GYN history taking.

Introduce
Confirms name and DOB
Partner should not be in the room (sensitive, domestic abuse, FGM etc.)
(You can ask occupation at the start).
P/C – how can I help?
 I have read from your GP that ____. May I just ask if you know why you are referred here?
 Give patient time to explain why they are – is it the GP or the patient that is worried?
 What worries? How does this affect your life?
o I understand why this is worrying.
o Problems are usually benign, although it can present quite dramatically. I would like
to ask more specific questions to ascertain what is really going on, then we can
discuss about how we can get you better.

Menorrhagia

Hx P/C:
 Address the P/C directly. “Bleeding heavily” – use their own words (not medical terms).
o How long?
 How many days do you bleed – which part is the heaviest?
 Normally first few days heaviest.
 3/28  3 days bleeding (but don’t tell which day heaviest).
 Other bleeding – IMB, PCB?

 (WHY PRESENT TO DOCTOR NOW?)

o Is it getting worse?
 What is your normal periods like?
 How many days between first day of one period and first day of the
next?
 Is it regular?
 Is there pain? SOCRATES + what has been tried? Does it come at any
other time of the cycle? Pain on intercourse (deep or superficial?)
 Pain starts T-minus 2 days before period and reach a
crescendo on day 1.
 LMP – when was your first day of your last period?
 Pregnancies are dated from 1st day of LMP.

o Qualify “heavy”:
 Do you pass clots (if so: how large?)?
 Need double protection (e.g. pads and tampons)?
 Would you describe it as “flooding”?

o What are you taking currently to try to stop it?

 Ask specifically: are you on any OTC medications, acupuncture, hot bottles,
herbal remedies, Rx drugs.

o What does it stop you from doing?

 “I have to go to bed… I can’t work… embarrassing… ”
GYN history taking.

 “Associated” questions to form your differentials – shows you are organised and thinking.

There are mainly 2 categories of causes – 1 is structural, the other is not. Firstly, there are a few
things I would want to rule out (pregnancy-related would be inferred from LMP question already).

Infections (not  Have you been pregnant before? Then specifically: previous problems
just STIs) with pregnancy (ectopic)?
 The following questions are quite sensitive, I ask them to everyone,
please do not get offended…
o How many partners do you have? Regular/casual? Do your
partners wear any condoms? Have you ever had sex with
someone with a known STI.
 PID/acute salpingitis – FEVER, bilateral pelvic pain, discharge, pain on SI,
PCB/IMB.

Cancer  General – weight loss, appetite changes, bowel habit changes, bloating
(endometrial  Cervical CA – ever had a smear test done before… what were the results?
CA if > 45 y) Ever had sexual intercourse before (based on above Hx)?
 Endometrial CA – post-menopausal bleed. Risk factors.

Structural for abnormal uterine bleed

PALM
Polyp Can’t do much from Hx – need speculum or hysteroscopy
Adenomyosis Can’t do much from Hx. O/E – symmetrical bulk uterus.
Leiomyoma  HMB that lasts for a week prompt this.
(fibroids)  Associated – pressure effect: frequency on urination, or difficulty
emptying? Pelvic pain? Constipation? Back pain?
Malignancy /  Malignancy/ hyperplasia: as above.
hyperplasia  Cervical ectropion – on speculum.

Non-structural causes
CIN
Coagulation  Do you bruise or bleed easily?
 Any family history of bleeding conditions?
Iatrogenic (in  Sometimes this can be due to side effects of contraception and from
this case: stopping them.
contraception  How do you go about avoiding being pregnant?
related) o Then specifically: do you take any pills e.g. for period pain or
acne?
o Then specifically: have you stopped using it (expired?); what
regime (could be breakthrough bleed).
o Then specifically: do you have an IUD inserted?

Not yet Endometriosis = cyclical + chronic pelvic pain, dyspareunia, dyschezia, PR bleed,
classified infertility.
DUB (most common) = no cause found, dx of exclusion.
GYN history taking.

PMHx, DHx, SHx, FHx

 Includes allergies, occupation (affects QOL), FHx cancers/PCOS/autoimmune (miscarry) etc.

Systems review
 Thyroid Sx – TAAT? Agitated? Low mood?
 Anaemia Sx – TAAT, SOB on exertion.
 Uro – (see fibroid Sx) frequency/volume/urgency/nocturia; dysuria/haematuria (DDx:
confused)
 GI – (see cancer Sx) PR bleed (DDx: confused)

Investigation
 Blood test – FBC esp. Hb, thyroid function (TAAT), coagulation screen (if indicated).
 Physical exam + speculum
o Asymmetric and bulky? Fibroids (usually > 3 cm).
o Cervical polyps (not endometrial) from speculum.
o Ectropion from speculum.
 Uterus palpable
o TVS – rule out local organic causes. If suspicious, endometrial Bx
 > 45 years old  2WW
 Hysteroscopy – allows detection of polyps and submucosal fibroids.

Management
 No structural problems  PHARM (start conservatively and Tx Sx, while awaiting Ix).
o Long-term i.e. 12 months IUS (Mirena) is 1st-line unless there is pelvic anatomy
distortion (< 3 cm fibroids)
 S/E: anticipated bleeding changes in 1st few cycles, and may last for > 6m.
o TXA (antifibrinolytic), NSAID (mefanamic acid)  good if hormonal Tx unacceptable
 NSAID > TXA if dysmenorrhoea co-exist.
 Stop if don’t improve within 3m.
o COCP
o High-dose progesterone (NET) from day 5 to 26 of cycle, or injected progestogens
o GnRH agonists (usually to shrink fibroid before operation)

 Fibroids > 3 cm
o Ulipristal acetate 5 mg (x4) if Hb < 102 (if > 102, consider).

 Other management options (to d/w patient and provide info).

o Fibroids:
 TCRF
 Myomectomy
 UAE (not recommended by fertility experts)
 Hysterectomy (all else fail, don’t want conceive, requests for it + fully
informed, and wishes for amenorrhoea).
o Endometrium:
 2nd-gen ablation e.g. balloon (if QOL affected and don’t want conceive;
should be offered initial Tx 1st, and be on effective contra).

 Hand them a PIL and address concerns (fertility, lifestyle). Support group e.g. for
endometriosis (fertility etc).
 F/U.
GYN history taking.

PV discharge

P/C:
 Nature: colour, consistency, odour?
 Amount?
 Has it change?
 Duration?
 Associated: itch, discolouration of vagina or any other skin changes
 Any treatment?

Differentials (more associated)

R/O
Infections Is the person sick as shit?

Screen for sexual Hx (and smears).

 STI = chlamydia, Gc, TV
o Chy
o Gc
o TV
Benign
 BV (not STI) – grey-white, no itch/discolouration. +ve whiff. Metro or clinda
creams.
 Candiasis (not STI)– cottage cheese, itchy + vulva irritation. Dx =
microscopy/culture. Topical canesten or PO fluconazole.
Malignancy As above.

FAP
Foreign body  Retained tampons or swabs after childbirth
 Offensive discharge
Atrophic vaginitis  E deficiency (before menarche, during lactation, after menopause)
PHYSIOLOGIC  Most common! Non-offensive.
 Increases around ovulation, during pregnancy; taking COCP
 Lochia = postpartum (brownish)
 Polyps do increase cervical mucus discharge.

PMHx, DHx, SHx, FHx

 Includes allergies, occupation (affects QOL), FHx cancers/PCOS/autoimmune (miscarry) etc.

Systems review
 Uro/GI/thyroid most relevant.

O/E + speculum (smear) + investigations

 If bacterial vaginosis or candidiasis suggested, treat without sampling.
 Otherwise, take swabs for microscopy and culture.

Management
 Treat infection with antibiotics if necessary.
 Remove any retained foreign bodies.
GYN history taking.

PMB (effectively taking a cancer + risk factor Hx)

P/C:
 Hx P/C
o Onset (when – PCB or…?), duration, severity, course (improving/worsening), cyclical?
o Precipitate/ relieving
o Previous episodes
 Associated
o Pain – SOCRATES
 GYN Hx (remember the patient is post-menopausal).
o FIRST MENARCHE and LAST PERIOD
o Any menopausal Sx
o Previous smears (+ regularity + results)
o Past problems + previous Tx e.g. PCOS and E-only HRT.
o Ever taken any contraception?
 Obstetric Hx
o G?PX+Y
o Any complications with each pregnancy (sensitive)
o Previous Tx
 ICE

Differentials
Endometrial RF: age, Hx atypical hyperplasia or CA, nulliparity, early menarche/late
CA menopause, E-only HRT, obesity (aromatase), infertility with anovulatory cycles
e.g. PCOS, other E-secreting tumours (granulosa cell tumour), Tamoxifen.
Cervical CA RF: HPV exposure (partners + OCP use), immunosuppression, smoking, diet (lack
of b-caterone).
Vulvar CA Is rare. Any skin changes + itch? Red = Paget’s. Melnoma.
RF: smoking, HPV, immunosuppression, previous XRT
Vaginal CA Is rare. Pt: bleeding
RF (squamous): HPV, previous pelvic XRT, chronic inflammation e.g. pessaries/
procidentia.
RF (adenoCA): DES exposure.
Infections As above
Endometrial On Bx
hyperplasia
Polyps Endometrial (hysteroscopy) or cervical (speculum)
Atrophic  PCB, vaginal dryness and soreness.
vaginitis
HRT  DHx
Coagulation  Bruise/bleed easily. FHx.

 MHx, DHx, FHx, SHx, systems review

o Any Hx of GYN or breast cancer or CRC?
o Any FHx of these?
 Cowden (PTEN) – fibroids, endometrial CA, GI harmatomas.
 Lynch/HNPCC (MMR) – gyn CA + CRC.
 BRCA – breast
o Occupation
o Smoking
GYN history taking.

 O/E + speculum
 Investigations
o FBC, thyroid, clotting
o TVS (> 4 mm abnormal postmenopausal).
o Pipelle Bx (or hysteroscopy if inconclusive/ untolerated).

 Management depends on the staging and functional status.

GYN history taking.

4 questions to ask everyone in GYN Hx

 Before I talk more about what I think it is, there are 4 questions that I ask everyone…
o LMP - when was your first day of your last period?

o Have you been pregnant before?

 P = parity (# deliveries), G = gravida (# pregnancy)
 P2+3 = P5 (5 pregnancies)
 The 1st number: past 24 weeks: viability (SB, C/S, normal delivery)
 The 2nd number: didn’t get to viability (TOP, miscarriage).

o How do you go about avoiding being pregnant?

 Best question – may not know they are on contraception/ partner
contraception/ sterile/ may be pregnant!

o Do you go for regular smear test? When was it? What was the result (have you
heard from the doctor)?
 If didn’t go – explain the benefits and offer smear test.
 If the results were abnormal – what was done?