Gynaecological History

Question 1

Menstrual History

Answer 1

Could you be pregnant? How have periods been?

LMP- first day of your last period

Cycle- are your cycles usually regular? How many days? How often? How long do they last?

Menarche- first period

Menorrhagia- heavy or painful periods?

NB- if menopausal- establish whether taking HRT

Question 2

Vaginal Bleeding (SOCRAT)

Answer 2

Site- is it definitely the vagina

Onset

Character- colour, clots, how much

Radiation- do you use tampons or pads? Does it soak them?

Associated symptoms- pain, discharge, menstruation, constitutional symptoms

Timing- is is there all the time, how often have you noticed it, could it be your period, does it occur mid cycle, does it come after sex

Question 3

Pain

Answer 3

Abdomen- pain in abdomen or further down

Dyspareunia- any pain on sex, deep or superficial entering pain

Question 4

Vaginal Discharge (same for penile)

Answer 4

Tell me about the discharge

Colour

Odour (eg. fishy)

Amount

Question 5

Sexual History

Answer 5

Last cervical smear

Sexually active

Partners- regular or different

Contraception/HRT (check compliance)

Previous STI’s/ symptoms of an STI now

Could you be pregnant?

Question 6

Obstetric History

Answer 6

Gravida- ask about this pregnancy/previous pregnancies

Complications- miscarriages, stillbirths, complications, HAVE YOU FELT BABY MOVE

Gestational age- how many weeks did you deliver your last baby at

Delivery- how were they deliver, why ceasean (if necessary)

Birth weight of previous children

Currently trying to conceive

NB- natural or assisted conceptions?

Question 7

Cervical Smears

Answer 7

When was your last cervical smear? Are you up to date with your smears?
Have you been vaccinated against HPV?
Any abnormal smears?
Any treatment required?

Question 8

Urinary Symptoms

Answer 8

Any problems with going to the toilet?
Are you passing urine more often (frequency)?
Do you have any burning or stinging on passing urine (dysuria)?
Do you have any problems with incontinence?
So you have the sensation of “dragging” in your vagina (prolapse)?

Question 9

Systems Review

Answer 9

How are you otherwise? Are you in good health?
Are you more tired than usual, short of breath, noticeable heartbeats/palpitations, pale? (anaemia)
Have you been having any abdominal pain or bloating? (malignancy but also endometriosis/fibroids)
Any fever, lethargy, weight loss, night sweats? (malignancy)
Any excessive tiredness, weight gain, dry hair/hair loss, feeling cold when others are not? (hypothyroidism)

Question 10

Way to remember the gynae history

Answer 10

HPC
Gynae SR eg. 4P’s (pain, pregnancy?, PV bleed, PV discharge)
MOSCC
1) Menstruation
2) Obstetric
3) Sexual
4) Contraception
5) Cervical smear