Executive Summary of the Lower Anogenital Tract Cancer Evidence Review Conference.

The Centers for Disease Control and Prevention sponsored a project conducted by the American College of Obstetricians and Gynecologists to develop educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. For this final module, focusing on the cancers of the lower anogenital tract (vulva, vagina, and anus), a panel of experts in evidence assessment from the Society for Academic Specialists in General Obstetrics and Gynecology, ASCCP, and the Society of Gynecologic Oncology reviewed relevant literature and current guidelines. Panel members conducted structured literature reviews, which were then reviewed by other panel members. Representatives from stakeholder professional and patient advocacy organizations met virtually in September 2022 to review and provide comment. This article is the executive summary of the review. It covers prevention, early diagnosis, and special considerations of lower anogenital tract cancer. Knowledge gaps are summarized to provide guidance for future research.

Health Disparities in Ovarian Cancer: Report From the Ovarian Cancer Evidence Review Conference.

Health disparity, defined by the Centers for Disease Control and Prevention (CDC) as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations," is seen across multiple diseases. We conducted an evidence review of health disparities and inequities and their mitigation strategies related to ovarian cancer as part of a CDC-sponsored project to develop educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. Our review found profound disparities in outcomes such as survival, treatment, and stage at diagnosis by factors such as race and ethnicity, insurance, socioeconomic status, and geographic location. We found little direct evidence on mitigation strategies. Studies support equivalent response to equivalent treatment between groups, suggesting that adherence to National Comprehensive Cancer Network guidelines can at least partially mitigate some of the differences.

Executive Summary of the Ovarian Cancer Evidence Review Conference.

The Centers for Disease Control and Prevention awarded funding to the American College of Obstetricians and Gynecologists to develop educational materials for clinicians on gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about ovarian cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in February 2022. This article is the executive summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of ovarian cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

Colposcopy Standards: Guidelines for Endocervical Curettage at Colposcopy.

OBJECTIVE: The most recent guidelines for colposcopy practice in the United States, the 2017 Colposcopy Standards Consensus Guidelines, did not include recommendations for endocervical curettage (ECC). This document provides updated guidelines for use of ECC among patients referred for colposcopy. METHODS: Consensus guidelines for the use of ECC were developed in 2012. To update these guidelines in concordance with the 2017 Colposcopy Standards process, an expert workgroup was convened in 2021. Literature had been previously reviewed through 2011, before the 2012 guideline. Literature from the years 2012-2021 and data from the NCI Biopsy study were reviewed, focusing on the additional yield of ECC. RESULTS: Endocervical curettage is recommended for patients with high-grade cytology, human papillomavirus 16/18 infection, positive results on dual staining for p16/Ki67, for those previously treated for known or suspected cervical precancer or considering observation of cervical intraepithelial neoplasia grade 2, and when the squamocolumnar junction is not fully visualized at colposcopy. Endocervical curettage is preferred for all patients aged older than 40 years. Endocervical curettage is acceptable for all nonpregnant patients undergoing colposcopy but may be omitted when a subsequent excisional procedure is planned, the endocervical canal does not admit a sampling device, or in nulliparous patients aged younger than 30 years, with cytology reported as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion regardless of whether the squamocolumnar junction is fully visualized. Endocervical curettage is unacceptable in pregnancy. CONCLUSIONS: These guidelines for ECC add to the 2017 consensus recommendations for colposcopy practice in the United States.

Am I Really Qualified To Be Here: Exploring The Impact Of Impostor Phenomenon On Training And Careers In OB/GYN Medical Education.

OBJECTIVE: Individuals with Impostor Phenomenon (IP) believe they have achieved success by fooling others into thinking they are intelligent/capable and fear they will be discovered. This fear has been shown to cause psychological distress and may affect OB/GYN training. The objective of this study was to investigate the prevalence of IP and correlation with anxiety among OB/GYN trainees and faculty. DESIGN/SETTING: An anonymous cross-sectional survey including a demographic questioner, Clance Impostor Scale, and Generalized Anxiety Disorder 2-items screening tool was distributed to 200 attendees at the 2019 American College of Obstetricians and Gynecologists Annual Meeting. PARTICIPANTS: Eighty-nine medical students, 38 residents, 3 fellows, and 9 attendings completed the survey for a response rate of 72%. RESULTS: The average participant experienced frequent feelings of IP with the mean score of 65 ± 18. Nine (8%) experienced few feelings of IP, 27 (24%) had moderate IP feelings, 55 (50%) had frequent IP feelings, and 20 (18%) had intense IP feeling. There was no difference between IP score and trainee/faculty gender, race, or region of country. The degree of IP was significantly associated with level of medical training with more experienced physicians scoring lower than trainees (F = 6.07, p = 0.001). Finally, an association was found between anxiety and IP; individuals with a positive GAD-2 screen had significantly more feelings of IP compared to individuals with a negative GAD-2 screen (t = 4/79, p < 0.001). CONCLUSION: This study suggests that IP is likely prevalent among OB/GYN trainees and correlate with anxiety. Further discussion is needed regarding the impact of IP on medical education training and career advancement in the field of OB/GYN and other surgical specialties.

Starting Health Disparities Education During Resident Orientation: Our Patients, Our Community.

Disparities in women's reproductive health outcomes are persistent and prevalent. Cultural competency education of trainees is central to reducing patient-, system-, and practitioner-level factors that promote disparate health outcomes. Such issues include health literacy, access to health care, and unconscious bias. We suggest that recognizing and reducing health disparities should be a longitudinal theme in resident education, first introduced during intern orientation and continued with dedicated didactics, experiential learning opportunities, grand rounds, and journal clubs built into the residency curricula. In this commentary, we present various methods of introducing health disparities education and commencing a larger conversation about inequity and race in medicine. We hope to encourage other training programs to incorporate this important topic earlier into their educational curriculum.

Effect of Immediate Loop Electrode Excisional Procedure for High-Grade Cervical Cytology in an Urban Academic Clinic Setting.

OBJECTIVE: The aim of the study was to determine whether treating all patients older than 25 years with high-grade squamous intraepithelial lesion (HSIL) Paps with immediate loop electrode excisional procedure (LEEP) improves rates of receiving indicated treatment and evaluating whether this practice results in overtreatment (defined by excisional pathology less than cervical intraepithelial neoplasia 2). MATERIALS AND METHODS: This was a retrospective cohort study at an urban, Medicaid-based clinic, which evaluated women older than 25 years with HSIL Pap results seen from June 2011 to December 2016. In June 2013, the clinic practice was restructured and management of HSIL Pap results in patients older than 25 years was standardized to immediate LEEP procedure, without intermediate colposcopic examination. Our primary outcome is the number of women who received LEEPs before and after this clinical practice change. The secondary outcome evaluated the number of women who received overtreatment. The χ test with a p value of 0.05 as significant was used to compare the results between groups. RESULTS: Twenty-three (82%) of the 28 women treated before clinical practice change received indicated treatment, with 19 receiving LEEPs. Twenty-four (96%) of the 25 women treated after the clinical practice change received indicated LEEPs (p = .11). Seven (37%) of the 19 women in the initial group had LEEP pathology results less than CIN 2, whereas only 4 (17%) of the 24 women in the immediate LEEP group had results less than CIN 2 (p = .13). CONCLUSIONS: Implementation of a standardized management of HSIL Pap with immediate LEEP did not statistically increase the amount of patients who received indicated LEEPs; however, implementation of this practice did not result in overtreatment.

Cervical ripening balloon with and without oxytocin in multiparas: a randomized controlled trial.

BACKGROUND: The optimal method for induction of labor for multiparous women with an unfavorable cervix is unknown. OBJECTIVE: We sought to determine if induction of labor with simultaneous use of oxytocin and a cervical ripening balloon, compared with sequential use, increases the likelihood of delivery within 24 hours in multiparous women. STUDY DESIGN: We performed a randomized controlled trial from November 2014 through June 2017. Eligible participants were multiparous women with a vertex presenting, nonanomalous singleton gestation ≥34 weeks undergoing induction of labor. Women were excluded for admission cervical examination >2 cm, ruptured membranes, chorioamnionitis or evidence of systemic infection, placental abruption, low-lying placenta, >1 prior cesarean delivery, or contraindication to vaginal delivery. Patients were randomly allocated to the following cervical ripening groups: simultaneous (oxytocin with cervical ripening balloon) or sequential (oxytocin following cervical ripening balloon expulsion). The primary outcome was delivery within 24 hours of cervical ripening balloon placement. Secondary outcomes included induction-to-delivery interval, time to cervical ripening balloon expulsion, mode of delivery, and adverse maternal or neonatal outcomes. RESULTS: In all, 180 patients were randomized (90 simultaneous, 90 sequential). Baseline demographic and obstetric characteristics were similar between study groups. Women in the simultaneous group were significantly more likely to deliver within 24 hours of cervical ripening balloon placement compared to the sequential group (87.8% vs 73.3%, P = .02). The simultaneous group also had a significantly shorter induction-to-delivery interval and greater cervical dilation at cervical ripening balloon expulsion. There were no differences in mode of delivery, chorioamnionitis, or adverse maternal or neonatal outcomes. CONCLUSION: In multiparous women with an unfavorable cervix, the simultaneous use of cervical ripening balloon and oxytocin results in an increased frequency of delivery within 24 hours and a shorter induction-to-delivery interval.

Evidence-based guidelines in labor management.

Evidence-based care of women in labor requires a thorough understanding of both "normal" and abnormal labor progress. In response to the growing cesarean delivery rate for dystocia at our institution, a multidisciplinary team of attending physicians, nurse-midwives, resident physicians, and nurses was established to review the literature and create evidence-based guidelines. This article describes the background literature and consensus guidelines reached for the diagnosis of active phase labor, active phase arrest, second-stage arrest, protraction of the active phase, and failed induction of labor. Our review illustrates that slower labor patterns than traditionally described often result in a vaginal delivery without unacceptable increases in maternal or neonatal morbidity.

The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: a pilot study.

UNLABELLED: The aim of this paper was to determine the effect of acupuncture on perceived stress levels in women on the day of embryo transfer (ET), and to determine if perceived stress levels at embryo transfer correlated with pregnancy rates. The study was an observational, prospective, cohort study based at the University IVF center. PATIENT(S): 57 infertile patients undergoing IVF or IVF/ICSI. INTERVENTIONS(S): Patients were undergoing Embryo Transfer with or without acupuncture as part of their standard clinical care. MAIN OUTCOME MEASURE(S): Perceive Stress Scale scores, pregnancy rates. RESULT(S): women who received this acupuncture regimen achieved pregnancy 64.7%, whereas those without acupuncture achieved pregnancy 42.5%. When stratified by donor recipient status, only non-donor recipients potentially had an improvement with acupuncture (35.5% without acupuncture vs. 55.6% with acupuncture). Those who received this acupuncture regimen had lower stress scores both pre-ET and post-ET compared to those who did not. Those with decreased their perceived stress scores compared to baseline had higher pregnancy rates than those who did not demonstrate this decrease, regardless of acupuncture status. CONCLUSIONS(S): The acupuncture regimen was associated with less stress both before and after embryo transfer, and it possibly improved pregnancy rates. Lower perceived stress at the time of embryo transfer may play a role in an improved pregnancy rate.