Gynae history taking ( Lecture)

Question 1

What settings would you take a gynae history in?

Answer 1

Outpatient clinic (general, infertility, colposcopy)
Pre-operative in theatre assessment unit
Inpatient ward (acute admission, post-operative

Question 2

What might you find different or difficult when taking a history in gynaecology compared to medicine or surgery?

Answer 2

Personal consultations
Ensure privacy and confidentiality
Time to talk, open questions
Majority of gynaecology is ‘benign’
- effect on lifestyle/QOL
- full discussion of management options

Question 3

Important points to remember when taking history?

Answer 3

Age - Women have a clear gynaecological and reproductive timeline (pre vs. post-menopausal)
Hidden agenda - May be underlying psychological or sexual issue

Question 4

How do we take a focused gynae history (key symptoms review)

Answer 4

Presenting complaint (inc. relation to cycle)
Review of key symptoms:
Pain (dysmenorrhoea, dyspareunia)
Bleeding (menorrhagia, IMB, PCB, PMB)
Urinary symptoms (frequency, urgency, incontinence)
Bowel symptoms (dyschezia)
Prolapse (‘something coming down’)
Sexual history

Question 5

Further questions to ask during a focused gynae history?

Answer 5

Menstrual history (all women are potentially pregnant)
Contraception and future fertility plans
Sexual history
Smears (date and result)
Past gynae history
Past obstetric history (pregnancies and outcomes)
Medical history
Family history

Question 6

What to ask for a patients menstrual history?

Answer 6

Last menstrual period (LMP) ? normal ? on time
Menstrual cycle expressed as X/Y
X= Duration (normal 2-7 days)
Y= Cycle (normal 21-35 days)
e.g. 5/28, 7-10/21-35
Cycle = days between Day 1 of period to Day 1 of next
Also: are periods heavy? Are periods painful? Change?

Question 7

You see Jane in clinic. She tells you that her periods are regular, last 5 days and there are 20 days in between
How long is her menstrual cycle?
How would you write it in the notes?

Answer 7

25 day cycle

5/25

Question 8

Bleeding terminology

Answer 8

Withdrawal bleeds: bleeding after withdrawal of exogenous oestrogen +/or progestogen
IMB
PCB
PMB

Question 9

What do menarche, menopause, climacteric and postmenopausal mean?

Answer 9

Menarche: age of 1st period (normal 10-16)
Menopause: age/date of last spontaneous period (normal 40-55, average 51)
Climacteric: years before menopause associated with menopausal symptoms but still menstruating
Postmenopausal: No periods for 1 year after the age of 50 (2 years if <50yrs)

Question 10

How can we ask for a broader gynae history?

Answer 10

Medical and surgical history
- Previous abdo/pelvic surgery
- Major CVS/resp/gastro disease
- Endocrine disease (thyroid, diabetes)
- Haematology (bleeding/clots)
- Breast Ca (↑risk ovarian/endometrial Ca)
FH breast or ovarian Ca (BRCA gene identified?)
Type 2 diabetes (↑ risk endometrial Ca, PCOS)

Question 11

How can we take a good sexual history?

Answer 11

HPC
Date of last sexual contact and number of partners in the last three months
Gender of partner(s), anatomic sites of exposure, condom use, any suspected infection, infection risk or symptoms in partners
Previous STIs
For women: last menstrual period (LMP), contraception, cervical cytology
Blood borne virus risk assessment and vaccination history
Establish competency, safeguarding children/vulnerable adults

Consider
Recognition of gender-based violence/intimate partner violence
Alcohol and recreational drug history

Question 12

How do we take a good fertility history

Answer 12

Duration of infertility, investigation results and previous treatment
Menstrual history.
Medical, surgical, and gynecological history (including STIs/PID, smears, Rubella immunity)
Systems review to include symptoms of thyroid disease, galactorrhea, hirsutism.
Obstetric history
Sexual history, including sexual dysfunction and frequency of coitus.
Family history, including infertility, birth defects, genetic mutations.
Lifestyle history: occupation, exercise, stress, weight, smoking, drug and alcohol use.
Male partner: children to previous partner, lifestyle, PMH including STIs, mumps, testicular trauma

Question 13

How do we take a good urogynaecological history?

Answer 13

HPC
General gynaecology (including obstetric and surgical)
Urinary symptoms: urgency, frequency, incontinence (urge/stress), voiding problems, nocturia
Bowel symptoms: constipation, IBS, digitation, incontinence
Prolapse symptoms: vaginal lump, sensation of SCD
Lifestyle – fluid intake, caffeine, weight,

Question 14

What is the main overview of an obstetric history?

Answer 14

Aim will depend on the situation/stage of pregnancy (booking visit at 12 weeks vs. bleeding)
Previous pregnancies - may strongly influence the course of events in this one
Most pregnant women are young and healthy but vital not to miss relevant personal or family history

Question 15

What is the setting for an obstetric history?

Answer 15

Early pregnancy assessment unit (G1) <20 weeks
Labour Ward Assessment unit >20 weeks
Antenatal clinic – booking visit or subsequent appointment
Labour Ward

Question 16

What is an early pregnancy?

Answer 16

Pregnancy dated by 1st trimester US
EDD (Estimated date of delivery) - 40 completed weeks

Question 17

What to ask for a booking visit history?

Answer 17

Previous pregnancies: year, gestation, outcome, mode of delivery, complications
Current symptoms: pain, bleeding, discharge, fetal movements.
Early pregnancy scans
FULL general medical & Gynae history
FH of diabetes, heart disease, genetic abnormalities, thrombophilia
Social HX: Smoking/alcohol/drugs, occupation
Remember mental health and domestic abuse
Risk factors for VTE/pre-eclampsia

Question 18

What is gravidity and parity?

Answer 18

TOTAL no. of pregnancies (including this one, multiple pregnancies count as one)
= Gravidity (G)
TOTAL no. of deliveries after 24 weeks = Parity (P)
Expressed as G_P_
– indicates a loss after 24 weeks (including neonatal)

Question 19

Jane Smith is booking at 8 weeks and tells you that previously she has had 3 normal deliveries, 2 miscarriages at less than 12 weeks and 1 stillbirth at 28 weeks.

Work out her Gravidity and Parity

Answer 19

G7

P4 -1

Question 20

What are the outcomes for pregnancy?

Answer 20

Miscarriage = loss of pregnancy before 24 weeks
Termination (TOP)/abortion (be sensitive)
Ectopic
Deliveries >24 weeks (live birth, IUFD, stillbirth, neonatal death [NND])

Question 21

What is IUFD, Stillbirth, Neonatal death, Early NND, Late NND?

Answer 21

IUFD: Babies with no sign of life in utero
Stillbirth: Baby delivered with no signs of life, known to have died after 24 completed weeks of pregnancy
Neonatal death: The death of a baby within the first 28 days of life.
Early NND: Up to 7 days
Late NND: Between 7 and 28 days

Question 22

What are the gestations of births?

Answer 22

Gestation of births

Term = 37 to 42 completed weeks gestation
Pre-term = < 37 weeks gestation
Post-term = > 42 weeks gestation

Complications during pregnancy or postnatally

Question 23

How to take history in labour?

Answer 23

May be very difficult if in established labour (can also ask birth partner) – use PARTOGRAM
Ask about show (mucus +/-blood)
Ask about contractions: onset, frequency, length, regularity
Ask about SROM (spontaneous rupture of membranes) or ‘waters broken’
May occur before contractions start (pre-labour) or remain intact until delivery
Colour important (clear, blood-stained, yellow/green

Question 24

Overall history of gynae

Answer 24

PC
HPC
PMH
PSH
POGH
DH
FH
SH

Question 25

What are the common presenting complaints during history?

Answer 25

Abdominal pain in early pregnancy
Abdominal pain not in pregnancy
Bleeding in early pregnancy
Bleeding not in pregnancy
Discharge/infection
Fertility
Prolapse/incontinence

Question 26

History of presenting complaint for gynae history?

Answer 26

Pain - SOCRATES
Associated symptoms - PV bleeding/discharge/dyspareunia
LUTS
Change in bowel habit/dyschezia/haematochezia
Pregnant?
Cyclical (endometriosis)
Non-cyclical - PID/ectopic
Dyspareunia

Question 27

HPC - bleeding in pregnancy

Answer 27

Clarify:
Last menstrual period (1st day of bleeding)
This allows you to estimate gestation (number of weeks from last period)
What are periods normally like?
How many days bleeding/how many days between - e.g. 5/28
Quantify - number of pads/tampons, flooding, symptoms of anaemia
Abnormal bleeding out of pregnancy - IMB, PCB?
Any pain?

Question 28

HPC - bleeding out of pregnancy

Answer 28

Period history (length/frequency/quantify)
IMB/PCB (red flags for endometrial/cervical ca)
Other symptoms (pain, LUTS, bowels)
Any treatment (contraception/TXA/NSAIDS)
Symptoms of anaemia

Question 29

What are some general O and G questions?

Answer 29

Gravidity (Gravid = pregnant)
Number of pregnancies regardless of outcome
Includes current pregnancy!
Parity (parturition is the process of labour)
Number of deliveries after 24 weeks regardless of outcome
Does not matter if child alive, IUFD, neonatal death
Noted as GxPx

Question 30

Examples of gravidity and parity?

Answer 30

Patient is pregnant, has previously had a Caesarean section at term
G2P1
Pregnant, 2 previous terminations at 8 and 10 weeks
G3P0
Pregnant, 3 previous miscarriages, 1 termination and 2 previous normal deliveries at term
G7P2

Question 31

What are some more general O and G questions to ask everyone?

Answer 31

Modes of delivery (CS/instrumental/normal)
LMP and period history
(Menopause)
Contraception
Smears
(Any STIs)

Question 32

What questions to ask about fertility?

Answer 32

Are they having sex? (And if so how - you’d be surprised!)
Any previous children for either partner
Any pre-existing health problems
Medication (prescription and non-prescription)
A lot of male factor infertility is due to taking protein supplements and steroids

Question 33

Prolapse overview:

Answer 33

Often presents as a dragging or bulging sensation
Urinary symptoms
Bowel symptoms
Sexual symptoms (if still sexually active this can alter management options)

ICE - what is their main concern as this should guide management

Question 34

Incontinence overview

Answer 34

Broadly 2 types
Stress incontinence
Leakage of urine when coughing/exercising
Increases in intra-abdominal pressure overcoming sphincter resistance
Urge incontinence (overactive bladder)
‘Key in the lock’
Unable to control the urge to wee

Question 35

Gynae examination

Answer 35

Verbal consent and a chaperone
Standard abdominal examination
Pelvic examination
Inspection
Speculum
Bimanual examination