How To Take Gynecological History Authors Dr Manisha

How To Take Gynecological History Author(s): Dr Manisha Mathur, MBBS, MRCOG (UK) Level: Basic Academic Affiliation : KK Women's and Children's Hospital Department of O&G, Consultant Version No: 1. 0 Submitted: August 2016 Editors’ Review:

2 Role of a Doctor • Listening to the patient tell her story • Generating a hypothesis • Testing the hypothesis – By interrogation 50% – By examination 10% – By selective testing 40% • If at first you don’t succeed… • Go back and listen to the patient

3 Considerations • History taking sequence remains same • Should follow a logical and chronological sequence • Some unique areas of focus specific to specialty • Requires sensitivity and preservation of dignity for the patient • Ensure confidentiality • Always consider the possibility of pregnancy when presented with abnormal bleeding or pain

4 Presenting Complaint The Gynecological History follows the usual method of taking a history but there are specific key areas that need to be expanded on. These are: • Menstrual history • Common gynae issues: vaginal discharge, abdominal/pelvic mass • Contraception and sexual health • Obstetric history • Uro-gynecological history • Pap smear and related vaccination history • Past gynae/surgical history

5 Menstrual History Fertility Phase 9 10 11 15 14 13 12

6 Patterns of Abnormal Menstrual Loss • Menorrhagia – Excessive menstrual loss at regular intervals • Metrorrhagia – Frequent and irregular menstrual loss • Polymenorrhoea – Regular cycles at <21 days • Oligomenorrhoea – Infrequent menstruation (>35 days) • Intermenstrual Bleeding – Bleeding between menstrual periods – Requires careful questioning

7 Menstrual History: Tips • Tell me about your Menses? – – – Age at menarche LMP? Arrive at expected time? Pattern of bleeding Was last period normal? • How often do they occur? Regularly? Irregularly? – Do they “come early” or do they “come late” – Regular menses – range 21 to 35 days – Usually 28 to 30 days • How long do they last for? – From the beginning of one period to the beginning of the next

8 Menstrual History: Tips • Estimating menstrual loss – How frequent do you change pad? – Pad completely soaked? – Clots/flooding • Are periods painful? Normally painful? – When does pain start? (Before menses or with menses? ) – Severity…. does it keep you off work? • Changes in period pattern? • Any post-coital bleeding (PCB)? • Any inter-menstrual bleeding (IMB)? – Ask specifically about brown or bloody discharge between periods

9 Menorrhagia Used loosely means excessive menstrual loss….

10 What is Excessive Menstrual Loss? • Escapes from normal menstrual protection • Large clots – frequently • Changing at night more than once • Lasts longer than 7 days “full flow” • Interferes with normal life or duties • Causes iron deficiency (anaemia) – Other causes excluded

11 Menorrhagia: HMB • Menorrhagia – – – • Enquire about – – – • Difficult to ascertain – can be subjective Ask about number towels/pads used Fully/partially soaked Blood clots (NOT NORMAL) – small pieces of tissue ‘Flooding’ – menstrual blood soaks through all protection Abnormal and distressing Do you change at night? – – How often How many nights • Do your periods interfere with your life • Have you any “accidents” • Associated Symptoms – – Anaemia Hypothyroidism http: //www. tutorvista. com/content/biology/ biology-ii/reproduction/menstruation-andmenstrual-cycle. php

12 Oligomenorrhoea • Irregular periods, Oligomenorrhoea or amenorrhea suggest anovulation or irregular ovulation • Amenorrhea = Absence of periods • Primary amenorrhea: Menstruation not established – – • 16 years with secondary sexual characters 14 years with no secondary characters Secondary amenorrhea: Absent of menses > 6 months – Think pregnancy • Oliogomenorrhoea: infrequent periods with a cycle of 35 days or more • Specific questions (causes of anovulation) – – – Weight change: Loss/Gain Acne/Greasy skin Hirsutism Galactorrhoea/Recurrent headaches Hyperthyroidism symptoms Flushes may help identify ovarian dysfunction: menopause

13 Dysmenorrhea • Primary – Starts with menses – Usually 2 to 3 days – Improves with age and after childbirth • Secondary – Secondary pathology – Usually starts a few days prior to menses • Severity: time off school/work? • Any aggravating/relieving factors • Any effect of painkillers • Family History: Endometriosis

14 Vaginal Discharge • Duration http: //www. pathology. stgeorges. nhs. uk/pathologyinvestigations/medical-microbiology/high-vaginal-swab-mcs • Cyclical? • Itchy • Amount • Colour: white/yellow/greenish/brown • Odour: odourless/fishy • Any previous history of same • Any treatment used • Other symptoms? Pain, fever, etc.

15 Mass in Abdomen • Duration • Change in size • Pain • Nausea, vomiting, change in bowel habits? • Weight loss • Associated symptoms: Menorrhagia, amenorrhea

16 Uro-gynaecological History • Any problems passing urine? • Urinary symptoms – frequency, nocturia, dysuria, incontinence, haematuria • Incontinence – Do you ever leak urine when don’t intend to? – Stress Incontinence: If so, find out what provokes it. e. g. coughing, sex, exercise – Urge Incontinence: Do you ever not make it to the toilet in time? Can you hold your urine without leaking? Do you pass small volumes frequently – Often a mixed picture • Prolapse: Associated with vaginal discomfort, feeling of something coming down

17 Obstetric History • Number of previous pregnancies • No. of children? – Birth weight • Any antenatal problems? • Mode of delivery labour prolonged? – Relevant to prolapse • Any terminations/Miscarriages – Surgical/Medical? – Gestation

18 Sexual History

19 Sexual History • Sensitive approach: Choose your words carefully • Begin with “I need to ask you some personal questions…. Hope that is OK? ” • Are you or have you ever been sexually active? • How old were you when you first had sex? • Are you in a stable relationship? • How many partners have you had in the last six months? • When was the last time you had sexual intercourse? • Have you ever suffered from any sexually transmitted infection? • Have you ever experienced sexual assault or incest? • Is there violence in any of your relationships?

20 Also Think About… • Previous gynaecological problems – STIs, endometriosis, infertility, surgery, polycystic ovarian disease • Contraception – Current/past – Hormonal/non-hormonal – Any problems? • Pap smear history – Date and results of last cervical smear – Any treatment in the past – Vaccine against cervival cancer • Bowel symptoms http: //www. cervexbrush. com/combi. html – Bleeding PR, fecal incontinence, bowel habits, mucus in stool, difficulty emptying bowel

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