Remember history taking in gynaecology requires you to ask extra questions on the Menstrual history, Obstetric history, Sexual history and Contraception/Cervical smear history (MOSC).

Pelvic pain

Exploring symptom

• Pain
  • Site
  • Onset
  • Character
  • Radiation
  • Associated symptoms
  • Timing (relation to period)
  • Exacerbating/relieving factors
  • Severity

Relevant system reviews

• General
  • Fever, sweats
• Gynaecological
  • PV bleeding: menorrhagia, intermenstrual, post-coital, post-menopausal 
  • PV discharge
  • Pain: dysmenorrhoea, dyspareunia
  • Pregnancy risk
•  Urological
  • Storage: frequency, volume, urgency, nocturia, incontinence
  • Infection: dysuria, haematuria, odour
• Gastrointestinal
  • Weight: loss, appetite change
  • Nausea/vomiting, bowel habit change, tenesmus, blood/mucus in stool

Differential diagnoses and clues

Gynaecological:

PID/acute salpingitis	-Bilateral pelvic pain -Vaginal discharge -Dyspareunia and dysmenorrhoea -Fever -May have post-coital or intermenstrual bleeding
Ectopic pregnancy	-Recent period of amenorrhoea -Trying to get pregnant or sex without contraception (usually occurs 4-12 weeks gestation) -May have some vaginal spotting -In tubal rupture, collapse and shoulder tip pain
Ovarian cyst torsion/rupture/ haemorrhage	-Sudden unilateral pelvic pain -May have fever/vomiting
Endometriosis	-Cyclical pelvic pain -Dysmenorrhoea -Deep dyspareunia  -Menstrual disturbance

Urological:

Pyelonephritis

-Fever/chills/rigors -Loin pain -Urinary frequency and dysuria

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

Others:

Other differentials

Mittelschmerz (ovulation pain), Fibroid degeneration, Renal colic, Bowel obstruction

PV bleeding

Exploring symptom

• Type
  • Menorrhagia
  • Intermenstrual
  • Post-coital
  • Post-menopausal
• Timeframe
  • Duration
  • Onset (sudden or gradual)
  • Progression
  • Timing (intermittent or continuous)
• Bleeding
  • Pattern: regular/irregular
  • Quantify loss: number of sanitary towels/tampons, passage of clots, flooding
  • Pain with blood loss, vaginal dryness and itching if post-menopausal
  • Anaemia symptoms: tiredness, breathlessness on exertion
  • Thyroid symptoms: cold intolerance, constipation etc.

Relevant system reviews

• General
  • Fever, sweats
• Gynaecological
  • PV discharge
  • Pain: pelvic, dysmenorrhoea, dyspareunia
  • Pregnancy risk

Differential diagnoses

Gynaecological:

Menorrhagia	Dysfunctional uterine bleeding (most common), Fibroids, Endometriosis, Pelvic inflammatory disease, IUD, Endometrial/cervical polyps, Endometrial carcinoma (if >45 years), Contraception NON-GYNAE: blood dyscrasia (e.g. von Willebrand), hypothyroidism
Intermenstrual	Mid-cycle fall in oestrogen production around ovulation, Endometrial/cervical polyps, Ectropion, Endometrial carcinoma (if >40 years), Cervicitis/vaginitis, Hormonal contraception (spotting), IUD, Pregnancy related, Pelvic inflammatory disease
Post-coital	Cervical trauma, Cervical polyps, Cervical carcinoma, Vaginal carcinoma, Cervicitis/vaginitis, Pelvic inflammatory disease
Post-menopausal	Endometrial carcinoma (until proven otherwise!), Atrophic vaginitis (90%), Foreign bodies, e.g. prolapse shelf, Cervical/vulva carcinoma, Cervical/endometrial polyps, Oestrogen withdrawal

Secondary amenorrhoea

Exploring symptom

• Timing
  • Duration
  • Triggers
• Clues to cause (work down body)
  • General: weight loss, stress, exercise, diet
  • Head: visual problems, headaches
  • Thyroid: symptoms
  • Torso: galactorrhoea, hirsutism, acne
  • Abdomen: possibility of pregnancy

Relevant system reviews

• Gynaecological
  • PV discharge
  • Pain: pelvic, dysmenorrhoea, dyspareunia
  • Pregnancy risk

Ensure you take a sexual and contraception history

Differential diagnoses and clues

Gynaecological:

Pregnancy	-Trying to get pregnant or unprotected sex
PCOS	-Acne, hirsutism, obesity
Menopause/premature ovarian failure	-Menopausal symptoms, e.g. sweats/flushes, aches and pains, previous erratic menstrual cycles, emotional changes etc.

Endocrine:

Hypothalamic amenorrhoea (e.g. anorexia, stress, athletes)	-Extreme anxiety, stress or exertion -Poor diet -Excessive weight loss -Low BMI
Cushing’s syndrome	-Steroid use -Thin skin/bruising -Central obesity and fat redistribution
Hyperprolactinaemia	-Use of antipsychotics is one cause -Visual symptoms if due to macroadenoma  -Galactorrhoea           -Infertility

Others:

Other differentials

Hyper/hypothyroidism, Severe systemic illness, Hypopituitarism/pituitary failure, Certain contraception methods, Post-pill amenorrhoea, Cervical stenosis, Drugs, e.g. hormonal treatments/contraception, chemotherapy, antipsychotics

Sub-fertility

Exploring symptom

• General
  • When started trying
• Coitus
  • Frequency
  • Difficulties
  • Relation to fertile days
  • Pain
• Partners (consider each separately)
  • Age
  • Occupation
  • Body mass index
  • Previous children (same or different partner?)
  • Smoking and alcohol
  • Current medications
  • Man’s PMHx
• Woman’s gynaecological health
  • Gynaecological systems review: discharge, pain, PV bleeding
  • PCOS symptoms: hirsutism, greasy skin, obesity
  • Prolactinoma symptoms: galactorrhoea
  • PMHx including STIs and pelvic operations

Differential diagnoses and clues

Gynaecological:

PCOS	-Acne, hirsutism, obesity
Fallopian tube damage (e.g. secondary to PID or  surgery)	-History of STIs, PID or pelvic surgery
Endometriosis	-Cyclical pelvic pain -Dysmenorrhoea -Deep dyspareunia  -Menstrual disturbance
Cervical barrier e.g. cervical stenosis, hostile mucus, polyp, inflammation	-Previous cervical surgery -Current STI symptoms
Hyperprolactinaemia	-Use of antipsychotics is one cause -Visual symptoms if due to macroadenoma -Galactorrhoea
Hypothalamic disturbance (e.g. anorexia, stress, athletes)	-Extreme anxiety, stress or exertion -Poor diet -Extreme efforts to lose weight/weight loss -Low BMI

Others:

Other female causes	Hypogonadotropic hypogonadism (e.g. pituitary disease), Hypergonadotropic hypogonadism (e.g. premature ovarian failure), Congenital uterine/vaginal malformation
Male causes	Hypogonadotropic hypogonadism (e.g. pituitary disease), Hypergonadotropic hypogonadism (e.g. Klinefelter, gonadal damage), Varicocele, Antisperm antibodies, Absence/blockage of vas deferens, Anatomical defects
Coital difficulty	Mechanical, Erectile dysfunction, Timing

Try some revision questions

Now it’s your time to shine!

1. Pelvic pain
2. Sexual health history
3. Subfertility
4. Menorrhagia
5. Try more here