Common presenting complaintsHistory taking
·15 min read

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

  • Bilateral pelvic pain
  • Vaginal discharge
  • Dyspareunia and dysmenorrhoea
  • Fever
  • May have post-coital or intermenstrual bleeding
  • 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
  • Sudden unilateral pelvic pain
  • May have fever/vomiting
  • Cyclical pelvic pain
  • Dysmenorrhoea
  • Deep dyspareunia 
  • Menstrual disturbance
  • Mittelschmerz (ovulation pain)
  • Fibroid degeneration

Urological

  • Fever/chills/rigors
  • Loin pain
  • Urinary frequency and dysuria
  • Spasms of loin to groin pain

Gastrointestinal

  • Young patient
  • Periumbilical pain
  • Moves to RIF
  • Anorexia
  • Elderly
  • LIF pain
  • Pyrexia
  • 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 bleeding (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 carcinoma (until proven otherwise!)
    • Atrophic vaginitis (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

  • Trying to get pregnant or unprotected sex
  • Acne
  • Hirsutism
  • Obesity
  • Menopausal symptoms, e.g. sweats/flushes, aches and pains, previous erratic menstrual cycles, emotional changes etc.
  • Certain contraception methods
  • Post-pill amenorrhoea
  • Cervical stenosis

Endocrine

May occur in anorexia, stress, athletes

  • Extreme anxiety, stress or exertion
  • Poor diet
  • Excessive weight loss
  • Low BMI
  • Steroid use
  • Thin skin/bruising
  • Central obesity and fat redistribution
  • Use of antipsychotics is one cause
  • Visual symptoms if due to macroadenoma 
  • Galactorrhoea
  • Infertility
  • 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
    • 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

Female causes – gynaecological

  • Acne
  • Hirsutism
  • Obesity

May occur secondary to PID or surgery

  • History of STIs, PID or pelvic surgery
  • Cyclical pelvic pain
  • Dysmenorrhoea
  • Deep dyspareunia 
  • Menstrual disturbance

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

  • Previous cervical surgery
  • Current STI symptoms
  • Congenital uterine/vaginal malformation

Female causes – endocrine

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

May occur in anorexia, stress, athletes

  • Extreme anxiety, stress or exertion
  • Poor diet
  • Extreme efforts to lose weight/weight loss
  • Low BMI
  • Hypogonadotropic hypogonadism (e.g. pituitary disease)
  • Hypergonadotropic hypogonadism (e.g. premature ovarian failure)

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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Common obstetric histories
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Common urinary histories
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