Principles before starting

1. Introduce yourself, confirm the patient’s name, age, and preferred form of address.
2. Ensure privacy, use a calm non-judgmental manner, and explain that some questions are personal but clinically relevant.
3. Obtain consent to take the history. Offer a professional chaperone, especially if an examination may follow.
4. Ask whether the patient would like anyone present, and whether it is safe to discuss sensitive matters privately.
5. Begin open-endedly:
   “What has brought you in today?”
   Do not interrupt early. Then clarify with focused questions.
6. Use ICE: ideas, concerns, and expectations. A sensitive, structured approach is recommended for gynaecological histories, including direct but respectful questioning about sexual and reproductive health, as described in this gynaecological history guide.

1. Core history for every O&G patient

A. Presenting complaint

• Main symptom(s) and duration
• History of presenting complaint using symptom analysis:
  • Onset, course, severity
  • Site and radiation of pain
  • Character and timing
  • Aggravating/relieving factors
  • Associated symptoms
  • Effect on daily life
• Specifically clarify:
  • Vaginal bleeding
  • Vaginal discharge or offensive smell
  • Lower abdominal or pelvic pain
  • Urinary symptoms
  • Bowel symptoms
  • Fever, vomiting, dizziness, fainting
  • Reduced fetal movements, contractions, or fluid loss if pregnant

B. Past medical and surgical history

• Hypertension, diabetes, thyroid disease, epilepsy, asthma
• Thromboembolism or clotting disorder
• Heart, renal, liver, autoimmune, or psychiatric illness
• Previous abdominal, pelvic, cervical, uterine, or ovarian surgery
• Any anaesthetic complications

C. Drug and allergy history

• Prescribed medicines, over-the-counter drugs, herbal remedies
• Anticoagulants, antiepileptics, insulin, antihypertensives
• Folic acid, iron, vitamin D in pregnancy
• Drug and latex allergies, and the reaction caused

D. Family history

• Venous thromboembolism
• Hypertension, diabetes
• Breast, ovarian, endometrial, colorectal cancers
• Recurrent miscarriage, congenital anomalies, inherited conditions

E. Social history

• Smoking, alcohol, recreational drugs
• Occupation and support at home
• Diet and exercise
• Safeguarding: ask sensitively about feeling safe at home, coercion, and intimate-partner violence when appropriate.

2. Obstetric history

• Gravida (G): total number of pregnancies, including the current pregnancy.
• Para (P): previous pregnancies reaching viability, often recorded as term-preterm-abortion-living children depending on local practice.

A. Current pregnancy

Dating and antenatal care

• First day of the last menstrual period (LMP)
• Estimated date of delivery (EDD)
• Gestational age today
• Was the pregnancy planned?
• Where is she receiving antenatal care?
• Booking visit, dating scan, anomaly scan, and results
• Any identified maternal or fetal risks

Symptoms in the current pregnancy

• Vaginal bleeding
• Abdominal pain
• Leakage of fluid
• Uterine tightenings or contractions
• Fetal movements:
  • When first felt
  • Whether movements are normal for her baby
  • Any reduction or cessation
• Headache, visual disturbance, right upper abdominal/epigastric pain, sudden swelling: possible pre-eclampsia symptoms
• Nausea, vomiting, pruritus, fever
• Dysuria, frequency, loin pain
• Breathlessness, chest pain, unilateral leg swelling

Pregnancy complications

• Hypertension or pre-eclampsia
• Gestational diabetes
• Anaemia
• Thrombosis
• Placenta praevia, placental abruption
• Fetal growth restriction or reduced movements
• Multiple pregnancy
• Infections
• RhD status and anti-D prophylaxis, where relevant
• Admissions, investigations, medications, and planned induction or caesarean birth

Antenatal screening

• Blood group and antibody screen
• Infection screening
• Genetic or chromosomal screening and results
• Cervical screening status, if relevant
• Vaccinations in pregnancy according to local policy

B. Previous obstetric history

• Previous caesarean section: indication, uterine incision if known, complications
• Shoulder dystocia or severe perineal tear
• Preterm birth
• Recurrent miscarriage or ectopic pregnancy
• Stillbirth or neonatal death
• Postpartum haemorrhage
• Postnatal depression or psychosis

C. Gynaecological and sexual history in an obstetric patient

• Menstrual pattern before pregnancy
• Fibroids, endometriosis, PCOS, ovarian cysts
• Cervical procedures such as LLETZ/cone biopsy
• STIs or pelvic inflammatory disease
• Fertility treatment or assisted conception
• Contraception before conception
• Sexual health and safety, only when relevant and with sensitivity

3. Gynaecological history

A. Menstrual history

• Age at menarche
• LMP
• Cycle frequency and regularity
• Duration of bleeding
• Amount of loss:
  • Number of pads/tampons
  • Flooding, clots, changing protection overnight
• Intermenstrual bleeding
• Postcoital bleeding
• Dysmenorrhoea:
  • Timing, severity, effect on work/school, response to analgesia
• Menopause:
  • Age at menopause
  • Any postmenopausal bleeding
  • Hormone replacement therapy

B. Presenting gynaecological symptoms

Pelvic or abdominal pain

• Site, onset, severity, character, radiation
• Cyclical or non-cyclical
• Relation to menstruation, intercourse, urination, or defecation
• Associated bleeding, fever, discharge, nausea/vomiting
• Possibility of pregnancy, ectopic pregnancy, torsion, or infection when clinically appropriate

Vaginal bleeding

• Heavy menstrual bleeding
• Intermenstrual or postcoital bleeding
• Bleeding in pregnancy
• Postmenopausal bleeding
• Clots, flooding, anaemia symptoms, pregnancy possibility

Vaginal discharge

• Colour, amount, odour, consistency
• Itching, soreness, dysuria, dyspareunia
• New sexual partner or possible STI exposure
• Fever or pelvic pain suggesting upper genital tract infection

Prolapse or urinary symptoms

• Vaginal lump, heaviness, “something coming down”
• Stress or urge urinary incontinence
• Dysuria, frequency, nocturia, incomplete emptying
• Recurrent urinary tract infection

Fertility concerns

• Duration of trying to conceive
• Frequency and timing of intercourse
• Previous pregnancies with current or prior partners
• Menstrual regularity and ovulation symptoms
• Previous pelvic infection, surgery, endometriosis, or chemotherapy
• Partner history where appropriate

C. Obstetric history

D. Contraceptive history

• Current and previous contraception
• Satisfaction, adherence, adverse effects, failures
• Emergency contraception use
• Pregnancy intentions:
  “Would you like to become pregnant now, in the next year, later, or not at all?”

E. Sexual history

“I need to ask a few questions about sexual health because they may be relevant. Is that okay?”

• Sexually active currently?
• Partners: use neutral wording such as “Do you have sex with men, women, or people of another gender?”
• New or multiple partners
• Condom use
• Pain during intercourse, bleeding after intercourse
• Previous STIs, testing, and treatment
• Risk of pregnancy
• Any sexual coercion, assault, or feeling unsafe

F. Cervical screening and breast history

• Date and result of last cervical screening test
• Previous abnormal tests, colposcopy, LLETZ, or cone biopsy
• Breast lumps, nipple discharge, skin changes
• Breast cancer family history

4. Closing the history

1. Summarise the key points aloud.
2. Ask: “Is there anything else you think may be important?”
3. Check ICE:
   • “What do you think may be causing this?”
   • “What worries you most?”
   • “What were you hoping we could do today?”
4. Explain the next step, such as vital signs, urine pregnancy test, abdominal examination, speculum/bimanual examination, fetal assessment, blood tests, ultrasound, or senior review.
5. Obtain specific consent before any intimate examination, explain what it involves, offer a chaperone, and allow the patient to stop at any time.

Fast bedside checklist

Red flags requiring urgent escalation

• Pregnancy with pain and bleeding, syncope, or shoulder-tip pain
• Heavy vaginal bleeding with haemodynamic symptoms
• Fever with pelvic pain or offensive discharge
• Reduced or absent fetal movements
• Severe headache, visual symptoms, epigastric/right upper quadrant pain in pregnancy
• Labour symptoms, rupture of membranes, or bleeding before term
• Postmenopausal bleeding