Menstrual History

Comprehensive exams in women’s health need to

As with any assessment, the chief complain is often what drives what our questions are and what clinical pathways we explore. With women’s health that approach is not any different, as we need to explore the “what was”, “what is” and “what will be” for the patient. The comprehensive assessment is one that is longer in nature and normally saved for the first visit, as if this patient will be a returning patient a more focused examine comes during their following appointments. The follow is a “blanket” comprehensive assessment that can be tweaked for any patient (Elson, 2008);

Chief complaint (is this a focused complaint or a first meeting or annual meeting)

History of present illness

Menstrual History

Age at menarche

Last menstrual period

Menstrual characteristics


How long is flow

Amount of flow

Other symptoms? (breast tenderness, pelvic pain, etc)5


Intermenstrual bleeding


Bleeding pattern

Vasomotor symptoms


Current method; is it working?

Previous method; any complications and reason for change

Cervical and vaginal cytology

Results and date of most recent pap

Hx of abnormal paps? Why? Treatment?


Hx of STD?

Hx of vaginitis (types, frequency and treatment)

Hx of PID


Any desire for future?

Difficulty conceiving? Treatments in past?

Sexual hx


Concerns about libido, orgasm, dyspareunia

Any hx of abuse? Assault?

Obstetric hx

Describe each pregnancy and outcome

Any maternal, fetal or neonatal complications?

Past medical history

Current and past illnesses

Hospital admissions

Surgical hx

GYN and Non-gyn


OTC, prescribed, herbal

Allergies to meds, food, environment and reactions?

Family hx

Significant illnesses of family

Hereditary concerns

Social hx

Relationship status

Level of education









18.Health Maintenance

Smoking, alcohol use, drug use


Supplement intake


Regular screenings (mammo, pap, colonoscopy)

Immunizations and dates

Health maintenance is very important for all ages when related to women’s health. The following are some ideas of health maintenance for each age group (Well-Woman Recommendations, 2018);


If sexually active the patient should have discussion with provider on sexually transmitted diseases and contraceptive use

Drugs and alcohol use

Peer pressure with sexual situations


Annual blood work to identify challenges in anemia, TSH, Cholesterol and minerals.

Breast self-awareness

Reproductive health plan

Imitate partner violence


Hormone therapy


Advance directives

Problems with sexual encounters (pain, dry, etc)


Sleep patterns

Changes of the body (hair growth, hormonal changes, sexual changes)

Breast self-awareness

Geriatric Women

Sexual function

Injury prevention


Elson, N. B. (2008, July). The Gynecologic History and Examination. Retrieved from The Global Library of Womens Health:

Well-Woman Recommendations. (2018, January 5). Retrieved from The American College of Obstetricians and Gynecologists:

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