Health History and Physical Examination · 8 min read
The Comprehensive Women's Health History
On the NCC WHNP exam this material sits in the Assessment, Diagnostic Testing and Interpretation domain, but history and examination skills also drive many gynecology and obstetrics items. Assess items ask which history detail matters most, which exam technique is correct, or which finding is abnormal. Diagnose items hand you a pattern of findings (a fixed, irregular breast mass; cervical motion tenderness; a high-riding testis) and ask what it means. Plan items ask what to do next with a finding. Because every NCC item has only three options, the best answer is usually the one that is both technically correct and the safest next step, and the two distractors are typically a skipped step or an unnecessary test.
This chapter covers the structure of the comprehensive and focused history, medication reconciliation, obstetric and gynecologic history with GTPAL, family and social history, and the sexual history using the 5 Ps.
Structure of the History
A comprehensive history covers the chief concern, history of present illness, medical, surgical, obstetric and gynecologic history, medications, allergies, family, social and sexual history, and review of systems; a focused history covers only what bears on the concern. Use a symptom framework such as OLDCARTS for pain and bleeding complaints.
Interview the patient alone for at least part of the visit, especially adolescents and any patient who may be experiencing intimate partner violence. Use a professional medical interpreter rather than a family member or partner when the patient's preferred language differs from yours.
Exam Tip: When a stem says a partner, parent or child "insists on staying in the room and answers for the patient," the best answer is to arrange time alone with the patient (and a professional interpreter if needed), not to continue the interview with the companion present.
Past Medical and Surgical History
Ask about chronic conditions that change women's health decisions: hypertension, diabetes, migraine with aura, VTE or thrombophilia, cardiovascular, liver, seizure and thyroid disease, lupus with antiphospholipid antibodies, cancer, bariatric surgery, mood disorders and HIV. Each of these alters contraceptive eligibility, menopausal hormone therapy choices, pregnancy risk or screening intervals.
Surgical history should include type and indication: hysterectomy (total versus supracervical, benign versus for cervical neoplasia), oophorectomy or salpingectomy, cesarean births and incision type, cervical excision (LEEP or cone), dilation and curettage (Asherman risk), tubal surgery (ectopic risk), breast surgery and bariatric surgery (reduced oral contraceptive absorption).
Common Trap: "History of hysterectomy" does not automatically end cervical screening. Screening stops only if the cervix was removed and the hysterectomy was for benign disease with no history of CIN2 or higher. A supracervical hysterectomy leaves the cervix, so screening continues.
Medication Reconciliation and Allergies
Medication reconciliation compares what the patient is actually taking with what the record lists, at every transition of care. Ask specifically about prescription drugs, over-the-counter drugs, vitamins, herbal products and supplements (St John's wort lowers hormonal contraceptive levels; black cohosh and other menopause supplements), contraceptives (the patient may not think of the ring or IUD as a medication), hormone therapy, topical and vaginal products, and recreational substances. Ask how each is taken, not only what is prescribed.
Key medication history questions in women's health:
In older women, potentially inappropriate medications (Beers criteria), such as strongly anticholinergic drugs for overactive bladder, long-acting benzodiazepines and sedative-hypnotics, which raise fall and cognitive risk.
Allergy history must separate a true allergy from an intolerance and document the reaction. "Penicillin allergy" is a high-yield topic: most patients who report it are not truly allergic, and the reaction type (hives, anaphylaxis, severe cutaneous reaction versus nausea) determines whether a cephalosporin can be used. Ask about latex allergy before using gloves, condoms, diaphragms or speculums, and about iodinated contrast reactions before hysterosalpingography.
Obstetric History and GTPAL
Gravida (G) is the number of times a person has been pregnant, including the current pregnancy, regardless of outcome. Para (P) in the two-number system is the number of pregnancies carried to 20 weeks or more. GTPAL expands parity:
GTPAL Notation
| Letter | Meaning | Counting rules |
|---|---|---|
| G | Gravida | All pregnancies, including current; twins count as one |
| T | Term births | Births at 37 0/7 weeks or later |
| P | Preterm births | Births from 20 0/7 through 36 6/7 weeks |
| A | Abortions and losses | Pregnancies ending before 20 weeks: spontaneous loss, induced abortion, ectopic, molar |
| L | Living children | Current number of living children; each twin counts |
A multiple gestation counts as one pregnancy and one birth event for G, T and P, but each living infant counts in L. A stillbirth at 20 weeks or more counts as a term or preterm birth (by gestational age), not as an abortion.
Case Snapshot: A 32-year-old is now 10 weeks pregnant. She had a spontaneous loss at 8 weeks, a term vaginal birth of a son who is living, and twins born at 34 weeks who are both living. Her notation is G4 T1 P1 A1 L3 (G4 P2 in two-number form). The twins count once for G and P but twice for L. On the exam, build GTPAL line by line from each pregnancy rather than in your head.
For each pregnancy, also record gestational age, mode of birth, birth weight and complications. These details predict risk in later pregnancies and long-term cardiovascular risk: preeclampsia, gestational hypertension, gestational diabetes, preterm birth and early menopause are cardiovascular risk enhancers.
Gynecologic History
The gynecologic history covers:
Family History
Take at least a three-generation family history (first- and second-degree relatives on both sides) with ages at diagnosis. High-yield items are cancers that suggest hereditary syndromes, premature cardiovascular disease, VTE and thrombophilia, diabetes, osteoporosis and hip fracture, and genetic conditions relevant to carrier screening.
Family History Red Flags
| Finding | Suggests | Action |
|---|---|---|
| Breast cancer before 50, bilateral breast cancer, male breast cancer, ovarian cancer at any age, Ashkenazi Jewish ancestry with breast or ovarian cancer | Hereditary breast and ovarian cancer (BRCA1/2 and others) | Use a familial risk tool; refer for genetic counseling if positive |
| Colon or endometrial cancer before 50, several relatives with colon, endometrial, ovarian or other Lynch cancers | Lynch syndrome | Genetic counseling; earlier colorectal and endometrial surveillance |
| Heart attack or stroke in a male first-degree relative before 55 or female before 65 | Premature ASCVD | Risk enhancer for statin decisions |
| Unprovoked VTE in a first-degree relative | Possible thrombophilia | Avoid assuming CHC is safe; consider progestin-only or nonhormonal methods |
| Parental hip fracture | Higher fracture risk | Input for FRAX |
Social History
Social history covers living situation, work, health literacy, food and housing security, activity, diet, sleep, safety (including firearms) and substance use.
Sexual History and the 5 Ps
The CDC framework for sexual history uses five Ps. Ask every patient, with neutral, nonjudgmental language, and ask about practices rather than assuming them from identity.
The 5 Ps of Sexual History
| P | What to ask |
|---|---|
| Partners | Number and gender of partners, new partners, partner's other partners |
| Practices | Vaginal, anal and oral sex; receptive or insertive; sex toys; exchange of sex for money or drugs |
| Protection from STIs | Condom and barrier use, PrEP, vaccination for HPV and hepatitis B |
| Past history of STIs | Prior diagnoses and treatment, partner diagnoses |
| Pregnancy intention | Desire for pregnancy, current contraception, need for preconception care |
Many clinicians add a sixth P (plus) for pleasure, problems and pride: sexual function, pain with sex, satisfaction, and support for sexual orientation and gender identity. The answer to "practices" determines extragenital testing: a woman who has receptive anal sex or oral sex needs rectal or pharyngeal NAAT based on exposure.
Clinical Pearl: Ask "Do you have sex with men, women, both, or people of other genders?" rather than "Do you have a boyfriend?" A woman who identifies as lesbian may have had male partners, and practices, not labels, guide testing.
Key Takeaways
Interview patients alone for part of every visit and use professional interpreters, not family or partners.
GTPAL: G counts pregnancies (twins once), T is 37 weeks or more, P is 20 0/7 through 36 6/7 weeks, A is losses before 20 weeks, L counts each living child.
Medication reconciliation includes OTC drugs, supplements, contraceptive devices and enzyme inducers; screen for teratogens in anyone who could become pregnant.
A three-generation family history with ages at diagnosis identifies hereditary cancer, premature ASCVD and thrombophilia risk.
The 5 Ps (partners, practices, protection, past STIs, pregnancy intention) guide STI testing sites and contraceptive planning.
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