and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
History
Whilst a gynaecological consultation is a specialist referral, it is important to consider the patient as a whole, and to have an overall understanding of her medical history. Therefore a general medical history should be obtained, followed by a gynaecological history.
The administrative staff will confirm the patient details prior to the consultation. This is important to ensure that the notes match the patient, but should also be confirmed by the clinician at the start of the consultation. Personal details must be treated confidentially.
It is also important to make a note of anyone else present during the consultation e.g. partner, health care assistant or medical student!
When the woman presents (or couple if it is a joint consultation, such as for subfertility) it is useful to enquire about occupation. This not only gives a clue as to how to explain things, but also acts as an ice breaker.
Menstrual History
This is the most important part of the consultation.
These are the important questions to ask:
Menarche (age of first menses)
Regularity of cycles. This is abbreviated as K = a − b/c − d, and X
a is the shortest number of days of bleeding
b is the longest number of days of bleeding
c is the shortest cycle (counting from the first day of one bleed to the first day of the next bleed)
d is the longest cycle
X is the average cycle length
Last normal menstrual cycle (LNMP)
The amount of menstrual bleeding (is it excessive – passing clots, flooding, the frequency of changing pads/tampons)
Are “periods” painful (dysmenorrhea)
Is it worse pre-menstrually and relieved by bleeding – (spasmodic dysmenorrhoea)
Does it get worse as menstruation progresses (suggestive of endometriosis)
Intermenstrual bleeding (IMB) or postcoital bleeding (PCB)?
Remember that women using hormonal contraception do not have a menstrual cycle. Women using combined hormonal contraception have withdrawal bleeds associated with a hormone free interval.
Contraceptive History
The use of contraception, including past and current methods should be recorded.
Obstetric History
Any previous pregnancies including their outcome; delivery, pregnancy loss, therapeutic termination of pregnancy (TOP).
The abbreviation used is PxGy– where P = Parity means the number of times the woman has given birth to a baby of at least 28 weeks gestation.
G = Gravidity and means the number of times the woman has been pregnant.
The outcome of pregnancies should be summarised (See Chap. 5).
Cervical Cytology
When was her last cervical smear test and what was the result.
General Medical History
Illnesses
Operations
Medications
Allergies
Social history – smoking/alcohol/recreational drug use
Presenting Problem
The appropriate questions for specific complaints will be covered in the relevant chapters. Examples of the correct questions to ask for frequently occurring conditions are given here.
Heavy Menstrual Bleeding (HMB)
When did the pattern change?
Precipitating factors, such as the use of intrauterine contraception (IUC)
Details regarding the woman’s cycle, as described above.
Intermenstrual Bleeding (IMB)
When did it start?
Are there any precipitating cause, such as sexual intercourse (post coital bleeding – PCB)
Relationship to menses
Subfertility
Duration without contraception – “trying”
Frequency and adequacy of sexual intercourse (timing, erections, penetration, ejaculation)
Symptoms and signs of ovulation (menstrual pattern, mucous changes, premenstrual breast changes, bloating, ovulation pain (Mittelschmerz))
Any history suggesting tubal disease (appendicitis, sexually transmitted infections (STIs))
History suggesting endometriosis (dysmenorrhoea)
Partner’s reproductive history, testicular injury, STIs, mumps
Urogynaecology
Complains of “something coming down”
Urinary frequency, urgency, incontinence, stress incontinence, dysuria, nocturia
Menopause
Regularity of “periods”
Symptoms of hormone imbalance/oestrogen deficiency. Classically this includes hot flushes and night sweats.
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