Basic clinical skills in gynaecology

The presenting problem(s)

The patient should be asked to describe the nature of her problem, and a simple statement of the presenting symptoms should be made in the case notes. A great deal can be learnt by using the actual words employed by the patient. It is important to ascertain the time scale of the problem and, where appropriate, the circumstances surrounding the onset of symptoms and their relationship to the menstrual cycle. It is also important to discover the degree of disability experienced for any given symptom.

More detailed questions will depend on the nature of the presenting problem(s). Disorders of menstruation are the commonest reason for gynaecological referral, and a full menstrual history should be taken from all women of reproductive age (see later). Another common presenting symptom is abdominal pain, and the history must include details of the time of onset and precipitants, i.e. intercourse, associated symptoms, the distribution and radiation of the pain and the relationship to the menstrual cycle

If vaginal discharge is the presenting symptom, the colour, odour and relationship to the periods should be noted, as well as any over-the-counter medications used to treat this. It may also be associated with vulval pruritus or skin changes, i.e. rash/lesions, particularly in the presence of specific infections. The presence of an abdominal mass may be noted by the patient or may be detected during the course of a routine examination. Symptoms may also result from pressure of the mass on adjacent pelvic organs, such as the bladder and bowel.

Vaginal and uterine prolapse is associated with symptoms of a mass protruding through the vaginal introitus or difficulties with micturition and defecation. Common urinary symptoms include frequency of micturition, pain or dysuria, incontinence and the passage of blood in the urine, or haematuria.

Where appropriate a sexual history should include reference to the coital frequency, the occurrence of pain during intercourse – dyspareunia – and functional details relating to libido, sexual satisfaction and sexual problems (see Chapter 19 ).

Menstrual history

The first question that should be asked in relation to the menstrual history is the date of the last menstrual period (LMP). In relation to the menstrual cycle, you should ascertain her normal cycle length, duration of bleeding, regularity/irregularity of cycle and whether any hormonal contraception is being used. It is also very common for women to now track their menstrual cycle with phone applications, especially if attempting to conceive.

The time of onset of the first period, the menarche, commonly occurs at 12 years of age and can be considered to be abnormally delayed over 16 years or abnormally early at 8 years. The absence of menstruation in a girl with otherwise normal development by the age of 16 is known as primary amenorrhoea . The term should be distinguished from the pubarche , which is the onset of the first signs of sexual maturation. Characteristically, the development of breasts and nipple enlargement predate the onset of menstruation by approximately 2 years (see Chapter 16 ).

The length of the menstrual cycle is the time between the first day of one period (i.e. first day of bleeding) and the first day of the following period. Whilst there is usually an interval of 28 days, the cycle length may vary between 21 and 42 days in normal women and may only be significant where there is a change in menstrual pattern. It is important to be sure that the patient does not describe the time between the last day of one period and the first day of the next period, as this may give a false impression of the frequency of menstruation.

Absence of menstruation for more than 6 months in a woman who is not pregnant and has previously had periods is known as secondary amenorrhoea . Oligomenorrhea is the occurrence of five or fewer menstrual periods over 12 months.

The amount and duration of the bleeding may change with age but may also provide a useful indication of a disease process. Normal menstruation lasts from 4 to 7 days, and normal blood loss varies between 30 and 40 mL (6–8 teaspoons). A change in pattern is often more noticeable and significant than the actual time and volume of loss. In practical terms, excessive menstrual loss is best assessed on the history of the number of pads or tampons used during a period and the presence or absence of clots and symptoms of anaemia.

Abnormal uterine bleeding (AUB) is any bleeding disturbance that occurs between menstrual periods or is excessive, prolonged or irregular. Intermenstrual bleeding is any bleeding that occurs between clearly defined, cyclical, regular menses. Postcoital bleeding is non-menstrual bleeding that occurs during or after sexual intercourse. AUB always requires investigation, as it may be the first symptom of an underlying potential medical condition.

The term heavy menstrual bleeding (HMB) is now used to describe any excessive or prolonged menstrual bleeding which is greater than 5–6 tablespoons of blood (>80 mL), irrespective of whether the cycle is regular ( menorrhagia ) or irregular ( metrorrhagia ).

The cessation of periods at the end of menstrual life is known as menopause, and bleeding which occurs more than 12 months after this is described as postmenopausal bleeding. A history of irregular vaginal bleeding or blood loss that occurs after coitus or between periods should be noted.

Previous gynaecological history

A detailed history of any previous gynaecological problems and treatments must be recorded. It is also important, where possible, to obtain any records of previous gynaecological surgery. Patients are often uncertain of the precise nature of their operations. The amount of detail needed about previous pregnancies will depend on the presenting problem. In most cases the number of previous pregnancies and their outcome (miscarriage, ectopic or delivery after 20 weeks, caesarean section delivery) is all that is required. If previous births have occurred, it is important to know the mode of delivery, i.e. normal vaginal delivery, caesarean section or assisted instrumental delivery via forceps or vacuum. Furthermore any injury to the perineum either via tear or episiotomy should be noted.

For all women of reproductive age who are sexually active, it is essential to ask about contraception and any screening for sexually transmitted infections. This is important not only to determine the possibility of pregnancy but also because the method of contraception used may itself be relevant to the presenting complaint (e.g. irregular bleeding may occur on the contraceptive pill or when an intrauterine device is present). For women over the age of 25, ask about the date and result of the last cervical screening test. Recent changes to cervical screening in Australia mean that women now begin testing at the age of 25 and every 5 years instead of the previous 2-year interval. The new cervical screening test combines human papilloma virus (HPV) genotype testing and liquid-based cytology (LBC) where appropriate.

Previous medical and surgical history

A comprehensive medical and surgical history is vital to any medical history, and gynaecology is no different. This should take particular account of any history of chronic lung disease, disorders of the cardiovascular system and previous surgeries and anaesthetics, as these are highly relevant where any surgical procedure is likely to be necessary. A record of all current medications (including non-prescription and over-the-counter treatments) and any known drug allergies should be made. If she is planning a pregnancy in the near future, check if she is taking folic acid supplements.

Psychosocial history

A psychosocial history is important with all medical presentations but is particularly relevant where the presenting difficulties relate to abortion or sterilization. For example, a 15-year-old female requesting a termination of pregnancy may be put under substantial pressure by her parents to have an abortion and yet may not really be happy about following this course of action. Ask about smoking, alcohol and other recreational drug use. It is important to ask about mental health history, including anxiety, depression and if they are currently being treated or seen by a mental health professional. Domestic violence is a significant issue for society and is particularly important in women’s health care and should be kept in mind when seeing women in clinic. In Australia, screening in pregnancy for domestic violence and sexual abuse is now a Medicare requirement. Up to 40% of women presenting for a well-woman check will give a history of domestic violence, although the figure is lower in gynaecology clinics.