Clinical approach To

Gynaecological Patient(Part 1)

Prof. M.C.Bansal.
MBBS, MS. FICOG, MICOG
NIMS medical College ,Jaipur.
Founder Principal & Controller ;
Jhalawar Medical College And Hospital , Jhalawar.
Ex. Principal & controller;
Mahatma Gandhi Medical College And Hospital ,
Sitapur, Jaipur .
 Women patient should be greeted and made
comfortable before one starts interrogating.
Let her be sure and confident that her privacy is
ensured.
Her preference regarding the presence of her partner ,
parent or relative during history taking and clinical
examination should be asked for and accepted.
Woman herself comes or bring her daughter / daughter
in law or any other relative/ friend as patient to her
gynaecologist for variety of problems , both
gynaecological or non gynaecological, as she feels
comfortable and friendly with him or her.
There fore gynaecolgist is her a primary health care
taker; more or less a family physician.
 Getting elaborate information about her
problem will depend on her confidence in
doctor, opportunity for gynaecologist to
assess the patients general condition
,mood , ability and willingness to
communicate and variety of non verbal
clues.
Patient should be given enough time to
narrate her problem in her own words
before asking leading questions.
 Significant Points of History Taking
Age.
Residence rural / urban ; contact number / postal
address.
Assess her socioeconomic status/ marital
status .,educational back ground.
Chief Complaints in chronological order with
duration.
History of present Illness.
Menstrual History.
Gynaecological history.
Obstetrical history . Contraceptive history.
Sexual history.
Menopausal history in women > 40.
Significant Points of History Taking----
Medications/ resent surgical procedure done.
Personal habits smoking , alcohol ,
substance abuse .
Past medical and general surgical history.
Family History.
Dietary history.
Occupational history / exposure to any
occupational hazard .
Symptoms pertaining to other system/
organs.
 Common disorders by Age Group
Childhood: foreign body , vulvo-vaginitis, vaginal
discharge , intra vaginal tumor(cervical grapes
sarcoma,hydrocolpos , hemato colpos ), Ovarian
tumors ( teratomas, embryomas)
Adolescence: precocious/ delayed puberty ,
Menstrual disorders, dysmenorrhoea, PCOS, ovarian
germ cell tumors , uterovaginal anomalies.
Reproductive age : Menstrual irregularities, Fibroids ,
PID / STDs , benign lesions of female genital tract , CIN,
breast lumps and cancer , pregnancy related problems,
contraceptive use/their failure/ side effects.
Older Age: menopause related problems.,
malignancies of Cervix, endometrium , myometrium ,
ovary, vulva ,vagina and secondaries from distant
organs like breast/ stomach.
 Residence rural / urban ; contact number /
postal address
Knowing her residential address and contact
number will help in developing good repot
and good follow up.
Certain gynaecological problems are more
common in urban and industrialized town
dwellers like STDs , Problems due to repeat
MTPs, Endometriosis, ovarian tumors, PCOS
.
Rural folk is more likely to have problems
due to multiparity ---Utero vaginal prolapse
and late stages of malignancies etc.
 ground .

Womans and her husbands occupation and

education status give an idea about the socio
economical status of the family. Husband living
away for long duration on his job like truck driver
, military service may be contributory factor in
STDs , HIV, Infertility. Patients with poor family
back ground need advise to get help from
charity, NGOS and GOVT Health schemes.
Marital status :Unmarried, separated , women
with live in relation may have problems of STDs,
Unwanted Pregnancy.
 Chief Complaints in chronological order with duration.

Chief complaints / presenting symptoms should be

recorded first with point of time or the duration of onset .
Complaints should be noted in chronological order and
with patients priorities.
Duration and exact timing of onset of problem gives an
idea about it being acute or chronic and even acute
exacerbation of pre existing chronic illness.
It is important to ask when last she felt normal.
The complain which is more worrisome to patient should
always be addressed.
Help the patient to narrate the story by her own and if
needed some leading questions can be asked to clarify
and confirm her statements when she is in state of agony
or shocked.
 Common Presenting Complaints ----
Amenorrhoea : Primary / secondary; ask for h/o
D&C,MTP, TB , Ocs, Prolong lactation ,milk discharge
from nipples, anti psychotic drug therapy. Symptoms of
premature ovarainfailure. .
Abnormal vaginal bleeding . Detailed H/O menstruation
present and past., Rx taking and its response, Anti
coagulant therapy, irregular use of sex hormones / OCS,
purpura,retained RPOC,IUCD.
Dysmenorrhea- dull aching,spasmodic , day of onset
and relief in relation to MC / any medication taken.
Vaginal Discharge mucoid, watery, curd like thick
associated with itching , burning ,fishy/ foul smell or
blood staining.
Pelvic Pain localization : supra pubic, one of the iliac
fosse radiating / shifting to back, thigh or above
umbilicus ,its nature dull, heaviness, spasmodic,
bursting of organ , twisting.
 H/O Common Presenting
Complaints ----
Dyspareunia related to change of partner
,superficial at the introitus( begin with entry
Vaginismus/ tight introitus after perineal repair or
vaginoplasty.Deep in fornices in endometriosis
external, chocolate cysts , prolapsed ovaries in
POD ,RV RF uterus in adenomyosis.
Mass Felt per abdomen above SP. pregnant
uterus, fibroid uterus, ovarian cyst, omental cake
in malignancy of ovary , mesenteric cyst,
encysted tubercular ascitis, Hydroneprotic pelvic
Kidney, to mass, Pyo/ hematometra, chronic
ectopic with large haematocoele ,Appendicular
lump, retroperitoneal tumor arising in hollow of
sacrum and enlarging upwards etc.
 H/O Common Presenting Complaints ----
Mass descending per vagina: Isolated Cystocoele
and /or rectocoele, uterine prolapse ( congenital),
acquired develops in multifarious and elderly women
with 3rd degree / procedentia.
Inverted uterus , fibroid polyp, polypoidal
ectocervical carcinoma, placental polyp, long IUCD
Thread / descending down IUCD in the process of
expulsion , Molar conceptus ,forgotten vaginal
packing/swabs/tampons/ broken and retained piece
of condom(male/ female).
Urethral mucosal prolapsed , prolapsed hemorrhoids
and rectal polyp should also be thought of as patient
may think it to be from vagina.
 H/O Common Presenting Complaints --
Inability to conceive: age of couple,
profession of couple, 1st / 2nd marriage /
previous history of having child by any one
of both (With same / or another partner),
STD/ HIV / Pelvic Inflammation, frequency
and timing of coitus, premature
ejaculation by partner/ flor seminis.
Vaginismus/ dyspareunia,Detailed
Obstetric history ( abortion, D&E, MTP,
Sepsis etc.) any investigations/ treatment
for infertility and its out come.
 H/O Common Presenting
Complaints --
Genital Ulcer / Swelling : painfulherpes, primary
chencre , gonococal ; painless secondary / tertiary
syphilitic( gamma) lesion, grannuloma venerum,
genital warts, condyloma Lata, icthymosis of vulva,
tubercular ulcer, pagets disease, rodent ulcer ,
carcinomatous ulcer or sweliing , bartholin cyst,
fibroma, lipoma, neurofibroma,dermoid cyst,
elephantitis, insect bite, painful boils. Bartholin
abscess etc.
Pruritus vulva---Itching at vulva may be part of
systemic disease like diabetes, obstructed Jaundice,
drugs, local creams , candidiasis, pin worm infestation
or ca Vulva.
 H/O Common Presenting
Complaints --
Urinary Symptoms--- burning micturation with or with
out fever , dysurea, retention, incontinence ( stress/
true / urge ) loin pain (dull . Colic ).,may be associated
in cases of utero vaginal prolapse, myomas.
Malignancy and pelvic mass. Burning at vulva may be
due to trichomonial vaginitis, neuropathy .
Bowel symptoms : diarrhea constipation as side of
drug prescribed for gynaecological or non
gynaecological problems. Constipation or feeling of
incomplete evacuation in presence of large rectocele/
enterocele, painful defecation(tenesmus) in cases of
collection in POD (pus/ blood) . Fecal incontenance in
complete perineal tear / rectovaginal fistula.
 H/o Presenting complaints------
Weight gain / Weight loss: weight gain may be
due to hypothyroidism, ocps, development of
obesity/ type 2 diabetes / PPCOD , Cushing
syndrome --- leading to menstrual abnormality
and infertility.
weight loss indicate hyperthyroidism ,
anorexia , tuberculosis , malignancy / chronic ill
health .
Each presenting complaint should be further
detailed in terms of time/ mode of onsetand
duration . , associated symptoms , relation to
food, vomit , change in bladder and bowel
habits, fever and fatigue.
 Menstrual History
Age at menarche , characteristics of the
menstrual cycle like duration of
bleeding , pattern of bleeding ,
regularity , volume , frequency of
menstrual cycle, premenstrual
symptoms, painless or painful. Early
menarche and late menopause are risk
factorCycle
forLength
endometrial cancer.
28 days ( 21-35 days )
Characteristics of
Mean Menstrual blood
loss
normal
30 -60 ml menstrual

cycleDuration
are : 2-7 days
Pain Mild tolerable pain in
sacral / supra pubic
region
 Volume of blood flow is assessed by number of pads /
tampons used whether the pads are fully/ partially
soaked , presence of clots. It can be better assessed by
pictorial Soaked -
Pad Area charts- 1st day 2nd 3rd 4th 5th 6th 7t
Day Day Day day Day h

D
a
y
// / /
X1
X /// //
5
///
X20
Daily 89(<1oo) Normal blood loss
Points
Tampons X1 // /
x5 ///
X 15 //////
 Blood Flow calculation
The chart consists of pads and tampons that are soaked lightly,
moderately or heavily.

The score is calculated by multiplying the number of pads by a factor of 1

, 5, or 20 for light, moderate or heavily soaking .

Factor 1, 5, 15 are used similarly in case of tampons respectively.

Clots are assigned a score 1 for clot size of 1 penny, 5 for 50 pennies and
flooding.
A total score of > 100 indicates excessive bleeding.

Menstrual blood is usually fluid in nature as clots are lysed by

fibrinolytics. Presence of clots indicate more than normal and rapid flow.

Menstrual history of past and present ( since onset of problem ) should

be taken in same way.

LMP should always be noted as to rule out pregnancy , decide the day of
many investigations and operative procedure ( in proliferative phase /
post ovulatory phase of menstrual cycle.
 Gynaecological History
Past history of gynaecological problem is
important., like vaginal infection ,pelvic
pain , myomas , ovarian cyst,
endometriosis, PID, STD and drug /
operative treatment given . Present
problem may be recurrence /complication
or squeal of previous disease.
Previous investigations ,treatment , event
during sickness and operative notes if
available should always be scrutinized.
 Obstetrical History
Age of marriage period of marital relationship when dealing with
infertility .
Parity, Number of miscarriage, IUFD , neonatal death
( obstetrical / Neonatal cause? )., MTP , molar and ectopic
pregnancy in order of sequence of events.
H/o each pregnancy--- includes any problem(obstetrical ,medical /
surgical ) arising in 1st/2ndr or 3rd trimester ; any treatment given
and its and response , ended as Ectopic/ abortion/ PROM, preterm
/term or post term pregnancy. Mode of delivery(sp N VAG?
I9nstrumental / LSCS delivery ?), fetal out come-- IUGR/ IUFD
/Small for date / premature / normal weight/ over weight baby .
Any resuscitation problem / Apgar score/ Usher score /neonatal
problems which are likely to be repeatative in nature.
Thecae all information can be collected from ANC card MCH card
and hospital records at which last delivery was managed.
History of postnatal events like fever , sepsis, DVT, convulsions,
wound infection , persistent High BP/ Glycosurea /proteinuriaetc.
 Co Relation OF obstetrical History and
present Gynaecological disease
Null parity---Endometriosis, fibroids, cancer
endometrium , breast cancer .
Multi parityAdenomyosis, prolapse, cervical
cancer , ovarian cancer , urinary incontinence,
DUB due to enlarged uterine size.
Recent delivery / miscarriage sepsis. Chronic
PID / Pelvic Pain /RPOC, secondary infertility,
cervical erosion/ cervical ectropia , perineal tears,
chronic Iron deficiency anaemia, intra uterine
synecae , mastitis/ breast abscess.
Molar pregnancy Gestational Trophoblastic
neoplasia.
 Details of Contraceptive
used
Abnormal uterine bleeding/ dysmenorrhoea may be
related to IUCD / OCS .
Galactorrhoea- amenorrhea syndrome due to prolong use
of combined OCs, they also protect against ovarian and
endometrial carcinoma if use for > 5years.May increase
risk of cancer cervix.
Tubal ligation may be responsible for DUB due to disturbed
ovarian vascularity / pelvic congestion syndrome.
Levonorgestrol containing IUCD (LUG-IUS) causes
amenorrhea.
Patient taking Inject able contraceptive can develop
osteoporosis and menopause like symptoms.
Barrier contraceptives protect against STD, HIV .HPV and
CIN--- decreased cancer cervix.
 Sexual History
Women often feel sigh in giving details regarding their sex
life. Gynecologist by now must have earned her confidence
and faith; can ask her comfortably regarding timing ,
frequency , use of contraception, veganism's, lack of
orgasm, dyspareunia, vaginal dryness and immediate out
flow of semen from vagina.
History about sex life of partner and his habits regarding

sex play.
Vaginismus may due to tight introitus or of

psychological origin. While lax introitus due to perineal

tears/
Prolapse may also be concerned with sexual satisfication.
H/o Multiple partner / premarital / extra marital sex per
chance by any of life partner may be contributory factor in
occurrence of STDs, HIV,/ and infertility/ bartholin cyst/
abscess ,CIN and cancer cervix ( HPV infection ) , PID , TO
masses (hydrosalpinx / pyosalpinx.)
 Menopausal History
In peri menopausal / post menopausal aged
women ;it is useful to know age of onset of
menopause any preceding symptoms like hot
flashes, night sweating , palpitation, dryness of
vagina, decreased sex desire ,sleep
disturbances, abnormal ,acyclic bleeding per
vagina , post coital spotting , backache,
incontinence of urine.
H/o hormone replacement therapy , daily
Calcium intake in diet / tab, exercise and
exposure to sun light .
Family H/O diabetes/ BP/Stroke/ CAD,
osteoporosis ,hip fractures, Cancer uterus and
ovary.
 History of taking Drugs
Medication For-
>obesity.
>Diabetes.
>Hypertension, cardiac disease, anticoagulants.
>Hormone replacement therapy(in detail) Estrogen/SERMS /
E+P combination(local creams/gels /patch/implants or oral
tabs).
> NSAIDs / Corticosteroids for joint pains or other medical
disease.
> Drugs for other gynaecological / medical disorder .
> Drugs which can cause amenorrhoea/ galactorrhoea/ blood
spotting per vagina.
> prolong use of vaginal pessary for procedentiadecubitus
ulcer ----carcinomatous changes .
> any habituation to drugs sleeping pill / drinks and smoking .
>Hormones should be prescribed cautiously to patient with
diabetes/ hypertension/ obesity/ DVT / thyroid/ liver and kidney
disorders.
 History of personal Habits
Smoking since how long and
number /day?
Alcohol-- since how long and amount
of liquor /day?
Addiction to cocaine, marrhijuna,
tobacco chewing , sleeping pills ,
crude opium etc.
Anti psychotic drugs for depression.
 Past medical & surgical History
women with medical disease like diabetes, BP, CAD, obesity
are prone to develop uterine cancer., DVT /PE are not
uncommon to develop during their post operative period .
Asthama , chronic lung disease , constipation increase intra
abdominal pressure to develop uterine prolapse.
In young girls obesity irregular periods, PCOD, Acne, hirsutism ,
metabolic syndrome .
Women with thyroid disorder are prone to have menstrual
abnormality weight gain, infertility and miscarriages.
Adolescent with coagulation disorder and thrombocytopenia
can present with DUB.
GI disorder like IBS , intestinal TB, crohns disease may present
as chronic lower abdominal pain.
Previous abdominal / pelvic surgery may cause intra abdominal
adhesion --- chronic abdominal pain , infertility, incisinal hernia.
Male partner operated for inguino-scrotal disorder may be
associated with disturbed testicular function ---impotence /
infertility .
 Family History
Women with family H/O following; may develop--
Endometrial, breast , ovarian have a familial
predisposition.
Breast / ovarian cancer / endometrial cancer
syndrome occur in women having BRCA mutation
carriers in family.
women with family background of diabetes ,
hypertension / obesity / CAD are prone to ovarian
and endometrial cancer and need evaluation in
peri and post menopausal period.
Androgen insensitivity syndrome and other
chromosomal aberrations ( turner, noon s
syndrome )causing amenorrhea are also familial.
 Occupational History
Male occupation , drivers , conductors, factory
workers with exposure to heat / chemicals are
prone to have oligo / azoospermia ---
infertility.
Women with Multiple sex partner / sex
workers and those on long stays away from
life partner are prone to have STD/ HIV/ HPV
--- infertility and ca cervix.
Women exposed to radiations/ anesthetic or
other chemical and drugs are prone to
develop cancers / infertility , habitual
abortions and fetal malformations.
Symptoms pertaining to other organ systems.
Cardiovascular/ pulmonary / liver and kidney dysfunction have
adverse effect on type of anesthesia and surgical procedure.
Hypothalamo-pituitary , thyroid, adrenal disorders may cause
menstrual abnormalities and infertility .
Drugs used for psychological / neurological problems may interact
with sex hormones an modulate their effect and tolerance.
Lower GIT /uteri vasical disease may come as chronic pelvic
pain similar to PID.
GIT and Uriary tract symptoms may also be due to gynacological
diseases like endometriosis, cancer extending to pelvic organs,
UV prolapse.
Often women with depression / anxiety/ cancer phobia often
present as pelvic pain chronic vaginal discharge and dyspareunia
breast tenderness or lump ,which may be present in menopausal
women too.
genital prolapse may be part of Generalized visceroptosi due to
neuro -muscular disorder.
OCS therapy may modify the dose effective of tubercular drugs
like rifampicin.
 After taking detailed history patient is
Thoroughly and gentaly examined ; using
general principals of clinical examination
> Inspection .
> Palpation .
> percussion ( when and where required ).
> auscultation (when and where required)
.It should be done as described in details in
next lecture Titled;
Clinical approach To
Gynaecological Patient(Part-2)