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Obstetrics and Gynecology/Gynecological History Taking

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Recent changes Gynecological history taking involves a series of methodical questioning of a gynecological patient with the aim of developing a diagnosis or a
Guided tours differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the
Random patient, further investigative testing or treatment of a diagnosed condition.
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There is a basic structure for all gynecological histories but this can differ slightly depending on the presenting complaint.

When taking any history in medicine it is essential to understand what the presenting complaint means and what the possible causes
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(differential diagnosis) of the presenting complaint may be. After all, it is the aetiology of a symptom that guides the physician's questioning.
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Sandbox 1 Basic Structure of a Gynecological History
Help desk 1.1 Introduction
1.2 Presenting Complaint
Tools
1.3 History of Presenting Complaint
What links here 1.4 Menstrual History
Related changes
1.5 Past Gynecological History
Special pages
1.6 Past Obstetric History
Permanent link
1.7 Past Medical History
Page information
Cite this page 1.8 Drug History
1.9 Personal History
Wikimedia projects 1.10 Family History
Commons 1.11 Social History
Wikibooks 2 Diagnosis
Wikipedia 2.1 Postcoital Bleeding
Wiktionary
2.2 Intermenstrual Bleeding
Wikiquote
2.3 Post-menopausal Bleeding
Wikisource
2.4 Menorrhagia
Wikinews
Wikispecies 2.5 Oligomenorrhea and Amenorrhea
Wikivoyage 2.6 Dysmenorrhea
Meta-Wiki 2.7 Dyspareunia in females
Outreach 3 The Complete History
MediaWiki 3.1 Cervical Carcinoma
Wikimania 3.2 Endometrial Carcinoma
3.3 Endometrial Fibroids
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3.4 Endometriosis
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3.5 Pelvic Inflammatory Disease
Download as PDF
3.6 Polycystic Ovary Syndrome
Printable version
4 References
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Basic Structure of a Gynecological History [ edit | edit source ]

Introduction [ edit | edit source ]

Name of patient
Age of patient
Consent for questioning

age of last baby

Presenting Complaint [ edit | edit source ]

It is important to ask as open a question as possible in this part of the history and to ensure the complaint is understood as everything else
follows on from here

History of Presenting Complaint [ edit | edit source ]

This will differ slightly depending on the presenting complaint but follows a vague structure:

If pain is involved in a certain site, radiation (if any) and character

Onset
Periodicity
Duration
Recurrence?
Aggravating & relieving factors
Severity

Menstrual History [ edit | edit source ]

Menarche and menopause

1st day of last menstrual period
Length of bleeding (days)
Frequency
Regularity
Bleeding between periods
Bleeding after intercourse
Any post menopausal bleeding *Nature of periods
Heavy?
Clots?
Flooding?

Past Gynecological History [ edit | edit source ]

Gynecological symptoms
Gynecological diagnoses
Gynecological surgery
Date & result of cervical smears
Contraception

Past Obstetric History [ edit | edit source ]

Gravidity and Parity

Dates of deliveries
Length of pregnancies
Induction of labor/Spontaneous
Mode of Delivery, SVD or C.S ?
Weight of babies
Sex of babies
Complications before, during and after delivery

Past Medical History [ edit | edit source ]

Current or past illnesses

Hospital admissions
Past surgeries

Drug History [ edit | edit source ]

Prescribed medications
Non-prescribed medications/herbal remedies
Recreational drugs
Any known drug allergies .

Contraception: Contraceptive history. Any recent unprotected intercourse. Reliability of method and user. Potential contra-indications to
different methods, eg combined pill. Permanent or temporary method required

Personal History [ edit | edit source ]

Sleep
Appetite
Micturition
Defecation
Weight loss or gain
Addiction

Family History [ edit | edit source ]

Medical conditions
Gynecological conditions
Malignancies
Consanguinity

Social History [ edit | edit source ]

Occupation
Support network
Smoking
Alcohol
Marital status
Ranking

Diagnosis [ edit | edit source ]

A differential diagnosis can be made after the history taking process. This is based upon a knowledge of the presenting complaints and the
history of presenting complaints in relation to certain disease states.

Although there is a general structure for history taking in gynecology, there are small differences in the approach depending on what the
presenting complaint is. It is essential for a physician to know the causes of each symptom and the other manifestations of those causes before
taking a history.

Postcoital Bleeding [ edit | edit source ]

This is bleeding after intercourse. Causes include:

Cervical causes (common causes)

Carcinoma
Polyps
Erosion
Cervicitis
Vaginal causes
Vaginitis
Carcinoma (very uncommon)

Intermenstrual Bleeding [ edit | edit source ]

This is vaginal bleeding between menstrual periods. Causes include:

Cervical causes
Carcinoma
Ectropion
Cervicitis
Polyps
Endometrial causes
Carcinoma
Polyps
Endometritis
Intrauterine Contraceptive Device
Oral Contraceptive Pill or Contraceptive Injection
Vaginal causes
Atrophic vaginitis
Infective vaginitis
Carcinoma
Ovarian causes
Estrogen-secreting tumor
Irregular Ovulation
Fallopian tube causes
Carcinoma

Post-menopausal Bleeding [ edit | edit source ]

This is vaginal bleeding more than 6 months after the menopause. Causes include:

Vaginal causes
Atrophic vaginitis
Cervical causes
Carcinoma
Polyps
Endometrial causes
Atrophic endometritis
Carcinoma
Polyps
Hyperplasia
Ovarian causes
Estrogen-secreting tumor
Other causes
Ring Pessary
Exogenous estrogens (HRT)

Menorrhagia [ edit | edit source ]

This is history of heavy cyclical blood loss over several consecutive menstrual cycles in the absence of any intermenstrual or postcoital
bleeding. Causes include:

Pelvic pathology
Uterine fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease
Endometrial polyps
Endocrine causes
Dysfunctional uterine bleeding
Hypothyroidism
Haematological causes
Disorders of coagulation
Thrombocytopena
Leukaemia

Oligomenorrhea and Amenorrhea [ edit | edit source ]

Oligomenorrhoea is infrequent menstruation defined by a cycle length between 6 weeks and 6 months. Amenorrhoea is absent menstruation
for at least 6 months. They both have the same list for causes with one exception - primary failure of elements of the
hypothalamic/pituitary/ovarian axis cause complete amenorrhoea, not oligomenorrhoea. Causes include:

Endocrine Causes

Hypothalamic disorders
Kallman's syndrome - hypogonadotrophic hypogonadism
Psychogenic - stress/shift work
Exercise
Excessive weight gain/loss
Tumours e.g. craniopharyngioma
Post-oral contraceptive use
Pituitary lesions
Pituitary adenomas
Sheehan's syndrome - infarction necrosis
Granulomatous infiltration e.g. sarcoidosis
Ovarian lesions
Turner's syndrome - ovarian dysgenesis
Polycystic ovarian syndrome
Resistant ovary syndrome
Premature ovarian failure
Androgen-secreting ovarian tumours
Other
Primary hypothyroidism/hyperthyroidism
Poorly controlled diabetes mellitus
Cushing's syndrome
Addison's disease

Dysmenorrhea [ edit | edit source ]

This is painful menstruation which can be primary (absence of pelvic pathology) or secondary (attributed to pelvic pathology).Causes include:

Endometriosis
Pelvic inflammatory disease
Submucosal fibroids
Endometrial polyps
Pelvic congestion syndrome
Intrauterine contraceptive device
Ovarian cysts
Adenomyosis

Dyspareunia in females [ edit | edit source ]

This is pain during intercourse. Causes include:

Superficial
Infection
Vaginal atrophy
Inadequate episiotomy repair
Vaginal/rectal tumor
Deep
Pelvic inflammatory disease
Endometriosis
Adenomyosis
Cervicitis

The Complete History [ edit | edit source ]

For each of the most common and life-threatening conditions, it is important for physicians and medical students to know the important aspects
that will present in the different parts of the history. It is this knowledge, that will guide the further management of the patient.

Cervical Carcinoma [ edit | edit source ]

Age:

This condition usually affects women between the ages of 35-55. Screening in UK has noticed a trend towards a younger age group and
the disease presenting itself in the 25-35 age group.

Clinical Features

Postcoital bleeding
Intermenstrual bleeding
Postmenopausal bleeding

Risk Factors

Early age of first experience of intercourse

High number of sexual partners of patient or patient's current or past sexual partners
HPV infection
Smoking
Low socioeconomic status

Endometrial Carcinoma [ edit | edit source ]

Age

>40 years

Clinical Features

Post-menopausal bleeding

Risk Factors

Obesity
Nulliparity
Late Menopause
Unopposed oestrogen stimulation
Diabetes Mellitus

Endometrial Fibroids [ edit | edit source ]

Age

Women of child-bearing age

Clinical Features

Menorrhagia
Abdominal swelling
Frequency of micturation
Pain
Infertility
Recurrent abortions Risk Factors
Pregnancy
Family History

Endometriosis [ edit | edit source ]

Age

Women of child-bearing age

Clinical Features

Cyclical Pelvic Pain

Dysmenorrhoea
Dyspareunia
Infertility

Pelvic Inflammatory Disease [ edit | edit source ]

Clinical Features

Bilateral lower abdominal pain

Fever
Vaginal discharge
Deep dyspareunia

Risk Factors

Multiple sexual partners

History of pregnancy termination

Polycystic Ovary Syndrome [ edit | edit source ]

Clinical Features

Oligomenorrhoea
Amenorrhoea
Hirsutism
Infertility
Acne
Obesity

References [ edit | edit source ]

McCarthy, A & Hunter, B (2003) Master Medicine: Obstetrics and Gynaecology (2nd ed.) Philadelphia: Elsevier Saunder
http://www.gpnotebook.co.uk

Category: Reproductive medicine

This page was last edited on 27 May 2020, at 01:19.

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