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Common gynaecological histories

History taking > Common presenting complaints

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 bleeding (most common)

      • Fibroids

      • Endometriosis

  • Less common

      • Pelvic inflammatory disease

      • Endometrial/cervical polyps

      • Endometrial carcinoma (if >45 years)

      • Contraception/IUD

  • Non-gynaecological

      • Bleeding disorders

      • Hypothyroidism

Intermenstrual bleeding

  • Endometrial/cervical polyps
  • Ectropion
  • Anovulation
  • Polycystic Ovary Syndrome
  • Endometrial carcinoma (if >40 years)
  • Fibroids
  • Cervicitis/vaginitis
  • Contraception
  • Pelvic inflammatory disease

Post-coital bleeding

  • Pelvic inflammatory disease/STIs
  • Cervical polyps/carcinoma/cervicitis/ ectropion
  • Vaginal atrophy/carcinoma

Post-menopausal bleeding

  • Endometrial carcinoma (must be excluded)
  • Endometrial atrophy/hyperplasia
  • Atrophic vaginitis
  • Cervical carcinoma
  • Polyps
  • Fibroids
  • Hormone replacement therapy

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

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

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

PCOS

  • Acne

  • Hirsutism

  • Obesity

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

  • Erectile dysfunction
  • Timing

Try some revision questions

What are the common symptoms of PCOS?

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What is Mittelschmerz and when does it occur?

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  1. Pelvic pain
  2. Sexual health history
  3. Subfertility
  4. Menorrhagia
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Common presenting complaints