Gynae history taking ( Lecture) Flashcards
What settings would you take a gynae history in?
Outpatient clinic (general, infertility, colposcopy)
Pre-operative in theatre assessment unit
Inpatient ward (acute admission, post-operative
What might you find different or difficult when taking a history in gynaecology compared to medicine or surgery?
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
Important points to remember when taking history?
Age - Women have a clear gynaecological and reproductive timeline (pre vs. post-menopausal)
Hidden agenda - May be underlying psychological or sexual issue
How do we take a focused gynae history (key symptoms review)
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
Further questions to ask during a focused gynae history?
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
What to ask for a patients menstrual history?
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?
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?
25 day cycle
5/25
Bleeding terminology
Withdrawal bleeds: bleeding after withdrawal of exogenous oestrogen +/or progestogen
IMB
PCB
PMB
What do menarche, menopause, climacteric and postmenopausal mean?
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)
How can we ask for a broader gynae history?
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)
How can we take a good sexual history?
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
How do we take a good fertility history
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
How do we take a good urogynaecological history?
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,
What is the main overview of an obstetric history?
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
What is the setting for an obstetric history?
Early pregnancy assessment unit (G1) <20 weeks
Labour Ward Assessment unit >20 weeks
Antenatal clinic – booking visit or subsequent appointment
Labour Ward
What is an early pregnancy?
Pregnancy dated by 1st trimester US
EDD (Estimated date of delivery) - 40 completed weeks
What to ask for a booking visit history?
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
What is gravidity and parity?
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)
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
G7
P4 -1
What are the outcomes for pregnancy?
Miscarriage = loss of pregnancy before 24 weeks
Termination (TOP)/abortion (be sensitive)
Ectopic
Deliveries >24 weeks (live birth, IUFD, stillbirth, neonatal death [NND])
What is IUFD, Stillbirth, Neonatal death, Early NND, Late NND?
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
What are the gestations of births?
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
How to take history in labour?
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
Overall history of gynae
PC
HPC
PMH
PSH
POGH
DH
FH
SH
What are the common presenting complaints during history?
Abdominal pain in early pregnancy
Abdominal pain not in pregnancy
Bleeding in early pregnancy
Bleeding not in pregnancy
Discharge/infection
Fertility
Prolapse/incontinence
History of presenting complaint for gynae history?
Pain - SOCRATES
Associated symptoms - PV bleeding/discharge/dyspareunia
LUTS
Change in bowel habit/dyschezia/haematochezia
Pregnant?
Cyclical (endometriosis)
Non-cyclical - PID/ectopic
Dyspareunia
HPC - bleeding in pregnancy
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?
HPC - bleeding out of pregnancy
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
What are some general O and G questions?
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
Examples of gravidity and parity?
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
What are some more general O and G questions to ask everyone?
Modes of delivery (CS/instrumental/normal)
LMP and period history
(Menopause)
Contraception
Smears
(Any STIs)
What questions to ask about fertility?
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
Prolapse overview:
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
Incontinence overview
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
Gynae examination
Verbal consent and a chaperone
Standard abdominal examination
Pelvic examination
Inspection
Speculum
Bimanual examination
