Obstetrics and Gynecology/Gynecological History Taking

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Gynecological history taking involves a series of methodical questioning of a gynecological patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the patient, further investigative testing or treatment of a diagnosed condition.

There is a basic structure for all gynecological histories but this can differ slightly depending on the presenting complaint.

When taking any history in medicine it is essential to understand what the presenting complaint means and what the possible causes (differential diagnosis) of the presenting complaint may be. After all, it is the aetiology of a symptom that guides the physician's questioning.


Basic Structure of a Gynecological History

Introduction

age of last baby

Presenting Complaint

It is important to ask as open a question as possible in this part of the history and to ensure the complaint is understood as everything else follows on from here

History of Presenting Complaint

This will differ slightly depending on the presenting complaint but follows a vague structure:

Menstrual History

Past Gynecological History

Past Obstetric History

Past Medical History

Drug History

Contraception: Contraceptive history. Any recent unprotected intercourse. Reliability of method and user. Potential contra-indications to different methods, eg combined pill. Permanent or temporary method required

Personal History

Family History

Social History

Diagnosis

A differential diagnosis can be made after the history taking process. This is based upon a knowledge of the presenting complaints and the history of presenting complaints in relation to certain disease states.

Although there is a general structure for history taking in gynecology, there are small differences in the approach depending on what the presenting complaint is. It is essential for a physician to know the causes of each symptom and the other manifestations of those causes before taking a history.

Postcoital Bleeding

This is bleeding after intercourse. Causes include:

Intermenstrual Bleeding

This is vaginal bleeding between menstrual periods. Causes include:

Post-menopausal Bleeding

This is vaginal bleeding more than 6 months after the menopause. Causes include:

Menorrhagia

This is history of heavy cyclical blood loss over several consecutive menstrual cycles in the absence of any intermenstrual or postcoital bleeding. Causes include:

Oligomenorrhea and Amenorrhea

Oligomenorrhoea is infrequent menstruation defined by a cycle length between 6 weeks and 6 months. Amenorrhoea is absent menstruation for at least 6 months. They both have the same list for causes with one exception - primary failure of elements of the hypothalamic/pituitary/ovarian axis cause complete amenorrhoea, not oligomenorrhoea. Causes include:

Endocrine Causes

Dysmenorrhea

This is painful menstruation which can be primary (absence of pelvic pathology) or secondary (attributed to pelvic pathology).Causes include:

Dyspareunia in females

This is pain during intercourse. Causes include:

The Complete History

For each of the most common and life-threatening conditions, it is important for physicians and medical students to know the important aspects that will present in the different parts of the history. It is this knowledge, that will guide the further management of the patient.

Cervical Carcinoma

Age:

Clinical Features

Risk Factors

Endometrial Carcinoma

Age

Clinical Features

Risk Factors

Endometrial Fibroids

Age

Clinical Features

Endometriosis

Age

Clinical Features

Pelvic Inflammatory Disease

Clinical Features

Risk Factors

Polycystic Ovary Syndrome

Clinical Features

References

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