Common Gynaecological Histories

Remember history taking in gynaecology requires you to ask extra questions on the Menstrual history, Obstetric history, Sexual history and Cervical/contraception history (MOSC) – see the gynaecological history section!

Presenting Exploding symptom Relevant system reviews Differential diagnoses Clues to differential complaint Grouping Differentials Pelvic pain Site General Gynaecological PID/acute •Bilateral pelvic pain Onset •Fever, sweats salpingitis •Vaginal discharge Character •Dyspareunia and dysmenorrhoea Radiation Gynaecological •Fever Associated symptoms •PV bleeding: menorrhagia/inter- •May be post-coital or inter-menstrual Timing & relation to period menstural/post-coital/post- bleeding Exacerbating/relieving factors menopausal Ectopic pregnancy •Recent period of amenorrhoea Severity •PV discharge •Trying to get pregnant or unprotected sex •Pain: dysmenorrhoea, •May be some vaginal spotting dyspareunia •In tubal rupture, collapse and shoulder tip •Chance could be pregnant pain Ovarian cyst •Sudden unilateral pelvic pain Urological torsion/rupture/ •May be fever/vomiting •Storage: frequency, volume, haemorrhage urgency/ nocturia •Infection: dysuria, haematuria Endometriosis •Cyclical pelvic pain •Dysmenorrhoea Gastrointestinal •Deep dyspareunia •Weight: loss, appetite change •Menstural disturbance •Work down body: dysphagia, Urological Pyelonephritis •Fever, chills, rigors nausea/ vomiting, indigestion/ •Loin pain heartburn, bowel habit change, •Urinary frequency and dysuria blood/ mucus in stool Gastrointestinal Appendicitis •Young patient •Periumbilical pain •Moves to RIF •Anorexia Diverticulitis •Elderly •LIF pain •Pyrexia IBS/IBD •Lower abdominal pain •Associated change in bowel habit •May pass blood/mucus in IBD Other Mittelschmerz (ovulation pain) differentials Fibroid degeneration Renal colic Bowel obstruction

PV bleeding Type General Menorrhagia Dysfunctional uterine bleeding (most) Menorrhagia/ •Fever, sweats Fibroids inter-menstural/ Endometriosis post-coital/ Gynaecological PID post-menopausal •PV discharge IUCD •Pain: pelvic, dysmenorrhoea, Endometrial/cervical polyps Timing dyspareunia Endometrial carcinoma (if >45y) •When started •Chance could be pregnant Contraception •Acute/ gradual onset NON-GYNAE: blood dyscrasia (e.g. von Willebrand), hypothyroidism •Duration Inter-menstrual Many… •Progression Mid-cycle oestrogen production fall around ovulation •Intermittent or continuous Endometrial/cervical polyps Ectropion Bleeding Endometrial carcinoma (if >40y) •Pattern: regular/irregular Cervicitis/vaginitis •Amount of loss: number of Hormonal contraception (spotting) sanitary towels/tampons, IUCD passage of clots, flooding Pregnancy related •Pain with blood loss, vaginal PID dryness and itching if post- Post-coital Cervical trauma menopausal Cervical polyps •Anaemia symptoms: Cervical carcinoma tiredness, breathlessness on Vaginal carcinoma exertion Cervicitis/vaginitis •Thyroid symptoms PID Post- Endometrial carcinoma (until proven otherwise!) menopausal Atrophic vaginitis (90%) Foreign bodies e.g. prolapse shelf Cervical/vulva carcinoma Cervical/endometrial polyps Oestrogen withdrawal

© 2014 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision Secondary Timing Clues to cause (work down body) Gynaecological Pregnancy •Trying to get pregnant or unprotected sex amenorrhoea •When started •General: weight loss, stress, PCOS •Acne, hirsutism, obesity •Duration exercise, diet Menopause/ •Menopausal symptoms e.g. sweats/flushes, •Any exacerbating factors •Head: visual problems, premature ovarian aches & pains, previous erratic menstrual headaches failure cycles, emotional changes etc •Thyroid: symptoms Endocrine Hypothalamic •Extreme anxiety, stress or exertion •Torso: galactorrhoea, hirsutism, amenorrhoea (e.g. •Poor diet acne anorexia, stress, •Extreme efforts to lose weight/weight loss •Abdomen: possibility of athletes) •Low BMI pregnancy Cushing’s syndrome •Steroid use

•Thin skin/bruising Gynaecological •Central obesity and fat redistribution •PV discharge Hyperprolactinaemia •Use of anti-psychotics is one cause •Pain: pelvic, dysmenorrhoea, •Visual symptoms if tumour dyspareunia •Galactorrhoea •Chance could be pregnant •Infertility

Other Hyper/hypothyroidism

differentials Severe systemic illness

Pituitary failure (e.g. Sheehan’s syndrome) Ensure you ask sexual and Certain contraception methods contraception history Post-pill amenorrhoea Cervical stenosis Drugs

Infertility General Coitus Gynaecological PCOS •Acne, hirsutism, obesity •When started trying •Frequency Fallopian tube •History of STI’s, PID or pelvic surgery •Difficulties damage (e.g. 2˚ to •Relation to fertile days PID or surgery) •Pain Endometriosis •Cyclical pelvic pain •Dysmenorrhoea Partners (consider each •Deep dyspareunia separately) •Menstural disturbance •Age Cervical barrier •Previous cervical surgery •Occupation e.g. cervical stenosis, •Current STI symptoms •Previous children (same or hostile mucus, polyp, different partner? inflammation •Smoking and alcohol Hyperprolactinaemia •Use of anti-psychotics is one cause •Current medications •Visual symptoms if tumour •Galactorrhoea Woman’s gynaecological health Hypothalamic •Extreme anxiety, stress or exertion •Gynae sys review (discharge, disturbance (e.g. •Poor diet pain, PV bleeding) anorexia, stress, •Extreme efforts to lose weight/weight loss •PCOS symptoms (hirsutism, athletes) •Low BMI greasy skin, obesity) Other Amenorrhoea associated (see causes above) •Prolactinoma symptoms (nipple differentials Systemic illness discharge) Defective sperm/ovulation Congenital uterine/vaginal malformation Chromosomal/genetic abnormalities Ensure you ask about previous Pituitary tumour STIs and pelvic operations in the Peri-menopausal PMHx Uterine fibroids/polyp Sexual dysfunction