The Woman’s Health History

1. The Woman’s Health History University of Nebraska College of Medicine M3 OB/GYN Clerkship

2. The Woman’s Health History • HPI • Gynecologic History • Obstetric History • PMH • PSH • Medications/Allergies • FH • SH • ROS

4. Gynecologic History • LMP or FMP (if postmenopausal) • Age of menarche • Menstrual history • Cycle length • Duration of bleeding • Amount of bleeding (heavy, light, clots) • Irregular bleeding • Intermenstrual bleeding • Postcoital bleeding

5. Gynecologic History • If menopausal • Age of final menstrual period (FMP) • Current of past HRT use • Postmenopausal bleeding/spotting • Menopausal sxs • Hot flashes/night sweats • Vaginal dryness • Sleep or mood disturbances • Are sxs affecting QOL?

6. Gynecologic History • History of abnormal paps • If yes • When was abnormal pap • What was the abnormality • How was it evaluated (colposcopy?) • Any treatment (cryotherapy, Leep, cone bx?) • Results of subsequent paps

7. Gynecologic History • History of STIs • HPV, gonorrhea, Chlamydia, HSV, syphilis • HIV, hepatitis B/C • When was dx and how was infxn treated • Assessment of if STI risk factors2 • Hx of multiple sexual partners • Partner with multiple sexual contacts • Sexual contact with persons with culture proven STI • Hx of repeated STIs • STI clinic attendance • Developmental disability

8. Gynecologic History • Sexual history • Age of coitarche • Total lifetime partners • Current relationship • Single or multiple partners • Sexual orientation • History of sexual abuse • Sexual satisfaction vs. concerns

9. Gynecologic History • Current method of contraception • Length of use • Satisfaction with current method vs. problems • Previous methods utilized • If no current method of contraception, • Why? • Possibility of pregnancy exists in any sexually active female until 1 year from FMP!

10. Obstetric History • Gravidity • Total number of pregnancies regardless of outcome • Parity (TPAL) • T = Number of term deliveries (>37 wks) • P = Number of preterm deliveries (20-36 6/7 wks) • A = Number of pregnancies ended <20 weeks (spontaneous and elective Abs, ectopics) • L = Number of living children

11. Obstetric History • Obtain specifics or each livebirth • Term vs. preterm delivery • Route of delivery • SVD, CD, forceps/vacuum • Complications of delivery • 3rd/4th degree laceration; hemorrhage (PPH) • Birth weight; gender • Pregnancy complications • Gestational DM (GDM) • Hypertensive disorders (GHTN, preeclampsia, “toxemia”)

12. Obstetric History • If gravida 0 • By choice? • History of infertility? • Evaluation, if performed • Treatment measures, if any

13. Family History • Diabetes, HTN, CAD? • Cancer hx • Breast, colon, ovarian • Genetic disorders • Congenital/inherited defects • Recurrent pregnancy losses/stillbirths • Family members with clots during pregnancy or on OCPs/HRT • Osteoporosis

14. Social History • Tobacco/EtOH/drug use • Intimate partner violence • Sexual abuse (may have been covered in gyn hx) • Nutrition/diet/exercise • Folic acid • Calcium

15. Health Maintenance • Immunizations • Chart with recommended vaccinations for women • HPV vaccination • Ages 9-26 years • Cervical cancer screening • Pap screening • Starting at age 21 • Breast Cancer screening • Clinical breast exam/mammogram screening • Colorectal screening • Starting at age 50 • Colonoscopy, preferred method • Osteoporosis screening • Assessment for risk factors (FH, Caucasian, smoker, poor nutrition, estrogen deficiency, low weight/low BMI, prior fracture, fall risk, inactivity) • BMD assessment starting at age 65, younger for postmenopausal women with one risk factor for osteoporosis

16. Recommended Vaccinations for Women

17. Health Maintenance • STI screening • HIV • All reproductive age women should be screened at least once • Annually for women with risk factors (IV drug users, have partners who are HIV+ or use IV drugs, dx of another STI within last year , >1 partner since last HIV test, exchange sex for drugs/money) • Chlamydia • Annually for women 25 yrs and younger who are sexually active • >26 yrs should be screened annually if high risk • Gonorrhea • Similar recommendations to Chlamydia • Syphilis • Annual screening if at increased risk • All pregnant women as early as possible

18. Health Maintenance • Diabetes • Screening fasting blood glucose starting at age 45 and every 3yrs thereafter • Begin sooner if risk factors (BMI>25, FH, hx of GDM, HTN, habitual inactivity) • Thyroid disease • TSH tested every 5 yrs starting at age 50 • HTN • Screen BP annually • Lipid disorders • No risk factors, screen every 5 yrs starting at age 45 • Earlier screening if risk factors (FH of hyperlipidemia or premature CV disease, DM, multiple CAD risk factors) • Obesity • BMI calculated annually

19. Periodic Assessments • ACOG Committee Opinion No. 292

22. Presenting Patients in Clinic • Begin presentation with age, gravida, para, (LMP, if appropriate) and chief complaint • 22yo G1 P1001 Caucasian female with LMP 6/30 who present for her annual exam • 56 yo G3 P2012 AA postmenopausal female with 3 days of vaginal bleeding • Tailor history/information gathering to reason for visit… annual vs. problem visit vs. OB visit

23. Pearls for Success in Clinic • Prepare for clinic • Look up clinic pts (past hx, reason given for visit) • Be proactive in seeing patients! • If you asked about a subject in clinic and you don’t know… • Look up the subject for next clinic day • Have fun learning!

24. Physical Examination • Breast exam • Reviewed in “Breast Disorders” lecture • Pelvic exam • Video and pelvic model

26. References • Beckman CRB., et al. The Woman’s Health Examination and The Obstetrician-Gynecologist’s Role in Screening and Preventative Care In: Obstetrics and Gynecology. 6th Edition. Philadelphia; 2010. • ACOG Committee Opinion No. 357 • ACOG Committee Opinion No. 292