While there is a large body of evidence on the effectiveness of Pap smears for cervical cancer screening and on screening for cervical gonorrhea and Chlamydia, there is sparse evidence to support other portions of the pelvic examination and little guidance on examination logistics. Maximizing comfort should be the goal; lubrication use and careful speculum selection and insertion can ease this intrusive procedure. This is particularly important in adolescent and menopausal women, sexual minorities, obese women, women with disabilities, and women with a history of trauma or prior instrumentation affecting the genitalia. We review the evidence and provide guidance to minimize physical and psychological discomfort with pelvic examination. P elvic examinations are performed to evaluate pain, bleeding, and vaginal discharge and to screen for cervical cancer and sexually transmitted infections. Little attention has focused on the mechanics of pelvic examination technique, yet the examination is an intrusive experience for many women who feel exposed and lack control. 1 Emotional distress and fear of pain are cited as reasons for reduced adherence to cervical screening especially among adolescents, 2 racial/ethnic 3-5 and sexual minority groups, 6 obese women, 7 victims of sexual assault and other trauma, 8 and women with disabilities. 9 Therefore, examination should be limited to components with proven utility and should be performed with cultural sensitivity and procedural excellence, especially in clinical situations that require particular finesse. Accordingly, we review the clinical evidence as it exists, and in areas that lack evidence offer our own experience to optimize technical aspects of speculum choice and insertion, and suggest strategies to manage challenging circumstances. When recommendations are not referenced, we are relating our experience in the absence of evidence. Bimanual examination is not useful as a screening test for ovarian cancer because of limited sensitivity and specificity. In one study, ovaries were palpable in 55% of women under 200 lbs during examination under anesthesia, but in only 9% of women over 200 lbs. 14 In another study under similar circumstances, uterine size and contour were correctly assessed in over 50% of patients; however, sensitivity of examination for adnexal masses of 5 cm or greater was only 28% among attending gynecologists and 16% among gynecology residents. 15 The USPFTF acknowledges poor performance characteristics of the bimanual examination in its recommendation about screening for ovarian cancer. 11 In the non-screening setting, bimanual examination is inadequate to evaluate acute abdominal pain or vaginal bleeding, 16 since ultrasound is so much more sensitive and specific. COMPONENTS OF THE FEMALE PELVIC EXAMINATIONThe most evidence-based approach would therefore suggest Pap smear collection alone and the speculum examination required to achieve that goal. We suggest that bimanual and sometimes rectovaginal examinations may be important in evaluating pelvi...
Lesbians, like other marginalized groups of women, underutilize health care services. Lesbians also present later for health care than heterosexual women. Lack of awareness of the health issues of lesbians by some health care professionals has produced lesbians' abstention from health services. After defining lesbianism, I discuss how homophobia is a public health problem. Health issues of lesbians and practical recommendations for providing optimal gynecologic and obstetric care are presented on the subjects of adolescence, sexual identity, behavior and practice, sexually transmitted diseases, human immunodeficiency virus, Papanicolaou smears, cancer risk, fertility, and parenting issues. The discussion addresses how women's health research can be shaped to enhance knowledge about lesbian health. By changing physicians' attitudes and knowledge about lesbians, better communication and more sensitive interactions should result, improving the health care of lesbian patients. (Obstet Gynecol 1999;93:611-3.
During the transition into menopause, women may experience a wide range of symptoms that negatively impact quality of life. The vasomotor symptoms (VMS) of hot flushes and night sweats are common and vary widely in frequency and severity. The treatment of menopause-associated VMS is a frequently encountered clinical challenge, with the goal of tailoring treatment for each individual woman's needs. Estrogen therapy is the most effective treatment for menopausal VMS. Current guidelines suggest that estrogen therapy be prescribed at the lowest effective dose for the shortest duration of time. Transdermal estrogen therapy has dominated the menopause prescribing practice in Europe for decades; however, in the United States, oral estrogen therapy is most commonly prescribed. Transdermal estrogen therapy can be prescribed at considerably lower doses than oral therapy yet has similar efficacy on the symptoms of menopause. Emerging research demonstrates transdermal estrogen, particularly 17beta-estradiol, may have the potential for fewer health risks than oral estrogen therapy. This review article discusses the spectrum of menopausal symptoms, addresses prevailing issues in the treatment of menopause, elaborates on the risks and benefits of oral and transdermal hormone therapies, and focuses on five nonpatch transdermal estradiol therapies currently available in the United States.
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