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Gynecologic History

by David H. Barad, MD, MS

A gynecologic evaluation starts with a series of questions related to menstruation and reproductive function. These questions usually focus on the reason for the visit to the doctor's office. The answers form the gynecologic history. A complete gynecologic history includes the following information:

  • The age at which menstrual bleeding began (menarche)

  • Frequency, regularity, and duration of menstrual periods

  • Amount of menstrual bleeding

  • Dates of the last two menstrual periods

  • Number of pregnancies, dates that they occurred, outcomes, and complications

Questions about abnormal bleeding—too much, too little, or between menstrual periods—are included.

A doctor usually asks about sexual activities to assess the risk of gynecologic infections, injuries, and pregnancy and to determine whether a woman has any sexual problems. A woman is asked whether she uses or wants to use birth control and whether she is interested in counseling or other information.

The doctor may ask the woman whether she has pain, cramps, or headaches during menstrual periods. She is asked whether she has pain during intercourse, in the middle of the menstrual cycle (which may indicate that the pain coincides with ovulation), or under other circumstances. If she has pain, she is asked how severe the pain is and what provides relief. The doctor also asks about breast problems, such as pain, lumps, areas of tenderness or redness, and discharge from the nipples. The woman is asked whether she examines her breasts, how often, and whether she needs any instruction on technique.

The doctor reviews the woman's history of past gynecologic disorders and usually obtains a general medical and surgical history that includes previous health problems. The doctor reviews all the drugs a woman is taking, including prescription and nonprescription drugs, illegal drugs, tobacco, and alcohol, because many of them affect gynecologic function. The woman is asked about mental, physical, or sexual abuse in the present and the past. Some questions about urination are asked to find out whether the woman has a urinary tract infection or has problems with leakage of urine (incontinence).