Clinical Approach to Gynecological Patient (part-1)
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
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 patient‘s general condition
,mood , ability and willingness to
communicate and variety of non verbal
Patient should be given enough time to
narrate her problem in her own words
before asking leading questions.
Residence– rural / urban ; contact number / postal
Assess her socioeconomic status/ marital status
.,educational back ground.
Chief Complaints in chronological order with duration.
History of present Illness.
Obstetrical history . Contraceptive history.
Menopausal history in women > 40.
Medications/ resent surgical procedure done.
Personal habits –smoking , alcohol ,
substance abuse .
Past medical and general surgical history.
Occupational history / exposure to any
occupational hazard .
Symptoms pertaining to other system/
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.
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.
Woman‘s and her husband‘s 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 / presenting symptoms should be
recorded first with point of time or the duration of
Complaints should be noted in chronological order and
with patient‘s 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.
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
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.
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.
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
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.
Genital Ulcer / Swelling : painful—herpes, 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.
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.
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.
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 factor
for endometrial cancer. Characteristics of
normal menstrual cycle are :Cycle Length 28 days ( 21-35 days )
Mean Menstrual blood loss 30 -60 ml
Duration 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 charts--
Pad Area Soaked 1st day 2nd Day 3rd
X1 // / /
X 5 /// //
89(<1oo) Normal blood loss
Tampons X1 // /
X 15 //////
Daily points 108 Excessive blood loss
The chart consists of pads and tampons that are soaked lightly, moderately or
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
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.
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.
Age of marriage –period of marital relationship when dealing with
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.
Null parity---Endometriosis, fibroids, cancer
endometrium , breast cancer .
Multi parity—Adenomyosis, 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
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
Levonorgestrol containing IUCD (LUG-IUS) causes
Patient taking Inject able contraceptive can develop
osteoporosis and menopause like symptoms.
Barrier contraceptives protect against STD, HIV .HPV
and CIN--- decreased cancer cervix.
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
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.)
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
>Hypertension, cardiac disease, anticoagulants.
>Hormone replacement therapy(in detail) –Estrogen/SERMS /
E+P combination(local creams/gels /patch/implants or oral
> NSAIDs / Corticosteroids for joint pains or other medical
> Drugs for other gynaecological / medical disorder .
> Drugs which can cause amenorrhoea/ galactorrhoea/ blood
spotting per vagina.
> prolong use of vaginal pessary for procedentia—decubitus
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
Smoking – since how long and number
Alcohol-- since how long and amount of
Addiction to cocaine, marrhijuna, tobacco
chewing , sleeping pills , crude opium etc.
Anti psychotic drugs for depression.
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, crohn‘s disease may
present as chronic lower abdominal pain.
Previous abdominal / pelvic surgery may cause intra
abdominal adhesion --- chronic abdominal pain , infertility,
Male partner operated for inguino-scrotal disorder may be
associated with disturbed testicular function ---impotence /
Women with family H/O following; may develop--
Endometrial, breast , ovarian have a familial
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.
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.
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
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