Reproductive System:

History Taking

Dr. Fidelis Nwachukwu

HISTORY AND PHYSICAL EXAM
Tips for taking the Sexual History

 Explain why you are taking the sexual history.

 Convey that you understand that this information is

highly personal, and encourage the patient to be open
and direct.

 Relate that you gather this history from all your patients.

 Affirm that your conversation is confidential.

Basic Information
BIODATA:
 Name of patient
 Hospital number
 Date of birth; age
 Sex/marital status
 Occupation
 Place of origin
 Place of residence
 Parity and Gravidity (O&G)
 EGA; EDD
CHIEF COMPLAINT

 Health problem/complaint in patient’s own words.

 ***keep it simple…
 C.C. x duration
 In order of occurrence with the latest coming last
 HISTORY OF PRESENT
COMPLAINT/ILLNESS

 Chronological order of time/place of symptom(s) onset,

duration, frequency, location, quality, quantity/severity,
aggravating/alleviating factors, associated symptoms,
self-treatment, relevant laboratory values, pertinent
negatives.
PAST MEDICAL HX

 GENERAL HEALTH: date, type, outcome, complications

of CHILDHOOD ILLNESSES (measles, mumps, rubella,
whooping cough, chicken pox, rheumatic fever, scarlet
fever, polio)
 ADULT ILLNESSES; ACCIDENTS/INJURIES;
hospitalizations not already listed.
 IMMUNIZATIONS (DPT, MMR, polio, hepatitis B, H.
influenza, S. pneumoniae, varicella)
PAST SURGICAL HX

 Operation date, type, reason, outcome, blood

transfusions, complications (if any).
PAST OBSTETRIC HISTORY

 Detailed history of each pregnancy

 No. of pregnancies, date (year, month), gestational age,,
labor and puerperal period, mode of delivery, outcome,
complications (if any), sex of baby, birth weight, days
spent before discharge, present state of the child.
 Including any abortions/TOP, at what week?, sex, reason
(if aware).
GYNECOLOGIC HISTORY
 Age at menarche; coitrache; Date of LMP
 CATEMENIA: duration of menstrual flow and length of
menstrual cycle, as well as regularity of the cycle. (e.g. she
menstruates for 4 days in a regular cycle of 29 days)
 Ask about hx of: menorrhagia, oligomenorrhea, dyspareunia,
dysmenorrhea, metrorhagia, etc
 Contraception: type used, duration, discontinuation? (reason)
 Female genital mutilation, hx of rape, vaginal discharge,
 Pap smear done if any, and when? SBE?
 Menopause? Age at menopause?
FAMILY HISTORY

 Age, health/death of parents, siblings, spouse, children.

 CHECK diabetes, heart disease, hypertension, stroke,
cancer, bleeding disorders, asthma, arthritis,
tuberculosis, epilepsy, mental illness, symptoms of
presenting illness.
SOCIAL HISTORY

 Birthplace, education (HEQ), employment, religion,

marriage/divorce, living accommodations, persons at
home, diet, exercise, hobbies.
MEDICATIONS

 Name, dose, frequency, duration, reason for taking,

compliance, availability.

ALLERGIES

 Medications/substances causing reactions (rash,

swelling, difficulty breathing, etc.)
 TOBACCO, ALCOHOL, DRUGS
 Type, amount, frequency, duration, reactions, treatment.
 REVIEW OF SYSTEMS
 GENERAL: weight change, fatigue, weakness, fever, chills, night sweats
 SKIN: skin, hair, nail changes; itching; rashes; sores; lumps; moles
 HEAD: trauma, headache location, frequency, nausea, vomiting, visual
changes
 EYES: glasses, contact lenses, blurriness, tearing, itching, acute visual
loss
 EARS: hearing loss, tinnitus, vertigo, discharge, earache
 NOSE, SINUSES: rhinorrhea, stuffiness, sneezing, itching, allergy,
epistaxis
 MOUTH, THROAT, NECK: bleeding gums, hoarseness, sore throat,
swollen neck.
 BREASTS: skin changes, masses/lumps, pain, discharge, self
exams
 CARDIAC: hypertension, murmurs, angina, palpitations, dyspnea on
exertion, orthopnea, PND, edema, last ECG.
 RESPIRATORY: shortness of breath, wheeze, cough, sputum,
hemoptysis, pneumonia, asthma, bronchitis, emphysema,
tuberculosis, last chest x-ray.
 GI: appetite, nausea, vomiting, indigestion, dysphagia, bowel
movement frequency/change, stool color, diarrhea, constipation,
bleeding (hematemesis, hemorrhoids, melena or hematechezia),
abdominal pain, jaundice, hepatitis.
 URINARY: frequency, hesitancy, urgency, polyuria, dysuria,
hematuria, nocturia, incontinence, stones, infection.
GENITAL:
 MALE: penile discharge or sores, testicular pain or masses,
hernias;
 FEMALE: dysmenorrhea, itching, discharge, sores,
menopause, hot flashes/sweats;
 GENERAL: STD history/treatment; sex interest, function,
problems
 VASCULAR: leg edema, claudication, varicose veins,
thromboses/emboli
 MSK: muscle weakness, pain, joint stiffness, range of motion,
instability, redness, swelling, arthritis, gout
 NEUROLOGIC: loss of sensation/numbness, tingling,
tremors, weakness/paralysis, fainting/blackouts, seizures
 HEMATOLOGIC: anemia, easy bruising/bleeding, petechiae,
purpura, transfusions
 ENDOCRINE: heat/cold intolerance, excessive sweating,
polyuria, polydipsia, polyphagia, thyroid problems, diabetes
 PSYCHIATRIC: mood, anxiety, depression, tension, memory.
  SUMMARY

…then,

 PHYSICAL EXAMINATION…
Male genitourinary diseases
The most common symptoms:
 Pain
 Dysuria
 Penile discharge
 Penile lesions
 Genital rashes
 Scrotal enlargement
 Groin mass or swelling
 ED
 Infertility
Pain
 Gradual enlargement of an organ is usually painless.
 Sudden distention of the ureter, renal pelvis, or bladder may
cause flank pain
 acute pyelonephritis or obstructive hydronephrosis: aching
pain in the costovertebral angle (sudden distention of the
renal capsule)
 Upper ureteral dilatation: spasmodic, colicky pain referred to
the testis on the same side.
 Lower ureteral dilatation: pain referred to the scrotum.
 The pain of ureteral distention is severe, and the patient is
restless and uncomfortable in any position.
 Bladder distention: lower abdominal fullness and suprapubic
pain, with an intense desire to urinate.
Groin Pain
• Scrotal masses
 Avascular necrosis (death of bone • Spermatocele
tissue due to limited blood flow)
• Sprains and strains
 Avulsion fracture
 Bursitis • Swollen lymph nodes
 Epididymitis • Tendinitis
 Hydrocele • Testicular cancer
 Inguinal hernia
• Testicular torsion (twisted
 Kidney stones
testicle)
 Mumps
 Muscle strain • Urinary tract infection (UTI)
 Orchitis • Varicocele (enlarged veins in
 Osteoarthritis the scrotum)
 Sciatica • Piriformis syndrome
• Retractile testicle
 Priapism: painful, persistent erection of the penis that is not a
result of sexual excitation.
 The sustained erection results from thrombosis of veins in the corpora
cavernosa.
 Seen in patients with sickle cell anemia or leukemia.
 Exact mechanism is unknown; appears to result from a blockage of venous
drainage from the penis while the arteries remain patent.
 Chronic priapism often results in organic ED.
Scrotal
pain
Evaluation
Questions
 “When did the pain begin?”
 “Where did the pain begin? Can you point to the
area?”
 “Do you feel the pain in any other area of your
body?”
 “Did the pain start suddenly?”
 “Have you ever had this type of pain before?”
 “Is the pain constant?”
 “What seems to make the pain worse? Less?”
 “Has the color of your urine changed?”
 “Is the pain associated with nausea? Vomiting?
Abdominal distention? Fever? Chills? Burning
sensation on urination?”
Dysuria

 Pain on urination frequently described as “burning.”

 It’s evidence of inflammation of the lower urinary tract.

 The patient may describe discomfort in the penis or in the

suprapubic area.

 Dysuria also implies difficulty in urination  result from

external meatal stenosis or from a urethral stricture.

 Painful urination is usually associated with urinary

frequency and urgency.
 Pneumaturia:
 passage of air in the urine, producing what the patient
describes as “bubbles of gas” in the urine.
 usually emitted at the end of urination.
 Causes: introduction of air by instrumentation, fistula to the
bowel, or UTI by gas-forming bacteria like E. coli or
Clostridia.
 Fecaluria:
 presence of fecal material in the urine; rare.
 Cause: entero-vesicular fistula or an urethrorectal fistula 
due to ulceration from the bowel to the urinary tract.
 Diverticulitis, carcinoma, and Crohn’s disease are frequent
causes.
 Pyuria/Pus in the urine:
 Cause: Bacteria, neoplasms and stones  Cystitis and
prostatitis.
Questions
 “How long have you noticed a burning sensation on
urination?”
 “How often do you urinate each day?”
 “How does your urination feel different?”
 “Is your urine clear?”
 “Does the urine smell bad?”
 “Do you have a discharge from your penis?”
 “Does the urine seem to have gas bubbles in it?”
 “Have you noticed any solid particles in your urine?”
 “Have you noticed pus in your urine?”
Changes in Urine Flow
 Include frequency and incontinence
 Most common symptom
 Frequency

 Causes: ↓ bladder size, bladder wall irritation, and

↑ urine volume
 Nocturia
 Polyuria: voiding large amounts of urine; usually accompanied by
polydipsia.
 Prostatic hyperplasia:
 MCC of reduced usable bladder capacity in men.

 Symptoms: frequency of urination, nocturia, urgency,

weak stream, intermittent stream, and a sensation of

incomplete emptying.

 Long-standing prostatic hypertrophy  complete inability

to urinate, necessitating catheterization (urinary retention)

 Most bladder diseases (cystitis) cause frequency due to irritation

of the bladder mucosa.

Questions:
 “Do you find that you must wake up at night to
urinate?”
 “Can you estimate the amount of urine passed
each time you urinate?”
 “Do you have sudden urges to urinate?”
 “Have you found that despite an urge to urinate,
you cannot start the stream?”
 “Has there been a change in the caliber of the
stream?”
 “Have you found that you must wait longer for the
stream to start?”
 “Do you have the sensation that after urination has
stopped, you still have to urinate?”
 “Do you have to strain at the end of urination?”
 “Have you been drinking more fluids recently?”
 Urinary incontinence: inability to retain urine voluntarily.

 Urge to urinate may be so intense that incontinence may

result.
 In addition to the questions regarding dysuria and
frequency, ask the following:
 “Do you involuntarily lose small amounts of urine?”
 “Do you lose your urine constantly?”
 “Do you lose your urine when lifting heavy objects?
Laughing? Coughing? Bending over?”
 “Do you have to press on your abdomen to urinate?”
 Overflow incontinence:
 chronically distended bladders (prostatic hypertrophy) 
always a large amount of residual urine  constant ↑
pressure within the bladder  even slight increase in intra-
abdominal pressure ↑ intravesicular pressure sufficiently to
overcome bladder neck resistance  urine escapes.
 Leakage may be steady or intermittent.
 Stress incontinence:
 Leakage that occurs only when the patient strains.
 The primary defect is a loss of muscular support in the
urethrovesicular region.
 Residual urine is insignificant. Any increase in intra-
abdominal pressure causes leakage. This type of
incontinence is more common in women
 Urge Incontinence
 Polyuria: increased amounts of urine > 3 L/day.
 D/D are diabetes mellitus, diabetes insipidus, and psychologic
diabetes insipidus.
 Ask the following questions:
 “How long have you been passing large amounts of urine?”
 “Was the onset sudden?”
 “How often do you have to urinate at night?”
 “Is there any variability in the urine flow from day to day?”
 “Do you have excessive thirst?”
 “Do you prefer water or other fluids?”
 “What happens if you don’t drink? Will you still have to
urinate?”
 “How is your appetite?”
 “Do you have any visual problems? Headaches?”
 “Are you aware of any emotional problems?”
Penile Discharge
 Continuous or intermittent flow of fluid from the urethra.
 Ask if pt has ever had a discharge  if +ve
 whether bloody (ulcerations, neoplasms, or urethritis) or
 purulent (thick and yellowish-green and may be associated with
gonococcal urethritis or chronic prostatitis)
 When the discharge was first noted?
 Tactful direct questions about H/o or exposure to STD’s.
 Determine the patient’s sexual orientation
 Type of sexual exposure—oral, vaginal, or anal
 Number of sexual partners and whether the partner or partners have
any known illnesses..
Purulent penile discharge of gonorrhea.
Penile Lesions
 History of lesions on the penis  possibility of venereal
disease.
 Differential diagnosis: ranges from benign conditions to those
that currently have no cure.
 Thorough history with focus on
 recent sexual exposures
 hygienic habits
 lesion is pruritic or painful
 possible preexistence of other skin disorders
 Any H/O gonorrhea, syphilis, herpes, trichomoniasis,
venereal warts, or other STD’s.
Genital Rashes
 Male genital rashes are very common.
 Confusing to identify and are often difficult to treat.
 Some rashes occur exclusively on the genitalia; others, which
are typically found on other parts of the body, have an atypical
appearance when present on the genitalia.
 M.C. inflammatory reaction  psoriasis (bright red, well-
defined, scaling plaques)
 Areas involved: scrotum, inguinal folds, penis.
 Uncircumcised men often lack the scale when lesions are
located on the glans
 Psoriatic patches on other body parts usually facilitate the
diagnosis.
Genital Rashes
 Contact dermatitis:
 May develop from soaps or disinfectants.
 Itching is a major symptom.
 Fixed drug eruptions:
 Sudden onset of multiple, well-defined, macular, eczematous,
bullous patches.
 If genitalia are involved  occur on distal penis and glans and
very painful.
 Drugs involved: NSAID, sulfonamides, laxatives, tetracycline, and
barbiturates.
 Lichen planus:
 The glans penis is frequently involved.
 Typical penile lichen planus is asymptomatic and commonly
resolves with residual hyperpigmentation, while oral examination
may also reveal the classic serpiginous white streaks on the
buccal mucosa.
Psoriasis Fixed drug reaction Lichen planus.
Scrotal Enlargement
 Common complain but difficult to determine which anatomic
structures in the scrotum are enlarged.
 Can be due to testicular or epididymal enlargement, hernia,
varicocele, spermatocele, or hydrocele.
 Testicular enlargement can result from inflammation or tumor.
 Most of the time, enlargement is unilateral.
 Painful scrotal enlargement can result from acute inflammation
of the epididymis or testis, torsion of the spermatic cord, or a
strangulated hernia.
 Varicoceles: Male infertility.
 Questions: timing, painful or not, change in size, any h/o injury,
hernia, problem with fertility.
Groin Mass or Swelling
 M.C.C. of swelling in the groin is a hernia.
 Hernias are reduced in size after the patient has been lying down.
 Adenopathy from any infection of the external genitalia may
produce inguinal swelling.
 Carcinoma of the testis produces inguinal node enlargement only
if the scrotal skin is involved.
 If a patient describes a mass in the groin, ask the following
questions:
 “When did you first notice the mass?”
 “Is the mass painful?”
 “Does the mass change in size with different positions?”
 “Have you had any venereal diseases?”
 Hydrocele
Varicocele
Erectile Dysfunction
 Persistent inability to achieve or maintain a penile erection sufficient
for satisfactory sexual performance.
 The typical patient: ~50 years old, usually married or in a long-term
monogamous relationship, and has had a year or more of gradually
progressive ED, with good mental and physical health.
 Penile erection is a neurovascular phenomenon, there are a number
of neurologic and vascular conditions that can lead to ED.
 Vascular disease such as atherosclerotic stenosis or occlusion
of the cavernosal arteries, or vascular problems secondary to
smoking.
 Antihypertensives, antidepressants, antiandrogens, histamine
type 2 receptor blockers, and recreational drugs are commonly
associated with ED.
 Diabetes, hypertension, hyperlipidemia, and alcohol use are risk
factors in ED.
 ED frequently provides insight into the patient’s emotional problems.
Erectile Dysfunction
 Delicate approach.
 Use tact and appropriate language that will be understood by
the patient.
 Explain that ED is a common problem.
 Deep-seated problems necessitate careful questioning.
 One may discover latent homosexuality; guilt and taboos
experienced early in life may have left a lasting impression,
affecting sexual performance.
 Important to classify the origin of the ED, because there are
specific therapies for different causes.
 “If you were to spend the rest of your life with your sexual function
just the way it is now, how would you feel about that?”
 “Are you satisfied with your sexual function?” If not, “What are the
reasons?”
 “What is your relationship status? Is it a happy one?”
 “Is your partner satisfied with your sexual function?” If not, “What
are the reasons?”
 “When was the last time you had a satisfactory erection?”
 “Over the last 4 weeks, how would you rate your confidence that
you could get and keep an erection?”
 “When you had erections with sexual stimulation, how often were
your erections hard enough for penetration (entering your
partner)?”
 “During sexual intercourse, how often were you able to maintain
your erection after you had penetrated (entered) your partner?”
 “During sexual intercourse, how difficult was it to maintain your
erection to completion of intercourse?”
A careful history is the most essential
component in the evaluation of ED

 “How much do or did you enjoy sexual intercourse?”

 “When you have sexual stimulation or intercourse, how often do you
ejaculate?”
 “How easily can you reach an orgasm (climax)?”
 “How strong is your sex drive?”
 “How easily are you sexually aroused?”
 “Are your orgasms satisfying?”
Determine the cause of ED
 Psychogenic causes: suspected in men who have a h/o unusual
anxiety, stress, or sexual abuse or in those with ethnic, cultural,
sexual, or religious inhibitions.
 ED is often psychogenic in men younger than 40 years.
 Ask the following questions:
 “Do you have early morning erections or nighttime emissions?”
 “Do any individuals other than your partner arouse you?”
 “Are you able to masturbate to an erection or climax?”
 An affirmative answer to any of these questions reassures that ED
is probably psychologic in origin.
 Letting the patient discuss his problems may allow him to vent some
of his anxieties, but the patient’s confidence must first be secured by
guaranteeing confidentiality.
Infertility
 Inability to conceive or to cause pregnancy.
 Common problem found in as many as 10% of all marriages.
 A couple is said to be infertile when after 1 year of normal
intercourse without the use of contraceptives, pregnancy does
not occur.
 30% of all infertility is attributable to a male factor.
 Question regarding a history of mumps, testicular injury, venereal
disease, history of diabetes, history of a varicocele, exposure to
radiation, or any urologic surgical procedure.
 Diabetic men may be infertile because of retrograde ejaculation
 Determine the frequency of sexual intercourse and any difficulty
in achieving or maintaining an erection.
 History of general work habits, medications taken, alcohol
consumption, and sleeping habits.
Causes
Causes
Female Genitourinary Disease
The most common symptoms are:
 Abnormal vaginal bleeding
 Dysmenorrhea
 Masses or lesions
 Vaginal discharge
 Vaginal itching
 Abdominal pain
 Dyspareunia
 Changes in hair distribution
 Changes in urinary pattern
 Infertility
Abnormal Vaginal Bleeding
Includes amenorrhea, menorrhagia, metrorrhagia, and
postmenopausal bleeding.
 Amenorrhea:
 Before puberty, amenorrhea is physiologic, as it is during
pregnancy and after menopause.
 primary amenorrhea: age cut-off 14 & 16
 secondary amenorrhea: pregnancy, long distance joggers,
anorexia, abnormally low body fat
 Diseases of the hypothalamus, pituitary gland, ovary,
uterus, and thyroid gland are associated with amenorrhea.
 Menorrhagia: excessive bleeding at the time of the menstrual
period.
 Causes: Uterine fibroids, leukemia, inherited clotting
abnormalities, decreased platelet states.
 Metrorrhagia: uterine bleeding of normal amount at irregular,
noncyclic intervals.
 Intrauterine devices, uterine or cervical polyps, ovarian and
uterine tumors.
 Menometrorrhagia: Increased bleeding between cycles as
well as heavier periods
 Polymenorrhea
 Oligomenorrhea
 Postmenopausal bleeding
 Cause: Uterine fibroids, tumors of the cervix, uterus, or ovary,
vaginal atrophy.
 “How long have you noticed the vaginal bleeding?”
 “Do you use contraceptives?” If yes, “What types of contraceptives do you
use?”
 “How often are your periods?”; “What is the duration of your menstrual flow?”
 “How many tampons or napkins do you use on each day of your flow?”
 “When was your last period?”
 “Have you noticed bleeding between your periods?”
 “Do you have abdominal pain during your periods?”
 “Do you have hot flashes? Cold sweats?”
 “Do you have children?” If yes, “When was your last one born?”
 “Do you think you might be pregnant?”
 “Are you under any unusual emotional stress?”
 “Have you noticed that you were warm in a room and others were not? Have
you noticed that you were cold in a room and others were not?”
 “Have you noticed a change in your vision?”
 “Have you had any headaches? Nausea? Change in hair pattern? Milk
discharge from your nipples?”
 “What is your diet like?”
Dysmenorrhea/Painful menstruation
 Difficult to define as abnormal because many healthy women have some
degree of menstrual discomfort.
 Mostly cramps subside with commencement of the menstrual flow.
 Dysmenorrhea: intermittent, crampy pain accompanying the menstrual flow with
pain felt in the lower abdomen and back, sometimes radiating down the legs.
 In severe cases, fainting, nausea, or vomiting may occur.
 2 types of dysmenorrhea
1. Primary dysmenorrhea:
2. Secondary dysmenorrhea:
 Caused by acquired disorders within the uterine cavity (e.g., intrauterine
devices, polyps, or fibroids), obstruction to flow (e.g., cervical stenosis),
or disorders of the pelvic peritoneum (e.g., endometriosis or pelvic
inflammatory disease).
Masses or Lesions
 Masses or lesions of the external genitalia are common.
 They may be related to venereal diseases, tumors, or infections.
 Ask these questions of any woman with a lesion on the genitalia:
 “When did you first notice the mass (lesion)?”
 “Is it painful?”
 “Has it changed since you first noticed it?”
 “Have you ever had it before?”
 “Have you been exposed to anyone with venereal disease?”
Vaginal Discharge/Leukorrhea
 Is there an associated foul odor?
 Although a whitish discharge is often normally present, a fetid discharge
often indicates a pathologic problem.
 Most common pathologic odor (bacterial vaginosis): Foul, fishy odor
(volatilization of amines produced by anaerobic metabolism of bacteria)
 Is itching also present?
 Women with candidiasis complain of intense pruritus and a white, dry
discharge that looks like cottage cheese.
 Other causes: glycosuria, vulvar leukoplakia, psychosomatic disease.
 Has the woman recently taken any medications, such as antibiotics?
 Antibiotics change the normal vaginal flora, and an overgrowth of
Candida may result.
Characteristics of Common Vaginal
Discharges
Abdominal Pain
 May be acute or chronic.
 Acute abdominal pain:
 Is the patient pregnant?
 Spontaneous abortion
 Uterine perforation
 Ectopic tubal pregnancy
 Acute PID: acute gonococcal salpingo-oophoritis
 UTI
 Mittelschmerz: Acute lower abdominal pain localized to one
side that occurs at the time of ovulation (small amount of
intraperitoneal bleeding when ovum is released).
Chronic abdominal pain:

 Sexual abuse

 Ectopic endometrial tissue

 Chronic PID

 Prolapse
 Ask the following questions in any woman with abdominal
pain:
 “When was your last period?”
 “Have you ever had any type of venereal disease?”
 “Is the pain related to your menstrual cycle?” If yes, “At
what time in your cycle does it occur?”
 “Do you experience a burning sensation when you
urinate?”
Dyspareunia
 Pain during or after sexual intercourse.
 Physiologic or psychogenic.
 Associated with:
 Infections of the vulva, introitus, vagina, cervix, uterus, fallopian
tubes, and ovaries.
 Tumors of the rectovaginal septum, uterus, and ovaries.
 History of painful pelvic examinations and fear of pregnancy
are common.
 Women may have “penetration anxiety” until they are assured.
 Such anxiety may lead to vaginismus
 Dryness of the vagina and labia may cause irritation 
dyspareunia (Vaginal lubrication especially during sexual
intercourse may be extremely helpful).
Changes in Hair Distribution

 May occur during certain states of hormonal imbalance.

 Hirsutism

 Virilization

 Cause: Increased androgen production by the adrenal glands

or ovaries

 Tumors of the ovary: amenorrhea, rapidly developing

hirsutism, and virilization.

 Polycystic ovarian disease.

Increased hair growth in a patient with PCOS

Increased hair growth

Increased hair growth in a caused by minoxidil
patient with an androgen- antihypertensive
secreting ovarian tumor. therapy.
Changes in Hair Distribution
 Determine whether the patient is taking any medications.
 cyclosporine, minoxidil, diazoxide, penicillamine, and
glucocorticoids

 Alopecia: Hair loss, many drugs may have a profound effect

on hair growth.
 H/O chemotherapeutic agents or any exposure to radiation.
 Has the patient been dieting? (crash diets and infectious
diseases reduce the nutrients available for hair growth 
secondary alopecia)
 Response to Increased androgens:
 Top and front of the scalp: hair loss
 Face: increased hair growth
Changes in Urinary Pattern
 Stress incontinence:
 urinary incontinence that occurs with straining or coughing.
 More common among women than men.
 Female urinary bladder and urethra are maintained in
position by muscular and fascial supports  estrogens may
cause the weakening of the pelvic support.
 With aging, the support of the bladder neck, the length of the
urethra, and the competence of the pelvic floor are
decreased.
 Repeated vaginal deliveries, strenuous exercise, and
chronic coughing increase the chance for stress
incontinence.
Changes in Urinary Pattern
 Patients with pure stress incontinence: Urine loss without urgency
that occurs during any activity that momentarily increases intra-
abdominal pressure.
 Important to r/o other types of incontinence like neurologic,
overflow, and psychogenic.
 Neurologic incontinence: due to cerebral dysfunction, spinal cord
disease, and peripheral nerve lesions. (commonly seen in Multiple
sclerosis  pt also have episode of temporary loss of vision)
 Overflow incontinence: occurs when the pressure in the bladder
exceeds the urethral pressure in the absence of bladder contraction.
 Seen in diabetes and atonic bladder.
 Psychogenic incontinence: Pts urinate in bed at night to “warm”
themselves or during the daytime in group settings to draw attention
to themselves.
 “Do you lose your urine on straining? Coughing? Lifting?
Laughing?”
 “Do you lose your urine constantly?”
 “Do you lose small amounts of urine?”
 “Are you aware of a full bladder?”
 “Do you have to press on your abdomen to void?”
 “Are you aware of any weakness in your limbs?”
 “Have you ever had a loss of vision?”
 “Do you have diabetes?”
Female Infertility
 Can be due to:
 Anovulation: failure to ovulate, inadequate function of the corpus luteum.
 occur in women with cyclic menstrual bleeding  Having a period does
not indicate fertility.
Questions:
 “Do you have regular menstrual periods?”
 “Have you kept a chart of your basal body temperature?”
 “Have you ever had venereal disease?”
 “Have you been tested for thyroid disease?”
 “Have you taken any medications to promote fertility?”
 Charting basal body temperature is a reliable method for detecting
ovulation.
Causes of Female Infertility
 Hormonal imbalance • Uterine Polyps
 Ovarian tumor or cyst • Endometriosis or fibroids
 Eating disorders such as
• Scar tissue or adhesions
anorexia or bulimia
 Alcohol or drug use • Chronic medical illness
 Thyroid gland problems • Previous ectopic (tubal)
 Obesity pregnancy
 Stress • Birth defects
 Intense exercise that causes a
• DES syndrome
significant loss of body fat
 Extremely brief menstrual
cycles
 Pelvic inflammatory disease
Gynecologic history and menstrual cycle:
 “At what age did you start to menstruate?”
 “How often do your periods occur?”
 “Are they regular?”
 “For how many days do you have menstrual flow?”
 “How many pads or tampons do you use each day of your flow?”
 “During your menstrual cycle, do you experience any breast
tenderness or breast pain? Bloating? Swelling? Headache?
Edema?”
 “When was your last menstrual period?”
 Catamenia: refers to the menstrual history and summarizes
the age at menarche, the cycle length, and the duration of
flow.
 If a woman reached menarche at age 12 years and has
had regular periods every 29 days lasting for 5 days, the
catamenia can be summarized as “CAT 12 × 29 × 5.”
 The date of the last menstrual period can be abbreviated
as, for example, “LMP: August 10, 2013.”

 Molimina: Recurrent, midcyclic symptoms associated with the

menstrual period, such as breast tenderness, and bloating.
 The presence of molimina is correlated with ovulation,
although not all women experience symptoms when
ovulation occurs.
 Therefore molimina are specific but non sensitive signs of
ovulation.
Obstetric history:
 “Have you ever been pregnant?”

If the woman has been pregnant:

 “What was the outcome of your pregnancy(ies)?”
 “How many full-term pregnancies have you had?”
 “Have you had any children born prematurely?”
 “How many living children do you have?”
 “How were your children delivered (vaginally, cesarean)?”
 “What were the birth weights of your children?”
 The obstetric history includes:
 Gravidity
 Parity
 If a woman has had:
 three full-term infants (born at 37 weeks or more of gestation),
 two premature infants (born at less than 37 weeks of gestation),
 one miscarriage (or abortion),
 four living children,
 her obstetric history can be summarized as …
 An easy way to remember this four-digit parity code is with the mnemonic
“Florida Power And Light,” which stands for full term, premature, abortions
(miscarriages), living.
 The woman in this example is gravida 6.
 Maintain sensitivity while asking the question, reminding the patient that
the medical term “abortion” means loss of any pregnancy, including
voluntary terminations, ectopic pregnancy, or spontaneous miscarriage.
 When asking a woman about the date of her last menstrual
period, never assume that menopause has occurred.
 Women of any age should be asked when their last menstrual
period occurred.
 Allow the patient to say that she has not had a period in, for
example, 12 years.
 A careful sexual history is important.

Questions:
 “Are you satisfied with your sexual activity?”
 Important to know whether the woman practices heterosexual,
homosexual, or bisexual activities.
 Is the patient married? How many times? For how long? Are
there other sexual partners?
 If the patient is not married, is she currently having sexual
relationships?
 What type of birth control is being used?
 It is important to ask all sexually active women the following:
 “How easily can you reach an orgasm or climax?”
 “How strong is your sex drive?”
 “How easily are you sexually aroused?”
 “How easily does your vagina become moist during sex?”
 “Are your orgasms satisfying?”
 Always determine whether the patient’s mother was given
diethylstilbestrol (DES) during her pregnancy.
 Use words that the patient will understand. It may be
necessary to use such terms as “lips” to refer to the labia or
“privates” to refer to the genitalia.
THANK YOU