Table of Contents
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 illnes, sHypopituitarism/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 |
