Taking a history
Taking a good history is fundamental in the diagnosis and management of any patient presenting with vulval symptoms. This step is the keystone for the clinical diagnosis and for establishing the doctor–patient relationship.
It is important to recognize that there are several factors that can make the history difficult to obtain in full. Older patients are reluctant to give intimate information. The presence of nonspecific symptoms such as itching, burning and pain can lead to confusion of the clinical picture and the short time for the consultation is often inadequate to evaluate the emotional aspects of the problem for a complete psychosexual assessment. Some of these issues may only become apparent during further follow‐up consultations.
First of all, it is important to use the right setting, choosing a quiet and discrete ambient area without disturbance. In establishing an initial rapport with the patient, the healthcare professional should be approachable with a friendly manner. After introducing yourself, it is important to explain the reason for the interview, seeking consent for taking notes, and demonstrating respect for, and interest in, the patient’s problem.
Ensure that there is correct identification of the patient with the date and place of birth. Open questions are useful initially to identify the patient’s major symptoms, focusing later on the specific reasons for attending for consultation. Show that you are listening, make eye contact with the patient, tailor the questions to the information being given, and reflect back what the patient is saying, using concise and easily understood language. The patient is often unfamiliar with the different parts of the vulva and they frequently use the term ‘vagina’ to describe the external genitalia. Try to discuss the anatomy of the vulva and the localization of the disease in a simple manner and clarify statements and jargon used by the patient.
To obtain all the clinical information it is suitable to start with an enquiry about the general medical history, followed by the gynaecological and dermatological history and, at the end, to explore a specific history about the vulval problem.
General medical history
- General medical condition and past medical history.
- Family history of disease.
- History of allergic disease such as asthma or hay fever.
- History of systemic, metabolic, autoimmune diseases. Diabetes, especially if poorly controlled, should deserve special attention in the investigation of some common vulval symptoms such as pruritus.
- It is useful to check for any medical prescriptions, for drugs taken orally or used topically in the previous 6 months. This should also include self‐administered preparations and those bought over the counter.
- Smoking history – this is very important as smoking is a significant risk factor in those with vulval intraepithelial neoplasia or hidradenitis suppurativa.
- Travel history – this may be relevant to some rare infections.
- A record of body mass index (BMI) is of particular importance because obesity affects vulval physiology with its unfavourable effect of increased friction on the skin potentially leading to maceration. This can then predispose to infections such as candidiasis. Hygiene practices may also be ineffective if the patient cannot reach the area adequately.
Gynaecological history
- Menstrual history – record the age of the first menses and, if relevant, the menopause
- Results of cervical cytology tests and any abnormalities or treatment required.
- Pregnancy – the number of pregnancies (including terminations and miscarriages) and mode of delivery. Any lacerations or problems after the delivery should be noted.
- Habits regarding hygiene and clothing.
- Mode of contraception should be noted, if relevant.
- Enquire about any previous sexually transmitted diseases or recurring infections.
- Presence of genital or anal prolapse, or urinary incontinence with daily use of pads should be checked.
- Any surgical procedures on the lower genital tract, radiotherapy or chemotherapy should be recorded.
