Gynaecological History Taking | Geeky Medics

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GYNAECOLOGICAL HISTORY TAKING

Gynaecological history taking has a number of questions that are not part of the
standard history taking format and therefore its important to understand what
information you are expected to gain when taking a gynaecological history.
Presenting Complaint
Its important to use open questioning to elicit the patients presenting
complaint
So whats 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
Duration of symptoms days, weeks, months, years
Progression of symptoms worsening, improving, stable, fluctuating
Cyclical? - do symptoms have any relationship to the menstrual cycle?
Associated symptoms
Dyspareunia pain during sex superficial (candidiasis) / deep (endometriosis)
Fever Pelvic inflammatory disease e.g. Chlamydia
Tiredness/Fatigue anaemia often occurs alongside menorrhagia
Pain if pain is a symptom, clarify the details of the pain using SOCRATES
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Site where exactly is the pain / where is the pain worst

Onset when did it start? / did it come on suddenly or gradually?
Character what does it feel like? (sharp stabbing / dull ache / burning?)
Radiation does the pain move anywhere else? (e.g. chest pain with left arm
radiation)
Associations any other symptoms associated with the pain (e.g. chest pain with
SOB)
Time course does the pain have a pattern (e.g. worse in the mornings)
Exacerbating / Relieving factors anything make it particularly worse or better?
Severity on a scale of 0-10, with 0 being no pain & 10 being the worst pain
youve ever felt
Ideas, Concerns & Expectations
Ideas what are the patients thoughts regarding their symptoms?
Concerns explore any worries the patient may have regarding their symptoms
Expectations gain an understanding of what the patient is hoping to achieve from
the consultation

Summarising
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.
It also allows the patient to correct any inaccurate information & expand further
on certain aspects.
Once you have summarised, ask the patient if theres anything else that
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youve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient;
What you have covered Ok, so weve talked about your symptoms & your
concerns regarding them
What you plan to cover next - Now Id like to discuss your past medical history
and your medications
Menstrual History
Age of menarche the earlier the greater the exposure to oestrogen risk of
breast Ca
LMP (first day of LMP)
Duration & Regularity ( X / 28 days)
Flow heavy/light - number of sanitary towels / tampons can be useful to estimate
loss
Menstrual Pain use the SOCRATES method shown above to assess menstrual pain
Irregular bleeding
Post-coital ectropion / STDs/ vaginitis
Intermenstrual
Consider malignancy in older females - e.g. endometrial Ca
Younger females may have unexplained irregular periods
Poor compliance with oral contraceptives can result in intermenstrual bleeding
Associated Symptoms Bowel, Bladder dysfunction or pain
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Menopausal symptoms hot flushes, vaginal dryness, irregular periods

Hormonal Contraceptives or HRT use? increased risk of breast Ca / VTE
If post-menopausal what age did they go through the menopause?
Past Gynae History
Previous cervical smears - date of last, abnormal results, treatments (LETZ etc)
Previous gynecological problems & treatments - STDs/PID
Current contraception COCP, POP, Depot, Implant, Coil
Past Obstetrics History
Gravidity number of times a woman has been pregnant, regardless of outcome
Parity - X = (any live or stillbirth after 24 weeks) | Y = (number lost before 24
weeks)
Each Pregnancy:
Current age of child
Birth weight
Complications of pregnancy, labour, after birth
Ask sensitively regarding miscarriages / terminations / ectopic pregnancies
Past Medical History
Medical conditions? CIN, Genital Tract Cancers, Breast Cancers, etc
Previous surgery abdominal or gynae?
Any hospital admissions? when & why?
Drug History

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Regular medication - e.g. tranexamic acid, HRT

Over the counter drugs
Contraception COCP / POP / Coil / Implant / Depot
ALLERGIES
Family History
Any illnesses that run in the family?
Uterine / Ovarian / Genital tract cancers
Breast cancer
Social History
Smoking - How many cigarettes do they smoke a day? How many years have they
smoked for?
Alcohol How many units a week? Be specific about type / volume / strength of
alcohol.
Recreational drug use
Living Situation:
House/bungalow? the presence of stairs is important will the patient manage?
Who lives with the patient? are they a source of support?
Any carer input? - what level of care do they receive?

Occupation?

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Systemic Enquiry
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. reduced urine output in
fluid overload
Choosing which symptoms to ask about depends on the presenting complaint & your
level of experience
Cardiovascular Chest pain / Palpitations / Cyanosis / SOB / Syncope
/ Orthopnoea / Ankle swelling
Respiratory Cough / Sputum / Chest Pain / SOB / Wheezing / Stridor/
Haemoptysis
GI - Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss /Pain /
Bowel habit
Urinary - Frequency / Dysuria / Polyurea / Urgency / Hesitancy / Nocturia /
Incontinence
Nervous System Vision / Headache / Weakness / Sensory disturbance / LOC /
Seizures / Incontinence
Musculoskeletal Bone & Joint pain / Muscle pain / Joint swelling / Difficulty
mobilising
Dermatology Rashes / Skin breaks / Ulcers

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