What symptoms should be asked about when clerking a gynecology case, considering the patient's age, reproductive history, and medical history, including menstrual irregularities, vaginal discharge, pelvic pain, and sexual history?

Essential Symptoms to Assess When Clerking a Gynecology Case

When clerking a gynecology case, systematically inquire about menstrual history, vaginal discharge characteristics, pelvic pain patterns, sexual history including dyspareunia, urinary symptoms, and constitutional symptoms, as these form the foundation for diagnosing the vast majority of gynecologic conditions. 1

Menstrual History (Critical Foundation)

• Document cycle regularity over at least 6 months: Ask specifically about cycle length, with polymenorrhea defined as <23 days, oligomenorrhea as >35 days, and amenorrhea as no bleeding for >6 months 2
• Quantify bleeding patterns: Heavy menstrual bleeding, intermenstrual bleeding, and postcoital bleeding are red flags requiring targeted investigation 1
• Assess dysmenorrhea severity: Determine if pain is responsive to NSAIDs, as unresponsive dysmenorrhea warrants pelvic examination and further workup 2, 1
• Age at menarche and last menstrual period: Essential for assessing pubertal development in adolescents and identifying postmenopausal bleeding, which mandates endometrial evaluation 2

Vaginal Discharge and Bleeding

• Characterize discharge: Color, consistency, odor, and associated symptoms (pruritus, burning) help differentiate infectious from non-infectious causes 2
• Postmenopausal bleeding: Any vaginal bleeding after menopause is abnormal and requires urgent evaluation for endometrial pathology 2, 1
• Abnormal bleeding patterns: Distinguish between anovulatory bleeding (irregular, unpredictable) and anatomic causes (fibroids, polyps) 2, 3

Pelvic Pain Assessment (Location and Timing Matter)

• Acute versus chronic: Pain lasting >6 months defines chronic pelvic pain and suggests different etiologies than acute presentations 2, 4
• Location specificity: Deep pelvic pain suggests intraperitoneal pathology (endometriosis, adhesions, pelvic inflammatory disease), while perineal/vulvar pain points to vulvodynia, vaginal atrophy, or pelvic floor dysfunction 2, 4
• Cyclical versus non-cyclical: Cyclical pain strongly suggests endometriosis or adenomyosis, while non-cyclical pain has broader differential 4
• Associated symptoms: Fever and pain suggest pelvic inflammatory disease or tubo-ovarian abscess; sudden severe pain with nausea suggests adnexal torsion or ruptured cyst 5, 6, 7

Sexual and Reproductive History

• Sexual activity status: Determines STI risk and need for contraception counseling 2, 1
• Dyspareunia: Distinguish between superficial (vulvovaginal causes) and deep (endometriosis, pelvic inflammatory disease, adhesions) 1, 4
• Contraception history: Current and past methods, complications, and satisfaction 1
• STI history: Previous infections increase risk for pelvic inflammatory disease and chronic pelvic pain 2, 1
• Fertility concerns: Inability to conceive after >12 months of unprotected intercourse warrants endocrine evaluation 2

Urinary and Bowel Symptoms

• Dysuria in sexually active patients: May indicate STI and warrants testing even without pelvic examination 1
• Urinary frequency, urgency, or incontinence: Common in pelvic floor dysfunction and may coexist with gynecologic pathology 2, 4
• Bowel habit changes: Bloating, constipation, or diarrhea may indicate ovarian pathology or endometriosis involving bowel 2

Constitutional and Endocrine Symptoms

• Weight changes: Unexplained weight gain with menstrual irregularity suggests PCOS or thyroid dysfunction; weight loss with pain raises concern for malignancy 2
• Hirsutism: Male-pattern hair growth with menstrual irregularity indicates hyperandrogenism, commonly from PCOS 2
• Galactorrhea: Nipple discharge in non-lactating women suggests hyperprolactinemia requiring pituitary evaluation 2
• Heat/cold intolerance, fatigue: Screen for thyroid dysfunction, a reversible cause of menstrual irregularity 2, 8

Red Flag Symptoms Requiring Urgent Investigation

• Acute severe pelvic pain: Suspect ectopic pregnancy, ovarian torsion, ruptured cyst, or tubo-ovarian abscess 5, 6, 7
• Postmenopausal bleeding: Endometrial cancer until proven otherwise 2, 1
• Persistent bloating with early satiety: Ovarian cancer presentation, especially in postmenopausal women 2
• Recurrent urinary symptoms: May indicate pelvic mass or malignancy 2

Age-Specific Considerations

Adolescents: Focus on pubertal development assessment, primary amenorrhea if no menses by age 15, and sexual abuse screening given higher vulnerability 2

Reproductive age: Pregnancy must be excluded first in any woman with amenorrhea or abnormal bleeding; assess contraceptive needs and fertility desires 1, 8

Postmenopausal: Any bleeding is abnormal; assess for genitourinary syndrome of menopause (vulvovaginal dryness, dyspareunia, urinary symptoms) even in non-sexually active women 2, 1

Critical Pitfalls to Avoid

• Never assume amenorrhea at age 45 is simply menopause: Requires hormonal evaluation (FSH, LH, prolactin, TSH) to identify reversible causes and prevent complications of prolonged hypoestrogenism 8
• Don't delay pregnancy testing: Even with "reliable" contraception, pregnancy (including ectopic) must be excluded in reproductive-age women with amenorrhea or pain 6, 7
• Recognize that pelvic inflammatory disease often presents with minimal symptoms: Low threshold for testing sexually active women with lower abdominal pain and cervical motion tenderness 2
• Document sexual abuse history sensitively: Past or current abuse affects examination tolerance and may explain chronic pain; offer female examiner when possible 2