Abdominal pain history taking in gynaecology

1. Presenting complaint and pain analysis

• Site: suprapubic, right or left iliac fossa, central lower abdomen, generalized, loin.
• Onset: sudden or gradual; exact time and activity at onset.
• Character: cramping/colicky, sharp, stabbing, dull ache, burning.
• Severity: pain score out of 10; effect on walking, sleep, work, and daily activities.
• Radiation: back, groin, thigh, shoulder tip.
• Timing/course: constant or intermittent; duration; progressive, recurrent, or cyclical.
• Aggravating factors: movement, cough, intercourse, menstruation, urination, defecation, meals.
• Relieving factors: rest, analgesia, heat, opening bowels, passing urine.
• Previous episodes: similar pain in the past, diagnosis made, and treatment received.

2. Menstrual history

• Last menstrual period: date, duration, amount, and character
• Is the period overdue or abnormal?
• Cycle regularity and usual cycle length
• Dysmenorrhoea: primary or new onset; does pain start before or during menstruation?
• Intermenstrual bleeding, postcoital bleeding, menorrhagia, or spotting
• Any recent change in menstrual pattern

3. Pregnancy-related history

• Possibility of pregnancy and contraceptive failure
• Amenorrhoea or missed period
• Nausea, vomiting, breast tenderness
• Vaginal bleeding or spotting
• Previous positive pregnancy test and its timing
• Assisted conception or IVF
• Previous ectopic pregnancy, miscarriage, termination, or molar pregnancy

4. Gynaecological symptoms

• Vaginal discharge: amount, colour, odour, purulent discharge, itching
• Dyspareunia: superficial or deep
• Postcoital bleeding
• Pelvic pressure or mass sensation
• Infertility/subfertility
• Prior diagnoses of endometriosis, fibroids, ovarian cysts, PID, or adenomyosis
• Previous gynaecological operations, including laparoscopy, caesarean section, and tubal surgery

5. Sexual and contraception history

• Current and recent sexual partners
• New partner or unprotected intercourse
• Condom use
• Previous or current STI, PID, and treatment of partners
• Current and previous contraception, including IUCD insertion date
• Emergency contraception
• Possibility of sexual assault or coercion, when appropriate

6. Associated non-gynaecological symptoms

• Anorexia, nausea, vomiting
• Bloating, diarrhoea, constipation, obstipation or inability to pass flatus
• Pain related to meals or defecation
• Rectal bleeding or mucus in stool

• Dysuria, frequency, urgency, hesitancy
• Haematuria
• Flank pain or renal-colic type pain

• Fever, chills, malaise
• Weight loss, anorexia, fatigue

7. Past history

• Previous ectopic pregnancy or PID
• Endometriosis, fibroids, ovarian cysts, malignancy
• Previous abdominal or pelvic surgery, including appendicectomy
• Medical conditions: inflammatory bowel disease, IBS, renal stones, bleeding disorders
• Drug history: analgesics already taken, anticoagulants, hormonal therapy
• Allergies
• Family history: endometriosis, ovarian/breast/colorectal cancer
• Smoking, alcohol, and recreational drugs

8. Focused red-flag questions

• Sudden severe unilateral pain with nausea/vomiting: consider adnexal torsion
• Missed period plus pain/bleeding: consider ectopic pregnancy
• Collapse, faintness, shoulder-tip pain, or severe worsening pain: possible ruptured ectopic pregnancy/haemoperitoneum
• Fever, purulent discharge, or severe pelvic pain: consider PID or tubo-ovarian abscess
• Pain migrating from the umbilicus to the right iliac fossa: consider appendicitis
• Distension, vomiting, no stool/flatus: consider bowel obstruction

A concise exam presentation format

“This is a woman of reproductive age with acute/chronic lower abdominal pain. I would first assess severity and ask about the onset, site, character, radiation, timing, severity, aggravating and relieving factors. I would establish menstrual and pregnancy history, including LMP and abnormal bleeding, then ask about vaginal discharge, dyspareunia, sexual and contraceptive history, STI/PID risk, gastrointestinal and urinary symptoms, systemic symptoms, previous gynaecological disease or surgery, medications, and relevant red flags for ectopic pregnancy, torsion, PID, and non-gynaecological surgical causes.”

Endometrial polyp: history taking, symptoms, and signs

1. History taking

Presenting symptom: abnormal uterine bleeding

• Intermenstrual bleeding or spotting
• Heavy menstrual bleeding: flooding, clots, changing pads frequently, prolonged periods
• Irregular menstrual cycles
• Prolonged menstruation, usually more than 7 days
• Postcoital bleeding
• Postmenopausal bleeding: any vaginal bleeding after 12 months of amenorrhoea is significant
• Onset, duration, progression, and impact on daily activities
• Symptoms of anaemia: fatigue, dizziness, palpitations, exertional breathlessness

Pain and related symptoms

• Pelvic pain, crampy lower abdominal pain, or dysmenorrhoea
• Pain during intercourse
• Vaginal discharge, especially if offensive or blood-stained
• Pressure symptoms, though these suggest a large lesion or an alternative diagnosis

Fertility and reproductive history

• Difficulty conceiving and duration of infertility
• Previous miscarriages or failed implantation/IVF
• Obstetric history: pregnancies, deliveries, miscarriages, ectopic pregnancies
• Current pregnancy possibility and last menstrual period
• Contraception, particularly a hormonal intrauterine device or tamoxifen exposure

Menstrual and hormonal history

• Age at menarche and usual cycle pattern
• Perimenopausal or postmenopausal status
• Hormone replacement therapy
• Polycystic ovary syndrome or chronic anovulation
• Use of oestrogen-containing medication

Risk factors for endometrial hyperplasia or malignancy

• Postmenopausal bleeding
• Obesity
• Diabetes mellitus
• Hypertension
• Tamoxifen treatment
• Family history of endometrial, colorectal, or Lynch syndrome-associated cancers
• Previous endometrial hyperplasia or cancer

Common symptoms

Examination signs

General examination

• Pallor, tachycardia, or postural hypotension if bleeding is heavy
• Obesity, hypertension, or other metabolic risk factors

Abdominal examination

• Usually no mass or tenderness
• Lower abdominal tenderness may suggest another cause such as fibroid degeneration, PID, ovarian pathology, or malignancy

Speculum examination

• Blood from the cervical os
• A polyp may occasionally protrude through the cervix into the vagina
• Check for cervical polyp, cervical lesion, vaginal lesion, discharge, and source of bleeding

Bimanual examination

• Uterus is often normal size
• Assess uterine size, tenderness, mobility, adnexal masses, and cervical motion tenderness
• A bulky irregular uterus suggests fibroids rather than an isolated endometrial polyp

Important differentials for abnormal uterine bleeding

• Pregnancy-related bleeding, including miscarriage and ectopic pregnancy
• Fibroids, especially submucosal fibroids
• Adenomyosis
• Endometrial hyperplasia or endometrial cancer
• Cervical polyp or cervical cancer
• Ovulatory dysfunction, including PCOS
• Coagulopathy
• Thyroid disease
• Pelvic inflammatory disease

Red flags requiring prompt assessment

• Any postmenopausal bleeding
• Heavy bleeding with haemodynamic symptoms, syncope, or symptomatic anaemia
• Persistent intermenstrual or postcoital bleeding
• Unexplained weight loss, persistent pelvic pain, or pelvic mass
• Abnormal discharge, especially watery/blood-stained discharge
• Tamoxifen use or a history of endometrial hyperplasia/cancer

Short clinical presentation

“A patient with endometrial polyp commonly presents with abnormal uterine bleeding, particularly intermenstrual spotting, heavy or prolonged menstruation, irregular cycles, or postmenopausal bleeding. Many patients are asymptomatic. History should cover bleeding pattern, LMP and pregnancy possibility, symptoms of anaemia, infertility, hormonal and drug history including tamoxifen, and risk factors for endometrial hyperplasia or malignancy. Examination is frequently normal, though a polyp may rarely be seen protruding through the cervical os.”

Vaginal bleeding and vaginal discharge: history taking

1. Vaginal bleeding history

Presenting complaint

• When did the bleeding start?
• Is it the first episode or recurrent?
• Is it related to menstruation, intercourse, pregnancy, menopause, or a procedure?
• Is bleeding improving, stable, or worsening?

Quantify the bleeding

• Spotting or heavy flow?
• Number of pads/tampons used and how often they are changed
• Flooding, passage of clots, soaking clothes or bedding
• Duration of bleeding
• Colour: bright red, dark red, brown
• Any tissue passed per vaginam

Relation to the menstrual cycle

• LMP: first day of the last normal menstrual period
• Usual cycle length, regularity, duration, and normal amount of bleeding
• Menorrhagia/heavy menstrual bleeding
• Intermenstrual bleeding
• Prolonged or frequent bleeding
• Postcoital bleeding
• Dysmenorrhoea

Pregnancy history

• Could you be pregnant?
• Missed or late period?
• Pregnancy test and result
• Nausea, vomiting, breast tenderness
• Lower abdominal or unilateral pelvic pain
• Previous miscarriage, ectopic pregnancy, termination, IVF, or tubal surgery

Associated symptoms

• Lower abdominal or pelvic pain
• Fever, chills, feeling unwell
• Dizziness, palpitations, breathlessness, fatigue: possible significant blood loss/anaemia
• Urinary symptoms: dysuria, frequency, haematuria
• Bowel symptoms: pain on defecation, constipation, diarrhoea, rectal bleeding
• Weight loss, reduced appetite, pelvic mass or pressure symptoms

Menopausal status and cancer risk

• Obesity, diabetes, hypertension
• Tamoxifen
• Hormone replacement therapy, including missed or changed doses
• Unopposed oestrogen exposure
• Previous endometrial hyperplasia or cancer
• Family history of endometrial, ovarian, breast, or colorectal cancer

2. Vaginal discharge history

Characterise the discharge

• Onset and duration
• Amount: scanty, moderate, profuse
• Colour: clear/white, yellow, green, grey, brown, blood-stained
• Consistency: thin, watery, frothy, thick/curdy, purulent
• Odour: fishy, offensive, or no odour
• Relation to menstruation, intercourse, pregnancy, antibiotics, or use of vaginal products

Associated local symptoms

• Vulval itching or irritation
• Burning or soreness
• Vaginal pain
• External dysuria, when urine contacts inflamed vulval skin
• Dyspareunia, superficial or deep
• Vulval sores, ulcers, blisters, warts, rash, swelling
• Pelvic or lower abdominal pain
• Postcoital or intermenstrual bleeding

Sexual and STI history

• Current sexual activity
• New or multiple sexual partners
• Condom use
• Partner with genital symptoms or known STI
• Previous STI, PID, or treatment
• Last STI screen
• Possibility of sexual assault or coercion, if clinically appropriate

Other relevant history

• Recent antibiotics or corticosteroids
• Diabetes or immunosuppression
• Pregnancy
• Recent gynaecological procedure, miscarriage, delivery, or intrauterine device insertion
• Foreign body possibility, for example retained tampon or condom
• Douching, scented soaps, vaginal washes, lubricants, or spermicides
• Previous similar episode and response to treatment

Pattern clues

Urgent red flags

• Heavy vaginal bleeding with fainting, tachycardia, dizziness, or collapse
• Positive pregnancy test with pain or bleeding
• Severe unilateral pelvic pain, shoulder-tip pain, or syncope
• Fever, severe pelvic pain, purulent discharge, or vomiting
• Postmenopausal bleeding
• Persistent postcoital bleeding
• Blood-stained or watery offensive discharge with weight loss or pelvic mass
• Recent pregnancy, miscarriage, delivery, or gynaecological surgery with bleeding, pain, fever, or offensive discharge

Short exam-style summary

“In a patient with vaginal bleeding and discharge, I would establish the onset, amount, colour, duration, and relation to menstruation, intercourse, pregnancy, and menopause. I would ask about LMP and pregnancy possibility, pelvic pain, systemic symptoms, anaemic symptoms, urinary and bowel symptoms, and cancer red flags. For discharge, I would assess its amount, colour, consistency, smell, associated itching, soreness, dysuria, dyspareunia, lesions, and pelvic pain. I would then take a sensitive sexual, contraceptive, STI, obstetric, menstrual, medical, medication, and gynaecological history.”