The history used to diagnose vulvovaginal disease includes both the general health history and a review of associated systems known to be linked to disorders of the vulva and vagina, as well as the history of the current complaint. The point is to recognize that the vulva and vagina do not function in isolation from the rest of the body and to collect all pertinent data so that you will make the most educated diagnosis possible.

Vulvovaginal and other health records

Patient records, whether from internal or external sources, are important for an understanding of the vulvovaginal history (especially if cultures or biopsies and other testing have been done). The rest of the patient’s health issues may be highly relevant to her current complaint and are important to know about, whether relating to the medications she is taking, or the health problems or diseases she has.

No assumptions can be made with record review. Avoid pigeonholing a patient because of common features of her case, or accepting a diagnosis because specialists or other clinicians have given it. When you meet with the patient, start with a clean slate. Keep an open mind and listen well. Be constantly wary of being misled by the assumptions that the patient herself has made about her case.

Use of a questionnaire

The number of questions required appears daunting, but whether the symptoms have been present for a day or a year, the clinician needs this information. We ask that our initial patients fill out a questionnaire covering all pertinent information prior to the appointment. (initial visit patient questionnaire). We use a different questionnaire for follow up visits. (follow up visit questionnaire) In our experience, the questionnaires greatly facilitate history taking; they eliminate actually asking many questions and save time, allowing for easier documentation later, as well.

Questionnaires can be used creatively in different types of practices. One of our vulvovaginal specialist colleagues has a 36 page questionnaire from which she collects data points for research. (She publishes extensively). Another colleague, a dermatologist, reports that while she asks her patients to fill out a questionnaire, she usually goes to the exam immediately after learning the chief complaint. After the exam, she targets her questions to obtain a proper history and uses the questionnaire as back up.

Not all the questions have to be asked at once; indeed some details of the sexual history may be obtained at a later visit. (Some patients do not want to write down details about sexuality, even if it is a problem for them. That is why the questionnaires are deliberately vague on this point.) Extensive details from associated systems and review of systems are not necessary, but if, for example, you did not know of irritable bowel symptoms with years of chronic constipation you might miss an important link to pelvic floor dysfunction manifesting as burning. (Annotation L: The pelvic floor.)

Demographics

How old is the patient?

• Age is always pertinent to your diagnosis based on the presence or absence of estrogen at different stages of life, presence or absence of sexual activity, and the existence of other health problems.
• Genital dermatoses occur at all ages (Annotation H: The vulvar skin)
• Vulvar pain and vulvodynia, in our experience, occur at all ages, including in children. (Annotation K: Vulvar pain and vulvodynia).
• Candida albicans is hormonally linked; without the presence of estrogen-related glycogen in the vaginal epithelial cells, Candidal infection before puberty and after menopause is rare. (Atrophy in Annotation P: Vaginal secretions, pH, microscopy, and cultures).
• Contact dermatitis is seen at all ages. (Annotation J: Lifestyle issues).

 

What is her occupation?

• Some occupations require special clothing, e.g. daily pantyhose for many women; some necessitate activity that can affect the vulva, such as long periods of sitting, standing, bending and lifting.

What is her ethnicity?

• Ethnicity is important in developing a picture of the patient as an individual and in recognizing that her problems may be influenced by her culture. It is possible that such cultural differences could extensively alter a teaching tool of this nature. Ethnicity has not been well studied in relation to vulvovaginal complaints. Pain has been documented in women of different ethnicities, reported to be lower in black compared to white and Latina women.¹  Use of a different terminology to describe vulvar pain symptoms may play a role in the lower prevalence as investigated in a recent study² to compare pain descriptors used by black and white women with clinically confirmed provoked vulvodynia. Of statistical significance, white women more often described their pain as burning, stinging or itching compared with black women who described their pain as aching. The study suggests that black women are less likely to self-report their vulvar pain as burning which is the classic symptom of provoked vulvodynia. It is hypothesized that cultural differences and different underlying pain mechanisms may contribute to differences in symptoms reported by race.
• In addition, knowledge is growing about the human female vaginal microbiome. Studies show that while lactobacillus species are active in protecting the vaginas of all women, there are differences in which species dominate in different ethnic and regional groups.³ Vaginal microbiota affect vaginal pH and pH may be elevated in normal, healthy Hispanic and black women in comparison with Asian and white women.⁴ This must be kept in mind during the evaluation process, but is only one piece of the puzzle.

Chief complaint

What is the main problem, the one bothering the most?

• It is important to hear this in her own words to avoid the common cognitive error of attributing familiar symptoms to a familiar diagnosis. If the patient uses a diagnosis as a chief complaint, e.g., “yeast infection,” redirect the focus to exact symptoms. A one or two word description e.g. itching and discharge, may summarize the patient’s main concern(s).

History of present illness

When did the patient first note symptoms?

• Begin a careful timeline to develop accurate pattern recognition of the disease, starting with the patient’s earliest memory of the problem.

What was going on at the time?

Possible precipitating event examples:

• illness with prolonged antibiotic use, possibly influencing development of recurrent Candida
• development of a disease requiring immunosuppressant treatment leading to recurrent Candida
• chemotherapy producing a vulvovaginal drug reaction
• radiation yielding radiation vulvitis
• new medications producing vulvovaginal drug reactions or lichenoid drug reactions
• new partner with increased frequency of intercourse associated with vaginitis⁵⁶
• menarche or menopause with estrogen changes
• childbirth or lactation
• pelvic surgery with possible injury to nerves supplying vulva and vagina
• gynecologic procedures necessitating prolonged lithotomy position or instrumentation of the groin, both possible causes of nerve irritation or compression
• new exercise or sports in patient with a musculoskeletal problem such as significant scoliosis, dysplasia of hips

With the onset of symptoms, what did the patient do?

• She may have self-treated, seen a clinician for treatment, or rationalized that symptoms were normal and sought no help. Keep asking “and then what happened?” until you arrive at the present. Continue this question line to obtain all steps in care up to today.

What are the specifics about the symptoms that may help with disease pattern matching?

• Are the symptom patterns constant or intermittent? When present, do they last hours, days, weeks, years? How long have they persisted?
• Are they present when she opens her eyes in the morning, or do they awaken her from sleep at night? Either of these suggests significant pathology.
• How long can the patient go free of symptoms? Long periods with freedom from symptoms may warrant observation or minimal treatment, avoiding centrally acting medication in the case of pain.

Has the patient ever been free of symptoms?

• If she complains of dyspareunia, has she ever had pain-free sex? If she complains of itching and burning, has she ever been symptom-free since it started?
• Relentless itching and burning symptoms prompt consideration of hyperpathic itching or neuropathic pain (after other causes have been ruled out).

What is the severity of the symptoms?

• Are they mild, moderate, or severe?
• To be specific, quantify the symptoms. Ask the patient: on a scale from zero to 10, what is the most pain you have had? Also, ask: on a scale from zero to 10, what is your pain level today?
• Repeat the question for itching. A score above 5/10 is considered moderate to severe and may warrant consideration of centrally acting drugs for itching or pain. (Annotation I: Pain and symptom mapping and the Q-tip test).

What is the location of the symptoms?

Is her discomfort on the mons, on the labia, around the vaginal introitus, in the vestibule, in the perianal area, inside the vaginal canal, outside of the vulva entirely, varying from one site to another?

• Patients often lack anatomical knowledge or vocabulary to describe the location of their symptoms. To avoid making incorrect assumptions, you will need them to show you the location by touching or pointing to the area during the examination.
• Neuropathic pain may vary from one site to another or persist in one location.
• Dermatitis and dermatosis may occur in one or more areas.
• Pain in the mons pubis or anterior labia may arise from the ilioinguinal (as opposed to pudendal) nerve.

What modifies the symptoms? What triggers or aggravates them?

• Sitting, standing, walking, tight clothes, touch as with washing, wiping, applying topical medications, foreplay and arousal, vaginal penetration, urination?

What helps?

• Reclining, removal of clothes, heat, cold, baths, medications, application of topical treatments?
• Neuropathic pain often persists unimproved by any modality.

What treatments, prescription or other (including alternative treatments or those that the patient has made up herself), have been used? What worked? What did not?

• What worked, e.g., antifungal or steroidal, with return of symptoms after discontinuation?

What worsens symptoms?

• Loss of epithelial barrier function with age, atrophy, or atopy; epithelial injury causes burning with any topical treatment, even water in severe cases. Burning neuropathic pain can be triggered by the touch of applying topical treatments.

What is going on today?

• Is the chief complaint present or not?
• Are you seeing her at her worst or during a good period? A currently symptom-free patient may need to return when flaring.

When was treatment last used?

• Steroids, antibiotics, antifungals may mask signs and symptoms. Biopsy is not helpful for dermatosis if steroids have been used in the past two weeks; topical steroids, however, will not mask malignancy.

When was an antifungal last used?

• Loss of epithelial barrier function with age, atrophy, or atopy; epithelial injury causes burning with any topical treatment, even water in severe cases. Burning neuropathic pain can be triggered by the touch of applying topical treatments.

What is the impact of the symptoms on her life?

• Significance can vary from nuisance of minor recurrent itching to life altering pain, inability to function sexually, and loss of self-esteem. (Vulvovaginal pain and sexuality.)

Past vulvovaginal history

• Obtain details of any past vulvovaginal problem. Include Candida, sexually transmitted infections, Bartholin gland cyst or abscess, dermatitis or dermatosis, or hidradenitis suppurativa. Search records for accurate documentation of conditions, treatments used. If possible, obtain previous culture and biopsy reports.

Relationship and sexual history

 

• Pain syndromes and chronic vulvovaginal conditions may seriously impair the ability to have normal relationships, sexual or interpersonal. (Vulvovaginal pain and sexuality) Information about her relationships and support system and her sexual functioning are integral to developing a diagnosis.
• The questionnaire can elicit sexual information (although women do not always complete the questions), or you can ask. It may take several visits before you have obtained all the information you need. Be prepared to listen without judgment or demonstration of surprise.
• To set the atmosphere that you are open to this kind of information, be aware that your own comfort with these kinds of questions is conveyed to the patient both verbally and non-verbally. It helps to be thoroughly familiar with normal sexual functioning in order to obtain a good history. (Vulvovaginal pain and sexuality). In addition, it is very important to not only gain the patient’s permission to ask sensitive questions, but also to give her permission to safely reveal whatever she needs to so that you can help her more effectively. (See the PLISSIT model of sex therapy for more on this.) Once that permission has been gained and given, open-ended questions facilitate obtaining good information. For example, you can say, “Tell me what happens in a typical sexual encounter between you and your partner.” If this kind of discussion is personally difficult for you, there is excellent education available. (AASECT (American Association of Sex Counselors, Educators, and Therapists) info@aasect.org, SSTAR (Society for Sex Therapy and Research) http://sstarnet.org/, ISSWSH (International Society for the Study of Women’s Sexual Health) http://www.isswsh.org/), SIECUS (Sexuality Information and Education Council of the United States) http://www.siecus.org/, or WPATH (World Professional Association for Transgender Health) http://www.wpath.org/. The CDC has a PDF on taking a sexual history: https://www.cdc.gov/std/treatment/sexualhistory.htm. Locating a helpful sexual therapist who can work with you and the patient may facilitate obtaining this kind of history. However, be aware that sex therapists do not perform the essential physical evaluation vital to a complete understanding of the woman’s problem(s).
• As you obtain sexual information, keep in mind that a situation is a problem only if the patient perceives it as such. Loss of libido may not bother her. Lack of orgasm may not be an issue for her. On the other hand, sexual education for her may help her recognize situations that are problems for many women, such as inadequate lubrication.

The sexual history should include the following questions:

• “Would you be willing to tell me about your sexual activity so I can ask you the best questions to help with your current problem?”
• “Do you have any questions or concerns about your sex life?”
• “What is your sexual preference: male, female, both?” Sexual response physiology and pain are the same in both heterosexual and same-sex partners, but your discussion may need to be modified depending on sexual preference, practices, and medical problems.
• “Do you currently have a partner? Is there more than one partner? If there is no partner now, have you ever had a partner in the past?”
• “What is the length of your current relationship? Has your libido changed in any way?”
• Ask about type of intimate behavior: Is there self-stimulation? Does it feel good? Can you communicate what feels good to your partner? Is vaginal penetration possible; do you use non-vaginal stimulation; is activity limited to embracing and cuddling; do you avoid sex entirely? If vaginal penetration occurs, how often does it occur? When was the last episode of intercourse/vaginal penetration?
• What is the duration of intercourse/vaginal penetration (how long does touch or thrusting go on)? The average duration is four to seven minutes.
• Ask: “what are you feeling when you are being kissed and hugged? Are you thinking how good it feels to be kissed and hugged or are you worrying that this will lead to painful sex?”
• “Do you arouse and lubricate? Or, do you tolerate dryness? If there is lubricant use, what kind is it?”
• What sexual devices/sex toys are used? Do they cause any problems?
• Is she able to have an orgasm? Does she have orgasms with external stimulation, with penetration, with both? Is there any pain with orgasm?
• Is dyspareunia present? Obtain details: is there pain with vulvar touch and foreplay? Is there pain with vaginal penetration (digital, penile, sex toy)? Is there pain with thrusting and movement? Is there pain after sexual activity? Has pain with intercourse been present from the first experience? If not, when did pain develop? Is the pain superficial to the vulva, deep in the vagina, or deep in the pelvis?
• “Is sexual activity enjoyable or is it something that you tolerate or avoid entirely? Do you continue to have intercourse despite the pain? If so, at what frequency does it occur?”
• “How do you protect yourself from sexually transmitted infections?”
• Is there a history of sexual abuse or assault? Clinicians need to be aware that behavioral health treatment after abuse or assault can facilitate healing and allow development of sexuality albeit some aspects of the sexual menu may be excluded. Many women, however, have never disclosed the assault to anyone; or if they have done so without treatment, ongoing issues remain.

Personal hygiene and exposure to irritants history

It is important to recognize that use of a certain soap or detergent or type of clothing seldom represents the etiology of major vulvovaginal symptoms, but may be one of the many contributing factors to ongoing discomfort. The following questions are covered in Annotation J: lifestyle issues.

• Are her bathing practices contributing to her symptoms?
• Does she wash the vulva with a cloth or her fingers? Some women “scrub” the skin inappropriately. What kind of soap does she use?
• What are her toileting practices?
• Hair removal: does she shave the vulva? Hair growing in can be itchy and many women get folliculitis.
• Menstrual hygiene practices: what does she use to protect her clothing? Does she use tampons or pads during the days she does not have her period?
• Clothing: are her clothes too tight? Does she wear thongs, tight jeans with a thick seam, etc?
• Laundry: some products are more irritating to the skin than others are.
• Exercise, sports: avid exercisers may wear tight Lycra that does not breathe or experience friction with repetitive patterns of exercise. Horseback riding, bicycle or unicycle riding cause their own vulvar pressure problems.

Family history

• Does anyone in the family have any vulvovaginal problem? Does anyone in the family have any autoimmune disorders?
• Obtain details. There is a family association with lichen sclerosus and lichen planus; other autoimmune conditions sometimes associated with vulvar disease, such as hypothyroidism or diabetes can also be familial.

Associated systems review

• Each of the following systems is known to be linked to particular vulvovaginal problems.

Urinary

Frequency

• A woman should be able to go two hours without voiding. More than eight voids per day are considered excessive. Urinary tract infection is often over-diagnosed in women with vulvovaginal complaints, but still requires your evaluation with urinalysis and culture. Consider fluid intake data and obtain a log of symptoms if necessary.
• If frequency is present, does she have an overactive bladder that can affect the pelvic floor? Is she a dysfunctional voider? For example, some jobs such as nursing and teaching lead to holding urine for hours without voiding. Other women develop the habit of voiding too frequently. Both patterns affect the pelvic floor. (Annotation L: The pelvic floor.)
• Is frequency accompanied by bladder pain? Painful Bladder Syndrome/Interstitial cystitis (PBS/IC) becomes a consideration.

Urgency

• The constant need to void may come from the peri-urethral irritation of epithelial disorders, and vulvodynia. A history of frequency and urgency with repeatedly negative urine cultures can be seen with vulvodynia. (Annotation K: Vulvar pain and vulvodynia).

Nocturia

• Voiding more than two times during the night is considered excessive. Some women awaken with vulvar symptoms more than once during the night and get up to void; this is not nocturia. Evening fluid intake, medications, interstitial cystitis, cardiac disease are considerations.

Dysuria: burning with urination

• Is this a contact dysuria (as urine touches inflamed skin) or is this up inside the urinary tract, suggesting true dysuria. Since the urethra occupies a central point in the vestibule, any epithelial disorder can cause urethritis and dysuria. STIs can also cause urethritis and burning. Vulvodynia is associated with dysuria, as well. (Annotation K: Vulvar pain and vulvodynia)

Incontinence

• Urinary loss is a source of contact dermatitis from the urine as well as from menstrual pads that women frequently use. Women need to use a product designed for incontinence, to wick away moisture from the skin.

Gastrointestinal

• Ask about constipation and diarrhea. For some women, constipation starts with childhood withholding patterns that are retained into adulthood. Irritable Bowel Syndrome is a common problem that can lead to up-regulation of the dorsal horn, ongoing pain, and pelvic floor dysfunction.⁷ (Annotation L: The pelvic floor).
• Perianal dermatitis associated with cleaning habits or with constipation, diarrhea, or fecal soilage, is a common problem. Pruritus ani may be associated with Candida or dermatoses, including lichen sclerosus, that can affect the anus. (lichen sclerosus, Atlas of vulvar disorders).
• Women frequently inaccurately attribute perianal symptoms to hemorrhoids. Crohn disease may have vulvar manifestations including ulceration and is associated with hidradenitis. (hidradenitis suppurativa, Atlas of vulvar disorders). Fistula formation may also occur. (Annotation N: The vaginal architecture).

Musculoskeletal

• This system is frequently overlooked in searching for the etiology of vulvar pain.
• An imbalance and rotational obliquity of the pelvic girdle that may accompany scoliosis, short leg syndrome, or dysplasia of the hips, may lead to sacro-iliac joint dysfunction and pelvic floor muscle imbalance.⁸
• Two muscles that are frequently affected are the pubourethalis and obturator internus.⁹ A hypertonic pubourethralis muscle will give symptoms of urgency, frequency, suprapubic pain, and aberrant urinary flow. In spasm, the obturator internus can irritate the pudendal nerve in Alcock’s canal and lead to clitoral/perineal discomfort that worsens with sitting.¹⁰
• Ask if there have been any problems in the past with back, hips, knees, need for orthopedic treatment or physical therapy.

Dermatological

• Atopy and eczema may lead to sensitive skin and contact dermatitis that may occur in isolation or exacerbate conditions such as lichen sclerosus.
• Psoriasis elsewhere on the body should prompt a check for vulvar psoriatic lesions.
• A history of acne or axillary or submammary boils should prompt a check for hidradenitis.
• Women often fail to mention oral lichen planus that often accompanies vulvar lichen planus. Aphthous ulcers of the mouth may also occur with vulvar aphthae in complex aphthosis. (aphthosis, Atlas of vulvar disorders).

Gynecological

What is the patient’s menstrual and contraceptive status?

• Ask about regularity or alteration in menses, either naturally through breastfeeding, pregnancy, menopause, or by exogenous hormones or chemotherapy.
• Lack of estrogen can cause symptomatic atrophy of the vulva and vagina that is progressive, increasing fivefold as women advance through menopause.¹¹ While atrophy typically occurs in menopausal women, it can occur in women of any age who experience a fall in estrogenic stimulation to the urogenital tissues. Loss of the epithelial barrier that occurs with vulvar atrophy can exacerbate a dermatosis such as lichen sclerosus.
• Note current contraception. While studies are conflicting, many investigators believe that oral contraceptives (OCP) predispose women to recurrent candidosis.¹² There is also a possibility that sustained use of the OCP may be a factor in vulvar pain.¹³ Increased carriage of yeast is reported, in some studies, in users of intrauterine contraceptive devices, contraceptive sponges, diaphragms, and condoms, with or without spermicides.^{14 15} An extensive study of college students, however, did not show an increase in the risk of symptomatic vulvovaginal candidosis in users of oral contraceptives, diaphragms, condoms, or spermicides.¹⁶
• Women often feel that their vulvar problems are associated with specific times in the menstrual cycle. Whether these symptoms are related to hormonal variation or other factors has not been studied well; clear association of symptoms with menses may lead to menstrual suppression for treatment or to evaluation for hormonal allergy such as autoimmune progesterone dermatitis.¹⁷ (autoimmune progesterone dermatitis). Menstrual hygiene may also influence pain, dermatitis, and dermatosis.

What gynecologic problems or procedures has she had?

Ask: Have you had an abnormal pap smear? If yes, how was this managed?

• It is important to recognize that the human papilloma virus is the cause of cervical disease and genital condyloma. See the American Society for Colposcopy and Cervical Pathology, ASCCP, for cervical cancer screening guidelines and information on HPV.
•  Many vulvar experts do not manage abnormal pap smears. You need to be clear whether you will be following the Pap smear or HPV test or if it is being managed by another identified clinician. Remember to ask patients about most recent Paps at subsequent visits because they often assume that, because you evaluate the vulva and vagina, you are doing their Paps.
• Be aware also that use of topical steroids may lower local immunity in the vulvar epithelium and lead to exacerbation of condyloma as well as herpes.

Obstetrical

Ask about number of pregnancies, number of births, and type of birth (spontaneous vaginal, forceps or vacuum, or cesarean).

• Complications of delivery (prolonged second stage, then instrumentation, laceration repair necessitating operating room intervention, extensive hematoma, infection with prolonged antibiotic use, urinary dysfunction with extended catheterization, prolonged pelvic or vulvovaginal pain) may cause prolonged symptoms.
• Any pregnancy-related event that could influence the vulva, vagina, or pelvic floor (prolonged lithotomy position, complicated abortion, ruptured ectopic, etc) may do the same.
• Infertility associated with premature ovarian failure may suggest autoimmune disease such as lichen planus or lichen sclerosus.¹⁸
• If there is a history of irritation or pain since delivery, ascertain history of any symptoms prior to the pregnancy. Episiotomy and laceration are sometimes thought the source of discomfort for an undiagnosed dermatosis such as lichen sclerosus.
• Pregnancy and delivery may unmask underlying abnormality of the sacrum or pelvic girdle leading to pelvic floor dysfunction and vulvar pain. Direct neuromuscular injury to the pelvic floor results in pelvic floor muscle spasm, dysfunction, and pain. This type of injury occurs in traumatic vaginal deliveries especially if forceps or vacuum extractors were involved.¹⁹
• The low estrogen state immediately postpartum and in breastfeeding mothers may be a temporary cause of vulvovaginal pain and dyspareunia.
• Plans for pregnancy in the near future may influence treatment plans for vulvar pain; vulvovaginal problems may force a woman to decide which is the priority in her life: having a baby (putting medications and treatment on hold in order to pursue pregnancy) or commitment to obtain control of vulvovaginal issues prior to conception. When intercourse is not possible because of pain, assisted reproductive technology is available.
• Good data regarding method of delivery of women with vulvar pain do not exist but successful vaginal deliveries after vestibulectomy are reported.
• If a woman has a dermatosis with active erosions, on-going fissuring, restriction of the introitus by scarring, consideration of cesarean delivery is prudent. Weak and damaged vulvar tissue heals poorly. There is little medical evidence on this topic.

Past medical/surgical history and review of systems

• You need to know about an allergy history suggesting atopy that leads to sensitive skin and complicates dermatoses. (Atlas of vulvar disorders, section on contact dermatitis, allergic and irritant, section on atopy).
• Frequent ear infections, streptococcal throat infections, tonsillitis, acne treatments, and sinus infections lead to antibiotics and Candida.
• Asthma can necessitate antibiotics and prednisone, also leading to Candida. Autoimmune disorders are seen in women with lichen sclerosus and lichen planus.
• Diabetes can be associated with Candida and also decreases lubrication;²⁰ hypothyroidism is associated with lichen sclerosus.
• Ask: what hospitalizations or surgeries have you had besides the ones listed in the GYN history.
• The Review of Systems elicits current symptoms or health problems.

Medications

• Ask about current prescriptions, vitamins, or supplements. Women often neglect to mention recent antibiotics, antifungals, topical treatments, and over-the-counter products.
• The list of medications should be reviewed and updated at every visit to make sure that the patient is adherent to the treatment program and has not added new medications that may affect the vulva and vagina.
• Some medications may directly cause vulvar symptoms, as in the case of fixed drug eruption or the possibility of an association of some medications with the development of lichen planus.
• Medication interactions may also affect treatments for vulvovaginal problems. Fluconazole, for example, interacts with other medications of the cytochrome P450 system. An index giving all possible drug reactions (epithelium, hair, gastrointestinal, and so on) is Litt’s Drug Eruption and Reaction Manual, 23rd edition, available through Amazon, or by subscription at https://www.drugeruptiondata.com/.

Allergies

• A propensity for environmental allergies can be a clue to a potential for atopic dermatitis.²¹
• It is always important to know about medication allergies.

Social history

The social history needs to be done to be complete. Each element might have an impact on the cause or the treatment of vulvar disorders. Ask the following:

• Do you drink alcohol? How many drinks a week?
• Do you smoke cigarettes? How many packs a week?
• Do you use recreational drugs? If so, which ones?
• Do you feel safe at home? If no, please explain.
• Do you exercise regularly? If yes, what form of exercise do you do? How many hours a week do you exercise? Avid exercisers may have irritation from tight Lycra clothing, sweat, or friction from repetitive actions.

 

EXAMPLES OF CRITICAL POINTS FROM HISTORY (read across)