Chapter 21: Female Genitalia

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Welcome back to the Deep Dive.

Today we are opening the book on a topic that is arguably one of the most high stakes interactions in all of medicine.

We aren't just talking about anatomy.

We're talking about vulnerability, technical precision, and, you know, the real art of the physical exam.

We are looking at Bates' Guide to Physical Examination, specifically Chapter 21,

Female Genitalia.

It is a massive topic.

And frankly, it's the chapter that makes most medical students and even residents the most nervous.

I can believe that.

You're dealing with such an intimate area of the body, a patient who is very likely anxious and a procedure that requires a very specific manual dexterity.

It's kind of the perfect storm for a novice clinician.

That is exactly why we're doing this.

Our mission today is to take that anxiety and hopefully replace it with confidence.

We're going to deconstruct the entire chapter from the microscopic changes in cervical cells all the way to the proper way to hold a speculum so you don't hurt your patient.

There's a lot to cover.

A ton.

We've got anatomy, the health history, the exam itself, and then the really crucial life -saving health promotion at the end.

And the source material here, Bates.

It's the gold standard.

But, you know, we need to read between the lines a little.

The text gives you the steps.

We need to talk about the feel and the why behind those steps.

Exactly.

Let's start where Bates starts, which is the geography of the region, anatomy and physiology.

And we have to be really precise here because, you know, down there is not a medical term.

Right.

Precision is absolutely key.

We start with the vulva.

This is the collective term for all the external genitalia.

It's not just one structure.

Okay.

So what's included in that?

Well, you have the mons pubis, which is that hair -covered fat pad that sits right over the symphysis pubis.

Its primary job is really just cushioning.

Right.

Protection.

Exactly.

Then you move to the labia.

And you have the majora and the menorah.

The labia majora are those outer rounded folds of adipose tissue.

You can think of them as the protective gates.

Then inside those, you have the labia menorah.

These are thinner, more pinkish -red folds.

No hair on those, right?

Correct.

No hair follicles.

And they extend anteriorly to form what's called the prepuce, which is the hood of the clitoris.

And the geography gets really specific between those inner folds.

Bates calls it the boat -shaped fossa,

which is a surprisingly poetic description for a medical text.

It is, isn't it?

That's the vestibule.

And if you're a student, you need to memorize the vestibule, because that is where your key landmarks are.

Okay.

So what are we looking for in the vestibule?

Interiorly.

So toward the front, you have the urethral meatus.

That's the exit for urine.

And then posterior to that, you'll find the introitus, which is the vaginal opening itself.

And just behind the introitus?

That's the perineum.

It's that tissue bridge between the vagina and the anus.

This area is so clinically vital, because during childbirth, this is the tissue that has to stretch an incredible amount, and sometimes it tears.

Now, hidden in this landscape are some glands.

We always memorize them for exams, bartholins, and skeins.

But in a healthy patient, are we actually seeing these glands?

Almost never.

And that's a really common misconception.

Students are looking for them.

The openings of the bartholin glands are tucked away posteriorly at roughly the four o 'clock and eight o 'clock positions, if you imagine the vaginal opening as a clock face.

So you wouldn't see them?

Not unless they're infected or are formed to cyst.

Then they can become quite large and painful.

And the same goes for the pararythal glands, also called skein glands, which are near the urethra.

If you can see them, usually something is wrong.

Okay, so let's move inward.

Past the introitus, we're in the vagina.

Bates describes it as a musculomembranous tube.

Which sounds very rigid, but it's actually highly distensible.

It sits sandwiched between the bladder and urethra in the front and the rectum in the back.

And the texture inside is interesting.

It is.

One thing you'll notice during an exam is that it's not smooth like the inside of your cheek.

It has these transverse ridges, or folds, called rugae.

And the orientation of the vagina isn't straight up and down, right?

I think that's a common mistake.

100%.

It's a crucial error people make with the speculum.

The vagina actually tilts posteriorly back toward the sacrum.

But probably the most important structural concept for the exam itself is the fornix.

Explain the fornix.

It sounds like a fortress or something.

It's actually Latin for arch, or vault.

Think of it this way.

The vagina is a tube.

And the cervix is like a cylinder that pokes down into the very top of that tube.

So because the cervix is sticking down into that space, it creates these deep recesses or pockets all around it.

Those pockets are the fornices.

You have an anterior one, a posterior one, and two lateral ones.

And why should a clinician care about a little pocket of space?

What's the significance?

Because they are your windows to the inside.

When you do a bimanual exam, you are pushing your fingers into these fornices to feel the organs that are behind the vaginal wall.

You press your fingers into the lateral fornix to try and feel the ovary on that side.

You press into the posterior fornix to feel the back of the uterus.

If you don't use the fornices, you're just poking at the cervix, which is firm.

It doesn't really tell you much.

It helps no one.

That's a great visualization.

It's not about pushing.

It's about getting to that space.

Exactly.

So speaking of the cervix, Bates calls it the gatekeeper.

It really is.

It connects the vagina to the uterus.

It's firm.

It's collagenous.

If you touch it, it feels almost like the tip of your nose.

Interesting.

Yeah.

And when you look at it through the speculum, you're seeing the ectocervix, which is the outer surface, with the external

opening right in the center.

OK, now this is where we need to get down to the cellular level.

There's a concept here that is arguably the most important thing for cancer screening, the transformation zone.

This is the high yield insight for this entire section.

You have two different types of skin or epithelium meeting right there on the cervix.

Yes.

The ectocervix, the part you can see in the vagina, is covered in a shiny pink squamous epithelium.

It's tough.

It's durable, sort of like the skin inside your mouth.

OK.

But inside the canal, the endocervix, it's lined with a deep red, plushy columnar epithelium.

It's more glandular and delicate.

So you have squamous meeting columnar.

Right.

But they don't just stay put in one place their whole life.

During puberty, under the influence of hormones, that plushy columnar tissue from inside starts to get replaced by the tougher squamous tissue from the outside.

That process of one cell type changing into another is called metaplasia.

And the area where this change is actively happening is the transformation zone.

Exactly.

And because the cells there are rapidly changing and dividing, they are highly vulnerable to DNA damage, specifically from the human papillomavirus or HPV.

This zone is ground zero for cervical cancer.

So when we do a pap smear, we aren't just swabbing some random cervical slime, we are specifically hunting for the transformation zone.

If you miss it on your swab, you've essentially missed the whole point of the cancer screening.

That completely changes how you visualize what you're doing with that little brush.

You're aiming for a very specific dynamic target.

Moving target, yeah.

Let's move up from there to the uterus itself.

The inverted pair.

Oh.

It has the corpus, which is the main body, the fund at the very top, and the isthmus, which is the part that narrows down to connect to the cervix.

It's a muscular powerhouse.

And flanking it, we have the adnexa.

I always thought that sounded like some kind of sci -fi term.

It's latin for appendages.

It's just a collective term for the ovaries and the fallopian tubes.

Okay.

The ovaries are the hormone factories.

They produce estrogen, progesterone, and a little bit of testosterone.

Here is a reality check from the text that I found really reassuring for students.

You cannot always feel the ovaries.

No.

And students panic about this all the time.

They think they're failing the exam.

But in a healthy woman during her reproductive years,

you can probably palpate the ovaries maybe 50 % of the time.

Only 50%.

At best.

If the woman is obese or her abdominal muscles are tense, that number drops significantly.

And the fallopian tubes.

You generally can't feel them at all unless they're inflamed or swollen, like in an ectopic pregnancy.

So if you can't feel them, that's a normal finding.

It is a normal finding.

There is one more anatomical space we need to define before we leave this section.

The rectutoring pouch.

Also known as the pouch of Douglas.

It's the cul -de -sac, the lowest point in the female pelvis that sits between the urethra and the rectum.

And why is that important?

Gravity works here.

If there is an infection or blood from a ruptured cyst or any kind of fluid in the abdomen, it tends to pool in this pouch.

You can often feel that bogginess or fullness on a rectovaginal exam.

And holding all of this up against gravity is the

The sling.

Or maybe a hammock is a better word.

It's a complex weave of muscles, mainly the levator, anion, and costagist muscles, plus ligaments and fascia.

It has a pretty thankless job.

Which is?

It holds up the bladder, the uterus, and the rectum against gravity for decades.

It's also involved in sexual function and continence.

And when it fails?

When that sling weakens?

Prolapse.

Gravity wins.

If the anterior wall weakens, the bladder falls backward into the vagina.

That's a cystoseal.

If the posterior wall weakens, the rectum pushes forward into the vagina.

That's a rectoseal.

And if the very top of the vagina falls in, the small bowel can herniate down and enter a seal.

This isn't just a cosmetic issue.

It causes incontinence, pain, and a feeling of pressure.

Lastly, for anatomy, the lymphatics.

We always check lymph nodes in the neck or armpit.

Do we check them here?

We check the ones we can reach.

The lymphatic drainage is split, which is a key concept.

The vulva and the lower part of the vagina drain to the inguinal nodes, the ones in the groin crease.

You can palpate those.

So you can feel those if there's a problem.

Correct.

But the internal organs, the cervix, uterus, ovaries, they drain deep into the pelvic and abdominal nodes.

You can't feel those on a physical exam.

So what's the implication of that?

It means that early -stage ovarian or uterine cancer won't give you a palpable lymph node until it's very, very advanced.

The disease can be spreading internally long before you'd ever feel a bump in the groin.

That is a critical distinction.

Okay, we have the map.

Now let's talk about the detective work.

Section 2, the health history.

The interview.

This is where you build trust or you lose it.

Bates is very clear.

The setting matters.

You cannot have this conversation while the patient is half naked and lying on an exam table.

Right.

The power dynamic is already completely skewed at that point.

Totally.

You have the patient fully closed, sitting upright, eye to eye.

That restores some of their agency.

And while you might need a chaperone for the exam itself, you absolutely need private time for the history.

Why is that so important?

You can't ask about domestic violence or sexual partners or history of abuse with the patient's mother or their boyfriend sitting in the room.

You just won't get an honest answer.

Makes sense.

Let's drill down on the menstrual history.

Bates talks about the three M's.

Menarche, menstruation, and menopause.

Right.

Menarche is the start of menses.

The median age is around 12 to 13 in the U .S.

Then you need to understand the cycle itself.

We need numbers.

How often, how long, how heavy.

What's considered normal?

Normal is a pretty wide range.

Yeah.

A frequency of 24 to 32 days apart is typical, lasting anywhere from three to seven days.

Bates gives us a whole vocabulary list in Box 2101.

We need to define these clearly because a patient will just say, I have bad cramps, but we need to chart dysmenorrhea.

Exactly.

Dysmenorrhea is the medical term for painful periods.

But you have to ask a follow -up.

Is it primary or secondary?

What's the difference?

Primary dysmenorrhea means I've always had bad cramps ever since I was a teenager.

That's usually just caused by prostaglandins.

Secondary dysmenorrhea means my periods were fine, and now at age 30, they hurt like crazy.

That screams organic pathology.

Like what?

Endometriosis, fibroids, polyps, endomyosis.

It needs a workup.

Then there's a menorrhea.

No period at all.

And again, you have to ask, is it primary or secondary?

Primary menorrhea is I'm 16 and I've never had a period.

That requires an endocrine workup.

Secondary is I used to have periods and they stopped.

And what is the number one rule of secondary menorrhea?

Assume pregnancy until proven otherwise.

Always.

Always.

Even if the patient says it's impossible, check the urine pregnancy test.

It's the most common cause by a mile.

What about abnormal bleeding patterns?

The terms get a little tricky here, like menorrhagia versus metroragia.

Yeah, the roots help.

Menorrhagia is excessive, heavy flow during an otherwise regular cycle, soaking through pads or tampons every hour.

Metroragia is bleeding that happens between periods like spotting.

And then there's polymenorrhea.

Right.

Poly means many, so that's periods that are too frequent, less than 21 days apart.

And oligomenorrhea is the opposite, periods that are too infrequent.

There is a specific red flag regarding bleeding that we absolutely cannot ignore, postmenopausal bleeding.

This is a stop the presses symptom.

It's an alarm bell.

By definition, menopause is 12 consecutive months without a period.

If a woman is 60 years old and starts spotting again, you cannot dismiss it.

What could it be?

It could be benign vaginal atrophy, sure, or a side effect of hormone therapy.

But it is endometrial cancer until you prove it isn't.

That patient needs an ultrasound and very likely a biopsy.

Speaking of menopause, it's not just the stopping of the period.

It's a systemic change, really.

It's an estrogen withdrawal state.

The whole body is affected.

You get the classic hot flashes, the vasomotor symptoms.

But you also get local changes in the pelvis.

Like what?

Vaginal atrophy.

The tissues get thin, dry, and fragile without estrogen.

This leads directly to dysparenia, which is painful intercourse, and even urinary symptoms like urgency or frequency, because the urethra needs estrogen too.

Let's shift gears to pelvic pain.

The differential diagnosis here is terrifyingly broad.

It really is.

If a woman of reproductive age comes into the emergency room with acute pelvic pain,

you have to think in life or death terms first.

Such as?

Could this be a ruptured ectopic pregnancy?

A ruptured ovarian cyst?

Is it appendicitis presenting weirdly?

Or is it ovarian torsion where the ovary twists on its own blood supply and starts to die?

That's a surgical emergency.

And then there's PID, pelvic inflammatory disease.

PID is the most common cause of acute pelvic pain, usually from an STI like chlamydia or gonorrhea that has ascended.

But you have to rule out the surgical life -threatening emergencies first.

What about chronic pain?

Chronic pain is defined as pain lasting more than six months.

This is a much trickier situation.

It could be something like endometriosis, which is notoriously hard to diagnose.

Bates also mentions another major risk factor.

Yes, and it's so important not to miss this.

He explicitly highlights the correlation with a history of sexual abuse.

The body keeps the score.

Chronic pelvic pain is very often a somatic, a physical manifestation of deep -seated trauma.

You have to approach this history with incredible sensitivity.

One last history, Adam.

Vulvovaginal symptoms.

Discharge.

Itching.

Patients often just say it itches.

And you have to play 20 questions.

Where does it itch?

Is it external?

On the skin of the labia?

Maybe that's contact dermatitis from a new soap.

Or maybe it's lice.

Versus internal.

Exactly.

If it's internal, inside the vagina, now we're thinking more about a yeast infection.

If it burns when they pee, you have to clarify.

Does it burn on the inside like a UTI?

Or does it burn because the urine is touching raw, irritated skin on the outside?

That points you to two totally different diagnoses.

Specificity saves you from ordering the wrong tests.

Absolutely.

Okay, we have the history.

Now we move to the physical exam.

Section 3.

The preparation is almost as important as the exam itself, isn't it?

It is the exam, in a way.

If you fail the prep, the exam will be suboptimal at best.

And dramatic at worst.

Because the patient will be tense, the muscles will clamp down, and you won't be able to feel anything.

So what are the keys?

How do we prevent that?

Communication.

Explanation.

Narration.

Tell the patient every single thing you're about to do before you do it.

I'm going to slide the drape down now.

You will feel my hand on your thigh.

No surprises.

That's huge.

And verify that they have emptied their bladder.

A full bladder is uncomfortable for the patient, and physically it gets in the way.

It pushes the uterus back and makes it much harder to feel.

And let's talk about the position.

The lithotomy position.

Yeah.

While it's incredibly vulnerable.

It's the standard, but we have to acknowledge how awkward it is.

The patient is on their back, legs up in stirrups.

The key technical point is to ensure their buttocks are slightly beyond the edge of the exam table.

Why hang off the edge like that?

It's all about geometry.

If they're too high up on the table when you go to insert the speculum, the handle will hit the table before you can get the correct downward angle to visualize the cervix.

You need that clearance.

That's a great practical tip.

Speaking of the speculum, we have choices.

There's metal or plastic, and then Peterson or Graves.

This isn't just a random selection.

No, not at all.

Size and shape matter.

The Peterson speculum has flat, narrow blades.

It's your slim fit option.

You should use this for patients who are virgins, for elderly women with atrophy, or for anyone you suspect has a small entroitis.

And the Graves?

The Graves speculum has wider, curved blades.

It's designed for the Paris woman, someone who has had vaginal deliveries.

The vaginal walls can be more lax, and that curve on the blade helps hold back the loose tissue so you can actually see the cervix.

Using a Peterson on a Paris woman is like trying to see the back of a cave with a tiny flashlight.

And the metal ones?

They get cold.

Ice cold.

Bates puts this in a special box for a reason.

Warm the speculum.

Just run it under warm tap water for a few seconds.

It makes a world of difference.

Touching a patient such a sensitive area with a piece of cold steel is a very quick way to induce muscle guarding and anxiety.

So simple, but so important.

Let's start the external exam.

We are inspecting the landscape that we mapped out earlier.

Right.

You start by looking at the mons pubis for any nits or lice.

You look at the labia.

You are hunting for any lesions, any bumps, sores, or ulcers.

Bates gives us a table of common abnormalities.

We need to be able to distinguish the different kinds of ulcers.

This is very high yield for exams and for real life.

Herpes typically presents as a cluster of small, shallow, very painful ulcers on a red base.

The key word is painful.

They hurt.

Okay.

Syphilis, the primary chancre, is classically a single,

firm, painless ulcer.

If a patient has a sore down there but says, eh, it doesn't really hurt, you should have a very high subscription for syphilis.

And then there's condyloma.

Right.

Or genital warts caused by HPV.

Those aren't ulcers.

They look like fleshy, sometimes cauliflower -like bumps or growths.

We're also checking for bulges here on the external exam.

Yes.

Ask the patient to bear down like they're having a bowel movement.

If you see a small, red, benign -looking tumor at the urethral metadus, that might be urethral caruncle.

If the anterior vaginal wall bulges out, that's your cystosal.

If the posterior wall bulges, that's your rectocele.

What about those bartholin glands?

Do we palpate those on everyone?

No, definitely not.

Only if the patient reports swelling or pain in that area.

If you do need to check, it's a pincer grasp.

Your index finger goes just inside the vagina and your thumb is on the outside at the four and eight o 'clock positions.

You're palpating the tissue between your fingers.

And what would an abscess feel like?

It would be hot, very tender, and fluctuant, meaning it feels like a little water balloon of pus under the skin.

Those are incredibly painful and often need to be surgically drained.

Okay, now comes the moment of truth for many students.

Section four,

the internal examination.

Inserting the speculum.

This is where the technique really, really matters.

This is a pilot's checklist.

You cannot just shove it in.

So what's step one?

Step one, lubricate.

Moisten the speculum with warm water.

You can use a little bit of water -based lubricant, but use it sparingly because a big glob of gel can actually ruin your pap smear or culture results.

It can interfere with the analysis.

Step two.

Separate the labia with your non -dominant hand.

You need a clear path to the introitus.

You don't want to be pinching the labia minora with the speculum.

And the angle of insertion.

This is the secret.

This is the key.

You don't aim straight in horizontally and you definitely don't aim up.

You aim downward at about a 30 or 45 degree angle toward the patient's lower back.

Why is that so important?

Because the urethra and the clitoris are on that anterior or top wall.

That area is incredibly sensitive.

If you scrape the top wall with the speculum, you will cause pain.

If you ride along the posterior or bottom wall, it's much more comfortable for the patient.

So we're in past the introitus at that downward angle.

Now you rotate the speculum so the handle is pointing straight down horizontally.

And here's the rule.

Insert it to its full length before you open the blades.

Why is that?

If you open it halfway in, you are stretching the

Get the speculum all the way in until the handle is almost at the perineum.

Then gently open the blades.

And if you did everything right, the cervix should pop right into view between the blades.

Ideally, yes.

You gently cup the cervix with the blades and then lock the screw to hold it open.

Now your hands are free and you can inspect.

We're looking for color, surface characteristics, any discharge.

What are those little translucent bumps we sometimes see on the cervix?

They look like tiny pimples.

Those are nobothean cysts.

They look like little pearls or clear blisters on the cervix.

They're just blocked mucus glands.

They are totally 100 % benign.

Don't biopsy them.

Don't panic.

Just note them and move on.

But a cervical polyp is different.

Very different.

A polyp is a bright red, soft, often fragile growth that's actually protruding from the external os.

They bleed very easily if you judge them.

They're usually benign, but they often get removed just to be safe and for definitive diagnosis.

And if we see pus.

Mucopurulent discharge, that's a thick yellow or greenish discharge coming directly from the os, is the hallmark of cervicitis, an inflammation of the cervix.

Your top suspects should be chlamydia, gonorrhea, or hopes.

Now for the main event of the speculum exam.

The pap smear.

The cytology.

We're going back to that transformation zone we talked about.

We need to harvest cells from that specific danger zone.

Bates lists a few different tools.

The cervical broom is very popular now.

Looks like a little plastic broom.

The long central bristles go into the canal and the shorter outer bristles stay on the outside surface.

And you just spin it.

You place it in the os and you rotate it clockwise, about five times.

Why specifically clockwise?

It sounds trivial, but it's not.

The bristles are designed and shaped like little scythes.

They only scrape off cells effectively if you turn them in the intended direction.

If you go counterclockwise, you're basically just petting the cervix, not collecting an adequate sample.

Or you can use the older two -step method, the brush and spatula.

Right.

The spatula is used to scrape the outside of the ectocervix.

Then the brush, which looks like a tiny pipe cleaner, goes inside the canal, the endocervix, and you roll it between your fingers.

This method ensures you get both cell types from both sides of the junction.

There's a note here.

Avoid doing a pap smear during menses or if there's a heavy infection.

Yeah, a lot of blood or inflammatory cells on the slide can obscure the cervical cells, making it impossible for the pathologist to read.

You'll just get a result back that says,

specimen unsatisfactory.

The speculum is coming out.

Is the internal exam done?

Not yet.

As you slowly withdraw the speculum, you are inspecting the vaginal walls.

You keep the blades slightly open so they don't pinch the mucosa, and you look at the color and texture of the walls as they come back into view.

And this is where we can diagnose the common causes of vaginitis.

Bates highlights three big ones in table 21 -3.

The vaginitis trio.

Every student has to know these coal.

Let's go to them.

Number one, candida or a yeast infection.

This gives you a thick, white, curd -y discharge.

The classic description is that it looks like cottage cheese and it itches like crazy.

Okay, number two.

Number two is trichomonas.

This is a protozoan and STI.

The discharge is typically yellow -green.

It can be frothy or bubbly, and it's often malodorous.

You might also see tiny red spots on the cervix called a strawberry cervix.

And the third one?

Bacterial vaginosis, or BV.

This isn't really an infection.

It's an overgrowth of normal anaerobic bacteria.

The discharge is thin, gray, or white, and it has a very characteristic fishy odor.

And that's where the smell test comes in.

That's the whiff test.

You take a sample of the discharge on a slide and you add a drop of potassium hydroxide, or KOH.

If it releases a strong fishy odor, that is a positive test for BV.

It's distinctive.

Once you smell it, you never forget it.

Okay, the speculum is finally out.

We might change our gloves.

Now we move on to section five, the bimanual examination.

This feels like magic to a student.

You're feeling things you can't see.

It requires a lot of practice and proprioception.

First thing, you stand up.

You can't do this exam while sitting down.

You need the leverage.

And the hand position.

Lubricate your dominant hands, index, and middle fingers.

The hand position is absolutely critical.

Your thumb should be abducted, sticking way out, and your ring and pinky finger should be folded down into your palm.

Why that specific position?

You want to avoid your thumb accidentally hitting the clitoris, which is very painful.

And you want to avoid your other fingers pressing against the pernium or the anus, which is uncomfortable and unhygienic.

So two fingers go into the vagina.

What is the very first move?

The first thing you do is find the cervix with your fingertips.

You verify its position, but then you wiggle it.

You gently move it from side to side.

Why are we wiggling the cervix?

To check for something called cervical motion tenderness, or CMT.

If simply moving the cervix causes the patient to wince in pain or jump off the table, what we call the chandelier sign, that is a major alarm bell.

What does it signify?

It suggests that the infection is not just on the cervix, but has ascended into the uterus, the fallopian tubes, and the peritoneum.

It's the classic hallmark of pelvic inflammatory disease.

Okay, so after checking for CMT, we move to the uterus.

How in the world do you feel it?

You have to trap it.

It's the sandwich maneuver.

Your internal fingers in the vagina lift the cervix up toward the ceiling.

At the same time, your external non -dominant hand presses down firmly on the abdomen, just above the pubic bone.

You are trying to catch the body of the uterus between your two hands.

And what are we assessing when we do that size, shape?

Exactly.

Size, shape, consistency, mobility,

tenderness.

Is it smooth?

Or does it feel lumpy, bumpy?

A lumpy, bumpy, or irregular contour usually means the patient has fibroids, also called myomas.

These are benign muscle tumors, but they can make the uterus feel very knobby and large.

And we're also assessing its position, Antiverted versus retroverted.

Right.

Most women, about 80%, have an antiverted uterus.

That means it's tipped forward, leaning over the bladder.

You can usually feel this pretty easily with the sandwich maneuver.

And retroverted.

Some women have a retroverted uterus.

It's tipped backward toward the rectum.

In these cases, you might not feel the uterus with your abdominal hand at all.

Your main clue is that when you feel the cervix, it's pointing forward toward the front.

Now, for what everyone says is the hardest part of the entire exam,

feeling the ovaries.

The anexa.

This is difficult even for seasoned experts, so don't feel bad if you can't do it at first.

What's the technique?

You move your abdominal hand from the midline out to the lower quadrant, either right or left.

At the same time, you move your pelvic singers deep into the corresponding lateral fornix.

Then you press your hands together and try to let the anexal tissue slide between your fingers as you bring your hands together.

What does a normal ovary feel like if you can find it?

It feels like a small, firm almond.

And importantly, a normal ovary is tender.

If you apply a little pressure to it, the patient will feel a twinge of discomfort.

That tenderness is actually a good sign that tells you you're on the right structure.

But there's a crucial life or death caveat here for post -menopausal women.

Yes.

I cannot stress this enough.

This is a must -know.

After menopause, the ovaries atrophy.

They shrink down to the size of a pea or even smaller.

You should not be able to feel a post -menopausal ovary.

So if you can?

If you feel a palpable ovary in a 65 -year -old woman, that is a mass.

It is ovarian cancer until proven otherwise.

It's sometimes called the palpable ovary syndrome and it requires an immediate workup with an ultrasound.

That is a vital clinical pearl.

What about the pelvic floor muscles?

How do we test those?

While your fingers are still in the vagina, you can simply ask the patient to squeeze.

Can you tighten your muscles around my fingers like you're trying to stop the flow of urine?

And you ask them to hold it for at least three seconds.

This gives you a rough gauge of the strength of the pelvic floor.

Okay, section six.

The rectovaginal examination.

This isn't a routine part of every exam.

No, it's not.

You would do it for specific indications.

For example, if the uterus is retroverted and you can't feel it well on the bimanual exam, the only way to palpate the back of it is through the rectum.

Or if you're screening for colorectal cancer in an older patient.

How is it performed?

You have to change gloves for obvious reasons.

Relubricate.

Your index finger goes into the vagina and your middle finger goes into the rectum.

To make insertion easier, you can ask the patient to strain down like they're having a bowel movement.

This helps to relax the anal sphincter.

And what are we feeling for in there?

Well, any masses in the rectum, obviously.

And you can test the stool for occult blood.

But you're also palpating the thin rectovaginal septum, the wall between the two canals.

And you're feeling for the uterus sacral ligaments.

If those ligaments feel nodular or beaded, like a string of pearls, that is a classic physical exam sign of deep infiltrating endometriosis.

And finally, a quick word on hernias.

We usually think of this as a male exam component.

But women get hernias too, usually indirect equinal hernias, which are the most common type in women.

For this part of the exam, the patient needs to stand up so that gravity can do its work and make the hernia protrude.

And what do you do?

You palpate the labia majora and you follow the tissue upward toward the pubic cubicles.

Then you ask the patient to cough or bear down.

If you feel a distinct bulge against your fingertips, that's likely a hernia.

We've gathered all this data.

Section seven is about documentation.

Bakes is huge on using accurate, concise phrasing.

Right.

You don't write a novel on the chart.

You use crisp, descriptive phrases.

A normal exam note might sound something like, external genitalia, no lesions or swelling, vagina,

pink, well -regated, no abnormal discharge,

cervix, nulliparous, pink, smooth, no CMT, uterus, anteverted, midline, smooth, non -tender, adnexa.

No masses or tenderness appreciated bilaterally.

And if it's abnormal?

You just describe what you see, specifically.

For example, thin, homogenous, white -gray discharge noted in the vaginal vault, strong fishy odor elicited on whiff test, pH greater than 4 .5.

That paints a perfect picture of bacterial vaginosis without even having to say the words.

We are in the home stretch now.

Section eight, health promotion and counseling.

This is where we stop treating problems and start preventing them.

Let's talk about the big victory of modern gynecology, cervical cancer and HPV.

This is a remarkable story.

We now know that this is a cancer caused by a virus.

The human papillomavirus, specifically type 16 and 18, are responsible for about 70 % of all cervical cancers.

And because it's a virus, we have a vaccine.

The HPV vaccine.

It is a genuine triumph of public health.

The ACIP recommends routine vaccination for all kids, boys and girls at age 11 or 12.

Why so young?

Two reasons.

First, you have to give the vaccine before they are ever sexually exposed to the virus for it to be effective.

And second, the immune response to the vaccine is actually much more robust at that younger age.

But you can do catch -up shots through age 26 and sometimes older in certain situations.

Now, screening.

The Pap smear guidelines have changed so much over the years.

It used to be every single year for everyone.

What's the standard now?

Less is more.

We realized we were over -treating a lot of benign HPV infections in young women that would have cleared on their own.

So rule number one.

Do not start screening before age 21, even if they are sexually active.

OK, what's next?

Rule number two.

For ages 21 to 29, the recommendation is cytology the Pap smear alone every three years.

We don't routinely test for HPV in this age group because transient infections are so common.

And for women over 30?

For ages 30 to 65, you have a couple of options.

But the preferred method is co -testing.

That's doing cytology plus an HPV test every five years.

The HPV test is actually more sensitive than the Pap, so by combining them, you can safely extend the screening interval.

And when do we get to stop screening?

You can generally stop at age 65, assuming they've had an adequate history of negative screens for the last decade.

Next controversial topic, menopausal hormone replacement therapy, or HRT.

This pendulum has swung wildly.

In the 90s, it felt like almost every menopausal woman was put on hormones.

Then the Big Women's Health Initiative, the WHI study, came out in 2002 and showed increased risks of breast cancer, stroke, and blood clots.

And almost overnight,

everyone stopped prescribing it.

So where do we stand now, after all that?

We've landed in a more nuanced middle ground.

We do not use HRT for the primary prevention of chronic diseases, like heart disease or dementia.

The data just doesn't support that.

But what if someone is really suffering with symptoms?

For a woman with miserable, life -disrupting hot flashes and night sweats, systemic HRT is still the most effective treatment we have.

The modern guideline is,

use the lowest effective dose for the shortest duration necessary to manage symptoms.

And you always have a very thorough discussion about the individual risks and benefits.

Finally, let's talk about ovarian cancer, often called the silent killer.

It's called that because the symptoms are so vague and nonspecific, especially early on.

Things like abdominal bloating, feeling full quickly when you're eating, a change in bowel habits or urinary frequency.

Things that could be anything.

Right.

They could be IBS or just aging.

The key is that if a woman, especially over 50, has these symptoms and they are new and persistent, you have to think about the ovaries.

Is there a good screening test, like a mammogram for the breasts or a pap smear for the cervix?

Sadly, no.

And this is a huge source of confusion.

The CA1255 blood marker and transvaginal ultrasound cause way too many false positives in average risk women.

We end up doing a lot of unnecessary risky surgeries on healthy women.

So for that reason, we do not screen the general population for ovarian cancer.

But we do pay close attention to genetics.

Absolutely.

We look for mutations to the BRCA1 and BRCA2 genes.

If a patient has a strong family history of breast and ovarian cancer, genetic testing can be life -saving.

If they test positive, they might be a candidate for prophylactic surgery to remove the ovaries and tubes before cancer ever has a chance to start.

We have covered a massive amount of ground today.

From the detailed anatomy of the vestibule to the fine -tuned technique of the bimanual exam, all the way to the nuances of hormone therapy.

It's a lot.

But if I could leave the listener with just one thought, it's this.

This exam is a privilege.

You are being allowed into a patient's most private space.

Technical skill is mandatory.

You have to learn the angles.

Yes, learn the anatomy.

But your demeanor is what truly defines the encounter.

If you're respectful, gentle, and communicative, you can turn what could be a terrifying experience into a routine, comfortable checkup.

Competence breeds comfort.

Know your anatomy.

Warm your speculum.

And most importantly, listen to your patient.

Couldn't have said it better myself.

That's it for this deep dive into Bates's Chapter 21.

From the Last Minute Lecture Team, thanks for joining us.

Study hard, practice your sandwich maneuver, and we'll see you on the next rotation.

Stay curious.