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Gynaecological history taking

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Lewis Potter 9/20/2010

Gynaecological history taking has a number of questions that are not part of the standard history taking format and
therefore it’s important to understand what information you are expected to gain when taking a gynaecological history.
Check out the gynaecological history taking mark scheme here.

Introduction
Introduce yourself – name / role

Confirm patient details – name / DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable

Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint

“So what’s brought you in today?” or “Tell me about your symptoms”

Allow the patient time to answer, trying not to interrupt or direct the conversation.

Facilitate the patient to expand on their presenting complaint if required

“Ok, so tell me more about that” “Can you explain what that pain was like?”

History of presenting complaint

Onset – when did the symptom start? / was the onset acute or gradual?

Duration – minutes / hours / days / weeks / months / years

Severity – e.g. if symptom is vaginal bleeding – how many sanitary pads are they using?

Course – is the symptom worsening, improving, or continuing to fluctuate?

Cyclical – do symptoms have any relationship to the menstrual cycle?

Intermittent or continuous? – is the symptom always present or does it come and go?
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Precipitating factors – are there any obvious triggers for the symptom?

Relieving factors – does anything appear to improve the symptoms e.g. an inhaler/?

Associated features – are there other symptoms that appear associated e.g. fever / malaise?

Previous episodes – has the patient experienced this symptoms previously?

Key gynaecological symptoms:

Abnormal vaginal discharge – suggestive of infection

Vaginal bleeding – menorrhagia / intermenstrual/ post-coital / post-menopausal
Vulval itching / discomfort / skin changes
Abdominal / pelvic pain – dysmenorrhea / dyspareunia

Other relevant symptoms:

Urinary symptoms – frequency / urgency / dysuria

Bowel symptoms – change in bowel habit / pain on defecation
Fever – pelvic inflammatory disease – e.g. chlamydia
Tiredness / fatigue – anaemia – often occurs alongside menorrhagia
Weight loss – may suggest malignancy
Abdominal distension – uterine / ovarian malignancy

Pain – if pain is a symptom, clarify the details of the pain using SOCRATES

Site – where is the pain

Onset – when did it start? / sudden vs gradual?
Character – sharp / dull ache
Radiation – does the pain move anywhere else?
Associations – other symptoms associated with the pain
Time course – worsening / improving / fluctuating / time of day dependent
Exacerbating / Relieving factors – anything make the pain worse or better?
Severity – on a scale of 0-10, how severe is the pain?

Ideas, Concerns and Expectations

Ideas – what are the patient’s thoughts regarding their symptoms?

Concerns – explore any worries the patient may have regarding their symptoms
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Expectations – gain an understanding of what the patient is hoping to achieve from the consultation

Summarising

Summarise what the patient has told you about their presenting complaint.

This allows you to check your understanding regarding everything the patient has told you.

It also allows the patient to correct any inaccurate information and expand further on certain aspects.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.

Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting involves explaining to the patient:

What you have covered – “Ok, so we’ve talked about your symptoms”
What you plan to cover next – “Now I’d like to discuss your past medical history”

Menstrual history
Age at menarche – the earlier, the greater exposure to oestrogen – ↑ risk of breast cancer

Last menstrual period (LMP) – defined as the first day of the LMP

Duration and regularity – e.g. 5 day period occurring regularly every 28 days

Flow – heavy / light – number of sanitary towels / tampons can be useful to estimate loss

Menstrual pain – use the SOCRATES method shown above to assess menstrual pain

Menopausal symptoms – hot flushes / vaginal dryness / infrequent periods

Hormonal contraceptives – combined oral contraceptive pill (COCP) / progesterone only pill (POP) / depot / implant

If postmenopausal – what age did they go through the menopause?

Irregular bleeding

Post-coital bleeding – e.g. cervical ectropion / STDs/ vaginitis

Intermenstrual bleeding:

Consider malignancy in older females – e.g. endometrial cancer

Younger females may have unexplained irregular periods
Poor compliance with oral contraceptives can result in intermenstrual bleeding

Gynaecological history
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Previous cervical smears – when? / results? / treatment (e.g. LETZ )

Previous gynecological problems and treatments – STDs / PID

Current contraception – COCP / POP / Depot / Implant / Implanted uterine device

Obstetrics history
Current pregnancy? – how many weeks? / recent scans?

Gravidity – number of times a woman has been pregnant, regardless of the outcome

Parity – X = (any live or stillbirth after 24 weeks) | Y = (number lost before 24 weeks)

Each pregnancy:

Current age of child

Birth weight
Complications – antenatal / perinatal / postnatal

Ask sensitively regarding miscarriages, terminations and ectopic pregnancies

Past medical history

Gynaecological conditions – STDs / cervical dysplasia / malignancy

Other medical conditions?

Surgical history – C-section / LETZ / prolapse repair / hysterectomy

Any recent hospital admissions? – when and why?

Drug history
Gynaecological medications:

COCP / POP / Implant / Depot

Tranexamic acid
Hormone replacement therapy
Antifungals

Other regular medication

Antibiotics

Over the counter drugs

ALLERGIES
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Family history
Uterine / ovarian / genital tract cancers

Breast cancer

Social history
Smoking – How many cigarettes a day? How long have they smoked for?

Alcohol – How many units a week? – be specific about type / volume / strength of alcohol

Recreational drug use

Living situation:

House / flat – stairs / adaptations

Who lives with the patient? – important when considering discharging home from hospital
Any carer input? – what level of care do they receive?

Activities of daily living:

Is the patient independent and able to fully care for themselves?

Can they manage self hygiene / housework / food shopping?
Is the illness interfering with these daily activities?

Occupation

Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.

This may pick up on symptoms the patient failed to mention in the presenting complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).

Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.

Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema

Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

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Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

Closing the consultation

Thank patient

Summarise the history