Common or Concerning Symptoms

■ Menarche, menstruation, menopause

■ Vulvovaginal symptoms

■ Sexual activity

Questions in this section focus on menstruation, pregnancy and related topics, vulvovaginal symptoms, and sexual function.

Menarche, Menstruation, Menopause. For the menstrual history, ask the patient how old she was when her monthly, or menstrual, periods began (age at menarche). When did her last period start, and, if possible, the one before that? How often do the periods come (as measured by the intervals between the first days of successive periods)? How regular or irregular are they? How long do they last? How heavy is the flow? What color is it? Flow can be assessed roughly by the number of pads or tampons used daily. Because women vary in their practices for sanitary measures, however, ask the patient whether she usually soaks a pad or tampon, spots it lightly, etc. CFurther, does she use more than one at a time? Does she have any bleeding between periods? Any bleeding after intercourse or after douching?

Does the patient have any discomfort or pain before or during her periods? If so, what is it like, how long does it last, and does it interfere with her usual activities? Are there other associated symptoms? Ask a middle-aged or older woman if she has stopped menstruating. When? Did any symptoms accompany her change? Has she had any bleeding since?

Questions about menarche, menstruation, and menopause often give you an opportunity to explore the patient's need for information and her attitude

The dates of previous periods may alert you to possible pregnancy or menstrual irregularities.

Unlike the normal dark red menstrual discharge, excessive flow tends to be bright red and may include "clots" (not true fibrin clots).

toward her body. When talking with an adolescent girl, for example, opening questions might include: "How did you first learn about monthly periods? How did you feel when they started? Many girls worry when their periods aren't regular or come late. Has anything like that bothered you?" You can explain that girls in the United States usually begin to menstruate between the ages of 9 and 16 years, and often take a year or more before they settle into a reasonable, regular pattern. Age at menarche is variable, depending on genetic endowment, socioeconomic status, and nutrition. The interval between periods ranges roughly from 24 to 32 days; the flow lasts from 3 to 7 days.

Menopause, the absence of menses for 12 consecutive months, usually occurs between the ages of 45 and 52 years. Associated symptoms include hot flashes, flushing, sweating, and disturbances of sleep. Often you will ask, "How do (did) you feel about not having your periods anymore? Has it affected your life in any way?" Postmenopausal bleeding is defined as bleeding that occurs after 6 months without periods and warrants further investigation.

Amenorrhea refers to the absence of periods. Failure to initiate periods is called primary amenorrhea, while the cessation of periods after they have been established is termed secondary amenorrhea. Pregnancy, lactation, and menopause are physiologic forms of the secondary type. Oligomenorrhea refers to infrequent periods, which may also be irregular. This pattern is common for as long as 2 years after menarche, and it also occurs before menopause.

Dysmenorrhea is pain with menstruation, and is usually felt as a bearing down, aching, or cramping sensation in the lower abdomen and pelvis. Women may report premenstrual syndrome (PMS), a complex of symptoms occurring 4 to 10 days before a period. PMS symptoms include tension, nervousness, irritability, depression, and mood swings; weight gain, abdominal bloating, edema, and tenderness of the breasts; and headaches. Though usually mild, PMS symptoms may be severe and disabling.

Polymenorrhea means abnormally frequent periods, and menorrhagia refers to an increased amount or duration of flow. Bleeding may also occur between periods, termed metrorrhagia or intermenstrual bleeding, after intercourse (postcoital bleeding), or after other vaginal contact from practices such as douching.

Pregnancy. Questions relating to pregnancy include: "Have you ever been (or how often have you been) pregnant? Have you ever had a miscarriage or an abortion? How often? How many living children do you have?" Inquire about any difficulties with the pregnancies and the timing and the ^circumstances of any abortion (spontaneous or induced). What kind of birth control methods, if any, have the patient and her partner used, and how sat-

sfied is she with them?

iInf ifonef amenorrhea suggests a current pregnancy, inquire about the history of tercourse and common early symptoms: tenderness, tingling, or increased size f the breasts; urinary frequency; nausea and vomiting; easy fatigability; and elings that the baby is moving (the last usually noted at about 20 weeks).

Postmenopausal bleeding raises the question of endometrial cancer, although it also has other causes. Other causes of secondary amenorrhea include low body weight from any cause, including malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction.

Increased frequency, increased flow, or bleeding between periods may have systemic causes or may be dysfunctional. Postcoital bleeding suggests cervical disease (e.g., polyps, cancer) or, in an older woman, atrophic vaginitis.

Amenorrhea followed by heavy bleeding suggests a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation.

Be alert to the patient's feelings in discussing all these topics and explore them as seems indicated. (See also Chapter 12, The Pregnant Woman).

Vulvovaginal Symptoms. The most common vulvovaginal symptoms are vaginal discharge and local itching. Follow your usual approach. If the patient reports a discharge, inquire about its amount, color, consistency, and odor. Ask about any local sores or lumps in the vulvar area. Are they painful or not? Because patients vary in their understanding of anatomic terms, be prepared to try alternative phrasing such as "Any itching (or other symptoms) near your vagina? . . . between your legs? . . . where you urinate?"

Sexual Activity. Start with general questions such as "How is sex for you?" Or "Are you having any problems with sex?" You can also ask, "Are you satisfied with your sex life as it is now? Has there been any significant change in the last few years? Are you satisfied with you ability to perform sexually? How satisfied do you think your partner is? Do you feel that your partner is satisfied with the frequency of sexual activity?"

If the patient seems to have a sexual problem, ask her to tell you about it. Direct questions help you assess each phase of the sexual response: desire, arousal, and orgasm. "Do you have an interest in (appetite for) sex?" inquires about the desire phase. For the orgasmic phase, "Are you able to reach climax (reach an orgasm or 'come')?" "Is it important for you to reach climax?" For arousal, "Do you get sexually aroused? Do you lubricate easily (get wet or slippery)? Do you stay too dry?"

Ask also about dyspareunia, or discomfort or pain during intercourse. If present, try to localize the symptom. Is it near the outside, occurring at the start of intercourse, or does she feel it farther in, when her partner is pushing deeper? Vaginismus refers to an involuntary spasm of the muscles surrounding the vaginal orifice that makes penetration during intercourse painful or impossible.

In addition to ascertaining the nature of a sexual problem, ask about its

5onset, severity (persistent or sporadic), setting, and factors, if any, that make better or worse. What does the patient think is the cause of the prob-m, what has she tried to do about it, and what does she hope for? The tting of sexual dysfunction is an important but complicated topic, in-)lving the patient's general health, medications and drugs, including use ' alcohol, her partner's and her own knowledge of sexual practices and echniques, her attitudes, values, and fears, the relationship and commu-lication between her and her partner(s), and the setting in which sexual activity takes place.

Local symptoms or findings on physical examination may raise the possibility of sexually transmitted diseases (STDs). After establishing the usual attributes of any symptoms, identify the sexual preference as to partners (male, female,

See Table 11-1, Lesions of the Vulva p._.

Sexual dysfunctions are classified by the phase of sexual response. A woman may lack desire, she may fail to become aroused and to attain adequate vaginal lubrication, or, despite adequate arousal, she may be unable to reach orgasm much or all of the time. Causes include lack of estrogen, medical illness, and psychiatric conditions.

Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication; deeper pain may be due to pelvic disorders or pressure on a normal ovary. The cause of vaginismus may be physical or psychological.

More commonly, however, a sexual problem is related to situational or psychosocial factors.

or both). Inquire about sexual contacts and establish the number of sexual partners in the prior month. Ask if the patient has concerns about HIV infection, desires HIV testing, or has current or past partners at risk. Also ask about oral and anal sex and, if indicated, about symptoms involving the mouth, throat, anus, and rectum. Review the past history of venereal disease. "Have you ever had herpes? . . . any other problems such as gonorrhea? . . . syphilis? . . . pelvic infections?" Continue with the more general questions suggested on pp._.

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