Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
Key initial gynaecological 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.
Gravity and parity
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).
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, can you tell me more about that?”
“Can you explain what that pain was like?”
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
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.
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Ask about the location of the symptom:
“Where is the pain?”
“Can you point to where you experience the pain?”
Clarify how and when the symptom developed:
“Did the pain come on suddenly or gradually?”
“When did the pain first start?”
“How long have you been experiencing the pain?”
Ask about the specificcharacteristics of the symptom:
“How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
“Is the pain constant or does it come and go?”
Ask if the symptom movesanywhere else:
“Does the pain spread elsewhere?” (e.g. shoulder tip pain in ectopic pregnancy)
Ask if there are other symptoms which are associated with the primary symptom:
“Are there any other symptoms that seem associated with the pain?” (e.g. patients presenting with an ectopic pregnancy may have associated nausea and vomiting)
Clarify how the symptom has changed over time:
“How has the pain changed over time?”
Ask if the symptom has any relationship to the menstrualcycle:
“Have you noticed if this symptom is worse at a particular time in the month?”
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better:
“Does anything make the pain worse?” (e.g. patients with symphysis pubis dysfunction may find going up or down the stairs makes things worse)
“Does anything make the pain better?” (e.g. patients with gastro-oesophageal reflux may find that antacid medication helps with their symptoms)
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
“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?”
Ask the patient if the symptom is having a significant impact on their day to day life:
“How is the pain impacting your daily life?”
Once you have completed exploring the history of presenting complaint, you need to move on to more focusedquestioning relating to the common symptoms of gynaecologicaldisease.
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.
Summary of key gynaecological symptoms
Key gynaecologysymptoms to ask about include:
Abdominal and pelvic pain: causes include ectopic pregnancy, ruptured ovarian cyst, endometriosis, pelvic inflammatory disease and ovarian torsion.
Post-coital vaginal bleeding: vaginal bleeding occurring after sexual intercourse. Causes include cervical ectropion, cervical cancer, gonorrhoea, chlamydia and vaginitis.
Post-menopausal bleeding: bleeding that occurs after the menopause. Causes include vaginal atrophy, hormone replacement therapy and malignancy (e.g. uterine cancer, cervical cancer and vaginal cancer).
Abnormal vaginal discharge: causes include bacterial vaginosis, chlamydia and gonorrhoea.
Dyspareunia: causes include endometriosis, vaginal atrophy, gonorrhoea and chlamydia.
Vulval skin changes and itching: causes include vaginal atrophy, vaginal thrush, gonorrhoea and lichen sclerosus.
Systemic symptoms: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease) and weight loss (e.g. malignancy).
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormalvaginaldischarge when taking a gynaecological history.
You should ask if the patient has noticed any changes to the following characteristics of their vaginaldischarge:
Volume: “Have you noticed any change in the amount of vaginal discharge?”
Colour (e.g. green, yellow or blood-stained): “Have you noticed any change in the colour of your discharge?”
Consistency (e.g. thickened or watery): “Have you noticed that your discharge has become more watery or thickened recently?”
Smell: “Have you noticed any change in the smell of the vaginal discharge?”
Several STIs can cause abnormalvaginaldischarge:
Gonorrhoea and chlamydia may present with abnormal vaginal discharge.
Bacterialvaginosis typically presents with an offensive, fishy-smelling vaginal discharge, without any associated soreness or irritation.
Trichomonasvaginalis typically presents with yellow frothy discharge with associated vaginal itching and irritation.
Dyspareunia refers to pain that occurs duringsexualintercourse. 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 within the pelvis.
You should clarify:
the duration of the symptom
the location of the pain (e.g. superficial or deep)
the 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:
Infections such as candida (thrush), bacterial vaginosis and sexually transmitted infections (e.g. gonorrhoea).
Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina.
Lichen sclerosus appears as white patches on the vulva and is associated with itching.
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 may be associated with pelvic inflammatory disease.
Fatigue is a non-specific symptom, but its presence may indicate anaemia or 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 with ascites.
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
“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?”
“What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then we’ll discuss your menstrual cycle.“
A systemicenquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
Musculoskeletal: shoulder tip pain (e.g. ectopic pregnancy)
Dermatological: white patches on the vulva/vagina associated with pruritis (e.g. lichen sclerosus)
A menstrualhistory involves exploring the characteristics of the patient’s menstrual cycle.
Ask the patient about the duration of their periods:
“How long do your periods typically last?”
The average duration of menstruation is 5 days, with more than 7 days considered prolonged.
Ask the patient about the frequency of their periods:
“How often do your periods occur?”
“Are they regular and predictable?”
Periods typically occur every 28 days, however, there is significant variation between individuals (21-40 days).
Menstrual blood flow
Ask the patient about the volume of their periods:
“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?”
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, 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.
Menstrual pain (dysmenorrhoea)
Ask the patient if their periods are particularly painful:
“Do you have painful periods which interfere with your day to day life?”
“Have your recent periods been more painful than usual?”
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 quality of life. Use the SOCRATES acronym shown above to further explore menstrual pain.
Date of last menstrual period
Ask the patient when the first day of their last menstrual period was:
“What date was the first day of your last menstrual period?”
If the patient’s period is late, consider performing a pregnancy test, particularly in the context of abdominal pain (to rule out ectopic pregnancy).
Age at menarche
Ask the patient how old they were when they started having periods:
“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)
Ask the patient how old they were when they went through the menopause:
“Do you remember how old you were when you went through the menopause?”
If the patient is perimenopausal ask about symptoms such as hot flushes and vaginal dryness.
Clarify the type of contraception currently used:
Combined contraceptives: combined oral contraceptive pill and the contraceptive patch.
Progesterone only pill (POP)
Depot injection (progesterone)
Long-acting reversible contraceptives (LARCs): hormonal coil, implant and copper coil.
Explore the patient’s previouscontraceptionhistory:
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 havingchildren 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).
Past gynaecological history
It is important to ask about a woman’s previous gynaecological history, as this may influence further investigations and management options.
Ask if the patient has previously had any gynaecologicalproblems:
Sexually transmitted infections
Malignancy (e.g. cervical, endometrial, ovarian)
Gynaecological surgery or procedures
Ask the patient if they’ve previously undergone any surgery or procedures in the past such as:
Abdominal or pelvic surgery
Loop excision of the transitional zone (LETZ)
Vaginal prolapse repair
Clarify the patient’s cervicalscreening history:
Confirm the date and result of the last cervical screening test.
Ask if the patient received any treatment (if the cervical screening test was abnormal) and ask if follow up is in place.
Ask if the patient has been vaccinated against HPV.
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.
Ask if the patient has any medicalconditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospitaladmissions.
It’s essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of allergic reaction the patient experienced.
Examples of medical conditions relevant to gynaecological presentations
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.
It is important to take a brief obstetrichistory as part of a gynaecological assessment, as it may be relevant to the patient’s presentation. This is less detailed than a focused obstetric history.
Gravidity and parity
Gravidity is the number of times a woman has been pregnant, regardless of the outcome.
Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).
Gather key details about the patient’s currentpregnancy (if relevant):
Symptoms associated with pregnancy (e.g. nausea, vomiting, back pain)
Hormone replacement therapy (e.g. combined or oestrogen-only)
NSAIDs (e.g. to manage dysmenorrhoea)
GnRH analogues (e.g. to manage endometriosis)
Ask the patient if there is any family history of ovarian, endometrial or breastcancer which may suggest possible familial inheritance (e.g. BRCA gene):
“Is there any history of cancer of the womb, ovaries or breasts in your close relatives?” (e.g. BRCA gene)
Ask the patient if there is any family history of bleeding disorders as menorrhagia may be the first presenting symptom of an inherited bleeding disorder such as Von Willebrand’s disease:
“Is there any history of bleeding disorders in your family?” (menorrhagia can be the first presenting symptom of an inherited bleeding disorder e.g. Von Willebrand disease)
Ask the patient if there is any family history of bloodclots. 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 may be contraindicated:
“Have any of your close family members had blood clots in the past?”
Understanding the social context of a patient is absolutely key to building a complete picture of their health.
General social context
Explore the patient’s general social context including:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
Record the patient’s smokinghistory, including the type and amount of tobacco used.
Consider if medications such as the COCP are contraindicated because of the patients smoking status:
If smoking more than 40 cigarettes a day, the COCP would be contraindicated.
If over 35-years-old and smoking more than 15 cigarettes a day, the COCP would be contraindicated.