Gynae History Taking

1. Max Brinsmead PhD FRANZCOG February 2010 Gynae History Taking

2. A Diagnosis is Made by: • Listening to the patient tell her story • Generating a hypothesis • Testing the hypothesis • By interrogation • 50 % • By examination • 10% • By selective testing • 40% • If at first you don’t succeed... • Go back and listen to the patient

3. Major Hypotheses in Gynaecology 1 • Reproductive tract dysfunction • Dysmenorrhoea • Dysfunctional uterine bleeding • Functional ovarian cysts • Endometriosis • Pregnancy • Miscarriage • Ectopic • Pregnancy-related disease

4. Major Hypotheses in Gynaecology 2 • Reproductive Tract Infections • Vaginitis • Pelvic inflammatory disease • Reproductive Tract Cancer • Cervix • Uterus - endometrium • Ovaries • Benign tumours • Fibroids • Polyps of cervix and endometrium • Ovarian • UterovaginalProlapse • Urinary dysfunction • Anorectal dysfunction

5. Major Hypotheses in Gynaecology 3 • Psychosexual • Pelvic Pain • Dyspareunia/ Vaginismus • Sexual Assault • Libido • Homosexuality (not usually a problem for the gynaecologist) • Iatrogenic • Arising from contraception/HRT • Arising from other drugs • Other Diseases • With pelvic manifestations • Infertility • Male

6. Components of a Gynae History • Menstrual history • Contraceptive history • Sexual history • Past gynaecological and other medical history • Drug history • Bladder and Bowel function

7. Menstrual History • Menarche • Cycle • Usually expressed as daysbleeding/cyclelength • Last menstrual period (LMP) • Intermenstrual bleeding (IMB) • Postcoital bleeding (PCB) • Postmenopausal bleeding (PMB) • Menstrual pain

8. Menstrual history tips • How often do your periods come • From the beginning of one period to the beginning of the next • What do you mean by regular • Do they “come early” or do they “come late” • How much early, how late • Do you get any bleeding between your periods • When does it occur in the cycle • Do you know of anything that brings this on • Does your period start as a full flow • How many days of “mucking about” • When was your last normal period • First day of the last period • Not the date of the missed period

9. Assessing menstrual loss • For how long do you have a period • How many heavy days • How many light days • What do you call heavy • How many pads or tampons • How often do you change • Do you change at night • How often • How many nights • Do you pass clots • How big • How often • Do your periods interfere with your life • Have you had any “accidents”

10. Menorrhagia Used loosely means excessive menstrual loss...

11. What is excessive menstrual loss? • Escapes from normal menstrual protection • Large clots – frequently • Changing at night more than once • Lasts longer than 7 days “full flow” • Interferes with normal life or duties • Causes iron deficiency (anaemia) • Other causes excluded

12. Patterns of abnormal menstrual loss • Menorrhagia • Excessive menstrual loss at regular intervals • Metrorrhagia • Frequent and irregular menstrual loss • Polymenorrhoea • Regular cycles at <21 days • Oligomenorrhoea • Infrequent menstruation (>35 days) • Intermenstrual Bleeding • Bleeding between menstrual periods • Requires careful questioning

13. Assessing pelvic pain • Do you get pain with your periods • Is this the same as its always been • If changing with time how and when • Which is the worse day for pain • What do you do for the pain • Analgesia used. How many tablets Does it help • Does the pain interfere with your life. Your sleep • Describe the pain • Nature and location. Aggravating factors • Pain with intercourse • Frequency • Nature and location

14. Obtaining a sexual history • Choose your words carefully, sometimes with preamble • How long have you been in your current relationship • Is sexual intercourse occurring • Have you ever been in a relationship • When was the last relationship • How many partners have you had in (period of time) • or before your current relationship • What does you or your partner do to avoid pregnancy • Does your partner travel • or spend nights away from home • or have other sexual partners

15. Past gynaecological history • Any other serious illnesses. Any operations • Any gynaecological operations • on your tubes, ovaries or uterus • Any vaginal surgery • Any curettes or keyhole surgery • Any treatment to the cervix for pre cancer changes • What was done in those operations • What were you told after • Do you have regular Pap tests • When was the last or where was it done • What was the result • Has there ever been any abnormality • How many have you had in (period of time) • Have you ever been treated for inflammation of the pelvis, tubes or for a sexually transmitted disease? • Did you have any trouble getting pregnant?

16. Past obstetric history • Any infertility treatment(s) • Number of pregnancies (G) and births (P) • Gravida = number of pregnancies • Para = births after 20w (and twins =1) • T= termination of pregnancy • A= miscarriage E=ectopic • Birthweights and mode of delivery • Spontaneous or assisted vaginal birth • Birth trauma • Pregnancy complications

17. Drug history • Are you on any drugs or medications • Any hormones • The pill, injections or implants • Patches or hormone creams • Vaginal pessaries or creams • Details of the drug, dose and dates can be very important • Any vitamins, minerals , supplements or herbal remedies? • Do you smoke?

18. Bladder and bowel functions • Do you get up at night to pass urine • Do you have to get there in a hurry • Ever wet before you get there • How long can you hold on during the day • Do you ever wet • If you cough or sneeze • A little or a lot • Do you have any difficulty emptying your bladder • or getting started • Do you have good stream • Any bladder infections • Any difficulty getting your bowels emptied • What happens when you strain • Can you control your wind • How about a loose bowel motion?

19. Infertility Questions • The most important calculation is the number of months that the woman has been exposed to the possibility of pregnancy but has not conceived • This may not be the same as the couple’s view of how long they have been “trying” • Take a careful “contraceptive history” • Other useful questions • Have you ever been pregnant • Have you ever fathered a pregnancy (in any other relationship or tried) • How often is intercourse occurring • Any (intercourse) problems?