History Taking: Ovarian Cyst & Pelvic Inflammatory Disease (PID)

PART 1 — OVARIAN CYST

1. Presenting Complaint

• Nature of pain: dull, aching, pressure-like (chronic cyst) vs. sudden sharp unilateral pain (rupture, torsion)
• Side of pain: unilateral is typical; bilateral is less common
• Onset and duration: acute (rupture/torsion) vs. gradual/recurrent
• Radiation: to the inner thigh or back

2. Associated Symptoms

• Pressure effects on adjacent organs:
  • Urinary frequency or retention (bladder compression)
  • Constipation, early satiety (bowel compression) - Berek & Novak's Gynecology
• Intraperitoneal complications: sudden severe pain with shoulder-tip pain (haemoperitoneum from rupture)
• Nausea and vomiting (especially with torsion)
• Abdominal distension

3. Menstrual History (MUST ask)

• LMP (last menstrual period) - excludes ectopic pregnancy, dates pregnancy-related cysts
• Cycle regularity: irregular cycles suggest functional cysts (follicular or corpus luteum)
• Dysmenorrhoea: cyclical, progressive pain is a hallmark of endometriosis/endometrioma ("chocolate cyst") - Sabiston Textbook of Surgery
• Menorrhagia or intermenstrual bleeding

4. Sexual and Gynaecological History

• Sexual activity, contraceptive method (OCP reduces functional cysts; IUD increases PID risk)
• Dyspareunia (deep dyspareunia points to endometrioma)
• Fertility concerns / desire for future pregnancy (critical for management planning)
• Previous pelvic/gynaecological surgery

5. Family History

• BRCA1/BRCA2 mutation carriers or family history of ovarian or breast cancer - elevated malignancy risk in any adnexal mass in these patients (Sabiston)
• Family history of endometriosis

6. Past Medical History

• Endometriosis (risk of endometrioma recurrence)
• Previous ovarian cyst (type, management)
• Polycystic ovary syndrome (PCOS)

7. Systems Review for Red Flags (Malignancy)

• Unintentional weight loss
• Abdominal bloating, change in bowel habit
• Post-menopausal status + new pelvic mass = suspect malignancy until proven otherwise

Types of Ovarian Cysts and Their Key History Features

PART 2 — PELVIC INFLAMMATORY DISEASE (PID)

1. Presenting Complaint

• Lower abdominal or pelvic pain - bilateral, dull, constant
• Onset: often begins during or just after menstruation (menstruation facilitates ascending infection) - Harrison's Principles of Internal Medicine 22E
• Abnormal vaginal discharge: increased volume, purulent, malodorous
• Dyspareunia (cervical motion causes pain)

2. Associated Symptoms

• Fever and chills (systemic infection)
• Nausea and vomiting (severe cases, peritonitis)
• Dysuria (urethral involvement)
• Right upper quadrant pain - Fitz-Hugh-Curtis syndrome (perihepatitis) - patient may present as if they have liver/gallbladder disease; ask specifically if right-side pain accompanies the pelvic pain - Harrison's
• Abnormal uterine bleeding (endometritis causes irregular bleeding)

3. Sexual History (Critical - always ask sensitively)

• Sexual activity, number of recent partners, new partner (increased STI exposure)
• Unprotected intercourse (no barrier contraception)
• Recent STI history or contact: gonorrhoea (N. gonorrhoeae), chlamydia (C. trachomatis), Mycoplasma genitalium
• Previous history of PID (strongest predictor of recurrence)
• Partner symptoms (urethral discharge, dysuria)

4. Gynaecological/Obstetric History

• IUD insertion (especially within the last few weeks - major risk factor) - Harrison's
• Recent intrauterine procedure: D&C, termination of pregnancy, hysterosalpingography
• Recent miscarriage or delivery
• Vaginal douching (disrupts normal flora, risk factor for PID)
• Previous pelvic/abdominal surgery

5. Menstrual History

• LMP (to exclude ectopic pregnancy - critical differential)
• Irregular bleeding or post-coital bleeding (endocervicitis)

6. Contraceptive History

• Oral contraceptive pill: protective against symptomatic PID
• Tubal sterilisation: reduces risk of salpingitis by preventing intraluminal spread
• IUD: increases risk, especially within 20 days of insertion - Harrison's

7. Past Medical History

• Previous PID (recurrent episodes increase risk of infertility and ectopic pregnancy)
• Bacterial vaginosis (BV) - co-existing BV is an independent risk factor for ascending infection
• HIV status (immune compromised patients may need inpatient treatment)
• Appendicitis or bowel disease (can cause secondary pelvic infection or mimic PID)

8. Social History

• Age: highest incidence in sexually active women aged 15-25 years
• Substance use (affects ability to adhere to outpatient antibiotic regimens)
• Living circumstances (relevant for outpatient vs. inpatient management decision)

Minimum Diagnostic Criteria to Screen for During History (CDC-Based)

1. Pelvic or lower abdominal pain
2. Cervical motion tenderness
3. Uterine or adnexal tenderness

• "No other cause for the pain can be identified" - Harrison's 22E (CDC criteria)

Distinguishing Features in History: Ovarian Cyst vs. PID

Key Points to Always Cover

• Pregnancy test - MUST exclude ectopic pregnancy in any woman of reproductive age presenting with pelvic pain (regardless of stated sexual activity) - Berek & Novak's
• Ovarian torsion is a surgical emergency: sudden-onset, severe unilateral pain with nausea - ask specifically
• In PID, complications to ask about include: tubo-ovarian abscess (TOA) - indicated by severe illness, mass on examination, failure to respond to antibiotics

Sources: Harrison's Principles of Internal Medicine 22E, p. 1148-1188 | Sabiston Textbook of Surgery, p. 2802 | Berek & Novak's Gynecology, p. 415-417

Risk Factor-Focused History Taking

OVARIAN CYST - Specific Questions to Ask

Ask to identify the type of cyst and risk of malignancy:

• "How old are you?" - Functional cysts (follicular, corpus luteum) are common in reproductive age. Any cyst in a post-menopausal woman is malignant until proven otherwise. Risk of malignant teratoma rises with age >45. - Tintinalli's Emergency Medicine

• "Are your periods regular?"
• "When was your last period?" - Irregular or absent periods suggest anovulation/PCOS, which predisposes to persistent follicular cysts

• "Do you have very painful periods?" (dysmenorrhoea)
• "Do you have pain during sex?" (deep dyspareunia)
• "Have you had difficulty getting pregnant?" - These three together are the classic endometriosis triad

• "Have you ever had fertility injections or IVF?" - Ovarian stimulation (gonadotrophins) is a direct risk factor for ovarian hyperstimulation syndrome (OHSS) and multiple cyst formation - Tintinalli's

• "Has anyone in your family had ovarian cancer, breast cancer, or bowel cancer?"
• "Do you know if you carry the BRCA gene?" - BRCA1/2 carriers have a markedly elevated ovarian malignancy risk - Sabiston Textbook of Surgery

• "Have you had an ultrasound before? What did it show?"
• Cysts >8 cm, solid, or multiloculated = worrisome; rapid growth = red flag for malignancy - Tintinalli's

PID - Specific Questions to Ask

Sexual history

• "Have you had more than one sexual partner recently?" - Multiple partners = #1 risk factor
• "Have you had a new partner in the last few months?"
• "Has your partner had any symptoms - discharge, burning when passing urine?"
• "Do you use condoms?" - No barrier contraception = higher STI risk

STI / PID history

• "Have you ever been diagnosed with chlamydia, gonorrhoea, or any other sexual infection?" - Prior STI is a strong independent risk factor
• "Have you had PID before?" - Previous PID is the single biggest predictor of recurrence; each episode multiplies the risk of infertility and ectopic pregnancy by 12-50% - Tintinalli's

Intrauterine procedures (iatrogenic risk)

• "Do you have a coil (IUD)? When was it put in?" - Risk is highest in the first 21 days after IUD insertion - Tintinalli's
• "Have you recently had a termination (abortion), D&C, or any procedure inside the womb?" - All are direct risk factors for ascending infection

Age

• "How old are you?" - PID is most common in adolescents and young adults (<25 years) - Harrison's 22E
• Younger age = higher-risk sexual behaviour + less likely to seek early treatment

Vaginal douching

• "Do you ever use products to wash inside the vagina?" - Frequent douching destroys the protective vaginal flora and degrades the cervical mucus barrier, allowing bacteria to ascend - Tintinalli's

Sexual abuse

• "Has anyone ever forced you into sexual activity?" - A sensitively asked question; history of sexual abuse is a recognised independent risk factor - Tintinalli's

Social/socioeconomic

• "Do you have easy access to healthcare?" - Lower socioeconomic status is associated with delayed presentation and higher severity

Quick Comparison: What to Ask and Why

Sources: Tintinalli's Emergency Medicine, Table 103-2 | Harrison's Principles of Internal Medicine 22E | Sabiston Textbook of Surgery