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OB/GYN Care

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Routine/Low risk PAPs/Breast Exam/Contraception (other than IUD)/STD screening and treatment/Menopause treatment

  • Refer to IMA Well Women's Clinic/ IMA GYN --> this is a gyn clinic run by internists (IMA attendings) for routine screening. Please make sure the patient has a CERVIX before referring to this clinic!

  • Hours: Wed AM

  • Epic Consult: "Consult to Well Women's Clinic (IMA GYN)".

  • Contact Person: Dr. Irene Rahman and Dr. Christine Schindler

  • 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

OB/pregnancy

Expedited Appointment/Pregnancy Interruption

Please email Natasha Barsattee natasha.barsattee@mountsinai.org with the following information:

  • Patient First and Last name
  • MRN
  • DOB
  • Reason for request

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: .IMAGYNTEMPLATE

Pap Smear:

  • 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

Frequency: q1-2yrs

Screening age guidelines are ambiguous:

Risk Factors:

  • age
  • 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

Menopause

Age

  • Avg: 45-55yo
  • Early: <45yo (indication for early DEXA screening)

Treatment of Perimenopausal Symptoms

  1. Lifestyle modifications
  2. SSRI/SNRI (e.g. Effexor)
  3. Gabapentin
  4. Clonidine
  5. Herbals (black cohosh, evening primrose oil)
  6. Hormonal replacement therapy (referral to Gyn)

Atrophic Vaginitis

  • 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

Osteoporosis

  • <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

STIs

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

Contraception

Questionnaire for best form of contraception

OCPs: contraindicated if >35sm, h/o clots, h/o cancer, migraines