The key to any consultation is taking an accurate and complete history. This is relevant in all medical disciplines and particularly in gynecology. Do not assume that the referral letter contains all the relevant information. It is important to ask what the main problem is – it may be hidden away among a list of relatively unimportant or misleading complaints.
Women may find discussing gynecological symptoms difficult and require.
The following points are very important to consider:
Privacy: The consultation should be held in a room with adequate facilities and privacy. Permission should be sought for any students who are present.
Time: The patient should be allowed to tell her own story before any attempt is made to elicit specific symptoms.
Sympathy: The doctor’s manner must be one of interest and understanding.
Gynecological history follows the standard principles of medical history taking but there are a number of other issues that are relevant to gynecology.
Here is a list given first for the standard history and then the points that are additional for gynecology history.
Standard history taking
- Age
- Presenting complaint
- Past medical history
- Medication history
- Allergies
- Social history
- Family history
- Systemic inquiry
Additional features relevant to gynecology
Parity and Obstetric History:
The parity is defined by two different numbers. The first number refers to the number of pregnancies beyond 24 weeks. This cut off largely relates to the gestation of potential viability although any live born infant before 24 weeks would also be counted among this number. The second number refers to pregnancies of less than 24 weeks. In practical terms, the easiest way to ask about this is to ask if the woman has any children and then ask if she has had any other pregnancies. Pregnancies in this category are likely to be miscarriages, terminations or ectopic pregnancies. It is important to be sensitive about the terminology when discussing pregnancy loss. The term ‘abortion’ is out
dated and should not be used when discussing miscarriage.
Details of the mode of delivery of any children are always important in gynecology, but other factors such as perineal trauma and postnatal infection are also relevant.
Uses of any Contraceptives or history of Infertility:
This information will be relevant to many gynecological issues as potential treatments may affect fertility, and many contraceptive treatments will have a useful effect; for example, the combined oral contraceptive pill and menstrual loss and dysmenorrhoea.
Infertility may also be the presenting complaint.
Smear history:
Women should be asked when their last cervical smear (pap smear) was performed and if the result was normal. Any abnormal smears and colposcopy history should be noted.
Menstrual History:
At the very minimum, the last menstrual period (LMP) should be recorded. For premenopausal women, the length of a menstrual period and frequency of period should be recorded. This is conveniently expressed as a numerical fraction. Thus, 5/28 means the cycle lasts for 5 days
and occurs every 28 days. Make sure that you obtain the number of days from the start of one
period to the start of the next.
Irregular cycle may produce fractions such as 5–10/21–35.
Other Gynecological Symptoms:
It is important to ask other symptoms like:
Premenstrual Symptoms: like mood disturbance,breast tenderness, bloating and headaches before the onset of menses.
Vaginal Discharge: Women who complain of a vaginal discharge should be asked about the color, odor and any associated vaginal irritation or systemic upset. It can also be useful to determine any
relationship to the menstrual cycle as the discharge may be physiological in nature.
Vaginal Prolapse: Women with prolapse present with a sensation of something coming down within the vagina. They may also experience backache and a dragging sensation.
Urinary Symptoms: Women are frequently referred to gynaecology with the complaint of urinary incontinence.Other urinary symptoms like pain or burning should also be considered.
Other Gynecological Symptoms:
It is important to ask other symptoms like:
Premenstrual Symptoms: like mood disturbance,breast tenderness, bloating and headaches before the onset of menses.
Vaginal Discharge: Women who complain of a vaginal discharge should be asked about the color, odor and any associated vaginal irritation or systemic upset. It can also be useful to determine any
relationship to the menstrual cycle as the discharge may be physiological in nature.
Vaginal Prolapse: Women with prolapse present with a sensation of something coming down within the vagina. They may also experience backache and a dragging sensation.
Urinary Symptoms: Women are frequently referred to gynaecology with the complaint of urinary incontinence.Other urinary symptoms like pain or burning should also be considered.
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