Obstetrics and Gynecology/Gynecological History Taking

Gynecological history taking involves a series of methodical questioning of a gynecological patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the patient, further investigative testing or treatment of a diagnosed condition.

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 (differential diagnosis) of the presenting complaint may be. After all, it is the aetiology of a symptom that guides the physician's questioning.

Basic Structure of a Gynecological History

Introduction

• Name of patient
• Age of patient
• Consent for questioning

age of last baby

Presenting Complaint

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

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

• 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

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

Past Obstetric History

• 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

• Current or past illnesses
• Hospital admissions
• Past surgeries

Drug History

• 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

• Sleep
• Appetite
• Micturition
• Defecation
• Weight loss or gain
• Addiction

Family History

• Medical conditions
• Gynecological conditions
• Malignancies
• Consanguinity

Social History

• Occupation
• Support network
• Smoking
• Alcohol
• Marital status

• Ranking

Diagnosis

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

This is bleeding after intercourse. Causes include:

• Cervical causes (common causes)
  • Carcinoma
  • Polyps
  • Erosion
  • Cervicitis
• Vaginal causes
  • Vaginitis
  • Carcinoma (very uncommon)

Intermenstrual Bleeding

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

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

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

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

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

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

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

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

Age

• >40 years

Clinical Features

• Post-menopausal bleeding

Risk Factors

• Obesity
• Nulliparity
• Late Menopause
• Unopposed oestrogen stimulation
• Diabetes Mellitus

Endometrial Fibroids

Age

• Women of child-bearing age

Clinical Features

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

Endometriosis

Age

• Women of child-bearing age

Clinical Features

• Cyclical Pelvic Pain
• Dysmenorrhoea
• Dyspareunia
• Infertility

Pelvic Inflammatory Disease

Clinical Features

• Bilateral lower abdominal pain
• Fever
• Vaginal discharge
• Deep dyspareunia

Risk Factors

• Multiple sexual partners
• History of pregnancy termination

Polycystic Ovary Syndrome

Clinical Features

• Oligomenorrhoea
• Amenorrhoea
• Hirsutism
• Infertility
• Acne
• Obesity

References

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