Medical assistant's role in gynecologic examinations: assisting the provider

Assisting with an examination

The pelvic and breast examination can be an embarrassing and emotionally difficult medical experience. In our society, reproduction is not openly talked about. Aside from the embarrassment, many women fear the provider’s findings. By behaving in a professional manner, explaining what is going to happen, and showing a genuine interest in the patient’s concerns, the medical assistant can help lay to rest most of the patient’s anxieties and fears.

The medical assistant is responsible for supporting the patient and assisting the provider during the procedure. The procedure should be fully explained to the patient to prevent unnecessary embarrassment and discomfort. During the explanation, the medical assistant has the opportunity to provide patient education. This should be done using terms that are easy for the patient to understand. The medical assistant should remain in the examination room to provide reassurance to the patient and legal protection for the provider.

The patient should be instructed to empty her bladder, completely disrobe, and put on an examination gown. Some providers prefer that the patient put the gown on with the opening in the front, whereas others prefer the opening in the back. As the medical assistant, you should be aware of your provider’s preference and instruct the patient accordingly.

Pap test and other guidelines for women

• Women ages 21 to 29 should have a Pap test alone every 3 years. HPV testing alone is not recommended
• Women ages 30 to 65 should have a Pap test and an HPV test (co-testing) every 5 years (preferred). It also is acceptable to have only a Pap test every 3 years or an HPV test every 5 years.
• If you have had a hysterectomy, you still may need screening. The decision is based on whether your cervix was removed, why the hysterectomy was needed, and whether you have a history of moderate or severe cervical cell changes or cervical cancer. Even if your cervix is removed at the time of hysterectomy, cervical cells can still be present at the top of the vagina. If you have a history of cervical cancer or cervical cell changes, you should continue to have a screening for 20 years after the time of your surgery.
• You can stop having cervical cancer screening after age 65 years if the following conditions apply:
  • You do not have a history of moderate or severe abnormal cervical cells or cervical cancer, and
  • You have had either three negative Pap test results in a row or two negative co-test results in a row within the past 10 years, with the most recent test performed within the past 5 years.

Breast examination

The first part of the gynecologic examination is the breast examination. The exam begins with the patient in the sitting position to allow for a visual check of the breasts. The gown should be adjusted so that the breast tissue can be easily exposed. After the visual inspection, the patient will be placed in the supine position. The medical assistant should be prepared to help the patient to lie down on the examination table. The footrest should be extended, and a small pillow may be placed under the patient’s head for comfort. If needed, the gown and drape should be adjusted to protect the patient’s modesty. Palpation will be used to determine if there is thickening or lumps in the breast and collar bone area. The provider will instruct the patient to place her arms above her head to allow assessment of the underarm area using palpation. When the examination is complete, the gown is readjusted to cover the breasts. The provider may choose to discuss breast self-examination with the patient at this time or may inform the patient that the medical assistant will explain the technique at the end of the examination.

According to the American Cancer Society, research has not shown a benefit for a patient or provider breast exam when women are also getting mammograms. It is recommended that women with an average risk of breast cancer start having yearly mammograms by age 45. It is optional to start earlier.

It is important for all women to know what is normal with their breasts. Any abnormality should be reported to their provider. Some providers still recommend monthly breast self-exams (BSEs) to be done after the menses. It is helpful for the medical assistant to provide the patient with a brochure showing the technique. It is also recommended to show the technique on a model. If possible, the patient should demonstrate the technique back to the medical assistant. This practice helps the medical assistant to determine if the patient understood the coaching.

Warning signs of breast cancer

• Change in the skin (redness, warmth, darkening of the color, dimpling, puckering)
• Lump or hard area inside the breast or in the axilla area
• Change in the size or shape of the breast
• Change in the nipple (inverted or pulling in appearance, rash, sore, or drainage)
• Pain that does not go away

Abdominal examination

While the patient is in the supine position, the provider will palpate the abdomen. This is done to confirm normal symmetry of the pelvic organs and detect any masses. The provider also watches for any signs of discomfort or pain that could indicate a problem.

Pelvic examination

For the pelvic examination, the patient is placed in the lithotomy position. This can be an awkward position for the patient to assume without assistance, and it may be embarrassing to the patient. If needed, the medical assistant should be available to help the patient into this position. Never place the patient in the lithotomy position until the provider is ready to begin the examination. When you assist the patient into the lithotomy position, always keep her totally covered.

You should stand at the patient’s side so you can observe her yet still be able to move quickly (if needed by the provider). First, the provider inspects the external genitalia and palpates the perineal area. The patient may be asked to bear down to show any muscular weaknesses that may be the result of lacerations in the perineal body during childbirth. A third-degree laceration may have involved the rectal sphincter and may cause rectal incontinence.

Next, the vaginal speculum is inserted for examination of the cervix and the vaginal canal to obtain the Pap specimen. The speculum should be prewarmed with warm water. Have the patient take some deep breaths to help relax the abdominal muscles. The normal cervix points posteriorly and has smooth, pink, squamous epithelium. Abnormalities most frequently seen are ulcerations (erosions), Bartholin cysts, and cervical polyps. Because erosions cannot be palpated, inspection is the only method of detecting them. Healed lacerations from childbirth are common in a patient who has had multiple deliveries. Pregnancy increases the size of the cervix, and hormone deficiency causes it to atrophy. The vaginal wall is reddish pink and has a corrugated appearance from the overlapping tissue (rugae) lining. Vaginal infections change the appearance of the vaginal mucosa.

After inspecting the vaginal wall, the provider may collect a specimen for a Pap test. When the specimen has been obtained, the medical assistant may be responsible for labeling it and preparing it for transport to the cytology laboratory. Be sure to follow laboratory instructions during the preparation to avoid having to repeat the examination.

After removal of the vaginal speculum, the provider does a bimanual examination. For a bimanual examination, two gloved fingers are lubricated with a water-soluble jelly (lubricant) and inserted into the vaginal canal, and the other hand palpates the abdomen over the pelvic organs and the mons pubis. The uterus is examined for shape, size, and consistency, and its position is noted. A normal uterus is freely movable with limited discomfort. A laterally displaced uterus is usually the result of pelvic adhesions or displacement caused by a pelvic tumor. The fallopian tubes and ovaries are evaluated. Normal tubes and ovaries are difficult to palpate, which is why the provider may have to press firmly in the pelvic area, causing minor discomfort for the patient. A digital rectal exam may be done at this time. This involves the insertion of a gloved finger into the rectum. A small amount of stool is left on the glove and can be used for a fecal occult blood test.

Post-examination duties

When the examination is finished, help the patient into a sitting position and into the dressing room, if needed. Following the Standard Precautions established by the Occupational Safety and Health Administration (OSHA), remove the examination equipment and supplies while the patient is dressing so that when the provider returns to talk to the patient, the room is neat and clean. Once the patient has left, the room should be sanitized, disinfected, and restocked as necessary so it is ready for the next patient.