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11/13/24, 8\:10 PM Guide | Gynaecological history

Gynaecological history

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Open vs closed questions
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History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Once the patient has had time to communicate their presenting complaint, you should then begin to explore the issue with
further open and closed questions.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient's presenting symptoms in more detail. It is most
commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may
not be relevant to all symptoms.
Site
Ask about the location of the symptom\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
Onset
Clarify how and when the symptom developed\:
" D i d t h e p a i n c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h e n d i d t h e p a i n
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g t h e p a i n ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?" (e.g. dull ache, throbbing, sharp)
" I s t h e p a i n c o n s t a n t o r d o e s i t c o m e a n d go ?"
Radiation
Ask if the symptom moves anywhere else\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?" (e.g. shoulder tip pain in ectopic pregnancy)
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?" (e.g. patients presenting with an ectopic pregnancy may
have associated nausea and vomiting)
Time course
Clarify how the symptom has changed over time\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
Ask if the symptom has any relationship to the menstrual cycle\:
" H a v e y o u n o t i c e d i f t h i s s y m p t o m i s w o r s e a t a p a r t i c u l a r t i m e i n t h e m o n t h ?"
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better\:
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?" (e.g. patients with symphysis pubis dysfunction may
makes things worse)
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?" (e.g. many patients will have tried multiple treatments before presenting with
dysmenorrhea, e.g. heat pads, NSAIDs)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10\:
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" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
Ask the patient if the symptom is having a signi
" H o w i s t h e p a i n / b l e e d i n g i m p a c t i n g y o u r d a i l y l i f e ?"

Gynaecological symptoms

Once you have completed exploring the history of presenting complaint, you need to move on to more focused questioning
relating to the common symptoms of gynaecological disease.
We have included a focused list of the key symptoms to ask about when taking a gynaecological history, followed by some
background information on each, should you want to know a little more.
Summary of key gynaecological symptoms
Key gynaecology symptoms to ask about include\:
Abdominal and pelvic pain\: causes include ectopic pregnancy, ruptured ovarian cyst, endometriosis, pelvic
in
Post-coital vaginal bleeding\: vaginal bleeding occurring after sexual intercourse. Causes include cervical ectropion,
cervical cancer, gonorrhoea, chlamydia and vaginitis.
Intermenstrual vaginal bleeding\: vaginal bleeding occurring between menstrual periods. Causes include
contraception (e.g. Mirena coil), ovulation, miscarriage, gonorrhoea, chlamydia, uterine
malignancy (e.g. uterine cancer, cervical cancer, vaginal cancer).
Abnormally heavy menstrual bleeding (menorrhagia)\: causes include endometriosis, contraception (e.g. copper coil),

Abnormally painful menstrual bleeding (dysmenorrhea)\: pain that is signi
that is abnormal for what the patient experiences as ‘normal’
. Causes include endometriosis, contraception (e.g. copper
coil), perimenopause and pelvic infection.
Post-menopausal bleeding\: bleeding that occurs after the menopause. Causes include vaginal atrophy, hormone
replacement therapy and malignancy (e.g. uterine cancer, cervical cancer and vaginal cancer).
Abnormal vaginal discharge\: causes include vaginal candidiasis, bacterial vaginosis, chlamydia and gonorrhoea.
Dyspareunia\: causes include endometriosis, vaginal atrophy, gonorrhoea, chlamydia and pelvic in
Vulval skin changes and itching\: causes include vaginal atrophy, vaginal thrush, gonorrhoea and lichen sclerosus.
Systemic symptoms\: fatigue (e.g. anaemia), fever (e.g. pelvic in
Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and
abnormal vaginal discharge when taking a gynaecological history.
You should ask if the patient has noticed any changes to the following characteristics of their vaginal discharge\:
Volume\:
" H a v e y o u n o t i c e d a n y c h a n g e i n t h e a m o u n t o f v a g i n a l d i s c h a r g e ?"
Colour (e.g. green, yellow or blood-stained)\:
" H a v e y o u n o t i c e d a n y c h a n g e i n t h e c o l o u r o f y o u r d i s c h a r g e ?"
Consistency (e.g. thickened or watery)\:
" H a v e y o u n o t i c e d t h a t y o u r d i s c h a r ge h a s b e c o m e m o r e w a t e r y o r t h i c k e n e d
r e c e n t l y ?"
Smell\:
" H a v e y o u n o t i c e d a n y c h a n g e i n t h e s m e l l o f t h e v a g i n a l d i s c h a r g e ?"
Several infections can cause abnormal vaginal discharge\:
Candidiasis may present with thick, white or creamy lumpy discharge with associated vaginal itching and irritation.
Gonorrhoea and chlamydia may present with abnormal vaginal discharge.
Bacterial vaginosis typically presents with an o
irritation.
Trichomonas vaginalis typically presents with yellow frothy discharge with associated vaginal itching and irritation.
Dyspareunia
Dyspareunia refers to pain that occurs during sexual intercourse. It has several causes including infections, endometriosis,
vaginal atrophy, malignancy and bladder in
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The location of the pain varies between patients\:
Super
vaginal introitus)
You should clarify\:
Deep dyspareunia\: pain deep within the pelvis (e.g. endometriosis,
the duration of the symptom
the location of the pain (e.g. super
the nature of the pain (e.g. sharp, aching, burning)
Vulval skin changes and itching
Vulval skin changes and itching are common symptoms which can have several underlying causes\:
Infections such as candida (thrush), bacterial vaginosis and sexually transmitted infections (e.g. gonorrhoea).
Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina.
Lichen sclerosus appears as white patches on the vulva and is associated with itching.
Other symptoms
Urinary symptoms such as frequency, urgency and dysuria can be relevant to gynaecological problems (e.g. vaginal prolapse,
vaginal atrophy, infection or
Bowel symptoms such as a change in bowel habit or pain during defecation can be associated with endometriosis.
Fever may be associated with pelvic in
Fatigue is a non-speci
Unintentional weight loss is a concerning feature that may indicate underlying malignancy.
Abdominal distension is often a benign symptom, however, it can be associated with serious underlying pathology such as
ovarian cancer with ascites.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"
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Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
c y c l e .
"
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n w e' l l d i s c u s s y o u r m e n s t r u a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fatigue (e.g. anaemia), fever (e.g. pelvic in
cancer)
Respiratory\: dyspnoea (e.g. anaemia), haemoptysis (e.g. endometriosis)
Gastrointestinal\: abdominal pain (e.g. ectopic pregnancy, dysmenorrhoea), painful defecation (e.g. endometriosis),
abdominal bloating (e.g. ovarian cancer)
Genitourinary\: urinary frequency, dysuria and urgency (e.g. urinary tract infection), abnormal vaginal discharge (e.g. vaginal
candidiasis, gonorrhoea)
Musculoskeletal\: shoulder tip pain (e.g. ectopic pregnancy)
Dermatological\: white patches on the vulva/vagina associated with pruritis (e.g. lichen sclerosus)

Menstrual history

A menstrual history involves exploring the characteristics of the patient's menstrual cycle.
Duration
Ask the patient about the duration of their periods\:
" H o w l o n g d o y o u r p e r i o d s t y p i c a l l y l a s t ?"
The average duration of menstruation is 5 days, with more than 7 days considered prolonged.
Frequency
Ask the patient about the frequency of their periods\:
" H o w o f t e n d o y o u r p e r i o d s o c c u r ?"
" A r e t h e y r e g u l a r a n d p r e d i c t a b l e ?"
Periods typically occur every 28 days, however, there is signi
Menstrual blood
Ask the patient about the volume of their periods\:
" A r e y o u r c u r r e n t p e r i o d s h e a v i e r t h a n y o u r u s u a l p e r i o d s ?"
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" H o w o f t e n d o y o u n e e d t o c h a n g e s a n i t a r y p r o d u c t s ?
" W h a t a b s o r b e n c y p r o d u c t d o y o u u s e , a n d h a s t h i s c h a n g e d r e c e n t l y ?"
" H a v e y o u b e e n
" H a v e y o u b e e n p a s s i n g b l o o d c l o t s l a r g e r t h a n a 1 0 p c o i n ?"
" A r e t h e h e a v y p e r i o d s i m p a c t i n g y o u r d a y t o d a y l i f e ?"
The average menstrual blood loss is approximately 40mls (8 teaspoons). Heavy menstrual blood loss is de
80mls (16 teaspoons) or having periods that last longer than 7 days.
The de
woman how the current periods compare to her usual loss. If the volume of bleeding is impacting on the woman's day to day
life, it is signi
Menstrual pain (dysmenorrhoea)
Ask the patient if their periods are particularly painful\:
" D o y o u h a v e p a i n f u l p e r i o d s w h i c h i n t e r f e r e w i t h y o u r d a y t o d a y l i f e ?"
" H a v e y o u r r e c e n t p e r i o d s b e e n m o r e p a i n f u l t h a n u s u a l ?"
It is common for women to experience abdominal and pelvic pain when menstruating. Menstrual pain can sometimes be
severe and have a signi
menstrual pain.
Date of last menstrual period
Ask the patient when the
" W h a t d a t e w a s t h e
If the patient's period is late, consider performing a pregnancy test, particularly in the context of abdominal pain (to rule out
ectopic pregnancy).
Age at menarche
Ask the patient how old they were when they started having periods\:
" A t w h a t a g e d i d y o u s t a r t h a v i n g p e r i o d s ?"
Early menarche is associated with an increased risk of breast cancer and cardiovascular disease.
Menopause (if relevant)
Ask the patient how old they were when they went through the menopause\:
" D o y o u r e m e m b e r h o w o l d y o u w e r e w h e n y o u w e n t t h r o u g h t h e m e n o p a u s e ?"
If the patient is perimenopausal ask about symptoms such as hot

Contraception

Clarify the type of contraception currently used\:
Combined contraceptives\: combined oral contraceptive pill and the contraceptive patch.
Progesterone only pill (POP)
Depot injection (progesterone)
Long-acting reversible contraceptives (LARCs)\: hormonal coil, implant and copper coil.
Barrier methods
Explore the patient's previous contraception history\:
It is useful to be aware of what the patient has previously tried, particularly if considering a change to their current choice of
contraception.

Reproductive plans

You should ask the patient if they are considering having children in the future (or are currently trying to fall pregnant).
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This is important to know when considering treatments for their gynaecological issue (e.g. you wouldn't suggest endometrial
ablation or hysterectomy for menorrhagia if the patient was planning for a future pregnancy).

Past gynaecological history

It is important to ask about a woman's previous gynaecological history, as this may in
management options.

Gynaecological conditions

Ask if the patient has previously had any gynaecological problems\:
Ectopic pregnancy
Sexually transmitted infections
Endometriosis
Bartholin's cyst
Cervical ectropion
Malignancy (e.g. cervical, endometrial, ovarian)

Gynaecological surgery or procedures

Ask the patient if they've previously undergone any surgery or procedures in the past such as\:
Abdominal or pelvic surgery
Caesarean section
Loop excision of the transitional zone (LETZ)
Vaginal prolapse repair
Hysterectomy

Cervical screening

Clarify the patient's cervical screening history\:
Con
Ask if the patient received any treatment (if the cervical screening test was abnormal) and ask if follow up is in place.
Ask if the patient has been vaccinated against HPV.

Past medical history

It is important to ask about the patient's non-gynaecological medical history, as these conditions may impact the
gynaecological problem and may themselves be impacted by or prevent the use of speci
Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Allergies
It's essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of
allergic reaction the patient experienced.
Examples of medical conditions relevant to gynaecological presentations
Migraine with aura\: oestrogen containing medications (e.g. combined oral contraceptive) would be contraindicated.
Previous venous thromboembolism (VTE)\: oestrogen containing medications would be contraindicated.
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Breast cancer (current or previous)\: use of oestrogen containing medications would be usually be contraindicated or
require specialist input before being commenced.
Bleeding disorders (e.g. Von Willebrand's) would be relevant if a patient presented with heavy vaginal bleeding.

Obstetric history

It is important to take a brief obstetric history as part of a gynaecological assessment, as it may be relevant to the patient's
presentation. This is less detailed than a focused obstetric history.

Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.
Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Current pregnancy

Gather key details about the patient's current pregnancy (if relevant)\:
Gestation
Symptoms associated with pregnancy (e.g. nausea, vomiting, back pain)
Complications (e.g. pre-eclampsia, gestational diabetes, cervical neck incompetence)
Recent scans results

Previous pregnancies

Gather key details about the patient's previous pregnancies (if relevant)\:
Age of children
Birth weight
Mode of delivery
Complications in the antenatal, perinatal, postnatal period
If relevant, ask if the patient is currently breastfeeding, as this is a contraindication to some types of contraceptives (e.g.
combined oral contraceptive)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter
medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
Some medications may cause gynaecological issues or interfere with gynaecological medications\:
St John's Wort increases the metabolism of the COCP reducing its e
Antibiotics may cause secondary vaginal thrush.
If the patient is taking hormonal replacement therapy (HRT) clarify the following details\:
Duration of use
Method of delivery (e.g. patch, gel, pessary)
Frequency of treatment (e.g. cyclical or continuous)
Type of treatment (e.g. combined or oestrogen-only)
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Medication examples
Medications commonly prescribed to patients with gynaecological disease include\:
Tranexamic acid (e.g. to manage menorrhagia)
Contraceptives (e.g. COCP, POP)
Hormone replacement therapy (e.g. combined or oestrogen-only)
NSAIDs (e.g. to manage dysmenorrhoea)
GnRH analogues (e.g. to manage endometriosis)

Family history

Ask the patient if there is any family history of ovarian, endometrial or breast cancer which may suggest possible familial
inheritance (e.g. BRCA gene)\:
“ I s t h e r e a n y h i s t o r y o f c a n c e r o f t h e w o m b , o v a r i e s o r b r e a s t s i n y o u r c l o s e r e l a t i v e s ?" (e.g. BRCA gene)
Ask the patient if there is any family history of bleeding disorders as menorrhagia may be the
inherited bleeding disorder such as Von Willebrand's disease\:
" I s t h e r e a n y h i s t o r y o f b l e e d i n g d i s o r d e r s i n y o u r f a m i l y ?" (menorrhagia can be the
bleeding disorder e.g. Von Willebrand disease)
Ask the patient if there is any family history of blood clots. Patients who have a signi
relative (particularly if they were less than 45 when it developed) may be at increased risk of VTE and therefore medications
such as combined oral contraceptives may be contraindicated\:
" H a v e a n y o f y o u r c l o s e f a m i l y m e m b e r s h a d b l o o d c l o t s i n t h e p a s t ?"

Social history

Understanding the social context of a patient is absolutely key to building a complete picture of their health.
General social context
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Consider if medications such as the COCP are contraindicated because of the patients smoking status\:
If smoking more than 40 cigarettes a day, the COCP would be contraindicated.
If over 35-years-old and smoking more than 15 cigarettes a day, the COCP would be contraindicated.
Osmoking cessation guide for more details).
Alcohol
information).
Record the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more
O
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
If recreational drug use is identi
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Diet and weight
Ask if the patient what their diet looks like on an average day.
Ask about the patient's current weight\:
Obesity signi
Anorexia can result in oligomenorrhoea (infrequent periods) or amenorrhoea (absence of menstruation).
A raised BMI may be a contraindication to some treatments, including combined oral contraceptives.
Occupation
Ask about the patient's current occupation and if they are managing ok at work with their current symptoms.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Venkatesh Subramanian
Obstetrics & Gynaecology Registrar in London
Dr Elizabeth Ferguson
General Practitioner
Source\: geekymedics.com
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