The Female Sex- and Gender-Specific History and Examination

The female gender-specific history and examination is the cornerstone to providing optimal health care for female patients. A comprehensive female gender-specific history includes the patient’s menstrual, obstetric, sexual, breast, and past medical history. A family history screens for evidence of inherited cancers and disorders, especially breast and ovarian, and the review of systems (ROS) in a female patient should include breast, gynecologic, and urologic symptoms which are often not emphasized in a generic ROS template. A female gender-specific examination includes a pelvic and clinical breast examination. A standard pelvic examination has three components: visual inspection of the external genitalia, speculum examination, and a bimanual examination. Providers should be aware of patient populations that may require increased sensitivity or adaptations of the standard technique, including adolescents, older adults, LGBT patients, patients with disabilities, and those with a history of sexual trauma, vulvodynia, or atrophic vaginitis. A standard clinical breast examination includes two major components: inspection and palpation. In this chapter, we will discuss components of a comprehensive female gender-specific history and detail indications and techniques for clinical pelvic and breast examinations.