Chapter 5 History and Examination
Taking the history
The key to any consultation is taking an accurate and complete history. This is relevant in all medical disciplines and particularly in gynaecology. Do not assume that the referral letter contains all the relevant information. It is important to ask what the main problem is – it may be hidden away among a list of relatively unimportant or misleading complaints.
Women may find discussing gynaecological symptoms difficult and require
| Privacy | Time | Sympathy |
|---|---|---|
| The consultation should be held in a room with adequate facilities and privacy. Permission should be sought for any students who are present | The patient should be allowed to tell her own story before any attempt is made to elicit specific symptoms | The doctor’s manner must be one of interest and understanding |
Gynaecological history follows the standard principles of medical history taking but there are a number of other issues that are relevant to gynaecology.
| Standard history taking | Additional features relevant to gynaecology |
|---|---|
| Age | Parity |
| Presenting complaint | Obstetric history |
| Past medical history | Contraception and fertility requirements |
| Medication history | Smear history |
| Allergies | Menstrual history – this will often be part of the presenting complaint |
| Social history | |
| Family history | |
| Systemic enquiry |
Parity and obstetric history
The first number refers to the number of pregnancies beyond 24 weeks. This cut off largely relates to the gestation of potential viability although any liveborn infant before 24 weeks would also be counted among this number. The second number refers to pregnancies of less than 24 weeks. In practical terms, the easiest way to ask about this is to ask if the woman has any children and then ask if she has had any other pregnancies. Pregnancies in this category are likely to be miscarriages, terminations or ectopic pregnancies. It is important to be sensitive about the terminology when discussing pregnancy loss. The term ‘abortion’ is out dated and should not be used when discussing miscarriage.
Details of the mode of delivery of any children are always important in gynaecology, but other factors such as perineal trauma and postnatal infection are also relevant.
Contraceptive and fertility requirements
This information will be relevant to many gynaecological issues as potential treatments may affect fertility, and many contraceptive treatments will have a useful effect; for example, the combined oral contraceptive pill and menstrual loss and dysmenorrhoea. Infertility may also be the presenting complaint.
Smear history
Women should be asked when their last cervical smear was performed and if the result was normal. Any abnormal smears and colposcopy history should be noted. Within the UK, routine smears are generally performed by primary care, but cervical cytology may be required for symptomatic women.
Menstrual history
At the very minimum, the last menstrual period (LMP) should be recorded. For premenopausal women, the length of a menstrual period and frequency of period should be recorded. This is conveniently expressed as a numerical fraction. Thus, 5/28 means the cycle lasts for 5 days and occurs every 28 days. Make sure that you obtain the number of days from the start of one period to the start of the next. Irregular cycle may produce fractions such as 5–10/21–35.
Useful definitions
Menarche – first menstrual period.
Menopause – date of final menstrual period. This can only be defined with certainty after a year has elapsed since the final menstrual period. It is also useful to ask about menopausal symptoms and hormone replacement therapy (HRT) use. The classic menopausal symptom is vasomotor flushes, but a myriad of other symptoms can also be experienced (see Chapter 18 The Menopause).
Menorrhagia – heavy periods. This is one of the commonest reasons that women are referred to gynaecology. You should ask for how long and how often bleeding occurs. The passage of clots and flooding through sanitary protection are signs that the menstrual flow is excessive. It can also be useful to ask about frequency of changing sanitary protection and whether ‘double’ protection is required, that is, having to wear a sanitary towel and tampon at the same time.
Abnormal Bleeding
Postcoital bleeding – bleeding occurring after intercourse.
Intermenstrual bleeding – bleeding between periods.
Postmenopausal bleeding – bleeding more than one year since LMP.
Irregular Bleeding
Primary amenorrhoea – failure to menstruate by age 16.
Secondary amenorrhoea – no menstruation for 6 months after periods are established.
Remember that anovulatory cycles occur at the extremes of menstrual life. It is therefore physiological to have erratic infrequent periods in the first few years after menarche and in the perimenopause.
Pelvic pain
This may or may not be related to the menstrual cycle. Premenstrual pain may represent endometriosis. Dysmenorrhoea refers to painful menses, usually of a crampy nature. This is usually central low abdominal cramp but can be referred to the thighs and lower back.
Primary dysmenorrhoea – periods have been painful since established menstruation has occurred.
Secondary dysmenorrhoea – periods have become painful. This is thought to be more likely to be associated with pelvic pathology.
Mittelshmertz – mid-cycle pain related to ovulation.
There are a number of other organ systems that can be responsible for pelvic pain. The most likely sources within the pelvis are the gastrointestinal and urinary tracts. It is important to ask about these systems when assessing for a source of pain. For example, acute right iliac fossa pain could represent an ovarian cyst accident or appendicitis among other diagnoses. Classically, appendicitis will also present with anorexia.
The nature and pattern of pain will also be useful. Bladder pain is central and low, but renal pain will radiate to the loins.
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