Gynaecological examination, cervical sampling and colposcopy

• A gynaecological examination is planned from the history: most problems are diagnosed by what the woman reports, with the examination confirming, mapping severity, and excluding red flags.
• Consent is specific, voluntary, and can be withdrawn at any time; every intimate examination should be offered a trained, impartial chaperone, and this offer and response should be documented.
• The pelvic examination has three parts in turn: external inspection, speculum examination of the vagina and cervix, then bimanual (and sometimes rectovaginal) palpation; each step is explained before it happens.
• Cervical screening is taken from the transformation zone as a liquid-based sample and fixed immediately; in the English programme it is now a primary human papillomavirus (HPV) test, with cytology added when HPV is positive.
• Colposcopy is a magnified, illuminated inspection of the cervix after acetic acid, used to diagnose and sometimes treat cervical precancer; it is painless, and it is not the same as taking a screening sample.

By the end of this page you should be able to:

1. Take a focused gynaecological history and identify bleeding, infection and pain red flags.
2. Explain the legal and ethical requirements for consent and chaperones at an intimate examination, and adapt the examination for a woman who is anxious or has experienced trauma.
3. Perform and record a gynaecological examination in a logical order, explaining each step to the woman.
4. Take an adequate cervical sample that samples the whole transformation zone, and know when not to take one.
5. Describe how colposcopy is performed, what acetic acid and iodine show, and when biopsy or excision is indicated.
6. Outline the pathway from an abnormal screening result to colposcopy, treatment, and test of cure, recognising where referral is urgent.

A gynaecological examination is one of the most sensitive examinations a clinician performs. It crosses professional, cultural and personal boundaries within minutes of meeting a patient, so the groundwork done beforehand matters as much as the examination itself. Much of the value of the consultation is intellectual, and not manual: a carefully taken history often narrows the diagnosis before the couch is reached ^[5]. The physical examination is then used to confirm, to measure, to exclude disease, and to make safe management possible. It should never be done "because it is a gynaecology clinic": it is done when the information gained changes care, and when the woman has consented to it specifically ^[1].

This topic treats gynaecological examination, cervical sampling and colposcopy as one procedure family, because in practice one leads to the next: symptoms lead to examination, examination leads to sampling, and sampling leads to colposcopy when the result is abnormal. The emphasis throughout is on patient comfort, dignity, safety and truth-telling, with regional variation stated where it matters.

• Abnormal vaginal bleeding, including postmenopausal, intermenstrual or postcoital bleeding.
• Pelvic pain, dyspareunia or deep dyspareunia.
• Vaginal discharge, itching or suspected infection.
• A palpable pelvic lump, abdominal distension, or symptoms suggestive of pelvic organ prolapse.
• Assessment of contraception, intrauterine device (IUD) threads or problems with a pessary.
• Follow-up after treatment for cervical intraepithelial neoplasia (CIN).
• Cervical screening as part of the organised programme, or an opportunistic sample when clinically indicated.
• Evaluation of infertility, endometriosis, fibroids, ovarian masses and other gynaecological conditions.
• Pre-operative assessment before gynaecological surgery.

There is no absolute medical contraindication to a vaginal examination, but there are situations in which the examination should not proceed as planned:

• Refusal. A competent adult's refusal is final. The examination is offered, explained, and, if declined, the reasons are documented and alternatives discussed ^[1][2].
• Inability to consent (unconscious, severely distressed, or lacking capacity): the examination waits unless it is needed immediately to save life or prevent serious harm, and a best-interests decision is documented.
• Suspected acute trauma or fracture of the pelvis, in which case imaging and a senior review come first.
• Severe pain at rest can make a standard examination intolerable; analgesia, a smaller speculum, a different position, or examination under anaesthesia may be needed ^[5].
• Referral for colposcopy should not be triggered by bleeding at sampling alone when malignancy is not suspected; contact bleeding is common and is not an indication for referral in the absence of other symptoms ^[10].

In practice a clinician should always be prepared not to examine: the willingness to stop is itself therapeutic, and the history alone often guides the next step.

The examination makes sense only if the underlying anatomy is held clearly in the mind:

• Vulva: mons pubis, labia majora and minora, clitoris, vestibule, urethral meatus, vaginal introitus and perineum. The Bartholin glands sit posterolaterally at about 4 and 8 o'clock on the vestibule and are not palpable normally ^[5].
• Vagina is a muscular tube directed posteriorly and superiorly toward the sacrum; at its apex the cervix projects into it, creating the anterior, posterior and lateral fornices.
• Cervix: firm and smooth. The external os is the opening in the centre and may be circular in a nulliparous woman and slit-like (transverse) after vaginal birth.
• Transformation zone (TZ) is the area between the original squamocolumnar junction (SCJ) and the new SCJ. It is where metaplastic change occurs, and it is where cervical precancer develops. The SCJ's position varies with age, pregnancy and oestrogen exposure: in young women it is often visible on the ectocervix, and after menopause it may be pulled into the endocervical canal.
• Uterus is normally anteverted and anteflexed; when it is retroverted it sits back in the pelvis and is often better palpated through the posterior fornix, sometimes with a rectovaginal examination.
• Adnexa lie lateral and slightly posterior to the uterus and contain the fallopian tubes and ovaries. In a relaxed, thin woman the ovaries may be felt; in obesity, after menopause or when the patient is tense they often are not ^[5].

• Gloves (non-latex if there is an allergy), apron, good light, disposable specula of several sizes, water-soluble lubricant, and sterile gauze or cotton swabs.
• For cervical sampling: an adjustable-height couch, specula, a Cervex-Brush (broom), endocervical brushes, liquid-based cytology vials and packaging ^[6].
• For colposcopy: a permanent couch and colposcope, suitable sterile instruments set up separately for each person, colposcopic records software, and resuscitation equipment staff are trained to use ^[8].
• A private changing area, toilet, warm room, tissues and sanitary products; a cover sheet or gown so that she is undressed for no longer than necessary ^[3].

Consent to a gynaecological examination is not a formality. Under the Montgomery standard, the clinician must outline what is being offered and why, including the risks and implications of examination and of not examining, discuss alternatives, and check that the woman has understood before agreeing ^[1][11]. Consent is valid only when the woman is competent, informed and acting voluntarily, and she must be aware that she can withdraw it at any time ^[3]. Verbal consent is appropriate for an examination, and it should be documented; written consent is added when a procedure is planned ^[1].

Several practical points follow from this:

• Chaperone. A trained, impartial observer should be offered for every intimate examination, regardless of the clinician's gender, and the offer and response recorded with the chaperone's name and role ^[2][3][4]. The RCOG regards the presence of a chaperone as essential for every pelvic examination ^[1]. A chaperone should be trained for the role, familiar with the procedure or briefed in advance, able to stay for the whole examination and to see what is being done, sensitive and alert to distress, and willing to raise concerns ^[2]. A relative or friend is not an impartial observer and is not usually a suitable chaperone, but a request for a support person to be present as well should be met where reasonable ^[2][4]. If no suitable chaperone is available, the examination may be delayed if the delay would not harm the patient ^[2]; the Royal College of Nursing advise that professionals should also consider having a colleague present to protect both parties ^[3].
• Communication. Explain before each step what you are about to do, how it will feel, and that it should not hurt but may be uncomfortable; tell her she can ask you to stop at any time, and check at intervals that she is still comfortable ^[2][3][11].
• Privacy and dignity. Provide privacy for disrobing, limit nudity to the minimum and time needed, use a sheet, and keep the room warm and well lit ^[3][5][6].
• Bladder. Ask her to empty her bladder first; an exception is when urethral sampling is needed before urination ^[5].
• Trauma-informed practice. Examination can be distressing after trauma or abuse; warn beforehand, move slowly, stop at any request, offer a support person and interpreter, and document any decline without judgement ^[1][3][11].
• Cultural and religious preferences, including the gender of the clinician and chaperone, should be asked about early ^[3][4].
• Allergies to latex and iodine should be checked before starting, because they determine which gloves and which colposcopy reagents can be used ^[3].

A good history is structured and gentle. Begin with the woman's own words, then systematically cover:

• Bleeding. Last menstrual period, cycle length and regularity, heavy or prolonged periods, intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding, and whether bleeding is related to contraception or hormone use.
• Discharge and infection. Onset, colour, odour, itching, dysuria; sexual partners, sexually transmitted infection (STI) risk and barrier contraception use; contraception (including intrauterine device fitting dates and threads).
• Pain. Cyclical pelvic pain, dysmenorrhoea, dyspareunia, deep dyspareunia, non-cyclical pain, and pain related to bowel or bladder.
• Pregnancy. Gravidity, parity, miscarriages, terminations, and current pregnancy or fertility plans; last cervical screen and result; previous abnormal smears or colposcopy.
• Past and family history. Previous gynaecological surgery, pelvic infection, endometriosis, fibroids, cancers, and family history of breast, ovarian, colorectal or endometrial cancer; bleeding disorders.
• Menopause. Age at menopause, vasomotor symptoms, vaginal dryness, hormone therapy use.
• Systemic and bladder or bowel symptoms, including change in bowel habit, abdominal distension, weight loss and fatigue.
• Social and cultural context, including support, work, caregiving, and preferences about the examination.

Red flags that should never be dismissed: postmenopausal bleeding; bleeding after intercourse or between periods that is new or persistent; heavy or prolonged bleeding in an older woman; pelvic mass or ascites; unexplained weight loss, appetite change or bowel habit change; urinary frequency with an adnexal mass; and fever with pelvic pain.

The examination starts with rapport, a general medical assessment, and an abdominal examination for masses, tenderness, distension, hernias and scars. Note pubic hair and facial or axillary hair distribution, which can be informative. Ask her to void first ^[5]. When she changes, be clear where clothes go and keep the door or curtain closed.

Inform her that the examination is beginning. Inspect the mons pubis, labia, clitoris, vestibule, urethral meatus, introitus, perineum and perianal area for swellings, erythema, rashes, lesions, ulcers, nodules, discharge or prolapse. Gentle palpation can characterise a mass or tenderness, and nodules can be captured between thumb and index finger ^[1]. Note labial development and symmetry. Then ask her to bear down to look for prolapse of the vaginal walls or uterus ^[5].

The speculum examination inspects the vagina and cervix. Lubricate the blades with water or water-soluble lubricant, avoiding the tip so that cervical cells are not contaminated when a sample is taken ^[6]. Hold the speculum in the palm with the blades between the index and middle fingers so that they stay closed, spread the labia and apply gentle downward pressure at the posterior introitus ^[5]. Insert the blades about 45 degrees off the midline directed posteriorly toward the sacrum, then rotate to the upright position and advance to full length; gentle downward pressure during insertion protects the urethra ^[5]. In the dorsal or left lateral position, both are acceptable and the woman can choose ^[6].

Once inserted, place the inferior blade in the posterior fornix and open carefully until the cervix is cupped. The cervix appears as a smooth, firm bulge against the rugated vaginal mucosa ^[5]. Record:

• position, size and colour of the cervix;
• the external os (circular or slit-like);
• lesions, erosions, polyps, cysts, ulcers, bleeding or discharge;
• whether the SCJ and transformation zone are visible, and their type.

If the cervix is hard to find, withdraw slightly, reposition and reopen, and a bimanual examination can help locate it ^[5].

Any foreign body is noted and removed, purulent discharge prompts sampling for infection, and a mass concerning for malignancy needs colposcopy and biopsy rather than a screening sample ^[5]. During removal, release the blades, withdraw slightly open to inspect the vaginal walls for inflammation, discharge or lesions, then close at the introitus ^[5].

Cervical sampling is taken while the speculum is still in place, after visualising the cervix. In the English programme, the cervical screening test is primarily an HPV test on a liquid-based sample; cytology is performed if HPV is positive. The woman should usually be screened regularly from the age of 25 to 64 (invitation from 24.5 years in the English programme; every 5 years in England, Scotland and Wales; in Northern Ireland every 3 years at ages 25–49 and every 5 years at ages 50–64, although RCOG patient information describes Northern Ireland screening as every 3 years) ^[6][11][13]; samples can be delayed during pregnancy and taken again from about 3 months after the end of pregnancy ^[11]. ^[6][8]

The whole transformation zone must be sampled: CIN can develop anywhere in the vaginally exposed columnar epithelium, and the part of the TZ next to the SCJ is the most vulnerable. If the SCJ is visible, the sample must include the whole circumference of the SCJ and the adjacent 1 centimetre of squamous epithelium; if the SCJ lies in the endocervical canal and is not visible, cells from the canal as well as the ectocervix must be included ^[6]. The laboratory cannot be certain from cellularity alone that the whole circumference was sampled, so the sample taker must visualise and sample the whole TZ ^[6].

To take the sample with a Cervex-Brush (broom) ^[6]:

1. Insert the central bristles into the endocervical canal so that the shorter outer bristles fully contact the ectocervix.
2. Using pencil pressure, rotate 5 times clockwise, beveling the plastic fronds so they splay against the cervix; apply firm pressure for the whole of the 5 rotations. ^[6]
3. Place the broom, as it is, into the fixative vial and push it to the bottom with a vigorous swirling motion at least 10 times, forcing the bristles apart; pass any remaining material over the rim of the vial, make sure the material reaches the liquid, tighten the cap so the torque lines meet, shake if needed, label, and rinse any second (endocervical) brush in the same vial. ^[6]
4. Fix the sample at once, before removing the speculum, to achieve immediate fixation.

An additional endocervical sample is considered only in limited circumstances, such as a tight or stenosed os, follow-up of borderline endocervical changes, or follow-up after treated endocervical glandular disease; it is taken with an endocervical brush inserted into the os with the lower bristles visible, rotated one full turn clockwise, and fixed in the same vial with the reason documented on the request form ^[6]. When a wide ectropion is present, a second brush may be used to sweep the TZ ^[6].

Do not take a cervical sample ^[6]:

• during menstruation;
• less than 3 months after a birth;
• less than 12 weeks after a miscarriage or termination of pregnancy; ^[6]
• if infection or discharge is present, treating first;
• and leave 3 months after any procedure that disturbs the cervix (hysteroscopy, IUD insertion or removal) so the epithelium regenerates ^[7].

If the cervix cannot be visualised, refer to colposcopy rather than attempting blind sampling ^[6]. Postmenopausal atrophy can be managed with a short course of intravaginal oestrogen, stopped 48 hours before sampling; if an IUD is present, take care not to tangle or remove the threads ^[7]. Bleeding on sampling is common, especially from columnar epithelium, and is not alone evidence of disease ^[10].

Samples must be sent the same day with 3 minimum identifiers on the vial and form (full name, date of birth and NHS number or address); they are dispatched in a leak-proof manner ^[7].

Lubricate the index and middle fingers of the dominant hand and insert them gently, directing pressure posteriorly with the thumb abducted to avoid the urethra and clitoris ^[5]. The non-dominant hand is placed on the lower abdomen in the suprapubic region. Locate the cervix and move it slightly to assess position, consistency, mobility, cervical motion tenderness and nodularity ^[5]. Then place the internal fingers beneath the cervix while the abdominal hand presses down and inward, grasping the uterus between the two hands to assess size, shape, mobility and tenderness ^[5]. An enlarged uterus with irregular contours suggests leiomyoma; marked tenderness suggests endometriosis or pelvic inflammatory disease; poor mobility suggests adhesions or malignancy ^[5]. A retroverted uterus may be better assessed by rectovaginal examination. Palpate each adnexa in turn by moving the pelvic hand to the lateral fornix and the abdominal hand to the corresponding quadrant, attempting to sweep structures into the pelvic hand; record size, shape, mobility and tenderness, and remember that normal ovaries are often not palpable ^[5]. Withdraw the internal fingers gently at the end ^[5].

This is often omitted, so it must be discussed explicitly beforehand. It allows palpation of the uterosacral ligaments, rectovaginal septum, posterior cul-de-sac, adnexa and a retroverted uterus. The lubricated third finger is inserted into the rectum as the patient bears down, with the index finger in the vagina; both are used to palpate posterior structures, with downward pressure from the abdominal hand ^[5]. Inspect the rectal circumference on withdrawal for masses, mucus or blood.

Record the examination findings (external, speculum, bimanual, rectovaginal), the sampling performed, the cervical appearance, and any abnormality and referral decision. Ask whether she has questions, offer time to recover and dress in private, and arrange results and follow-up ^[8].

After cervical sampling, the results should reach the woman, usually within 14 days in the English programme, with a failsafe system to ensure no result is missed and no referral delayed ^[7]. After colposcopy, she is told what was done and how and when results will be given; biopsy results should be communicated within 4 weeks for at least 90 percent of women, and all within 8 weeks ^[8]. After colposcopy outpatient treatment she should avoid tampons for 4 weeks, avoid vaginal intercourse for 4 weeks, and avoid swimming for 2 weeks; treatment is tailored to her circumstances and more extensive excision may be needed ^[8]. She should be given written information, allowed time to ask questions, and have her history taken with an interpreter where needed ^[8]. ^[6]

Colposcopy is a magnified, illuminated examination of the cervix, vagina and vulva, used to look for precancer and cancer after an abnormal screen; it is not a screening test and it is usually no more uncomfortable than a smear test, although a biopsy can cause brief cramping pain. It is performed by a colposcopist certified through the BSCCP and Royal College of Obstetricians and Gynaecologists (RCOG) scheme, in a dedicated clinic with certified staff, audited against national standards ^[8].

The standard steps are ^[12]:

1. Introduce yourself and the team, discuss the referral, explain the assessment and possible procedures, and obtain written consent if treatment is planned; allow time for questions.
2. Guide the woman to the changing area, position her on the colposcopy couch, and explain each step.
3. Inspect the vulva, then insert a lubricated speculum of appropriate size and visualise the cervix; assess the vagina and cervix before applying any solution.
4. Take any required screening samples using the appropriate device.
5. Remove excess mucus with normal saline, apply 5 percent acetic acid to the entire cervix (waiting about a minute for acetowhitening to develop), and inspect with appropriate magnification; use the green filter to enhance vascular patterns, and record the SCJ, TZ size and type, any lesion, acetowhite density, punctuation or mosaicism, and endocervical canal involvement. ^[12]
6. Apply Lugol's iodine if needed to demarcate the treatment zone.
7. If biopsy is required, explain, take samples from the most abnormal areas (often more than one), and apply Monsel's solution or silver nitrate to control bleeding.
8. Withdraw the speculum, guide her to change and recover, then discuss findings and follow-up and provide information before leaving.

An IARC-based description of the same procedure includes a panoramic inspection at low magnification, examination of vessels with a green or blue filter, application of 3 to 5 percent acetic acid to the cervix for about 1 minute, and application of Lugol's iodine with inspection for staining ^[12]. In the NHSCSP, the cervix and SCJ must be wholly visible for the examination to be called adequate, and the examination is documented against the IFCPC 2011 nomenclature, including the type of transformation zone (type 1, 2 or 3) ^[9].

Acetic acid causes dysplastic cells to dehydrate and turn white ("acetowhite"), revealing areas of abnormal epithelium and allowing the examiner to map the transformation zone; abnormal vessels appear more clearly after it has pooled and then receded. Lugol's iodine stains normal glycogen-containing squamous epithelium brown; immature or dysplastic epithelium does not take up the stain, producing a yellow "Schiller-positive" area that helps demarcate the treatment zone ^[12].

Punch biopsy is taken whenever a recognisably atypical transformation zone is present and when cytology is high grade; multiple biopsies are commonly taken. Adequate biopsies should be suitable for histological interpretation in at least 90 percent of cases, and an inadequate directed biopsy is repeated when a residual lesion remains ^[9]. Excision is recommended instead of or in addition to punch biopsy when most of the ectocervix is replaced by high-grade change, when low-grade colposcopic change accompanies severe dyskaryosis or worse, when a lesion extends into the endocervical canal, or when cytology suggests invasive disease or glandular neoplasia; in these situations punch biopsy is not considered reliably informative and excision is performed in over 95 percent of such cases ^[9].

The depth of excision depends on the type of transformation zone: more than 7 millimetres for a type I zone (aiming for under 10 millimetres in women of reproductive age), 10 to 15 millimetres for type II, and 15 to 25 millimetres for type III ^[9]. Treatment is performed with adequate pain control after counselling, usually under local anaesthetic, with reasons for general anaesthesia recorded; at least 85 percent (target 90 percent) of individuals should be managed as outpatients under local anaesthetic ^[9].

Ablative treatment (for example cryocautery using a double freeze-thaw-freeze technique for low-grade CIN) is only suitable when the whole transformation zone is visible, no glandular abnormality or invasive disease is suspected, cytology and histology agree, there is no postcoital or intermenstrual bleeding, no gland crypt involvement or previous treatment, and only rarely in women over 50 ^[9]. At first-visit "see and treat" clinics, local analgesia and treatment may be offered to women with high-grade referrals, but not for hrHPV positive and cytology-negative or low-grade referrals unless the abnormality is long-standing; at least 90 percent of those treated at the first visit should have CIN2, CIN3 or CGIN on histology, and treatment at first visit for hrHPV-positive low-grade referrals is not recommended because of the risk of unnecessary treatment ^[9].

The colposcopist must have the woman's screening results before starting, and should not repeat a screening sample at the first colposcopy after referral for cytological abnormality or hrHPV positive and cytology negative results ^[9]. All women who are hrHPV positive with abnormal cytology are referred to colposcopy, as are those who remain hrHPV positive with negative or inadequate cytology at 24 months ^[9]. Referral is urgent for suspicious appearances or symptoms consistent with cervical cancer (2-week targets apply in the English programme) ^[10]. The positive predictive value of a colposcopic impression of high-grade disease is at least 75 percent in women referred with high-grade cytology and at least 35 percent for all other referrals ^[9].

High-grade CIN is treated promptly, within 4 weeks of the biopsy report for at least 90 percent of women and at most within 8 weeks (except in pregnancy), and conservative management of CIN2 is offered only when the colposcopy is adequate and has excluded CIN3 and invasive disease, the lesion occupies no more than 2 quadrants of the cervix, histology has been reviewed at a multidisciplinary team meeting (MDT), and 6-monthly follow-up is agreed; treatment must be offered if the CIN2 has not resolved within 24 months ^[9]. Glandular abnormalities (CGIN/SMILE) are assessed and treated with excision including the endocervical canal, and all cases are discussed at the MDT ^[9]. ^[10]

After treatment, women are recalled at 6 months; if HPV-negative they are returned to routine recall in 3 years, and if positive they are referred back to colposcopy. Treated women are 2 to 5 times more likely than the general population to develop cervical cancer, so compliance with follow-up must be encouraged ^[9]. Only about 5 percent of histological treatment failures should occur within 12 months of treatment ^[9].

• Discomfort and vasovagal episodes: reassure, stop, lower the head of the couch and monitor. Examination should not be painful; if it is, stop and reassess.
• Pain or bleeding after biopsy is expected and can be controlled with pressure or Monsel's solution; heavy bleeding is uncommon.
• Infection after sampling is rare.
• Inadequate sample (reported by the laboratory) requires repeat sampling in about 3 months.
• False reassurance: a normal screening result only means low current risk; it does not prevent all cancers, so symptoms still matter.
• Psychological harm: embarrassment, anxiety or re-traumatisation can be minimised by preparation, consent, chaperones and sensitive communication.
• Cervical stenosis after repeated excision can make future sampling or pregnancy assessment more difficult and is part of consent before treatment.

• Pregnancy. Cervical screening is not normally performed during pregnancy; the program still invites women, and a test due in pregnancy can be deferred to about 3 months after delivery ^[11]. Colposcopy in pregnancy is reserved for suspected cancer and is usually observational, with treatment deferred unless invasive disease is suspected; the NHSCSP gives specific pathways for these cases.
• Postmenopausal women. Atrophic change can make examination and sampling uncomfortable and can lead to inadequate samples; use a small speculum, gentle technique and, where appropriate, a short course of intravaginal oestrogen stopped 48 hours before sampling ^[7].
• Adolescents. Be especially careful with consent, capacity, confidentiality and explanation; screening does not begin before the programme age.
• Women with previous trauma or sexual violence. Offer control, transparency, a support person, an interpreter, and the option to defer; document refusal respectfully.
• Trans and non-binary people. Use the person's own terms, and remember that anyone with a cervix may need screening and examination, regardless of gender identity.
• Older and frail women. Colposcopy or treatment under general anaesthetic may be preferable when examination is not tolerated, and treatment must be individualised.
• Immunocompromised women. They may require more frequent colposcopic follow-up; programme guidance sets out specific pathways.

• A pelvic examination, speculum and cytology or HPV testing can be performed with basic equipment; the priority is a warm, private space, a variety of speculum sizes, good lighting and safe waste disposal.
• Acetic acid (5 percent, freshly prepared) and a hand magnifier can be used for visual inspection with acetic acid (VIA) where colposcopy is unavailable, with treatment offered on the same visit where feasible; WHO guidance supports screen-and-treat approaches.
• Colposcopy and loop excision require a colposcope, trained staff and electricity; when unavailable, refer early and treat bleeding, infection and obvious masses.
• Always ensure that a sample taker, examiner or counsellor is the same person who takes responsibility for results and referral; a broken failsafe is more harmful than an imperfect test.
• Lubricant and atrophic change can be managed with water and, where available, local oestrogen.

• History comes first: most gynaecological diagnoses are made from what the woman reports.
• Every intimate examination needs specific consent and an offer of a trained, impartial chaperone, with both documented.
• Privacy, warmth, explanation and the freedom to stop at any time are clinical, not cosmetic, duties.
• The examination runs external, speculum, bimanual, then rectovaginal only if indicated; each step has a diagnostic purpose.
• Sampling the whole transformation zone, rotating the Cervex-Brush 5 times clockwise and fixing immediately, is what makes a sample adequate.
• Cervical screening in the English programme is a primary HPV test from age 25 to 64, with cytology added when HPV is positive.
• Colposcopy is a magnified examination after acetic acid; it is diagnostic, and treatment is guided by the transformation zone type and histology.
• High-grade CIN must be treated within weeks, and treated women need a test of cure and long-term follow-up.
• Red flags (postmenopausal, postcoital and intermenstrual bleeding, masses, systemic symptoms) must trigger prompt referral, not reassurance.
• Adapt the examination for pregnancy, menopause, trauma, disability and low-resource settings rather than abandoning it.

Plain-text related topics include: abnormal uterine bleeding, vaginitis and vaginal discharge, pelvic organ prolapse and incontinence, polycystic ovary syndrome, endometriosis, uterine leiomyoma, cervical cancer and screening, ovarian cancer and adnexal masses, pelvic inflammatory disease, contraception and intrauterine systems, menopause and hormone therapy, sexual health and STIs. These MedGrasp topic links are listed as plain text until the corresponding pages are verified.