Taking a sensitive and structured gynaecological history is essential for accurate diagnosis, effective management, and building patient trust. Confidentiality, empathy, and patient-centred language are vital.

👩‍⚕️ Roles in Gynaecological History Taking

Introduction & Role: Introduce yourself, explain your role.
Consent: Obtain verbal consent before starting.
Rapport: Ensure privacy, respect, and a supportive environment.

🟢 Opening Questions

Menstrual History: “When was your last period? Are your cycles regular?”
Sexual/Contraception: “Are you sexually active? What contraception do you use?”
Pregnancy Risk: “Is there any chance you could be pregnant?”
STI History: “Have you had an STI or recent screening?”
Obstetric History: “Have you ever been pregnant or had any pregnancy complications?”

🧾 Background Information

Demographics: Name, age, DOB.
Marital/Relationship status: Single, married, widowed, divorced, separated.

🏠 Social Information

Occupation: Patient’s and partner’s jobs.
Living conditions: Housing, support at home.
Work stress/exposures.
Substance use: Smoking, alcohol, drugs.
Safeguarding: Domestic violence, coercion, mental health concerns.

❗ Chief Complaints & Symptom Assessment

Pain: Site, onset, character, duration, severity, timing, aggravating/relieving factors.
Abnormal Bleeding: Intermenstrual, postcoital, menorrhagia, postmenopausal (red flag).
Infection Symptoms: Fever, pelvic pain, recurrent UTIs/vaginitis.
Discharge: Colour, consistency, odour, volume; associated irritation/itching.

📚 Past Medical History

Medications: OCP, HRT, anticoagulants, antibiotics, others.
Medical/Surgical History: Previous illnesses, surgeries, admissions.
Family History: Relevant cancers (ovarian, breast, colon), endometriosis, clotting disorders.

🔎 Specific Questions

Sexual History: Dyspareunia, libido, contraception, STI risk.
Obstetric History: GTPAL (Gravida, Term, Preterm, Abortions, Living). Pregnancy outcomes, complications, child health.
Menstrual History: Menarche age, cycle length, flow, dysmenorrhoea, LMP, smear results.
Vaginal Discharge: Nature, associated itch/irritation.
Urinary & Bowel Function: Frequency, urgency, incontinence, constipation, rectal bleeding.

💡 Clinical Pearls

Always ask sensitively about red flags: postmenopausal bleeding, intermenstrual bleeding, rapid abdominal distension.
Use OLDCARTS for pain: Onset, Location, Duration, Character, Aggravating, Relieving, Timing, Severity.
OSCE Tip: Offer a chaperone if examination is anticipated.

✅ Conclusion

A comprehensive gynaecological history requires a structured, sensitive approach covering menstrual, sexual, obstetric, medical, and social domains. Attention to safeguarding, fertility wishes, and red-flag symptoms ensures safe and holistic care.

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Gynaecological History Taking

📖 Introduction