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.
 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.
 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.
 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.
 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 / 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.
 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.
 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
vagina.
 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 : 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.
 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
Cycle Length of normal
28 daysmenstrual
( 21-35 days ) cycle
are : Mean Menstrual blood 30 -60 ml
loss
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
Pad Area- Soaked
charts- 1st day 2nd Day 3rd 4th 5th 6th 7th
Day Day day Day D
ay

X1 // / /

X5 /// //

X20 ///

Daily Points 89(<1oo) Normal blood loss

Tampons X1 // /

x5 ///
X 15 //////
Daily points 108 Excessive blood loss
 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.
 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
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.
 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.
 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.
 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.)
 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.
 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 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
kidney disorders.
 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.
 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 .
 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.
 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
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)