GYNAECOLOGICAL HISTORY
Menstrual questions Other Hx
• How long is the cycle? • Past obstetric hx
• How long does menstruation last? o Details about previous pregnancies in
• Regular or irregular? chronological order
• Is it heavy? o Ask gestation, weight and delivery
o No. of pads or passage of clots method
• Is it or the days leading up to it painful? o Ask how infant is now
• Intermenstrual bleeding (IMB)? o Any major complications in
• Post-coital bleeding (PCB)? pregnancy or labour?
• Any vaginal discharge? What is it like? • PMHx
• Premenstrual tension? o Previous operations
• Last menstrual period (LMP)? o VTE
• Postmenopausal bleeding (PMB)? o Diabetes
o Lung and heart disease
• Symptoms of anaemia?
o HTN
o Jaundice
Sexual/contraceptive questions
o Any admissions to hospital?
• Sexually active?
• Systems review
• Painful?
o CV
o Penetration? = superficial
o Respiratory
dyspareunia
o Neurology
o Deep inside? = deep dyspareunia
o GI symptoms and urinary
o During or after (delayed)
symptoms more important to
• Contraceptive currently in use? Any different
screen for
types in the past?
• DHx
o Regular medication
Cervical smear questions
o NKDA
• When was her last smear? Should be every 3 years
• FHx
aged 25-49, every 5 years between 50-64 years
o Breast or ovarian ca
o Ever had an abnormal smear?
o DM
o If yes, what was done?
o VTE
o CVD
Urinary/prolapse questions
o HTN
• Frequency?
• SHx
o Normal = 4-7 times per day
o Smoking (RF for many conditions)
• Nocturia
o Alcohol
• Urgency
o Relationships? Home? Support at home?
• Ever leak urine? o What made her come to you about
o Nocturnal enuresis = whilst asleep this problem now? E.g. does she
• How severe? want to get pregnant?
• Any associations (stress) e.g. coughing, lifting, o How does problem affect her life?
urgency Unable to work? Cannot sleep?
• Dysuria? Relationship problems?
• Haematuria? • ICE
• Dragging sensation/feel a mass in/at vagina?
History of presenting complaint
Dysmenorrhoea: - Pill, pregnancy, antibiotics, STDs
- Primary or secondary?
- Relationship to periods Pelvic Pain:
- Site and duration - Usual Questions
- Relieved by menstruation or the pill - Relationship to bodily functions eg menstruation,
defecation, micturition and intercourse.
Vaginal Discharge: - Other symptoms, eg discharge, fever, collapse
- Duration
- Colour Infertility:
- Smell - Ovulation
- Itch - Anatomical problems eg tubal disease
- Blood - Male factors
- Variation
,Presenting the Hx: This is … a … year old (parity) with a (time) history of …, who … (most significant findings on hx). Summarise
whole history after this, and finish in one sentence.
CLINICAL SCENARIOS:
34 year old, heavy periods.
Differential diagnosis:
• Fibroids
• Dysfunctional uterine bleeding (hormonal)
• Adenomyosis (similar pathology to endometriosis, where endometrial lining invades into myometrium)
Key questions:
• How long for
• Menstrual history:
- Cycle length
- Bleeding length
- Quantify
• Dysmenorrhoea e.g. fibroids don’t usually cause pain but adenomyosis causes heavy and painful periods
• Pressure symptoms (bladder/bowel) e.g. fibroids growing large
• Symptoms of anaemia e.g. dizziness, fatigue
• Previous treatments – “Is this the first time you have spoken to a doctor about this?”
• Effect on her life
• Family history – fibroids often run in families.
26 year old, history of lower abdominal pelvic pain.
Differential diagnosis:
• Endometriosis
• Chronic PID
• Non-Gynae (GI or bladder)
Key Questions:
• Pain history (SOCRATES)
• Is it cyclical? If no pattern/association with menstrual cycle then unlikely to be gynaecological in origin
• Bowel or urinary symptoms
• STI and PID history (any vaginal discharge)
• Menstrual history e.g. endometriosis causes pain before period starts
• Social history
60-year-old woman, leakage of urine.
Differential diagnosis:
• Stress urinary incontinence (sphincter problem)
• Urge urinary incontinence (detrusor over activity)
• Mixed incontinence
• Pressure from fibroids/pelvic mass
Key Questions:
• Always begin with asking about duration of symptoms
• Does it occur during:
- Coughing
- Sneezing
- Exertion
- Rules out stress incontinence
• Associated urinary symptoms
- Urgency (urge incontinence)
- Frequency
- Nocturia
- Dysuria à UTI
• Caffeine and fluid intake
• Menstrual history
• Past obstetric history
• BMI
• Smoker/chronic cough/asthma (stress incontinence)
,64-year-old patient presenting with bleeding.
Differential diagnosis:
• Commonest cause is atrophic vaginitis – low oestrogen and vaginal tissue becomes friable and can bleed
• Next commonest cause is polyps which are generally benign and can be either cervical or
endometrial
• Most risky = endometrial cancer. Only 5-10% of patients with post-menopausal bleeding will have cancer.
However, needs to be excluded.
Key Questions:
• Bleeding details
- Timing
- Number of episodes
- Provoked
- Nature
• Endometrial cancer risk factors
- Hyperoestrogenic state
o Early menarche
o Late menopause
o Nulliparity
o Obesity
o Diabetes
o HRT (length and type)
• Patient ICE
32-year-old presents to A&E, she is pregnant with a history of bleeding.
Differential Diagnosis:
• Miscarriage
• Ectopic
• Viable pregnancy
Key Questions:
• LMP
• Nature of bleeding (how severe?)
• Pain (cramping – miscarriage is often bilateral cramping pain or sharp; ectopic is usually sharp pain at one point)
• Previous gynae and obs history (e.g. previous ectopic increases risk of next)
• STI
• Any pregnancy scans
• Remember these patients may be very anxious
GYNAECOLOGICAL EXAMINATION
General
• Effects or, more rarely, causes of gynaecological problems
• Assess general health and incidental disease
• General appearance
• Weight
• Temperature
• BP and pulse
• Anaemia, jaundice or lymphadenopathy should be noted
Abdominal Examination
• Inspect
o Scars – especially just above symphysis pubis and in the umbilicus
o Distribution of body hair
o Irregularities, striae and hernias
• Palpate
o Masses or tenderness
o Palpate down from above umbilicus down to symphysis pubis
• Percuss
o Look particularly for shifting dullness
• Auscultate
o Bowel sounds
, Vaginal Examination
• Inspect
o Coloured areas, ulcers or lumps on vulva
o Evident prolapse at intraoitus
• Digital bimanual examination
o To assess pelvic organs
o Press left hand on abdomen above symphysis pubs and two fingers of right hand inserted into vagina
o Uterus is normally size and shape of a small pear
§ Assess size, consistency, regularity, mobility, anteversion or retroversion and tenderness
o Cervix
§ Hard or irregular
o Adnexa
§ Lateral to uterus on either side, containing tube and ovary
§ Tenderness, size and consistency assessed
§ ? Separate from uterus
o Pouch of douglas
§ Uterosacral ligaments should be palpable
§ Even, irregular or tender?
§ Palpable mass?
• Cusco’s speculum
o Allows inspection of cervix and vaginal walls
o Look for ulceration, spontaneous bleeding or irregularities
o Cervical smear can be taken
• Sim’s speculum
o Better inspection of vaginal walls and prolapse
o Patient positioned in left lateral position with legs partly curled up
o Press one end into the posterior wall to allow visualisation of anterior wall
o Prolapse of the wall or cervix or vaginal vault can be assessed if you ask the patient to bear down
• Rectal examination
o Appropriate if posterior wall prolapse to distinguish between enterocoele and rectocoele
o Also for assessing malignant cervical disease
o Also rectovaginal endometriosis
