Women

Presenting complaint

The presenting complaint is a statement of what the patient perceives to be the problem. As the consultation progresses and the relationship between doctor and patient develops, it may become apparent that the real presenting problem is something separate. Even so, it is important to start with the patient’s chief concern as a way of building trust and rapport with someone who is likely to be anxious.

History of presenting complaint

Take a detailed description of the presenting complaint, with an emphasis on the timeline (when the problem started and how it developed over time) and the degree of symptomatology (how much the problem is affecting the patient).

In order to assess a woman’s gynaecological wellbeing, certain areas of focused questioning are needed. Many students feel awkward taking a gynaecological history, but this is often unnecessary, because women with gynaecological problems will be expecting such questions. It may be helpful, at least initially, to use pre-prepared direct questions in order to overcome this initial self-consciousness.

Pain history

It can be very difficult to know from the history if lower abdominal pain has its origins in the gynaecological, gastrointestinal or urinary system. The principles of eliciting a pain history outlined throughout this book apply in gynaecological practice. In addition, cyclical pain associated with periods is typically caused by endometriosis, whereas pain that was originally cyclical but later becomes continuous is often caused by adhesions. In all cases it is necessary to take an accurate history of bowel and bladder symptoms, because a substantial number of patients attending the gynaecology clinic with pain symptoms subsequently turn out to have bowel pathology (e.g. irritable bowel syndrome) or bladder pathology (e.g. interstitial cystitis). The two major gynaecological causes of chronic pain are endometriosis and pelvic inflammatory disease; in both cases the symptoms may be caused by the formation of pelvic adhesions.

Menstrual history

For premenopausal women, a menstrual history is mandatory. This can be done quite quickly with practice but is usually dependent on direct questioning. Menstruation (the cyclical loss of sanguineous fluid from the uterus) is recorded as the days of menstrual loss and the duration of the interval from the first day of one period to the first day of the next, for example 5/28. Medical and ‘lay’ terminologies sometimes overlap confusingly in medicine, although, in this context, the words ‘period’, ‘menstrual period’ and ‘menstrual cycle’ can be used interchangeably by doctor and patient alike. The aim of this section of the history is to establish if the patient’s menstrual periods are problematic and, if so, in what way. Box 5.1 shows some examples of direct questions around the menstrual history, together with some points requiring clarification. In addition, Box 5.2 lists several other questions that are required in order to check for bleeding problems not connected to periods.

If the patient is post- or perimenopausal, the history taking should reflect this. Some examples of direct, focused questions that could be asked are the following:

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  Are you still having periods? or

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  When did you have your last period?

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  Has there been any bleeding since your last period? (This relates to a definition of postmenopausal bleeding—generally defined as bleeding 1 year after the last period, unless the patient is taking hormone replacement therapy, in which case it is important to establish which type. Exclusion of organic pathology is mandatory in this situation.)

Occasionally, gynaecological conditions may be associated with cyclical blood loss from the anus or urethra.

Vaginal discharge

Even if vaginal discharge is not the presenting symptom, routinely enquire about it. If there is a troublesome discharge, enquire about its colour, smell, amount, presence of blood, whether there is an associated vulval itch and, if so, if there are other sites of itching. In women with an abnormal vaginal discharge, questions relating to sexually transmitted disease naturally follow but can be difficult to pose. If the patient is in a sexual relationship, ask about symptoms in her partner(s) and whether either (any) of them is aware of the presence of warts.

Urinary tract and uterovaginal prolapse symptoms

Uterovaginal prolapse refers to a situation in which the uterus ‘sinks’ or ‘slides’ down from its normal position in the body. Frequently a woman will notice a bulge (‘a lump down below’) at the introitus (entrance) of the vagina and may report urinary symptoms consequent upon changes in the pelvic floor muscles that alter the angulation and therefore reliability of the bladder neck. It is very unusual for symptomatic prolapse to occur in women who have not had vaginal deliveries. If this appears to be the presenting complaint, the history can be explored with carefully phrased direct questions ( Box 5.3 ).

It should be clear to the history taker if the reason for any incontinence is in part owing to mobility limitations, but a general enquiry should be made about the layout of the home and symptoms of cough or constipation that may lead to repeated increases in intra-abdominal pressure. Where the history is not clear or needs more objectivity, it is sometimes useful to recommend a simple frequency/volume chart on which the patient can record her symptoms and bring it to a subsequent appointment.

Sexual symptoms

A full sexual history would not be appropriate at the first appointment unless the history taker has specific training in this area. If you know that the patient is in a sexual relationship, it is reasonable routinely to ask her whether she experiences or has experienced pain with sexual intercourse (dyspareunia). Sometimes the patient will present with painful sex on penetration; again, direct but sensitive questions are useful in this context ( Box 5.4 ).

In addition, it is essential to ask whether the patient has had any previous sexually transmitted infections, particularly chlamydia and gonorrhoea, which are associated with pelvic inflammatory disease.

Cervical cytology history

A gynaecological history should always include details of any cervical smears, their dates and whether there have been any abnormalities or treatments. The opportunity also arises to ask if any other screening has taken place, such as mammography and chlamydia, and what the results were.

Past obstetric history

It is inevitable that a gynaecological history will include a truncated obstetric history. This can be a sensitive issue, as medical and lay terminologies regarding lost pregnancies can cause potential confusion and inadvertent distress. Spontaneous abortion is no longer used as the medical term for a miscarriage; what many women refer to as an ‘abortion’ is a termination of pregnancy in medical language. If the questions are incorrectly constructed, the boundaries of confidentiality can be breached if the history is taken in the presence of a third person. No pressure should be placed on a patient during this part of the history, especially in the presence of others. It is important, however, to know the number of pregnancies, their outcome (gestational ages and weights), mode of delivery, age of the children, whether there was any infertility at any time and, if so, the details of any investigations or treatments. Direct questions that may help assimilate this information are listed in Box 5.5 .

Past gynaecological history

With the passage of time, many patients forget certain aspects of their past medical history (e.g. tonsillectomy, cataract removal). Women with a gynaecological history do not often forget, so a simple question ‘Have you had any gynaecological problems or procedures in the past?’ is sufficient to establish any significant gynaecological background, which should then be explored.

Past medical/surgical/anaesthetic history

In order to get a broad view of the patient’s medical background, you could ask a simple question such as ‘Is there anything in your past medical or surgical history that I should know about?’ This is a helpful introductory question that can be followed by more focused enquiry, depending on the case. For example, complicated appendicitis may be related to infertility, or a previous blood transfusion, which has produced blood group antibodies, may be related to a subsequent pregnancy loss. If an anaesthetic is anticipated as part of the patient’s management, it is important to assess whether this is likely to be problematic. Ask if she has had an anaesthetic in the recent past and whether there were any problems with it.

Medication or treatment history

Medication and treatment history are standard enquiries and may be contributory. An awareness of medications taken in the past, with their success or failure, is a useful observation. Be aware that patients may take various kinds of supplements which they do not regard as medicines, but which may affect gynaecological health, for example Chinese herbal remedies, agnus castus, black cohosh. Allergic reactions should be recorded and clearly displayed.

Social history

Enquiry as to occupational history, present and past, is appropriate. Even during the course of the relatively short time to take a history, a picture of the patient may emerge indicating how well adjusted she is to her life, her relationships and external influences. These may affect her prospects for recovery from illness or when planning the support of a child. For instance, if the patient is a victim of domestic violence, a request for termination of pregnancy may be considered differently or this may be relevant to antenatal or postnatal care.

Family history

Few purely gynaecological conditions have a familial basis. In the context of infertility, it is important to check whether recurrent familial conditions are present, both on the patient’s and her partner’s side; recessive and autosomal dominant genetic conditions are often known to patients.

Abdominal examination

The system of examination described in Chapter 14 is recommended but should focus on inspection and palpation; percussion and auscultation are less important in gynaecological practice. The presence or absence of scars should be noted. Laparoscopic scars can be subtle, particularly if tucked within the umbilicus. Occasionally (usually to avoid the risk of perforation through adhesions in the lower abdomen) the entry point for laparoscopic surgery may be via Palmer’s point in the mid-clavicular line, under the rib cage. Transverse suprapubic (Pfannenstiel’s) incisions may also be difficult to see in the suprapubic crease unless specifically looked for.

Suprapubic examination is particularly important because a gynaecological mass arises out of the pelvis and the examining hand cannot get below it. Do this part of the abdominal palpation with the ulnar border of the left hand, starting at or around the umbilicus, and work your way down. When an abdomino-pelvic mass is present, its characteristics and size, either in centimetres measured from the symphysis pubis upwards or estimated as weeks’ gestation of an equivalent-size pregnancy, are recorded (see Fig. 5.1 ). Note its consistency (hard if a fibroid, usually soft if a pregnancy), regularity (subserosal fibroids and ovarian masses are usually irregular) and the presence of any tenderness. It can sometimes be difficult to elicit such signs if there is a scar in the lower abdomen or if the patient is obese. If nothing is palpable arising out of the pelvis, it is reasonable to conclude that any pelvic swelling is less than the size of a 12-week pregnancy. If ascites is suspected, check the supraclavicular and inguinal lymph nodes and look for an associated hydrothorax.

Pelvic examination

In gynaecology, pelvic examination (PE) is usually undertaken vaginally, but it may also be performed rectally. The instruments used are shown in Figure 5.2 . PE should always be preceded by an abdominal examination. To reduce patient anxiety, it is crucial to explain every step sensitively but clearly. Medical students should undertake a PE only in the presence of a supervisor; the same applies to trainees in gynaecology, except where specific permission has been granted by the trainer. In many centres, students begin to learn the technique of PE using artificial manikins and models.

The PE commences with inspection of the perineum in the dorsal (or occasionally left lateral) position and is followed by internal digital examination, using the index and middle fingers (use one finger if the vagina does not accommodate two). Generally, but not always, a speculum examination precedes the digital examination (if it is important to visualize any discharge, take swabs or take a cervical smear, the speculum should always be passed first; Fig. 5.3 ). If the patient experiences undue discomfort (be it speculum or digital), the examination should cease immediately. Note any inflammation, swelling, soreness, ulceration or neoplasia of the vulva, perineum or anus ( Fig. 5.4 ). Women from certain communities may have been circumcised in childhood: this is known as female genital mutilation (FGM) and can range from scarring of the labia to removal of the external genitalia. Small warts (condylomata acuminata) appearing as papillary growths may occur scattered over the vulva; these are caused by infection with the human papilloma virus. Inspect the clitoris and urethra and ask the patient to strain and then cough to demonstrate any uterovaginal prolapse or stress incontinence. ( Fig. 5.5 shows the various types of prolapse.) If the patient has given a history of involuntary incontinence, it is important that the bladder is reasonably full and that more than one substantial cough is taken, because the first cough frequently fails to demonstrate leakage of urine.

For the digital examination, disposable gloves are used and the examining fingers should be lightly lubricated with a water-based jelly. With the patient in the supine position and with her knees drawn up and separated, the labia are gently parted with the index finger and thumb of the left hand while the index finger of the right hand is inserted into the vagina, avoiding the urethral meatus and exerting a sustained pressure on the perineal body until the perineal musculature relaxes. Watch for any sign of discomfort. The full length of the finger is then introduced, assessing the vaginal walls in transit until the cervix is located. At this stage, a second finger can be inserted to improve the quality of the digital examination or, alternatively, a speculum can be used if a cervical smear is required. The examination is continued with the left hand placed on the abdomen above the symphysis pubis and below the umbilicus—the bimanual examination ( Fig. 5.6 ). The hand provides gentle directional pressure to bring the pelvic viscera towards the examiner’s fingers in the vagina and serves to assess the size, mobility and regularity of masses. The cervix is then identified; it is approximately 3 cm in diameter, with a variably sized and shaped dimple in the middle, the cervical os. When the uterus is anteflexed and anteverted, the os is normally directed posteriorly. A retroverted uterus means the uterus is tipped backwards so that it aims towards the rectum instead of forward towards the abdomen. The consistency of the cervix is firm and its shape is irregular when scarred. Increased hardness of the cervix may be caused by fibrosis or carcinoma. As a ‘soft’ cervix indicates the possibility of pregnancy, even greater caution and gentleness are necessary. The mobility of the cervix is usually 1 to 2 cm in all directions and testing this movement should produce only mild discomfort. If the cervix is moved when there is pelvic inflammation, particularly in association with ectopic pregnancy, extreme pain (cervical excitation) results.

It is possible to estimate the size, shape, position, consistency and regularity of the uterus and the relationship of the fundus of the uterus to the cervix (flexion). Uterine size is generally described as normal, bulky or in terms of weeks of gestation (e.g. 6 weeks, 8 weeks, 10 weeks size) even in the absence of pregnancy. Its mobility and shape (symmetrical or non-symmetrical) may be assessed and the ovaries and fallopian tubes (also known as the adnexae) palpated, although these can be difficult to feel in healthy women. Aside from the ovaries in some women, no other swellings should be palpable about the uterus in women of reproductive years. However, adnexal tenderness is an important finding. The pouch of Douglas is then explored through the posterior fornix via the arch formed by the uterosacral ligaments and the cervix.

Pelvic examination in special circumstances