Gynaecology history-taking

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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1 Gynaecology history-taking

Chapter Contents

The consultation

Presenting complaint

Abnormal bleeding
Urinary symptoms

Past history

Past medical history
Past surgical history
Systems review
Drug history
Family history
Personal and social history

Presenting a history

The importance of taking an accurate and detailed history cannot be overemphasized, particularly in gynaecology where the symptoms are often embarrassing and patients may not wish to discuss them unless specifically asked. The very nature of the specialty requires the history-taker to be respectful, sensitive and on the alert for both verbal and non-verbal cues. It is essential that during the consultation one tries to put the patient at ease so that she feels as comfortable as she can discussing her symptoms.

The consultation

The consultation should commence with a professional introduction assuming one has looked at the referral letter or the notes beforehand so that the woman can be addressed appropriately. As with all histories, it is easiest to start with the presenting complaint. When did the problem first begin, how long has it been present and how frequently does it occur? How much does it affect her quality of life? If the problem is pain, then one must elicit what exacerbates the pain and what alleviates it. The site and nature of the pain must be determined. As with all history-taking it is important to ask open questions rather than direct questions initially. Enquire whether she has ever consulted anyone else about this problem, and if so, what was the management?

Presenting complaint

Abnormal bleeding

If the problem is abnormal bleeding, a more detailed menstrual history should be taken. When did menarche occur? How often does she menstruate and how long does it last?

Is it regular or irregular, heavy, or painful? If the bleeding is heavy, it is important to enquire as to the number of tampons/pads used and whether extra protection is also needed. Is there any premenstrual pain or intermenstrual or postcoital bleeding? If she is of reproductive age, then enquire as to her last menstrual period.

Enquire whether the woman is sexually active and if so, whether there are any problems with intercourse. What type of contraception is she currently using and what has she used in the past?

Does she suffer with a vaginal discharge and has she ever had pelvic inflammatory disease?

With regard to cervical smear history, one needs to know the date of the last smear and whether or not it was abnormal, and whether or not she has ever had an abnormal smear in the past, and if so, what was the treatment?

Urinary symptoms

With regards to urinary symptoms one needs to enquire about frequency, dysuria, nocturia, urgency or incontinence. If she does suffer from urinary incontinence, then one needs to assess how often it is occurring and whether it is affecting her quality of life; are there any aggravating factors, for example smoking, coughing, constipation? She should be asked specifically whether she has ever had a dragging sensation in the pelvis or felt a lump coming through the vagina.

It is important to ascertain whether or not she has a normal bowel habit and whether she has any pain or bleeding with defecation.

Past history

With regard to past history one should ascertain whether the woman has had any previous gynaecological problems and whether she has had any gynaecological surgery in the past (Fig. 1.1).

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Figure 1.1 History sheet.

It is best to enquire with a general statement about the obstetric history, for example: ‘Have you ever been pregnant?’ If the answer is no, then one proceeds, but if the answer is yes, then it is best to record the pregnancies in chronological order, noting the year, gestation and outcome. If there were deliveries, then enquire about the length of pregnancy and whether there were any problems, the duration of labour and second stage and the mode of delivery. Check that there were no complications during the pregnancy or labour. If there were miscarriages or terminations, enquire about the gestation and the method of termination or, in the case of a miscarriage, whether an evacuation was performed.

Past medical history

As with any history, one asks if she has or has had any medical problems or if she has ever been admitted to hospital.

Past surgical history

Any previous operations, apart from gynaecological operations, should be enquired about. Were there any postoperative complications?

Systems review

Symptoms relating to respiratory, cardiovascular, abdominal and neurological systems should be ascertained.

Drug history

Is she currently taking any medications? Does she take any recreational drugs? Is she taking any prepregnancy vitamins? It is important to ascertain whether she is allergic to any drugs.

Family history

It is best to start with an open-ended question, such as: ‘Are there any significant diseases in your family?’ and then particularly enquire about a family history of breast, ovarian or cervical carcinoma, diabetes, heart disease, thromboembolic disease and hypertension.

Personal and social history

One should enquire as to occupation, whether she is currently smoking and whether she has smoked in the past, as well as weekly intake of alcohol. Is she in a stable relationship and, if not, does she live in a supportive environment?

Having taken a thorough history it is worth enquiring whether the patient feels that there is anything else that she should tell you. She should be asked what she thinks might be causing the problem and what she might be expecting from the consultation in terms of investigations or treatments.

Presenting a history

In presenting a gynaecological history one should start with name, age, presenting complaint, duration of presenting complaint and other significant features. For example, Mrs Fairhall is a 35-year-old nulliparous woman, presenting with a 6-month history of irregular heavy bleeding. Then go through the presenting complaint in detail, other relevant gynaecology or obstetric past history and then the other histories. Then summarize at the end, which usually means repeating the original sentence that you started with.

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