SMEAR

TYPES OF SCREENING

Named after the Greek MD Georgios

Papanikolaou
A screening test used to detect
premalignant and malignant processes of
the ectocervix
Also detects infections and some
abnormalities in the endocervix and
endometrium

Conventional Cytology
Liquid-based monolayer Cytology

CONVENTIONAL CYTOLOGY

CONVENTIONAL CYTOLOGY
Physician collects the smear and
applies the fixative
Slide is sent to a laboratory for
evaluation
Accuracy:
Sensitivity 72%
Specificity 94%

TIMING OF PAP SMEAR

Sensitivity 61-66%
Specificity 82-91%

SURE-PATH
THIN-PREP

PAP SMEAR REPORT

INDICATION FOR COLPOSCOPY

COLPOSCOPY

Midcycle
No intercourse for 24 hours prior
Nothing in the vagina for 48 hours prior
No douching

Unexplained vaginal bleeding

Post-coital bleeding
Positive screening test by
Cervicography or Speculoscopy

Once placed in the vial, the sample is

processed at the laboratory into a cell-thin
layer, stained, and examined by light
microscopy
Advantage: suitable for high-risk HPV testing
Accuracy:

The sample is placed in a vial

containing a liquid medium that
preserves the cells, usually ethanolbased media
2 types:

Anytime that menstrual bleeding is not

present
Optimal timing

INDICATION FOR COLPOSCOPY

LIQUID BASED CYTOLOGY

LIQUID BASED MONOLAYER CYTOLOGY

OBJECTIVES IN COLPOSCOPY
Determines the presence of invasive
cancer
Localizes the squamo-columnar
junction
Identifies the most severe disease for
biopsy
Evaluates the extent of disease

Epithelial Cell abnormalities detected by

cervical cytology
(+) high risk HPV DNA in ASCUS triage
Suspicious cervical lesions
Vulvar or Vaginal neoplasia
History of in-utero DES exposure
Sexual partner of patients with genital
tract neoplasia

COLPOSCOPY

ULTRASOUND MACHINE

ULTRASOUND

TRANSABDOMINAL ULTRASOUND

TRANSABDOMINAL ULTRASOUND

Done with full urinary bladder

Provides a wider field of view than
TVS
Superficial structures & structures
which are remote from vagina
Visualize high or laterally located
ovaries & pelvic masses

Visualization of pelvic area limited

by:

TRANSVAGINAL ULTRASOUND

TRANSVAGINAL ULTRASOUND

TRANSABDOMINAL ULTRASOUND

TRANSABDOMINAL ULTRASOUND

TRANSVAGINAL ULTRASOUND

TRANSVAGINAL ULTRASOUND

Anterior abdominal wall

Subcutaneous & peritoneal fat
Fat in the mesentery & omentum

By-passes attenuating tissues

Uses high-frequency probes
Demonstrates anatomic details of
the uterus, ovaries & adnexa

INDICATIONS
Gynecologic sonography
Early first trimester obstetric
sonography

TRANSVAGINAL ULTRASOUND
INDICATIONS
Obstetric application late in pregnancy
like:
Placenta previa
Evaluation of fetal lumbosacral spine in breech
fetuses
Evaluation of fetal intracranial contents in
cephalic fetuses
Evaluation of fetal nuchal region before 14 weeks

TRANSVAGINAL ULTRASOUND
INDICATIONS
Suspected ectopic pregnancy
Suspected of having lower abdominal
disease
Follicle monitoring
Monitoring of assisted reproductive
techniques

TRANSVAGINAL ULTRASOUND
CONTRAINDICATED in:

Pre-menarcheal or virginal patients

Any patient who does not give a
consent to the examination
(verbal)

TRANSVAGINAL ULTRASOUND

TRANSVAGINAL ULTRASOUND

HYSTEROSALPINGOGRAM

TAS vs. TVS

HYSTEROSALPINGOGRAM

HYSTEROSALPINGOGRAM

HYSTEROSALPINGOGRAM

SONOHYSTEROSALPINGOGRAM

SONOHYSTEROSALPINGOGRAM
OR
SALINE INFUSION
SONOHYSTEROSALPINGOGRAM
(S.I.S.)

SONOHYSTEROSALPINGOGRAM

S.I.S.

An X-ray test that looks at the inside of

the uterus and fallopian tubes and the
area around them
Infertility work-up
A dye is put through a thin tube that is
put thru the vagina and into the uterus
Detects uterine and tubal problems
NSAID for cramps/pain

Saline in infused into the uterus and

fallopian tubes thru the vagina
Real time ultrasound will document
the flow of the saline through the
tubes when they are patent
Endometrial masses are also
detected

S.I.S.

CULDOCENTESIS

CULDOCENTESIS
Aspiration of fluid from the rectouterine space by puncture of the
vaginal vault near the midline
between the uterosacral ligaments
Rarely performed with easy access to
ultrasound

CULDOCENTESIS INDICATIONS
To diagnose hemoperitoneum in
ruptured Ectopic Pregnancy
Detect hemoperitoneum in blunt
abdominal trauma
Diagnose ruptured ovarian cysts
Aid in the Dx and Tx of PID
Diagnosis of Ascites

CULDOCENTESIS

BIOPSY

BIOPSY: VULVA, VAGINA CERVIX

A biopsy of the vulva and vagina can
usually be done in the doctor's office
and requires use of a local
anesthetic.
Cervical punch biopsy can also be
done in the clinic

ENDOCERVICAL CURETTAGE

BIOPSY: ENDOMETRIUM

BIOPSY: ENDOMETRIUM

a speculum is used to spread the walls of the

vagina, and a small metal or plastic tube is
inserted through the cervix into the uterus. The
tube is used to suction tissue from the uterine
lining.
This procedure is usually done to determine the
cause of abnormal vaginal bleeding. Also,
infertility specialists use this procedure to
determine whether ovulation is occurring
normally and whether the uterus is ready for
implantation of embryos.

An endometrial biopsy can be done in a

doctor's office and usually does not require
an anesthetic. Typically, it feels like strong
menstrual cramps. Taking a nonsteroidal antiinflammatory drug (NSAID), such
as ibuprofen , 20 minutes before the
procedure may help relieve discomfort during
the procedure.

ENDOCERVICAL CURETTAGE

ENDOCERVICAL CURETTAGE

Consists of inserting a small, sharp,

scoop-shaped instrument (curet) into the
passageway through the cervix (cervical
canal) to obtain tissue.

BIOPSY: ENDOMETRIUM

FRACTIONAL DILATATION &

CURETTAGE

The curet is used to scrape a small

amount of tissue from high inside the
cervical canal.

D and C

D and C

a speculum is used to spread the

walls of the vagina. Then, metal rods
are used to stretch open (dilate) the
cervix so that a small, sharp, scoopshaped instrument (curette) can be
inserted to remove tissue from the
lining of the uterus.

To treat women who have had an

incomplete (partial) miscarriage
Sometimes used to identify
abnormalities of the uterine lining when
biopsy results are inconclusive - but it is
no longer commonly used for this purpose
because biopsies usually provide as much
information and can be done in the
doctor's office.

HYSTEROSCOPY

HYSTEROSCOPY

To view the interior of the uterus, doctors

can insert a thin viewing tube
(hysteroscope) through the vagina and
cervix into the uterus. The tube is about
inch in diameter and contains cables
that transmit light. Instruments used for a
biopsy, electrocautery (heat), or surgery
may be threaded through the tube.

The site of abnormal bleeding or other

abnormalities can usually be seen and
can be sampled for a biopsy, sealed off
using heat, or removed. This procedure
may be done in a doctor's office or in a
hospital with a general anesthetic at the
same time as a dilation and curettage.

D and C

HYSTEROSCOPY

HYSTEROSCOPY

LAPAROSCOPY

LAPAROSCOPY
To directly examine the uterus,
fallopian tubes, or ovaries, doctors
use a viewing tube called a
laparoscope.

LAPAROSCOPY

LAPAROSCOPY

The laparoscope is attached to a thin cable

containing flexible plastic or glass rods that
transmit light. The laparoscope is inserted into
the abdominal cavity through a small incision
just below the navel. A probe is inserted
through the vagina and into the uterus. The
probe enables doctors to manipulate the organs
for better viewing. Carbon dioxide is pumped
through the laparoscope to inflate the
abdomen, so that organs in the abdomen and
pelvis can be seen clearly.

Often, laparoscopy is used to determine the

cause of pelvic pain, infertility, and other
gynecologic disorders. Instruments can be
threaded through the laparoscope to perform
some surgical procedures, such as biopsies,
sterilization procedures, and removal of an
ectopic pregnancy in a fallopian tube. Additional
incisions may be required if surgical procedures,
such as removal of an ovarian cyst or the uterus
(hysterectomy), are needed.

LAPAROSCOPY
Laparoscopy is done in a hospital and requires
an anesthetic, usually a general anesthetic.
An overnight stay in the hospital is usually not
required. Laparoscopy may cause abdominal
pain, but normal activities can usually be
resumed in 3 to 5 days, depending on the
extent of the procedure that is performed
through the laparoscope.

LEEP

LEEP

In a loop electrical excision

procedure (LEEP), a thin wire loop
that conducts an electrical current is
used to remove a piece of tissue.
Typically, this piece of tissue is larger
than that obtained in a cervical
biopsy.

Done after an abnormal Pap test result to

evaluate the abnormality more accurately or to
remove the abnormal tissue. LEEP requires an
anesthetic (often a local one), takes about 5 to 10
minutes, and can be done in a doctor's office.
Afterward, women may feel mild to moderate
discomfort and have a small amount of bleeding.
Taking an NSAID, such as ibuprofen , 20 minutes
before the procedure may help relieve discomfort
during the procedure.

LOOP ELECTRICAL EXCISION

PROCEDURE
(LEEP)

LEEP

Thank you!
FRANCIENE F. PAALANVASQUEZ, MD, FPOGS