3-39
it side to side by grasping the cervix between the 2 examining fingers. The ovaries may be palpated by
moving the vaginal hand to the right or left and reaching upward to the side of the uterus. Sweep the
abdominal hand down to meet the vaginal hand along the uterus. Feel the tissue to the side of the uterus.
The ovary will normally be pulled down in to the vaginal hand by sweeping along the side of the uterus.
Premenopausal ovaries are 3-5 cm in length and 2-4 cm in width. The ovaries are normally tender to
palpation. This tenderness is localized to the time of exam and is usually described as an aching sensation.
Rectovaginal Examination:
Always change gloves (so no blood is carried to the rectum) and obtain a large dollop of lubricant prior to
rectovaginal examination. Ask the patient to relax the anal sphincter. The middle finger is inserted into the
rectum and the index finger into the vagina. It is helpful to have the patient bear down as the rectal finger
is inserted slowly. The rectovaginal septum can be felt between the index and middle finger. Palpate the
posterior aspect of the uterus, uterosacral ligaments and posterior cul-de-sac along with the anorectal area.
Note masses, nodularity and pain. A simple rectal examination is the only way to assess the pelvis in an
infant or child. Test a sample of fecal material for occult blood.
What Not To Do:
Do not be insensitive, unprofessional or humorous with the patient during the exam.
Do not perform routine pelvic exams during pregnancy. Most women will not require such exams unless
there is a strong suspicion of vaginal pathology. The exam may introduce harmful organisms into the vagina
or otherwise endanger the fetus.
Do not perform the exam in stages. Do a complete exam the first time and allow the patient to get dressed.
Do not perform an occult blood test with gloves that have been used to examine the vagina. The test will
likely be falsely positive.
Symptom: GYN Problems: Abnormal Uterine Bleeding
MAJ Ann Friedmann, MC, USAIntroduction: Abnormal uterine bleeding (AUB) is symptom that can have a variety of etiologies, ranging from
simple to life-threatening illnesses. The work-up of abnormal uterine bleeding is systematic and will usually
lead to diagnosis. AUB is characterized by changes in the interval and duration of menstrual flow. The
normal menstrual interval is 28 days with a range of 21-35 days. The normal duration of the menstrual
flow is 2-7 days with average blood loss < 80 cc. AUB can present as vaginal hemorrhage, which is the
primary focus of this section.
Subjective: Symptoms
Significant change in menstrual pattern or amount of bleeding. Acute, excessive menstrual blood loss can
lead to symptomatic anemia, if so, patient will complain of fatigue, orthostatic changes, and heart palpitations.
Excessive blood loss may be described as “gushing”; large clots may be passed; pregnant patients may
complain of associated early pregnancy symptoms such as nausea and vomiting, breast tenderness and
missing last menstrual cycle.
Objective: Signs
Using Basic Tools: May have large amounts of blood issuing from the vagina; the cervix may be obscured
with blood; uterus may be misshapen by a uterine fibroid, a common cause of heavy menses; patients with
acute anemia will have heart rate and blood pressure changes based on the volume of blood loss.
Using Advanced Tools: Lab: Assess anemia via hematocrit; perform pregnancy test
Assessment:
Differential diagnosis: For many of these etiologies of AUB, physical findings will be minimal and limited