Key Feature 3b: In a woman with abdominal pain: Suspect gynecologic etiology for abdominal pain.
Skill: Clinical Reasoning
Phase: Hypothesis generation
In the 13 year old female per the last two posts, I suspected gynecologic etiology for her abdominal pain as my ddx for paediatric (and nonpediatric) abdominal pain is inclusive of this possibility.
My generic gynecological history-taking mnemonic is (one of those silly mnemonics that for whatever reason just sticks): MC HAMMER
M - Menarche/last menstrual period/menopause
C - Cycle (regularity and length of time [number of days of entire cycle and subset of days having flow])
H - Hemorrhage (qty of flow and any intermittent spotting)
A - Aches associated with menstruation (dysmenorrhea)
M - Motherhood (GTPALM history, at what age the events occurred, if there were any associated complications, be it in the labour, delivery, or abortion as relevant)
M - Mishaps/miscarriages (usually this is obtained during my "motherhood" questioning, but there have been times where I've been happy to have a dedicated mnemonic letter for this as it gets me to think twice about explicitly asking about abortions, be they spontaneous or induced, and there has been a time I can remember when asking again deliberately prompted a patient to clarify that she indeed had had an abortion)
E - Evading pregnancy (use of contraception or fertility difficulties)
R - Risk factors (if pregnancy is being considered or not actively being prevented, such as folic acid supplementation, substance use, achieving or maintaining a healthy weight and lifestyle)
I gathered clinical information on the possibility of a gynaecological etiology in my 13 year old female patient by asking if she had reached menarche (yes), when the first date of her last menstrual period was (a few days before Christmas), if her cycles were typically regular (yes) and if there had been any alteration in this pattern recently (no). I asked her if she had any recent abnormal vaginal bleeding in terms of the pattern or quantity (no), and if she has had cramping associated with menstruation (not really), or any other pattern of pelvic/abdominal cramping (no). I asked if she is on or has ever been started on any sort of contraception (no), and opportunistically if she was considering that she might want to be prescribed contraception (not yet).
I then went on to obtain a sexual history using the 5 Ps (as I have adapted, for my own purposes, the original format as advocated by the CDC).
**Always start with a statement regarding confidentiality, particularly when taking a sexual history from adolescents, and the reasons why I am about to ask these sexual health questions.**
P - Practices (when was the last time that the patient was sexually active, and if they say "never," clarify that this includes oral-genital activity and not just penetrative intercourse)
P - Partners (how many partners has the patient had in the past month or year, and have they been males, females, or both?)*
P - Protection (does the patient use protection and if not, why not, or if yes, what and how often) (opportunity to ask if they have any questions about protection)
P - Past STI history (have they ever been diagnosed +/- treated for an STI, and if not, have they ever been tested and would they like to be at this time?)
P- Pregnancy prevention (are they using contraception, and if not, are they trying to conceive and would they be concerned if conception occurred? [prenatal counselling may be indicated]) (opportunity to ask if they have any questions about contraception)
Obtaining my sexual history with this patient revealed that she had never been sexually active (at all), and that she didn't feel she needed to explore methods of protection or contraception at this visit. I made sure to tell her that she can always return to the clinic at any time to discuss anything regarding sexual health, and told her about my favourite website she could explore for general sexual health information.
*Disclaimer: When I originally adapted the 5Ps for my own sexual history taking in medical school, appreciation of the gender spectrum as more than binary was lacking. Exploring the sexual and gender identities of their previous partners may or may not be indicated.
This patient had no pertinent positives on gynecological and sexual history. If there were any pertinent positives suggesting gynecological or STI-related pathology, relevant investigations may have included: B hCG to rule out pregnancy, STI testing, and an ultrasound of the pelvis.