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CME/CE Released: 06/21/2010; Valid for credit through 06/21/2011

Target Audience

This activity is intended for primary care providers caring for older women.

Goal

The goal of this activity is to review the basic components and techniques of the geriatric gynecologic examination.

Learning Objectives

Upon completion of this activity, participants will be able to:

1. List the normal changes with aging that affect the female genitalia
2. Identify normal observations of the external genitalia and the components of a careful, sensitive internal
examination

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Author(s)

Mark E. Williams, MD

Ward K. Ensminger Distinguished Professor of Geriatric Medicine, University of Virginia,

Editor(s) University of Virginia Health System, Charlottesville, Virginia; Attending Physician, University of
Virginia Healthsystem, Charlottesville, Virginia
Carol Peckham
Disclosure: Mark
Director, Editorial Development, E. Williams,
Medscape, LLC MD, has disclosed the following relevant financial relationships:
He is a Co-Founder and Chief Scientist of BioMotion Analytics, LLC
Owns stock,
Disclosure: Carol Peckham stock options,
has disclosed or bonds
no relevant from:relationships.
financial BioMotion Analytics, LLC
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Sarah Fleischman

CME Program Manager, Medscape, LLC

Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

Laurie Scudder, DNP, NP

CME Accreditation Coordinator, Medscape, LLC

Disclosure: Laurie Scudder, DNP, NP, has disclosed no relevant financial relationships.

From MedscapeCME Family Medicine

The Basic Geriatric Gynecologic Examination CME/CE
Mark E. Williams, MD
CME/CE Released: 06/21/2010; Valid for credit through 06/21/2011

Overview

Gynecologic concerns can have significant impact on the function and quality of life of older women. With the average age
of menopause between 50 and 55 years and increases in life expectancy, the postmenopausal years may even exceed
the duration of the reproductive years for some women. The gynecologic evaluation of the older women is an important
aspect of comprehensive geriatric care. After menopause a number of changes occur in the female genitourinary system
that reflects the decline in circulating estrogens. Genitourinary problems can significantly affect daily function, self-esteem,
well being, and even longevity in elderly women. For example, a urinary tract infection may be a nuisance for a college
co-ed, but in an octogenarian it could result in confusion or a fall, leading to injury or loss of independence. In addition,
comorbid illnesses that may affect older women, such as osteoarthritis and cognitive impairment, may require significant
modifications in examination positioning and technique. As a general note, any ulcerations, masses, bleeding, or
discharge need to be carefully and thoroughly evaluated before beginning empiric treatments.

Normal Aging Changes

Geriatric gynecologic disorders generally result from variations in neuroendocrine or musculoskeletal function. The female
genitourinary tract is primarily dependent on circulating estrogens, and the changes seen in genital tissues with aging
reflect the progressive decline in gonadal-endocrine stimulation. Estrogen causes the epithelium to differentiate and
deposit glycogen in the vulva and vagina. Vaginal flora metabolizes the glycogen to acetic and lactic acid producing an
acid pH. Estrogen also promotes normal lubrication and tissue vascularity.

The ovary is the primary site of hormone change and decline in estrogen (more specifically 17 beta estradiol) production
at the menopause. Hypothalamic and pituitary function appear to be relatively unaffected by aging, so levels of follicle-
stimulating hormone and luteinizing hormone rise. Adipose tissue metabolizes androstenedione from the adrenal glands
into estrone, which is an estrogen but is biologically less potent than estradiol. Atrophy of the female genital reproductive
system results from the lower estrogen levels.

Postmenopausal vulvar changes include thinning and graying pubic hair, thinning and pallor of tissue, diminution of the
labia minor, and the presence of petechiae (especially in sexually active older women). The vaginal wall thins and
becomes pale. Atrophy of the subcutaneous tissues can cause shortening and narrowing of the vaginal canal. Basal
epithelial cells, reflecting estrogen deficiency, predominate on cytological analysis. The cervix atrophies and the os may
become stenosed. The uterus shrinks in size, the endometrium thins and becomes atrophic, and the myometrium is
replaced with fibrous tissue. Ovarian tissue decreases and the ovaries cannot normally be felt on examination.

Performing the Pelvic Examination

Having laid the appropriate groundwork with an attentive history and thoughtful physical examination to this point will make
the female genital exam easier and help relax the patient. Review with the patient what you are going to do before you start
and allow the patient to empty her bowels or bladder. Make sure the end of the table does not face a door and that the
room is warm. Male examiners should have a female assistant in the room at all times.

Appreciate the patient's sense of vulnerability and act respectfully and carefully. Make sure your gloved hands are warm
and the patient is comfortable. Position the patient at the end of the examination table and help her get into the stirrups.
Patients with degenerative joint disease involving the hips can be examined in Sim's position (left lateral decubitus) with
her right thigh flexed.

External Observation of the Vulva

Observing the Mons Pubis

Check the general area. Ecchymoses on the mons pubis, perineum, or labia suggests pelvic fracture (Coopernail's sign).
Look carefully at the pubic hair and check for lice eggs, which attach to the hairs. Absent pubic hair suggests endocrine
dysfunction.

Observing the Vulvar Vestibule

First inform the patient that you will be examining this area. Touch the patient's inner thigh and then gently spread the labia
majora. Note the labia minora, which is a common site for malignancy. Look for any ulcers or masses. Examine the clitoris;
enlargement suggests an endocrine problem.

Observing the Urethra

Carefully look at the urethra. Generally it is the same color as the surrounding skin. A cherry red urethra suggests urethral
prolapse (urethral caruncle). Polyps, if present, are often on the posterior surface. Seeing a purulent discharge suggests
urethral diverticulum, urethritis, or significant urinary tract infection.

Skin Changes and Lesions

Skin changes seen elsewhere, such as seborrheic keratoses or skin tags (acrochordons), can also be seen on the vulva
and are generally treated as they would be in other locations.

Any fissures, ulcerations, hypertrophic or verrucous lesions should be considered as potential malignancies, and a biopsy
is usually undertaken. Basal cell carcinoma, for example, is sometimes found on the vulva, which is characterized by
indolent growth and a pearly appearance with telangiectasias. Look carefully for pigmented and hypopigmented labial
lesions. A pigmented macule with irregular borders suggests malignant melanoma or a dysplastic nevus.

Lichen sclerosis et atrophicus. Symmetric hypopigmented, shiny, itchy macules suggest lichen sclerosis et atrophicus.
The white lesion of lichen sclerosis (called kraurosis vulvae when it appears in the anogenital area) resembles severe
estrogen deficiency, with very thin, "cigarette paper" or "papyrus" skin. Atrophy may progress to vaginal stenosis and loss
of the labia minora. Sometimes the perirectal area will be involved in addition to the vulvar tissues. The diagnosis is
confirmed by biopsy, which is usually performed when topical estrogen therapy (for presumed estrogen deficiency) fails to
resolve the condition. In fact, low-potency topical corticosteroids may increase the symptoms.

Masses. The presence of several nontender nodules along the outer border of the labia suggests sebaceous cysts.
Bartholin's glands, located on the inner labial wall, can develop cysts when obstructed or abscesses when infected.
Multiple small cysts that line the inner vaginal wall are Gartner's duct cysts. Raised dome-like papules with a central
depression suggest molluscum contagiosum. Multiple irregular flesh-colored papules suggest condyloma acuminatum.
Plaques with central pearly exudates suggest condyloma latum.

Genital ulcers. Painful vesicles suggest herpes infection. A single painless ulcer with a fibrotic rim suggests primary
syphilis. A single painful ulcer suggests lymphogranuloma venereum. Seeing an ulcerated plaque with irregular margins
suggests vulvar malignancy, Behçet's syndrome, dermatitis herpetiformis, and erythema multiforme.

Invasive carcinoma of the vulva. Invasive carcinoma of the vulva is primarily a disease seen in older women,
with peak incidence at age 85. It most often resembles a flat infiltrative or ulcerative lesion. The anterior vulva --
around the clitoris, the vestibule, or along the labia -- is the most common site of involvement. When a vulvar lesion
is seen --especially if it is white, brown, red, raised or ulcerated -- a biopsy is usually indicated. One technique for
performing the biopsy is to stain the vulva with toluidine blue and then wash the area with 1% acetic acid. The
suspicious areas retain the blue stain to direct the biopsy to the most productive location.

Genital plaques. Red plaques that itch and have serous oozing suggest contact dermatitis. A bright red rash that involves
the labia suggests Candidiasis. A bright red rash that spares the labia suggests tinea cruris. Red plaques with silver
scales and well-demarcated borders suggest psoriasis.

Note: A plaque that resembles psoriasis but is darker red and friable suggests Paget's disease of the vulva. Also, a "yeast
infection" that does not clear after aggressive treatment should be biopsied to rule out Paget's disease. The identification
of Paget's disease suggests a 30% incidence of coexistent cancer of the breast, cervix, bladder, gallbladder, or colon.
Additional evaluation of these sites to search for occult malignancy is indicated.

Fistulous tracts. Fistulae suggests Crohn's disease, perirectal abscess, diverticulosis, or malignancy.

Swelling and Thickening

Vulvar swelling or areas of thickening raise the possibility of malignancy. Swelling on either side of the posterior vulva at
approximately 4 and 8 o'clock positions typically reflects inflammation of Bartholin's glands. Any enlargement of these
glands should be carefully evaluated, because adenocarcinoma of Bartholin's glands is very aggressive.

Swelling around the urethra can be caused by circumferential prolapse. In this condition, the entire urethral meatus
appears bright red and the friable mucosa can be an etiology of bleeding. A localized area of swelling and prolapse
(resembling a polyp) around the urethra is a urethral caruncle. These lesions may reflect estrogen deficiency and respond
to estrogen replacement. If the lesions do not respond, then biopsy is indicated to rule out malignancy.

Prolapse

Prolapse is usually easy to appreciate on examination of the introitus, but determining the precise organ or structure that is
prolapsing can be more difficult, and it is sometimes necessary to use a small speculum and separate the blades to
identify the source. Prolapse is graded by the extent of descent:

Grade 1 (or first-degree) prolapse: There is some movement of the organ from its usual position;
Grade 2 prolapse The organ is near the vaginal introitus;
Grade 3 prolapse: the organ is at or bulging from the introitus.

Bulging of the anterior vaginal wall suggests bladder prolapse (cystocele); bulging of the posterior vaginal wall from the
rectum is a rectocele; and internal herniation of the small intestine into the rectovaginal septum is an enterocele. The
uterus can also prolapse, as can the vaginal apex in women who had hysterectomies. More than 1 structure can prolapse:
uterine prolapse is often seen with a coexistent cystocele, rectocele, or enterocele, in which case the rectovaginal septum
is enlarged as the uterus drops.

Uterine prolapse, sometimes called descensus, is related to damage of genital structures during childbirth. Procidentia is
total eversion of the vagina. Cervical protrusion can predispose to mucosal dryness and infection.

Cystocele. Cystocele occurs in the pubovesical and pubocervical fascia and produces an anterior wall bulge. It may
compromise bladder emptying, leading to increased postvoid residual urine volume and recurrent urinary tract infections.
Urethrocele is also usually present. A large cystocele may put a kink in the urethra, effectively increasing the resistance to
urine flow. Urinary incontinence can also result if the prolapse affects the posterior urethra-vesical angle. Normally this
angle is 90 degrees. An increase in this angle due to prolapse can compromise the transmission of intra-abdominal
pressure that normally pinches the bladder neck shut when abdominal pressure acutely increases. Loss of this
mechanism can allow the bladder pressure to exceed the urethral resistance, causing leakage with increases in abdominal
pressure such as laughing, jogging, sneezing, squatting, or bending over.

Rectocele. Rectocele is caused by a defect in the rectovaginal fascia with separation of the levator ani musculature.

Enterocele. An enterocele is a true hernia through the pelvic outlet that may cause lower abdominal pain and pelvic
pressure that is relieved by lying down. The condition may not be evident on supine pelvic examination, even with the
patient bearing down. If the provider's suspicion for an enterocele is high, the patient should be examined while standing
with one leg placed on a 10- to 12-inch step. When the patient bears down, the bowel can be felt to slide into the
rectovaginal septum.

External Palpation

Palpation of the Labia

Gently palpate along the labia. Bartholin's glands are not normally palpable. Palpable glands suggest inflammation or
malignancy.

Examining the Urethra and Checking Pelvic Muscle Tone

Carefully palpate the urethra. Gently insert your gloved finger 2 inches into the introitus and feel the posterior urethral
margin on the superior vaginal wall. Note any urethral discharge. Skene's glands are on either side of the urethra.

Now check the pelvic muscle tone. Gently insert both your forefinger and middle finger into the introitus and have patient
squeeze your fingers (do not tell patient to relax since this is counterproductive and really does not work). Pay attention to
the muscle tone. Gently separate your fingers laterally and have the patient bear down. Seeing urine flow suggests stress
urinary incontinence.

Next, perform the Bonney-Reed-Marchetti test to examine the integrity of the posterior urethrovesicular angle. First, gently
elevate the urethra approximately a centimeter with your forefinger and middle finger and have the patient bear down
again. No urine flow is a positive test result and suggests loss of the posterior urethrovesical angle. Feel the vaginal walls
for carcinoma or fistulae.

Check for swelling at the obturator foramen on the lateral border between the pubic symphysis and the ischium. The
presence of swelling that causes pain to the patient suggests a Richter's hernia, which may also present as knee pain
(Howship-Romberg sign) and limited range of motion of the hip.

Internal Examination Using the Speculum

Insertion of the Speculum

Inform the patient that you will be conducting an internal examination using a speculum. Touch the patient's inner thigh to
give the her the sense that the exam will begin. Gently place your forefinger and middle fingers into the introitus and gently
push down. Move the left labia to the side with your left thumb to reduce the likelihood of pinching the labia or getting hair
caught in the speculum. Gently insert the closed speculum horizontally just over your fingers. Have the patient bear down
to help relax the perineum.

Watch the skin texture and color for stretching or pallor, which indicates an improper angle. Once inserted, slowly advance
the speculum to avoid discomfort. Gently separate the blades of the speculum by moving posteriorly. Vigorous
movements can be painful. In addition, vaginal atrophy is associated with mucosal thinning and care must be taken in
opening the blades of the speculum to avoid irritation or bleeding. Note: Some clinicians prefer the narrower blades of the
Pederson speculum over the standard (Grave's) speculum.

Discharge

Atrophic vaginitis seems to be the most common cause of vaginal discharge in an elderly woman not on corticosteroids or
antibiotics. It does not have a foul odor and should be distinguished from other causes of discharge that include the
following specific characteristics:

Monilial ("yeast") infection. Discharge has consistency of cottage cheese with thick clumps. Usually pruritus is
present and microscopically hyphae are seen when the discharge is suspended in 10% potassium hydroxide.
Trichomonas or Gardnerella vaginalis is characterized by foamy discharge with a fishy smell. May occur rarely in
sexually active postmenopausal women.
Bacterial infection: Discharge is thin and purulent. More common in elderly than in younger women, since the
thinning of the vaginal mucosa makes it easier for bacteria to enter the subepithelial tissues.
Discharge generally results from vaginal diseases, but fistulae need to be considered, especially if the patient has a
history of pelvic radiation, malignancy, or inflammatory bowel disease.

Examining the Cervix

Locate and examine the cervix. (This is sometimes easier said than done; experience is key!) The cervix is usually 3
centimeters long and may be difficult to see in an elderly woman because vaginal atrophy can reduce the viewing area. In
addition, the cervical os may be stenosed and appear to be the vaginal apex. These senescent changes can create
complications if fluid is trapped in the endometrial cavity by malignancy, bleeding, or infection. Patience and careful,
systematic inspection are key features of the examination of the cervix.

Note any discharge or secretions from the os, which is generally a slit. Purulent discharge suggests cervicitis. Check for
masses, ulcers, or changes in pigmentation. A soft polyp is a cervical polyp. An ulcer on the cervix suggests cervical
cancer. Smooth, round, tan-colored lesions are likely to be nabothian cysts. Any questionable lesions seen around the
cervix should be biopsied. Cervical cancer occurs more commonly in younger women but it can also occur in geriatric
women.

Obtaining a Pap smear is sometimes reasonable during this examination, in which case care must be taken to obtain an
adequate endocervical sample. This process can be challenging because the cervical os may be stenotic and the
squamocolumnar junction has usually retreated within the cervical canal. A small brush inserted 1 to 2 centimeters into the
cervical os is an appropriate approach to obtain the Pap smear.

As you withdraw the speculum, examine the vaginal mucosa and check for openings, which would suggest rectovaginal
fistulae.

Bimanual Examination

Gently insert your forefinger and middle finger posteriorly into the vaginal introitus. Check the vaginal walls, noting any
masses or irregularities.

Palpate the cervix. Deviation from the midline suggests a mass, inflammation, or other abnormality. The shape and texture
of the cervix should be smooth and not lumpy. Note the cervical mobility by pushing upward; it should easily move a
centimeter or so in each direction. Tenderness to movement suggests pelvic inflammation. A rock-hard sensation
suggests malignancy. Palpate around the cervix.

Examining the Uterus

Gently push down between the umbilicus and the pubic symphysis with your free hand. Gently push upward with your
internal hand to feel the uterus between your hands. Pay attention to the size and texture. The uterus usually is small after
menopause, so any uterine enlargement requires additional evaluation. Bogginess of the uterus with a purulent discharge
from the os suggests endometritis. Feel for any masses along the uterine surface, such as leiomyoma. Note any limitation
of movement to palpation, which suggests adhesions or malignancy.

Palpating the Adnexal

Move lateral with the internal hand to the uterine fundus (to the patient's left) and lateral with your abdominal hand to the left
lower quadrant. Gently push your hands together in a forward-pulling movement to feel the left ovary. Ovaries are not
generally felt in postmenopausal women. Note any masses, irregularities, or other abnormalities. Then, repeat this
examination on the right-side structures. Adnexal masses suggest ovarian neoplasm, stool in the sigmoid colon,
redundant sigmoid colon, distended cecum, appendiceal abscess, and pelvic tuberculosis.

A large mass may be an enlarged ovarian cyst. Confirm this with Blaxland's test: Place a ruler on the abdomen just above
the iliac crest. Push down on the ruler. If you can feel the aortic pulse with the ruler, it is a positive test result. Ascites or
other swelling will not produce the aortic pulsation.

Rectovaginal Examination

Change gloves. Gently insert your forefinger into the introitus and your lubricated middle finger into the anal opening. Feel
between your fingers for atrophy of the perineal muscle. Feel carefully for masses along the rectovaginal septum. Feel the
uterus and adnexa using the bimanual technique.
Summary

The gynecologic evaluation of the older women is an important aspect of comprehensive geriatric care. The changes that
take place after menopause can have significant effects on the genitourinary system, which can be exacerbated by
comorbid conditions that are common in the elderly. Any changes or abnormalities found on an physical examination need
to be carefully and thoroughly evaluated before beginning empiric treatments.

This article is a CME/CE certified activity. To earn credit for this activity visit:
http://cme.medscape.com/viewarticle/723565

Suggested Reading

Williams ME. Geriatric Physical Diagnosis: A Guide to Observation and Assessment, 2008. McFarland and Co:
Jefferson, NC.

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MedscapeCME Family Medicine © 2010 MedscapeCME

This article is a CME/CE certified activity. To earn credit for this activity visit:
http://cme.medscape.com/viewarticle/723565