Speculum self-insertion: an alternative method for gynaecological examination?

BACKGROUND: Speculum examination is an intrusive practice in the clinical care of women. It requires privacy and patients may experience discomfort or anxiety related to the procedure, which can result in delays or avoidance of necessary healthcare. Speculum self-insertion originated in the United States in the 1970s as part of the self-help movement. However, this clinical practice is largely unknown among healthcare providers and has rarely been assessed. AIM: This study investigates the women's views and healthcare providers' experiences of the self-insertion method. METHOD: A qualitative study was conducted between December 2021 and October 2022, including fieldwork combining semi-structured interviews (10 women) and focus groups associated with individual interviews of 13 healthcare providers. The data collected were independently coded by 2 authors and analysed using an inductive approach and grounded theory method. RESULTS: Speculum self-insertion was described as a way to decrease discomfort and facilitate speculum insertion. Self-insertion was proposed as a means of allowing women to participate in the examination, reducing their vulnerability against power imbalances in the doctor-patient relationship. Both patients and healthcare providers have reported that speculum self-insertion is a method that can contribute to improving trust and communication during the examination. CONCLUSION: The practice of speculum self-insertion during the consultation is an alternative to traditional practitioner insertion and may be offered to all women by any practitioner who wishes to use this technique.

The use of a speculum is common in gynaecological consultations and most women are likely to encounter this tool during a medical examination. Several studies have already shown that this examination can cause pain and anxiety. Speculum self-insertion is not widely used and consists of allowing the woman to insert the speculum herself while being assisted by the practitioner. A study was conducted with 10 women and 13 healthcare providers to evaluate this technique and its impact on women's healthcare. This technique reduces the discomfort that can be felt during the examination. The woman will regain control of her body during the examination and this technique will reduce the hierarchical relationship felt by some women. A discussion about the gynaecological examination and women's healthcare is created during the consultation. Even if this technique does not seem to be suitable for all women, routinely offering self-insertion allows the healthcare provider to adapt to each woman and to her choice. The proposal of speculum self-insertion is an alternative technique that can improves women's feelings and their overall health.

Do women with suspected endometriosis benefit from pelvic examination to improve diagnostic and management strategy?

OBJECTIVE: To analyze the literature and expose best evidence available regarding the benefit of pelvic examination for women with suspected endometriosis METHODS: the AGREE II and GRADE systems for grading scientific evidence. RESULTS: Endometriosis is characterized by the heterogeneity in its clinical presentation with many different symptoms reported by patients. In the literature, questioning for each symptom has a high sensitivity, reaching 76-98 %, but lacks specificity (20 - 58 %). The symptom-based approach is limited by its low specificity, the absence of external validation for most of the models developed and the inability to characterize the extent of the disease, which could have major implications in the decision - making process. The latest systematic review and meta-analysis included a total of 30 studies with 4,565 participants, compared the diagnostic performance of several modalities for endometriosis. Physical examination had a pooled sensitivity of 71 % and a specificity of 69 %, with an average diagnostic accuracy of 0.76. Overall, the value of pelvic examination is conferred by its high positive likehood ratio and specificity. Besides its diagnostic value, pelvic examination improves patients' management by allowing the identification of a possible myofascial syndrome as a differential diagnosis. It also increases the quality of the preoperative workup and influences the quality of surgical excision and decreases the time to diagnosis. CONCLUSION: Despite the lack of studies in the primary care context, pelvic examination (vaginal speculum and digital vaginal examination) increases the diagnostic value for suspected endometriosis in association with questioning for symptoms.

Frequency of digital vaginal examination and associated factors among mothers admitted to labor and delivery wards in public health facilities of Arba Minch town, southern Ethiopia.

OBJECTIVE: To assess the frequency of digital examination and its associated factors among laboring mothers in public health facilities in Arba Minch town, southern Ethiopia. Digital vaginal examination (DVE) is the commonly applied clinical assessment method used to discover the progress of labor and delivery. However, frequent DVE may not be free of risk for maternal and neonatal health, and pain during intrapartum care. METHODS: An institution-based descriptive cross-sectional study was employed from May 3 to July 6, 2022. Study participants were selected by a serial sampling method. Data were entered into epi data version 7.2 and exported to SPSS v.25 for data analysis. Binary and multivariate logistic regression analyses were employed to assess associations between study variables. Statistical significance was declared at a P value less than 0.05. RESULTS: A total of 374 women responded to the interview, making a response rate of 98.4%. In all, 230 (61.5%) of the laboring mothers underwent five or more DVE. Being a primipara, being in latent phase at admission, having augmentation of labor, prolonged labor, being admitted with intact membranes, and vacuum delivery showed significant associations with frequent DVE. CONCLUSION: Frequency of DVE among laboring mothers is relatively high in the study area. The frequent DVE were mainly caused by healthcare provider's interventions to shorten the time of labor. Emphasis on training and monitoring the practice of healthcare givers would be helpful to mitigate this problem.

Understanding Medical Students' Concerns about Explicit Informed Consent for Pelvic Exams Under Anesthesia.

BACKGROUND: Medical student involvement in procedures, including pelvic exams under anesthesia (EUAs), is a fundamental part of medical education. While guidelines exist regarding informed consent for medical student participation, there is ongoing debate and uncertainty regarding the requirement and modality of obtaining explicit consent for pelvic EUAs. This study aims to explore the perceptions and experiences of medical students who do not favor an explicit informed consent process for pelvic EUAs. METHODS: An anonymous online questionnaire was distributed to third- and fourth-year medical students at the University of Pittsburgh School of Medicine who had completed their obstetrics and gynecology core clerkship. The questionnaire included both quantitative and qualitative sections. Qualitative analysis was conducted using a mixed inductive and deductive coding approach, with key patterns, categories, and themes identified through content analysis. RESULTS: Among the 201 students included in the analysis, 50 students did not endorse an explicit informed consent process for pelvic EUAs. Themes that emerged from their open-ended responses included: (1) the belief that medical student involvement is implicitly included in patient agreements at teaching hospitals; (2) the perception that pelvic EUAs are an essential first step in gynecologic surgery; (3) the view that pelvic EUAs are comparable to other medical procedures; (4) concern that explicit consent would limit educational opportunities; and (5) the belief that pelvic EUAs are not harmful or traumatic to patients. DISCUSSION: The findings highlight the justifications provided by medical students who do not support explicit informed consent for pelvic EUAs. While some arguments align with previous ethical analyses, this study provides empirical and qualitative insights into students' perspectives. The belief that patients implicitly consent to medical student involvement at teaching hospitals warrants further examination, as patient awareness and understanding may vary. The differentiation between pelvic exams and other EUAs, as well as the perception of minimal harm, should be critically evaluated in the context of trauma-informed care and patient autonomy. Furthermore, the interconnectedness of educational and surgical aspects of pelvic EUAs should be clarified in patient-physician communication. CONCLUSION: Understanding the perspectives of medical students who do not favor explicit consent for pelvic EUAs is crucial for developing and implementing consent processes. The findings emphasize the need for enhanced patient-physician communication, standardized frameworks for learner involvement, and curricular adaptations to address patient perceptions and trauma-informed care. Future research should explore these themes in larger and more diverse cohorts to inform best practices in obtaining informed consent for medical student participation in pelvic EUAs.

Incidence of Abnormal Findings During Pelvic Examinations in Women Aged 21-35 Years.

To describe the incidence of abnormal gynecologic examination findings in asymptomatic compared with symptomatic patients during preventive visits, we conducted a retrospective study of 1,121 visits for patients between the ages of 21 and 35 years from January 2017 to March 2017. Only 1.2% (95% CI, 0.5%,1.9%) of asymptomatic patients had abnormal findings on pelvic examination, compared with 32.4% (95% CI, 27.0%, 37.8%) of those with symptoms ( P ≤.001). In symptomatic patients, the most common symptoms were vaginal discharge (25.1%), pelvic pain (16.4%), and vaginal bleeding (15.7%). In asymptomatic patients, the most common findings were bacterial vaginosis and Candida infection. Asymptomatic patients presenting for a routine preventive visit have low rates of abnormalities detected on examination, and routine pelvic examinations should be re-considered.

A gynaecological examination could have prevented a long and painful diagnostic work-up of a patient with hymen imperforatus.

Haematocolpos, caused by imperforate hymen, is a rare condition where menstrual blood accumulates in the vagina. Adolescent girls presenting with amenorrhoea, cyclical abdominal pain, and pelvis mass should be evaluated for this condition. Diagnosis requires a gynaecological examination. However, myths surrounding the hymen may impede proper medical care. Addressing these misconceptions is essential for promoting gynaecological care and ensuring timely evaluation and treatment. This case report emphasises the significance of effective communication in preventing misdiagnoses and care delays.

Consent Policies for Pelvic Exams Under Anesthesia Performed by Medical Students: A National Assessment.

Background: Medical students report low confidence in their ability to perform pelvic exams. Pelvic exams under anesthesia (EUA) are one way for students to practice the exam, but this needs to be balanced with patients' bodily autonomy through explicit disclosure and consent. This study seeks to characterize U.S. medical schools' policies regarding the consent process for students to perform pelvic EUA. Materials and Methods: Obstetrics and gynecology clerkship directors were anonymously surveyed about their medical school affiliated hospitals' (MSAH) consent policies for pelvic EUA in general and explicitly for medical students. Chi-square and Fisher's exact test were used to test for differences between categorical variables and thematic analysis was used to review qualitative responses. Results: A total of 87 clerkship directors completed the survey (44.4% response rate). Most MSAH explicitly consent patients for pelvic EUA (80.2%), and specifically for performance by medical students (79.1%). Sixty-nine respondents (79.3%) stated that performing pelvic EUA is important for medical student education. Five themes were identified from review of qualitative responses, including consent policy details, the importance of pelvic EUA, other opportunities for pelvic exam teaching, barriers to standardization, and outside guidance. Conclusions: The pelvic EUA is a necessary part of both surgical care and medical education but patient dignity must be protected too. Most MSAH have consent policies for students to perform pelvic EUA. Still, these policies need to be further strengthened and standardized across institutions to protect patients' rights while continuing to teach students the pelvic exam.

New method of video-assisted vaginoscopy in Nellore heifers.

Vaginoscopy allows an intravaginal endoscopic evaluation and can help in the diagnosis of female bovine genital tract disorders. The aim of this study is to validate a new method of gynaecological examination using a Scope VOR&GDI videovaginoscope. Twenty-six heifers were used, divided into 2 groups with 13 animals, control group (GC) and videovaginoscopic group (GV). In the CG, vaginoscopy was performed with a vaginal speculum and in the GV with a Scope VOR&GDI videovaginoscope. All heifers underwent vaginoscopy on day 0 (D0), and 9 days later, on day 9 (D9). Vaginoscopy provided adequate intravaginal inspection. In the CG, 23% (3/13) of the heifers showed discomfort during the test. In GV, vaginal inspection was better due to better image quality. The videovaginoscope is the most effective equipment for carrying out the vaginoscopy procedure in Nellore heifers, as it produces sharper and clearer images and can help in the diagnostic and therapeutic routine of veterinarians.

Improving visualization of the cervix during pelvic exams: A simulation using a physical model of the speculum and human vagina as a steppingstone to reducing disparities in gynecological cancers.

Pelvic exams are frequently complicated by collapse of the lateral vaginal walls, obstructing the view of the cervix. To overcome this, physicians frequently repurpose a glove or a condom as a sheath placed over the speculum blades to retract the lateral vaginal walls. Despite their regular use in clinical practice, little research has been done comparing the relative efficacy of these methods. Better visualization of the cervix can benefit patients by decreasing examination-related discomfort, improving cancer screening accuracy, and preventing the need to move the examination to the operating room under general anesthesia. This study presents a physical model that simulates vaginal pressure being exerted around a speculum. Using it, we conduct controlled experiments comparing the efficacy of different condom types, glove materials, glove sizes, and techniques to place gloves on the speculum. The results show that the best sheath is the middle finger of nitrile-material gloves. They provide adequate lateral wall retraction without significantly restricting the opening of the speculum. In comparison, condoms provide a smaller amount of retraction due to loosely fitting the speculum. They may still be a reasonable option for a different speculum size. However, vinyl-material gloves are an impractical option for sheaths; they greatly restrict speculum opening, occasionally even breaking the speculum, which overcome its retraction benefits. Glove size, condom brand, and condom material (latex vs polyisoprene) had minimal impact. This study serves as a guide for clinicians as they use easily accessible tools to perform difficult pelvic exams. We recommend that physicians consider nitrile gloves as the preferred option for a sheath around a speculum. Additionally, this study demonstrates proof-of-concept of a physical model that quantitatively describes different materials on their ability to improve cervical access. This model can be used in future research with more speculum and material combinations, including with materials custom-designed for vaginal retraction.

Simulation training for pelvic examination: A systematic review.

OBJECTIVE: Pelvic examination including vaginal digital examination and speculum inspection are crucial medical skills that are challenging to teach for both professors and students, because of its intimate nature. Consequently, education has shifted from a traditional approach to a simulation-enhanced education. This literature review summarizes the level of evidence for these not-so-new training modalities. METHODS: For this systematic review, the Pudmed database have been consulted using the following keywords: (Pelvic examination OR Vaginal examination) AND simulation. Eligible studies had to be published in French or English within the past 20 years and investigate simulation training for pelvic examination in the field of gynecology and obstetrics. For each paper, the following outcomes were analyzed: Competence, confidence and communication, and were classified according to the Kirkpatrick hierarchy. RESULTS: About competence, in initial training, one meta-analysis (9 studies of which 4 randomized studies) about pelvic examination teaching on procedural simulators have shown a significant benefit of simulation. One meta-analysis and one systematic review also demonstrated that Gynecological Teaching Associates (GTAs) teaching, who exist in Northern America and Scandinavian countries, was better that pelvic task trainers in terms of technical competence, and comfort. For the vaginal examination of women in labor, two randomized trials also showed a positive impact of pelvic task trainer on students' accuracy. CONCLUSION: Simulation-enhanced education of pelvic examination brings a significant benefit in comparison to a classic education without simulation in terms of competence, confidence and communication. GTAs have the best impact on competence and communication, but they do not exist currently in France. Hybrid simulation (a patient actor combined with a pelvic task trainer) could be a solution to teach both technical skills and communication.

Primary extracranial meningioma of the pelvis discovered on screening pelvic examination.

Many conditions that affect a woman's health can be evaluated through the pelvic examination. Early detection and treatment of a range of gynaecologic and non-gynaecological conditions, including unusual pelvic masses, may decrease a woman's morbidity and mortality. Here, we have a female patient in her early 20s who was found to have a mass on her first screening pelvic examination. Subsequent imaging followed by surgical resection were performed with the final diagnosis of a pelvic meningioma. Routine pelvic examinations in asymptomatic women may be more useful than merely screening for cervical cancer and sexually transmitted infections. Once detected, the differential diagnosis of a pelvic mass may include aetiologies outside of the gynaecological organ system.

The importance of gynecological examination in adolescent girls and adult women with Prader-Willi syndrome.

Current published guidelines for routine care of women with Prader-Willi syndrome (PWS) do not include recommendations for gynecologic examinations. We describe our experience with gynecological examinations in women with PWS and offer recommendations for routine health care for these patients. Data were collected on all 41 PWS females ages ≥12 year, followed in our national Israeli multidisciplinary clinic between the years 2011 and 2022. Menstrual data and findings on external gynecological examination, including evaluation of the vulva and hymen were recorded at yearly visits. During the gynecological evaluation the topic of sexual education was discussed. Pelvic ultrasound, specifically for antral follicular count, was performed for those visiting the clinic during 2020-2022. Blood samples for luteinizing hormone (LH), follicular stimulating hormone (FSH), and estradiol were obtained routinely and DEXA scans for bone density were done when indicated. Of the 41 women, (median age at start of follow-up 17 years, range [12.3-39], BMI 30.4 kg/m2 [IQR 23.5-37.1]), 39 women agreed to external gynecological examination. Eleven women (27%) had spontaneous menses, with menarche at the age of 14 to as late as 31 years. The hymen was intact in all except one. Poor hygiene was observed in eight women, three women with vulvovaginitis, and five with irritated vulva related to poor hygiene. Gynecological ultrasound was performed in 27 women. In 22, endometrial thickness was less than 5 mm. The median antral follicular count (AFC) was 6 (<10th percentile for age). No correlation between AFC and menstruation or BMI was found. Mean FSH level was 5.7 ± 3.6 IU, LH was 2.29 ± 2.23, and estradiol was 128 ± 76 pmol/L. Data on DEXA measurements were available in 25 women aged 16-39. Median spine T score was -1.3 (range between 0.5 and -3.7), and hip T score was -1.2 (range between 0.8 and -3.3). A negative correlation was found between endometrial thickness and the presence of osteopenia or osteoporosis (r = -0.5, p = 0.013). Despite our recommendations, only eight of 14 women agreed to hormonal treatment or contraception. One woman who received treatment had a thromboembolic event. Routine health care for women with PWS should include gynecological examinations. The gynecological evaluation should include external genital examination, assessment of hygiene, obtaining a blood sample for hormone levels, and documenting a history of sexual experience or sexual abuse. Hormonal treatment or contraception should be offered when appropriate.

Exploring women's experiences, views and understanding of vaginal examinations during intrapartum care: A meta-ethnographic synthesis.

OBJECTIVE: To conduct a systematic review exploring women's experiences, views and understanding of any vaginal examinations during intrapartum care, in any care setting and by any healthcare professional. Intrapartum vaginal examination is deemed both an essential assessment tool and routine intervention during labour. It is an intervention that can cause significant distress, embarrassment, and pain for women, as well as reinforce outdated gender roles. In view of its widespread and frequently reported excessive use, it is important to understand women's views on vaginal examination to inform further research and current practice. DESIGN: A systematic search and meta-ethnography synthesis informed by Noblit and Hare (1988) and the eMERGe guidance (France et al. 2019) was undertaken. Nine electronic databases were searched systematically using predefined search terms in August 2021, and again in March 2023. Studies meeting the following criteria: English language, qualitative and mixed-method studies, published from 2000 onwards, and relevant to the topic, were eligible for quality appraisal and inclusion. FINDINGS: Six studies met the inclusion criteria. Three from Turkey, one from Palestine, one from Hong Kong and one from New Zealand. One disconfirming study was identified. Following both a reciprocal and refutational synthesis, four 3rd order constructs were formed, titled: Suffering the examination, Challenging the power dynamic, Cervical-centric labour culture embedded in societal expectations, and Context of care. Finally, a line of argument was arrived at, which brought together and summarised the 3rd order constructs. KEY CONCLUSIONS AND IMPLICATIONS OF PRACTICE: The dominant biomedical discourse of vaginal examination and cervical dilatation as central to the birthing process does not align with midwifery philosophy or women's embodied experience. Women experience examinations as painful and distressing but tolerate them as they view them as necessary and unavoidable. Factors such as context of care setting, environment, privacy, midwifery care, particularly in a continuity of carer model, have considerable positive affect on women's experience of examinations. Further research into women's experiences of vaginal examination in different care models as well as research into less invasive intrapartum assessment tools that promote physiological processes is urgently required.

Adherencias del capuchón del clítoris al glande: una condición poco estudiada y poco examinada / Clitoral hood adhesions to the glans penis: an understudied and under-examined condition

INTRODUCCIÓN: El clítoris es una de las estructuras vulvares menos examinadas, pese a su relevancia en la vida sexual y sus importantes relaciones anatómicas. Las adherencias del capuchón del clítoris han sido descritas y clasificadas según la exposición del glande, siendo relacionadas con trastornos del deseo sexual. La inervación del clítoris depende de raíces de S3-S4, siendo posible que síntomas frecuentes del piso pélvico tengan relación con esta condición. Realizamos un análisis retrospectivo de pacientes de policlínico de piso pélvico entre noviembre de 2021 y abril de 2022. Se incluyeron 100 pacientes con adherencias al ingreso. RESULTADOS: Promedio de edad 45,8 ± 15,5 años. Las adherencias fueron el 19% leves, el 62% moderadas y el 18% graves. Los principales síntomas eran mal vaciado vesical (38%), dolor (28%), disfunción sexual (39%) y síntomas irritativos vesicales (43%); solo una paciente fue asintomática. El área visible promedio del clítoris era de 20,7 ± 13,7 mm2. CONCLUSIONES: Las adherencias del capuchón del clítoris son un hallazgo común, muchas veces no diagnosticadas, por lo que su evaluación debe ser parte de la exploración física. Pueden asociarse a sintomatología de piso pélvico.

INTRODUCTION: The clitoris is one of the least examined vulvar structures despite its relevance in sexual life and important anatomical relationships. Clitoral hood adhesions have been described in the literature, classified based on glans exposure, and related to sexual desire disorders. The innervation of the clitoris depends on the roots of S3-S4, and frequent pelvic floor symptoms may be associated with this condition. We retrospectively analyzed the clinical record of patients admitted to a pelvic floor clinic between November 2021 and April 2022. One hundred patients with adhesions at the time of admission were registered. RESULTS: Average 45.8 ± 15.5 years. Clitoral hood adhesions were mild (19%), moderated (62%), or severe (18%). The main symptoms were voiding dysfunction symptoms (38%), pain (28%), sexual dysfunction (39%), and irritative bladder symptoms (43%); only one patient was asymptomatic. The visible area of the clitoris was 20.7 ± 13.7 mm2. CONCLUSIONS: Adhesions of the clitoral hood are often undiagnosed, and its analysis should be part of the physical exam. Clitoral hood adhesions could be associated with pelvic floor symptoms.

Omission of Pelvic Examination Before Gender-Affirming Hysterectomy and Vaginectomy.

Surgeons may be performing pelvic examinations on transgender patients before gender-affirming pelvic surgery (hysterectomy and vaginectomy) without a clinically significant indication. A retrospective cohort study was conducted at a single-institution academic referral center comparing 30-day perioperative outcomes of all 62 gender-affirming pelvic surgeries, including hysterectomy alone, hysterectomy with vaginectomy, and vaginectomy alone, between April 2018 and March 2022. More than half (53.2%, n=33) of the 62 patients did not have an in-office, preoperative, internal pelvic examination within 1 year of gender-affirming surgery. There were no significant differences in patient characteristics nor 30-day perioperative outcomes between the examined and examination-omitted groups, suggesting that omission of a preoperative pelvic examination is probably safe before gender-affirming hysterectomy and vaginectomy, minimizing barriers to gender-affirming surgical care.

Danish women's preferences regarding gynecological examination support international recommendations: A cross-sectional study.

OBJECTIVE: Gynecological examinations (GEs) are challenging for many women. Several recommendations and guidelines have emerged, partly based on common sense and clinicians' consensus. However, there is a lack of knowledge regarding women's opinions. Therefore, this study aimed to describe women's preferences and experiences in relation to GEs and investigate whether they are dependent on their socioeconomic status. METHODS: In Denmark, GEs are typically performed by general practitioners or resident specialists in gynecology (RSGs) in gynecological hospital departments. This cross-sectional questionnaire and register study included approximately 3000 randomly selected patients who visited six RSGs from January 1, 2020, to March 1, 2021. The main outcome measurement involved women's preferences and experiences regarding GEs. RESULTS: Overall, 37% of the women thought that a changing room was important, 20% preferred a garment to cover themselves, 18% preferred a separate examination room, and 13% thought that the presence of a chaperone was important. Compared with working and retired women, more women outside the workforce felt insufficiently informed, considered their experience with RSGs unprofessional, and found GEs painful. CONCLUSION: Our results support existing recommendations regarding GEs and the related environment, confirming that privacy and modesty are factors to take into consideration as they are of concern for a relatively large group of women. Thus, providers should focus on women outside the workforce, because this group appears to feel vulnerable in this environment.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]. / Examen pelvien en gynécologie et obstétrique : recommandations pour la pratique clinique.

OBJECTIVE: To provide guidelines for the pelvic clinical exam in gynecology and obstetrics. MATERIAL AND METHODS: A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature. CONCLUSIONS: The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.