Gynecological Health: In this section we will talk about how to take a gynae history in a structured manner.
Gynecologic Care: Dispelling the Myths
Many people think the first time they should see a gynecologist should be when they’re an adult and that’s actually a myth. The first time the patient should see a gynecologist is between the ages of 13 to 15 years of age for their initial reproductive preventive health visit.
This allows the gynecologist the opportunity to begin to develop the patient-physician relationship, counsel about healthy behaviors, and dispel any myths and concerns.
So, I think it’s helpful for a parent to discuss with their child that they’re going to behaving their initial reproductive GYN visit, and to reiterate to them that they probably will not require an internal pelvic exam and a Pap test will not be performed.
We’re going to be discussing their menstrual cycle and prior to coming in for their office visit, it’s very helpful to track their cycle on a calendar and to bring that with them to their first office visit.
As gynecologists we like to think of the menstrual cycle as a vital sign just like you think about blood pressure, or heart rate, and an abnormality in those conditions might be indicative of a medical problem, just like an abnormal menstrual cycle might lead us to think of future potential health concerns.
Patients at a minimum would be seen on a yearly basis, however, based on their individual medical condition and needs, might be seen sooner as indicated.
You know, as patients go through their adolescent years, I think it’s important that they’re seen yearly because their needs will change as they go through adolescence.
And finally, you know, I really advocate that parents and their children have an open dialogue with one another so that they can share with both their feelings and concerns.
Role of a Doctor
- Listening to the patient tell her story.
- Generate a hypothesis.
- Testing the hypothesis.
- By Interrogation 50%
- By Examination 10%
- By Investigation 40%
- If at first you don’t succeed.
- Go back and listen to the patient.
The role of a doctor is actually listening to the patient tell her story, and from the story we generate a hypothesis or a diagnosis.
This diagnosis, obviously, is made up of 50% by interrogation, 10% by examination, and by investigation the rest, which is 40%. If you don’t come to any conclusion, the best way of doing it is obviously we’ve missed something in the history.
The idea would be to go back to the patient and double check their history and come to a conclusion next time. The idea of this slide is to emphasize the importance of history, taking a thorough, good, structured history.
Credit: Learning in 10
- History taking sequence remains same.
- Should follow a logical and chronological sequence.
- Some unique area of focus specific to speciality.
- Requires sensitivity and preservation of dignity for the patient.
- Ensure confidentiality.
- Always consider possibility of pregnancy when presented with abnormal bleeding or pain.
Some considerations before we start the history. In gynae the history-taking sequence, essentially it is similar to a case would be a medical history. So, therefore, we follow a logical and chronological sequence of history of presenting complaints, past medical, surgical history, and so on.
However, in gynecology there are some specific areas that we need to focus on, and I will touch upon these in the next slide. Gynae history is a bit peculiar in the sense that it requires sensitive history and confidentiality is important.
We also have to ensure the dignity of the patient, and this should be communicated to the patient. Possibility of pregnancy should always be considered, especially when there is history of abnormal bleeding or pain, although the patient may not bring this as a diagnosis.
The Gynecological History follows the usual method of talking a history but there are specific key areas that need to be expended on. There are:
- Menstrual History
- Common Gynae Issues: Vaginal Discharge, Pelvic Mass, Abdominal Mass
- Contraception and Sexual Health
- Obstetric History
- Uro-Gynecological History
- Pap smear and related vaccination history
- Past Gynae and Surgical History
We come to presenting complaints. So, as mentioned, gynae history usually follows the same sequence. However, there are some key areas that we need to focus on. I will delve into the details of these in the next few slides.
Some of these are Menstrual History, the common gynae issues— for example, vaginal discharge, pelvic mass, abdominal mass. Contraception and sexual health is essential component of a gynae history which we shall talk about. Although Obstetric History— detailed obstetric history– is not required, we do require basic obstetric history even for a gynae complain.
Uro-gynecological history may be of relevance and will also be considered. Pap smear. Details of last pap smear and vaccination against cervical cancer would also be an essential component of this history taking. Past gynae or surgical history will obviously complete the entire history sequence. So firstly we will consider menstrual history in details.
Patterns Of Abnormal Menstrual Blood Loss
- Excessive Menstrual Blood Loss At Regular Intervals
- Frequent And Irregular Menstrual Blood Loss
- Regular Cycle less than 21 days
- Infrequent Menstruation more than 35 days
- Intermenstrual Bleeding
- Bleeding Between Menstrual Periods
- Requires careful questioning
So there are certain patterns of abnormal menstrual blood loss, and we shall define these first. We often hear about menorrhagia. Menorrhagia means excessive menstrual blood loss at regular intervals.
There’s also a terminology that’s used quite frequently. That’s Metrorrhagia. That means frequent and irregular menstrual blood loss which may be off with the normal cycle. Polymenorrhoea. Polymenorrhoea means a cycle that occurs too frequently, that is less than 21 days.
Oligomenorrhoea means infrequent menstruation or scanty menstruation, usually occurring after more than 35 days. Intermenstrual bleeding is bleeding in between the menstrual periods and has to be defined quite clearly, whether it’s part of the cyclical pattern or not. It therefore requires careful questioning.
Menstrual History: Tips
- Tell me about your menses?
- Age at menarche
- Arrive at expected time?
- Pattern of bleeding
- Was last period normal?
There are tips of obtaining a good menstrual history. An easy way to begin is tell me about your menses. We also need to focus on the age of menarche usually in younger patients. Obviously, in some cases, it may not be of relevance.
The last menstrual period is very important. What is more important is to get the date of the first day of the last menstrual period, as often the patients give you the last day of the last menstrual period.
Also important to know whether the last period was normal and whether it arrived at an expected time. Also ascertain the pattern of bleeding. Was it normal or was it abnormal? Important to know how often the periods occur.
- How often do they occur? Regularly? or Irregularly?
- Do they “come early” or do they “come late”
- Regular menses – range 21 to 35 days
- Usually 28 to 30 days
Whether they are regular or irregular. We therefore have to know whether they come too early or too late. It’s important to understand that the periods don’t need– not every cycle needs to be 28 days. Periods are considered normal between 21 and 35 days. And usually for most people it happens between 28 to 30 days.
- How long do they last for?
- From the beginning of one period to the beginning of next period
Also, another question would be how long do they last for. And this would include counting from the beginning of one period to the beginning of next period.
- Estimate the Menstrual Loss
- How frequently do you change your pads?
- Pad completely soaked?
Further on in menstrual it is important to estimate the menstrual loss in order to diagnosis a case of menorrhagia. This can be often challenging.
Some questions that can be asked are how frequently do you change your pads? Was your pad completely soaked? Was there any clots or flooding?
If they do not understand the term clots, you can ask whether they passed any tissues or liver-like substance.
- Are Periods Painful? Normally Painful?
- When does pain start? (Before menses or with menses)
- Severity…. does it keep you off work?
Peak dysmenorrhea is another important symptom, so you need to ask whether the periods are painful and are they more painful now or how bad is the pain in terms of mild, moderate, or severe.
And the timing of the pain is important as it gives you the diagnosis, whether it’s primary or secondary dysmenorrhea. Severity. To assess severity, one important question is does it keep you off work or school?
- Change in the Period Pattern?
Also important to consider any recent change in the period pattern.
- Any post-coital bleeding (PCB)?
Any post-coital bleeding. That is bleeding after sex. Important to know about post-coital bleeding. Post-coital bleeding can be an important sign of cervical cancer or it can be often related to a benign condition known as cervical ectropian.
- Inter-menstrual bleeding (IMB)?
- Ask specifically about brown or bloody discharge between periods
Inter-menstrual bleeding can be a sign of infection, can be hormonal, or can be related to polyps. Hence, it’s important to establish whether it’s cyclical or non-cyclical.
- Used loosely means Excessive Menstrual Blood Loss
Coming back to menorrhagia, as this is the most important presentation in gynecological clinic or in an related to gynae. It’s loosely defined as excessive menstrual blood loss.
- What is excessive menstrual blood loss?
- Escapes from Normal Menstrual Protection
- Large Clots – Frequently
- Changing at night more than once
- Last longer than 7 days “full flow”
- Interferes with normal life or duties
- Causes iron deficiency (anaemia)
- Other causes excluded
What is excessive menstrual blood loss? Let’s talk about it in more depth. When the menstruation escapes the normal menstrual protection, it may be excessive. When the patient passes large clots and that too for two or three days, it can be excessive.
When the patient has to get up more than once to change her pad at night, the menstruation is considered excessive. Also, when it lasts longer than seven days of full flow. Normally the menstruation will be heavy for day two or day three and then becomes less frequent to last for a total of about 7 days on average.
Then excessive menstruation interferes with normal life or duties or leads to a change in lifestyle. For example, a patient wearing dark clothes during her menstruation for the fear of getting flooded. Also, when it leads to iron deficiency anaemia despite supplements when we have specially excluded other causes of anemia.
- Difficult to ascertain – can be subjective
- Ask about number Towels/Pads used
- Fully/Partially soaked
So let’s talk about obtaining a detailed history for heavy menstrual bleeding, or menorrhagia. It is very difficult to ascertain and can be subjective. However, it’s impossible or impractical to try to ascertain it objectively.
This would mean collecting menstrual material, which is impractical. Therefore, we have to ask in detail about the number of towels or pads used, whether they were fully or partially soaked.
- Enquire about
- Blood Cots (NOT NORMAL) – small pieces of tissue
- “Flooding” – menstrual blood soaks through all protection
- Abnormal and Distressing
We also need to ask about whether the blood clots were normal, whether they were small or whether they were large, and how frequently they were passed.
As mentioned, flooding is menstrual blood that soaks through all protection and stains the clothes or even bedding in extreme cases.
It is often abnormal and distressing, and sometimes the patient has to be questioned about it and will not be forth coming about this, as they may be embarrassed.
- Do you change at night?
- How often
- How many nights
Getting up at night more than once usually means menorrhagia, so you have to ask how many times do they get up and do they get up every night or is it only once or twice.
- Do your periods interfere with your life
It’s also important to know whether the heavy menstrual bleeding actually interferes with their life.
- Have you any “accidents”
Have you had any accidents related to your periods means menstrual protection staining your clothes at time of work or school.
- Associated Symptoms
Do you have any associated symptoms of anaemia such as feeling tired, run-down. This may also be related to hypothyroidism. Hence, it’s important to ask about symptoms related to hypothyroidism as well.
- Irregular Periods, oligomenorrhoea or amenorrhea suggests anovulation or irregular ovulation
- Amenorrhea: Absence of Periods
- Primary amenorrhea: Menstruation not established
- 16 years old with secondary sexual characters
- 14 years old with no secondary sexual characters
- Secondary amenorrhea: Absence of menses more than six months
- Think pregnancy
- Specific questions (Causes of Anovulation)
- Weight Change: Loss/Gain
- Acne/ Greasy Skin
- Galactorrhea/Recurrent headaches
- Hyperthyroid symptoms
- Flushes may help identify ovarian dysfunction: menopause
Let’s talk about oligomenorrhoea, scanty menstruation. Loosely, it means irregular periods and it suggests anovulation or irregular ovulation. Amenorrhea means total absence of periods. Amenorrhea may be primary, which means menstruation has never been established.
If the girl is 16 years old with secondary sexual characters and has never had menses, then she suffers from primary amenorrhea. The other way to define it is when she’s 14 years old but does not have any secondary sexual characters, this would also be diagnosed as primary amenorrhea. Amenorrhea can also be secondary, which means absence of menses for more than six months in continuation.
It’s important to remember that the most important cause of secondary amenorrhea is pregnancy, so the first step would be a pregnancy test to exclude that cause. Oligomenorrhoea means infrequent periods with a cycle of more than 35 days. It’s important to ask specific questions related to anovulation.
The first question would be any recent weight change. So excessive weight loss or weight gain is important. Weight loss, as in athletes or in people who exercise heavily or in girls related to an anorexia nervosa may lead to hypothalamic suppression and, hence, amenorrhea or oligomenorrhoea. Excessive weight gain is often related to polycystic ovarian syndrome, which also is associated with anovulation and oligomenorrhoea.
Polycystic ovarian syndrome also is associated with acne and greasy skin, and this should be a leading question. Hirsutism or abnormal hair growth, for example, on the chin or on the chest or other facial areas is also a sign of poly COS. Also important to consider would be hyper galactorrhea, and for this we need to question about galactorrhea.
That is any discharge from the breast or nipple and recurrent headaches, as this will require specific investigations, including hormones and emission. Hyperthyroid symptoms are also important and should be inquired.
Not to forget about menopause. Although menopause is expected in either late 40s or early 50s, it is not uncommon to have premature menopause in woman younger than that, and, therefore, one should always ask in an oligomenorrhoea and amenorrhea about hot flashes and night sweats.
- Starts with menses
- Usually 2 to 3 days
- improves with age and after childbirth
Coming back to dysmenorrhea, let’s ask detailed questions. So as mentioned, the dysmenorrhea is considered primary when no significant cause or no organic cause for a disease is found. It usually begins with beginning of bleeding or menses, lasts for first two to three days, and usually improves once the girl matures or has children.
- Secondary pathology
- Usually starts a few days prior to the menses
Dysmenorrhea may be secondary when it’s secondary to some second pathology such as endometriosis, fibroids, or chronic pelvic inflammatory disease. This usually begins few days prior to the menses and gets better once the bleeding begins. Obviously, this would be associated with other signs of the associated disease.
- Severity: time off work/school?
- Any Aggravating/Relieving Factors
- Any effect of painkillers
- Family history: Endometriosis
It’s important to ask about severity of dysmenorrhea, as a severe dysmenorrhea will lead to time off work or school. Is this a recurrent feature would also be an important question. Important also to consider any aggravating or relieving factors of a disease.
Do they take painkillers? If so, do they take it regularly and does it make the symptom better is important thing to consider. Also important to ask about family history of conditions such as endometriosis, as endometriosis is known to run in families.
- Colour: white/yellow/greenish/brown
- Odour: odourless/fishy
- Any previous history of same
- Any treatment used
- Other symptoms? Pain, fever, etc.
Another important presentation at the gynae clinic is vaginal discharge. Let’s talk about it next. So, important to know how long the discharge had been present for. Is it cyclical? That is, does it become more during a particular part of the cycle? As we know that during ovulation period, the discharge is thin and mucousy.
Closer to start of menstruation, the discharge becomes thick and whitish, and this is hormonal and normal. Is there any associated symptom of the discharge, for example, itch or any order? The amount of discharge is also important to document.
The color of discharge can help you with a diagnosis. So while discharge may be either physiological or related to thrush. Yellow or greenish may be related to an infection, and brown discharge may give you an idea that it may be old blood, or older blood. The odor is usually normal in case of physiological discharge.
However, the odor may be typically fishy in case of bacterial vaginosis. Is this a recurring feature, or have you had this in the past would be important to know. Have you used any treatments, as sometimes recurrent courses of antibiotics may lead to thrush, so important to know any other treatments related to treatment of infection, as often the infections can be properly treated. Any other symptoms such as pain or fever may indicate pelvic imflammatory disesase, which is an important cause of vaginal discharge.
Mass in Abdomen
- Change in size
- Nausea, Vomiting, change in bowel habits?
- Weight loss
- Associated Symptoms: Menorrhagia, amenorrhea
Patients may present to you in the clinic with a mass in the abdomen, so let’s see what questions we need to consider. For how long has this mass been present? Has there been a change in size? Has it increased recently? Is there any associated pain or tenderness? Does it hurt when you touch?
Any associated symptoms such as nausea, vomiting, or recent constipation or diarrhea? Any weight loss? Weight loss can be associated with malignancy and is an important part of the questioning.
Any other symptoms to consider would be heavy menses or amenorrhea, as heavy menses with a mass would be a feature of fibroid, and amenorrhea can be related to a pregnancy, which can often present as mass.
- Any problems passing urine?
- Urinary Symptoms – frequency, nocturia, dysuria, incontinence, haematuria
- Do you ever leak urine when don’t intend to?
- Stress Incontinence: If so, find out what provokes it. e.g. coughing, sex, exercise
- Urge incontinence: Do you ever not make it to the toilet in time? Can you hold your urine without leaking? Do you pass small volumes frequently
- Often a mixed picture
- Prolapse: Associated with vaginal discomfort, feeling of something coming down
Let’s talk in brief about uro-gynaecological history. Easy way to begin is, any problems passing urine? The common urinary symptoms are urinary frequency, getting up frequently at night to pass urine, pain passing urine, any urinary incontinence, and also blood in the urine, et cetera.
Incontinence has to be defined in terms of whether it is related to stress or urge, which carries different diagnosis. So to ask about stress urine incontinence, good way to begin is do you leave urine when you don’t intend to? And is it related to, operable by certain acts, such as coughing, having sex, or heavy exercise?
This is a feature of stress incontinence. Urge incontinence is related to and usually found in post-menopausal women. Good way of questioning is do you ever make it to the toilet in time or can you hold your urine without leaking? Another way of questioning is do you pass small volumes of urine quite frequently?
The patient may also present with a mixed picture and may require further investigation. Another presentation of uro-gynae is prolapse, so it’s important to ask about symptoms related to vaginal discomfort, feeling of a lump or something coming down, especially after exercise or heavy work.
- Number of Previous Pregnancies
- of children
- Birth Weight
- Any antenatal Problems?
- Mode of delivery labor prolonged?
- Relevant to prolapsed
- Any Terminations/Miscarriage
Let’s talk in brief about obstetric history, which will be covered in another section but is relevant to a gynae patient as well. The number of previous pregnancies is important to know and should be documented.
It’s also important to know number of children, as some of these pregnancies may either be miscarriages or terminations. Birth of a big baby is related to prolapse. Any problems during pregnancy or labor? What was the mode of delivery?
Was the labor very prolonged? As prolonged labor and delivery of a big baby can be related to a positive of prolapse. Any terminations or miscarriage? If so, what was the procedure– whether it was surgical or medical, and at what gestation did it occur.
- Sensitive approach: Choose your words carefully
- Begin with ”I need to ask you some personal questions….Hope that is OK?”
- Are you or have you ever been sexually active?
- How old were you when you first had sex?
- Are you in a stable relationship?
- How many partners have you had in the last six months?
- When was the last time you had sexual intercourse?
- Have you ever suffered from any sexually transmitted infections
- Have you ever experienced sexual assault or incest?
- Is there violence in any of your relationship?
Sexual history can often be intimidating. It’s important to approach it in a sensitive and structured manner. Easy way to begin is, I need to ask you some personal questions. I hope that’s OK with you.
The patient may never have been sexually active. Therefore, this must be considered and usually one should begin with are you or have you ever been sexually active? It’s important to know the age of first intercourse.
Therefore, this should be documented. Also important to know how many partners they have had in the last six months, as having more than two partners in the six months increases the risk of having a pelvic inflammatory disease.
When was the last time you had sexual intercourse is an important leading question, as this will give you an idea of chances of pregnancy and also the risk of pelvic inflammatory disease. Also important to know whether they have had any sexually transmitted infections in the past or they’ve had any sexual assault or incest. Another important point to consider is domestic violence. Therefore, this should be questioned when appropriate.
- Previous gynae problems
- sexually transmitted infection, endometriosis, infertility, any gynae surgery, any polycystic ovarian disease
- Any Problems?
- Pap smear history
- Date and Result of the last Cervical Smear
- Any treatment in the past
- Vaccine against Cervical Cancer
- Bowl Symptoms
- Bleeding PR, fecal incontinence, bowel habits, mucous in the stool, and difficulty emptying bowl
And, finally, few other things to consider. Previous gynae problems such as sexually transmitted infection, endometriosis, infertility, any gynae surgery, any polycystic ovarian disease may have a bearing on their history and should be inquired about. Contraception is very important.
Therefore, important to know about current as well as past contraception. Any abnormal or irregular bleeding may be related to contraception and should always be asked about.
Therefore, important to know whether the contraception is hormonal or non-hormonal. In non-hormonal contraception such as IUCD can be related to dysmenorrhea and amenorragia, and, therefore, the importance of knowing the type of contraception. Any problems with the current contraception, as they may require a change of contraception or further advice.
Pap smear history is an integral part of the gynae history. One should always ask about the date and the result of the last cervical smear. Any treatment related to colposcopy or abnormal pap smear in the past. Also important in today’s world to know about any vaccine against cervical cancer.
So details of that vaccine, the duration of that, and when was the last injection taken would be important. Any bowl symptoms such as bleeding PR, fecal incontinence, bowel habits, mucous in the stool, and difficulty emptying bowl may have a bearing on the gynae diagnosis and are important to consider to complete the total gynae history.