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disease.

      Another vital facet of multidisciplinary working relates to clinicopathological correlation, and working closely with the pathologist is essential. It is important that the clinical and histological diagnosis concur, and if there is doubt, biopsies may need to be repeated. Agreement and understanding of changing classifications and terminology must also occur between clinicians and pathologists to avoid confusion. It has been shown that cooperation between gynaecology and dermatology pathologists improves the accuracy of reporting of vulval biopsies [16].

The consultation

      History

      The importance of an accurate and thorough history cannot be overemphasised. Many find it convenient to have a formal proforma as a basis for history taking, and to then enlarge upon particular aspects in the light of the individual patient’s problem. A structured form ensures that essential information is collected. It is also useful to have similar baseline data for each patient to be used for future comparative clinical research. Some clinicians advocate the use of pre‐clinic questionnaires where the patient can provide basic information which can then act as the basis for more detailed face‐to‐face questioning [17]. However, it is possible to be misled and easy to miss non‐verbal cues from the patient with this approach. It can be helpful to use validated questionnaires to give a quantifiable assessment of how the vulval problem affects quality of life. It is common for even mild vulval disease to have a severe impact on the patient [18], which can be overlooked in history taking. Several tools are available, but these are usually generic and not specific to the vulva [19]. A Vulval Disease Quality of Life Index in lichen sclerosus has recently been published [20]. The Dermatology Quality of Life Index (DLQI) [21], Female Sexual Function Index (FSFI) [22], Female Sexual Distress Scale (FSDS) [23], and Hospital Anxiety and Depression Scale (HADS) [24] are frequently used in practice. In patients with pain, the McGill Pain Questionnaire [25] is most often used but several outcome measures are used in studies, which make results difficult to compare [26].

      It is important that the initial interview should take place in a relaxed and sympathetic atmosphere, as this is the first encounter with the patient. Building a good rapport at this stage will help them gain confidence in the consultation. If there are language difficulties which will impede good history taking, an interpreter is needed, but this can unfortunately limit the information that the patient is willing to give. A professional interpreter should always be used in order to ensure that you are receiving the correct information, which may not be given accurately by a family member. In the setting of a teaching clinic, it is essential to ensure that the patient is content to have a student or observer present before starting to take the history.

There are several areas to be covered in the consultation, which are listed in Table 5.1. It is often best to start with an open‐ended question so that the patient can express the main problem. Details of the presenting complaint should include duration and initiating, provoking, and alleviating factors. Previous treatments used and their effects should be noted, either prescribed or bought ‘over the counter’. A general medical history, including medication taken and a previous dermatological and gynaecological history, is essential as the vulval problem may be part of more widespread disease. A sexual history [27] and some basic questions about psychosexual issues are important and will need referral to the appropriate specialist if indicated. If a sexually transmitted infection is possible from the history, a full travel history and assessment by a genitourinary physician are needed. Features of the social history, such as smoking, are highly relevant in conditions such as high‐grade squamous intraepithelial lesion (HSIL) and hidradenitis suppurativa.

Table 5.1 History taking in patients with vulval symptoms.

		Supplementary questions
Presenting complaint	Duration
	Triggers/alleviating factors
	Constant/intermittent
	Associated features
	Treatments used	Prescribed/over the counter Duration of treatment Response to treatment
Past medical history	Other medical issues
	Autoimmune disease
Family history	Atopy
	Skin disease
	Vulval disease
	Autoimmune disease
Drug history	Current drugs taken Allergies
Dermatological	Other skin disease
	Atopy
	Hygiene practice	Frequency Products used
Gynaecological	Menarche	Any delay in puberty
	Cycle	Relationship of symptoms to cycle
	Menorrhagia
	Vaginal discharge	Type Colour Constant or intermittent
	Contraception
	Cervical cytology
	HPV vaccination
	Bleeding*
	Dyspareunia	Superficial or deep Recovery – minutes, hours, days
Obstetric	Number of pregnancies	Miscarriages, terminations
	Mode of delivery	Episiotomy/obstetric tears
	Complications of delivery
Urinary	Incontinence	Stress/urgency Use of pads
	Dysuria
	Difficulty with stream
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