Preventive Medicine

in
Womens Health
OFFICE GYNECOLOGY
H. B. Albao, MD. FPOGS

Overview of frequently used

diagnostic procedures in gynecology
Tests for Vulvovaginitis
Gram Stain
Culture & Sensitivity Test
Vaginal pH
Whiff Test
KOH Smear

Overview of frequently used

diagnostic procedures in gynecology
Screening Tests for Cancer of the Cervix
Visual inspection using Acetic Acid
(VIA)
Papanicoulau Smear (Pap Smear)

Overview of frequently used

diagnostic procedures in
gynecology
Endometrial biopsy

BBT
Maturation Index
Fern test
Spinnbarkheit Test
Serum progesterone or urinary
progesterone metabolites levels
determination

Overview of frequently used

diagnostic procedures in
gynecology

Colposcopy
Ultrasound
Magnetic Resonance Imaging (MRI)
Computed Tonography Scan
Hysteroscopy
Hysterosalpingography

Gram stain for Vaginal Infections

A sample of the vaginal discharge is placed
on a microscope slide.
A special dye (Gram Stain) is put on the
slide.
This causes certain types of bacteria:
Gram-positive bacteria to turn a shade of
purple
Gram-negative bacteria turn pink.
Ex. Gardnerella - Gm (-) Bacterial vaginosis

Vaginal pH Test
pH test paper & a color chart
for determining your vaginal
pH:
To perform the test,
hold the pH test paper
against the wall of your
vagina for a few seconds.
compare the color of your
pH test paper to the color
chart.
choose the color your test
result most closely
resembles to the pH
paper.

Vaginal pH
Normal vaginal pH - 3.8 - 4.5 (slightly acidic)
Maintained by lactobacillus, which produce
hydrogen peroxide;
diphtheroids & Staphylococcus epidermidis.

May increase with

age & phase of menstrual cycle,

sexual activity,
contraception choice,
pregnancy,
presence of necrotic tissue or foreign bodies,
use of hygienic products or antibiotics,
infections

Vaginal pH Test
Conditions
Normal vaginal pH

pH

Bacterial vaginosis

3.8 4.5
> 4.5

Vulvovaginal candidiasis (VVC)

4.5

Trichomonas vaginalis

> 4.5

Whiff Test
Drops of a 10% potassium hydroxide
(KOH) solution are added to a sample of
vaginal discharge.
(+) Whiff Test
A FISHY AMINE odor
Suggestive of Bacterial vaginosis (BV)

Four clinical criteria for the diagnosis of

bacterial vaginosis (must meet 3 of 4)
(1) a homogeneous vaginal discharge is
present;
(2) the vaginal discharge has a pH equal to
or greater than 4.5;
(3) the vaginal discharge has an amine-like
odor when mixed with KOH; whiff tests;
(4) a wet smear of the vaginal discharge
demonstrates clue cells greater in
number than 20% of the number of the
vaginal epithelial cells.

Wet mount with NSS

Drops of a normal saline solution (NSS)
are added to a sample of vaginal
discharge in a glass slide.
Examine directly under microscope with
the 400x objective.

Wet mount with NSS

The presence of
squamous epithelial
cells laden with
macrophages
(+) clue cells - Bacterial vaginosis
(BV)

Hanging Drop
Technique
Drops of a normal saline solution
(NSS) are added to a sample of vaginal
discharge in a SPECIAL glass slide with
a concavity at the center.
Put a cover slip, invert the slide &
examine directly under the microscope
under the 400x objective.

Hanging Drop
Technique
Presence of
motile
protozoans with
undulating
membranes - Trichomonas
vaginalis

KOH Smear
A simple and reliable technique for
diagnosis of vulvovaginal candidiasis
(VVC).
Drops of a 10% potassium hydroxide
(KOH) solution are added to a sample of
vaginal discharge.
Examine in the microscopic under the
100X objective.

KOH Smear
The presence of
hyphae Candida albicans
C. albicans a commensal
agent in 15-20% of
women

Vulvovaginal
candidiasis (VVC)

Screening Tests for Cancer

of the Cervix
For Early Detection of Cancer of the Cervix:
Visual Inspection with Acetic Acid
Papaniculao Smear
Pap Smear or Pap Test
Cancer in Women:
1. Breast
2. Cervix
3. Colon

Types of visual inspection tests:

Visual inspection with acetic acid (VIA)
can be done with
the naked eye - cervicoscopy or direct visual
inspection [DVI]), or
with low magnification - gynoscopy, aided VI, or
VIAM.

Visual inspection with Lugols iodine

(VILI),
also known as Schillers test
uses Lugols iodine instead of acetic acid.

What does VIA involve?

Performing a vaginal speculum exam
during which a dilute (3-5%) acetic acid
(vinegar) is applied to the cervix.
Abnormal tissue temporarily appears white
when exposed to vinegar.

Viewing the cervix with the naked eye to

identify color changes on the cervix.
Determining whether the test result is
positive or negative for possible
precancerous lesions or cancer.

What infrastructure does VIA

require?
Private exam area
Examination table
Trained health professionals
Adequate light source
Sterile vaginal speculum
New examination gloves, or HLD surgical gloves
Large cotton swabs
Dilute (3-5%) acetic acid (vinegar) and a small
bowl
Containers with 0.5% chlorine solution
A plastic bucket with a plastic bag
Quality assurance system to maximize accuracy

Categories for VIA test results:

VIA Category
Test-negative

Clinical Findings
No acetowhite lesions or faint
acetowhite lesions; polyp,
cervicitis, inflammation,
Nabothian cysts.

Test-positive

Sharp, distinct, well-defined,

dense (opaque/dull or oyster
white) acetowhite areaswith or
without raised margins touching
the squamocolumnar junction
(SCJ); leukoplakia and warts.

Suspicious for
cancer

Clinically visible ulcerative,

cauliflower-like growth or ulcer;
oozing and/or bleeding on touch.

Categories for VIA tests results:

Acetowhite area far from squamocolumnar junction (SCJ) and not
touching it is insignificant.
Acetowhite area adjacent to SCJ is significant.

Negative
Photo source: JHPIEGO

Positive

Categories for VIA tests results:

Suspicious for cancer

Photo source: PAHO, Jose Jeronimo

Management options: What to

do if the VIA test is positive?
Offer to treat immediately.
Refer for confirmatory diagnosis or
adjunctive test.

Schillers test:
Visual inspection with Lugols iodine
(VILI),
uses Lugols iodine instead of acetic acid.

A vaginal speculum exam during which a health

care provider applies Lugols iodine solution to
the cervix.

How VILI works:

Squamous epithelium contains glycogen,
whereas precancerous lesions and
invasive cancer contain little or no
glycogen.
Iodine is glycophilic and is taken up by the
squamous epithelium, staining it
mahogany brown or black.

How VILI works:

Columnar epithelium does not change color,
as it has no glycogen.
Immature metaplasia and inflammatory
lesions are at most only partially
glycogenated and, when stained
appear as scattered, ill-defined uptake areas.

Precancerous lesions and invasive cancer do

not take up iodine (as they lack glycogen)
appear as well-defined, thick, mustard or saffron
yellow areas.

Categories for Schillers test

results:
Category
Test-negative

Clinical Findings
Squamous epithelium turns
brown and columnar epithelium
does not change color; or
irregular, partial or non-iodine
uptake areas appear.

Test-positive

Well-defined, bright yellow iodine

non-uptake areas touching the
squamo-columnar junction (SCJ)
or close to the os if SCJ is not
seen.

Suspicious for
cancer

Clinically visible ulcerative,

cauliflower- like growth or ulcer;

VILI: test-negative
The squamous epithelium
turns brown and columnar
epithelium does not
change color.

There are scattered and

irregular, partial or noniodine uptake areas
associated with immature
squamous metaplasia or
inflammation.
Photo source: IARC

VILI: test-positive
Well-defined, bright
yellow iodine nonuptake areas touching
the squamocolumnar
junction (SCJ).

Well-defined, bright
yellow iodine nonuptake areas close to
the os if SCJ is not seen,
or covering the entire
cervix.
Photo source: IARC

VILI: Suspicious for cancer

Clinically visible
ulcerative,
cauliflower-like
growth or ulcer;
oozing and/or
bleeding on touch.

Photo source: IARC

Management options if the VILI

result is positive:
Offer to treat immediately.
without colposcopy or biopsy,
known as the test-and-treat or singlevisit approach.
Refer for colposcopy and biopsy and then offer
treatment if a precancerous lesion is confirmed.

Management options if the VILI

result is suspicious for cancer:
Refer for colposcopy and biopsy and
further management:

Surgery
Radiotherapy
Chemotherapy
Palliative care

Papanicolaou Smear
Screening or Early Detection for
Cancer of the Cervix
Cervical cytology testing
Done by examining a cellular sample
scraped from the uterine cervix and
properly prepared and stained.

Pap Smear
Initial screening should begin
at age 21 or
3 years after the individual becomes sexually
active.
High-risk women, those with a history of early
sexual activity and multiple partners, ANNUALLY.
Those with later exposure to coitus who have only
one sexual partner and who have had three
successive negative annual smears may be
considered low risk and should be screened every
2 to 3 years at the discretion of the physician.

Technique of Pap Smear

The cervix must be visualized after
placement of a speculum into the
vagina.
The portio of the cervix is then
scraped using either a "broom" or
the combination of a plastic
spatula and an endocervical brush.

Pap Smear: Objective

To sample
exfoliated cells
from the
endocervical canal
and to scrape the
transitional zone.
It is also useful to
sample the
vaginal pool.

Technique (1) of Pap

Smear
The endocervical
canal is sampled
using
a cotton-tipped
applicator or
a cytobrush,

which is placed into

the canal and
rotated to dislodge
the cells.

the cytobrush appears to give

more accurate results & higher
yields of positive findings.

Technique (1) of Pap

Smear
The material obtained is
then smeared thinly on a
microscope slide by
rotation of the swab or
brush on the glass
surface.
This is labeled endocervix
and fixed immediately
by use of a spray fixative
or
by immersion of the slide
into a fixative solution.
Do not allow to air-dry.

Technique (2) of Pap

Smear
Using the Ayres spatula
the entire
transformation zone is
scraped and the
sample smeared thinly
on a second slide,
which is immediately
fixed.
A sample of the
vaginal pool, this may
be taken with the
reverse side of the
Ayres spatula.

Recent data suggest an extended-tip

spatula is better for collecting
endocervical cells.
Best results come from using both
the cytobrush & an extended-tip
spatula.

Technique (2) of Pap

Smear
Using the Ayres
spatula the entire
transformation zone
is scraped and the
sample smeared
thinly on a second
slide, which is
immediately fixed.
A sample from the
vaginal pool may be
collected also.

Fixatives for Pap Smear

It is important that fixative be applied immediately
before drying and distortion of the cells takes
place.
Hair Spray fixative
95% ethyl alcohol solution
Newer liquid-based, thin-layer Pap smear
preparations are available.
No slides are needed.
The cytobrush and spatula are used to obtain
cervical cells & are placed in a liquid jar of
fixative and gently rotated to dislodge cells in
the liquid.

Fixatives for Pap Smear

It is important that fixative be applied immediately before
drying and distortion of the cells takes place.
Hair Spray fixative
95% ethyl alcohol solution
Newer liquid-based, thin-layer Pap smear preparations
are available.
No slides are needed.
The cytobrush and spatula are used to obtain cervical
cells as described earlier, and they both are placed in
a liquid jar of fixative and gently rotated to dislodge
cells in the liquid.
Evidence-based data show both Pap slide prepared in a
conventional manner and liquid-based methods for cervical
cytology screening are acceptable.

Pap Smear Result

using the following descriptive system
(2001 Bethesda system)
Negative for Intraepithelial Lesion or
Malignancy
Epithelial Cell Abnormality
Squamous cell
Atypical squamous cells (ASC)
Low-grade squamous intraepithelial
lesions (LSIL)
High-grade squamous intraepithelial
lesions (HGSIL)
Squamous cell carcinoma

Pap Smear Result

using the following descriptive system
(2001 Bethesda system)
Negative for Intraepithelial Lesion or
Malignancy
Epithelial Cell Abnormality
Glandular cell

Atypical glandular cells (AGC)

Typical glandular cells - favor neoplastic
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma

Pap Smear Result

using the following descriptive system
(2001 Bethesda system)
Negative for Intraepithelial Lesion or Malignancy
Epithelial Cell Abnormality
Interpretation/Result
Other nonneoplastic findings:
Reactive
Inflammation
Radiation
intrauterine contraceptive device
Glandular cells status posthysterectomy
Atrophy

Pap Smear Result

using the following descriptive system
(2001 Bethesda system)
Negative for Intraepithelial Lesion or Malignancy
Epithelial Cell Abnormality
Interpretation/Result
Organisms
Cellular changes consistent with herpes
simplex
Trichomonas vaginalis infection
Bacteria consistent with Actinomyces
infection
Fungal organisms
Shift in flora suggestive of bacterial vaginosis

C/S Test for GC & Chlamydia

Indications, particularly with new patients and
women younger than 25 y.o.
it is appropriate to culture & sensitivity test
for
gonorrhea and Chlamydia
using swabs that sample secretions
from the endocervical canal.
This step may be performed after the
Pap smear.

Tests to Determine Ovulation

Endometrial biopsy
BBT
Maturation Index
Fern test
Spinnbarkheit Test
Serum progesterone or urinary progesterone
metabolites levels
determination

Endometrial biopsy
One of the diagnostic tests most
frequently performed by gynecologists
on an OPD basis.
A rapid, safe, and inexpensive sampling
of the endometrial lining is a common
procedure in the clinical workup of
women with abnormal vaginal bleeding.

Endometrial biopsy
Indications are:
Ovulation and Dysfunctional uterine
bleeding (DUB)
demonstrate secretory endometrium
Postmenopausal bleeding
To investigate AUB associated with HRT
Chronic uterine infection
Demonstrate the classic giant cell &
tubercules
i.e. TB

Endometrial biopsy
Uses instruments
that aspirate tissue
from the
endometrial lining
following abrasion
or scraping with a
small curette or
perforated cannula.
Office endometrial aspiration
with 3-mm Randall suction
curette.

Endometrial biopsy
Uses cannulas in that
are 2 to 4 mm in
diameter and are
plastic.
Aspiration of the
endometrium is usually
accomplished by a
syringe.
Pipelle endometrial suction curette.
Note small diameter and flexible nature.
Suction is produced by partly withdrawing
inner stem.

Endometrial biopsy
Pipelle cannula
thin, flexible
polypropylene is as
effective as rigid
instruments in obtaining
endometrial specimen
often with less discomfort.
instrument of first choice
for endometrial sampling.

Other flexible plastic

cannulas are equally
effective.
Pipelle endometrial suction curette.
Note small diameter and flexible nature.
Suction is produced by partly withdrawing
inner stem.

Endometrial biopsy
Contraindications:
Profuse bleeding is a relative
contraindication.
Endometrial biopsy should not be
performed more than 14 to 16 days
after ovulation
because of the possibility of interfering with
an early pregnancy.

Endometrial biopsy
OPD Procedure
It is helpful to explain to
the patient that she will
experience uterine
cramping during the short
time that the biopsy
instrument is inside the
uterus.
A bimanual examination is
performed to note the size
of the uterus and direction
of the uterine cavity.

Endometrial biopsy
A single-toothed
tenaculum used to secure
the anterior cervical lip.
The exocervix is then
cleaned of mucus and
bacteria with an iodine
solution prior to sampling.
In abnormal bleeding
at least four separate areas
should be abraded.

Endometrial biopsy
Cervical stenosis or spasm.
most frequent problem in
performing endometrial
sampling.

to obtain pain relief and

discomfort & overcome
resistance is a paracervical
block with 1% lidocaine.
Subsequently, the cervix can
be dilated painlessly with
narrow metal dilators, and
the biopsy can be completed.

Endometrial biopsy
Major advantages of the endometrial
biopsy over D&C are:
convenience and cost savings
The clinical results obtained depend on
two factors:
1. the patient's acceptance
acceptance is higher with narrow cannulas made
of plastic.

2. the physician's skill and perseverance.

Endometrial biopsy
Routine preoperative endometrial
biopsy in asymptomatic women
undergoing hysterectomy:
is an unnecessary procedure
does not improve patient care.

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