Be Proactive During Your OB-GYN Visits

For over 5 years I was Genito-Urinary Teaching Associate for Johns Hopkins School of Medicine. I taught 3rd year medical students the protocol and techniques for performing an OB-GYN examination. This entails being the patient and the teacher, as I went through a scripted exam with 2 students per training. The benefits to doing this work made me a pro-active patient and gave me the training to, not only teach students, but to share this information with other women, with you. I urge you to read through this article, take notes, print it out and use it to empower you, to ensure you are receiving the best medical care during your OB-GYN visits.Much of what is included in this post, can also be beneficial to your own self-care, in special regards to the breast exam techniques. All of this should be taught to all girls before they have their first exam. Being pro-active and knowing what the exam is about, on a technical level, makes you your own advocate. I have even brought my own doctors up to date on techniques and have boldly requested protocols that were not being practiced. This has also helped me make informed decisions when choosing a OB-GYN or Midwife. All women have a right to excellent medical care, to be heard and to be treated with respect. I hope that this information empowers you to take an active role in knowing your reproductive health, and making sure you are getting the best medical care. Most reproductive cancers are detected early by women who have  pro-active approach to their OB-GYN visits, knowledge of their bodies and perform self-breast exams.

At this point a doctor may introduce a large mirror. This is for your education, so that you can observe what your doctor observes. It can be used to point out any unusual findings during the breast exam. (However, problematic findings should be discussed after you are dressed.) The doctor should encourage you to perform a regular breast self exam at home with a wall mirror and a large hand mirror.

Before the Examination

The doctor will want you to have emptied your bladder prior to the exam. If your bladder is full, it can be uncomfortable for you and can make it difficult for the doctor to palpate the uterus during the pelvic exam.

It is important to remember that the examination is for your benefit. Your doctor should always show respect to you as the patient, which can start by knocking before entering the room and addressing you by your surname. The more your doctor collaborates in your care with you, the more you will understand about the exam and the better it will work for both of you. Be sure to ask questions at any time during the exam and if you like you can ask the doctor to explain the exam and the main steps.

The main purpose of the exam should be to check for any signs of disease in your reproductive system. This will require both a breast and a pelvic exam.

Communication skills are very important. They help to put you at ease and make sure the doctor gets all of your information and history. The doctor should also be using non-suggestive, commonly understood words. Before you are undressed and in your gown the doctor should discuss your reproductive and sexual history. It is strongly encouraged that there always be a chaperon in the room at all times. This is protection for the doctor and the patient. It is also helpful to have another person in the room as an assistant, specifically during the pelvic exam.

You are free to stop the exam at any time, and while there may, at some points, be some physical discomfort, there should, at no time, be any pain. The doctor should not usually leave the room once the exam has begun.

Part of your doctor’s preparation for this exam should include pre-set of functioning equipment and supplies. Also, appropriate grooming, such as having hair pulled back, nails clipped, wearing a lab coat and general cleanliness are important indicators. The next, very important step is for the doctor to practice universal precautions, by washing his/her hands. Even if they have already been washed, they should do so again in front of you as a reassurance of hygienic practice. Once the doctor has washed their hands, they should only be touching the patient or one hand to another. If they touch anything else in the room, then they should rewash. This is why an assistant is helpful.

Another purpose of the exam is for your education about your own health care. Your health care provider should be discussing breast self examination with you. They should be asking whether you perform regular breast self exams, discussing its importance in early detection of cancer (and when the best time of month to do the exam), discussing the current recommendation for a mammogram (age and regularity) and advising on the most current researched techniques for performing the exam at home.

Visual Examination of the Breasts

The first thing we want to do is to uncover both breasts completely and seated with weight evenly distributed. Usually, shoulders will then be level. Your doctor should simply ask you to lower the gown to your waist. Now the doctor, standing in front of you, will visually examine your breasts with the patient in the seated position, looking side to side, and if necessary (as in the case of a woman with large or pendulous breasts), they may ask you to raise or lift your breasts with your hands so that they may see underneath. If there is any nipple discharge, lesions on your breasts or if you are a nursing mother, then they should glove before palpating. If there are any cuts, open sores, etc. on the doctors hands, they need to protect you from this. The following are some of the things we are looking for during the visual exam – symmetry, masses, lesions, skin changes and dimpling.

Now, you should be asked to put your hands on your hips and to raise your shoulders, squeezing shoulder and chest muscles, or shrug or curl the shoulders forward. The doctor visually examines the breasts looking side to side, looking at the various aspects of the breast tissue. Now the doctor visually examines the breasts with you leaning forward. Then they should ask you to raise your arms above your head slowly. The doctor should be visually examining the breast tissue, noticing the movement and whether it moves as a whole. If anything tugs or dimples, this could indicate a problem.

Seated Exam

Now the physical examination of the breast tissue begins. The key elements of the palpation of the breast, for the doctor and for self breast examination, are:

    • Be thorough and don’t miss anything. Cover the entire breast including the tail (the area of skin that fans up to shoulder.)

    • Palpate in a methodical path using the pads of 3 fingers (or 2, depending on size of fingers) in dime-size circular motions with 3 degrees of pressure (light, medium, and deep). Some findings are only evident with a particular degree of pressure from the examiner.

The fingers should maintain contact with the surface of the skin, and proper spacing between palpitations should be used. This will help to assure that no area is missed

Palpation of the Breasts

Palpation Technique

Following the head-to-toe path of the body, the seated exam begins by palpating the supraclavicular and infraclavicular lymph nodes located above and below the clavicle (collar bone). So that you are not unnecessarily exposed, be advised that you may raise your gown up to just below the collarbone (either tucking it under your arms, or putting your arms into the sleeves). The doctor should let you know that you are beginning the physical exam and explain what she/he is doing.

The technique they will use is the same technique used for self breast examination so I will describe it in detail. This palpation technique should be used throughout the breast exam. With the pads or flats (the entire area from the last joint to the end of the finger) of the 3 middle fingers (or 2, depending on hand size) apply a light, medium, then deep pressure in dime-size circles (imagine tracing the outline of a dime with your middle finger). The light pressure is very gentle, enough to move the skin without disturbing the tissue underneath. The deep pressure should be deep enough to reach the chest wall. The pads are the most sensitive part of the fingers, so the tips should not be used. Holding your hands straight or even bowed back a little will help keep your fingers flat. After each palpation, drag fingers to the next location, allowing them to overlap the areas palpated. A good technique for dragging after each circular palpation, and to ensure proper spacing, is to step over about 2 cm (or about 1 inch) with the leading finger, then slide the other two fingers over, being careful to keep the 3 fingers together for the next palpation. Be sure not to lift all 3 fingers from the surface as you don’t want to lose your place. The doctor should begin palpating supraclavicular and infraclavicular lymph nodes.

Palpation of the Breasts

Now the doctor should palpate the right breast and axilla. (It doesn’t matter which breast is examined first, as long as the breasts are examined one at a time, and that both breasts of patient are to be examined.) The doctor may want to use cornstarch powder (baby powder) dispensed from an individual container so that there fingers glide more easily. (You can also use cornstarch to make self-exam more comfortable.)

So that you are not unnecessarily exposed, you may cover your left breast. Expose only what is necessary to examine at the time.You should be asked to either place your right hand on your hip, or your arm over your shoulder. Using the 3 degrees of pressure and the pads of their 2 – 3 fingers, the doctor begins to palpate the breast tissue starting at the top of the tail. The breast tissue goes up this high and is more than what fits into the bra cup; this should also be a part of your monthly self-exam. Never losing contact with the breast tissue, the doctor drags her/his fingers to the next location; overlapping the areas palpated. In horizontal strips, they palpate the upper boundary of breast tissue, starting near the collarbone, back and forth from the sternum to the axilla, working down to the beginning of the breast fullness, the part of the breast that fits into the bra cup.

Manual Mammogram

Here they should use the manual mammogram technique to examine the breast tissue. This is especially useful for women with larger or more pendulous breasts. They place one hand underneath the breast, supporting it and keeping the lower hand flat and level or even slightly bowed. With the other hand palpating downward, as they did before with 3 degrees of pressure and the circle and drag technique through the breast tissue against there hand (similar to the horizontal plates of a mammogram). They should start at the chest wall and work outward in a methodical pattern, back and forth, working toward the nipple. It may be necessary move the hand underneath. At this point, they also palpate the nipple and areola in the same fashion, and note any discharge that may come from the nipple.

Other Important Lymph Nodes

Now from the breast, they should move into the right axilla and palpate the deep central axillary area (center of armpit), the lateral lymph nodes (the fingers palpate between the muscles of the underside of the upper right arm), the medial axillary area (down along the side of the body just under the armpit), the pectoral lymph nodes (inside armpit and forward), and the sub scapular lymph nodes (inside armpit towards the back). Your arm should be relaxed. It may help to take a deep breath to relax.

Now all this should be repeated on the left side/breast.

Lying Down Exam

Now the doctor examines the breasts with you lying down. The breast tissue being palpated should be evenly distributed over the chest wall, providing a firm surface for examination. There are a number of positions to use to accomplish this. Most women will probably need to be in two positions:

  • Supine position with your right hand (when examining right breast) under the pillow (if pillow is available) and upper arm at a right angle to the torso. This position is used when examining from the chest center/sternum to the nipple.

  • The position that can be used to examine from the nipple to the armpit is the Cahan position (side-lying position). For this position, you need to lie on your side opposite the breast being examined. Then open the arm and shoulder on the side being examined towards the exam table, bring your arm up, with the back of your hand resting on your forehead. The doctor may position a pillow, or folded towels, under your arm and shoulder to assist in comfort and help distribute the breast tissue. The benefit of having the hand on the forehead is that the pectoral muscles are more relaxed than if hand is over the head.

The pattern that is most effective is the vertical strips pattern (also called lawnmower technique). Research has shown this pattern to give more thorough coverage over the concentric circles and radial spokes patterns. This involves examining in long, straight, vertical strips, going up and down between the clavicle and the bra line. To examine all breast tissue, rows should be overlapping with the doctor palpating towards themselves. One generally has better control over hand movement when working towards self.

  1. The doctor palpates from the sternum to the nipple with you in the supine position (the nipple is a clear marker as a place to stop and begin again – this should also be palpated)

  2. You are asked to turn on your side in the Cahan position (as previously described)

  3. The doctor palpates from the nipple to the axilla, continuing in the vertical strips pattern.

  • The order would also be reversed when doing your self breast exam, so that you should palpate toward the center of your body. (1) Turn on side into Cahan position (or use pillows if this is too uncomfortable), (2) palpate in the vertical strips pattern from axilla to nipple, (3) lie in the supine position and (4) palpate from nipple to sternum.

  • This part of the exams continues using the same methods as with all palpation of breast tissue: pads of 2-3 fingers, dime-size circular motions, 3 degrees of pressure, fingers should maintain contact with surface, and proper spacing.

  • If you have complained of nipple discharge, or if it is noted in the examination, the doctor may attempt to locate the source of the discharge in this position by first palpating the aureola, applying pressure against the nipple with their finger, then stripping the quadrants (4 sections of the breast upper right & left, lower right & left), moving in towards the nipple.

That concludes the breast exam. At this point, the doctor should discuss with you the date of your next self breast exam and your next clinical breast exam.

Pelvic Examination

Now the doctor will move on to the pelvic exam. Here you will be assisted the into the lithotomy position with the back of the table adjusted to a 45-degree angle. At this time, you may be offered the opportunity to see the pelvic exam with the help of a small hand-held mirror. This is a very informative level of education and participation, though of course if you are not comfortable with this, it is perfectly fine to decline from holding the mirror. At this time you should be given a draping sheet to cover your lap. If you have not do not hesitate asking, as this may greatly improve your comfort level. The doctor will adjust the foot rests and ask you to place your feet in the foot rests, and ask you to place your hand on the edge of the table and slide forward until you feel your hand. The footrests should be adjusted so that your knees fall to at least your shoulder width.

At this point you should take a deep breath and relax yourself. If you are not comfortable ask the doctor for assistance. The doctor will then adjust the lamp to illuminate the perineum and you should feel the warmth of the lamp. The doctor should then wash their hands, put on gloves and let you know the pelvic exam is to begin. The doctor will lift the draping sheet just enough to begin the visual examination of the external genitalia, first viewing the perineum and mons pubis. The doctor should only expose what is necessary to examine at the time, so the legs should remain covered. This helps you feel more comfortable and less exposed. The doctor will be looking for any abnormalities, signs of trauma (bruises, cuts or abrasions that could indicate abuse), inflammation, rashes, nits, crabs, lice, lesions, masses, etc. Also noting the pattern of hair growth; in women it is usually triangular shaped, and in men it is usually diamond shaped. Before the doctor begins, they should always verbally alert you that they are about to begin the physical part of the exam. They should establish a tactile signal as well by touching the back of their hand against your thigh. They will begin palpating the mons pubis, the area on the hairline and pubic area, using the circle and drag technique, working back and forth with one hand, then working down and palpating the inguinal lymph nodes (in the crevice of leg and pelvis). Normally once they have established the signal and have begun the physical exam, they should not break that physical contact. If they do, then they reintroduce the signal and verbal alert. Ideally, you want to have this exam proceed as smoothly as possible, being thorough, but at the same time not leaving you exposed too long.

From the mons pubis, they will next examine and palpate the labia majora, the outer folds then the labia minora, the inner folds. The doctor palpates each fold gently between their thumb and forefinger, working down from the top to the bottom of each fold. Then they retract the prepuce, the clitoral covering, careful not to touch the clitoris, and visually examine the clitoris.

With one hand, they separate the labia minora and visually examine the urethral meatus, the opening of the urethra, and the introitus, the opening to the vagina. They then insert their index finger into the introitus up to the first joint and palpate or milk the Skene’s glands that would be located at ten and two o’clock. They will only be able to detect something if there is a problem. Now they should rotate their finger down to palpate the Bartholin’s glands at about 5 and 7 o’clock. Again, it may not be easy to locate these unless they are inflamed. They remove their finger, and visually examine the perineum, the space between the introitus and anus, then visually examine the anus, the entrance to the rectum.

Speculum Examination

The doctor will now perform the speculum exam. There are a number of shapes and sizes of speculums they may use. The two major types are called Graves and Pederson. The Graves are wider in the bill than the Pederson, and the Pederson is more tapered. The Graves is generally used for sexually active women and the Pederson is preferred for the woman with a “relatively small introitus, such as a virgin or an elderly woman, and is often more comfortable for other patients as well” (Bates Guide to Physical Examination, 7th edition). Both Graves and Pederson come in metal and plastic and in small, medium and large sizes. A fiber optic light can be inserted into a plastic speculum to optimize visibility of the vaginal walls. There are also some special products for pediatrics and for obese patients.

Once the doctor has chosen the appropriate speculum, they should check it mechanically. The screw at the handle adjusts the height of the opening. This should be adjusted and tightened before insertion. The lever can be depressed to open the bills, and the screw at the lever holds them in place in the open position. This screw at the lever should be loose when inserting the speculum and the bills should be closed.

If this is your first pelvic exam, the doctor should show you the speculum. If they do not you can still ask to be shown the speculum. The doctor always holds the speculum with their index finger over the top of the bills, their other three fingers underneath and around the handle, and the thumb underneath the lever. Most doctors check to see that the speculum is not too cold. The temperature of the speculum can be checked by touching it against the inside of your thigh. If it is too cold, the doctor can run it under warm water. Some doctors keep their speculums in warm water.

Before inserting the speculum, the doctor should alert you that the speculum examination is about to begin. Take a breath and exhale. The doctor should re-establish the tactile signal and insert it at a 45-degree angle. As they slowly insert the speculum more fully, they rotate it to a flat position so that the handle is perpendicular to the floor. The bills should remain closed as they insert the speculum. The doctor will then push the speculum in gently until they feel some resistance. They should not force it in, but they also want it to be deep enough that they are able to see the cervix when they open the bills. Once the speculum is in far enough, they hold the handle with one hand to hold it in place. They slowly depress the lever to open the bills with the other hand until they are able to see the cervix. You may feel your cervix fall into place as the speculum is opened. It is not painful but slightly uncomfortable.

Once they have the cervix in view, they tighten the screw on the lever enough that it holds the bills open. At this point, with the bills open, the speculum will stay in place and the doctor should have the cervix in view and visually examine it, size, color, and configuration of the OS (center/opening). If all appears normal then the doctor should reassure you. This is an opportune time to use the hand held mirror to view your own cervix.

This is when the doctor takes cultures for the Pap smear, they should alert you that you will feel some pressure and discomfort, but no pain as they gently swipe off the cultures from your cervix. They will now remove the speculum with bills open until it is free of the cervix. Then they will allow it to close partially and rotate it to a 45-degree angle, observing the vaginal walls. The speculum will close completely as it is fully removed.

Bimanual Vaginal Abdominal Examination

If the doctor has an assistant they should help with lubricant. This should be applied to the middle and forefinger of the doctor’s hand. The lubricant package should not touch the glove. The doctor should alert you verbally that the bimanual examination is about to begin, again establishing a tactile signal. Take a deep breath and exhale.

The doctor introduces the tips of two fingers into the vagina. Then he/she inserts both fingers into the vagina up to the middle knuckle, then turns the hand palm up and continues inserting, hyper extending the thumb and flexing the 4th and 5th fingers toward the palm. They should keep their hand flexible to keep the outside fingers from agitating the external genitalia during this part of the exam. They should be standing for this part of the exam.

The doctor palpates the vaginal rugae (tissue), checking for depth and noting anything unusual such as cysts, scarring or deformity. Now they locate the cervix. Checking the size direction, consistency and tenderness of the cervix. (The cervix normally is firm, but a hard cervix could indicate cancer.) Now they get their fingers underneath the cervix. Remember to take a deep breath and relax your abdominal muscles. With the inside hand pushing up gently, and their outside hand pushing down on the abdomen, the doctor palpates the uterus. They will note the size, position, consistency (firm vs. soft), direction (anteverted vs. retroverted) and tenderness.

Next they move the vaginal fingers over with the abdominal hand to palpate for each ovary. The ovaries are often difficult to palpate. It’s very subtle. They note the thickness of the parametrial tissue and whether there are any pelvic masses. They now remove fingers smoothly, and remove the outer glove, holding hand down and turning glove inside out to prevent any splattering. They should discard the glove in biohazard waste bin or bag. With the help of the assistant, they re-glove and again apply lubricant to middle and forefinger of dominant hand.

Bimanual Rectovaginal Examination

Now for the the rectovaginal examination. I have experienced OB-GYN visits where this part of the examination was excluded entirely. This is not acceptable. Many people would like to avoid this rectal exam due to discomfort and fear but should not, as many polyps are discovered rectally and this small part of the exam could save your life. In this final part of the exam, the doctor will be inserting their index finger into the vagina, and at the same time, inserting their middle finger into the rectum. Again, they should alert you that the exam is about to begin. Reestablish the tactile signal. They place the forefinger at the entrance to the vagina and middle finger at the entrance to the rectum. While you may feel some discomfort, you should not feel any pain. Take a deep breath as they bear down as if you are having a bowel movement, in order to relax the anal sphincter. They then insert both fingers. Again, they palpate the uterus and ovaries. In a woman with a retroverted uterus, the uterus may be easier to palpate from this position. They then palpate the posterior rectal wall, then in a sweeping motion, palpate the septum between the two fingers and finally remove the fingers smoothly, and again remove gloves, holding hand down and turning glove inside out. Then they discard the gloves and wash their hands again.

After the Exam

Your doctor should discuss the examination findings with you after you are dressed. In the meeting, they should reiterate the importance of a regular self-breast exam, which should be performed one week after the onset of menstruation, or at the same time each month if you are not menstruating. They should also discuss your next clinical exam, mammogram, pelvic exam and Pap smear.

Now for the the rectovaginal examination. I have experienced OB-GYN visits where this part of the examination was excluded entirely. This is not acceptable. Many people would like to avoid this rectal exam due to discomfort and fear but should not, as many polyps are discovered rectally and this small part of the exam could save your life. In this final part of the exam, the doctor will be inserting their index finger into the vagina, and at the same time, inserting their middle finger into the rectum. Again, they should alert you that the exam is about to begin. Reestablish the tactile signal. They place the forefinger at the entrance to the vagina and middle finger at the entrance to the rectum. While you may feel some discomfort, you should not feel any pain. Take a deep breath as they bear down as if you are having a bowel movement, in order to relax the anal sphincter. They then insert both fingers. Again, they palpate the uterus and ovaries. In a woman with a retroverted uterus, the uterus may be easier to palpate from this position. They then palpate the posterior rectal wall, then in a sweeping motion, palpate the septum between the two fingers and finally remove the fingers smoothly, and again remove gloves, holding hand down and turning glove inside out. Then they discard the gloves and wash their hands again.

After the Exam

 Your doctor should discuss the examination findings with you after you are dressed. In the meeting, they should reiterate the importance of a regular self-breast exam, which should be performed one week after the onset of menstruation, or at the same time each month if you are not menstruating. They should also discuss your next clinical exam, mammogram, pelvic exam and Pap smear.

Denise Cumor