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Gynaecological History Taking

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The ability to take a gynaecological history is often assessed in OSCEs. This guide provides a structured approach to taking a gynaecological history in an OSCE setting.


Opening the consultation

Wash your hands and don PPE if appropriate.

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.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “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 presenting complaint 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 closed questions. 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.

SOCRATES

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.

Site

Ask about the location of the symptom:

  • “Where is the pain?”
  • “Can you point to where you experience the pain?”

Onset

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?”

Character

Ask about the specific characteristics 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?”

Radiation

Ask if the symptom moves anywhere else:

  • “Does the pain spread elsewhere?” (e.g. shoulder tip pain in ectopic pregnancy)

Associated symptoms

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)

Time course

Clarify how the symptom has changed over time:

  • “How has the pain changed over time?”

Ask if the symptom has any relationship to the menstrual cycle:

  • “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)

Severity

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?”

Gynaecological symptoms

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.

Summary of key gynaecological symptoms

Key gynaecology symptoms 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.
  • Intermenstrual vaginal bleeding: vaginal bleeding occurring between menstrual periods. Causes include contraception (e.g. Mirena coil), ovulation, miscarriage, gonorrhoea, chlamydia, uterine fibroids, perimenopause and malignancy (e.g. uterine cancer, cervical cancer, vaginal cancer).
  • 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 sclerosis.
  • Systemic symptoms: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease) and weight loss (e.g. malignancy).

Vaginal discharge

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:

  • 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 abnormal vaginal discharge:

  • Gonorrhoea and chlamydia may present with abnormal vaginal discharge.
  • Bacterial vaginosis typically presents with an offensive, fishy-smelling vaginal discharge, without any associated soreness or irritation.
  • Trichomonas vaginalis typically presents with yellow frothy discharge with associated vaginal itching and irritation.

Dyspareunia

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 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 sclerosis appears as white patches on the vulva and is associated with itching.

Other 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 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.

Ideas

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.”

Concerns

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?”

Expectations

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?”

Summarising

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

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.

Signposting examples

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.


Systemic enquiry

A systemic enquiry 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:

  • Systemic: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease, urinary tract infection), weight loss (e.g. endometrial cancer)
  • Respiratory: dyspnoea (e.g. anaemia), haemoptysis (e.g. endometriosis)
  • Gastrointestinal: abdominal pain (e.g. ectopic pregnancy, dysmenorrhoea), painful defecation (e.g. endometriosis), abdominal bloating (e.g. ovarian cancer)
  • Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract infection), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
  • Musculoskeletal: shoulder tip pain (e.g. ectopic pregnancy)
  • Dermatological: white patches on the vulva/vagina associated with pruritis (e.g. lichen sclerosis)

Menstrual history

A menstrual history involves exploring the characteristics of the patient’s menstrual cycle.

Duration

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.

Frequency

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.


Contraception

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.
  • Barrier methods

Explore the patient’s 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.

Reproductive plans

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).


Past gynaecological history

It is important to ask about a woman’s previous gynaecological history, as this may influence further investigations and management options.

Gynaecological conditions

Ask if the patient has previously had any gynaecological problems:

  • Ectopic pregnancy
  • Sexually transmitted infections
  • Endometriosis
  • Bartholin’s cyst
  • Cervical ectropion
  • 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
  • Caesarian section
  • Loop excision of the transitional zone (LETZ)
  • Vaginal prolapse repair
  • Hysterectomy

Cervical screening

Clarify the patient’s cervical screening 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 medical conditions: 

  • “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 how well controlled 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 hospital admissions.

Allergies

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.


Obstetric history

It is important to take a brief obstetric history 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).

Current pregnancy

Gather key details about the patient’s current pregnancy (if relevant):

  • Gestation
  • Symptoms associated with pregnancy (e.g. nausea, vomiting, back pain)
  • Complications (e.g. pre-eclampsia, cervical neck incompetence)
  • Recent scans results

Previous pregnancies

Gather key details about the patient’s previous pregnancies (if relevant):

  • Age of children
  • Birth weight
  • Mode of delivery
  • Complications in the antenatal, perinatal, postnatal period
  • If relevant, ask if the patient is currently breastfeeding, as this is a contraindication to some types of contraceptives (e.g. combined oral contraceptive)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication namedosefrequencyform and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”

Some medications may cause gynaecological issues or interfere with gynaecological medications:

  • St John’s Wart increases the metabolism of the COCP reducing its effectiveness.
  • Antibiotics may cause secondary vaginal thrush.

If the patient is taking hormonal replacement therapy (HRT) clarify the following details:

  • 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)
Medication examples

Medications commonly prescribed to patients with gynaecological disease include:

  • Tranexamic acid (e.g. to manage menorrhagia)
  • Contraceptives (e.g. COCP, POP)
  • Hormone replacement therapy (e.g. combined or oestrogen-only)
  • NSAIDs (e.g. to manage dysmenorrhoea)
  • GnRH analogues (e.g. to manage endometriosis)

Family history

Ask the patient if there is any family history of ovarian, endometrial or breast cancer 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 blood clots. 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?”

Social history

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)

Smoking

Record the patient’s smoking history, 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.

Offer smoking cessation services (see our smoking cessation guide for more details).

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information).

Offer support services to assist the patient in reducing their alcohol intake.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.

If recreational drug use is identified, patients can be offered input from drug cessation services.

Diet and weight

Ask if the patient what their diet looks like on an average day.

Ask about the patient’s current weight:

  • Obesity significantly increases the risk of developing malignancy and is also associated with polycystic ovarian syndrome.
  • 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.

Occupation

Ask about the patient’s current occupation and if they are managing ok at work with their current symptoms.


Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Reviewer

Dr Venkatesh Subramanian

Obstetrics & Gynaecology Registrar in London


 

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