Learning Objectives
By the end of this section, you will be able to:
- Identify the information needed for a comprehensive health history for persons AFAB
- Discuss the components of a wellness exam for persons AFAB
- Perform nursing actions to promote well care in specific populations of persons assigned female at birth
A wellness exam, also known as a preventive care visit or annual gynecologic exam, is essential to a person’s health. It involves comprehensively assessing a person’s overall health and reproductive system. The wellness exam is an excellent opportunity to engage in preventive health care, identify health issues early, and receive guidance on maintaining optimal health throughout life. It is important to tailor the exam to each person’s needs and to provide a supportive and comfortable environment for discussing sensitive topics. This section will review a reproductive wellness exam and address special populations. Trauma-informed care will also be discussed.
History and Physical Wellness Examination of Persons Assigned Female at Birth
A wellness exam for persons AFAB allows for health promotion and disease prevention. The exam, sometimes called an annual exam or gynecologic exam, is performed by a health-care provider specialized in care of the person AFAB or by a primary care provider. The components of the exam are dependent upon the person’s age, sexual activity, and medical history. The wellness exam is a time for open communication between the health-care provider, nurse, and patient. It is an excellent opportunity for nurses to educate patients and encourage a healthy lifestyle.
Health History
A comprehensive health history is a critical component of a wellness exam. It helps health-care providers gain insights into the patient's overall health, identify risk factors, and tailor health-care recommendations. The components of a health history for a wellness exam are described in Table 3.15.
| Component | Specifics |
|---|---|
| Personal information |
|
| Chief complaint/Reason for visit |
|
| Medical history |
|
| Gynecologic history |
|
| Reproductive health |
|
| Medications and supplements |
|
| Allergies |
|
| Immunization history |
|
| Social history |
|
| Psychosocial history |
|
| Review of systems |
|
| Preventive health measures |
|
| Occupational and environmental exposures |
|
| Special considerations |
|
| Safety considerations |
|
The health history provides a foundation for a well-person exam, helping the health-care provider to tailor the examination, screening tests, and counseling to the individual’s health needs and concerns. It is essential for fostering a patient-provider partnership and ensuring a comprehensive approach to care.
Sexual History
The sexual history is an important part of a comprehensive health assessment, especially during discussions about sexual health, reproductive health, and the risk of sexually transmitted infections (STIs). Nurses should approach this topic sensitively, ensuring a nonjudgmental and confidential environment. The sexual history may include the components outlined in Table 3.16.
| Components | Specifics |
|---|---|
| Sexual orientation and gender identity | Openly asking about a person's sexual orientation and gender identity helps create a supportive and inclusive environment. |
| Current sexual activity | Inquire about the individual's current sexual activity, including vaginal, anal, and oral sex. |
| Number of sexual partners | Asking about the number of sexual partners helps assess the risk of STI transmission. |
| Type of sexual partners | Inquiring about the gender of sexual partners helps the nurse to understand the individual's risk of specific STIs and pregnancy. |
| Contraceptive or menopausal hormone use | Discussing the use of contraception, including condoms, birth control pills, intrauterine devices (IUDs), or other methods, will help in assessing the risk of unintended pregnancies. Discuss the use of menopausal hormone therapy to determine the improvement in perimenopausal or menopausal symptoms. |
| History of STIs | Inquire about past or current STIs to assess the individual's risk and need for testing and partner notification. |
| History of HIV testing | Ask about previous HIV testing and the frequency of testing. |
| Use of barrier methods | Discuss the use of condoms or dental dams to prevent STI transmission. |
| Exposure to risky sexual behaviors | Discuss risky behaviors, such as unprotected sex, sharing needles, or sex under the influence of drugs or alcohol. |
| History of sexual assault or abuse | Inquire about any history of sexual assault or abuse to provide appropriate support and care. |
| Sexual satisfaction and concerns | Ask about sexual satisfaction, concerns, or any issues affecting sexual health. |
| Reproductive plans | Inquire about plans for family planning, including desires for pregnancy or contraceptive needs. |
| Education and counseling | Provide education on sexual health, STI prevention, and contraceptive options. |
| Practicing safer sex | Encourage the practice of safer sex and discuss strategies to reduce the risk of STIs and unintended pregnancies. |
| Offering STI testing and vaccination | Based on the individual's sexual history and risk factors, offer STI testing and vaccination, such as HPV vaccination. |
Just as the health-care provider uses the results of the health history to help focus the general health screenings, they will use the sexual history to determine the possibility of sexual health risks. Table 3.17 shows how components of the patient’s sexual history suggest the possible need for screening or other tests.
| History Component | Potential Health Risks |
|---|---|
| Unprotected penetrative sex | Risk: Unprotected vaginal or anal intercourse without using condoms or other barrier methods can lead to the transmission of STIs, including HIV, chlamydia, gonorrhea, syphilis, and herpes. Prevention: Using condoms or dental dams can significantly reduce the risk of STI transmission. |
| Multiple sexual partners | Risk: Having multiple sexual partners increases the likelihood of exposure to different STIs, and it can also complicate partner notification and treatment in case of infection. Prevention: Practicing mutual monogamy or using condoms with each sexual encounter can reduce the risk. |
| Oral sex | Risk: Engaging in oral sex without using barriers (e.g., condoms or dental dams) can lead to the transmission of STIs, such as herpes, gonorrhea, syphilis, and HPV. Prevention: Using condoms or dental dams during oral sex can reduce the risk of STI transmission. |
| Anal sex | Risk: Unprotected anal intercourse can result in the transmission of STIs, including HIV, gonorrhea, chlamydia, and hepatitis. Prevention: Using condoms with plenty of water-based lubricants can reduce the risk of STI transmission during anal sex. |
| Sharing sex toys | Risk: Sharing sex toys without proper cleaning or using condoms on them can lead to the transmission of STIs. Prevention: Cleaning sex toys thoroughly between uses or using condoms on sex toys can reduce the risk. |
| Substance use during sex | Risk: Substance use, particularly alcohol and drugs, can impair judgment and increase the likelihood of engaging in risky sexual behaviors, leading to unprotected sex and higher STI transmission risk. Prevention: Practicing safe sex and avoiding substance use during sexual encounters can minimize risks. |
| Consent and communication | Risk: Engaging in sexual activities without clear and enthusiastic consent from all parties involved can lead to emotional and psychologic harm. Prevention: Open and honest communication about boundaries, desires, and consent is crucial for healthy sexual experiences. |
Physical Examination
The annual physical examination is essential to preventive health care and involves a comprehensive assessment of overall health and well-being. The specific components of the annual physical exam may vary based on the person's age, medical history, and risk factors. The exam allows health-care providers to identify health issues early, offer counseling, and promote overall wellness.
Trauma-Informed Physical Exam
A trauma-informed examination is a compassionate and sensitive approach to providing health care for those who may have experienced trauma. It acknowledges the potential impact of trauma on a person's physical and emotional health and aims to create a safe and supportive environment for the patient during the examination (Gorfinkel et al., 2021). The fundamental principles and considerations for conducting a trauma-informed gynecologic examination are listed in Table 3.18.
| Components of Trauma-Informed Care | Explanation of the Components |
|---|---|
| Establishing safety and trust | Prioritize creating a safe and comfortable environment for the patient. Begin the examination by explaining the process and obtaining informed consent. Ensure the patient knows they can stop or pause the exam anytime if they feel uncomfortable or triggered. |
| Respecting autonomy and empowerment | Recognize that trauma survivors may have varying levels of comfort with medical procedures and intimate examinations. Always ask for permission before proceeding with any part of the examination and offer options for the patient to feel more in control of the process. |
| Trauma-sensitive language and communication | Use trauma-sensitive language and avoid using medical jargon that might be intimidating or confusing to the patient. Communicate clearly and compassionately, and actively listen to the patient's concerns and preferences. |
| Providing information and explanation | Give the patient clear explanations of each step of the examination. Let them know what to expect and why each procedure is important for their health. Providing information and explanation helps reduce anxiety and empowers patients to participate in their health care actively. |
| Avoiding triggering situations | Be mindful of potential triggers during the examination. Trauma survivors may have specific triggers related to touch, invasive procedures, or certain body positions. Respect their boundaries and be flexible in modifying the examination to avoid retraumatization. |
| Recognizing signs of distress | Be attentive to nonverbal cues and signs of distress during the examination. If the patient appears uncomfortable or anxious, check in with them and offer support or a break if needed. |
| Offering support and resources | Be prepared to provide information about trauma support resources, counseling services, or support groups if the patient expresses a need for additional help in dealing with trauma-related issues. |
| Cultural sensitivity | Be aware of cultural factors that may influence the patient's response to the examination. Cultural beliefs and practices may impact their comfort level and understanding of health-care procedures. |
| Collaborative decision making | Involve the patient in decision making about their health care, including screening tests, treatment options, and follow-up care. Collaborative decision making empowers patients to make choices aligned with their values and preferences. |
A trauma-informed gynecologic examination recognizes the importance of sensitivity and empathy in providing health care to people who have experienced trauma. By incorporating these principles into the examination, health-care providers can create a supportive and respectful environment that promotes the well-being of trauma survivors and enhances the overall patient experience (Gorfinkel et al., 2021).
Pelvic Exam
The gynecologic exam is a crucial part of preventive health care for persons AFAB and is performed to evaluate gynecologic health, identify any abnormalities or conditions, and assess for signs of potential reproductive issues. A gynecologic or pelvic exam (Table 3.19) is a comprehensive assessment of a person's reproductive and pelvic health. A chaperone, such as a nurse or medical assistant, will be in the room during this part of the exam to help the patient feel comfortable and nonthreatened.
| Components | Examination |
|---|---|
| External examination | The provider visually inspects the external genitalia for any changes in appearance, such as rashes, lumps, or lesions. |
| Speculum examination | The provider inserts a speculum into the vagina to visualize the cervix and the walls of the vagina. This allows them to check for any abnormalities, such as inflammation, infections, or cervical abnormalities. During the speculum examination, the provider may collect cells from the cervix using a small brush or spatula. These cells are then sent to a laboratory for analysis to screen for cervical cancer or detect precancerous changes, and the presence of high-risk HPV. |
| Bimanual examination | The provider inserts one or two gloved fingers into the vagina while gently pressing on the lower abdomen with the other hand. This bimanual examination allows them to assess the uterus and the ovaries' size, shape, and position. They also check for any tenderness or masses. The provider assesses the pelvic floor muscles by asking the patient to squeeze the muscles around the inserted fingers. |
| Rectovaginal examination (optional) | Sometimes, the provider may perform a rectovaginal examination by inserting one gloved finger into the vagina and another into the rectum. This examination allows them to assess the back of the uterus and check for any abnormalities in the rectovaginal septum. |
Physiologic Changes in the Reproductive Stages
As a person AFAB ages, many changes occur to their body. A person AFAB will begin to see changes to their body during puberty. Their body also changes during pregnancy and postpartum. As a person progresses through menopause, even more changes occur. Nurses can educate their patients on what to expect during these different life stages.
Puberty and Menarche
Puberty is defined as “the process of physical maturation where an adolescent reaches sexual maturity and becomes capable of reproduction” (Breehl & Caban, 2023, p. 1). Puberty is associated with breast growth, development of pubic hair, menarche, and increase in height. The growth of breasts is called thelarche. The growth of pubic hair is called pubarche. The first menstrual period is menarche. Table 3.20 describes the development of the person AFAB during puberty.
| Development | Description of Development |
|---|---|
| Thelarche (breast growth) | Breast growth is the first sign of puberty; occurs at approximately age 9 to 10. |
| Pubarche (pubic hair growth) | The growth of pubic hair occurs approximately 6 months after the start of thelarche; begins with light, straight hair, then grows into coarse, dark hair. |
| Menarche (first menstrual period) | Menarche usually occurs 1–3 years after thelarche; average age is 12.8 years. First ovulation is normally 6–9 months after the first period. |
| Ovarian growth | Ovaries increase in size from 0.5 cm to 4.0 cm |
| Uterine growth | Uterus grows in length and thickness. |
| Labial growth | Both labia minora and majora increase in size. |
Nurses provide anticipatory guidance to patients as they go through puberty. Nurses can help patients understand the changes they see occurring in their body.
Link to Learning
HealthyWomen provides health information for “women in the middle” (ages 35 to 64). Their video called Breast Changes across the Lifespan discusses and demonstrates the changes in breasts as they develop from prepuberty to menopause.
Perimenopause and Menopause
Physical changes occur during perimenopause and menopause due to the decrease in estrogen, progesterone, and testosterone. The walls of the arteries stiffen, muscles lose flexibility and strength, and cataracts grow on the lenses of the eyes. During this stage, the vaginal walls are thinner, drier, pale, have less elasticity, and can be irritated during sexual intercourse (Jacobson et al., 2022). These changes increase the risk for vaginal infections, such as candidal infections. Urinary changes are also seen, including urinary incontinence and increased urinary tract infections as the pelvic floor relaxes, causing prolapse of the uterus or bladder. A decrease in breast tissue is also noted. The skin loses elasticity and becomes more prone to injury and bruising. Wrinkles and small skin tags can be seen. Due to loss of bone mass, some menopausal persons will have a rounding of the upper back called kyphosis (Figure 3.12). Health-care providers will assess for these changes and discuss the extent to which these changes affect the patient’s life.
Link to Learning
Let’s Talk Menopause is a nonprofit organization focused on education and advocacy surrounding menopause.
Gerontologic
As people age, several gerontologic changes can affect the reproductive tract. These changes may require modifications to the history and physical examination. For example, as a transgender woman ages, their body can experience benign prostatic hyperplasia, and they will need a health-care provider to perform a digital rectal exam to assess the prostate gland. Persons AFAB will need screening for osteoporosis after the age of 65 due to the loss of bone during menopause. Table 3.21 lists examples of physiologic changes throughout the lifespan.
| Puberty | Perimenopause | Postmenopause | |
|---|---|---|---|
| Age | Younger (8–16 years) for menarche transition | Typically, age 40s but can begin earlier or later | Average age of 51 but can begin earlier or later |
| Hormones | Erratic fluctuations Follicles present in the ovaries, but regular ovulation may not occur for a few years |
Decline in the number of oocytes Fluctuations in FSH Fluctuations in estrogen, progesterone, and LH |
Cessation of ovarian follicular activity Persistently elevated FSH Decrease in estrogen and progesterone |
| Menstruation | Begins approximately 2–2.5 years after the person reaches Tanner Stage 2 May be irregular for a few years |
Variability in the length of the menstrual cycle | Menopause marked by absence of periods for 12 months |
| Physical changes | Secondary sex characteristics Growth spurt |
Hot flashes, sleep difficulties, fatigue, mood changes, depression, vaginal dryness, dyspareunia Decreased bone density, increased urinary tract infections |
Perimenopausal symptoms and changes more persistent Thinning of skin, loss and or dryness of hair Loss of muscle mass |