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Common gynaecological histories

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

Other gynaecological differentials

  • Mittelschmerz (ovulation pain)
  • Fibroid degeneration

Urological

Pyelonephritis

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

Renal colic

Spasms of loin to groin pain

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

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

Menorrhagia

  • Common

    • Dysfunctional uterine bleedingย (most common)
    • Fibroids
    • Endometriosis

  • Less common

    • Pelvic inflammatory disease
    • IUD
    • Endometrial/cervical polyps
    • Endometrial carcinoma (if >45 years)
    • Contraception

  • Non-gynaecological

    • Blood dyscrasias (e.g. von Willebrand)
    • Hypothyroidism

Intermenstrual bleeding

  • 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 bleeding

  • Common

    • Cervical trauma
    • Cervical polyps
    • Cervical carcinoma

  • Less common

    • Vaginal carcinoma
    • Cervicitis/vaginitis
    • Pelvic inflammatory disease

Post-menopausal bleeding

  • Common

    • Endometrial carcinomaย (until proven otherwise!)
    • Atrophic vaginitisย (90%)

  • Less common

    • 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.

Other gynaecological causes

  • Certain contraception methods
  • Post-pill amenorrhoea
  • Cervical stenosis

Endocrine

Hypothalamic amenorrhoea

May occur in anorexia, stress, athletes

  • Extreme anxiety, stress or exertion
  • Poor diet
  • Excessive weight loss
  • Low BMI

Cushingโ€™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

Other endocrine causes

  • Hyper/hypothyroidism
  • Hypopituitarism/pituitary failure
  • 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
    • Manโ€™s PMHx
  • Womanโ€™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

Female causes – gynaecological

PCOS

  • Acne
  • Hirsutism
  • Obesity

Fallopian tube damage

May occur secondary to PID orย surgery

  • History of STIs, PID or pelvic surgery

Endometriosis

  • Cyclical pelvic pain
  • Dysmenorrhoea
  • Deep dyspareunia
  • Menstrual disturbance

Cervical barrier

For example, cervical stenosis, hostile mucus, polyp, or inflammation

  • Previous cervical surgery
  • Current STI symptoms

Other female gynaecological differentials

Congenital uterine / vaginal malformation

Female causes – endocrine

Hyperprolactinaemia

  • Use of antipsychotics is one cause
  • Visual symptoms if due to macroadenoma
  • Galactorrhoea

Hypothalamic disturbance

May occur in anorexia, stress, athletes

  • Extreme anxiety, stress or exertion
  • Poor diet
  • Extreme efforts to lose weight/weight loss
  • Low BMI

Other female endocrine differentials

  • Hypogonadotropic hypogonadism (e.g. pituitary disease)
  • Hypergonadotropic hypogonadism (e.g. premature ovarian failure)

Other

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 difficulties

  • Mechanical
  • Erectile dysfunction
  • Timing

Try some revision questions

How would you classify types of PV bleeding? Please name three causes of each.

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What are the common symptoms of PCOS?

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What is Mittelschmerz and when does it occur?

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Now it’s your time to shine!

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

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