Gynecological History Taking
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

Name of patient

Age of patient

Consent for questioning

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:

If pain is involved ascertain site, radiation (if any) and character

Onset

Periodicity

Duration

Recurrence?

Aggravating & relieving factors

Severity
Menstrual History

Menarche and menopause

1st day of last menstrual period

Length of bleeding (days)

Frequency

Regularity

Bleeding between periods

Bleeding after intercourse

Any post menopausal bleeding *Nature of periods

Heavy?

Clots?

Flooding?
Past Gynecological History

Gynecological symptoms

Gynecological diagnoses

Gynecological surgery

Date & result of cervical smears

Contraception
Past Obstetric History

Gravidity and Parity

Dates of deliveries

Length of pregnancies

Induction of labor/Spontaneous

Normal Delivery?

Weight of babies

Sex of babies

Complications before, during and after delivery
Past Medical History

Current or past illnesses

Hospital admissions

Past surgeries
Drug History

Prescribed medications

Non-prescribed medications/herbal remedies

Recreational drugs

Any known drug allergies .
Personal History

Sleep *Appetite *Micturation *Defecation *Weight loss or gain *Addiction === Family History ===

Medical conditions

Gynecological conditions

Malignancies

Consanguinity
Social History

Occupation

Support network

Smoking

Alcohol

marital status

Ranking
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:


Cervical causes (common causes)

Carcinoma

Polyps

Erosion

Cervicitis
Vaginal causes

Vaginitis

Carcinoma (very uncommon)
Intermenstrual Bleeding
This is vaginal bleeding between menstrual periods. Causes include:





Cervical causes

Carcinoma

Ectropion

Cervicitis

Polyps
Endometrial causes

Carcinoma

Polyps

Endometritis

Intrauterine Contraceptive Device

Oral Contraceptive Pill or Contraceptive Injection
Vaginal causes

Atrophic vaginitis

Infective vaginitis

Carcinoma
Ovarian causes

Estrogen-secreting tumor

Irregular Ovulation
Fallopian tube causes

Carcinoma
Post-menopausal Bleeding
This is vaginal bleeding more than 6 months after the menopause. Causes include:

Vaginal causes




Cervical causes

Carcinoma

Polyps
Endometrial causes

Atrophic endometritis

Carcinoma

Polyps

Hyperplasia
Ovarian causes


Atrophic vaginitis
Estrogen-secreting tumor
Other causes

Ring Pessary

Exogenous estrogens (HRT)
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:



Pelvic pathology

Uterine fibroids

Endometriosis and adenomyosis

Pelvic inflammatory disease

Endometrial polyps
Endocrine causes

Dysfunctional uterine bleeding

Hypothyroidism
Haematological causes

Disorders of coagulation

Thrombocytopena

Leukaemia
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




Hypothalamic disorders

Kallman's syndrome - hypogonadotrophic hypogonadism

Psychogenic - stress/shift work

Exercise

Excessive weight gain/loss

Tumours e.g. craniopharyngioma

Post-oral contraceptive use
Pituitary lesions

Pituitary adenomas

Sheehan's syndrome - infarction necrosis

Granulomatous infiltration e.g. sarcoidosis
Ovarian lesions

Turner's syndrome - ovarian dysgenesis

Polycystic ovarian syndrome

Resistant ovary syndrome

Premature ovarian failure

Androgen-secreting ovarian tumours
Other

Primary hypothyroidism/hyperthyroidism

Poorly controlled diabetes mellitus

Cushing's syndrome

Addison's disease
Dysmenorrhea
This is painful menstruation which can be primary (absence of pelvic pathology) or secondary (attributed to
pelvic pathology).Causes include:

Endometriosis

Pelvic inflammatory disease

Submucosal fibroids

Endometrial polyps

Pelvic congestion syndrome

Intrauterine contraceptive device

Ovarian cysts

Adenomyosis
Dyspareunia in females
This is pain during intercourse. Causes include:


Superficial

Infection

Vaginal atrophy

Inadequate episiotomy repair

Vaginal/rectal tumor
Deep

Pelvic inflammatory disease

Endometriosis

Adenomyosis

Cervicitis
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:

This condition usually affects women between the ages of 35-55. Screening in UK has noticed a trend
towards a younger age group and the disease presenting itself in the 25-35 age group.
Clinical Features

Postcoital bleeding

Intermenstrual bleeding

Postmenopausal bleeding
Risk Factors

Early age of first experience of intercourse

High number of sexual partners of patient or patient's current or past sexual partners

HPV infection

Smoking

Low socioeconomic status
Endometrial Carcinoma
Age

>40 years
Clinical Features

Post-menopausal bleeding
Risk Factors

Obesity

Nulliparity

Late Menopause

Unopposed oestrogen stimulation

Diabetes Mellitus
Endometrial Fibroids/myomer
Age

Women of child-bearing age
Clinical Features

Menorrhagia

Abdominal swelling

Frequency of micturation

Pain

Infertility

Recurrent abortions Risk Factors

Pregnancy

Family History
Endometriosis
Age

Women of child-bearing age
Clinical Features

Cyclical Pelvic Pain

Dysmenorrhoea

Dyspareunia

Infertility
Pelvic Inflammatory Disease
Clinical Features

Bilateral lower abdominal pain

Fever

Vaginal discharge

Deep dyspareunia
Risk Factors

Multiple sexual partners

History of pregnancy termination
Polycystic Ovary Syndrome
Clinical Features

Oligomenorrhoea

Amenorrhoea

Hirsutism

Infertility

Acne

Obesity
References

McCarthy, A & Hunter, B (2003) Master Medicine: Obstetrics and Gynaecology (2nd ed.) Philadelphia:
Elsevier Saunder