The menstrual history should include the age at onset of menstruation (menarche) and of cessation of menstruation (menopause) as appropriate. Details of the menstrual cycle should also include the date of the first day of the last menstrual period and the duration of menses (Table 5.23). The norma! age of the menarche varies from the ages 10-15. Thereafter, patients who fail to menstruate at all, primary amenorrhoea, should be investigated for possihle gynaecological or endocrinological abnormalities.
The normal age of the menopause varies considerably within the age range 45-55. Secondary amenorrhoea is commonly due to pregnancy. If this is not the case, organic causes such as severe systemic illness, hyper-prolactinaemia, androgen excess or hypopituitarism should be excluded before attributing it to a psychological disorder. Useful questions in the menstrual history arc shown in Table 5.23.
The obstetric history comprises details of all pregnancies, successful or otherwise, and any problems experienced during pregnancy, such as high blood pressure or urinary infection (Table 5.24). If a woman has never been pregnant, it may be appropriate to enquire whether this was by choice or whether difficulties in conceiving have been experienced.
The presence of a vaginal discharge requires to be assessed and note made of its colour, consistency and smell; for example, particularly strong odour may indicate anaerobic bacterial infection. Vaginal bleeding occurring after intercourse is usually caused by local pathology, e.g. cervical erosions, polyps or carcinoma. The presence of a vaginal discharge or intermenstrual, postcoital or postmenopausal bleeding, is an indication for a gynaecological assessment and examination.
TABLE 5.23 Checklist of the menstrual history
Age at onset of the first period (menarche)
Age at cessation of menstruation (menopause)
Use of contraceptive drugs or hormone replacement therapy
Date of the first day ol the last menstrual period
Frequency, regularity and duration of menstruation
Is menstrual blood loss unusually heavy?
Number of pregnancies and live berths, miscarriages and terminations Any health problems during pregnancies or after delivery?" Were the previous deliveries vaginal or caesarean? Were forceps or episiotomy used?
A 30-year-0ld female schoolteacher was admitted for investigation of 7 kg weight loss, tiredness and malaise of 3 months' duration. Systemic enquiry was otherwise normal. She had two children by her partner in a stable relationship of 5 years' duration. There was no history of drug use and physical examination was initially normal. The diagnosis was unclear until after complaining of a sore throat, she was found to have oral candidiasis. Suspecting an immunodeficiency disorder, a sexual history was then taken and reveaied that 2 years previously, while her partner was abroad, she had unprotected sexual intercourse with a bisexual friend. An HIV test was performed and was positive; her partner and her second child were also later found to be HIV-positive.
• An inadequate history may delay both the diagnosis and treatment.
• HIV infection should be considered in patients with unexplained immunodeficiency states even if risk factors are not Immediately apparent.
TABLE 5.25 Checklist for the sexual history
How many sexual partners have you had in the lasl 12 months?
How many of your partners have been male and how many female?
How many of your partners have been casual relationships?
Do you use a condom most of the time, all of the time or not at all?
Have you ever had a sexually transmitted disease?
Males. Have you had any problems with sexual drive, erections, penetration, ejaculation, or orgasm? Females: Have you had any problems with sexual drive, pain during intercourse or orgasm?
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