Gynaecological History

Gynaecological History

Taking a gynaecological history can at first be difficult as you are asking very personal questions, which sometimes patients are uncomfortable to talk about. Fear of embarrassment (both yourself and the patient!) however should not stop you from asking necessary questions. The more gynaecological histories that you take the easier it becomes and the more at ease you are in asking such personal questions.

The Gyaecological History follows the usual method of taking a history but there are specific key areas that need to be expanded on, these are:
- menstrual
- fertility
- urogynaecological
- obstetric

Presenting Complaint and History of Presenting Complaint

Elicit a full history of the presenting complaint:
- if painful intercourse determine if superficial or deep:

o superficial: suggests dryness or a local abnormality in the introitus
o deep: suggests pelvic pathology: scarring, adhensions, endometriosis or masses that restrict uterine mobility.
o can also be due to involuntary muscle contractions of pelvic floor: vaginismus: associated with anxiety.

- if discharge: when occurs, colour, smell, itchy? Amount?

- if bleeding: use the questions asked in a menstrual history
**if post-menopausal determine how many years that they have been post-menopausal (menopause is lack of periods for more than 12 months as a result of ovarian failure): depending on how long after their last period (menopause) that they have started bleeding again determines whether further investigation is warranted. Often a woman experiences irregular periods in the perimenopause period and so hasn’t actually gone through menopause.

Menstrual history

‘tell me about your periods’ can be an easy way of eliciting all the necessary information

- last menstrual period?
- Normal? Arrive at expected time?
- pattern of bleeding?

o How often do they occur?
o Regularly?
o How long do they last for? (learn what is a ‘normal cycle’- but be aware that what sometimes appears abnormal e.g.long cycle may be ‘normal’ for some women.)

o Heavy? Clots or flooding?
o How many pads/tampons use a day? Rough estimate of blood loss
o Was last period normal?
o Are periods painful? Normally painful?
o Changes in period pattern?
o Postcoital bleeding?
o Intermenstrual bleeding? Ask specifically about brown or bloody discharge between periods

Bleeding too little

Amenorrhea = absence of periods

Primary amenorrhea: 16 years and not started period
Secondary amenorrhea: start period but have since been absent for longer than 6 months

Oligomennorhea = infrequent periods with a cycle of 42 days or more

Irregular periods, oligomenorrhoea or amennorheao suggest anovulation or irregular ovulation.
Specific questions about weight, weight change, acne, greasy skin, hirsutism, flushes may help identify ovarian dysfunction e.g PCOS, menopause

Bleeding too much

Menorrhagia - heavy bleeding

Difficult to ascertain- can be subjective.
Ask about number towels/ pads used.

Also inquire about blood clots (NOT NORMAL)- small pieces of tissue are.
‘Flooding’- menstrual blood soaks through all protection: abnormal and distressing

Symptoms of anaemia may be present. In fact the commonest cause of anaemia in women is blood loss during their menstrual cycles.

Past Medical history

Any current medical disorders that they suffer from:
‘are you otherwise fit and well?’
‘do you see your GP regularly for anything?’
‘have you been in hospital before?’

Drug history

Do they currently take any tablets/ over the counter meds? Are they allergic to any medicines?

Fertility/ Contraception

- currently in a physical sexual relationship
- are you using any contraception at present
- unprotected intercourse, risk of STI?
- contraception previously used, any problems?

It may be appropriate to include a sexual history in women who are presenting with bleeding, discharge or dyspareunia (painful intercourse) as it could be the result of an STI. Asking if the patient is currently in a physical relationship and how long she has been in one can often be helpful. Approach such questions professionally and respectfully as you will both probably feel uncomfortable when such questions have to be asked.

Obstetric

- any children or previous pregnancies
- any antenatal problems? Delivery?
- Any terminations- at what stage and how?

If you ask the patient how many pregnancies she's had she is more likely to mention any miscarriages, rather than asking how many childen she has- as sometimes the patient won't think to mention miscarriages.

Urogynaecological

‘Any problems with your waterworks?'

- do they ever leak urine when do don’t intend to?
- If so find out what provokes it-e.g. coughing, sex, exercise
- Do you ever not make it to the toilet in time? Can help identify urge incontinence as well as passing small volumes frequently
- Often a mixed picture
- Prolapse? Associated with vaginal discomfort, feeling of something coming down


Last cervical smear

Date? Normal? Any previous abnormal smears?

Bowel symptoms?

Opening bowels normally?


This history is quite extensive and covers all the necessary areas. In most instances you will probably not have to ask all these questions: e.g if you ask a patient if she has any problems with her water works, any leaking and she hasn’t then there is no need to ask about the provoking factors or making it to the toilet in time.
With experience you will learn how to direct your histories to gain the necessary information to make your diagnosis.
Many of the questions are screening for important information e.g last cervical smear is important as it highlights if the patient has had a previous history of atypical cells on a smear or treatments as a result of abnormality. This is very relevant if such a patient presents with PV bleeding.