01Purpose and principlesWhat the assessment is for and the core concepts behind it.
Create privacy before content. Introduce everyone present, confirm the patient’s preferred name and communication needs, and explain that some reproductive questions are asked routinely because they affect diagnosis and safety. Ask companions to leave for part of the consultation unless the patient does not want this and no safeguarding concern prevents it. A professional interpreter preserves accuracy and confidentiality; children and partners should not translate intimate disclosures. Check whether electronic records, texts, voicemail, letters or pharmacy collection might be visible to someone controlling the patient.
Build a time line rather than collecting disconnected labels. Menstrual assessment includes age at menarche where relevant, last normal menstrual period, usual cycle interval and variation, bleeding duration and quantity, dysmenorrhoea, bleeding between periods or after sex, and change from baseline. Translate ‘heavy’ into impact: flooding, double protection, changing at night, clots, missed work, fatigue or breathlessness. In perimenopause ask how long amenorrhoea has lasted and about hormone therapy; any bleeding after established menopause needs its own pathway.
Sexual history should be proportionate and non-assumptive. Explain the reason, then ask about current and recent partners, genders only where clinically relevant, anatomical practices and sites of exposure, condoms or barriers, contraception, pregnancy intentions, previous STI tests or treatment, pain, bleeding and sexual wellbeing. Ask whether every encounter is wanted and whether anyone interferes with contraception or pregnancy decisions. A person can decline any question; this should lead to explanation of diagnostic limitations, not coercion.
Obstetric history is best recorded pregnancy by pregnancy. Include year, gestation, antenatal complications, pregnancy loss or termination using the patient’s terms, ectopic or molar pregnancy, mode and place of birth, labour complications, postpartum haemorrhage, infection, thrombosis, mental health and neonatal outcome. Gravidity and parity are useful summaries but can conceal recurrent early loss, traumatic birth or a previous classical caesarean. Ask permission before revisiting bereavement and avoid describing a loss as merely an ‘abortion’ when that wording is not clinically necessary.
Complete the context: contraception and adherence, fertility goals, cervical screening and results, previous pelvic infection, endometriosis, fibroids, surgery, FGM if relevant, urinary and bowel symptoms, medicines including anticoagulants and teratogens, allergies, tobacco, alcohol and family history of breast, ovarian, endometrial or colorectal cancer. End by reflecting the account, identifying emergencies and uncertainties, and agreeing the next step. History never creates automatic consent for examination, pregnancy testing, STI sampling or information sharing; each requires its own conversation.
Key points
- Begin by explaining why particular questions matter, what will be recorded, and the limits of confidentiality; ask the patient how they prefer body parts, gender, partners and pregnancies to be described.
- Offer part of the consultation alone as routine, use a professional interpreter rather than a partner, and check that later messages, letters and portal access are safe.
- For bleeding, define last normal period, cycle interval and regularity, duration, flooding, clots, products changed, night leakage, pain, intermenstrual or postcoital bleeding and anaemia symptoms.
- A sexual history is shaped by the clinical question: partners, practices, protection from infection, pregnancy prevention, previous infections, pain, bleeding, sexual function, consent and what the patient wants from care.
- Record each pregnancy chronologically, including intendedness, gestation and outcome, ectopic or molar pregnancy, mode of birth, haemorrhage, hypertension, diabetes, prematurity, loss and the health of parent and child.
- Ask about cervical screening, contraception, fertility goals, menopause symptoms, gynaecological procedures, medicines, anticoagulants and relevant family cancers without assuming anatomy or reproductive capacity.
- Use neutral questions before direct safeguarding enquiry, then assess immediate danger, children or dependants, sexual violence and coercive control; do not promise absolute secrecy.
- Summarise the timeline back to the patient, distinguish fact from uncertainty, agree examination and tests separately, and document declined elements without judgement or repeated pressure.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
Bleeding is clinically important when it disrupts physical, social, emotional or material quality of life; estimated millilitres are less useful than flooding, product use, anaemia and impact.
A missed or atypical period with unilateral pain, syncope, shoulder-tip pain or bleeding requires pregnancy testing and urgent ectopic assessment even when contraception was reportedly used.
New discharge, dysuria, pelvic pain, postcoital bleeding or a partner with infection guides site-specific STI testing, while absence of symptoms does not exclude infection.
A partner answering, refusing privacy, monitoring communication, controlling medicines or sabotaging contraception can indicate coercive control and should prompt safe private enquiry.
Postmenopausal bleeding, persistent intermenstrual bleeding, suspicious cervix, abdominal distension, pelvic mass or unexplained weight change requires age- and symptom-specific urgent assessment.
Freezing, dissociation, fragmented recall, distress around position or examination can reflect prior trauma; these signs call for control and pacing, not a credibility judgement.
03Method and interpretationA systematic approach to the test and its findings.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Private, consented clinical interviewFirst step - Why
- Obtain an accurate history and enable disclosure without a companion shaping the account.
- Interpretation and limitations
- Offer privacy routinely and document who was present, interpreter use and any unsafe contact method. A refusal of private discussion is not proof of abuse but may limit assessment.
- 02
Bleeding and cycle chronology - Why
- Separate menstrual, intermenstrual, postcoital, pregnancy-related and postmenopausal bleeding patterns.
- Interpretation and limitations
- Record last normal period and change from baseline. Pattern narrows possibilities but cannot by itself exclude pregnancy, infection, structural disease or malignancy.
- 03
Pregnancy assessment - Why
- Identify pregnancy where it changes urgent differential diagnoses, medicines or imaging decisions.
- Interpretation and limitations
- Seek consent for testing. A negative urine result can be falsely reassuring very early or with dilute urine; repeat or use serum hCG when clinical suspicion remains.
- 04
Site-specific sexual health assessment - Why
- Choose appropriate chlamydia, gonorrhoea, HIV, syphilis or other testing from exposure and symptoms.
- Interpretation and limitations
- Anatomical practices determine sampling sites. Explain window periods and arrange results ownership; screening must not replace examination when severe pain, bleeding or sepsis is present.
- 05
Full blood count and selected blood tests - Why
- Measure anaemia and investigate endocrine, inflammatory or pregnancy-related hypotheses raised by history.
- Interpretation and limitations
- NICE recommends a full blood count alongside treatment for heavy menstrual bleeding. Thyroid, coagulation or hormone tests are selective rather than a universal panel.
- 06
Focused examination or imaging - Why
- Answer a defined question after history identifies structural, infectious, cervical or adnexal possibilities.
- Interpretation and limitations
- Obtain separate consent and offer a chaperone for intimate examination. A normal pelvic examination does not exclude ectopic pregnancy, endometriosis or intrauterine pathology.
04Clinical next stepsHow the result changes management or prompts escalation.
01Opening sequenceEstablish safety, privacy and the presenting timelineFirst stepAny consultation includes menstrual, sexual, obstetric or reproductive symptoms.+
- 1Explain the purpose of sensitive questions, confirm communication preferences and confidentiality limits, and arrange professional interpretation where needed.
- 2Offer time alone, identify safe contact routes and establish physiology, bleeding severity, pain, pregnancy possibility and immediate safeguarding threats.
- 3Take a chronological symptom and reproductive history using neutral language, then summarise it back and correct misunderstandings before planning tests.
02Bleeding routeClassify bleeding before selecting investigationThe patient reports heavy, irregular, intermenstrual, postcoital or postmenopausal bleeding.+
- 1Quantify impact and anaemia symptoms, determine cycle and pregnancy context, and review contraception, anticoagulants, examination findings and cancer indicators.
- 2Arrange pregnancy testing and full blood count when indicated, then choose examination, STI tests, ultrasound, hysteroscopy or urgent referral for the specific pattern.
- 3EscalationTreat symptoms where safe while tracking results, defining escalation for worsening bleeding, syncope, pain, fever or new postmenopausal recurrence.
03Disclosure routeRespond without removing controlThe history reveals sexual violence, coercion, exploitation, forced marriage, FGM or immediate danger.+
- 1Validate the disclosure, ask what the patient needs now and assess urgent medical care, danger, children or adults at risk and whether the alleged perpetrator can access communications.
- 2Explain confidentiality and any safeguarding or legal duty before sharing where practicable, use exact words in objective records and contact specialist services through a safe route.
- 3Do not confront family or perpetrator, impose an examination or leave unsafe written material; agree a contingency plan and named follow-up.
04Closing sequenceConvert narrative into shared next stepsEnough information has been gathered to formulate the initial differential and plan.+
- 1State the leading explanations and serious alternatives in plain language, including what the history cannot determine.
- 2Seek separate consent for examination, samples, pregnancy testing and information sharing, recording any declined component and its practical consequence.
- 3Confirm how results will be communicated, who owns follow-up and which symptoms should trigger same-day or emergency reassessment.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
- Track every ordered pregnancy, blood, microbiology, cytology, histology or imaging result to documented interpretation and communication through a contact route the patient considers safe.
- Reassess bleeding volume, pain, cycle pattern, haemoglobin symptoms, pregnancy status and functional impact rather than repeating the original history without measuring change.
- When safeguarding concerns exist, review immediate risk, children or dependants, communication safety and whether referral was received; avoid routine messages that could expose disclosure.
- Document evolving preferences, capacity, consent and declined interventions at each encounter because agreement to one examination or test does not carry forward automatically.
- Escalate new syncope, shoulder-tip pain, severe unilateral pain, fever, heavy ongoing bleeding, postmenopausal recurrence or inability to contact a high-risk patient through the agreed pathway.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Routine privacy reduces stigma
Offering everyone time alone avoids singling out a patient and makes disclosure possible without requiring visible distress or a clinician’s suspicion first.
Anatomy beats assumptions
Pregnancy potential, organs present and sites of sexual exposure determine clinical questions; identity labels alone do not establish which tests are relevant.
Counts need context
Gravidity and parity are indexing tools, not adequate accounts of losses, traumatic births, ectopic pregnancy, neonatal outcomes or the patient’s priorities.
Silence has several meanings
A declined question may reflect privacy, culture, trauma, fear, fatigue or irrelevance; explain the reason and leave room to return without repeated pressure.
Safe contact is clinical data
A correct diagnosis can still cause harm if a result, letter or prescription is exposed to a controlling partner or family member.
07Common pitfallsFrequent interpretation and management errors.
- 01
Using heterosexual, cisgender or pregnancy assumptions instead of asking relevant anatomy, exposure and reproductive intention.
- 02
Collecting a sexual history in front of a partner or relying on that partner to interpret sensitive disclosures.
- 03
Treating gravidity and parity as a substitute for a chronological obstetric history and previous complications.
- 04
Promising complete confidentiality before explaining safeguarding, serious-harm and statutory disclosure boundaries.
- 05
Ordering a routine pelvic examination without stating the clinical question or seeking separate informed consent.
- 06
Documenting coercive disclosure in language or a portal location that the alleged perpetrator can access.