Speculum Exam

Differentials

Presenting Feature	What might it be?	What might I find?
Unscheduled vaginal bleeding	Physiological	Irregular menses, oligomenorrhoea, spotting on ovulation. Bleeding pattern changes in perimenopausal women.
	Breakthrough bleeding	Common with hormonal contraception use e.g., when switching to new method or with extended use e.g., COCP. Speculum examination will be normal.
	Cervical ectropion	Associated with high oestrogen RF: pregnancy, COCP, younger age. May be asymptomatic or present with post-coital bleeding. Well-defined area of darker red, friable tissue around os.
	Cervical cancer	RF: young,UPSI, multiple partners, HPV+, HIV+, smoking. May be asymptomatic or picked up on routine screening. Post-coital or inter-menstrual bleeding, weight loss. Irregular, ulcerated, inflamed cervix, visible mass/tumour.
	Cervical polyp	RF: increasing age, multi-parity. Post-coital/inter-menstrual bleed, discharge, menorrhagia. Polyp seen protruding from cervical os.
	Infection	Common cause of unscheduled bleeding – see below.
	Pregnancy	Vaginal bleeding associated with pregnancy includes: Implantation bleed, early pregnancy bleeding, miscarriage, ectopic pregnancy. Investigation & management guided by dates, appearance of cervical os (open/closed) and USS findings.
Vaginal discharge	Physiological	Discharge in keeping with what is normal for the patient. Usually white/clear, thin, non-offensive smelling. Varies with menstrual phase, sexual activity, hormonal use.
	Candida	RF: pregnancy, diabetes, iatrogenic e.g., steroid, antibiotic. Vulvovaginal itch, discomfort, white cottage-cheese discharge, dysuria, dyspareunia.
	Bacterial vaginosis	RF: cu coil, excessive vaginal bathing, smoking, antibiotics. Up to 50% of infections are asymptomatic. Not an STI. Offensive fishy smelling, white-grey watery discharge.
	Chlamydia	Sexually transmitted, incr. risk if multiple partners, UPSI. May be asymptomatic but is still transmissible. Purulent discharge, dysuria, dyspareunia, PCB/IMB. Inflamed cervix, discharge, cervical motion tenderness.
	Gonorrhoea	Sexually transmitted, incr. risk if multiple partners, UPSI. May be asymptomatic but is still transmissible. Purulent discharge, dysuria, pelvic pain.

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the procedure and get consent
• Explain the presence and purpose of the chaperone

“I have been asked carry out a speculum examination. This involves inserting a plastic tube called a speculum into the vagina to look at the neck of the womb. You will feel some pressure and the cold jelly, but it should not be painful. You can ask me to stop at any time. There will be a chaperone present whilst I carry out this examination. Are you happy for me to do that?”

Ask the patient to undress from the waist down. Position the patient lying on the examination couch with knees drawn up to chest and ask the patient to let their legs relax apart so that their thighs are abducted. Cover the patient until you are ready to start the examination. 

Gather the equipment you will need for the examination including gloves, lubricating jelly and a speculum, ensuring you choose an appropriately sized speculum. Base this decision on the size of the patient, age, menopausal status, whether they are sexually active etc. Some patients may know which size speculum they require. Ensure you have a good source of light.

Speculum examination may be combined with vaginal swab taking in practice.

External Inspection

Put on gloves for the examination. Expose the patient and check they are comfortable. Inspect the external genitalia including labia majora, labia minora, clitoris and introitus as well as the perineum. Note the skin colour, is there any redness or breakdown of skin integrity; as well as any excoriation marks indicating sore or itchy vulval skin.

Examine the vulval area for:

• Hair distribution
• Ulceration
• Scarring e.g., lichen sclerosus or previous episiotomy
• Atrophic changes e.g., Thin, fragile, inflamed skin
• Lumps or swelling
• Bleeding or discharge

Look for any prolapse at the vaginal introitus. Ask the patient to bear down and cough and again observe for presence of prolapse which has appeared with increased intra-abdominal pressure. 

Be observant for any changes which raise suspicion for female genital mutilation (cut or missing part of genitalia). If suspected this needs urgent discussion with a senior. 

Speculum Exam

Apply lubricating jelly to the speculum blades. Ensure patient ready and part the labia with your non-dominant hand whilst placing the speculum at the vaginal introitus with your dominant hand with the blades closed and rotated so that the lock is facing to the left or right side. Slowly and gently advance the speculum, checking the patient is tolerating the examination and rotating the speculum 90° so that the lock is facing upwards. Gradually open the speculum blades and check if the cervix is visible.

If the cervix is visible, gently fully open the blades and turn the lock to secure the speculum in place. Keep your hand on the speculum so that it does not start to slide out with the blades open which could be painful for the patient. 

If the cervix is not visible, gently withdraw the speculum a small distance and reinsert as above. Some methods to try if it is difficult to find the cervix include:

• Ask the patient to make fists with their hands and place under their bottom
• Ask the patient to cough or bear down
• Ask the patient if they have ever been told that their cervix sits especially anterior/posterior/lateral 
• Take out the speculum and perform a vaginal examination to palpate the cervix and ascertain its location

Once the cervix is located, observe the following:

• Presence of foreign body e.g., Tampon
• Cervical appearance e.g., Is there any evidence of inflammation, ulceration, colour change, ectropion, cysts?
• Cervical os – open, closed, nulliparous (pinhole), multiparous (slit-like)
• Presence of coil threads
• Presence of any bleeding or discharge

Once you have examined the cervix, unscrew the lock and gently begin to withdraw the speculum, turning 90° so that the lock faces left or right as it did during insertion. As you remove the speculum, observe the vaginal walls for any abnormality e.g., mass, ulceration, prolapse, bleeding point etc.

Finishing

Thank the patient and allow them to cover themselves, offering them a paper towel to wipe away any excess lubricating jelly. Wash your hands.

Depending on the speculum examination findings you may wish to carry out a vaginal examination; or organise investigations including vaginal swabs, blood tests, or referrals for colposcopy or further imaging e.g., ultrasound scan.

Last updated Dec 2024

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