Clinical exam · History taking and the interview

Gynecologic and obstetric history !

History

The gynaecologic and obstetric history covers a woman's menstrual history, pregnancies, contraception and screening.

Updated 2026-11-01

What it is

The gynaecologic and obstetric history is taken from every woman, even when she comes for another reason. It includes the menstrual history, pregnancies and their outcomes, contraception, sexual history, cervical screening and menopause. The last menstrual period is key: in every woman of reproductive age with abdominal pain or bleeding, pregnancy is considered.

What it must include

Menarche, cycles (frequency, duration, amount), dysmenorrhoea and LMP.
Obstetric formula and details of each pregnancy: year, mode of delivery, gestational age, birth weight and complications.
Current contraceptive method.
Age at first intercourse, number of partners, sexually transmitted infections.
Pap smear or HPV test, mammography according to age.
Age at menopause, symptoms and postmenopausal bleeding.

How to ask

'How old were you when you had your first period?'
'How often does it come, how many days does it last and how many pads or tampons do you use on the heaviest day?'
'What was the first day of your last period? Was it normal?'
'Have you been pregnant? How many times? How did each pregnancy end: vaginal birth, caesarean, loss?'
'Were there complications in any pregnancy, such as high blood pressure, diabetes or bleeding?'
'Do you use any contraception? Which one and since when?'
'When was your last Pap smear and what was the result?'
If relevant: 'At what age did your periods stop? Have you had any bleeding since then?'

Test yourself

Think of the answer, then tap the question to see it.

How is the due date calculated with Naegele's rule?

Add 7 days to the first day of the last menstrual period, subtract 3 months and add 1 year.

What does the formula G3P1C1A1V2 mean?

Three pregnancies: one vaginal birth, one caesarean and one abortion or miscarriage, with two living children.

Why is the LMP asked of a woman of reproductive age with abdominal pain?

Because a late period means pregnancy must be ruled out, especially ectopic pregnancy, which can be an emergency.

Which symptom in a postmenopausal woman calls for careful investigation?

Genital bleeding after menopause, because it may come from an endometrial lesion, including cancer.

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Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: 12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024).

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