Cervical screening — HPV test, CST pathway, colposcopy referral

Overview

Conducting intimate examinations with skill, sensitivity, and professionalism is a core competency for Australian general practice. Pelvic examination, cervical screening, and clinical breast examination are among the most common procedures performed in a GP clinic. Each carries a medico-legal and ethical dimension that is inseparable from clinical technique. The GP must be technically proficient, obtain genuine informed consent, and create an environment in which patients feel safe to disclose concerns and control the pace of the encounter.

Ethical and Medico-Legal Framework

Informed Consent

• Consent for intimate examinations must be explicit, verbal (documented), and ongoing: patients retain the right to stop the examination at any point.
• Explain the purpose, what the examination involves (including the possibility of discomfort), and what findings may be sought before starting.
• Document consent in the medical record, including the offer and outcome of the chaperone discussion.
• Consent obtained before anaesthesia for an intimate examination should ideally be in writing.

Chaperone Policy

• A chaperone should routinely be offered for all intimate examinations; this protects both patient and clinician.
• Ideally the chaperone is a trained female staff member. Record the chaperone's name in the notes.
• If the patient declines a chaperone, document the offer and the patient's decision.
• If a chaperone cannot be provided for practical reasons, explain this and offer to reschedule where clinically safe to do so.
• Male GP students and doctors must have a female chaperone when performing gynaecological or breast examinations.

Privacy and Dignity

• Use a lockable or clearly private room; do not lock the patient in but ensure clinic staff do not interrupt.
• Provide a drape or modesty sheet; give the patient privacy to undress and dress independently unless assistance is explicitly requested.
• Avoid unnecessary personal comments; keep all discussion clinically relevant.
• Patients who have experienced sexual trauma, abuse, or assault require exceptional sensitivity. Do not assume all patients who express difficulty with pelvic examinations have a trauma history, but remain alert to verbal and non-verbal distress signals throughout.

Pelvic Examination

Indications

Bimanual and speculum examination is indicated for:

• Abnormal vaginal discharge
• Intermenstrual or postcoital bleeding
• Postmenopausal bleeding
• Pelvic pain, dyspareunia
• Assessment of a pelvic mass
• Cervical screening (speculum component)
• Investigation of suspected sexually transmitted infection (STI)

Contraindications/caution: Intact hymen or prepubertal patient (examination under anaesthesia preferred if clinically essential); ectopic pregnancy suspected (bimanual examination may precipitate rupture).

Preparing the Patient

1. Explain the procedure clearly and answer questions before starting.
2. Ask about the possibility of pregnancy.
3. Offer a chaperone and document the decision.
4. Ask the patient to empty their bladder.
5. Provide a drape and ask the patient to remove underwear and lie in the modified lithotomy position: supine, heels drawn toward the buttocks, knees apart.
6. Ensure bright, directed illumination of the perineum.
7. Wear gloves on both hands throughout.

The left lateral (Sims) position (knees drawn up, patient on left side) is an alternative when the patient cannot adopt the supine position, or when visualisation of the anterior vaginal wall is required (e.g. suspected urinary fistula).

External Genitalia Inspection

• Inspect labia majora and minora, clitoris, urethral meatus, introitus, and perineum.
• Note: ulcers, warts, skin changes, discharge, atrophy, evidence of female genital mutilation (FGM), or structural abnormality.

Speculum Examination

Ectropion: a ring of reddened columnar epithelium around the external os is a common, normal finding, particularly in younger women and those on the combined oral contraceptive pill; do not over-investigate unless symptomatic.

Bimanual Examination

1. Apply small amount of lubricant gel to gloved fingers.
2. Insert index and middle fingers of the dominant hand into the vagina.
3. Place the non-dominant hand on the lower abdomen.
4. Palpate the cervix: assess size, consistency, mobility, and cervical excitation (tenderness on movement, suggesting pelvic inflammatory disease or ectopic pregnancy).
5. Palpate the uterus: size, position (anteverted, retroverted), shape, consistency, mobility, tenderness.
6. Palpate adnexa: move fingers into each lateral fornix and press toward the abdominal hand to assess ovaries and tubes; note masses, tenderness, or fullness.

Cervical Screening

Australian National Cervical Screening Program (NCSP)

From December 2017, Australia replaced the 2-yearly Pap smear with a 5-yearly cervical screening test (CST) using liquid-based cytology (LBC) and primary HPV testing.

Who Needs to Be Screened

• Women who have been sexually active (any type of intercourse); same-sex relationships do not exclude HPV transmission risk.
• Transgender men with a cervix should be offered screening with attention to cultural and physical barriers (atrophic changes, dysphoria).
• History of HPV vaccination does not reduce frequency; vaccinated individuals still require 5-yearly CST.
• Post-hysterectomy: vaginal vault cytology only if hysterectomy was performed for cervical dysplasia (high-grade); otherwise no further screening required.

Performing the Cervical Screening Test

1. Use a broom-type collection device (Cervex-Brush or similar).
2. Insert the central bristles into the endocervical canal and rotate five times clockwise.
3. Rinse the brush into the liquid-based cytology vial by pushing and rotating; cells are preserved in preservative fluid.
4. Label the vial immediately with patient identifiers; complete the pathology request including LMP, contraception, and relevant history.
5. Avoid lubricant gel on the cervix prior to cell collection (use water or collect cells before applying gel).

Interpreting Results and Follow-Up

Referral to colposcopy is arranged via gynaecology or a colposcopy clinic. GPs should document the result clearly and establish an active recall system to ensure follow-up.

Special Situations

• Pregnancy: CST can be performed during pregnancy if overdue; colposcopy should be performed by an experienced colposcopist; treatment for CIN is deferred until postpartum unless invasive cancer is suspected.
• Postmenopausal/atrophic changes: Topical oestrogen for 4-6 weeks may improve sample adequacy; inform the pathologist of menopausal status.
• Immunocompromised patients (HIV, solid organ transplant, long-term immunosuppression): Annual CST recommended; lower threshold for colposcopy referral.

Clinical Breast Examination

Role in Australian General Practice

Clinical breast examination (CBE) is not part of the Australian BreastScreen national screening program (which uses mammography). However, CBE is indicated when:

• A patient presents with a breast symptom (lump, pain, nipple discharge, skin change)
• As part of a focused women's health assessment
• To assess a palpable abnormality identified by the patient or on imaging

CBE alone is not a substitute for mammographic screening and should not be used as a primary screening tool in asymptomatic women.

Preparation

• Explain the procedure; obtain consent; ensure a chaperone is available.
• Patient should undress to the waist with a sheet available for modesty.
• Examine in two positions: sitting upright (arms at sides, then raised above head, then hands pressed on hips to contract pectorals) and supine (arm on the examined side behind the head).

Inspection

Inspect both breasts systematically:

• Symmetry and contour: asymmetry, visible lumps, distortion
• Skin: dimpling (tethering), peau d'orange (oedema from lymphatic obstruction), erythema, ulceration
• Nipple: inversion (new-onset), retraction, deviation, Paget's disease changes (eczematous changes to the nipple-areola complex)
• Arms raised accentuates tethering; pectoral contraction accentuates attachment to chest wall

Palpation

1. Use the flat of the fingers (pads of index, middle, and ring fingers), not the fingertips.
2. Use a systematic pattern: concentric circles, radial, or vertical strip technique; cover the entire breast including the axillary tail of Spence.
3. Axillary lymph nodes: support the patient's arm with your non-dominant hand and palpate the anterior, posterior, medial, and apical nodal groups.
4. Supraclavicular nodes: examine from behind the patient.
5. If a lump is found, assess:

Nipple Discharge Assessment

• Bilateral, multi-duct, non-bloody: most commonly physiological or medication-related (antipsychotics, metoclopramide); check prolactin.
• Unilateral, single-duct, bloody or serous: refer; exclude intraductal papilloma or malignancy.
• Galactorrhoea not attributable to recent pregnancy/breastfeeding: check prolactin, TFTs, medication review, pituitary MRI if prolactin elevated.

Referral Criteria (Breast Lump)

Any of the following warrant urgent referral to a breast surgeon or breast clinic:

• Any new discrete lump in a woman $\geq 40$ years
• Any lump with hard consistency, irregular borders, or fixation
• Skin tethering or nipple changes associated with a lump
• Unilateral bloody or serous nipple discharge
• Axillary lymphadenopathy associated with a breast symptom
• Paget's disease of the nipple
• In younger women ($< 35$ years): discrete firm lump not resolving after one menstrual cycle; any clinically suspicious feature

BreastScreen Australia offers free 2-yearly mammographic screening for women aged 50-74 years (women aged 40-49 and 75+ may self-refer but are not actively invited).

Sensitive Populations and Special Circumstances

Survivors of Sexual Trauma or Abuse

• Acknowledge before the examination that some women find intimate examinations difficult; invite the patient to share any concerns.
• Do not assume that difficulty with pelvic examination indicates a trauma history, but remain alert.
• Allow maximum patient control: positioning, pacing, stopping at any time.
• Consider referral to a practitioner with specific trauma-informed care skills if examinations are consistently distressing.

Female Genital Mutilation (FGM)

• Enquire sensitively as part of the gynaecological history when relevant.
• Document type (WHO classification I-IV) without making assumptions about cultural background.
• In some cases, speculum examination or CST may require a smaller speculum, topical anaesthetic, or referral to a specialist clinic.
• De-infibulation prior to cervical screening may be required; refer to a gynaecologist with FGM expertise.

Transgender and Gender-Diverse Patients

• Affirm the patient's gender identity throughout the encounter.
• Transgender men with a cervix require cervical screening; testosterone-induced atrophy may complicate speculum examination (topical oestrogen may help).
• Adapt examination language and documentation to the patient's preferences.

GP Clinic Considerations

• Maintain an active recall system for cervical screening (MyHealthRecord integration; practice recall software).
• MBS item numbers apply to cervical screening tests and clinical examinations; ensure correct billing.
• Use the RACGP Red Book recommendations for preventive screening intervals to guide proactive patient outreach.
• Refer to the National Cervical Screening Program guidelines (managed via NCSP) for management pathways.
• Document all examinations contemporaneously: findings, consent, chaperone, and any patient concerns or communication needs.
• If an abnormal finding is identified on pelvic examination or breast examination, communicate findings clearly to the patient, arrange appropriate imaging or referral, and maintain safety-netting documentation with a clear recall plan.

Key Examination Pitfalls to Avoid

• Performing a speculum examination without checking whether the patient has an intact hymen or is prepubertal (these are not routine settings for speculum examination without anaesthesia).
• Applying lubricant gel to the cervix before collecting LBC cells (degrades sample quality).
• Failing to document the chaperone's name or the patient's consent in the medical record.
• Dismissing an ectropion without documenting it; conversely, over-investigating a normal ectropion.
• Missing the axillary tail during breast palpation; this is a common site for palpable abnormalities.
• Forgetting to formally offer a chaperone to patients examined by a male clinician or student; this is both an ethical obligation and a medico-legal protection.

Sources

• MBS Online (Medicare Benefits Schedule)
• RACGP Red Book, Guidelines for preventive activities in general practice
• RACGP clinical guidelines