Well-woman examination

A well woman examination is an exam offered to women to review elements of their reproductive health. It is recommended once a year for most women. The exam includes a breast examination, a pelvic examination and a pap smear but may also include other procedures. Hospitals employ strict policies relating to the provision of consent by the patient, the availability of chaperones at the examination, and the absence of other parties.^[1][2]

Most healthcare providers also allow the patient to specify if they have any preferences towards the examiner's gender.

Importance

The well-woman examination by a medical professional is recommended at least once a year to women over 18 years old and/or women who are sexually active.^[3] Its importance lies in identifying potential early health problems. The most important tests included in an examination is the breast exam, pelvic exam and the pap test, although some doctors consider other tests in the examination, including measurement of blood pressure, HIV testing, and other laboratory tests such as urinalysis, CBC (Complete blood count) and testing for other sexually transmitted diseases. The procedure is important also to detect certain cancers, especially breast and cervical cancer.^[3][4]

Breast examination

Visual inspection

The breast examination begins with a visual inspection. With the patient in a prone or seated position, the medical professional will look at both breasts to check the color, symmetry, dimensions according to age, lean body mass, the physiological (pregnancy and lactation) and race, looking for abnormalities, such as bulges and shrinkage.^[5] One of these abnormalities is changed in the areola or nipple. If it is flattened or retracted (umbilicated), it is necessary to consider the possibility of a cancerous lesion which has caused the malformation.^[5][6]

Palpation

Next, the breasts are palpated, again with the patient lying or sitting. The patient has to lift the arm and put one hand behind her head. With this position, the entire gland is palpated. It is also important to examine the armpits, because of masses that may be found there.^[5] The test is executed pressing the gland with two or three fingers against the chest wall, making a radial route or by quadrants. The nipple is also squeezed check for secretions, such as secretion of milk (galactorrhea), serous, blood or purulent secretions. If a node is detected, it is necessary to determine its place, size, shape, edges, consistency and sensitivity.^[5]

Self-examination

In addition to the yearly check by a professional, women over the age of 18 should also perform this examination monthly. It is important because regular and comprehensive examinations of the breasts can be used to find breast changes that occur between every clinical examination and detect early breast cancer. This auto examination should to be performed seven days after the onset of the menstrual period. If a woman finds a lump or notice any changes in her breast, she should seek medical attention promptly.^[7][7]

Further examination of the breasts

A mammogram or mammography is a special x-ray of the breasts. They are the procedure most likely to detect early breast cancer in asymptomatic women. Mammograms can show tumors long before they are large enough to palpate. They are recommended for women who have symptoms of breast cancer or who are at increased risk of developing the disease. They are performed with the patient standing, the breast pressed between two plastic plates, as the image is taken. The interpretation has to be performed by a specialist.^[8]

Breast ultrasound is a complementary study of mammography. In many women the tissue that makes up the breast is very dense, representing fibrous tissue and glandular tissue, which produces milk during lactation. This limits the radiologist interpreting the study, so, in these cases, the ultrasound is helpful, since this is capable of distinguishing tumors in women with dense breast tissue, where identification is otherwise difficult. Additionally, it is advisable to follow up a mammogram that shows indications of tumors with an ultrasound, to confirm, before more invasive procedures are undertaken.^[9]

Pelvic exam

The pelvic exam is part of the physical examination of the pelvic area of a woman, which generally also includes the taking of a sample for a pap smear. This test includes three parts. These are the general inspection of the external genitalia, bimanual examination, and inspection of the vaginal canal using a speculum.^[10]

Inspection of external female genitalia

The patient is placed in a supine position on a special examination table, which has two protrusions called "stirrups." With the feet in these stirrups, the legs are placed in a position such that the medical professional can access the pelvic area. The external genitalia is examined first, looking for abnormalities like lesions, ulcers, warts and color changes. The elements of this exam include the vulva, which contains the Mons pubis, of which there are two longitudinal folds of skin forming the labia majora; then the labia minora and hair follicles. The clitoral hood is also checked.^[10]

Bimanual exam

The purpose of this exam is to palpate organs which cannot be seen with visual inspection. The index and middle finger are inserted into the vagina. This maneuver allows the doctor to check the orientation, length and width of the vagina. Next, the cervix and vaginal fornices are palpated, to check position, size, consistency, mobility and sensibility.^[11] The other hand is placed in the pubis pressing it to feel the uterus between both hands. The most important characteristics to examine are the size of the uterus, presence of nodes or agglomerations, consistency, size, tilt, and mobility. With this technique, the ovaries are also palpable.^[11]

Speculum examination

The speculum examination is recommended for only women over 21 years old, irrespective of her sexual activity.^[12] The speculum is an instrument made of metal or plastic and is constructed with two flaps. Its purpose is separate and widen the vaginal opening and keep it open. This allows direct observation by the physician into the vaginal canal with the help of a lamp or a mirror.^[13]

There are different types of speculums used within the different characteristics of each patient such as age, sex life, and other factors. The first step is to open the vaginal opening with two fingers at the vulvo-perineal angle, then separate the fingers slightly and press down, then insert the speculum arranging the width of the tip of the flaps in anteroposterior. Then the speculum is moved into the vagina at an angle of 45°, following the natural contour of the posterior vaginal wall. When the speculum is in place, the fingers are removed and the device is rotated so that the flaps are horizontal. The flaps are then separated and locked into place when the cervical neck is completely visible.^[13]

Pap smear

The pap smear is a screening test to test for abnormalities such as cervical cancer and human papillomavirus infections, which require early treatment. To be viable, the patient should not be menstruating and had not used a vaginal contraceptive in the prior 24–48 hours.^[14] The procedure begins with the scraping of cells from the cervix and the uterine fornix, done during the speculum examination as there is access to the cervix. The scraping is done with a spatula, cervical brush or swab. Some women experience temporary bleeding from this procedure. The scrapings are placed on a slide,covered with a fixative for later examination under a microscope to determine if they are normal or abnormal.^[14]

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