Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic symptoms), tests to identify the disorder causing them (diagnostic procedures) may need to be done.
Screening Tests
Two important screening tests for women are
Cervical cell (cytology) testing, such as the Papanicolaou (Pap) test, or a human papillomavirus (HPV) test to check for cancer of the cervix (the lower part of the uterus)
Mammography to check for breast cancer
Women at risk of sexually transmitted infections (such as chlamydial infections or gonorrhea) should be screened for these infections. Other screening tests are done as part of care during pregnancy.
Screening for Cervical Cancer
Tests used to screen for cervical cancer include the following:
Papanicolaou (Pap) test: Cells from the cervix are examined under a microscope to determine whether any are cancerous or abnormal and may, without treatment, progress to cancer (precancerous cells).
Human papillomavirus (HPV) test: A sample from the cervix is tested to determine whether HPV is present. HPV can lead to cervical cancer.
In both the Pap test and HPV test, doctors collect a sample from the cervix. Doctors collect the sample by inserting a speculum (a metal or plastic instrument) into the vagina to spread the walls of the vagina apart and using a plastic brush to remove some cells from the surface of the cervix and from the passageway through the cervix (cervical canal). The samples are sent to a laboratory, where they are examined under a microscope to look for abnormal cells, which may indicate precancerous changes or, rarely, cervical cancer.
Usually, the Pap test feels scratchy or crampy, but it is not painful and takes only a few seconds.
Pap tests identify most cervical cancers, even very early-stage cancer. They can also detect precancerous changes in cervical cells. These changes, called cervical intraepithelial neoplasia (CIN), can be treated, thus helping prevent cancer from progressing and spreading.
Pap tests are most accurate if the woman is not having her period and does not douche or use vaginal creams for at least 24 hours before the test.
Experts now recommend that the first Pap test be done in most women after the age of 21 years. Women with an HIV (human immunodeficiency virus) infection may be tested at a younger age.
How often testing is needed depends mainly on the woman’s age and the results of previous Pap tests:
Under age 21: Screening not needed
From age 21 to 30: Testing is usually done every 3 years using a Pap test alone. HPV testing is optional and somewhat discouraged because HPV infection is common among young adult women and often goes away on its own.
From age 30 to 65: Testing is done every 3 years if only a Pap test is done or every 5 years if a Pap test and a test for HPV are done. However, women with a high risk of cervical cancer need to be tested more frequently. Such women include those who have an HIV infection, who have a weakened immune system (which may result from taking a drug or having a disorder that suppresses the immune system), or who have had abnormal Pap test results.
After age 65: Most women no longer need to be tested if they have had no abnormal test result in the last 10 years.
Pap tests in older women may be resumed or continued if a woman has a new sex partner or if she has several sex partners.
Women who have had their uterus completely removed (total hysterectomy) and have not had any abnormal Pap test results do not need to be screened for cervical cancer. However, if the hysterectomy left cervix in place, screening is needed. (The cervix is the lower part of the uterus that opens into the vagina.)
Screening for Sexually Transmitted Infections
Women at risk of sexually transmitted infections should be screened yearly for these diseases, even if they have no symptoms. At-risk women include the following:
Sexually active women aged 25 and younger
Women who are just beginning sexual activity
Women who have several sex partners
Women whose partner is bisexual or whose partner has had several sex partners
Women who have had a sexually transmitted infection
Women who do not consistently use a barrier contraceptive (such as a condom) and are not in a mutually monogamous relationship or are unsure whether the relationship is mutually monogamous
Pregnant women
Women who have a vaginal discharge
Women who think they may have a sexually transmitted infection can request screening.
For most sexually transmitted infections, the doctor uses a swab to obtain a small amount of cervical discharge from the cervix. The sample is sent to a laboratory for analysis. Testing for gonorrhea and chlamydial infection can also be done using a urine specimen or a sample from inside the vagina obtained by the woman with a swab.
A doctor may consider screening women for HPV if any of the following are present:
They are 30 years old or older.
A Pap test detected abnormalities that may result from HPV infection.
The results of a Pap test were not clear.
HPV can cause genital warts and may increase the risk of cervical cancer. A sample of vaginal discharge, obtained with a swab, is used for the HPV test. Normal results of an HPV test indicate that cervical cancer and precancerous conditions are highly unlikely. For women at high risk of HPV infection, the HPV test can be done at the same time as a Pap test. If results of a Pap test and an HPV test are normal in women older than 30, neither test needs to be repeated for at least 3 years.
Assessment of Fertility
If women are having problems with becoming pregnant, doctors may take a sample of mucus from cervix and examine it. Based on the appearance of the mucus, doctors may recommend additional tests to evaluate fertility fully.
Diagnostic Procedures
Occasionally, more extensive diagnostic procedures are needed.
Biopsy
A biopsy consists of removing a small sample of tissue for examination under a microscope. Biopsy of the vulva, vagina, cervix, or lining of the uterus can be done.
Cervix or vagina
A cervical biopsy is done when
A condition likely to eventually lead to cancer (precancerous condition) or cancer is suspected, usually because a Pap test result was abnormal.
A biopsy of the cervix or vagina is usually done during colposcopy. During colposcopy, doctors can identify the area that looks most abnormal and take tissue samples from it.
Vulva
A biopsy of the vulva (the area around the opening of the vagina) is done when
A diagnosis cannot be made based on the woman’s symptoms and results of a physical examination.
Cancer of the vulva is suspected.
Biopsy of the vulva can usually be done in the doctor's office and requires use of a local anesthetic.
Uterus
A biopsy of the lining of the uterus (endometrial biopsy) is usually done to
Determine the cause of abnormal vaginal bleeding
Check for cancer of the lining of the uterus (endometrial cancer) when this cancer is suspected
Also, infertility specialists use this procedure to determine whether ovulation is occurring normally and whether the uterus is ready for implantation of embryos.
For an endometrial biopsy (endometrial aspiration), a speculum is used to spread the walls of the vagina, and a small plastic tube is inserted through the cervix into the uterus. The tube is used to suction tissue from the uterine lining.
Colposcopy
For colposcopy, a speculum is used to spread the walls of the vagina and a binocular magnifying lens (similar to that of a microscope) is used to inspect the cervix for signs of cancer. Often, a sample of tissue is removed for examination under a microscope (biopsy).
Colposcopy is often done when
Results of a Papanicolaou (Pap) test are abnormal.
Women usually feel some discomfort when the speculum is inserted, but colposcopy alone (without biopsy) is painless and thus requires no anesthetic. The biopsy procedure is typically described as causing a crampy sensation and also does not require an anesthetic. The procedure usually takes 10 to 15 minutes.
Dilation and Curettage
For dilation and curettage (D and C), conscious sedation or a general anesthetic is usually used. (With conscious sedation, people can respond to directions but do not feel pain.) Then, a speculum is used to spread the walls of the vagina, and the cervix is widened (dilated) using thin rods of increasing size. Sometimes a drug is used to help dilate the cervix. Then a small, sharp, scoop-shaped instrument (curet) can be inserted to remove tissue from the lining of the uterus. Sometimes a plastic tube attached to a suction machine (suction curet) is used to remove tissue from the uterus.
D and C
After the speculum is in place, tapered curved metal rod (dilators—not shown) are used to stretch open the cervix so that the curet can be inserted into the uterus. The curet is used to remove tissue from the lining of the uterus. |
D and C may be used to treat women who have had an incomplete (partial) miscarriage. D and C is sometimes used to identify abnormalities of the uterine lining when biopsy results are inconclusive, but it is no longer commonly used for this purpose because biopsies usually provide as much information and can be done in the doctor’s office.
D and C is often done in a hospital. However, most women do not have to stay overnight in the hospital.
Endocervical Curettage
Endocervical curettage consists of inserting a small, sharp, scoop-shaped instrument (curet) into the passageway through the cervix (cervical canal) to obtain tissue. The curet is used to scrape a small amount of tissue from high inside the cervical canal. A cervical biopsy (to remove a smaller piece of tissue from the surface of the cervix) is typically done at the same time. The tissue samples are examined under a microscope by a pathologist.
Endocervical curettage is done when
Endometrial or cervical cancer is suspected or needs to be ruled out.
Usually, it is done during colposcopy and does not require an anesthetic.
Hysterosalpingography
For hysterosalpingography, x-rays are taken after a radiopaque contrast agent, which can be seen on x-rays, is injected through the cervix to outline the interior of the uterus and fallopian tubes.
Hysterosalpingography is often used to do the following:
To help determine the cause of infertility
To confirm that a sterilization procedure to block the tubes is successful
The procedure is done in a place where x-rays can be taken, such as a hospital or the radiology suite of a doctor's office.
Hysteroscopy
To view the interior of the uterus, doctors can insert a thin viewing tube (hysteroscope) through the vagina and cervix into the uterus. The tube is about 1/4 inch in diameter and contains cables that transmit light. Instruments used for a biopsy, electrocautery (heat), or surgery may be threaded through the tube. The site of abnormal bleeding or other abnormalities can usually be seen and can be sampled for a biopsy, sealed off using heat, or removed.
Hysteroscopy may be used to do the following:
To look for abnormalities inside the uterus when cancer of the uterine lining (endometrial cancer) is suspected
To look for abnormalities in the uterus (such as fibroids) if women are having problems becoming pregnant
To prevent pregnancy permanently by blocking or otherwise disrupting the fallopian tubes (sterilization)
Hysteroscopy may be done in a doctor's office, or it may be done in a hospital with a general anesthetic at the same time as dilation and curettage.
Laparoscopy
To directly examine the uterus, fallopian tubes, or ovaries, doctors use a viewing tube called a laparoscope. The laparoscope is attached to a thin cable containing flexible plastic or glass rods that transmit light.
The laparoscope is inserted into the abdominal cavity through a small incision just below the navel. A probe is inserted through the vagina and into the uterus. The probe enables doctors to manipulate the organs for better viewing. Carbon dioxide is pumped through the laparoscope to inflate the abdomen, so that organs in the abdomen and pelvis can be seen clearly.
Often, laparoscopy is used to do the following:
To determine the cause of pelvic pain, infertility, and other gynecologic disorders
To do some surgical procedures (such as biopsies, sterilization procedures, and removal of an ectopic pregnancy in a fallopian tube) using instruments threaded through the laparoscope
Laparoscopy can detect structural abnormalities too small to be detected by imaging, as well as abnormalities on the surfaces of organs, such as endometriosis (endometrial tissue outside the uterus), inflammation, and scarring.
Additional incisions may be required if surgical procedures, such as removal of an ovarian cyst or the uterus (hysterectomy), are needed.
Laparoscopy is done in a hospital and requires an anesthetic, usually a general anesthetic. An overnight stay in the hospital is usually not required. Laparoscopy may cause abdominal pain, but normal activities can usually be resumed in 3 to 5 days, depending on the extent of the procedure that is done through the laparoscope.
Loop Electrical Excision Procedure
In a loop electrical excision procedure (LEEP), a thin wire loop that conducts an electrical current is used to remove a piece of tissue. Typically, this piece of tissue is larger than that obtained in a biopsy of the cervix.
This procedure may be done after an abnormal Pap test result
To evaluate the abnormality more accurately
To remove the abnormal tissue (and thus treat early-stage cancer, including cervical cancer)
Pregnancy Testing
Most women who are of childbearing age and who have gynecologic symptoms are tested for pregnancy. Doctors take a sample of urine or sometimes blood from the woman and test it to determine whether she is pregnant.
These tests are more than 99% accurate.
Saline Sonography
For saline sonography (sonohysterography), fluid is placed in the uterus through a thin tube (catheter) that is inserted through the vagina and then the cervix. Then ultrasonography is done. The fluid fills and stretches (distends) the uterus so that abnormalities inside the uterus, such as polyps or fibroids, can be more easily detected.
Ultrasonography
Ultrasonography (sonography) uses ultrasound waves, produced at a frequency too high to be heard. The ultrasound waves are emitted by a handheld device that is placed on the abdomen (called abdominal ultrasonography) or inside the vagina (called transvaginal ultrasonography). The waves reflect off internal structures, and the pattern of this reflection can be displayed on a monitor.
Ultrasonography can detect the following:
Tumors, cysts, and other abnormalities in the internal reproductive organs (ovaries, fallopian tubes, uterus, and vagina)
Ultrasonography is commonly done during pregnancy for the following reasons:
To determine the condition and size of the fetus
To monitor the fetus
To guide the placement of instruments during amniocentesis or chorionic villus sampling
Ultrasonography is painless and has no known risks.
