Components of a gynae hx
Specific gynaecological questions
Past obstetric hx
Past medical hx
DHx: allergies, penicillin and latex
PC in G
Impact on QoL
Order multiple PCs in order of severity/impact on life
Menstrual questions in G Hx
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
Vaginal discharge- characterise
Does she experience premenstrual tension?
When was her LMP?
If post-menopausal, has there been PMB?
Sexual/contraceptive questiosn in G
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?
Cervical smear questions in G
When was her last smear
Ever had an abnormal smear?
What was done?
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
Urinary/prolapse questions in G
Frequency (normal is 4-7pd)
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)
Dragging sensation or feel a mass in or at the vagina?
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?
PMHx in G
Previous gynaecological operations
Ask about DVT, DM, lung and CHD, HTN, jaundice etc as in other medical histories
Systems R/V in G
CV, Resp, Neuro.
Specifically ask about urinary and GI symptoms
FHx in G
FHx of breast, ovarian carcinoma?
Personal/social history in G
Support at home?
Where does she live and what sort of accomodation
Allergies in G
Ask specifically about penicllin and latex
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.
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
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
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?
Allows inspection of the cervix and vaginal walls.
NB anteverted uterus.
Look for ulceration, spontaneous bleeding or irregularities.
Slowly withdraw partly closing speculum to allow inspection of the vaginal walls to the introitus and rotate as retract
Allows better inspection of the vaginal walls and te prolapse.
Patient in left lateral position.
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
What is thelarche and when does it begin?
What controls secondary sexual characteristics?
Beginning of breast development: 9-11 y
Growth of pubic hair (11-12)
Endometrium is shed as hormonal support is withdrawn, myometrial contraction also occurs
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
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
What can be used to delay menstruation and why?
Continuous administration of exogenous progesterone as it maintains the secretory endometrium
Normal mensturation cut offs
Blood loss <80ml
Cycle length 23-25
Heavy menstrual bleeding
Bleeding between periods
Periods outside of the range of 23-35d with a variability of >7d between the shortest and longest cycle
Periods stop for 6m or more.
Irregular periods, >35d-6m