Periodic gynecological care

• prevents illness and discomfort
• allows for early detection of cancers of the breast and cervix — when they are more curable
• detects sexually transmitted infections and other conditions before they cause serious damage
• prevents sterility
• promotes healthy pregnancy and childbirth

Staying healthy is important, and good gynecological care is the key to good health.

Take Control of Your Health
It takes teamwork to have good health.  Your job is to learn how your body works and what is normal for you.  Watch for changes in your body and its rhythms that may signal problems.  Your clinician's job is to help you identify problems before they become serious and to provide care if you become ill.  Team up with your clinician for periodic gynecological (GYN) exams.  Learn how the GYN visit and exam can work for you.

Women should start having Pap tests three years after they have vaginal intercourse or when they become 21 years old — whether or not they have had vaginal intercourse.  Talk with your clinician about how often you should have periodic GYN visits and exams. 

You may need to have frequent checkups if you have

• a breast lump
• a history of abnormal Pap test results
• a history of sexual health problems
• a mother or sister who developed breast cancer before menopause
• a sexually related illness
• a sexually transmitted infection or a sex partner with an infection

You should visit your clinician, no matter how old you are, if you have

• abnormal or unexplained change in vaginal bleeding or discharge
• any concerns about your sexual or reproductive health
• changes in size or shape of the breast
• growths or thickening of the breast or armpit
• increased pain or discomfort before your period
• newly retracted nipples or bleeding or discharge from the nipple
• pain, swelling, or tenderness of the vulva or vagina
• puckering, dimpling, or other changes in the skin of the breast
• severe pelvic or lower abdominal pain
• sores, lumps, or itching of the vulva or vagina
• unusual vaginal or pelvic pain

Many women worry about having a GYN exam — especially if it's the first time.  You will be more comfortable if you know what to expect.

Periodic GYN visits and exams may include

• talking about your personal, family, sexual, and medical history
• laboratory tests and screening for sexually transmitted infections and other conditions (at your own or your clinician’s request)
• counseling
• a breast exam
• a pelvic exam

PREPARE FOR YOUR OFFICE VISIT
1.  Schedule your GYN visit and exam for a time when you will not have your period — unless you have bleeding problems that your clinician wants to observe.  Menstrual fluid can affect the results of some lab tests.  Let your clinician know if it turns out that you will be having your period during the exam.  You may want to reschedule.

2.  Make a list of all the questions and problems you want to talk about.  Include

• bleeding after sex
• heavier than usual flow
• pelvic pain or other problems
• spotting between periods
• vaginal discharge
• unpleasant vaginal odors

It's easy to forget these things during your appointment.

3.  Women shouldn’t douche.  If you do, however, don't douche for at least 24 hours before the appointment.  Don’t use any other vaginal preparation, either.  They can mask many vaginal conditions.

4.  Don’t have vaginal intercourse or insert anything into your vagina for between 24–48 hours before your visit.

YOUR MEDICAL HISTORY
Before you are examined, you will be asked to fill out a questionnaire.  It will include some of these questions:

• When was your last period?
• How often do you have periods?
• How long do they last?
• Do you have any bleeding between periods?
• Do you feel any pain when having sex?
• Is there any bleeding after sex?
• Do you have any unusual genital pain, itching, or discharge?
• Do you have any other medical conditions?
• What medical problems do other members of your family have?
• Are you using birth control?
• Do you suspect you are pregnant?
• Are you trying to become pregnant?
• What method do you use to prevent sexually transmitted infections?

You will be asked about your history of allergies, illnesses, pregnancy, risks for sexually transmitted infection, and surgery.  You may be asked about your lifestyle, for example if you smoke, how much you smoke, or if you drink alcohol or use other drugs.  You may also be asked if you have problems holding your urine.

Your clinician will review your contraceptive needs. If you are using birth control, you will be asked if you’ve had side effects.

Your contraceptive needs change throughout your life.  To decide which one to use now, consider how well each method will work for you:

• How well will it fit into your lifestyle?
• How effective will it be?
• How safe will it be?
• How affordable will it be?
• How reversible will it be?
• Will it protect against sexually transmitted infections?

Your clinician can provide you with the information you need to make the best choice for you.

It is very important to be frank and honest about your sex life.  Up to one out of two women will have a sexually transmitted infection in her lifetime.  These infections can cause sterility, cancer, as well as problems with pregnancy, childbirth, and infant health.  Some can cause death.  Great harm can be done even when there are no symptoms.  Very often, women have no symptoms. That’s why it’s important to let your clinician know whether or not you are at risk for sexually transmitted infections. 

Previous pregnancies, sexually transmitted infections, or bruising may be detected during the exam.  But, in general, your clinician will not be able to tell if you’ve had sex, how often you have it, how many partners you have, or if you masturbate.  So don’t let embarrassment become a health risk.   Be precise about your sexual health risks and questions about your sex life.  Being clear will help your clinician suggest the best solutions.
  
THE URINE TEST
You may be asked for a urine sample.  The test can tell if you're pregnant.  It can also help screen for some sexually transmitted infections and other health problems.

Urinating before a pelvic exam to empty your bladder may also make you more comfortable during the exam.  It will also be easier for the clinician to examine you — your cervix and uterus are located behind your bladder. 

THE BREAST EXAM
You will change into an examination gown or be covered with a drape sheet.  Some clinicians provide both.  Your clinician will examine your breasts for lumps, thickening, irregularities, and discharge.  Many clinicians will continue to talk to you about your health history during the breast exam.

Breast lumps are often discovered by a woman or her sex partner.  Your clinician will ask if you have noticed any changes in your breasts since your last exam.  You should become familiar with the way your breasts normally look and feel.  That way you will be more likely to notice any changes. 

Some women use breast self-exams (BSEs) to get to know their breasts.  If you would like to learn how to do a BSE, your clinician can teach you.  The best time for a BSE is one week after your period, when your breasts are not swollen or tender.  Lumps are also noticed during day-to-day activities such as showering or sex play.  Most lumps are not cancerous.  But report anything unusual to your clinician as soon as possible.

Four-Step Breast Self-Exam

1. Stand up and place one hand behind your head.  Hold the fingers of the other hand flat.  Gently touch every part of the breast below the raised arm.   Feel for lumps, bumps, or thickening.  Now do the other breast.

2. Stand in front of a mirror.  Place your hands on your hips.  Inspect each breast for changes in size, shape, and form.  Do it again with your arms raised above your head.

3. Lie back with a pillow or folded towel under your right shoulder. Place your right hand behind your head.  Examine every part of your breast with the fingers of the left hand held flat.  Gently press in small circles.  Start at the top outermost edge and spiral in to the nipple.  Feel for lumps, bumps, or thickening.  Now do the other breast.  Be sure to follow a consistent pattern.  You may want to use one of the following patterns:

Do not miss any part of the breast.

4.  Rest your arm on a firm surface like the top of a bookshelf.  Examine the underarm.  Feel for lumps, bumps, or thickening in the same way.  Now do the other underarm. 

Mammography
Annual breast exams and telling your clinician about any changes in your breasts are only two of the three important ways women can protect themselves from breast cancer.  The third is mammography — x-ray photographs of the breasts.  These x-rays can detect abnormalities, and can help make early, lifesaving, diagnosis of cancer. Mammography can detect a lump up to two years before it can be felt.

Women over 40 should have mammograms every year.  Younger women whose families have a history of breast cancer should consult with their clinicians about whether or not mammograms would be of value to them.

Most often, clinicians who provide GYN exams do not have the special equipment and training for mammography.  Your clinician can refer you to a high-quality mammography facility.

The mammography technician will

• place and slightly compress each breast between plastic plates
• take x-rays of each breast

You may feel some discomfort for a few seconds as each breast is compressed.  The entire procedure takes about 15 minutes. 

Additional x-rays or ultrasound examination may be needed if you have dense breast tissue, large breasts, implants, small cysts, or abnormal test results.

Interpreting Mammograms
Radiologists and clinicians are very careful about interpreting mammograms and recommending follow-up care.  They don’t want to overlook any abnormality.  They are aware that failure to detect early cancers can lead to serious and even deadly consequences.  Their caution may lead them to advise you to have further x-rays and ultrasounds.  They may ask for more follow-up and recommend breast biopsies.

Fewer cancers are overlooked with these extra precautions.  But waiting while more tests are done can lead to more anxiety, as well as expense.  It is reassuring that all precautions do improve the chance of finding abnormal growths as early as possible.

THE PELVIC EXAM
After your breasts have been examined, you will be asked to place your feet in the footrests at the end of the table.  Some tables have knee rests instead of footrests.

Slide your hips down to the edge of the table.  Let your knees spread wide apart, and relax as much as possible.  If your buttocks and abdominal and vaginal muscles are relaxed, you will be more comfortable, and the exam will be more complete.  You can cover your lower abdomen and thighs with the drape sheet to feel less exposed and more comfortable during the procedure.

You'll feel less tense if you

• Breathe slowly and deeply with your mouth open.
• Let your stomach muscles go soft.
• Relax your shoulders.
• Relax the muscles between your legs.
• Ask the clinician to describe what's being done as it's happening.

If your clinician is a man, you may request having another woman in the room.  Her presence may help you feel more relaxed.  She may hold your hand or just talk with you to ease your tension.  Ask in advance if you want to see what's going on and/or know what your vagina and cervix look like.  A mirror may be positioned so you can see.

Sexual Abuse and Other Concerns
Some women are very anxious about having a pelvic exam because of difficult experiences that may include sexual abuse.  You may have more pelvic pain, fear, and discomfort during your pelvic exam if you’ve

• been sexually abused in the past
• heard alarming stories about GYN exams
• had other negative sexual experiences 

Remember that the exam is not emotional or sexual for your clinician.  Talk with your clinician about

• your fears
• any pelvic pain you may have
• your experience of abuse

Talking with your clinician about your experience will help your clinician

• tailor the exam to your special needs
• help you feel as comfortable as possible
• understand how your physical and emotional health may be affected

It is also okay to have a trusted friend or relative with you during the exam.

Usually, the exam lasts just a few minutes.  There are four steps:
Step 1.    The External Genital Exam 
The clinician visually examines the soft folds of the vulva and the opening of the vagina to check for signs of irritation, discharge, cysts, genital warts, or other conditions.

Step 2.   The Speculum Exam
The clinician inserts a metal or plastic speculum into the vagina.  When opened, it separates the walls of the vagina, which normally are closed and touch each other, so that the cervix can be seen.

You may feel some degree of pressure or mild discomfort when the speculum is inserted and opened.  You will likely feel more discomfort if you are tense or if your vagina or pelvic organs are infected.  The position of your cervix or uterus may affect your comfort as well.  If a metal speculum is used, you may feel the chill of the metal.  Most clinicians lubricate the speculum and warm it to body temperature for more comfort.  Talk with your clinician about any discomfort you feel.

Once the speculum is in place, the clinician checks for any irritation, growth, or abnormal discharge from the cervix.  Tests for gonorrhea, human papilloma virus, chlamydia, or other sexually transmitted infections may be taken by collecting cervical mucus on a cotton swab.  These tests may not be done unless you have a concern about infections and ask for testing.  Be sure to talk with your clinician if you have symptoms or concerns about your partner(s).

Usually a small spatula or tiny brush is used to gently collect cells from the cervix for a Pap test.  The cells are tested for abnormalities — the presence of precancerous or cancerous cells.  You may have some staining or bleeding after the sample is taken.

As the clinician removes the speculum, the vaginal walls that were covered by it are also checked for irritation, injury, and any other problems.

Pap tests can detect

• the presence of abnormal cells in the cervix
• infections and inflammations of the cervix (Pap tests cannot identify specific sexually transmitted infections, but they may detect symptoms.)
• thinning of the vaginal lining from lack of estrogen commonly related to menopause

The cell sample will be sent to a laboratory.  The results will be sent back to your clinician within a few weeks. Pap tests need to be repeated if there is too much blood present for an accurate reading or if there are not enough cells to be examined.

Interpreting Pap Tests
Cytologists and clinicians are very careful about interpreting Pap tests and recommending follow-up care.  They don’t want to overlook any abnormality.  They are also aware that failure to detect early cancers can lead to serious and even deadly consequences.  Their caution may lead them to request re-doing the Pap test, or doing other tests.  In some cases, the cytologist is unsure about whether or not there are precancerous changes.  In such a case, your clinician will recommend repeat testing or other tests to be more sure.

As with mammography, fewer cancers are overlooked with these precautions.  But having more tests done can lead to more anxiety, as well as expense.  It is reassuring that these precautions improve the chance of finding abnormal cell changes as early as possible.

If you have abnormal results, your clinician will advise you on follow-up care:

• If noncancerous abnormalities and infections are found, be sure to complete the prescribed treatment and repeat the tests as advised.
• If early precancerous or suspicious growths are found, you will need careful follow-up.  You may also be advised to 
• Repeat the Pap test in a few weeks or have them at more frequent intervals.
• Have other tests.
• Have a colposcopy and biopsy.
• Have growths removed with cryotherapy, laser therapy, or electrocautery.
• If cancerous growths are found
• Discuss your options with your clinician.
• See another provider or specialist.

Remember — 

• Most abnormalities that are detected are not cancer.  
• Early treatment of precancerous growths can prevent cancer from developing.
• Follow-up examinations are necessary if an abnormal condition is found.

Step 3.    The Bimanual Exam
Wearing an examination glove, the clinician inserts one or two lubricated fingers into the vagina.  The other hand presses down on the lower abdomen.

The clinician can then feel the internal organs of the pelvis between the two fingers in the vagina and the fingers on the abdomen.

The clinician examines the internal organs with both hands to check for
• size, shape, and position of the uterus
• an enlarged uterus, which could indicate a pregnancy or fibroids
• tenderness or pain, which might indicate infection or other conditions
• swelling of the fallopian tubes
• enlarged ovaries, cysts, or tumors
 
The bimanual part of the exam causes a sensation of pressure.  You may find it somewhat uncomfortable.  Deep breathing through the mouth helps.  If you feel pain, tell the clinician.

Step 4.    The Rectovaginal Exam 
Many clinicians complete the bimanual exam by inserting a gloved finger into the rectum to check the condition of muscles that separate the vagina and rectum.  They also check for possible tumors located behind the uterus, on the lower wall of the vagina, and in the rectum.  Some clinicians insert one finger in the anus and another in the vagina for a more thorough examination of the tissue in between.

During this procedure, you may feel as though you need to have a bowel movement.  This is normal and lasts only a few seconds.

OTHER PROCEDURES
Blood Pressure.  It's important to have blood pressure measured on a regular basis, since you can have high blood pressure and not have any symptoms.  Detecting and treating high blood pressure can reduce the risk of problems such as heart attack and stroke.

Weight.  Rising or falling weight can give important clues to overall health.  You should discuss any significant change with your clinician.

Other areas the clinician may examine include the abdomen, the thyroid gland in the neck, the heart, and the lungs.  In some cases, a blood test may be necessary to check for anemia.  Be sure to point out to your clinician any abnormality in your body that you have seen or felt.

AFTER YOUR EXAM
This is a time for further consultation with your clinician.  You will discuss the results of your exam, arrange for any follow-up or consultation that may be needed, and ask any further questions you may have.   This is another opportunity to discuss your concerns about sex and sexuality, birth control, pregnancy, abortion, sexually transmitted infections, problems holding your urine, inherited disorders, infertility, cancer signals, changes in your breasts, and menopause.  Don't let embarrassment become a health risk.  Speak up.

If the lab tests indicate anything unusual, you will be contacted when the results are completed.  Pregnancy test results are usually ready during your visit.  Other test results may take a few days or weeks.  Your clinician will tell you how long you'll have to wait.  Be sure your clinician has your current address and phone number.

Remember — for good health

• Eat properly — get plenty of folic acid and vitamins C and D.
• Drink when you’re thirsty.
• Get enough sleep.
• Exercise.
• Avoid taking health risks with your mind and body.
• Have periodic GYN visits and exams.
• Take advantage of immunizations that are available.

Good health is a matter of teamwork — you and your clinician working together and maintaining good communication.

GLOSSARY

anus — The opening through which the bowels empty feces from the digestive tract.
biopsy — The removal of small bits of body tissue to be examined under a microscope for diagnosis.
bladder — The organ that contains and collects urine from the kidneys.
clinician — A qualified health care professional, such as a doctor or nurse practitioner.
cervix — The lower part of the uterus, with an opening connecting the uterus to the vagina.
colposcope — A viewing instrument with a bright light and magnifying lens that is used to examine the cervix from outside the vagina.
cryotherapy — A surgical treatment in which a growth or abnormal tissue is destroyed by freezing.
cytologist — A technician who studies the microscopic appearance of cells.
electrocautery — A surgical treatment in which electric current is used to remove growths.  Newer techniques of electrocautery are called loop electrosurgical excision procedures (LEEP), in which low voltage radio waves are used to remove growths.
fallopian tube — One of two narrow tubes that carry the egg from the ovary to the uterus.
fibroids — Benign, noncancerous growths on the uterus.
laser surgery — A treatment that uses a concentrated beam of light to cut away abnormal tissue.
menopause — The time when menstruation stops, marked by the last menstrual period.
ovaries — The two organs that store eggs in a woman's body and produce hormones associated with sex and reproduction.
Pap test — A procedure used to study the cells of the cervix; detects precancerous or cancerous cells in the cervix.
rectum — The lowest end of the bowel before the anus, where feces are stored.
speculum — A plastic or metal instrument used to separate the walls of the vagina so the clinician can examine the vagina and cervix.
urethra — The tube from the bladder that carries urine from the body.
uterus — The pear shaped reproductive organ from which women menstruate, and where normal pregnancy develops.
vagina — The passage that connects a woman's outer sex organs with the cervix and uterus.
vulva — A woman's outer sex organs, including the clitoris, the labia, and opening to the vagina.