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

Length

How long is flow

Amount of flow

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

Pain?

Intermenstrual bleeding

Perimenopause/menopause

Bleeding pattern

Vasomotor symptoms

Contraception

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?

Infections

Hx of STD?

Hx of vaginitis (types, frequency and treatment)

Hx of PID

Fertility/infertility

Any desire for future?

Difficulty conceiving? Treatments in past?

Sexual hx

Type

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

Medications/allergies

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

Occupation

R.O.S.

Abdomino-pelvic

GYN

GI

GU

Breast

Others

18.Health Maintenance

Smoking, alcohol use, drug use

Diet

Supplement intake

Exercise

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);

Adolescents

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

Childbearing

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

Breast self-awareness

Reproductive health plan

Imitate partner violence

Peri-menopausal

Hormone therapy

Mammograms

Advance directives

Problems with sexual encounters (pain, dry, etc)

Menopausal

Sleep patterns

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

Breast self-awareness

Geriatric Women

Sexual function

Injury prevention

Neglect/abuse

Elson, N. B. (2008, July). The Gynecologic History and Examination. Retrieved from The Global Library of Womens Health: https://www.glowm.com/section_view/heading/TheGynecologicHistoryandExamination/item/3#3521

Well-Woman Recommendations. (2018, January 5). Retrieved from The American College of Obstetricians and Gynecologists: https://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations?IsMobileSet=false

 

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