---

Gynaecological History - 80/20 Framework

---

THE 80% - General Medical History

1. Patient Demographics

• Name, age, occupation, marital status, parity

2. Presenting Complaint (PC)

• One or two words in the patient's own terms
• Duration

3. History of Presenting Complaint (HPC) - Use SOCRATES or Table 1-5 approach:

4. Past Medical History (PMH)

• Previous medical conditions (diabetes, hypertension, thyroid)
• Previous STIs, pelvic infections
• Prior surgery - especially pelvic/abdominal

5. Drug History (DH)

• Current medications including OCP, HRT, hormonal implants/IUD
• Over-the-counter medications
• Herbal/complementary therapies
• Allergies

6. Family History (FH)

• Breast cancer, ovarian cancer, cervical cancer, uterine cancer
• Coagulopathies (relevant to menorrhagia)
• Endometriosis, fibroids (familial tendency)
• Osteoporosis

7. Social History (SH)

• Smoking (cervical cancer risk, contraceptive implications)
• Alcohol and substance use
• Occupation (stress, physical demands)
• Living situation / support network
• Recent travel

8. Systems Review

• Urinary: frequency, urgency, incontinence, haematuria
• Bowel: constipation, diarrhoea, rectal bleeding, tenesmus
• General: weight loss, fatigue, anorexia (malignancy screen)
• Endocrine: hot flushes, galactorrhoea, hirsutism, acne

---

THE 20% - Gynaecology-Specific History

1. Menstrual History (MH)

2. Obstetric History (OH)

• G - Gravida (total pregnancies)
• T - Term deliveries (≥37 weeks)
• P - Preterm deliveries (24-36 weeks)
• A - Abortions/miscarriages (spontaneous or induced)
• L - Living children

3. Sexual History

• Sexually active? Current partner(s)?
• Gender of partners (sensitive, non-judgmental approach)
• Dyspareunia (superficial vs deep - deep suggests endometriosis/PID)
• Contraception used (type, duration, compliance)
• Concerns about fertility

4. Cervical Smear / Screening History

• Date of last smear (Pap/cervical screening)
• Results - any previous abnormalities? Colposcopy? Treatment (LLETZ, cone biopsy)?
• HPV vaccination status

5. Vaginal Discharge

• Colour, consistency, smell, amount
• Associated itch, soreness
• Any known STI history
• Any previous swabs/treatment

---

Red Flag Symptoms in Gynaecological History

---

Mnemonic Summary - "MOSSFIELD"

---

Key Communication Points (from Berek & Novak's Gynecology)

• Establish rapport before sensitive questions - the intimate nature of gynaecology requires particular sensitivity
• Avoid being judgmental about sexual practices, gender identity, and sexual orientation
• Complete history includes: medical/surgical history, reproductive history (menstrual + obstetric), medications including OTC and complementary, and thorough family/social history
• Consider referral to psychologist, sex counsellor, or social worker when appropriate
• Clarify your role (e.g., primary care vs specialist)

---

1. LMP + cycle regularity
2. PMB / PCB / IMB asked directly
3. Obstetric history using GTPAL
4. Smear history with date
5. Sexual history asked sensitively with contraception
6. Red flag symptoms screened systematically

---

Describing Common Gynaecological Complaints in HoPI

---

1. ABNORMAL UTERINE BLEEDING (AUB)

SOCRATES + Specific Questions:

How to Write/Say It in HoPI:

"Mrs X presents with a 3-month history of heavy, regular menstrual bleeding. She reports soaking 6-8 pads per day for the first 3 days of her cycle, with passage of clots. Her cycle is every 28 days and lasts 7 days, previously 5 days. She denies intermenstrual or post-coital bleeding. Her LMP was [date] and was heavier than usual. She reports associated lower abdominal cramps but no dyspareunia, discharge, or weight loss."

Key differentiating questions by type:

• Intermenstrual bleeding (IMB) - ask: relationship to cycle, oral contraceptive use, any new partner
• Post-coital bleeding (PCB) - ask: occurs after every act of intercourse? Any cervical smear history? (Red flag: cervical carcinoma)
• Post-menopausal bleeding (PMB) - ask: last period, how long post-menopause, any HRT use (Red flag: endometrial carcinoma until proven otherwise)

---

2. PELVIC PAIN

SOCRATES + Specific Questions:

How to Write/Say It in HoPI:

"Miss Y presents with a 6-month history of cyclical lower abdominal pain. The pain begins 2 days before her period, peaks on day 1-2 of menstruation, and resolves by day 3. It is described as crampy in nature, 7/10 in severity, and is associated with nausea. She also reports deep dyspareunia and pain on defaecation during her period. There is no fever, abnormal discharge, or urinary symptoms. Her cycles are regular at 28 days."

Timing clues:

---

3. VAGINAL DISCHARGE

SOCRATES + Specific Questions:

How to Write/Say It in HoPI:

"Ms Z presents with a 1-week history of increased vaginal discharge. She describes it as thick, white, and curdy in consistency, with associated vulval itching and soreness. There is no offensive odour. She denies dysuria, pelvic pain, or dyspareunia. She is not in a new relationship and her last menstrual period was 2 weeks ago. She has had similar episodes in the past which resolved with antifungal treatment."

Discharge pattern guide:

---

4. DYSMENORRHOEA (Painful Periods)

SOCRATES + Specific Questions:

How to Write/Say It in HoPI:

"Miss A presents with a 2-year history of painful periods that have become progressively worse. The pain starts 1-2 days before bleeding and persists for the first 3 days of her cycle. She describes it as severe cramping, 8/10, associated with nausea and diarrhoea. She has missed work on several occasions. She also reports deep dyspareunia and pain on opening her bowels during menstruation. NSAIDs provide only partial relief. There is no intermenstrual or post-coital bleeding."

---

5. DYSPAREUNIA (Painful Intercourse)

SOCRATES + Specific Questions:

---

6. PELVIC ORGAN PROLAPSE

SOCRATES + Specific Questions:

---

7. URINARY INCONTINENCE

---

8. VULVAL SYMPTOMS (Itch, Soreness, Lesions)

---

9. INFERTILITY

---

Quick Reference: HoPI Extras by Complaint

---

How to Describe Per Vaginal (PV) Bleeding in HoPI

---

Step 1 - Establish the Type of PV Bleeding First

---

Step 2 - Full HoPI Characterisation Using SOCRATES

O - Onset

• When did the bleeding first start?
• Was it sudden or gradual?
• Did anything trigger it (e.g. started a new pill, new partner, after intercourse)?

S - Site / Source

• Confirmed to be vaginal (vs urinary or rectal)?
• Ask: "Is the blood coming from your vagina, or could it be from when you pass urine or open your bowels?"

C - Character (MOST IMPORTANT section)

Normal mean blood loss = 35 mL per cycle. Heavy menstrual bleeding = >80 mL per cycle, which causes anaemia if recurrent. (Berek & Novak's Gynecology, p. 436)

R - Radiation / Relation to Cycle

• Is the bleeding cyclical (regular periods) or random?
• What day of the cycle does it occur?
  • At menstruation = abnormal uterine bleeding
  • Between periods = IMB
  • After sex = PCB
  • After menopause = PMB

A - Associations

T - Timing and Pattern

E - Exacerbating / Relieving Factors

• Worse with exercise or physical activity?
• Any relation to stress?
• Does it improve at any point in the cycle?

S - Severity

• Impact on daily life, work, social activities?
• Does she need to change plans because of heavy bleeding?
• Impact on sex life?
• Any symptoms of anaemia: fatigue, breathlessness, dizziness, pallor?

---

Step 3 - The Non-Negotiable Extra Questions for PV Bleeding

LMP and Cycle Details

• "When was your last menstrual period? Was it normal?"
• "How long is your usual cycle? (e.g. every 28 days)"
• "How many days do you bleed?"
• "Is your cycle regular or irregular?"

Pregnancy Status

"Pregnancy should always be excluded in women of reproductive age presenting with AUB." - Berek & Novak's Gynecology, p. 437

• "Is there any chance you could be pregnant?"
• "What contraception are you using?"
• "Any missed periods before this bleeding started?"

Contraception / Hormonal Use

• Currently on OCP, patch, ring, implant, Mirena, DMPA (Depo)?
• Any missed pills?
• Irregular bleeding is seen in up to 30-40% of women in the first cycle of the combined pill (Berek & Novak's, p. 404)

Smear History

• When was her last cervical smear? Result?
• Any history of abnormal smears, colposcopy, LLETZ?

Past Gynaecological History

• Any previous episodes of abnormal bleeding? What happened?
• Any known fibroids, polyps, PCOS, endometriosis?
• Any history of STIs, PID?

---

Step 4 - Age-Specific Differential Framing

---

Step 5 - PALM-COEIN Classification (Modern Standard)

---

How to Write it Up - Model HoPI Paragraph

"Mrs Ahmed, a 38-year-old woman, presents with a 6-month history of heavy per vaginal bleeding. She describes her periods as occurring every 26 days, lasting 8 days, which represents a change from her previous 5-day cycle. She soaks 7-8 pads per day on days 2 and 3, with passage of large clots and occasional flooding onto her clothes. She denies intermenstrual or post-coital bleeding. Her LMP was 2 weeks ago and was similarly heavy. She reports associated lower abdominal cramps and increasing fatigue and breathlessness on exertion, suggestive of anaemia. There is no dyspareunia, vaginal discharge, or weight loss. She is not pregnant and uses no hormonal contraception. Her last cervical smear was 2 years ago and was normal. She has no known bleeding disorder and her family history is unremarkable."

---

Red Flags - Must Not Miss