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
- 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
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
- 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
- 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
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
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
Other endocrine causes
- Hyper/hypothyroidism
- Hypopituitarism/pituitary failure
- Drugs, e.g. hormonal treatments/contraception, chemotherapy, antipsychotics
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Sub-fertility
Exploring symptom
- General
- 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
PCOS
Fallopian tube damage
May occur secondary to PID or 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 is Mittelschmerz and when does it occur?
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- Pelvic pain
- Sexual health history
- Subfertility
- Menorrhagia
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