A gynaecological history involves asking questions relevant to the female reproductive system. Some of the questions are highly personal and therefore good communication skills and a respectful manner are absolutely essential.
Taking a gynaecological history requires asking a lot of questions that are not part of the “standard” history taking format and therefore it’s important to understand what information you are expected to gain.
Opening the consultation
- Introduce yourself (including your name and role)
- Confirm the patient’s details (name and date of birth)
- Explain the need to take a history
- Gain consent
- Ensure the patient is currently comfortable
Other relevant details
- It is useful to confirm the last menstrual period (LMP), gravidity and parity early on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely.
- LMP is useful to know when considering the possibility of ectopic pregnancy.
- Gravidity (G)is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).
- Parity (P) is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).
It’s important to use open questioning to elicit the patient’s presenting complaint:
- “So what’s brought you in today?” or “Tell me about your symptoms”
- Allow the patient time to answer, trying not to interrupt or direct the conversation
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, so tell me more about that”
- “Can you explain what that pain was like?”
History of presenting complaint
Once the patient has had time to communicate their presenting complaint, you should then begin to explore the issue with further open and closed questions.
- When did the symptom start?
- Was the onset acute or gradual?
- How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years)
- How severe does the patient feel the symptom is?
- Is it impacting significantly on their day to day life?
- Is the symptom worsening, improving, or continuing to fluctuate?
- Do symptoms have any relationship to the menstrual cycle?
Intermittent or continuous:
- Is the symptom always present or does it come and go?
- If intermittent, how frequent is the symptom?
- Are there any obvious triggers for the symptom?
- Does anything appear to improve the symptoms?
- Are there other symptoms that appear associated (e.g. fever/malaise)?
- Has the patient experienced this symptom previously?
- When did they last experience the symptom?
Abdominal or pelvic pain
The acronym SOCRATES provides a useful framework for asking about pain, as shown below.
- Where is the pain?
- When did it start?
- Was the onset sudden or gradual?
- Is the pain sharp or a dull ache?
- Is the pain intermittent or continuous?
- Does the pain radiate anywhere? (e.g. shoulder tip pain can occur in ectopic pregnancy)
- Are there any other symptoms associated with the pain?
- What is the overall time course of the pain? (e.g. worsening, improving, fluctuating)
Exacerbating or relieving factors:
- Does anything make the pain worse or better?
- Dyspareunia refers to pain experienced during sexual intercourse
- Dysmenorrhea refers to pain associated with menstrual periods
- On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?
Once you have completed exploring the history of presenting complaint, you need to move on to more focused questioning relating to the common symptoms of gynaecological disease.
We have included a focused list of the key symptoms to ask about when taking a gynaecological history, followed by some background information on each, should you want to know a little more.
Key symptoms to ask about
- Abdominal or pelvic pain (ectopic pregnancy, pelvic inflammatory disease, ovarain torsion)
- Post-coital vaginal bleeding (STIs, vaginitis, cervical ectropion, malignancy)
- Intermenstrual vaginal bleeding (STIs, malignancy, uterine fibroids, endometriosis)
- Post-menopausal bleeding (malignancy, vaginal atrophy, hormonal replacement therapy)
- Abnormal vaginal discharge (STIs, bacterial vaginosis)
- Dyspareunia (STIs, endometriosis, vaginal atrophy)
- Vulval skin changes and itching (vaginal atrophy, candida, STIs, lichen sclerosis)
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of gynaecological disease.
- Vaginal bleeding occurring after sexual intercourse
- Causes include cervical ectropion, infection (including STIs), vaginitis, malignancy (e.g. cervical cancer)
- Vaginal bleeding occurring between menstrual periods
- Causes include infection (including STIs), malignancy (e.g. cervical or endometrial cancer), uterine fibroids, endometriosis, hormonal contraception (e.g. Mirena coil) and pregnancy
- Vaginal bleeding that occurs after the menopause (when there should be no further menstrual periods)
- Causes include malignancy (e.g. cervical or endometrial cancer), hormonal replacement therapy and vaginal atrophy
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking a gynaecological history.
You should ask if the patient has noticed any changes to the following characteristics of their vaginal discharge:
- Colour (e.g. green, yellow or blood-stained)
- Consistency (e.g. thickened or watery)
- Smell (e.g. fish-like smell in bacterial vaginosis)
Dyspareunia refers to pain that occurs during sexual intercourse. It has several causes including infections, endometriosis, vaginal atrophy, malignancy and bladder inflammation.
The location of the pain varies between patients:
- Superficial dyspareunia – pain at the external surface of the genitalia
- Deep dyspareunia – pain deep in the pelvis
You should clarify:
- Duration of the symptom
- Location of the pain (e.g. superficial or deep)
- Nature of the pain (e.g. sharp, aching, burning)
Vulval skin changes and itching
Vulval skin changes and itching are common symptoms which can have several underlying causes including:
- Infections such as candida (thrush), bacterial vaginosis and sexually transmitted infections
- Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina
- Lichen sclerosis appears as white patches on the vulva and is associated with itching
Other relevant symptoms
- Urinary symptoms such as frequency, urgency and dysuria can be relevant to gynaecological problems (e.g. dyspareunia, vaginal prolapse, pelvic pain).
- Bowel symptoms such as a change in bowel habit or pain during defecation can be associated with endometriosis.
- Fever is important to ask about when considering diagnoses such as pelvic inflammatory disease or other infectious pathology.
- Malaise is a non-specific symptom, but its presence may indicate serious underlying pathology such as anaemia and malignancy.
- Unintentional weight loss is a concerning feature that may indicate underlying malignancy.
- Abdominal distension is often a benign symptom, however, it can be associated with serious underlying pathology such as ovarian cancer.
Ideas, Concerns and Expectations (ICE)
- Clarify what the patient’s thoughts are regarding their symptoms
- What do you think is going on?
- Explore any worries the patient may have regarding their symptoms
- Is there anything that you’re concerned about at the moment?
- Is there anything that is troubling you at the moment?
- Gain an understanding of what the patient is hoping to achieve from the consultation
- What were you hoping you’d get out of our consultation today?
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you so far.
It also provides an opportunity for the patient to correct any inaccurate information and expand further on relevant aspects of the history.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient:
- What you have covered so far: “Ok, so we’ve talked about your symptoms.”
- What you plan to cover next: “Now I’d like to discuss your past medical history.”
A menstrual history involves clarifying the details of a woman’s menstrual cycle. It is an essential part of any gynaecological history and it, therefore, it should not be missed.
Menstrual cycle details
- Average duration is 5 days
- More than 7 days would be considered prolonged
- “How long do your periods typically last?”
- The average is 28 days
- “How often do your periods happen?”
- “Are they regular and predictable?”
Menstrual blood flow:
- This is an assessment of the volume of menstrual bleeding
- The average menstrual blood loss is approximately 40mls (8 teaspoons)
- Heavy menstrual blood loss is defined as more than 80mls (16 teaspoons) or having periods that last longer than 7 days
- The definition of what is a “heavy period” compared to a “normal period” is highly subjective and therefore you should ask the woman how the current periods compare to her usual loss. If the volume of bleeding is impacting on the woman’s day to day life, it is significant.
- “Are your current periods heavier than your usual periods?”
- “Have you been flooding through sanitary towels?”
- “Have you been passing blood clots larger than a 10p coin?”
- “Are the heavy periods impacting your day to day life?”
Menstrual pain (dysmenorrhoea):
- It is common for women to experience abdominal and pelvic pain when menstruating.
- Menstrual pain can sometimes be severe and have a significant impact on a woman’s day to day quality of life.
- Use the SOCRATES acronym shown above to further assess menstrual pain.
- “Have your recent periods been more painful than usual?”
Date of last menstrual period (LMP):
- Defined as the first day of the last menstrual period
- If late, consider performing a pregnancy test, particularly in the context of abdominal pain (to rule out ectopic pregnancy).
Age at menarche:
- “At what age did you start having periods?”
- Early menarche is associated with an increased risk of breast cancer and cardiovascular disease
Menopause (if relevant):
- Age at menopause
- Ask about menopausal symptoms such as hot flushes and vaginal dryness
Clarify the type of contraception currently used:
- Combined contraceptives – combined oral contraceptive pill, contraceptive patch)
- Progesterone only pill (POP)
- Depot injection (progesterone)
- Long-acting reversible contraceptives (LARCs) – hormonal coil, implant, copper coil
- Barrier methods
Ask about previous contraception history:
- It is useful to be aware of what the patient has previously tried, particularly if considering a change to their current choice of contraception.
You should ask the patient if they are considering having children in the future (or are currently trying to fall pregnant).
This is important to know when considering treatments for their gynaecological issue (e.g. you wouldn’t suggest endometrial ablation or hysterectomy for menorrhagia if the patient was planning for a future pregnancy).
- Confirm the date of the last cervical screening test
- Confirm the result of the last cervical screening test
- Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up is in place
- Ask if the patient received the HPV vaccine
Past gynaecological history
Previous gynaecological diagnoses and treatments:
- Ectopic pregnancy
- Sexually transmitted infections
- Bartholin’s cyst
- Cervical ectropion
- Malignancy (e.g. cervical, endometrial, ovarian)
Past medical history
It is important to ask about the patient’s non-gynaecological medical history, as these conditions may impact the gynaecological problem and may themselves be impacted by or prevent the use of specific gynaecological treatments.
Some examples are provided below:
- Migraine with aura – oestrogen containing medications (e.g. combined oral contraceptive) would be contraindicated
- Previous venous thromboembolism (VTE) – oestrogen containing medications would be contraindicated
- Breast cancer (current or previous) – use of oestrogen containing medications would be usually be contraindicated or require specialist input before being commenced
- Bleeding disorders (e.g. Von Willebrand’s) would be relevant if a patient presented with heavy vaginal bleeding
Past surgical history
Previous surgical procedures such as :
- Abdominal or pelvic surgery
- Caesarian section
- Loop excision of the transitional zone (LETZ)
- Vaginal prolapse repair
It is important to take a brief obstetric history as part of a gynaecological assessment, as it may be relevant. This is less detailed than a focused obstetric history.
You need to ask questions in a sensitive manner, as discussing previous miscarriages and terminations can be very difficult for the patient.
Gravidity: The number of times a woman has been pregnant, regardless of the outcome.
- X (any live or stillbirth after 24 weeks)
- Y (number of pregnancies lost before 24 weeks)
Current pregnancy (if relevant)
- Symptoms of pregnancy (e.g. nausea, vomiting, back pain)
- Complications (e.g. pre-eclampsia, cervical neck incompetence)
- Recent scans results
- Age of children
- Birth weight
- Mode of delivery
- Complications in the antenatal, perinatal, postnatal period
- If relevant, ask if the patient is currently breast feeding, as this is a contraindication to some types of contraceptives (e.g. combined oral contraceptive)
Hormonal replacement therapy (HRT)
- Duration of use
- Method of delivery (e.g. patch, gel, pessary)
- Frequency of treatment (e.g. cyclical or continuous)
- Type of treatment (e.g. combined or oestrogen only)
- Recent antibiotics (increased the risk of vaginal thrush)
- Liver enzyme-inducing drugs (e.g. Rifampicin) can be a contraindication to commencing patients on the combined oral contraceptive pill
- Other regular medication
- Over the counter medication (e.g. St John’s Wart can interfere with the metabolism of the COCP)
- Drug allergies
Important conditions to consider that may be relevant to a gynaecological presentation:
- Ovarian, endometrial and breast cancer – possible familial inheritance (e.g. BRCA gene)
- Bleeding disorders – menorrhagia can sometimes be the first presentation of an inherited bleeding disorder (e.g. Von Willebrand disease)
- Venous thromboembolism (VTE) – patients who have a significant family history of VTE in a first-degree relative (particularly if they were less than 45 when it developed) may be at increased risk of VTE and therefore medications such as combined oral contraceptives, would often be contraindicated
Understanding the social context of a patient is absolutely key to building a complete picture of their health. Social factors have a significant influence on a patient’s overall health and it’s therefore key that a comprehensive social history is obtained.
- How many cigarettes a day?
- How long have they smoked for?
- If smoking more than 40 a day, the combined oral contraceptive would be contraindicated
- If a women over 35 years old is smoking more than 15 cigarettes a day, this would also be a contraindication to the combined oral contraceptive
Alcohol and recreational drug use:
- How many units a week?
- Clarify the type, volume and strength of the alcohol
- Clarify the types of recreational drugs used
- Obesity is associated with polycystic ovarian syndrome and carries a greater risk of endometrial cancer
- Anorexia can result in oligomenorrhoea (infrequent periods) or amenorrhoea (absence of menstruation)
- A raised BMI may be a contraindication to some treatments, including combined oral contraceptives
- Who lives with the patient?
- Do they feel like they are well supported?
- Is the patient independent or do they require assistance?
- How is the disease impacting on their ability to carry out activities of daily living?
- If receiving care input, what level are they requiring?
- All of these factors are important when planning management of the patient’s health problem.
- How is the disease process impacting their ability to work?
- Have they been exposed to any industrial carcinogens?
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. painful defecation secondary to endometriosis).
Choosing which symptoms to ask about depends on the presenting complaint, however, a selection of potentially relevant systemic symptoms to a gynaecological presentation are shown below.
- Pelvic inflammatory disease
- Dyspnoea (secondary to anaemia)
- Haemoptysis (secondary to endometriosis)
- Abdominal pain (secondary to menstruation)
- Painful defecation (secondary to endometriosis)
- Abdominal bloating (ovarian cancer)
- Frequency, dysuria and urgency (secondary to menopausal changes)
- Shoulder tip pain (ectopic pregnancy)
- White patches on the vulva/vagina associated with pruritis (lichen sclerosis)
Closing the consultation
- Summarise the history and ask the patient if there’s anything else they’d like to add.
- Thank the patient
Dr Venkatesh Subramanian
Obstetrics & Gynaecology Registrar (ST5) in London