The gynecologist needs to approach each patient not just as a person requiring medical intervention for a specific presenting problem, but also as one who may have a variety of factors possibly affecting her health. The initial approach to the gynecologic patient and the general diagnostic procedures available for the investigation of gynecologic complaints are presented here. Although other aspects of the general medical examination are left to other texts, concern for the patient's total health and well-being is mandatory.
It is now a generally accepted part of the physician's responsibility to advise patients to have periodic medical evaluations. The frequency of visits varies according to the patient's age and specific problem.
The periodic health screening examination helps detect the following ailments of women that are especially amenable to early diagnosis and treatment: diabetes mellitus; urinary tract infection or tumor; hypertension; malnutrition or obesity; thyroid dysfunction or tumor; and breast, abdominal, or pelvic tumor. These conditions can be detected by a review of systems, with specific questions regarding recent abnormalities or any variation in function. Determination of weight, blood pressure, and urinalysis may reveal variations from the previous examination. An examination of the thyroid gland, breasts, abdomen, and pelvis, including a Papanicolaou (Pap) smear, should then be performed. A rectal examination also is advisable, and a conveniently packaged test for occult blood (Hemoccult) is recommended for patients older than 40 years. Patients of an advanced age (>50 years) may undergo blood test for lipid profile, bone density scan, pelvic ultrasound examination, and mammogram.
The physician should be concerned about conditions other than purely somatic ones. Unless a patient's problems require the services of a psychiatrist or some other specialist, the doctor should be prepared to act as a counselor and work with the patient during a mutually agreeable time when it is possible to listen to her problems without being hurried and to give support, counsel, and other kinds of help as required.
To adequately evaluate the gynecologic patient, it is important to establish a rapport during the history taking. The patient needs to tell her story to an interested listener who does not allow body language or facial expressions to imply disinterest or boredom. One should avoid cutting off the patient's story, because doing so may obscure important clues or other problems that may have contributed to the reasons for the visit.
The following outline varies from the routine medical history because, in evaluating the gynecologic patient, the problem often can be clarified if the history is obtained in the following order.
Knowledge of the patient's age sets the tone for the complaint and the approach to the patient. Obviously, the problems and the approach to them vary at different stages in a woman's life (pubescence, adolescence, childbearing years, and premenopausal and postmenopausal years).