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Gynecological Care

Posted February 2009

VII. GYNECOLOGICAL CARE

Recommendations:

Clinicians should obtain a baseline gynecological history for HIV-infected women (see Table 1).

Clinicians should perform a gynecological examination in women or refer them to a gynecologist at baseline and at least annually (see Table 2).

Clinicians should consider social, cultural, religious, or behavioral issues that may affect a woman’s willingness to undergo a complete pelvic examination, such as previous history of sexual assault, partial or complete female circumcision, genital mutilation, or infibulation.

Primary care clinicians should address women’s health issues in the provision of routine HIV care. See Women’s Health guidelines for more information on the clinical care of HIV-infected women. In addition to a comprehensive gynecological history and examination, clinicians should provide sexual risk-reduction counseling for all HIV-infected women (see Secondary Prevention of HIV Transmission, Section II: Prevention of Sexual Transmission).

Strategies that may help alleviate a woman’s concerns about undergoing a pelvic examination include the following: addressing the patient’s fears, explaining each step of the examination prior to performing it, using a smaller speculum, and/or postponing the pelvic examination until the patient becomes more acquainted with the clinician. Also, some women may prefer to be examined by a female clinician.

Table 1: Elements of a Gynecological History for HIV-Infected Women
  • Age of menarche
  • Menstrual history: frequency, duration, last menstrual period
  • Number of pregnancies and outcomes: full-term and premature births, miscarriages, terminations
  • Date of last Pap test and results
  • History of abnormal Pap tests
  • History of GYN procedures: LEEP, ablation, cone biopsy, hysterectomy, tubal ligation
  • History of STIs, bacterial vaginosis, multiple or difficult to treat vaginal yeast infections
  • Contraceptive use and needs
  • Genitourinary symptoms: vaginal discharge, vaginal pain, dysuria, genital/rectal warts or ulcers, bleeding

Table 2: Elements of a Gynecological Physical Examination for HIV-Infected Women
Breast Examination:

  • Examine for the following:
    - masses
    - nipple discharge
    - dimpling
    - enlargement
  • Refer women ≥40 for annual mammogram
Pelvic Examination:

  • Examine for the following:
    - friable cervix
    - venereal warts (HPV)
    - vaginal discharge
    - classic and atypical herpes simplex virus (HSV)
    - ulcerative genital disease
    - cervical motion tenderness

- lesions on the vulva or perineum

Perianal Examination

  • Examine for the following:
    - visible anal lesions (particularly HSV and/or HPV)
    - evidence of skin abnormality around the anus- Candida
    - hemorrhoids
  • Perform digital rectal examination (baseline and annually)
  • Refer women with abnormal anal physical findings for high-resolution anoscopy and/or examination with biopsy
Cytologic Screening
Cervical Cytology

  • Obtain cervical Pap test at baseline, 6 months after baseline, then annually as long as results are normal
  • Abnormal results should be repeated every 3 to 6 months until two successive normal Pap tests are reported
  • Perform colposcopy for women with abnormal Pap test results; follow-up varies on a case-by-case basis
  • Refer women with cervical HSIL for high-resolution anoscopy and/or examination with biopsy

Anal Cytology

  • Obtain anal Pap test for women with a history of anogenital condyloma or abnormal cervical/vulvar histology (baseline and annually)
  • Refer women with abnormal anal cytology for high-resolution anoscopy and possible biopsy
STI Screening*
Syphilis

  • RPR or VDRL with verification of reactive tests by confirmatory FTA-Abs or TP-PA (baseline and at least annually). Screen patients with continued high-risk behavior every 3 months.

Gonorrhea and Chlamydia

  • Screen all sites of exposure, including the cervix, rectum, and pharynx, as follows:
    - Sexually active women under the age of 25 at baseline and at least annually
    - Women 25 years of age or older if they have or have had a recent STI, have multiple sexual partners, have had a new sexual partner, or have a sexual partner with symptoms of an STI (baseline and at least annually)
  • Screen for gonorrhea using culture or nucleic acid amplification tests (NAT)
  • Screen for chlamydia using immunofluorescence or DNA amplification
*Patients who continue to engage in unsafe sexual practices are at increased risk for STIs. More frequent screening may be indicated for patients at higher risk.

 

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