Max Brinsmead MB BS PhD May 2015

 Listening to the patient tell her story  Generating a hypothesis  Testing the hypothesis ▪ By interrogation ▪ 50 % ▪ By examination ▪ 10% ▪ By selective testing ▪ 40%  If at first you don’t succeed...  Go back and listen to the patient

 Reproductive tract dysfunction  Dysmenorrhoea  Dysfunctional uterine bleeding  Functional ovarian cysts  Endometriosis  Pregnancy  Miscarriage  Ectopic  Pregnancy-related disease

 Reproductive Tract Infections  Vaginitis  Pelvic inflammatory disease  Reproductive Tract Cancer  Cervix  Uterus - endometrium  Ovaries  Benign tumours  Fibroids  Polyps of cervix and endometrium  Ovarian  Uterovaginal Prolapse  Urinary dysfunction  Anorectal dysfunction

 Psychosexual  Pelvic Pain  Dyspareunia/ Vaginismus  Sexual Assault  Libido  Homosexuality (not usually a problem for the gynaecologist)  Iatrogenic  Arising from contraception/HRT  Arising from other drugs  Other Diseases  With pelvic manifestations  Infertility  Male

 Menstrual history  Contraceptive history  Sexual history  Past gynaecological and other medical history  Drug history  Bladder and Bowel function

 Menarche  Cycle  Usually expressed as days bleeding/cycle length  Last menstrual period (LMP)  Intermenstrual bleeding (IMB)  Postcoital bleeding (PCB)  Postmenopausal bleeding (PMB)  Menstrual pain

 How often do your periods come  From the beginning of one period to the beginning of the next  What do you mean by regular  Do they “come early” or do they “come late”  How much early, how late  Do you get any bleeding between your periods  When does it occur in the cycle  Do you know of anything that brings this on  Does your period start as a full flow  How many days of “mucking about”  When was your last normal period  First day of the last period  Not the date of the missed period

 For how long do you have a period  How many heavy days  How many light days  What do you call heavy  How many pads or tampons  How often do you change  Do you change at night  How often  How many nights  Do you pass clots  How big  How often  Do your periods interfere with your life  Have you had any “accidents”

Used loosely means excessive menstrual loss...

 Escapes from normal menstrual protection  Large clots – frequently  Changing at night more than once  Lasts longer than 7 days “full flow”  Interferes with normal life or duties  Causes iron deficiency (anaemia)  Other causes excluded

 Menorrhagia  Excessive menstrual loss at regular intervals  Metrorrhagia  Frequent and irregular menstrual loss  Polymenorrhoea  Regular cycles at <21 days  Oligomenorrhoea  Infrequent menstruation (>35 days)  Intermenstrual Bleeding  B leeding between menstrual periods  Requires careful questioning

 Do you get pain with your periods  Is this the same as its always been  If changing with time how and when  Which is the worse day for pain  What do you do for the pain  Analgesia used. How many tablets Does it help  Does the pain interfere with your life. Your sleep  Describe the pain  Nature and location. Aggravating factors  Pain with intercourse  Frequency  Nature and location

 Choose your words carefully, sometimes with preamble  How long have you been in your current relationship  Is sexual intercourse occurring  Have you ever been in a relationship  When was the last relationship  How many partners have you had in (period of time)  or before your current relationship  What does you or your partner do to avoid pregnancy  Does your partner travel  or spend nights away from home  or have other sexual partners

 Any other serious illnesses. Any operations  Any gynaecological operations  on your tubes, ovaries or uterus  Any vaginal surgery  Any curettes or keyhole surgery  Any treatment to the cervix for pre cancer changes  What was done in those operations  What were you told after  Do you have regular Pap tests  When was the last or where was it done  What was the result  Has there ever been any abnormality  How many have you had in (period of time)  Have you ever been treated for inflammation of the pelvis, tubes or for a sexually transmitted disease?  Did you have any trouble getting pregnant?

 Any infertility treatment(s)  Number of pregnancies (G) and births (P)  Gravida = number of pregnancies  Para = births after 20w (and twins =1)  T= termination of pregnancy  A= miscarriage E=ectopic  Birthweights and mode of delivery  Spontaneous or assisted vaginal birth  Birth trauma  Pregnancy complications

 Are you on any drugs or medications  Any hormones  The pill, injections or implants  Patches or hormone creams  Vaginal pessaries or creams  Details of the drug, dose and dates can be very important  Any vitamins, minerals, supplements or herbal remedies?  Do you smoke?

 Do you get up at night to pass urine  Do you have to get there in a hurry  Ever wet before you get there  How long can you hold on during the day  Do you ever wet  If you cough or sneeze  A little or a lot  Do you have any difficulty emptying your bladder  or getting started  Do you have good stream  Any bladder infections  Any difficulty getting your bowels emptied  What happens when you strain  Can you control your wind  How about a loose bowel motion?

 The most important calculation is the number of months that the woman has been exposed to the possibility of pregnancy but has not conceived  This may not be the same as the couple’s view of how long they have been “trying”  Take a careful “contraceptive history”  Other useful questions  Have you ever been pregnant  Have you ever fathered a pregnancy (in any other relationship or tried)  How often is intercourse occurring  Any (intercourse) problems?

 Read the companion text to this Powerpoint : 