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1

Components of a gynae hx

Personal details

PC

Specific gynaecological questions

Past obstetric hx

Past medical hx

Systems r/v

DHx: allergies, penicillin and latex

FHx

Personal/Social hx

2

PC in G

SOCRATES

NOTEPAD

Impact on QoL

Previous consultations

Order multiple PCs in order of severity/impact on life

3

Menstrual questions in G Hx

FMP

How often, how many days from the first day of bleeding to the next first day?

How long does it last? (/28)

Is it regular or irregular

Heavy (number of pads, flooding, presence of clots)

Is it or the days leading up to it painful

IMB?

PCB?

Vaginal discharge- characterise

Does she experience premenstrual tension?

When was her LMP?

If post-menopausal, has there been PMB?

4

Sexual/contraceptive questiosn in G

Sexually active?

Painful- penetration (superficial dyspareunia) or deep inside (deep), during and or after (delayed)

What contraceptive does she use and has she used in the past?

5

Cervical smear questions in G

When was her last smear

Ever had an abnormal smear?

What was done?

6

Cervical screening

Every 3 years between 25 and 49

Every 5 years between 50 and 64

Not performed after 64 unless never screened or hx of recent abnormal tests

7

Urinary/prolapse questions in G

Frequency (normal is 4-7pd)

Nocturia

Urgency

Leak urine, including when asleep (nocturnal enuresis), if so how severe is it and with what is it associated (e.g. coughing, lifting/straining, urgency)

Dysuria?

Haematuria

Dragging sensation or feel a mass in or at the vagina?

8

Past obstetric hx in G

Have you ever been pregnant?

If yes ask about previous pregnancies in chronological order

Ask how infant was born, weight and how the infant is now. Name

Any major complications in pregnancy or labour?

9

PMHx in G

Previous gynaecological operations

Ask about DVT, DM, lung and CHD, HTN, jaundice etc as in other medical histories

10

Systems R/V in G

CV, Resp, Neuro. 

Specifically ask about urinary and GI symptoms

11

FHx in G

FHx of breast, ovarian carcinoma?

DM?

VTE

CHD

HTN

12

Personal/social history in G

Smoke

ETOH

MarriedStable relationship

Support at home?

Where does she live and what sort of accomodation

13

Allergies in G

Ask specifically about penicllin and latex

14

Abdo exam in G

General examination: seek the systemic effects of gynaecological problems and assess general health.

Appearance and weight. T. BP. Pulse and possible anaemia, jaundice or lymphadenopathy. 

Comfortably on back with head on pillow. Exposed from xiphisternum to pubic symphysis. 

EMPTY BLADDER

Inspect: scars, body hair distribution, irregularities, striae and hernias

Palpate: tenderness, palpate the abdomen generally looking for masses. Then palpate specifically looking for masses from above the umbilicus down to the pubic symphysis. If masses are present, do they arise from the pelvis (can you get below them)

 

Percuss: look for shifting dullness

 

Auscultate: BS

 

Vaginal Examination

 

Rectal examination

15

Vaginal examination in G

Privacy, explain, use bathroom. Chaperone- name documented in the notes. Use lubricating jelly. 

Inspect: vulva and vaginal orifices

Digital bimanual examination

Cusco's speculum examination

Sim's speculum examination

 

16

Digital bimanual exmaination

Assesses pelvic organs

Left hand on aboomen above the pubic symphysis and pushed down so the organs are palpated

Two fingers inserted into the vagina

Uterus: normally the size and shape of a small pear. Size, consistency, regularity, mobility, anteversion/retroversion and tenderness

Cervix: hard or irregular?

Adnexa: lateral to the uterus on either side. Tenderness and size and consistency of any amss assessed. Separate from the uterus

Pouch of Douglas: uterosacral ligaments should be palpable: even, irregular or tender, mass?

17

Cusco's speculum

Allows inspection of the cervix and vaginal walls. 

NB anteverted uterus.

Look for ulceration, spontaneous bleeding or irregularities.

Cervical smear

Slowly withdraw partly closing speculum to allow inspection of the vaginal walls to the introitus and rotate as retract

18

Sim's speculum

Allows better inspection of the vaginal walls and te prolapse.

Patient in left lateral position. 

19

Rectal examination

Appropriate if posterior wall prolapse, to distingusih between an enterocoele and a rectocoele and in assessing malignant cervical disease

May be necessary if a woman complains of cyclical rectal bleeding- ?rectovaginal endometriosis

20

What is thelarche and when does it begin?

 

Adrenarche?

 

Menarche

 

What controls secondary sexual characteristics?

Beginning of breast development: 9-11 y

 

Growth of pubic hair (11-12)

 

13y

 

Oestrogen

21

D1-4 mensturation

Endometrium is shed as hormonal support is withdrawn, myometrial contraction also occurs

22

D5-13 proliferative phase

GnRH stimulate LH and FSH which induce follicular growth

Follicle produces oestradiol and inhibin which suppress FSH. 

As oestradiol level rise and reach their maximum they cause a +ve feedback on the hypothalamus/pit and cause LH surge.

Ovulation occurs 36 hours after the LH surge

Oestradiol also promotes endometrial proliferation

23

D14-28 Luteal/secretory phase

Follicle becomes corpus luteum, produces oestradiol but relatively more progesterone, which peaks d21-28 

This induces secretory changes in hte endometrium. 

Towards the end of the luteal phase, the corpus luteum starts to fail if the egg hasn't been fertilised and oestradiol/progesterone levels fall. 

This decline in hormonal support causes the endometrium to break down, leading to menstruation and the restart of the cycle

24

What can be used to delay menstruation and why?

Continuous administration of exogenous progesterone as it maintains the secretory endometrium

25

Normal mensturation cut offs

Menarche <16y

Menopause >45y

Mensturation <8d

Blood loss <80ml

Cycle length 23-25

No IMB

26

Menorrhagia

Heavy menstrual bleeding

27

IMB

Bleeding between periods

28

Irregular periods

Periods outside of the range of 23-35d with a variability of >7d between the shortest and longest cycle

29

Secondary amenorrhoea

Periods stop for 6m or more.

30

Oligomenorrhoea

Irregular periods, >35d-6m