Gynecologic Office Research Articles

Evaluation of physical fitness in an ambulatory setting

The purpose of this study was to perform a brief physical fitness evaluation for ambulatory gynecologic patients and to determine whether a woman's perceived fitness level corresponded to her actual level. Except for patient report of exercise activity, no objective measures of fitness are assessed during annual gynecologic office visits. Written surveys and physical measurements were administered to 103 healthy women during their annual gynecologic visit. Patient self-report of fitness level, compared with actual fitness level determined by physical testing, was used as the main outcome measure. Physical fitness testing took 5-7 minutes to administer in a 3 x 2.2-meter office area. The woman's report of physical fitness did not correlate with actual fitness; rather, percent body fat as calculated by Lange skinfold caliper correlated most accurately with overall fitness (correlation coefficient, -0.389). Body mass index was correlated less strongly with a coefficient of -0.274; surprisingly, the waist/hip ratio had the weakest correlation to fitness (correlation coefficient, -0.129). Patient report does not appear to correlate with actual physical fitness. Physicians may consider initiating an objective measure, such as body fat measurement as calculated by Lange skinfold calipers, to the routine examination.

Colorectal Cancer Screening in Gynecology Patients

Objective: Gynecologists are essential primary care providers for female patients. Therefore, colorectal cancer (CRC) screening should be a part of their routine preventive practices. The purpose of our study is to evaluate CRC screening adherence in this population. Methods: A questionnaire was administered to a prospective cohort of female patients awaiting health maintenance exams at six academic and private gynecology offices. Patients reported demographic characteristics, CRC/breast/cervical screening compliance, previous CRC screening recommendations, and future likelihood of CRC screening. Results: 422 women aged 50 years and older completed the questionnaire. 91% were Caucasian with an average age of 58 years. 69% were seen by gynecologists with remaining patients seen by nurse practitioners (NP). 21% of subjects identified their gynecologist as their primary care provider (PCP). 75% of all respondents were compliant with one or more CRC screening modalities compared to 94% and 86% for breast and cervical cancer screening. Participants were more compliant with CRC screening in the academic setting (76%) vs. the private setting (62%). 76% of patients reported previous CRC screening recommendations from any physician. Gynecologists/NPs recommended CRC screening in 44% of patients (49% private, 40% academic). Colonoscopy was the most frequently utilized modality (55%). 65% of respondents were planning to undergo future CRC screening. On multivariable analysis, patient characteristics associated with previous CRC screening in the both settings included (odds ratio, 95% confidence interval) older age (1.1, 1.0-1.2), previous mammography (8.4, 2.8-24.7), PCP recommendation (4.3, 2.6-7.1) and family history (FH) of CRC (1.64, 1.3-4.5). Factors predicting future CRC screening included insurance status (4.7, 1.0-21), previous mammography (6.5, 2.9-6.2) PCP recommendation (3.9, 2.4-6.2) and FH of CRC and polyps (4.0, 2.1-7.5). Only older patients were less likely to undergo future CRC screening (0.96, 0.93-0.99). Patients in the academic setting were 60% more likely than those in non-academic settings to have previously undergone any CRC screening modality (1.64, 1.0-2.7), but they were not more likely to plan on having CRC screening. Conclusion: CRC screening adherence continues to lag behind breast and cervical cancer in gynecology patients. Strategies must be in place to prompt gynecologists and nurse practitioners to discuss CRC screening in eligible patients.

A Healthy Weight

In the gynecological office, as well as other health care practices, it is noticeable that patients are increasing in girth. It is not unusual anymore for a teen to have a body mass index (BMI) of >25. This reflects Centers for Disease Control (CDC) data that the incidence of obesity in the United States has risen significantly in the past 20 years. Thirty percent of adults 20 years of age and older—over 60 million people—are obese. The percentage among young people who are overweight has more than tripled since 1980.

Favorable clinical behavior in young ovarian carcinoma patients: a rationale for conservative surgery?

The objective of this study was to analyze prognostic factors and epidemiologic data in young women with invasive epithelial cancer (YWEOC). Forty consecutive cases were selected from our database, treated according to current standards. A control group with older patients (>40 years) was created using concurrent cohort technique (n= 114). Median follow-up was 95 months in YWEOC and 84 months in elder patients. They were grouped by FIGO stages, histologic type, and tumor grade. Oncologic family history was compared in both cohorts. Survival was calculated using Kaplan-Meier curves. Chi-square, log rank test, uni- and multivariate analyses were used for statistical comparison. Family history was obtained in 25 of 40 of YWEOC, and 7 had first-line relatives with hematologic tumors, while this was observed in 1 of 80 of the elder patients (OR 9.8; 1.2-74.7). Due to these findings, a <40-years control healthy group selected from the gynecology office was rated and when compared with YWEOC, statistically significant differences were observed (OR 39.2; 4.5-338). Tumors were more differentiated, compared to the elder group (G(1): 68% vs 7%, P < 0.0001); stage I was more frequent (70% vs 19%, P < 0.0001) as well as mucinous and endometroid histologic types (P < 0.03). Survival was higher among younger patients (81% vs 35%, P < 0.0001) and decreased by decade, especially after 41 years. In advanced cases, optimal cytoreduction was more frequently performed, and survival was significantly higher. Multivariate analysis revealed that the only independent prognostic factor was residual disease in both groups. Age is not an independent prognostic factor for ovarian cancer but it has a different biologic behavior. An interesting association with hematologic tumors was observed, suggesting another pathway for ovarian cancer oncogenesis.

Vulvar intraepithelial neoplasia in adolescents with abnormal pap smear results: A series report

ObjectiveThe objective of this study was to determine the prevalence of vulvar intraepithelial neoplasia (VIN) in adolescents presenting for cervical colposcopy in an adolescent gynecology office. Materials and methodsWe conducted a retrospective chart review from 1999 to 2002 of the concomitant diagnosis of cervical intraepithelial neoplasia and VIN in our private general pediatric and adolescent practice in patients younger than 22 years of age who underwent cervical colposcopy as well as evaluation of the vulva secondary to gross and microscopic visualized lesions. ResultsSixty-one patients underwent colposcopy for abnormal Pap smears; we found a 10% overall prevalence of vulvar intraepithelial neoplasia. Forty-four percent (n=27) underwent concomitant evaluation of the vulva; from these, 22% (n=6) fulfilled the characteristics of vulvar and cervical intraepithelial neoplasia. ConclusionIn the presence of cervical cytology abnormalities, VIN may be more common than recognized and careful screening is definitely warranted.

Economics of Reducing Menstruation With Trimonthly-Cycle Oral Contraceptive Therapy

In Brief OBJECTIVE To evaluate whether, and under what circumstances, trimonthly-cycle oral contraceptive pill (OCP) therapy is cost saving over standard-cycle OCP therapy for reducing the severity of menstrual-related symptoms. METHODS We created three economic models, with each model representing a unique cost perspective (societal, private third party, and patient), to estimate the incremental annual costs associated with women taking trimonthly-cycle rather than standard-cycle OCP. Direct costs considered were costs for OCP prescriptions, female hygiene products, generic over-the-counter pain relievers and iron tablets, home pregnancy tests, and physician visits for menstrual-related concerns. Indirect costs considered were lost wages due to menstruation-related disability and opportunity costs of physician visits. We derived base-case and sensitivity range estimates from prior literature, public use data, expert opinion, and cross-sectional survey data that we collected from 59 adult women taking standard-cycle OCP visiting a large, community-based gynecology office. All costs were adjusted to 2002 US dollars. RESULTS Under base-case assumptions that both regimens were equivalently priced ($1.16/pill) and trimonthly OCP reduces hygiene product use by 50%, annual societal costs per person were $460 for trimonthly OCP and $501 for standard OCP (incremental cost savings = $41). Assuming no difference in monthly drug copayment costs between the two regimens ($5.00), annual private third-party costs were nearly identical at $365 per regimen. Annual patient costs were $95 for trimonthly OCP and $136 for standard OCP. Trimonthly OCP remained cost saving to society as long its price remained below a 9% premium to standard OCP prices. The degree to which trimonthly OCP reduces hygiene product use also significantly influenced the cost difference between the two regimens. CONCLUSION Compared with standard-cycle OCP, tri-monthly-cycle OCP appears to be associated with significant societal and patient cost savings. These savings are highly conditional upon trimonthly OCP being priced similarly to standard OCP. Compared with standard-cycle oral contraceptive regimens, the trimonthly-cycle regimen holds considerable promise as a way to reduce direct and indirect costs associated with monthly menstruation.

Economics of reducing menstruation with trimonthly-cycle oral contraceptive therapy: comparison with standard-cycle regimens.

To evaluate whether, and under what circumstances, trimonthly-cycle oral contraceptive pill (OCP) therapy is cost saving over standard-cycle OCP therapy for reducing the severity of menstrual-related symptoms. We created three economic models, with each model representing a unique cost perspective (societal, private third party, and patient), to estimate the incremental annual costs associated with women taking trimonthly-cycle rather than standard-cycle OCP. Direct costs considered were costs for OCP prescriptions, female hygiene products, generic over-the-counter pain relievers and iron tablets, home pregnancy tests, and physician visits for menstrual-related concerns. Indirect costs considered were lost wages due to menstruation-related disability and opportunity costs of physician visits. We derived base-case and sensitivity range estimates from prior literature, public use data, expert opinion, and cross-sectional survey data that we collected from 59 adult women taking standard-cycle OCP visiting a large, community-based gynecology office. All costs were adjusted to 2002 US dollars. Under base-case assumptions that both regimens were equivalently priced (1.16 US dollars/pill) and trimonthly OCP reduces hygiene product use by 50%, annual societal costs per person were 460 US dollars for trimonthly OCP and 501 US dollars for standard OCP (incremental cost savings = 41 US dollars). Assuming no difference in monthly drug copayment costs between the two regimens (5.00 US dollars), annual private third-party costs were nearly identical at 365 US dollars per regimen. Annual patient costs were 95 US dollars for trimonthly OCP and 136 US dollars for standard OCP. Trimonthly OCP remained cost saving to society as long its price remained below a 9% premium to standard OCP prices. The degree to which trimonthly OCP reduces hygiene product use also significantly influenced the cost difference between the two regimens. Compared with standard-cycle OCP, trimonthly-cycle OCP appears to be associated with significant societal and patient cost savings. These savings are highly conditional upon trimonthly OCP being priced similarly to standard OCP.

Risk Factors Associated With Pelvic Floor Disorders in Women Undergoing Surgical Repair

In Brief OBJECTIVE To identify demographic, obstetric, and gynecologic risk factors associated with the development of pelvic floor disorders in women who undergo surgical correction. METHODS We conducted a case–control study, with cases selected from all women who had surgery by our urogynecology service from July 1, 1999 to July 1, 2000 and who had a first obstetric delivery at Magee Womens Hospital (n = 80). Controls were patients seen in the general gynecology office over the same time period who had no complaints associated with pelvic floor disorders in the previous 3 years, less than stage I prolapse on pelvic examination, and first obstetric delivery at Magee Womens Hospital (n = 176). Demographic, obstetric, and gynecologic variables were compared between cases and controls. RESULTS There were no significant differences in race, current age, gravidity, or parity. Cases were more likely than controls to have a higher body mass index (BMI) (28.6 ± 6.3 versus 26.4 ± 6.1 kg/m2, P = .01), to be younger at first delivery (25.8 ± 5.3 versus 28.4 ± 4.9 years, P < .001), to have undergone a forceps delivery (64% versus 44%, P ≤ .001), and to have had previous gynecologic surgery (34% versus 16%, P = .003). Using logistic regression modeling, all of these factors were found to be independently associated with pelvic floor disorders. After menopause, use of hormone replacement therapy 5 or more years was protective (P = .001). CONCLUSION In our surgical patients, younger age at first delivery, higher BMI, forceps delivery, and history of gynecologic surgery were significantly associated with subsequent development of pelvic floor disorders. Younger age at delivery, forceps delivery, increased body mass index, and previous gynecologic surgery are risk factors associated with subsequent surgery for pelvic floor disorders.

Risk factors associated with pelvic floor disorders in women undergoing surgical repair

Objective To identify demographic, obstetric, and gynecologic risk factors associated with the development of pelvic floor disorders in women who undergo surgical correction. Methods We conducted a case–control study, with cases selected from all women who had surgery by our urogynecology service from July 1, 1999 to July 1, 2000 and who had a first obstetric delivery at Magee Womens Hospital ( n = 80). Controls were patients seen in the general gynecology office over the same time period who had no complaints associated with pelvic floor disorders in the previous 3 years, less than stage I prolapse on pelvic examination, and first obstetric delivery at Magee Womens Hospital ( n = 176). Demographic, obstetric, and gynecologic variables were compared between cases and controls. Results There were no significant differences in race, current age, gravidity, or parity. Cases were more likely than controls to have a higher body mass index (BMI) (28.6 ± 6.3 versus 26.4 ± 6.1 kg/m 2, P = .01), to be younger at first delivery (25.8 ± 5.3 versus 28.4 ± 4.9 years, P < .001), to have undergone a forceps delivery (64% versus 44%, P ≤ .001), and to have had previous gynecologic surgery (34% versus 16%, P = .003). Using logistic regression modeling, all of these factors were found to be independently associated with pelvic floor disorders. After menopause, use of hormone replacement therapy 5 or more years was protective ( P = .001). Conclusion In our surgical patients, younger age at first delivery, higher BMI, forceps delivery, and history of gynecologic surgery were significantly associated with subsequent development of pelvic floor disorders.

Randomized trial evaluating efficacy of paracervical block for pipelle endometrial biopsy

Background: Endometrial biopsy is a common gynecological office procedure, and pain perception with satisfaction are important issues. We studied the effects of paracervical block anesthesia with pipelle endometrial biopsy in a randomized-controlled trial (RCT) to identify these issues.

Patient vaccine awareness in an obstetric and gynecologic office setting

The objective of our study was to better understand patient vaccine awareness in different ob/gyn settings. A masked questionnaire was completed by ob/gyn resident teaching clinic patients (CLINIC; n = 228) and private community physician patients (PVT; n = 254) exploring demographic, immunization recollection, and vaccine administration preferences. χ 2 and Student t test were used for statistical analyses. The results demonstrated that those in CLINIC compared with PVT were younger (27.2 ± 10.6 years old versus 38.0 ± 12.6 years old; P < .001) and more often presented for pregnancy-related visits (57.0% versus 21.6%; P < .001). PVT patients more commonly had documentation of childhood (34.3%) and adult (26.8%) vaccine status than those in CLINIC (25.6% and 15.5%, respectively; P < .03). Of the vaccine-preventable diseases (VPDs) surveyed, those in PVT (versus CLINIC) more often reported adequate vaccination or prior exposure to measles (68.5% versus 30.5%; P < .001) and varicella (65.7% versus 48.5%; P < .001). No differences were noted between study groups for hepatitis B, tetanus, and influenza. Those in PVT more often identified a non-ob/gyn provider for vaccine-related needs, as opposed to those in CLINIC, who more often relied on ob/gyn or health department sites for such needs. Over one third of both populations could not identify a provider for vaccine administration. Both groups strongly desired availability of vaccine services through their ob/gyn office. We conclude that PVT patients demonstrate a better awareness of vaccine status compared with those in CLINIC. However, overall both populations report poor documentation and inadequate immunity against most VPDs. A variety of practice sites are currently used for vaccination, although many patients cannot identify a place to go. The majority of patients would like to see this service available as a part of their ob/gyn care.

Breast cancer risk assessment in patients seen in a gynecologic oncology clinic.

The objective of this study was to determine if breast cancer risk assessment following the Gail model should be incorporated into a gynecologic oncology clinic. The Gail model was used to assess the risk of breast cancer in 329 patients with preinvasive lower genital tract disease (Pre, n = 86), invasive vulvar and cervical (Cx, n = 102), uterine (Ut, n = 87), and ovarian cancer (Ov, n = 54) seen in an inner city gynecologic oncology office. T-test, chi square test, and Pearson and Spearman correlation coefficients were used for statistical evaluation. A P-value of less than 0.05 was regarded significant. An estimated 5-year risk of breast cancer of 1.67 or more was noted in 9% of the Pre patients, 5% of Cx patients, 21% of the Ut patients, and 9% of the Ov patients. The difference between Cx and Ut patients was significant. The average 5-year risk was calculated at 0.77 for Pre patients, 0.77 for Cx patients, 1.18 for Ut patients, and 1.11 for Ov patients. These differences were significant, but mirror the age distribution. The average age was 43.6 for Pre patients, 52.2 years for Cx, 61.5 years for Ut, and 58.5 years for Ov patients; these differences were significant. When calculations were corrected for the mean age (53 years), there were no significant differences between groups regarding the average risk: Pre: 1.04, Cx: 0.81, Ut: 0.96, Ov: 0.97. Only eight patients (2.4%), six of them in the Pre and Cx group, would be expected to derive significant benefit from tamoxifen therapy. We conclude that elevated 5-year breast cancer risk to 1.67% or higher is noted in about 11% of patients seen in a gynecologic oncology office, mainly related to age and family history. Risk assessment and regular screening should be part of any follow-up exam.

An Effective Osteoporosis Screening and Patient Education Program for Gynecology Office Practice

An Effective Osteoporosis Screening and Patient Education Program for Gynecology Office Practice

An effective osteoporosis screening and patient education program for gynecology office practice

An effective osteoporosis screening and patient education program for gynecology office practice

Vaginal pH and parabasal cells in postmenopausal women

Objective: To determine the vaginal pH level that correlates with elevated parabasal cells in vaginal smears Methods: Postmenopausal women presenting to a gynecology office for routine annual and incontinence examinations were studied prospectively. Women were excluded if they had vaginal infections or pelvic organ prolapses past the hymen. pH was measured and cytology smears made from the midvagina. A pathologist who was not aware of pH results evaluated the smears. Spearman rho was used to correlate pH and percentage of parabasal cells. Logistic regression was used to analyze the relationship between pH and increased parabasal cells in vaginal smears. Predictive values were used to select a pH level as a cutoff point to predict increased parabasal cells. Results: Seventy-four women were enrolled and 70 completed the study. The correlation coefficient between pH and percentage of parabasal cells was 0.6 ( P < .001). Logistic regression showed association of pH with 20% or more parabasal cells ( P < .001). Positive and negative predictive values for pH level above 6.0 as a predictor of 20% or more parabasal cells were 96.3% and 87.5%, respectively. The prevalence of elevated parabasal cells was 22.9%. Conclusion: Vaginal pH above 6.0 correlates with high levels of parabasal cells (20% or more) from the midvagina.

Vaginal pH and Parabasal Cells in Postmenopausal Women

In Brief Objective To determine the vaginal pH level that correlates with elevated parabasal cells in vaginal smears Methods Postmenopausal women presenting to a gynecology office for routine annual and incontinence examinations were studied prospectively. Women were excluded if they had vaginal infections or pelvic organ prolapses past the hymen. pH was measured and cytology smears made from the midvagina. A pathologist who was not aware of pH results evaluated the smears. Spearman rho was used to correlate pH and percentage of parabasal cells. Logistic regression was used to analyze the relationship between pH and increased parabasal cells in vaginal smears. Predictive values were used to select a pH level as a cutoff point to predict increased parabasal cells. Results Seventy-four women were enrolled and 70 completed the study. The correlation coefficient between pH and percentage of parabasal cells was 0.6 (P < .001). Logistic regression showed association of pH with 20% or more parabasal cells (P < .001). Positive and negative predictive values for pH level above 6.0 as a predictor of 20% or more parabasal cells were 96.3% and 87.5%, respectively. The prevalence of elevated parabasal cells was 22.9%. Conclusion Vaginal pH above 6.0 correlates with high levels of parabasal cells (20% or more) from the midvagina. A vaginal pH exceeding 6.0 correlates significantly with high levels of parabasal cells from the midvagina.

Chaperone Use by Obstetrician/Gynecologists

OBJECTIVE To describe current practices of chaperone use during pelvic examinations among obstetrician/gynecologists affiliated with a large tertiary care teaching hospital. STUDY DESIGN Questionnaires were distributed at department of obstetrics and gynecology grand rounds to all practicing attending physicians to obtain physician demographic data, including age, years in practice, practice type (solo or group) and whether chaperones were currently used when performing pelvic examinations at the first obstetric or gynecologic office visit. Physicians were also asked whether they were taught to use chaperones for pelvic examinations during medical school or residency. RESULTS Of the 59 attending physicians, 100% responded to the questionnaire. As compared to female physicians, male physicians used chaperones more at the first obstetric examination (76.9% vs. 27.8%, P < .002), at gynecologic office visits (70.0% vs. 22.2%, P < .002) and for breast examinations (51.2% vs. 11.1%, P < .01). Physicians greater than 40 years old, in practice longer than 10 years and taught as medical students or residents to use chaperones were statistically more likely to use chaperones. No attendings, male or female, reported losing a patient to another provider or being sued or threatened with legal action because of not using a chaperone. CONCLUSION Chaperones were used more frequently during pelvic examinations by male physicians, age greater than 40, solo practice, and physicians in practice longer than 10 years. Education affected current practices as specific medical student or residency training influenced the use of chaperones in private practice.

Transvaginal salpingoscopy: an office procedure for infertility investigation

Objective: To evaluate the feasibility of salpingoscopy as an office procedure using transvaginal access to the pelvic cavity. Design: Descriptive study. Setting: Gynecology office. Patient(s): Infertile women with no obvious pelvic pathology. Intervention(s): Transvaginal Veress needle puncture and peritoneal distension by saline. Main Outcome Measurement(s): Visualization of distal tubal segment, cannulation, and salpingoscopy. Result(s): The fimbriae were visualized in all patients. Cannulation of the distal tubal segment was achieved without manipulation of the tube in 20% before ovulation and 55% in the early luteal phase. Conclusion(s): Transvaginal fimbrioscopy and salpingoscopy can be performed as an office procedure in patients without obvious pelvic pathology. In combination with hydrolaparoscopy and dye hydrotubation, the technique provides comprehensive screening of the tuboovarian structures in the early stage of infertility investigation.

Women Receive Less CVD Prevention Information

Cardiovascular disease (CVD) accounts for 41.5% of all deaths in the U.S. According to 1995 data from the CDC's National Ambulatory Medical Care Survey of medical or gynecologic office visits, clinicians are missing opportunities to prevent CVD. Participating physicians filled out surveys on …

Transvaginal ultrasonography in gynecologic office practice: Assessment in 663 premenopausal women

OBJECTIVES: We describe transvaginal ultrasonographic evaluation of 663 premenopausal women with signs or symptoms of gynecologic problems and compare the findings of transvaginal ultrasonography with those of antecedent bimanual examination. STUDY DESIGN: In this retrospective descriptive study, data on age, menstrual history, results of bimanual examination, and subsequent surgical and pathologic findings were abstracted from the medical record and linked to indications and results on transvaginal ultrasonography reports from May 1991 through October 1993. RESULTS: The result of bimanual examination of the uterus was normal in 125 of 347 women with transvaginal ultrasonography - diagnosed fibroids (36.0%). Findings were normal at bimanual examination of the corresponding adnexa in 134 of the 190 adnexa with transvaginal ultrasonography findings (70.5%). Among the subjects with normal results of bimanual examination of the adnexa, surgical procedures documented 12 endometriomas, 2 adnexal abscesses, and 5 benign and 1 malignant neoplasm. CONCLUSION: Given the apparent considerable limitations of the bimanual examination, the utility of routine in-office transvaginal ultrasonography screening of both women with and women without symptoms should be prospectively investigated. (Am J Obstet Gynecol 1996;175:1189-94.)