Gynae History Taking and Management

Question 1

Outline the structure of how to take a gynae history

Answer 1

History of presenting complaint
Ask about other key gynae sxs
Menstrual Hx
Sexual Hx
Contraception and Reproductive Plans
Obstetric Hx
Past gynae history and Smears
Fam Hx of gynae Problems
Past Medical Hx and Surgeries
Drug Hx and Allergies
Social Hx and ICE

Question 2

What sxs should you screen for in every gynae hx?

Answer 2

abdo pain, abnormal bleeding, abnormal discharge, dyspareunia, vulval skin changes, itch, fatigue, fever, weight loss, change in bowel habit or waterworks

Question 3

What conditions should you screen for in a gynae PMHx?

Answer 3

Migraine with aura, previous VTE and 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 4

What should you ask about in a HPC for bleeding in early pregnancy?

Answer 4

When did it start? How much bleeding? Clots? Pain?

Symptoms of an ectopic pregnancy:
Unilateral abdominal pain
Nausea & vomiting
Pre-syncope or syncope
Back pain, shoulder tip pain, rectal pressure or pain

Question 5

What should you screen for in the PMHx of bleeding in early pregnancy?

Answer 5

Previous pelvic inflammatory disease
Previous tubal surgery including sterilisation
Fertility treatment

Question 6

What can cause bleeding in early pregnancy?

Answer 6

Miscarriage
ectopic pregnancy
cervical ectropion
vaginitis
Trauma
polyps
implantation bleeding (dx of exclusion)

Question 7

How can you investigate bleeding in early pregnancy?

Answer 7

Observations including pulse, bp, temperature
Refer to EPAU
Beta-HCG
FBC, clotting profile, G&S/crossmatch
Antibody screen
Transvaginal USS

Question 8

What questions should you ask to explore a presenting complaint of abnormal menstrual bleeding?

Answer 8

What is the probelm?

LMP? How long did it last for? How long do your periods normally last? How long do you have between periods? (length of cycle)
Is your cycle regular?

What is the flow like? Do you pass any clots/have any flooding? Any pain?

How do your periods now compare to your periods in the past? When did you start your periods?

Question 9

What questions can you ask in addition to your menstrual history for a patient with suspected PCOS?

Answer 9

Any changes to your weight?
Any changes to your skin? (new acne or hyperpigmentation)
Any changes to your hair? Any new hair growth on your face?

Question 10

What can cause irregular menstrual bleeding?

Answer 10

PCOS
Perimenopause
Thyroid disease/Diabetes
Eating disorders/excessive exercise
Contraceptive/Hormonal treatments
Medications e.g. anti-psychotics, anti-epileptics

Question 11

How could you investigate irregular menstrual bleeding?

Answer 11

Pregnancy test

Blood tests:
TFTs and prolactin
Oestradiol/Progesterone/Testosterone
LH: FSH ratio (raised in PCOS)
SHBG (raised in PCOS)

Progesterone challenge test to elicit a withdrawal bleed:
A bleed suggests there are adequate levels of oestrogen however the patient is not ovulating i.e. PCOS.
No bleed could mean there are very low levels of oestrogen or an outflow obstruction.

Chech glucose tolerance

Ultrasound scan – to visualise ovaries and pelvic anatomy

Question 12

How could you investigate someone who has primary amenorrhea?

Answer 12

Same as for irregular menstrual bleeding

Also:
17 hydroxyprogesterone (congenital adrenal hyperplasia)

Karyotyping – if suspecting a genetic abnormality

Question 13

How does PCOS present in a history?

Answer 13

oligomenorrhea and amenorrhoea
subfertility and infertility
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans

Question 14

How can you diagnose PCOS?

Answer 14

Rotterdam Criteria
2/3 of the following:

Oligo- and/or anovulation
i.e. oligo- or amenorrhoea

Clinical and/or biochemical signs of hyperandrogenism
e.g. hirsutism, acne, or elevated levels of total or free testosterone

Polycystic ovaries (on USS)
12 or more follicles / increased ovarian volume (greater than 10 cm3).

Question 15

How can you manage PCOS?

Answer 15

COCP to regulate periods

topical eflornithine for hirsutism

weight reduction and clomifene for feriility, specialist referral required

Question 16

How would you explain a diagnosis of PCOS to a patient?

Answer 16

PCOS is a common condition (1/10 women affected) that affects how your ovaries work.

In PCOS, your ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs. Because of this they dont release eggs as regularly as they should, which is why your periods are less regular.

Women with PCOS also have high levels of “male” hormones, which may cause physical signs such as excess facial or body hair.

Question 17

What should you ask a patient with dysmenorrhea before going into the cycle length and flow etc?

Answer 17

Where abouts is the pain? When does it come on in relation to your period? Does anything relieve it?

Question 18

What can cause secondary dysmenorrhea?

Answer 18

Endometrios
Adenomyosis
Fibroids (myomas)
PID
Ovarian cancer
Cervical cancer
Recent IUD insertion
Non gynae e.g. IBS, lactose intolerance, appendicitis

Question 19

How does endometriosis present in the history and on examination?

Answer 19

secondary dysmenorrhea
deep dyspareunia
dysuria, dyschezia
subfertility

OE: reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions

Question 20

How would you investigate endometriosis?

Answer 20

laparoscopy is the gold-standard investigation

referral to gynaecology

Question 21

How would you explain the diagnosis of endometriosis to a patient?

Answer 21

Endometriosis is a condition where cells that make up the lining of the womb (uterus) are found elsewhere in the body (where they shouldn’t be)

When you have a normal period, the lining of your womb builds up and then breaks down and bleeds

Each month these cells (In other places) do the same thing, so they build up and then break down and bleed. Unlike the cells in the womb that leave the body as a period, this blood has no way to escape.

There is a really good website called Endometriosis UK that provides information about the condition and support.

Question 22

How would you explain the impact of endometriosis on fertility to a patient?

Answer 22

Unfortunately endometriosis can have an impact on fertility, because it can cause scar tissue to form. Scar tissue around the ovary can make it harder for an egg to be released and scar tissue around your tubes can make it harder for your egg to travel down the tube to your womb.

However, every person is unique and it depends on the severity of your endometriosis and other factors that effect your fertility such as age.

It is thought that roughly 50% of women with endometriosis have difficulty getting pregnant.

Question 23

How would you answer a patient who asks “ can you give me anything for my endometriosis to improve my fertility?”

Answer 23

Unfortunately research has shown that drug treatment for endometriosis does not improve fertility, and it’s main aim is pain relief. Also a lot of the drugs we give to manage endometriosis are actually contraceptives!

However surgery for endometriosis is known to improve fertility, so that is definetely something to consider.

Question 24

How would you manage endometriosis?

Answer 24

NSAIDs and/or paracetamol

COCP or progestogens e.g. medroxyprogesterone acetate

GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels

Surgery

Question 25

What questions should you ask in the history of presenting complaint for heavy menstrual bleeding?

Answer 25

Same as for any patient with abnormal menstrual bleeding

Rule out other causes:
Do you feel tired, short of breath or more short of breath on exertion? (screen for anaemia)

Have you been having any abdominal pain or bloating? (malignancy but also endometriosis/fibroids)

Any fever, lethargy, weight loss, or night sweats? (malignancy)

Any excessive tiredness, weight gain, dry hair/hair loss, feeling cold when others are not? (hypothyroidism)

Have you had any bleeding problems in the past, or does this run in the family? (coagulopathy)

Question 26

What should you look for in the examination of someone with heavy menstrual bleeding?

Answer 26

Look for signs of anaemia (pallor, glossitis, angular stomatitis)

Assess BMI

Speculum and Bimanual examination

Question 27

How would you investigate a patient with Heavy Menstrual Bleeding?

Answer 27

Pregnancy test
FBC: to exclude anaemia, Thyroid function test and coagulation screen

Imaging:
Refer for a transvaginal US to exclude local structural causes (fibroids, polyps)

Further investigations:
Hysteroscopy: for direct visualisation of the uterine cavity
Endometrial biopsy for histological examination (e.g. if abnormal endometrial thickness, intermenstrual bleeding or postmenopausal bleeding)
Vaginal swabs (if considering STI)

Question 28

Give some differential diagnoses for heavy menstrual bleeding

Answer 28

PALM COEIN

Polyps
Adenomyosis
Leiomyoma (fibroids)
Malignancy (endometrial cancer)
Coagulation disorders
Ovarian dysfunction (PCOS)
Endometrial (endometriosis)
Iatrogenic (copper coil, anti-coagulants)
Not otherwise classified (infection, hypothyroidism, extremes of reproductive age)

Question 29

What can you give for symptomatic mx of heavy menstrual bleeding?

Answer 29

Does not require contraception =
mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period

Requires contraception =
IUS (Mirena) should be considered first-line
COCP
long-acting progestogens

Question 30

How may fibroids present in a history?

Answer 30

heavy bleeding / iron-deficiency anaemia
lower abdominal cramping pains
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility

Question 31

How may you investigate and manage fibroids?

Answer 31

transvaginal USS

Managment of heavy bleeding:
levonorgestrel IUS: cannot be used if there is distortion of the uterine cavity
NSAIDs e.g. mefenamic acid
tranexamic acid
COCP

Shrinking/ removing fibroids:
GnRH agonists
myomectomy

Question 32

How would you explain fibroids to a patient?

Answer 32

We think your symptoms are being caused by something called fibroids, which are non cancerous growths that develop in or around the womb.

Fibroids are common, with around 2 in 3 women developing at least 1 fibroid at some point in their life.

It is thought that their growth might be to do with the hormone oestrogen, and because of this they often grow in your fertile years and shrink on their own after menopause.

Question 33

How would you answer “ can fibroids affect my fertility”?

Answer 33

This varies from person to person, but there is a chance that large fibroids can have an impact on fertility.

If they sit within the lining of the uterus they can sometimes put pressure on your tubes which makes it harder for an egg to travel down them.

If there are enough of them or they are big enough they might make it harder for an egg to attach itself to the lining of the womb.

However there are lots of options e.g. surgery to improve outcomes…

Question 34

What questions are important to ask in a history of presenting complaint for post menopausal bleeding?

Answer 34

Volume, frequency, clots, colour
Ask key gynae symptoms but especially weight loss, fatigue, loss of appetite, bloating

Question 35

What should you explore in a history of post menopausal bleeding (after the presenting complaint)?

Answer 35

Menstrual History: Including age of menarche and menopause
Past gynae history: Including surgery, smear tests
Obstetric History: Gravidity + parity
Medications: Especially HRT, anticoagulants
Family history: e.g., gynae cancers, breast cancer, bowel cancer

Question 36

How would you investigate post menopausal bleeding?

Answer 36

2WW referral because postmenopausal bleeding is cancer until proven otherwise

Bloods: FBC (checking for anaemia)
Abdominal, speculum and bimanual examination (cervical smear at the same time)
Transvaginal ultrasound scan – looking for thickening of endometrium (>4mm)
Hysteroscopy, colposcopy +/- biopsy – detect polyps or other lesions

Question 37

What can cause post menopausal bleeding?

Answer 37

Vaginal atrophy
Endometrial hyperplasia
Endometrial cancer
Cervical cancer
Polyps

Question 38

How could you explain vaginal atrophy to a patient?

Answer 38

the most common cause of bleeding after the menopause
reduction in oestrogen following the menopause causes the thinning, drying, and inflammation of the walls of the vagina

We can manage this with a topical oestrogen cream, lubrication and HRT.

Question 39

What should you ask in a sexual history?

Answer 39

Are you currently sexually active?Do you have a regular partner? When was your last sexual health screen?
Do any of your partners have any known STIs?
Are you using contraception? Have you used anything in the past?
Is there any chance you could be pregnant (e.g. missed pills)?
Do you have any vaginal symptoms (e.g. discharge, itching)?
Do you experience any problems during sex (e.g. dyspareunia)?

Question 40

What would be your differentials fopr someone with suspected PID?

Answer 40

uncomplicated STI
UTI / cystits / pyelonephritis
ectopic pregnancy
ovarian cyst rupture / ovarian torsion
endometriosis
appendicitis

Question 41

How would you investigate suspected PID?

Answer 41

Speculum and bimanual – assess for cervical motion tenderness
Temperature
Vulvovaginal, high vaginal and endocervical swabs
Urine dip, urine pregnancy test
Full STI screening including blood tests for HIV and syphilis

Question 42

How would you manage PID?

Answer 42

Oral doxycycline and metronidazole 14 days
IM ceftriaxone
Partner notification if required for STIs

Question 43

How would explain PID and its complications to a patient?

Answer 43

Pelvic Inflammatory Disease in when you have an infection, most commonly a sexual transmitted infection, which spreads upwards to involve your womb, fallopian tubes and your ovaries.

The fallopian tubes can become scarred and narrowed if they’re affected by PID. This can make it difficult for eggs to pass from the ovaries into the womb.

This can increase your chances of a pregnancy that grows outside the womb, also called an ectopic pregnancy. The longer treatment is delayed the higher the risk is, but luckily if we catch it early and treat it, the risk is much lower.

Question 44

How could you explore a presenting complaint of prolapse?

Answer 44

Can you feel something coming down? Dragging/ heavy sensation? Have you noticed a lump? Can can push it back?
Urinary sxs- incontinence, frequency, retention
Bowel sxs- constipation, urgency, incontinence
Are you currently sexually active? Sexual sxs- dyspareunia, altered sensation, reduced enjoyment

Question 45

What should you ask in the past medical history and family history of someone with prolapse?

Answer 45

Menstrual hx – are you currently menstruating? Date of menarche and menopause? Past menstrual problems?

Obstetric hx – how many children? Mode of delivery? If vaginal, were they prolonged or instrumental?

PMH – any chronic respiratory diseases (cough) , chronic constipation (straining)

Fam Hx – gynae issues, connective tissue disorders

Question 46

How would you investigate prolapse?

Answer 46

Ensure bladder and bowel are empty before examination
Speculum and bimanual, see if reducible, ask to cough
Bladder diaries if incontinent

Question 47

How would you explain prolapse to a patient?

Answer 47

Prolapse is when one of the organs in your pelvis (in your case your womb) bulges down into your vagina.

The chance of this happening increases as you get older, but it isn’t an inevitable or normal part of ageing and there is lots we can do for you!

It happens because your pelvic floor muscles that keep everything in place become weaker over time, and things like childbirth can stretch and strain them even more.

Question 48

How can you explain management of prolapse to a patient?

Answer 48

There are lots of things you can do yourself:
regular pelvic floor exercises to strength pelvic floor muscles
eat a high-fibre diet to avoid constipation or straining when you go to the toilet for a poo
avoid heavy lifting
maintain a healthy weight

And there are things we can do for you:
Vaginal oestrogen cream to reduce atrophy
Ring pessary
Surgery – avoid mesh procedures

Question 49

What can you ask in a presenting complaint of incontinence?

Answer 49

How long has it been going on? Does anything in particular make you pass urine? When you cough/sneeze/laugh? Do you have a sudden urge to go to the toilet and not make it in time?

Other sxs: Going more frequently? Waking up in the night? Pain? Blood in urine? Hesitancy? – do you ever struggle to start urinating? Terminal dribbling? – after you’ve finished urinating do you find it difficult to stop the stream / it slows to a dribble? Splitting of stream?

RULE OUT CAUDA EQUINA

Question 50

What do you need to ask in a social history of incontinence?

Answer 50

diet and bowel habit
caffeine intake
alcohol intake
smoking and chronic cough
heavy lifting? occupation?
Impact on mental health and social life!

Question 51

How should you investigate incontinence?

Answer 51

Examination:
Abdo exam , DRE
External genitalia
Cauda equina

Investigations:
urine dip
bladder diaries
QoL questionnaires
urodynamic assessment

Question 52

How would you explain stress incontinence to a patient?

Answer 52

We all have muscles in our pelvic floor that keep everything in place, and we also have spinchter muscles which sit outside your bladder and squeeze tightly to make a seal so that no urine slips out.

Sometimes over time these muscles can become weaker and not quite as good at doing their job.

When you do things like cough, or strain if youre having a poo, the pressure in your tummy goes up, and that squeezes your bladder. And if your muscles are a bit weaker, they might be able to manage throughout the day but theyre not strong enough to hold everything in when your bladder is being squeezed.

Question 53

How would you explain the management of stress incontinence to a patient?

Answer 53

Pelvic floor muscle exercises to strengthen those muscles
Fibre in your diet to help with any constipation because being backed up can put pressure on your bladder
Reducing caffeine and alcohol because that can irritate your bladder
Lose weight

Can give you a medication to help as well, called duloxetine

Can consider surgery

Question 54

How would you explain urge incontinence and its management to a patient?

Answer 54

bladder is getting signals from your brain to squeeze when it shouldn’t, so it is giving you the urge to go at unpredictable times

We can suggest regular toileting times to train your bladder and help it to remeber to squeeze on a bit of a schedule

We can also give you medication to tell your bladder to relax (eg mirabegron)