General
- Name, age and occupation
- A brief statement of the general nature and duration of the main complaints (try to use the patient’s own words rather than medical terms at this stage)
History of presenting complaint
- This section should focus on the presenting complaint, e.g. menstrual problems, pain, subfertility, urinary incontinence, etc. The detailed questions relating to each complaint are covered in more detail in the relevant chapters, but there are certain important aspects of a gynaecological history that should always be enquired about.
Menstrual history
- Age of menarche
- Usual duration of each period and length of cycle (usually written as mean number of days of bleeding over usual length of full cycle, e.g. 5/28)
- First day of the last period
- Pattern of bleeding: regular or irregular and length of cycle
- Amount of blood loss: more or less than usual, number of sanitary towels or tampons used, passage of clots or flooding
- Any intermenstrual or post-coital bleeding
- Any pain relating to the period, its severity and timing of onset
- Any medication taken during the period (including over-the-counter preparations).
Previous gynaecological history
- This section should include any previous gynaecological treatments or surgery.
Previous obstetric history
- Number of children with ages and birth weights.
- Any abnormalities with pregnancy, labour or the puerperium
- Number of miscarriages and gestation at which they occurred
- Any terminations of pregnancy with record of gestational age and any complications.
Previous medical history
- Any serious illnesses or operations with dates
- Family history.
Enquiry about other systems
- Appetite, weight loss, weight gain
- Bowel function (if urogynaecological complaint, more detail may be required)
- Bladder function (if urogynaecological complaint, more detail may be required).
- Enquiry of other systems
Social history
- Sensitive enquiry should be made about the woman’s social situation including details of her occupation, who she lives with, her housing and whether or not she’s in a stable relationship.
- A history regarding smoking and alcohol intake should also be obtained. Any pertinent family or other relevant social problems should be briefly discussed. If admission and surgery are being contemplated it’s necessary to establish what support she has at home, particularly if she is elderly or frail.
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