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Gynaecology & Obstetrics (OB/GYN) History Taking - Complete Guide
Source: Berek & Novak's Gynecology, TeachMeObGyn, Nurseslabs
Why OB/GYN History is Unique
Gynaecological and obstetric history is more nuanced than a general medical history because it involves intimate, often sensitive, and personal information about reproduction, sexuality, and bodily function. The key principles (from Berek & Novak's Gynecology, p. 39-55):
- Avoid being judgmental about sexual practices, gender identity, or orientation
- Establish trust and rapport first
- Allow the patient to speak freely before directing the interview
- Psychological, social, cultural, and family factors are all clinically relevant
- The assessment must address the "whole patient"
Structure of OB/GYN History
The history is divided into these sections:
1. Identifying Data
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Menstrual History
5. Obstetric History (GTPAL)
6. Sexual History
7. Contraceptive History
8. Gynaecological History (smears, STIs, procedures)
9. Past Medical and Surgical History
10. Drug History
11. Family History
12. Social History
13. Systems Review
1. Identifying Data
| Field | What to Ask |
|---|---|
| Name, age, date of birth | Basic identification |
| Marital/relationship status | Relevant to reproductive and social history |
| Occupation | Stress, toxin exposure |
| Ethnicity | Some conditions vary by race (e.g., fibroids more common in Black women) |
| Referred by | Who sent the patient and why |
2. Chief Complaint (CC)
Ask in the patient's own words: "What brings you in today?"
Common gynaecological chief complaints include:
| Complaint | Abbreviation/Term |
|---|---|
| Abnormal uterine bleeding | AUB |
| Pelvic pain | PP |
| Vaginal discharge | VD |
| Itching (vulval/vaginal) | Pruritus vulvae |
| Infertility | Primary (never conceived) or Secondary (previously conceived) |
| Urinary incontinence | UI |
| Postcoital bleeding | PCB |
| Postmenopausal bleeding | PMB |
| Lump or swelling in pelvis | - |
3. History of Present Illness (HPI)
Use the SOCRATES acronym to characterize the presenting complaint (especially pain or bleeding):
| Letter | Meaning | Example Question |
|---|---|---|
| S | Site | "Where exactly is the pain?" |
| O | Onset | "When did it start? Sudden or gradual?" |
| C | Character | "Is it crampy, stabbing, dull, burning?" |
| R | Radiation | "Does it spread anywhere - down the leg, to the back?" |
| A | Associations | "Any nausea, vomiting, fever, discharge with it?" |
| T | Time course | "Is it constant or does it come and go?" |
| E | Exacerbating/Relieving factors | "What makes it better or worse? Related to periods?" |
| S | Severity | "On a scale of 0-10, how bad is the pain?" |
4. Menstrual History
This is one of the most important parts of the gynaecological history. It tells you about the hormonal axis, uterine health, and ovarian function.
Key Questions and Terminology
| Term | Definition | What to Ask |
|---|---|---|
| Menarche | Age at first menstrual period | "How old were you when periods started?" |
| LMP | Last Menstrual Period - the first day of the last period | "What was the first day of your last period?" |
| Cycle length | Interval from Day 1 of one period to Day 1 of the next | "How many days between periods?" Normal = 21-35 days |
| Duration | How many days the period lasts | "How many days does bleeding last?" Normal = 3-7 days |
| Flow | Amount of bleeding | "How many pads/tampons per day? Do you pass clots?" |
| Dysmenorrhoea | Painful periods | "Do you have pain with your periods? Primary vs secondary?" |
| Menorrhagia | Heavy menstrual bleeding (>80 mL/cycle) | "Are your periods flooding or soaking through pads?" |
| Oligomenorrhoea | Infrequent periods (>35 days apart) | Cycles too far apart |
| Amenorrhoea | Absence of periods | Primary (never started) or Secondary (stopped >3 months) |
| Polymenorrhoea | Frequent periods (<21 days apart) | Cycles too close together |
| Menopause | Last menstrual period (confirmed after 12 months amenorrhoea) | "Have your periods stopped?" |
| IMB | Intermenstrual Bleeding - bleeding between periods | "Any bleeding between your periods?" |
| PCB | Postcoital Bleeding - bleeding after sex | "Do you bleed after intercourse?" |
| PMB | Postmenopausal Bleeding - any bleeding after menopause | Always investigate (rule out endometrial cancer) |
| Spotting | Very light, small amount of bleeding | Usually not enough to require a pad |
| Dyspareunia | Pain during intercourse | Superficial (at entry) or Deep (pelvic) |
Menstrual History Format
Document as: Cycle length / Duration, e.g.
- "28/5" = 28-day cycle, 5 days of bleeding (normal)
- "21/7" = 21-day cycle, 7 days bleeding
5. Obstetric History - GTPAL System
This is the standardized way to record a woman's full pregnancy history.
GTPAL Explained
| Letter | Term | Meaning |
|---|---|---|
| G | Gravida | Total number of pregnancies (including current), regardless of outcome |
| T | Term | Number of births at ≥37 weeks gestation |
| P | Preterm | Number of births between 20-36+6 weeks |
| A | Abortus | Number of losses before 20 weeks (spontaneous miscarriage + elective termination) |
| L | Living | Number of living children |
Key Obstetric Terms
| Term | Definition |
|---|---|
| Nulligravida | Never been pregnant |
| Primigravida | Currently pregnant for the first time |
| Multigravida | Has been pregnant more than once |
| Nullipara | Never delivered a viable baby |
| Primipara | Delivered one viable baby |
| Multipara | Delivered more than one viable baby |
| Grand multipara | Delivered 5 or more viable babies |
| Abortion | Pregnancy loss before 20 weeks (spontaneous or induced) |
| Miscarriage | Spontaneous pregnancy loss before 20 weeks |
| IUFD | Intrauterine Fetal Death (stillbirth - loss after 20 weeks) |
| Ectopic pregnancy | Pregnancy implanted outside the uterus (usually Fallopian tube) |
| EDD | Estimated Date of Delivery (= LMP + 280 days / Naegele's Rule) |
| EGA / GA | Estimated gestational age |
GTPAL Example
"A 32-year-old woman who had twins at 36 weeks, then a term baby at 39 weeks, one miscarriage at 10 weeks, and all 3 children are living. Now pregnant again."
- G = 4 (4 pregnancies including current)
- T = 1 (the 39-week delivery)
- P = 1 (twins at 36 weeks = preterm)
- A = 1 (miscarriage)
- L = 3 (three living children)
Documented as: G4 T1 P1 A1 L3
For Each Previous Pregnancy, Also Ask:
- Year of birth
- Mode of delivery (SVD = Spontaneous Vaginal Delivery, LSCS = Lower Segment Caesarean Section, Instrumental = forceps/ventouse)
- Birth weight and condition of baby
- Any complications (pre-eclampsia, gestational diabetes, PPH, etc.)
- Place of delivery
6. Sexual History
Approach sensitively. Explain why this is relevant. Use neutral, non-judgmental language.
| Question | Relevant to |
|---|---|
| Are you sexually active? | Baseline |
| What is the gender of your partner(s)? | STI risk, contraception relevance |
| How many partners in the past 3-6 months? | STI risk |
| Do you use barrier contraception (condoms)? | STI protection |
| Any pain during sex (dyspareunia)? | Endometriosis, vaginismus, infection |
| Any postcoital bleeding? | Cervical pathology |
| Any history of sexual abuse or assault? | Trauma-informed care |
7. Contraceptive History
| Question | Why it Matters |
|---|---|
| Current contraceptive method? | Drug interactions, bleeding patterns |
| How long using it? | Compliance, effectiveness |
| Any problems with it? | Side effects, method failures |
| Previous methods used? | History of failures or contraindications |
Common Contraceptive Methods:
| Method | Abbreviation |
|---|---|
| Combined Oral Contraceptive Pill | COCP |
| Progesterone-Only Pill | POP / Mini-pill |
| Levonorgestrel Intrauterine System | LNG-IUS (e.g., Mirena) |
| Copper Intrauterine Device | Cu-IUD |
| Injectable progesterone | DMPA (Depo-Provera) |
| Subdermal implant | Nexplanon |
| Barrier - male condom | - |
| Barrier - female condom / diaphragm | - |
| Emergency contraception | ECP / Morning-after pill |
8. Past Gynaecological History
| Area | What to Ask |
|---|---|
| Cervical screening | Last smear (Pap test), any abnormal results, any colposcopy/biopsy |
| STIs | Chlamydia, gonorrhoea, herpes, HPV, syphilis, HIV - treated or current? |
| Pelvic Inflammatory Disease (PID) | Hospitalised? IV antibiotics? |
| Previous gynaecological surgery | D&C, hysteroscopy, laparoscopy, LLETZ, myomectomy, hysterectomy |
| Endometriosis | Diagnosed? Treated surgically? |
| Fibroids (leiomyomas) | Known? Symptomatic? |
| Ovarian cysts | History, type (functional, dermoid, endometrioma) |
| Breast problems | Lumps, discharge, previous biopsies, mammogram results |
9. Past Medical & Surgical History
Important conditions to specifically ask about:
- Thyroid disorders (affect menstrual cycle)
- Clotting disorders (affect heavy bleeding)
- Diabetes (affects pregnancy, infection risk)
- Hypertension/cardiac disease (affects pregnancy safety)
- Cancer (especially breast, bowel, cervical)
- Autoimmune conditions (lupus - affects pregnancy)
- Anaemia (common with menorrhagia)
- Previous pelvic/abdominal surgery (adhesions)
10. Drug History
Ask specifically about:
- Hormones: HRT, OCP, steroids
- Anticoagulants: Warfarin, heparin (affect bleeding)
- Antipsychotics/antidepressants: Can cause hyperprolactinaemia → amenorrhoea
- Chemotherapy: Ovarian toxicity
- Over-the-counter: NSAIDs (affect bleeding), supplements
- Herbal remedies: Can interact with hormones
- Allergies: Always document
11. Family History
Particularly relevant in gynaecology:
| Condition | Why Relevant |
|---|---|
| Breast cancer | BRCA gene mutations, personal risk |
| Ovarian cancer | BRCA mutations, Lynch syndrome |
| Endometrial/colorectal cancer | Lynch syndrome |
| Cervical cancer | HPV-related, screening advice |
| Endometriosis | Strong familial component |
| Fibroids | Familial tendency, especially in Black women |
| Diabetes | Gestational diabetes risk |
| Hypertension | Pre-eclampsia risk in pregnancy |
| Blood clotting disorders | DVT/PE risk with hormonal contraception |
12. Social History
| Area | What to Ask |
|---|---|
| Smoking | Packs per day, years - affects cervical cancer, contraception (COCP) risk, fertility |
| Alcohol | Units per week |
| Recreational drugs | IV drug use → STI/HIV risk |
| Occupation | Stress, toxin exposure |
| Exercise & diet | BMI, PCOS, amenorrhoea in athletes |
| Domestic situation | Safeguarding, domestic violence (ask sensitively) |
| Partner support | Relevant for pregnancy, mental health |
13. Systems Review (Relevant to Gynaecology)
| System | Symptoms to Ask About |
|---|---|
| Urinary | Frequency, urgency, dysuria, incontinence, haematuria (urinary symptoms overlap with gynaecological disease) |
| Bowel | Constipation, diarrhoea, rectal bleeding, tenesmus (endometriosis, pelvic mass) |
| General | Weight loss, fatigue, night sweats, fever |
| Abdominal | Bloating, distension (ovarian malignancy) |
| Breast | Lumps, pain, nipple discharge |
Key Gynaecological Terminology - Glossary
| Word | Meaning |
|---|---|
| Adnexa | Structures adjacent to the uterus (ovaries and Fallopian tubes) |
| Cervix | Neck of the uterus, lower portion opening into the vagina |
| Colposcopy | Magnified examination of the cervix after abnormal smear |
| Corpus | Body of the uterus |
| Culdocentesis | Needle aspiration through the posterior vaginal fornix (to detect blood/fluid) |
| Curettage / D&C | Scraping of the uterine lining (diagnostic or therapeutic) |
| Dyspareunia | Painful sexual intercourse |
| Endometrium | Inner lining of the uterus |
| Endometriosis | Endometrial tissue growing outside the uterus |
| Fibroids / Leiomyoma | Benign smooth muscle tumours of the uterus |
| Fornix | Recesses at the top of the vagina (anterior, posterior, lateral) |
| Fundus | Top/dome of the uterus |
| Gravida | Number of pregnancies |
| HELLP syndrome | Haemolysis, Elevated Liver enzymes, Low Platelets - obstetric emergency |
| Hysterectomy | Surgical removal of the uterus |
| Laparoscopy | Keyhole surgery of the pelvis/abdomen |
| LMP | Last Menstrual Period |
| LLETZ / LEEP | Loop excision of the transformation zone (cervical treatment) |
| Menarche | First menstrual period |
| Menopause | Cessation of periods (confirmed 12 months after last period) |
| Myoma | Fibroid (benign uterine muscle tumour) |
| Myomectomy | Surgical removal of fibroids (uterus preserved) |
| Nullipara | Never delivered a viable infant |
| Oophorectomy | Removal of an ovary |
| Parametrium | Connective tissue around the uterus (where spread of cervical cancer occurs) |
| Para | Number of deliveries (viable) |
| Parity | Number of pregnancies reaching viable gestational age |
| Perimenopause | Transitional phase before menopause |
| PID | Pelvic Inflammatory Disease - infection of the upper reproductive tract |
| Placenta praevia | Placenta covering or near the cervical os |
| PPH | Postpartum Haemorrhage - >500 mL blood loss after delivery |
| Pre-eclampsia | Hypertension + proteinuria in pregnancy after 20 weeks |
| Primigravida | First pregnancy |
| Prolapse | Descent of pelvic organs into or through the vagina |
| Pruritus vulvae | Itching of the external genitalia |
| Salpingectomy | Removal of a Fallopian tube |
| Salpingitis | Infection/inflammation of the Fallopian tube |
| Speculum | Instrument used to open the vagina for cervical visualisation |
| Transformation Zone | Area of the cervix where squamous meets columnar epithelium (most cancer arises here) |
| Vaginismus | Involuntary spasm of vaginal muscles (causes painful/impossible penetration) |
| Vault | Top of the vagina (after hysterectomy) |
| Vulva | External female genitalia |
Technique of Taking the History (Berek & Novak's Method)
From Table 1-5, Berek & Novak's Gynecology, p. 54-55:
- Allow the patient to express the chief symptom in her own words - do not interrupt
- Establish the temporal relationship - when did this start? What were you doing?
- Use open-ended questions first ("Tell me about the bleeding"), then narrow with closed questions
- Avoid leading questions that suggest the answer
- Explore the symptom thoroughly before moving to the next
- Take note of what the patient is not saying - sometimes silence or hesitation signals important issues
- At the end, summarize back to the patient and ask: "Is there anything else you feel I should know?"
Template Summary Card
Name / Age / LMP:
Chief Complaint:
MENSTRUAL HISTORY:
Menarche age:
Cycle: ___ / ___ days (length/duration)
Flow: Light / Moderate / Heavy / Flooding
Clots: Yes / No
Dysmenorrhoea: Yes / No (Primary / Secondary)
IMB / PCB / PMB: Yes / No
OBSTETRIC HISTORY (GTPAL):
G: ___ T: ___ P: ___ A: ___ L: ___
(Details of each pregnancy: year, GA, mode of delivery, complications, baby weight)
GYNAECOLOGICAL HISTORY:
Last smear / result:
STIs:
Previous gyn surgery:
CONTRACEPTION:
Current method:
SEXUAL HISTORY:
Sexually active: Yes / No
Dyspareunia: Yes / No
PAST MEDICAL HISTORY:
DRUG HISTORY (inc. allergies):
FAMILY HISTORY:
SOCIAL HISTORY (smoking, alcohol, occupation):
SYSTEMS REVIEW:
Sources: Berek & Novak's Gynecology (17th ed.), p. 39-57; TeachMeObGyn.com (updated Dec 2024); Nurseslabs GTPAL Guide
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