Episode 26 Taking a Gynae History

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This page contains information directly transcribed from the MOGCAST podcast. You can listen to the episode on Spotify.

Hello, my name is Alison Bryant-Smith. I'm a consultant obstetrician gynaecologist at the Northern Hospital in Epping. I'm Jo Vivian Taylor and I'm the Head of Gynaecology at the Northern.

This MOGCAST episode will talk you through how to take a gynaecological history and we'll focus on taking history regarding menses, urinary incontinence, pelvic organ prolapse and menopause. We're hoping to impart some pearls of wisdom plus some tips on how to structure your gynaecological history taking.  As with all history taking, keep in the back of your mind what the likely diagnoses could be based on the patient's presenting complaint. Then target your questioning to work out which differential diagnosis is most likely.

First off, menstrual history. A good structure when taking a menstrual history which we'll go through in turn is menarche, timing, heavy periods, period pain and then other symptoms.

First off, I ask patients when they went through menarche, i.e. started getting their first period. The average age of menarche is 12 and a half years old. I ask how many days of bleeding they have. The normal duration of menses is up to eight days duration. I ask about the length of their menstrual cycle which is counted from the first day of one period to the first day of the next. The normal cycle length is 24 to 38 days with up to seven days variation month to month also being normal.

Once I've clarified the timing of a woman's period I move on to heavy menstrual bleeding. Common causes of heavy menstrual bleeding include fibroids, adenomyosis and anovulatory cycles. Menstrual cycles without ovulation which can be normal for the first few years after menarche and for a few years prior to menopause or the result of pathology.

Helpful questions regarding heavy periods include, how often do you need to change your pad or tampon? Do you pass any clots? If so, are they the size of a five cent piece - small? A golf ball - moderate? Or palm-sized - large? Do you have episodes of flooding where blood gushes onto your clothes or bed sheets? Have you ever had low iron due to your heavy periods? It's often helpful to clarify the time course. Have her periods always been heavy or have they changed over time? If so, how? Ask if she tried any treatment for her heavy periods in the past. If so, what and did it work? Also clarify whether or not she wants any more children as this will guide management.

After asking about heavy periods, I ask about dysmenorrhoea or period pain. Common causes of dysmenorrhoea include endometriosis and adenomyosis. Helpful questions about dysmenorrhoea include: Can you describe any pain associated with your periods? When does your pain start and end in relation to your bleeding? How would you rate your period pain out of 10? What is the character of the pain? What have you tried in the past to relieve the pain and did it work? Did you ever need to take time off work because of your period pain? As with heavy periods, clarify the time course. Have her periods always been painful or has this developed over time?

I then ask about cyclical bowel symptoms. Predictable changes in her bowel habits at different times of the month. For example, women with bowel endometriosis may report that they have a regular bowel habit during most of the month, constipation in the days leading up to their periods, then looser bowel motions during their periods.

While asking about symptoms of severe endometriosis, I also ask about dyspareunia, pain during sex, which is a common symptom of endometriosis. Helpful questions here include, do you experience any pain with penetrative sex? Is the pain outside near the entrance of the vagina or deep inside? Are some sexual positions more painful than others? To round out your menstrual history, ask about intermenstrual and post-coital bleeding.

Intermenstrual bleeding, bleeding between periods, occurs at ovulation in about 10% of women. It can be physiological or due to polyps or fibroids. Post-coital bleeding may be due to a sexually transmitted infection such as chlamydia, a cervical ectropion, which is innocent changes to the cervical cells which cause the cervix to bleed on contact, a cervical polyp or rarely cervical cancer.

It's also important to clarify a woman's usual menstrual cycle, both on and off exogenous hormones, such as the combined oral contraceptive pill. For example, a woman with polycystic ovarian syndrome may have oligomenorrhoea, a menstrual cycle lasting longer than 38 days. Once she starts taking the pill, her period will likely regulate to occur every 28 days. Women with endometriosis may find that their dysmenorrhoea improves while on the contraceptive pill.

So in summary, when taking a menstrual history, consider structuring it as follows. Age of menarche, duration of bleeding and the duration of their menstrual cycle, heavy menstrual bleeding, dysmenorrhoea, additional symptoms of endometriosis such as cyclical bowel habits and dyspareunia, and then intermenstrual and post-causal bleeding.

Moving on now to asking patients about a possible sexually transmitted infection or STI. Explaining the nuances of taking a thorough sexual history is beyond the scope of this podcast. However, if a patient presents requesting STI testing or with symptoms, it's worth asking. Have you had unprotected penetrative sex? If so, when? When was your last menstrual period? Is there any chance you could be pregnant? Have you noticed a change in your vaginal discharge, fever or abdominal or pelvic pain? Have any previous partners ever told you that they've been diagnosed with an STI? Have you had any STIs in the past? If so, how were they treated? We're now going to move on to taking urinary incontinence and prolapse history, typically from a post-menopausal woman.

Urinary incontinence is the involuntary leakage of urine. Risk factors include increasing age, especially being post-menopausal, obesity, increasing parity, especially vaginal births, and smoking. In addition to asking patients about these risk factors, also ask about their daily fluid intake. If their fluid intake, especially in the evenings, is deemed excessive, it's an easily modifiable risk factor.

Broadly speaking, there are two different types of urinary incontinence, stress incontinence and urge incontinence. These are two separate entities with different underlying pathophysiology. While they tend to cause different symptoms, many patients have elements of both stress and urge incontinence.

Stress urinary incontinence is due to damage to the pelvic floor muscles and vaginal connective tissue that can occur during a vaginal birth. Urinary leakage occurs due to the combination of increased intra-abdominal pressure, for example when sneezing, and the muscular tube of the urethra failing to close, which means that there is insufficient resistance to stop urine from flowing out of the bladder and urethra.

Patients typically experience involuntary urinary leakage when they sneeze, cough, laugh, and or exercise, all activities that raise the intra-abdominal pressure. Hence questioning would be along those lines.

Urge incontinence, on the other hand, is due to bladder overactivity. The detrusor or bladder muscle contracts involuntarily. Women with urge incontinence classically experience a strong urge to void their leakage of urine. The leakage volume can range from a few drops to completely emptying their bladder.

An example of how to ask about urge incontinence is, when you experience an urge to pass urine, do you need to find a toilet quickly otherwise you would leak? Additional symptoms include urinary frequency, emptying your bladder more than eight times in 24 hours, and nocturia, having to get up at night to empty your bladder.

When taking an incontinence history, it can be helpful to think of these two entities, stress and urge incontinence, in two different columns to guide your history taking. For stress incontinence, ask about urinary leakage during valsalva manoeuvres. For urge incontinence, ask about urgency, frequency, and nocturia. Some patients may report some symptoms from column A and some from column B. Urodynamic studies can objectively measure the relative contributions of both stress and urge incontinence to the patient's symptoms.

As with all history taking, from heavy and/or painful periods to urinary incontinence, ask patients the impact of their symptoms on their quality of life. For example, do they need to wear a continence pad every day? Does their incontinence limit their social activities? Ask what treatments they've tried in the past and whether it's worked.

So, to summarise taking an incontinence history, stress incontinence typically leads to urinary leakage during increased abdominal pressure, such as coughing, sneezing or exercise. Urge incontinence classically leads to urinary urgency, frequency, and nocturia.

There's often overlap between urinary incontinence symptoms and those of pelvic organ prolapse, which we'll cover next.

Prolapse is the herniation of pelvic organs, such as the bladder, uterus or bowels, into or beyond the vagina. Risk factors include increasing parity, especially injury to the levator ani muscles and or pudendal nerve during vaginal birth.

The bigger the baby and the longer the second or pushing stage of labour, the higher the risk of prolapse. Additional risk factors include being postmenopausal, obesity and chronically elevated intra-abdominal pressure, such as a chronic cough or straining, such as due to chronic constipation. It's helpful to think of prolapse risk factors in terms of non-modifiable, previous obstetric history and being postmenopausal, and modifiable, obesity, smoking, constipation and heavy lifting.

When taking a prolapse history from a patient, break it down into three symptom groups. Bulge symptoms, urinary symptoms and bowel symptoms. Bulge or pressure symptoms occur due to the front and/or back walls of the vagina and/or cervix, bulging down lower than they should be, at worst even beyond the vaginal introitus itself.

Ask about feeling a bulge down below and clarifying whether or not the patient has ever felt the bulge go beyond the entrance of the vagina. If so, does the bulge reduce back into the vagina or does it stay outside the introitus? Classically, women notice this bulge more often at the end of the day, after a long time on their feet or with straining, such as when they're heavy lifting. They may also describe a dragging sensation.

Next, urinary symptoms. Prolapse of the anterior vaginal wall can affect bladder and or urethral function. Hence, symptoms of stress incontinence often coexist with stage one or stage two anterior compartment prolapse.

As the woman's prolapse gets worse, there may be a paradoxical improvement in her stress incontinence symptoms. What's happening here is that the course of the urethra, which runs along the front wall of the vagina, becomes so kinked due to the bulging of that front wall of the vagina that the kinking actually prevents urinary leakage with valsalva. As her prolapse worsens to stage three or four, this kinking can lead to obstructive urinary symptoms, such as a sense of incomplete emptying or even complete urinary retention.

Next, bowel symptoms. Just as urinary symptoms tend to occur more often in women with anterior compartment prolapse, bowel symptoms tend to occur more often with posterior vagina wall prolapse. Common symptoms include constipation and even the need to splint.

Splinting refers to when a patient has to insert a finger vaginally and press backwards on the posterior vagina wall in order to defecate. Essentially what splinting does is correct the posterior compartment prolapse and subsequent kinking of the rectum in order to pass faeces.

As with heavy menstrual bleeding, dysmenorrhoea and urinary incontinence, ask the patient what treatments they've tried in the past and whether that worked. For frail patients with severe prolapse, one surgical option includes what's called a colpocleisis. In this operation, the vagina is essentially closed off and penetrative sex is not possible. So if relevant, ask whether or not the patient wants to have penetrative sex in future.

If so, colpocleisis s is not the appropriate management. So in summary, when taking a prolapse history, ask about bulge symptoms, bulge down into or even beyond the vagina, urinary symptoms such as leakage with valsalva, bowel symptoms such as constipation and the need to splint. So far we've covered menstrual history, urinary incontinence and prolapse.

Now on to taking a history around menopause. Menopause by definition is when a woman has had a year without a period. The average age of menopause is 52.

The years leading up to menopause are referred to as the perimenopause or menopause transition. During this stage, women often have heavy and erratic periods and start to develop hot flushes. Perimenopause lasts on average five years.

When a patient has not had any bleeding for 12 months, she's considered to be postmenopausal. When you're talking with a peri or postmenopausal patient, it's good to ask; what were your periods like before you started going through menopause? When was your last regular period? Have you had any bleeding since you went through menopause?

Any bleeding after menopause is abnormal and warrants a pelvic ultrasound to measure the thickness of the endometrium. Have you been troubled by hot flushes? If so, how severe are they? You need to ask how frequently they occur and severity when they do.

A good way to ask about severity is what do you need to do when you get a hot flush or night sweat? Remove clothes, take a shower, carry a fan, change your bed sheets and how hard is it to get back to sleep? Hot flushes and night sweats can impact on a woman's quality of life, especially when they disturb her sleep. Have you been troubled by any of; hot flushes, vaginal dryness, pain with penetrative sex, pain with urination, urinary urgency or recurrent urinary tract infections? These symptoms are part of the so-called genitourinary syndrome of menopause.

Mood changes, anxiety and depression, can occur at the time of menopause. While most women do not experience this, there is a small number of women for whom menopause is a trigger. It is important to differentiate between the symptoms of a mood disorder and the symptoms of menopause which can be difficult, such as irritability can be caused due to poor sleep, secondary to night sweats or due to a mood disorder. Changes in libido occur at the time of menopause and should be included in the history.

If it's present, this is not all related to hormonal changes but is a complex interaction between hormonal effects, atrophy of the vagina, consequences of vasomotor symptoms such as poor sleep and psychosocial factors associated with midlife.

Moving on to the last and shortest segment of our podcast, screening in gynaecology. There are some routine questions that should always be asked about screening for cervical and breast cancer. In Australia, women aged between 25 and 74 years old who've ever had penetrative sex should have a cervical screening test performed at least every five years, starting two years after their first sexual episode. Ask whether or not the patient received their human papilloma virus vaccinations, a series of two or three HPV vaccinations which were introduced in Australia in 2007 and recommended to girls and boys at 12 years old.

For breast cancer screening, all women aged 50 to 74 are encouraged to have a mammogram every two years. Questions about cervical and breast cancer screening should be included whenever you take a gynae history from a woman in the relevant age group.

So that about wraps up this podcast about taking a gynaecological history. During your women's health rotation, you will need to proactively make the most of your opportunities to take a gynae history from patients in clinic, in the anaesthetic bay, while patient is awaiting to have an operation, in the ward after their operation, after the ward round and in the emergency department.

Using the structure and the questions we've outlined here, you'll be well on your way to work out the patient's diagnosis. We both hope that the tips you've picked up listening to this podcast help you to make the most of your women's health rotation.