Gynae

Question 1

What is the format of the gynae history

Answer 1

WIPERQQ
Presenting Complaint
Gynae baselines and symptoms
Systems inquiry
Menstrual hx
Contraception
Reproductive plans
Past gynae history
Cervical screening
PMHx
Obstetric Hx
DHx
FHx
SHx
Close

Question 2

What are key symptoms to screen for in a gynae history (7)

Answer 2

abdo/pelvic pain
Postcoital bleeding
Intermenstrual/post-menopausal bleeding
Abnormal discharge
Dyspareunia
Vulva changes
Systemic symptoms

Question 3

What should you ask about in the systems review in the gynae hx

Answer 3

Systemic: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease, urinary tract infection), weight loss (e.g. endometrial cancer)

Respiratory: dyspnoea (e.g. anaemia), haemoptysis (e.g. endometriosis)

Gastrointestinal: abdominal pain (e.g. ectopic pregnancy, dysmenorrhoea), painful defecation (e.g. endometriosis), abdominal bloating (e.g. ovarian cancer)

Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract infection), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)

Musculoskeletal: shoulder tip pain (e.g. ectopic pregnancy)

Dermatological: white patches on the vulva/vagina associated with pruritis (e.g. lichen sclerosus)

Question 4

What do you ask about in a menstrual hx

Answer 4

Duration of periods
Frequency
Blood volume
Pain
Date of last period
Age at Menarche
Menopause

Question 5

What can the following conditions indicate in a gynae history
a) Abdominal/pelvic pain
b) Postcoital bleeding
c) intermenstrual bleeding

Answer 5

a) causes include ectopic pregnancy, ruptured ovarian cyst, endometriosis, pelvic inflammatory disease and ovarian torsion.

b) vaginal bleeding occurring after sexual intercourse. Causes include cervical ectropion, cervical cancer, gonorrhoea, chlamydia and vaginitis.

c) vaginal bleeding occurring between menstrual periods. Causes include contraception (e.g. Mirena coil), ovulation, miscarriage, gonorrhoea, chlamydia, uterine fibroids, perimenopause and malignancy (e.g. uterine cancer, cervical cancer, vaginal cancer).

Question 6

What can the following symptoms suggest in a gynae history
a) Post menopausal bleeding
b) abnormal vaginal discharge
c) dyspareunia

Answer 6

a) bleeding that occurs after the menopause. Causes include vaginal atrophy, hormone replacement therapy and malignancy (e.g. uterine cancer, cervical cancer and vaginal cancer).

b) causes include endometriosis, vaginal atrophy, gonorrhoea and chlamydia

c) causes include vaginal atrophy, vaginal thrush, gonorrhoea and lichen sclerosus.

Question 7

What further details should you ask about for vaginal discharge?

Answer 7

Volume
Colour
Consistency
Smell

Question 8

Give 4 STIs which can cause discharge

Answer 8

Gonorrhoea and chlamydia may present with abnormal vaginal discharge.

Bacterial vaginosis typically presents with an offensive, fishy-smelling vaginal discharge, without any associated soreness or irritation.

Trichomonas vaginalis typically presents with yellow frothy discharge with associated vaginal itching and irritation.

Question 9

What should you clarify about dyspareunia?

Answer 9

the duration of the symptom
the location of the pain (e.g. superficial or deep)
the nature of the pain (e.g. sharp, aching, burning)

Question 10

What underlying causes could vulval changes indicate

Answer 10

Infections such as candida (thrush), bacterial vaginosis and sexually transmitted infections (e.g. gonorrhoea).

Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina.

Lichen sclerosus appears as white patches on the vulva and is associated with itching.

Question 11

What is the average duration of a period

Answer 11

5 days (7 days is considered prolonged)

Question 12

How frequent are periods generally

Answer 12

Periods typically occur every 28 days, however, there is significant variation between individuals (21-40 days).

Question 13

How much is the average menstrual blood loss

Answer 13

~40mls (8 teaspoons).

Heavy menstrual blood loss is defined as more than 80mls (16 teaspoons) or having periods that last longer than 7 days.

The definition of what is a “heavy period” compared to a “normal period” is highly subjective, therefore you should ask the woman how the current periods compare to her usual loss. If the volume of bleeding is impacting on the woman’s day to day life, it is significant.

Question 14

Give examples of operations that patients may mention in a gynae hx

Answer 14

Abdominal or pelvic surgery
Caesarean section
Loop excision of the transitional zone (LETZ)
Vaginal prolapse repair
Hysterectomy

Question 15

Give 4 examples of medical conditions relevant to gynaecological presentations

Answer 15

Migraine with aura: oestrogen containing medications (e.g. combined oral contraceptive) would be contraindicated.

Previous venous thromboembolism (VTE): oestrogen containing medications would be contraindicated.

Breast cancer (current or previous): use of oestrogen containing medications would be usually be contraindicated or require specialist input before being commenced.

Bleeding disorders (e.g. Von Willebrand’s) would be relevant if a patient presented with heavy vaginal bleeding.

Question 16

What details of the current patient should you discover when history taking (if relevant) (4)

Answer 16

Gestation

Symptoms associated with pregnancy (e.g. nausea, vomiting, back pain)

Complications (e.g. pre-eclampsia, cervical neck incompetence)

Recent scans results

Question 17

What should you find out about previous pregnancies in a gynae hx

Answer 17

Age of children

Birth weight

Mode of delivery

Complications in the antenatal, perinatal, postnatal period

If relevant, ask if the patient is currently breastfeeding, as this is a contraindication to some types of contraceptives (e.g. combined oral contraceptive)

Question 18

Name 2 medications that can cause gynaecological issues or interfere with gynaecological medications:

Answer 18

St John’s Wort increases the metabolism of the COCP reducing its effectiveness.

Antibiotics may cause secondary vaginal thrush.

Question 19

What do you need to ascertain about someone using HRT

Answer 19

Duration of use

Method of delivery (e.g. patch, gel, pessary)

Frequency of treatment (e.g. cyclical or continuous)

Type of treatment (e.g. combined or oestrogen-only)

Question 20

Give 5 examples of medications commonly prescribed to patients with gynaecological disease

Answer 20

Tranexamic acid (e.g. to manage menorrhagia)

Contraceptives (e.g. COCP, POP)

Hormone replacement therapy (e.g. combined or oestrogen-only)

NSAIDs (e.g. to manage dysmenorrhoea)
GnRH analogues (e.g. to manage endometriosis)

Question 21

What should you be looking out in the family hx part of a gynae hx

Answer 21

bleeding disorders as menorrhagia may be the first presenting symptom of an inherited bleeding disorder such as Von Willebrand’s disease

Ask the patient if there is any family history of ovarian, endometrial or breast cancer which may suggest possible familial inheritance (e.g. BRCA gene)

blood clots. Patients who have a significant family history of VTE in a first-degree relative (particularly if they were less than 45 when it developed) may be at increased risk of VTE and therefore medications such as combined oral contraceptives may be contraindicated

Question 22

What part of the social hx would mean COCP is contraindicated

Answer 22

If smoking more than 40 cigarettes a day, the COCP would be contraindicated.

If over 35-years-old and smoking more than 15 cigarettes a day, the COCP would be contraindicated.

Question 23

Why is patient weight relevant to a gynae hx

Answer 23

Obesity significantly increases the risk of developing malignancy and is also associated with polycystic ovarian syndrome.

Anorexia can result in oligomenorrhoea (infrequent periods) or amenorrhoea (absence of menstruation).

A raised BMI may be a contraindication to some treatments, including combined oral contraceptives.