Gynaecological Hx Taking Flashcards
What’s the difference between Obs and Gynae?
An obstetrician deals with all aspects of pregnancy, from prenatal care to postnatal care. An obstetrician delivers babies, whereas a gynaecologist does not. An obstetrician can also provide therapies to help you get pregnant, such as fertility treatments. If you deliver a premature baby, an obstetrician can also provide guidance in the Neonatal Intensive Care Unit (NICU)
Obstetricians are also trained to handle pregnancy complications, such as ectopic pregnancy, signs of foetal distress, placenta issues, pre-eclampsia, delivery through C-section, postpartum depression
A gynaecologist specialises in caring for the reproductive health of a woman from the time she gets her 1st period all the way to post-menopause
Any conditions that affect the reproductive system, such as those with the cervix, uterus, ovaries, fallopian tubes, or vagina, are diagnosed and treated by a gynecologist. Gynecologists also perform recommended screenings such as breast exams, pap smears, and pelvic exams. They also perform hysterectomies and tubal ligations. A gynecologist can also provide human papillomavirus (HPV) shots to protect against cancer-causing HPV.
Gynecologists can also provide advice on sexual matters, such as responsible sexual practices, contraceptives, and protection against sexually transmitted diseases. All in all, if it’s a non-pregnancy issue that is related to female reproductive health, a gynecologist can take care of it.
As with any other Hx taking, how should you open the consultation?
Wash hands + PPE
Introduce yourself (name and role)
Confirm patient’s name and DOB (age)
Marital status and Occupation
Explain that you would like to take a Hx from the patient + gain consent - “I would like to ask you a few questions about why you have come to see me? What’s the issues? and discuss what we can do to help you. Is that okay?”
What are the key gynaecological details that you want to ask the patient before going into the presenting complaint?
Last menstrual period (LMP)
Gravidity (G) - refers to the number of times a woman has been pregnant, regardless of the outcome e.g. (G2)
Parity (P) - refers to the total number of pregnancies carried over the threshold of viability (typically 24 weeks or more)
It’s useful to confirm these early on, as this will assist you in determining which questions are most relevant and what conditions are most likely
How would you ask the patient regarding her parity?
You told me that you have had 3 pregnancies in total. Are they all full-term pregnancies?
If yes, you can start asking about her presenting complaint
If no, ask about which pregnancy was pre-term. Was it the 1st, 2nd or third? or 2nd and 3rd?
After that, ask about how preterm the baby was? Were they born after the 24 gestation weeks or before?
Let’s say the woman gave birth to 1 term baby and 2 pre-term babies, and the 2 pre-term babies were born on the 35th gestation week. Then, the woman’s parity is P3 (parity is the total number of pregnancies carried over the threshold of viability - usually 24 week or more)
How should you enquire about the patient’s presenting complaint?
Start off with OPEN QUESTIONS, this allows the patient to tell you what has happened in their own words. “What’s brought you in to see me today?” “Ok, can you tell me more about that?”
After asking open questions, you can follow up with CLOSED QUESTIONS which can allow the patient to explore the symptoms mentioned in more detail to gain a better understanding of their presentation. For example, they mentioned they have got pain. Then you can ask “Can you describe what the pain is like?” (SQIPTARS), “How bad is the pain?” “When did it start?” “Has it got worse ever since?”
What questions can you ask to explore the patient’s pain?
Abdominal and pelvic pain (SQIPTARS)
- Site - “Where is the pain?” “Can you point to where you experience the pain?” “Did the pain spread elsewhere?” (e.g. shoulder tip pain in ectopic pregnancy)
- Quality - “What does the pain feel like?” “Sharp/ throbbing/ dull pain?” “Is the pain always there or does it come and go?”
- Intensity - “How bad is the pain?” “How is it affecting your daily life?” “On a scale of 1-10, 1 being pain-free and 10 being the most severe pain you have ever experienced, how bad is it?”
- Previous episodes - “Have you experienced this pain before?” If so, is this the same type of pain you had before?” “Do you think this could be what you had?”
- Time - “Did the pain come on suddenly or gradually?” “When did the pain first start?” “How long have you been experiencing the pain?” “Has the pain changed over time?” **“Have you noticed if this symptom is worse at a particular time in the month?” (ask if the symptom has any relationship to the menstrual cycle)
- Aggrevating factors - “Does anything make the pain worse?” (e.g. patients with symphysis pubis dysfunction may find going up or down the stairs makes things worse)
- Relieving factors - “Does anything make the pain better?” (e.g. patients with gastro-oesophageal reflux may find that antacids helpes with their symptoms)
- Secondary symptoms - “Are there any other symptoms that seem associated with the pain?” (e.g. patients presenting with an ectopic pregnancy may have associated N&V)
When taking a thorough gynaecological Hx, it’s important to go through all the key common gynaecological symptoms (a checklist) that the patient may have other than their presenting complaint.
What are the key gynaecological symptoms to ask about? Please include the differential diagnoses for each symptom!
Key gynaecological symptoms: (LEARN THESE DIFFERENTIALS INSIDEOUT OR YOU WILL FAIL!)
-
Abdominal and pelvic pain
- Causes include:
- Ectopic pregnancy
- Ruptured ovarian cyst
- Endometriosis
- Pelvic inflammatory disease (PID)
- Ovarian torsion
- Mittelschmerz (pain during ovulation)
- Causes include:
-
Post-coital vaginal bleeding - vaginal bleeding that occurs after sexual intercourse
- Causes include:
- Cervical ectropion - (when cells that line the endocervix grow on the outside)
- Cervical or endometrial cancer
- STIs (gonorrhoea, chlamydia)
- Vaginitis
- Trauma
- Causes include:
-
Intermenstrual bleeding (IMB) - vaginal bleeding occurring between menstrual periods
- Causes include:
- Contraception e.g. Mirena coil, COCP, POP
- Ovulation
- Miscarriage
- STIs (gonorrhoea, chlamydia)
- Uterine fibroids
- Perimenopause
- Malignancy (e.g. uterine cancer, cervical cancer, vaginal cancer)
- Causes include:
-
Post-menopausal bleeding - bleeding that occurs after the menopause
- Causes include:
- Vaginal atrophy (also called atrophic vaginitis) - thinning, drying and inflammation of the vaginal walls that may occur when your body has less oestrogen (post-menopausal)
- HRT
- Malignancy (e.g. uterine cancer, cervical cancer, vaginal cancer)
- Causes include:
-
Menstrual irregularity (oligomenorrhoea)/ heavy menstrual bleeding (menorrhagia)/ painful menstruation (dysmenorrhoea) or absent periods (secondary amenorrhoea)
-
Causes of heavy menstrual bleeding (HMB) include:
- Structural
- Leiomyomata (uterine fibroids)
- Endometrial cancer - tho more likely initially to cause irregular bleeding
- Adenomyosis (associated with a uniformly enlarged tender uterus, HMB and dysmenorrhoea)
- Endometrial polyps (can also cause IMB)
- Endometrial hyperplasia (maybe associated with irregular, anovulatory cycles)
- Non-structural
- PCOS
- Hypothyroidism
- IUD (copper coil)
- Structural
- Causes of secondary amenorrhoea and oligomenorrhoea
- Physiological e.g. pregnancy, lactation (account for most cases of amenorrhoea)
- Pathological:
- Functional hypothalamic disorders
- Weight loss-related amenorrhoea
- Stress-related amenorrhoea
- Exercise-related amenorrhoea
- Anterior pituitary disorders (most commonly caused by high prolactin levels)
- Prolactinoma (micro/macroadenoma)
- Drugs (anti-dopaminergic effects) that cause hyperprolactinaemia include phenothiazines, antihistamines, butyrophenones, metoclopramide, cimetidine, methyldopa
- Sheehan’s syndrome (postpartum necrosis of the anterior pituitary from severe obstetric haemorrhage and hypotension)
- Disorders of the genital tract
- Premature ovarian failure (POF)
- PCOS
- Uterine causes
- Surgical removal of the uterus
- Conditions that scar the endometrium and cause intrauterine adhesions and loss of menses - TB, Asherman’s syndrome
- Cryptomenorrhoea (‘hidden menstruation’)
- Cervical stenosis from surgical procedures or infection can cause blockage of menses through obstruction of outflow
- Functional hypothalamic disorders
- Causes of dysmenorrhoea (the most common gynaecological symptom)
- Primary dysmenorrhoea - occurs in the absence of any pelvic pathology and is caused by excessive myometrial contractions producing uterine ischaemia in response to local release of prostaglandins from the endometrium
- Secondary or acquired dysmenorrhoea - occurs in association with pelvic pathology e.g. endometriosis, fibroids, adenomyosis, pelvic infections, adhesions and developmental anomalies
-
Causes of heavy menstrual bleeding (HMB) include:
- Bleeding or pain in early pregnancy
-
Abnormal vaginal discharge
- Causes include:
- Vaginal thrush
- Bacteria vaginosis (BV)
- STIs (gonorrhoea, chlamydia)
- Causes include:
-
Dyspareunia
- Causes include:
- Endometriosis
- Vaginal atrophy
- STIs (gonorrhoea, chlamydia)
- Malignancy
- Bladder inflammation (cystitis/ lower UTI)
- Causes include:
-
Vulval skin changes and itching
- Vaginal atrophy
- Vaginal thrush
- Gonorrhoea
- Lichen sclerosis - a skin condition that makes patches of skin look white, thickened and crinkly (creases and wrinkles). Most often affects the vulva or the anus
-
Systemic symptoms
- Fatigue (e.g. anaemia)
- Fever (e.g. PID)
- Weight loss (e.g. malignancy)
- Other symptoms e.g. urinary incontinence, infertility, feeling ‘something coming down’ (prolapse)
All healthy women will have some degree of regular vaginal discharge, so it’s important to distinguish between normal and abnormal vaginal discharge when taking a gynaecological history.
a) . What are the characteristics of a normal vaginal discharge?
b) . How does the amount of discharge vary during:
bi) . Pregnancy
bii) . Sexually active or on birth control
a) . Vaginal discharge is not usually anything to worry about if it does not have a strong or unpleasant smell, is clear or white, is thick and sticky, and is slippery and wet
b) . The discharge is heavier during pregnancy, if you are sexually active or if you are using birth control. It’s often slippery and wet for a few days between your periods (when you ovulate)
What are the features of a pathological vaginal discharge (i.e. sign of an infection)? (Please specify the cause/ diagnosis of the pathology)
Pathological vaginal discharge:
- Offensive fishy smell without any soreness or irritation –> Bacterial vaginosis
- Thick and white, like cottage cheese –> Thrush
- Green, yellow or frothy with associated vaginal itching and irritation –> Trichomoniasis
- With pelvic pain or bleeding –> Chlamydia or gonorrhoea, consider PID
- With blisters or sores –> Genital herpes
What questions can you ask about their vaginal discharge?
- Volume - “Have you noticed any change in the amount of vaginal discharge?”
- Consistency (e.g. thickened or watery) - “Have you noticed that your discharge has become more watery or thickened recently?”
- Colour (e.g. green, yellow or blood-stained) - “Have you noticed any change in the colour of your discharge?” “Was there any blood in it?”
- Smell - “Have you noticed any change in the smell of the vaginal discharge?”
The questions you would as regarding vaginal discharge is the same as asking about a patient’s sputum in a respiratory clinic
Dyspareunia is pain during sex and it’s a common symptom experienced by many women. What questions would you ask to explore this symptom?
Ask about: (SQIPTARS)
- _***Location_ of the pain
- Superficial dyspareunia: pain at the external surface of the genitalia
- Deep dyspareunia: pain deep within the pelvis
- “Can you tell me more about the location of the pain? Is it a superficial pain or a deep pain?”
- Duration of the pain
- “How long has it been?”
- Nature of the pain
- Sharp/ arching/ burning?
- Onset of the pain
- “Do you get it just before you have sex? or during or after sex?”
What questions can you ask about vulval skin changes and itching?
What are your differential diagnoses for vulval skin changes and itching?
- What skin changes have you noticed in your genital area?
- Are there any other symptoms associated with the change? e.g. itchy, bleed, abnormal vaginal discharge
- Was there itchiness associated with it?
Infections such as candida (thrush), BV, and STIs (e.g. gonorrhoea). Vaginal atrophy in post-menopausal women which can lead to itching and bleeding of the vagina. Lichen sclerosis appears as white patches on the vulva and is associated with itching
What other symptoms would you want to ask about in your gynaecological history?
Urinary symptoms (LUTS) e.g. frequency, urgency, dysuria, these can be relevant to gynaecological problems (e.g. dyspareunia, vaginal prolapse, pelvic pain)
Bowel symptoms e.g. change in bowel habit or pain during defaecation can be associated endometriosis
Fever - seen in PID
Fatigue –> anaemia or malignancy
Weight loss –> malignancy
Abdominal distension - usually benign but can be associated with ovarian cancer with ascites
At the end of the Hx of PC, you do systemic approach. What systems will you cover and what symptoms will you be looking for?
Systemic
- Fatigue e.g. anaemia or malignancy
- Fever e.g. PID, UTI
- Weight loss e.g. endometrial cancer
Cardiovascular
- Palpitations
- Fatigue e.g. anaemia
- Tachycardia e.g. anaemia or bleeds
- Syncope?
Respiratory
- Dyspnoea e.g. anaemia
- Haemoptysis (e.g. endometriosis)
GI
- Abdominal pain (e.g. ectopic pregnancy, dysmenorrhoea)
- Painful defaecation (e.g. endometriosis)
- Abdominal bloating (e.g. ovarian cancer)
GU
- LUTS - frequency, urgency, dysuria (e.g. UTI)
- Abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
MSK
- Shoulder tip pain (e.g. ectopic pregnancy)
Dermatological
- White patches on the vulva/ vagina associated with irritation and itchiness –> Lichen sclerosis
After you have obtained enough information for the Hx of PC, what should you do next and what 3 questions must you NOT forget to ask (as it’s part of the markscheme)?
ICE
Ideas
- “What do you think the problem is?”
- “What are your thoughts about what is happening?”
Concerns
- “Is there anything, in particular, that’s worrying you?”
- “What’s your number 1 concern regarding this problem at the moment?”
Expectations
- “What were you hoping I’d be able to do for you today?”
- “What would ideally need to happen for you to feel today’s consultation was a success?”
Summarise to the patient
- Summarise periodically what the patient has told you about their presenting complaint. Once summarised, ask the patient if there’s anything else that you have overlooked
Signposting
- Explain what you have covered so far
- “Ok, so now that we have covered your symptoms, your concerns and what you are hoping to achieve today.”
- What you plan to cover next
- “Next I’d like to discuss your menstrual cycle and then your past medical history if that’s okay with you.”
