Gynecological History

General Considerations Because a discussion of reproductive issues may be difficult for some women, it is important to obtain the history in a relaxed and private setting. The patient should be clothed, particularly if she is meeting the provider for the first time. Ordinarily, the patient should be interviewed alone. Exceptions may be made for children, adolescents, and mentally impaired women, or if the patient specifically requests the presence of a caretaker, friend, or family member. However, even in these circumstances, it is desirable for the patient to have some time to speak with the clinician privately. The manner of address should be formal using the title Mrs., Ms., Miss, or Dr. with the patient’s surname, unless the patient requests otherwise. In some settings, it may be appropriate for nursing staff to be involved with history taking. A nurse may be perceived as less threatening, and may be able to take the history in a less hurried manner.1 The provider can verify the history and focus on areas of concern. Alternatively, it may be helpful to ask the patient to complete a self-history form on paper or by computer prior to speaking with the provider. This allows the provider to devote time to addressing positive responses, and ensures that important questions are not missed. Hasley2 showed that responses to a computer-based questionnaire designed to update a patient’s gynecologic history were equivalent to those obtained during a personal interview. Several studies involving patients in non-gynecologic settings have shown that patients are more likely to provide sensitive information when responding to a computer-based questionnaire as opposed to a personal interview or even a paper questionnaire.3 In order to increase a patient’s level of comfort during the interview, questions should be asked in an open-ended and nonjudgmental way. Assumptions should not be made about aspects of the patient’s background such as sexual orientation. At the conclusion of the interview, patients should be asked whether there are concerns that they would like to discuss that were not addressed previously in the interview.