What Can I Expect At My Doctor’s Visit?
Print PageHistory and Physical Exam
The nurse records your vital signs (height, weight, blood pressure and temperature). The nurse and/or doctor will take your pulse twice, first when you have been lying down quietly for 5 minutes, and secondly when you have been standing fairly still for 1 to 3 minutes. The maximum amount your pulse should increase from lying to standing is 20 beats per minute. If you have bled so much that your blood volume is depleted, your pulse will increase by more than 20.
Be prepared to answer many personal questions from your doctor about your: Sex history; general health; genetic diseases in your family; previous illnesses; drug use (prescription and recreational street drugs); and stressors. Your doctor will then ask about the length and regularity of your menstrual cycle, and how many pads or tampons you use each cycle.
Pap Smear
The Australian government mandates that all women should have a routine Papanicolaou (Pap) smear every two years. New Zealand, Canada, the U.S.A., France and Britain recommend a Pap smear every three years. If you develop any of the signs or symptoms of hyperplasia, do not wait until your next scheduled Pap test. Ask your doctor for a thorough examination of your vulva, vagina, and a cervical smear to rule out causes of bleeding in your lower genital tract. The sooner abnormal cells are detected, the better your chances are of a full recovery. Download a copy of the Australian government’s guidelines for managing abnormal Pap smears from http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm
If you have never had a Pap smear before: Remove your clothing from the waist down, and cover yourself with the gown provided. Recline on the examination couch with your feet in the stirrups. Your doctor shines a bright light on your perineum to see clearly. Your doctor inserts a clean clamp (speculum) into your vagina to hold it open, which feels cold. Your doctor collects a small sample of cells from your cervix by scraping it gently with a Popsicle stick. He or she smears the sample on a glass slide and covers it with a hairspray like fixative so it will not be washed away when the lab stains it. He or she will swab your vagina with a long-handled Q-tip to check for yeast (candida albicans), chlamydia, trichomoniasis, gonorrhea, and other infections as a routine precaution.
Blood Tests
Your doctor orders these blood tests for anemia if you menstruate heavily:
| PROFILE | TEST | NORMAL ADULT – NON-PREGNANT – FEMALE VALUE |
|---|---|---|
| Complete Blood Count (CBC) | Red Blood Cells | 4.2 to 5.4 million/mm3 |
| White Blood Cells | 5,000 to 10,000/mm3 | |
| Hemoglobin | 12 to 16 g/dl | |
| Hematocrit | 37% to 47% | |
| Platelets | 150,000 to 400,000 mm3 | |
| MCV | 80 to 95 μm3 | |
| MCH | 27 to 31 pg | |
| MCHC | 32% to 36% | |
| Retics | 0.5% to 2% of total RBC | |
| Iron Studies | Serum Iron | 60 to 190 μg/dl |
| Ferritin | 12 to 300 mg/L or 56 ng/ml | |
| TIBC | 250 to 420 μg/dl |
The lab technologist examines your blood smear under a microscope to see if your red blood cells are too pale or too small, indicating your bone marrow is trying to compensate for lack of iron by quickly producing more red blood cells. Your doctor may follow up with an erythrocyte protoporhyrin blood test.
If your doctor suspects you are entering menopause, have PCOS, or another hormonal imbalance, he or she orders these additional tests:
| PROFILE | TEST | NORMAL ADULT – NON-PREGNANT – FEMALE VALUE |
|---|---|---|
| Thyroid | T3 | 110 to 230 ng/dL |
| T4 | 5 to 10 μg/dL | |
| TSH | 1 to 4 μU/mL | |
| Liver | AST | 5 to 40 IU/L |
| ALT | 5 to 35 IU/L | |
| ALP | 30 to 85 ImU/mL | |
| Bilirubin | 0.1 to 1.0 mg/dL | |
| Cholesterol | 150 to 250 mg/dL | |
| Kidney | Creatinine | 0.7 to 1.5 mg/dL |
| BUN | 7 to 20 mg/dL | |
| Adrenals | Cortisol | 2 to 28 μg/dL depending on time of day |
| ACTH | 15 to 100 pg/mL | |
| Hormones | GH | 0 to 8 ng/mL |
| FSH | 3 to 20 mIU/mL | |
| LH | <7 mIU/mL | |
| HCG | Negative unless pregnant | |
| Progesterone | <2 ng/mL before ovulation >5 ng/mL after ovulation |
|
| Estradiol | Varies from 25 pg/mL on Day 3 to 200 pg/mL at ovulation | |
| Prolactin | < 24 ng/mL | |
| Testosterone | 6 to 86 ng/dL | |
| SHBG | 18 to 114 nmol/L |
different normal values. Your laboratory adjusts its normal values for the local population it serves. It may use different units of measure. To find out more about diagnostic tests, visit Lab Tests Online:
http://www.labtestsonline.org/understanding/index.html
If the results of your hormone tests are abnormal, your family doctor refers you to an endocrinologist, a hormone specialist.
Transvaginal Ultrasound
The nurse schedules an appointment with Diagnostic Imaging for a transvaginal ultrasound, to measure the thickness of your endometrium and to find any obvious internal causes of bleeding, such as polyps and fibroid tumors.
A transvaginal scan is a painless ultrasound that takes about 30 minutes. Drink eight glasses (32 ounces) of water one hour before you go to the Diagnostic Imaging Lab, and retain your urine until after the scan has been completed. Drinking liquid provides contrast between the uterus and the nearby bladder. You must remove your clothing from the waist down and wear a gown.
First, the technologist records a pelvic ultrasound. The technologist coats your abdomen with electrolyte gel and moves a transducer across your pelvis to view your ovaries, fallopian tubes, and uterus on a monitor. The technologist is looking for an abnormally shaped uterus, scars, polyps, fibroids and cancer. The technologist may use a Doppler “gun” to determine if any blood vessels are blocked.
The technologist will ask you to empty your bladder for the transvaginal ultrasound. The technologist covers the small probe with a condom, coats it with lubricating gel, and inserts two or three inches of it into your vagina to measure the thickness of your endometrium. An endometrium more than 5 mm is considered too thick, and is the cause of your heavy bleeding (menorrhagia).
Endometrial Biopsy
An abnormal uterine ultrasound that does not show an obvious polyp or fibroid requires further investigation by microscopic examination. An endometrial biopsy also enables the pathologist to determine if your endometrium is reacting properly to the stimulation of the hormones estrogen and progesterone. It takes 5 to 15 minutes to collect an endometrial biopsy sample. If you are pregnant and wish to carry it to term, inform your doctor, as biopsy would terminate the pregnancy and should not be performed. If your vaginal swabs showed an infection of any kind, then the biopsy cannot proceed until you are clear of disease. To do so can spread the infection.
Schedule the uterine biopsy for a time when you will not be actively bleeding, so the doctor can reach right down to the uterine wall. A uterine biopsy can be performed in your doctor’s office. No anesthetic is required, but take two ibuprofen capsules (Advil®, Nuprin® or Motrin®) an hour before the procedure to minimize cramping. Wear a sanitary pad afterwards. Do not wear tampons, as they are not sterile and could introduce an infection. Do not douche before or after the biopsy. Schedule the day off work.
Your family doctor or gynecologist (specialist in female reproduction) has two options for performing the biopsy, either with pipelle or washing, brushing and aspiration:
Pipelle
Your doctor inserts a clean clamp (speculum) into your vagina to hold it open. Your doctor holds your cervix steady with another clamp (tenaculum). A pipelle is a thin, flexible tube your doctor passes through your cervix and into your womb. Your doctor applies gentle suction to vacuum out a small sample of endometrium through the tube, which is then sent to a pathologist for expert microscopic examination. The pipelle method is generally the least painful and time-consuming.
Brushing, Washing and Aspiration
The doctor brushes the endometrium to loosen some cells, and then washes them free with a jet of liquid (irrigation). He or she then applies gentle suction from a Vabra aspiration machine, or similar device, to collect the sample. Brushing, washing and aspiration causes more cramping than a pipelle.
You may sweat profusely, experience a tingling sensation, feel dizzy, nauseated or faint during your biopsy. Tell the doctor and nurse at once if you feel like vomiting or fainting. These responses are a natural vasovagal reaction from fear, pain, and trauma stimulating your nervous system, and will pass when the biopsy is finished. Try to persevere with the test. If an insufficient sample is collected, the pathologist may not be able to reach a conclusive decision, and you will need the test repeated.
Endometrial biopsy is a blind procedure. There is a slight chance you may have prolonged bleeding or infection after a biopsy. If you develop pelvic pain, fever, copious bleeding, foul-smelling vaginal discharge, or if bleeding lasts more than a week, seek medical attention.
Hysteroscopy
If a polyp, fibroid, suspicious growth, or a misshapen uterus is discovered through an ultrasound, your doctor will follow up with a hysteroscopy. A hysteroscopy is an invasive procedure where the doctor looks inside the uterus with a tiny telescope and a thin, flexible “straw” called a hysteroscope. It is usually performed as an out-patient procedure at a hospital or gynecology clinic. Schedule the day off work. Shower the night before your procedure. Do not eat or drink from midnight until your procedure is completed.
In addition to the technologist, a hysteroscopy requires the presence of a radiologist, a doctor specially trained to interpret the images. A doctor is absolutely required because there is a slight chance (0.012%) you could develop complications, such as:
- Adverse reaction to the anesthetic
- Torn cervix
- Leaking of the distention gas or liquid into the bloodstream
- Perforated uterus
- Hemorrhage
- Adhesions
- Infection
You will receive a local anesthetic in your cervix so you will feel no pain. Ask for an epidural or general anesthetic if the procedure makes you very apprehensive. Your cervix may be gently dilated before introducing the “straw”. Gas or liquid is piped through the hysteroscope to widen the uterus and make its interior visible.
If the radiologist discovers a problem, he or she will take a small tissue sample for the pathologist to examine. If there is an obvious mechanical problem causing your heavy bleeding (menorrhagia), like a misplaced IUD, the radiologist will call a gynecologist to consult. The gynecologist may be able to fix the cause on the spot.
Dilatation and Curettage (D&C)
A dilatation and curettage allows your doctor to remove your built-up endometrium and collect a tissue sample for Pathology at one fell swoop. However, it is only a temporary solution. A D&C does not cure hyperplasia, because the endometrium starts to grow back in the next cycle.
D&C has fallen out of favor because it is a blind procedure. For example, if your problem is a small fibroid tumor, the gynecologist could scrape the wrong area of the uterus and miss diagnosing the fibroid altogether. D&C is more traumatic to your reproductive system than a pipelle or suction aspiration biopsy, and hence, it takes longer to recover. The chances of developing complications from a D&C are higher than the other biopsy methods. Your cervix could be lacerated, your uterus could be perforated, or you might develop a pelvic infection that leads to scarring. Forty percent of D&Cs are performed to treat heavy menstrual bleeding (menorrhagia). However, most gynecologists no longer perform D&C merely to treat and biopsy hyperplasia.
Often, the doctor asks you to come the night before your D&C, so a laminaria tent can be inserted into your cervix. Laminaria is a black seaweed plug that resembles a matchstick. It will collect moisture from your body overnight, and swells to gently dilate your cervix. No anesthetic is required. Expect light cramping.
If you choose a local anesthetic, your doctor can perform the D&C in his or her office. If you choose a general anesthetic, then the D&C is performed in a hospital setting, in case you react badly to the anesthesia. Expect to be tired for a few days following general anesthesia. If your throat is raw from the endotracheal tube, then gargle with salt water daily and suck on soothing throat lozenges until the problem resolves.
The doctor must dilate your cervix further with a set of wands of gradually increasing diameter. When the cervix has widened enough to permit the passage of instruments, he or she will scrape the inside of your uterus with a sharp, spoon-like curette. D&C reduces the thickness of your endometrium immediately. The contents of your uterus are sent to a pathologist for microscopic examination.
For one week following the D&C, avoid infection and keep bleeding to a minimum by following these precautions:
- Shower or bed bath instead of submerging in a bathtub
- Wear sanitary napkins instead of tampons
- Do not lift anything weighing more than 5 lbs. (2 kg)
- Do not perform vigorous exercise
- Avoid vacuuming and other pushing movements
- Do not douche
- Do not have sexual intercourse