Routine/Low risk PAPs/Breast Exam/Contraception (other than IUD)/STD screening and treatment/Menopause treatment
Refer to IMA Well Women's Clinic --> this is a well women's clinic run by internists (IMA attendings) for routine screening. Please make sure the patient has a CREVIX before referring to this clinic!
Hours: Wed AM
Epic Consult: "Consult to IMA Well Women's Clinic".
Contact Person: Dr. Aparna Sarin/Dr. Rachel Solomon
Phone: (212) 659-8551
Criteria for referral to GYN: If the patient is established with (hospital) Gyn already, they can referred to gynecology instead, as well as if they have a history of abnormal PAP smears.
Other general GYN, colposcopy, LEEP, IUD, Gyn Onc, Uro-gyn
Expedited Appointment/Pregnancy Interruption
Order consult in Epic.
Clinical Questions: Omara Afzal, Medical Director email@example.com.
OBGYN NURSE TRIAGE LINE (urgent consultation, walk-ins)
- Nurse Triage Line: (212) 241 9791(leave VM if busy; call will be returned)
General Clinic How-Tos
- Progress Note Template: MS OBGYN FEMALE-PREVENTATIVE VISIT
- Order CYTOLOGY, GYN (also comes up with "PAP SMEAR") --> Pick A)CERVIX, PAP ONLY (and HPV On Reflex will autofill) if 21-29yo or B)CERVIX, PAP + HPV COTEST SCREENING if 30-65yo
- Brush: (small green brush) 1/4 to 1/2 turn inside the os --> swirl 10x along walls of collection vial and toss
- Broom: (big purple broom) 5 turns inside the os --> gently jab 10x on floor of collection vial and toss
Billing Level: EST4 (if attending comes in)
Billing Diagnosis: Try to put a non-Z code as primary if possible (e.g. if you discussed any symptoms). If not, use Cervical Cancer Screening.
What to do at the end of the visit:
- Pap Collection Vial: MAKE SURE IT IS LABELED! (MA/LPN prints out labels and places them on the counter outside the MA station -- these are printed for you without you having to enter any Epic orders) Place in inner pocket of a specimen bag.
- Pap Log Book: If you did a pap, place a patient label in the Pap Log Book.
- Order Requisition: Once the order is placed in Epic, place both copies of the order requisition pages that print (4 sheets) into the outer pocket of the lab specimen bag.
- STI Testing: If done, label the specimen by hand with the patient's last name and place it in the same specimen bag with the pap vial. The MA will place the test label on it for you.
- Specimen Bag: Leave specimen bag with requisition orders +/- STI vial in the lab (1st room).
Cervical Cancer Screening
Screening Age Guidelines:
- 21-29yo: cytology only q3y
- 30-65yo: cytology + HPV cotesting q5y OR cytology only q3y
- Stopping screening (around 65yo): if within the last 10 years, 3x negative cytology OR 2x neg cotesting, AND last negative test was within the last 5 years
90% HPV is cleared within 2 years
Guidelines for Abnormal Results: (https://urldefense.proofpoint.com/v2/url?u=http-3Awww.asccp.org_asccp-2Dguidelines-5D-28http-3Awww.asccp.org_asccp-2Dguidelines-29&d=DwIGAg&c=shNJtf5dKgNcPZ6Yh64b-A&r=bvUsdoY9cLO__ft6cYJDlvV3fRhAlUgC8t3LGrBqvZ0&m=xVPzqSN2nHaIFNp9jVMoVXvKCgaWHieqmGSx4-33Wfo&s=IUaPIX_GxfEgR6JzrUhHFfAJJ8g_PjmsmVp7dCJQJ98&e=)(If results are anything beyond ASCUS, refer to Gynecology)
Breast Cancer Screening
Screening age guidelines are ambiguous:
- USPSTF: 50-75yo
- ACOG: 40-75yo
- American Cancer Society: 45-75yo, screening during 40-44yo based on shared decision-making
- 75-80yo continued screening based on shared decision-making
- Breast Cancer Surveillance Consortium Risk Calculator
- family history
- dense breasts
- increased estrogen exposure (early menarche, late menopause, nullparity)
- personaly history of biopsied mass (even if benign)
BIRADs 0 = indeterminant
- if microcalcifications --> diagnostic mammogram
- if mass --> diagnostic ultrasound
BIRADs 1 = normal, q1-2y screening
BIRADs 2 = probably normal, q1-2y screening
BIRADs 3 = probably normal, but retest in 6 months
BIRADs 4 = likely malignant --> biopsy needed
BIRADs 5 = malignant --> oncology
- Avg: 45-55yo
- Early: <45yo (indication for early DEXA screening)
Treatment of Perimenopausal Symptoms
- Lifestyle modifications
- SSRI/SNRI (e.g. Effexor)
- Herbals (black cohosh, evening primrose oil)
- Hormonal replacement therapy (referral to Gyn)
- Symptoms: vaginal dryness/burning, dyspareunia, bleeding after sex, urinary symptoms
- Diagnosis: decreased lubrication, vulvovaginal pallor/erythemaintroital retraction, tissue fragility/fissures/petechiae
- Treatment: | topical lubricant (e.g. Replens) | estrogen cream (e.g. Estrace, Premarin) - daily for 2 wks, then taper to 1-2x per wk, then off
- <1.5 mild osteopenia --> repeat DEXA in 10-15yrs
- 1.5-2 moderate osteopenia --> repeat DEXA in 5yrs
- 2-2.5 severe osteopenia --> repeat DEXA in 1-2yrs
2.5 osteoporosis --> tx with bisphosphonate and repeat DEXA in 1-2yrs
- if <2.5 but high risk, calculate FRAX score to determine treatment course
Trichomonas: classically with green frothy discharge; check NAAT in high risk individuals, tx with metronidazole
- can be asymptomatic, many undiagnosed cases in the community
Gonorrhea: ceftriaxone + 250mg azithromycin
Chlamydia: 1g azithromycin
Syphilis: dx with +RPR --> +confirmatory --> if >4x titers = new/reactivated, if <4x titers = latent (no treatment)
- acute: penicillin x1 IM
- chronic: penicillin x3 IM
Questionnaire for best form of contraception
OCPs: contraindicated if >35sm, h/o clots, h/o cancer, migraines