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    Taking A Gynaecological History

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    asif_siddiqui_2
    This document outlines how to take a thorough gynaecological history, including topics such as: menstrual history, sexual history, obstetric history, family history, and past medical/surgical procedures. It describes key aspects to ask about under each topic, such as age of menarche/menopause, regularity of periods, contraceptive use, fertility wishes, and relevant medical conditions. The document also provides guidance on performing a gynaecological examination, including abdominal, pelvic, and bimanual components while maintaining professional standards.

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    Taking A Gynaecological History

    Uploaded by

    asif_siddiqui_2
    128 views21 pages
    This document outlines how to take a thorough gynaecological history, including topics such as: menstrual history, sexual history, obstetric history, family history, and past medical/surgical procedures. It describes key aspects to ask about under each topic, such as age of menarche/menopause, regularity of periods, contraceptive use, fertility wishes, and relevant medical conditions. The document also provides guidance on performing a gynaecological examination, including abdominal, pelvic, and bimanual components while maintaining professional standards.

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    Taking a Gynaecological History

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    This document outlines how to take a thorough gynaecological history, including topics such as: menstrual history, sexual history, obstetric history, family history, and past medical/surgical procedures. It describes key aspects to ask about under each topic, such as age of menarche/menopause, regularity of periods, contraceptive use, fertility wishes, and relevant medical conditions. The document also provides guidance on performing a gynaecological examination, including abdominal, pelvic, and bimanual components while maintaining professional standards.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    128 views21 pages

    Taking A Gynaecological History

    Uploaded by

    asif_siddiqui_2
    This document outlines how to take a thorough gynaecological history, including topics such as: menstrual history, sexual history, obstetric history, family history, and past medical/surgical procedures. It describes key aspects to ask about under each topic, such as age of menarche/menopause, regularity of periods, contraceptive use, fertility wishes, and relevant medical conditions. The document also provides guidance on performing a gynaecological examination, including abdominal, pelvic, and bimanual components while maintaining professional standards.

    Copyright:

    © All Rights Reserved
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    of 21

    Taking a Gynaecological History

    Patricia Crowley TCD Department of


    Obstetrics and Gynaecology

    Terminology
    Menarche

    Age or date of first


    menstruation
    (10-16)

    Menopause

    Age or date of last


    spontaneous period (4055 average 51)

    Menstruation
    Cycle

    Duration

    Withdrawal bleed

    No. of days between Day


    1 of period to Day 1 of
    next (Normal 21-35)
    Number of days of
    bleeding (Normal 2-7)
    Bleeding after cessation
    of exogenous oestrogen
    +/ or progestagen

    Menopause
    Menopause

    Climacteric

    Postmenopausal bleed

    Cessation of
    menstruation due to
    exhaustion of primordial
    follicles
    Years preceeding
    menopause, patient still
    menstruating
    Any vaginal bleeding one
    year or more after
    menopause, not provoked
    by exogenous hormones

    Abnormalities of Menstruation
    Dysmenorrhea

    Painful menstruation

    Menorrhagia

    Excessive menstrual
    blood loss

    Abnormalities of menstruation
    Primary Amenorrhea

    Secondary amenorrhea

    Oligomenorrhea

    Absence of spontaneous
    menstruation by 16 years
    of age
    Cessation of
    menstruation for 6
    months or more
    Menstrual intervals of 6
    weeks to 6 months

    Non-menstrual bleeding
    Intermenstrual bleeding

    Bleeding between periods

    Postcoital bleeding

    Bleeding after intercourse

    Breakthrough bleeding

    Bleeding during
    hormonal therapy e.g.
    OCP or HRT

    PAIN
    Dyspareunia

    Pain during or following


    sexual intercourse

    Dyschezia

    Pain during defaecation

    Mittleschmerz

    Pain at ovulation

    Taking a Gynaecological History

    Age at menarche
    Menstrual cycle
    Regularity
    Duration
    Any intermenstrual bleeding?
    Any post-coital bleeding?

    When was your last menstrual


    period?

    Taking a Gynaecological History

    Menorrhagia?
    Dysmenorrhea?
    Pain
    Urinary symptoms
    Sensation of prolapse

    Taking a Gynaecological History

    Sexually active or not?


    Currently/ever?
    Contraceptive use?
    History of sub-fertility, past/ current?
    Wishes for present and future fertility
    If menopausal, current or previous use of
    HRT

    Gynaecological
    Procedures/Investigations

    Date of last cervical smear + result


    Any gynaecological operations?
    Laparoscopy
    Hysteroscopy
    Dilatation and curettage

    Sexual History
    Number of partners is not relevant
    except in an STD clinic
    DO NOT ASK

    Additional Relevant History

    Obstetric history
    Medical, surgical, social history
    Medications
    Weight gain/loss, dieting, exercise
    Hirsutism, acne

    Family History

    Maturity onset diabetes?


    History suggestive of thrombophilia?
    Endometriosis
    Breast, ovary, endometrial and colonic
    carcinoma.
    Age of menarche and menopause in other
    female relatives when relevant

    Gynaecological Examination
    Height, weight, body mass index
    General physical examination
    Where relevant, secondary sexual
    characteristics
    Breast exam in women over 30 with
    chaperone and consent if not done recently
    Abdominal and pelvic examination

    Abdominal Examination in
    Gynaecology
    Masses especially mass arising out of pelvis
    Size is referred to in relation to a pregnancy
    e.g. 16 weeks size
    Ascites
    Tenderness
    Rebound tenderness

    Pelvic Examination

    Inspection of vulva and perineum


    Vagina prolapse?
    Speculum examination cervix and vagina
    Bimanual examination of uterus and adnexa

    Bimanual Examination

    Size of uterus
    Position
    Mobility
    Tenderness
    Adnexal masses and tenderness
    Cervical excitation

    Code of Practice for Pelvic


    Examination

    Chaperone
    Explanation and consent
    No personal comments
    Gloves on both hands
    Gentleness

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