Акушерський та гінекологічний анамнез

Taking an obstetric history usually begins with asking about previous pregnancies, including dates, outcomes, and complications.

For pregnant patients, a more detailed obstetric history is taken regarding prior pregnancies and the current pregnancy.

Taking a gynecologic history consists of asking patients about any symptoms or concerns that prompted the visit. The history should include a menstrual history, sexual history, urinary tract symptoms or history, and previous or current gynecologic conditions and treatments.

Current symptoms are explored using open-ended questions followed by specific questions about the following:

• Pelvic pain (location, duration, character, quality, triggering and relieving factors)

• Abnormal vaginal bleeding (quantity, duration, relation to the menstrual cycle)

• Vaginal discharge (color, odor, consistency)

• Vulvovaginal discomfort or pain (location, duration, character, quality, triggering and relieving factors)

• Menopausal symptoms

Menstrual history includes the following:

• Age at menarche or menopause

• Number of days of menses

• Length and regularity of the interval between cycles

• Start date of the last menstrual period (LMP)

• Dates of the preceding period (previous menstrual period [PMP])

• Volume of menses

• Passage of blood clots: Any history of passage of clots warrants further evaluation and referral to a gynecologist

• Any symptoms that occur with menses (eg, pain, cramping, migraine headaches)

The individual patient's menstrual history is compared with the normal ranges for characteristics of the menstrual cycle (frequency, regularity, duration, and volume of bleeding) (see table Normal Menstrual Parameters). If there are menstrual abnormalities, the patient is evaluated for the type and etiology of abnormal uterine bleeding.

Usually, menstrual bleeding lasts for ≤ 8 days, with 24 to 38 days between menses; average blood loss is 30 mL (range, 13 to 80 mL), with the most bleeding on the second day. A saturated pad or tampon absorbs 5 to 15 mL. Objective measurement of menstrual volume is done only in research studies, so clinicians should ask the patient about use of pads and tampons and passage of blood clots from the vagina. Descriptions that suggest heavy uterine blood flow include:

• Saturating ≥ 1 pad or tampon within 3 hours or less

• Saturating > 21 pads or tampons per cycle

• Frequently needing to change pad or tampon during the night to avoid leakage of blood on clothing or bedding

• Passing blood clots ≥ 1 inch in diameter

Cramping is common on the day before and on the first day of menses. Vaginal bleeding that is irregular, painless, scant, and abnormally brief or prolonged suggests ovulatory dysfunction.

Any postmenopausal vaginal bleeding (any volume, including spotting or pink or brown staining) requires further evaluation for endometrial hyperplasia or cancer. Menopause is diagnosed 12 months after cessation of menses. However, perimenopausal women may have irregular bleeding, or postmenopausal bleeding may be misinterpreted as menses. Thus, any heavy, irregular, or prolonged bleeding in women age ≥ 45 years should be further evaluated by endometrial biopsy irrespective of the etiology.

Past gynecologic history includes history of

• Sexually transmitted infection (STI) or pelvic inflammatory disease (including diagnosis, frequency, and treatment)

• Vulval/vaginal lesions, ovarian cysts, uterine fibroids, infertility, endometriosis, polycystic ovary syndrome, pelvic organ prolapse, or urine/stool incontinence (including mode of diagnosis and treatment received)

• Pap smear (normal or abnormal), colposcopy (including date, results, and treatment)

• Gynecologic procedures such as cervical/endometrial/vulval/vaginal biopsy, hysteroscopy, laparoscopy, hysterectomy (including date, indications, and complications)

Sexual history should be obtained in a professional and nonjudgmental way and includes the following (see CDC: A Guide to Taking a Sexual History):

• Gender of partners

• Sexual risk behaviors (eg, multiple partners, risk or history of sexual violence)

• Use of contraception (especially use of condoms)

• Concerns about sexual function (eg, dyspareunia, sexual interest, arousal, orgasm)

Medical history includes a history of systemic disorders including hematologic, autoimmune, hepatic, cardiac, and renal diseases, diabetes mellitus, and hypertension. Any bleeding disorders or use of medication that affects coagulation (eg, aspirin), nonsteroidal anti-inflammatory drugs (NSAIDs), or antidepressant or antipsychotic medications that affect hypothalamic-pituitary-ovarian axis should be noted.

Social history includes social stressors, exercise patterns, and substance misuse (including smoking) and completion of a drug and alcohol questionnaire. In adolescents, social history includes athletic participation, school absence rate, and decreased participation in hobbies/sports, especially if related to menstrual cycles.

Family history includes history of malignancy, bleeding disorders, infertility, menstrual disorders, fibroids, endometriosis, and thyroid diseases in first-degree and second-degree relatives. Family history of diabetes mellitus or disorders of lipids or triglycerides should be noted and may suggest polycystic ovary syndrome.

Review of systems should include any weight changes, fatigue, hirsutism, acne, vision changes, headaches, galactorrhea, changes in bowel habits, abdominal pain, heat/cold intolerance, and urinary and gastrointestinal symptoms. In adolescents, history of self-induced vomiting, eating disorders, undernutrition, easy bleeding/bruising (epistaxis, bleeding gums) is important.