To adequately evaluate the gynecologic patient, it is important to establish a rapport during the history taking. The patient needs to tell her story to an interested listener who does not allow body language or facial expressions to imply disinterest or boredom. One should avoid cutting off the patient's story, because doing so may obscure important clues or other problems that may have contributed to the reasons for the visit.
The following outline varies from the routine medical history because, in evaluating the gynecologic patient, the problem often can be clarified if the history is obtained in the following order.
Knowledge of the patient's age sets the tone for the complaint and the approach to the patient. Obviously, the problems and the approach to them vary at different stages in a woman's life (pubescence, adolescence, childbearing years, and premenopausal and postmenopausal years).
Last Normal Menstrual Period
The date of onset of the last normal menstrual period (LNMP) is important to define. A missed period, irregularity of periods, erratic bleeding, or other abnormalities may all imply certain events that are more easily diagnosed when the date of onset of the LNMP is established.
The process of taking the patient's obstetric history is detailed in Chapter 6, but the reproductive history should be recorded as part of the gynecologic evaluation. A convenient symbol for recording the reproductive history is a 4-digit code denoting the number of term pregnancies, premature deliveries, abortions, and living children (TPAL) (eg, 2-1-1-3 means 2 term pregnancies, 1 premature delivery, 1 abortion, and 3 living children).
The chief complaint usually is best elicited by asking “What kind of problem are you having?” or “How can I help you?” It is important to listen carefully to the way the patient responds to this question and to allow her to fully explain her complaint. The patient should be interrupted only to clarify certain points that may be unclear.
Each of the problems the patient describes must be obtained in detail by questioning regarding what exactly the problem is, where exactly the problem is occurring, the date and time of onset, whether the symptoms are abating or getting worse, the duration of the symptoms when they do occur, and how these symptoms are related to or influence other events in her life. For example, the site, duration, and intensity of pain must be accurately described. Getting a sense of how the pain affects her life often is helpful in evaluating the intensity of pain: “Does the pain prevent you from standing or walking?”
It is important to maintain eye contact with the patient and to listen to every word. Do not rely on a patient's sophistication as a measure of her knowledge of anatomy and medical terminology. It is important for the physician to judiciously adjust the level of terminology according to the patient's knowledge and vocabulary. Communicating with the patient in this manner may help the physician obtain an accurate history and establish rapport.
In addition to physiologic events and the life cycle, symptoms described could be related to starting a new job, the beginning of a new relationship or difficulties in the current relationship, an exercise regimen, new medication, and any emotional changes in the patient's life.
After the physician is satisfied that all possible information concerning the present illness and the important corollaries has been obtained, the past history should be elicited.
Continuing with the history, it is important to elicit whether the patient is using or needs some form of contraception. If she is using contraception, her level of satisfaction with her chosen method should be determined. In patients taking oral contraceptives, the history should reflect the agent and dose, whether there is a great variation in the time of day she takes her pill, and any impact of the pill on other physiologic functions. Other forms of hormonal contraceptives, including vaginal rings, dermal patches, and injectable contraceptives, have become available and have their own unique issues. It is extremely important to ask questions during the remainder of the history and to key the physical examination to ascertain whether there are any contraindications to the patient's current form of contraception.
Any medications, prescribed or otherwise, that are being taken or that were being taken when symptoms first occurred should be described. Particular attention must be directed to use of hormones, steroids, and other compounds likely to influence the reproductive tract. Herbal preparations may not be viewed by the patient as medications, so this question should be specifically asked. In addition to medications, the patient should be questioned concerning her use of street drugs. It must be ascertained whether the patient smokes and, if so, how much and for how long. It is important to ascertain the amount of alcohol ingested, if any. This questioning provides an ideal time to indicate the health risks of various habits.
It is important to discover any history of serious medical and psychiatric illnesses and whether hospitalization was required. Particularly important are illnesses in the major organ systems. It is important to know whether there is a major endocrinopathy in the patient's history. Notable weight gain or loss prior to the onset of the patient's current symptoms should be detailed. Other important details include when she had her last physical examination, including pelvic examination and Pap smear.
The surgical history includes all operations, the dates performed, and associated postoperative or anesthetic complications.
Questioning should continue relating any possible allergic reactions to drugs or specific foods. The reaction produced (eg, rash, gastrointestinal upset) must be elicited and the approximate time when it occurred ascertained. Any testing to confirm or deny the observation must be noted. Latex allergy has become more common and severe and should be considered prior to most medical procedures, such as drawing blood samples, pelvic examination, and taking blood pressures.
Bleeding & Thrombotic Diatheses
Determining whether or not the patient bleeds excessively in relation to prior surgery or minor trauma is important. A history of easy bruising or of bleeding from the gums while brushing teeth may be useful in this judgment. The patient should be asked whether she or one of her close relatives experienced venous thromboembolism (VTE). A history of VTE may guide the physician as to which treatment to offer. Suspicion of a bleeding or clotting problem indicates the need for further laboratory evaluation.
The obstetric history includes each of the patient's pregnancies listed in chronologic order. The date of birth; sex and weight of the offspring; duration of pregnancy; length of labor; type of delivery; type of anesthesia; and any complications should be included.
The first item in the gynecologic past history is the menstrual history: age at menarche, interval between periods, duration of flow, amount and character of flow, degree of discomfort, and age at menopause. The menstrual history often is an important clue in the diagnosis.
A prior history of sexually transmitted disease (STD) needs to be detailed. Although in the past it was more common to note only gonorrhea and syphilis, it is important to also document exposure to human immunodeficiency virus (HIV), hepatitis, herpesvirus, chlamydia, and papillomavirus. Any treatment or admissions to the hospital for treatment of salpingitis, endometritis, or tubo-ovarian abscess must be carefully documented. Attempts to assess the impact of these processes in relation to ectopic pregnancy, infertility, and type of contraception must be elicited.
Although its significance is less than that of the prior stated diseases, the occurrence of episodes of vaginitis should not be dismissed. Their frequency and the medications used to treat them should be discussed. In the case of such infections, it is important to detail whether or not the episode was pathologic or merely a misinterpreted physiologic circumstance.
The sexual history should be an integral part of any general gynecologic history. In taking a sexual history, the physician must be nonjudgmental and not embarrassed or critical.
Questions that may be covered include the following. Is she currently sexually active? Is the relationship satisfactory to her and, if not, why not? A question regarding whether the patient is heterosexual or lesbian is important but often difficult to ask because the question may be offensive to some patients. It is important, however, not to assume that a relationship is heterosexual because a lesbian woman will lose all rapport with the physician when the physician is insensitive to such issues.
A social history can be an extension of earlier questions pertaining to the marital and sexual history. Knowing the type of work the patient does, the type of educational background, and her community activities may assist in ascertaining the patient's relationship to her entire environment.
The patient's involvement with her own health care should be carefully elicited, including her attention and knowledge concerning diet, health screening examinations, recreation, and the degree of regular physical exercise.
The patient's family history must include the state of health of immediate relatives (parents, siblings, grandparents, and offspring). In addition to listing these relatives, it is useful in cases where genetic illnesses may be apparent to record a 3-generation pedigree.
The incidence of familial heart disease, hypertensive renal or vascular disease, diabetes mellitus (insulin-dependent or non–insulin-dependent), vascular accidents, and hematologic abnormalities should be ascertained. If the patient has a problem with hirsutism or if she perceives excessive hair growth, it is important to elicit whether anyone in her family has the same distribution of hair growth. Familial history of breast, ovarian, and colon cancers is important to elicit because a close familial history may require additional testing and close follow-up. It is important to relate the time of menopause in the mother or grandmother and to ascertain a history of osteoporosis.
American Cancer Society guidelines for breast cancer screening: update 2003. CA Cancer J Clin
American College of Obstetricians and Gynecologists. Cervical cytology screening. ACOG Practice Bulletin No. 45. Obstet Gynecol 2003;102:417.
Marrazzo JM, Stine K. Reproductive health history of lesbians: implications for care. Am J Obstet Gynecol
Nustaum MR, Hamilton CD. The proactive sexual health history. Am Fam Physician