Diagnosis and Management of Cervical Squamous Intraepithelial Lesions in Pregnancy and Postpartum.

Perinatal care provides important health care opportunities for many individuals at risk for cervical cancer. Pregnancy does not alter cervical cancer screening regimens. ASCCP risk-based management has a colposcopy threshold of a 4% immediate risk of cervical intraepithelial neoplasia (CIN) 3 or cancer, but the actual risk can be considerably higher based on current and past screening results. Improving cervical cancer outcomes with diagnosis during pregnancy rather than postpartum and facilitating further evaluation and treatment postpartum for lesser lesions are the perinatal management goals. Although colposcopy indications are unchanged in pregnancy, some individuals with lower risk of CIN 2-3 and reliable access to postpartum evaluation may defer colposcopy until after delivery. Cervical intraepithelial neoplasia diagnosed in pregnancy tends to be stable, with frequent regression postpartum, though this is not universal. Colposcopic inspection during pregnancy can be challenging. Although biopsies in pregnancy are subjectively associated with increased bleeding, they do not increase complications. Endocervical curettage and expedited treatment are unacceptable. Treatment of CIN 2-3 in pregnancy is not recommended. Excisional biopsies in pregnancy are reserved for suspicion of malignancy that cannot be confirmed by colposcopic biopsy and when excisional biopsy results would alter oncologic or pregnancy care. Surveillance of high-grade lesions in pregnancy uses human papillomavirus-based testing, cytology, and colposcopy, with biopsy of worsening lesions every 12-24 weeks from diagnosis until postpartum evaluation. Mode of delivery does not definitively affect persistence of CIN postpartum. Postpartum care may involve a full colposcopic evaluation or expedited excisional procedure if indicated.

Women 50 Years and Older With Negative Pap Test and Positive Human Papillomavirus Test for Genotypes Other Than 16 and 18-Follow-up Outcomes.

OBJECTIVE: A follow-up of women 50 years or older with concomitant positive high-risk human papillomavirus (HPV) genotypes other than 16 and 18 (hrHPVO) and negative Pap test (NILMPap) was conducted to better understand the implications of hrHPVO positivity on potential risk of developing significant high-grade lesions. MATERIAL AND METHODS: A retrospective review of 2014 cytology data of patients with co-testing (Pap test and HPV DNA) identified 85 women 50 years or older with NILMPap and hrHPVO+. RESULTS: Most patients (63) had repeat co-testing on next follow-up. Of these, 41 patients with persistent hrHPVO+ status, 3 developed cervical intraepithelial neoplasia 2 (CIN2), and 1 CIN3. Nineteen patients were followed with biopsies. Of these, 7 biopsies were abnormal, 5 of which showed low-grade (CIN1) and 2 high-grade (CIN3) histology; none progressed on further follow-up. Three patients were followed with Pap test only, all had NILMPap, and none progressed on further follow-up. In summary, of the 85 patients, 26 developed abnormal histology during follow-up, 6 of whom had high-grade histology (CIN2 and CIN3, 3 each).The 5-year risk of CIN1+ in this cohort was 43.8% and for CIN2+ was 12.3%. The risk of abnormal histology did not differ significantly by prior history of Pap tests, histology, and/or HPV results. CONCLUSIONS: A persistent positivity for hrHPVO indicated higher likelihood to develop a lesion, and this risk was not reduced for patients 50 and older compared with the published screening population risk.

Cervical cancer screening in menopause: when is it safe to exit?

IMPORTANCE AND OBJECTIVE: Despite a decreasing incidence of cervical cancer in North America overall, disparities in screening and cervical cancer rates persist, especially in the postmenopausal age group. METHODS: We reviewed the literature regarding cervical cancer screening considerations for postmenopausal persons, with a focus on cervical cancer in postmenopausal persons, existing guidelines, screening methods, and gaps in care. DISCUSSION AND CONCLUSION: Postmenopausal persons are an important population at risk because age 65 years in the United States and up to 70 years in some parts of Canada is a milestone for screening cessation if the criteria are met. Unfortunately, inadequate screening is common, with most women 65 years or older discontinuing ( exiting ) screening despite not meeting the criteria to do so. Screening cessation recommendations are nuanced, and if not all criteria are met, screening should be continued until they are. Cervical cancer screening should be stopped at the recommended age if adequate screening has occurred or at any age if life expectancy is limited or the patient has had a hysterectomy in the absence of high-grade preinvasive cervical lesions or cervical cancer. Human papillomavirus infection, which is causally linked to almost all cervical cancer cases, can persist or reactivate from a prior infection or can be newly acquired from sexual contact. With more persons aging with a cervix in place, the potential for cervical cancer has increased, and higher cancer rates may be observed if recommended screening is not adhered to. We propose an algorithm based on current cervical cancer screening guidelines to aid providers in identifying whether exit criteria have been met. Until adequate screening has been confirmed, cervical cancer screening should continue.

Influence of the COVID-19 pandemic on prenatal and postpartum patient experiences and well-being.

BACKGROUND: It has yet to be fully elucidated how differing populations of obstetric patients adapted to the disruptions in perinatal care and postpartum support from the COVID-19 pandemic. We surveyed an enriched sample of socioeconomically advantaged patients to understand the influence of COVID-19 on their perinatal care experience, well-being, and coping. METHODS: We surveyed pregnant and postpartum patients (n = 6140) at a large academic medical center in the Midwest of the United States using the Coronavirus and Perinatal Experiences instrument in Spring 2021. RESULTS: The survey was sent to 6141 pregnant and postpartum patients; 1180 (17.8%) respondents completed the survey, including 256 who were pregnant and 834 postpartum. Most pregnant patients experienced no changes in their prenatal care with 16.5% indicating somewhat worsened care. In the postpartum cohort, 37.5% stated their care had somewhat worsened. In describing influences on stress and mental health, 58.1% of postpartum respondents stated it was moderately, and 17.4% significantly, worse. The pandemic had a somewhat or moderately negative influence for 72.7% of respondents, with 11.0% stating these effects were extremely negative. Both cohorts characterized a range of coping strategies, most commonly, talking with friends and family (76.3%). CONCLUSION(S): Even among this sample of socioeconomically advantaged patients, respondents indicated that the pandemic disrupted many facets of their medical care and daily life, especially social activities and postpartum support. Our findings suggest that counseling on coping and adaptation strategies for stressors and increased health systems support be part of perinatal care during public health emergencies for all demographic groups.

"I had so many life-changing decisions I had to make without support": a qualitative analysis of women's pregnant and postpartum experiences during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has posed profound challenges for pregnant patients and their families. Studies conducted early in the pandemic found that pregnant individuals reported increased mental health concerns in response to pandemic-related stress. Many obstetric practices changed their healthcare delivery models, further impacting the experiences of pregnant patients. We conducted a survey study to explore the ways in which COVID-19 impacted the lives of pregnant and newly postpartum people. METHODS: A mixed-methods survey was distributed to all patients ≥18 years old who were pregnant between January 1st, 2020 - April 28, 2021 in a large Midwest health system. Open-ended survey responses were analyzed for common themes using standard qualitative methodology. RESULTS: Among the 1182 survey respondents, 647 women provided an open-ended response. Of these, 77% were in the postpartum period. The majority of respondents identified as white, were partnered or married, and owned their own home. Respondents reported feeling greater uncertainty, social isolation, as though they had limited social and practical support, and negative mental health effects as a result of the pandemic. Many cited sudden or arbitrary changes to their medical care as a contributing factor. Though in the minority, some respondents also reported benefits from the changes to daily life, including perceived improvements to medical care, better work-life balance, and opportunities for new perspectives. CONCLUSIONS: This large qualitative dataset provides insight into how healthcare policy and lifestyle changes impacted pregnant and postpartum people. Respondents expressed similar levels of uncertainty and mental health concerns compared to other cohorts but less overall positivity. Our findings suggest greater attention be given to the impact of pandemic-related stress on pregnant and postpartum women. As the pandemic continues, these data identify areas where investment in additional support may have the greatest impact.

Understanding the Second Victim Experience Among Multidisciplinary Providers in Obstetrics and Gynecology.

OBJECTIVE: The aim of the study was to determine the prevalence of second victim experience (SVE) among obstetrics and gynecology (OBGYN) clinical and nonclinical healthcare workers and compare healthcare workers who did and did not identify as a second victim (SV) in the last year. METHODS: The validated Second Victim Experience and Support Tool and additional questions designed to explore SVE topics specific to OBGYN healthcare workers were administered to a multidisciplinary group. RESULTS: Of 571 individuals sent a survey link, 205 completed the survey: 117 worked in obstetrics (OB), 73 in gynecology (GYN), and 15 in both areas. Overall, 44.8% of respondents identified as an SV sometime during their career, 18.8% within the last 12 months. Among nonclinical staff respondents, 26.7% identified as an SV during their career and 13.3% in the last 12 months. Respondents who identified as an SV in the last 12 months reported experiencing significantly more psychological and physical distress, a greater degree to which colleague and institutional support were perceived as inadequate, decreased professional self-efficacy, and increased turnover intentions. The most common events identified as likely triggers for SVE were fetal or neonatal loss (72.7%) and maternal death (68.2%) in OB and patient accusations or complaints (69.3%) in GYN. CONCLUSIONS: Among survey respondents, there was a high prevalence of SVs in OBGYN staff, distributed equally between OB and GYN. Nonclinical healthcare workers also identified as SVs. The OBGYN departments should consider using the Second Victim Experience and Support Tool to screen for potential SV among their healthcare workers to provide additional support after events.

Evaluation of a Second Victim Peer Support Program on Perceptions of Second Victim Experiences and Supportive Resources in Pediatric Clinical Specialties Using the Second Victim Experience and Support Tool (SVEST).

PURPOSE: Pediatric healthcare professionals (HCPs) may experience events that lead to psychological distress or second victim experiences (SVEs). This project evaluates the impact of a newly implemented peer support program on SVEs and perceptions of supportive resources among pediatric HCPs. DESIGN AND METHODS: A second victim (SV) peer support program was implemented in the pediatric inpatient and intensive care units in September 2019. Multidisciplinary HCPs in these units were invited to participate in an anonymous survey that included the Second Victim Experience and Support Tool before and one-year after implementation. The survey assessed HCPs' SVEs, desired support, and perceptions of the peer support program. RESULTS: 52.0% (194/373) completed the pre-implementation survey, and 43.9% (177/403) completed the post-implementation survey. At both timepoints, participants reported SV-related psychosocial distress, physical distress, or low professional self-efficacy; the most desired support was 'a respected peer to discuss the details of what happened'. Following implementation of the peer support program, HCPs were significantly more likely to have heard of the term 'second victim' (51.8 vs. 74.0%; p < 0.001) and to have felt like there were adequate resources to support SVs (35.8% vs. 89.1%; p < 0.001). In the post-implementation survey, most respondents indicated a likelihood to use the program for themselves (65.7%) or colleagues (84.6%) after involvement in future traumatic clinical events. CONCLUSIONS: Implementation of a peer support program significantly influenced awareness and perceptions of support available for SV-related distress. PRACTICE IMPLICATIONS: Peer support programs should be implemented to help HCPs navigate SVEs and decrease SV-related turnover intentions.

Decreased testosterone recovery after androgen deprivation therapy for prostate cancer.

INTRODUCTION Androgen deprivation therapy (ADT) is often used in the treatment of prostate cancer. Specific factors affecting testosterone recovery after cessation of ADT have not been well-characterized in existing literature. MATERIALS AND METHODS: We retrospectively reviewed patients at our institution who received ADT between 1999 and 2018. Patients with at least one course of ADT and subsequent testosterone level within 12 months of cessation of ADT were included. Patients received at least one of the following four agents: leuprolide, goserelin, triptorelin, and degarelix. Cox regression models were utilized to estimate the effect of patient and treatment characteristics on time to testosterone recovery(≥ 240 ng/dL) after ADT cessation. Patients without testosterone recovery were censored at last testosterone evaluation. To account for the possible dependency between multiple ADT courses within a patient, we used a robust sandwich variance estimate. RESULTS: Severty-six patients were included. Mean age was 64 +/- 8 years. Median duration of ADT was 15 months, with a median time to recovery of 19 months. On univariable analysis, age and duration of ADT were significant; a trend towards significance was noted for hypertension, diabetes, peripheral vascular disease, goserelin and bicalutamide. Patient age, duration of ADT, and treatment with the agent goserelin were significantly associated with prolonged hypogonadism on multivariable analysis (p < 0.01). CONCLUSIONS: Increasing age and duration of ADT therapy are associated with decreased likelihood to recover normal testosterone levels after cessation of therapy. The use of the ADT agent goserelin was also associated with decreased testosterone recovery for unclear reasons.

Evaluation of high-risk human papillomavirus testing and anal cytology to detect high-grade anal intraepithelial neoplasia.

INTRODUCTION: Optimal screening for detection of anal precancer has not been established, and most studies involve very high-risk populations. We evaluated high-risk human papillomavirus (HPV) testing and anal cytology to detect high-grade anal intraepithelial neoplasia (≥AIN2) in a cohort with mostly moderate risk factors for AIN. METHODS: Patients ≥35 years old undergoing anal biopsy for various lesions received HPV testing by Roche cobas and a subset by Hologic APTIMA HPV assays with concurrent anal ThinPrep cytology. Biopsies were blindly reviewed by 3 authors, and consensus diagnosis was compared with HPV and cytology results. Sensitivity and specificity for ≥AIN2 detection by HPV testing and cytology (≥ASC-US) were calculated. RESULTS: Among 64 patients, 19 (29.7%) showed ≥AIN2 on biopsy. All patients were tested by cobas, and 35 (54.7%) were positive. A subset of 39 patients were also tested by APTIMA, and 18 (46.2%) were positive. Positive cytology (≥ASC-US) was present in 37 (57.8%) patients, with 27 (73.0%) of these positive by cobas. HPV testing alone yielded 75.0% and 84.2% sensitivity for APTIMA and cobas, respectively; specificity was 66.7% and 57.8%. Sensitivity and specificity of cytology alone was 78.9% and 51.1%. Combined HPV testing and cytology had a sensitivity and specificity of 91.7% and 37.0% for APTIMA and 94.7% and 40.0% for cobas. CONCLUSIONS: Combined HPV testing and cytology had the highest sensitivity for ≥AIN2 detection, with a performance comparable to cervical cancer screening tests, suggesting this strategy may represent a viable screening option in a population with moderate risk factors for AIN.

Second Victim Experience among OBGYN Trainees: What Is Their Desired Form of Support?

OBJECTIVES: Physician trainees in obstetrics and gynecology (OBGYN) experience unexpected outcomes similar to those of supervising physicians. A relative lack of experience and perspective may make them more vulnerable to second victim experience (SVE), however. The objectives of our study were to contrast the prevalence of SVE between supervising physicians and trainees and to identify their preferred methods of support. METHODS: In 2019, the Second Victim Experience and Support Tool, a validated survey with supplemental questions, was administered to healthcare workers caring for OBGYN patients at a large academic center in the midwestern United States. RESULTS: The survey was sent to 571 healthcare workers working in OBGYN. A total of 205 healthcare workers completed the survey, including 18 (43.9% of 41) supervising physicians and 12 (48.0% of 25) resident/fellow physicians. The mean scores for the Second Victim Experience and Support Tool dimensions and outcomes were similar between the two groups. Seven (58.3%) trainees reported feeling like a second victim after an adverse patient safety event at some point in their work experience compared with 10 (55.6%) of the supervising physicians. Five (41.7%) trainees identified as a second victim in the previous 12 months compared with 3 (16.7%) supervising physicians (P = 0.21). The most common form of desired support for both groups was conversations with their peers. CONCLUSIONS: Trainees and supervising physicians are both at risk of SVE after an unexpected medical event and prefer conversations with peers as a desired form of support. Because trainees commonly encounter SVEs early in their careers, program directors should consider implementing a program for peer support after an unexpected event.

Would Women With Solid Organ Transplant Qualify for Triennial Cervical Cancer Screening as Recommended by the American College of Obstetricians and Gynecologists in 2016 and American Society for Colposcopy and Cervical Pathology in 2019?

OBJECTIVE: The aim of the study was to assess the applicability and safety of cervical cancer screening guidelines recommended by the American College of Obstetricians and Gynecologists (2016) and American Society for Colposcopy and Cervical Pathology (2019) for women with solid organ transplants (SOTs). MATERIALS AND METHODS: We analyzed data previously abstracted through December 2015 for 971 women (18-60 y) who received their first SOT at Mayo Clinic (Rochester, MN) from January 17, 1995, through December 31, 2011. Inclusion criteria were initial benign findings on cervical cytology after SOT and at least 1 subsequent cytologic screening. RESULTS: Of 415 women whose initial cytologic findings were benign, 310 met inclusion criteria. The cumulative incidence of abnormal cervical cytology among these 310 women was 4.3% (95% CI = 1.9%-6.7%) by 30 months and 11.2% (95% CI = 7.1%-15.4%) by 60 months after their initial benign results. Considering all women with SOT, 68.4% (284/415) had no documented abnormal cytologic findings within 60 months (26 had abnormality; 284 no abnormality; and 105 not assessed). In women with negative tests for human papillomavirus, high-grade squamous intraepithelial lesions were not documented on cytology with variable duration of follow-up. No cervical squamous cell carcinoma was identified. CONCLUSIONS: Of women with initial benign cervical cytology after SOT, more than two thirds would have been eligible for extended-interval screening. Further study is needed, particularly regarding the role of high-risk human papillomavirus testing.

Screening Women for Anal Cancers: Guidance for Health Care Professionals.

Anal cancer is rare in the general population but is steadily increasing in incidence over the past decade especially in women. Identification and screening of women with high risk facilitates detection of anal precancer and early-stage cancer, improves survival, and potentially uses less invasive therapies compared with the conventional chemoradiation treatments used for advanced cancers. No recently published guidelines currently describe details about screening women for anal squamous cell cancer (ASCC). The available evidence supports the existence of groups of women with higher prevalence of ASCC (e.g., women with human immunodeficiency virus, immune suppression, or previous lower-genital high-grade lesion or cancer) who would likely benefit from screening with some combination of anal cytology and human papillomavirus testing. Additional research is needed to establish the cost-effectiveness and the influence of screening on ASCC mortality rates.

Second victim experiences of nurses in obstetrics and gynaecology: A Second Victim Experience and Support Tool Survey.

AIM (S): To investigate second victim experiences and supportive resources for nurses in obstetrics and gynaecology. BACKGROUND: Nurses are at risk of developing second victim experiences after exposure to work related events. METHODS: Nurses at a single institution were invited to participate in an anonymous survey that included the validated Second Victim Experience and Support Tool to assess symptoms related to second victim experiences and current and desired supportive resources. RESULTS: Of 310 nurses, 115 (37.1%) completed the survey; 74.8% had not heard of the term 'second victim'. Overall, 47.8% reported feeling like a second victim during their career and 19.1% over the previous 12 months. As a result of a second victim experience, 18.4% experienced psychological distress, 14.3% turnover intentions, 13.0% decreased professional self-efficacy, and 12.2% felt that institutional support was poor. Both clinical and non-clinical events were reported as possible triggers for second victim experiences. Peer support was the most desired form of support as reported by 95.5%. CONCLUSION(S): Nurses in obstetrics and gynaecology face clinical and non-clinical situations that lead to potential second victim experiences. IMPLICATIONS FOR NURSING MANAGEMENT: The second victim experiences of nurses should be acknowledged, and resources should be implemented to navigate it. Educational opportunities and peer supportive interventions specific to second victim experiences should be encouraged.

Pregnancy Reasonably Excluded Guide (PREG) Evaluation of Pregnancy Status Before Contraceptive Procedures: Improved Availability of Same-Day Insertion.

OBJECTIVE: To determine whether implementation of the Pregnancy Reasonably Excluded Guide (PREG) in a primary care gynecology clinic improves access to contraceptive procedures and affects the number of urine human chorionic gonadotropin (hCG) tests. PATIENTS AND METHODS: PREG was administered to 981 women aged 18 to 50 years (1012 visits) who were seen in a primary care gynecology clinic for contraceptive procedures from September 30, 2015, through April 30, 2018. Contraceptive procedures included insertion of an intrauterine contraceptive (IUC) or subdermal contraceptive implant. After PREG review and patient discussion, health care professional decided to perform the procedure with or without hCG measurement or to reschedule if the patient's pregnancy status was uncertain. We collected data on the rate of same-day contraceptive procedures and the rate of hCG testing. Data from the PREG implementation period were compared with historical data from 185 women undergoing contraceptive procedures before PREG implementation. RESULTS: Measurement of hCG was performed in 53% of women before and 24.1% (224 of 1,012 visits) after PREG implementation in the primary care setting. After PREG implementation, 974 0f 1012 patients (96.2%) were eligible for a same-day contraceptive procedure. If traditional criteria, current menses, or a preexisting IUC or implant in place were required for IUC or implant insertion, only 594 patients (58.7%) would have qualified for a same-day procedure. No contraceptive procedures occurred in pregnant women. CONCLUSION: PREG implementation allowed for same-day IUC or implant insertion in 974 women (96.2%) seen for a contraceptive procedure. Most of the women (75.9%) did not require preprocedure hCG measurement.

Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection.

EXECUTIVE SUMMARY: The risk of cervical cancer (CC) among women immunosuppressed for a variety of reasons is well documented in the literature. Although there is improved organ function, quality of life and life expectancy gained through use of immunosuppressant therapy, there may be increased long-term risk of cervical neoplasia and cancer and the need for more intense screening, surveillance, and management. Although guidance for CC screening among HIV-infected women (see Table 1) has been supported by evidence from retrospective and prospective studies, recommendations for CC screening among non-HIV immunosuppressed women remains limited because quality evidence is lacking. Moreover, CC screening guidelines for HIV-infected women have changed because better treatments evolved and resulted in longer life expectancy.The objective of this report was to summarize current knowledge of CC, squamous intraepithelial lesions, and human papillomavirus (HPV) infection in non-HIV immunocompromised women to determine best practices for CC surveillance in this population and provide recommendations for screening. We evaluated those with solid organ transplant, hematopoietic stem cell transplant, and a number of autoimmune diseases.A panel of health care professionals involved in CC research and care was assembled to review and discuss existing literature on the subject and come to conclusions about screening based on available evidence and expert opinion. Literature searches were performed using key words such as CC, cervical dysplasia/squamous intraepithelial lesion, HPV, and type of immunosuppression resulting in an initial group of 346 articles. Additional publications were identified from review of citations in these articles. All generated abstracts were reviewed to identify relevant articles. Articles published within 10 years were considered priority for review. Reviews of the literature were summarized with relevant statistical comparisons. Recommendations for screening generated from each group were largely based on expert opinion. Adherence to screening, health benefits and risks, and available clinical expertise were all considered in formulating the recommendations to the degree that information was available. RESULTS: Solid Organ Transplant: Evidence specific for renal, heart/lung, liver, and pancreas transplants show a consistent increase in risk of cervical neoplasia and invasive CC, demonstrating the importance of long-term surveillance and treatment. Reports demonstrate continued risk long after transplantation, emphasizing the need for screening throughout a woman's lifetime.Hematopoietic Stem Cell Transplant: Although there is some evidence for an increase in CC in large cohort studies of these patients, conflicting results may reflect that many patients did not survive long enough to evaluate the incidence of slow-growing or delayed-onset cancers. Furthermore, history of cervical screening or previous hysterectomy was not included in registry study analysis, possibly leading to underestimation of CC incidence rates.Genital or chronic graft versus host disease is associated with an increase in high-grade cervical neoplasia and posttransplant HPV positivity.Inflammatory Bowel Disease: There is no strong evidence to support that inflammatory bowel disease alone increases cervical neoplasia or cancer risk. In contrast, immunosuppressant therapy does seem to increase the risk, although results of observational studies are conflicting regarding which type of immunosuppressant medication increases risk. Moreover, misclassification of cases may underestimate CC risk in this population. Recently published preventive care guidelines for women with inflammatory bowel disease taking immunosuppressive therapy recommend a need for continued long-term CC screening.Systemic Lupus Erythematosus and Rheumatoid Arthritis: The risk of cervical high-grade neoplasia and cancer was higher among women with systemic lupus erythematosus than those with rheumatoid arthritis (RA), although studies were limited by size, inclusion of women with low-grade neoplasia in main outcomes, and variability of disease severity or exposure to immunosuppressants. In studies designed to look specifically at immunosuppressant use, however, there did seem to be an increase in risk, identified mostly in women with RA. Although the strength of the evidence is limited, the increase in risk is consistent across studies.Type 1 DM: There is a paucity of evidence-based reports associating type 1 DM with an increased risk of cervical neoplasia and cancer. RECOMMENDATIONS: The panel proposed that CC screening guidelines for non-HIV immunocompromised women follow either the (1) guidelines for the general population or (2) current center for disease control guidelines for HIV-infected women. The following are the summaries for each group reviewed, and more details are noted in accompanying table:Solid Organ Transplant: The transplant population reflects a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance.Hematopoietic Stem Cell Transplant: These women have a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening. A new diagnosis of genital or chronic graft versus host disease in a woman post-stem cell transplant results in a greater risk of CC than in the general population and should result in more intensive screening and surveillance.Inflammatory Bowel Disease: Women with inflammatory bowel disease being treated with immunosuppressive drugs are at greater risk of cervical neoplasia and cancer than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance. Those women with inflammatory bowel disease not on immunosuppressive therapy are not at an increased risk and should follow screening guidelines for the general population.Systemic Lupus Erythematosus and Rheumatoid Arthritis: All women with systemic lupus erythematosus, whether on immunosuppressant therapy or not and those women with RA on immunosuppressant therapy have a greater risk of cervical neoplasia and cancer than the general population and should follow CC screening guidelines for HIV-infected women. Women with RA not on immunosuppressant therapy should follow CC screening guidelines for the general population.Type 1 Diabetes Mellitus: Because of a lack of evidence of increased risk of cervical neoplasia and cancer among women with type 1 DM, these women should follow the screening guidelines for the general population.

Implementation of the "Pregnancy Reasonably Excluded Guide" for Pregnancy Assessment: A Quality Initiative in Outpatient Gynecologic Surgery.

OBJECTIVE: Preoperative evaluation for pregnancy at our institution lacked standardization among individual health care providers and surgical services. This pilot project aimed to improve assessment for pregnancy before scheduled outpatient gynecologic surgical procedures. The Pregnancy Reasonably Excluded Guide incorporates historic, evidence-based criteria to facilitate identification of patients with a higher chance of pregnancy. METHODS: We retrospectively reviewed documentation for women undergoing gynecologic surgery at an outpatient surgical center from March through September 2016, before and after implementation of the pregnancy assessment protocol. After implementation, all eligible women (aged 18-50 years, not undergoing an emergent or pregnancy-related procedure) were assessed using the Pregnancy Reasonably Excluded Guide on arrival to the preoperative area. The Pregnancy Reasonably Excluded Guide checklist uses traditional and World Health Organization criteria for reasonable exclusion of pregnancy. Nursing staff reviewed responses with patients and pregnancy tests were completed as indicated by patient responses. Women who were unable to read, understand, or freely respond to the checklist received pregnancy testing. Pregnancy assessment, testing, results, and delays were recorded. This project was deemed exempt by the institutional review board. RESULTS: Two hundred thirteen eligible patients underwent outpatient gynecologic procedures during the study period (excluding a 2-week washout period at implementation). In the preimplementation period, 93 of 136 patients (68%) had pregnancy risk documented; 73 of 77 (95%) had documentation in the postimplementation period (P≤.01). Pregnancy tests were completed in 45 preimplementation patients (33%) and 16 postimplementation patients (21%) (P=.06). No pregnancy test results were positive. No procedural delays were associated with pregnancy assessment. CONCLUSION: Patient-centered assessment using the Pregnancy Reasonably Excluded Guide at presentation for outpatient gynecologic surgery significantly improved evaluation and documentation of pregnancy status before scheduled procedures without increasing the number of pregnancy tests or causing procedural delays.

Cervical Cytology and Histology After Solid Organ Transplant: A Longitudinal Cohort Study.

OBJECTIVES: The ideal frequency of cervical cancer screening in women with solid organ transplants (SOTs) remains to be determined. We aimed to assess the longitudinal rates of cytologic and histologic cervical abnormalities in women after SOT. METHODS: We retrospectively reviewed health records of women aged 18 to 60 years who received their first kidney, liver, pancreas, or combination transplant at Mayo Clinic (Rochester, Minnesota) from 1995 through 2011. Patient demographics, cervical cytology and histology, and high-risk human papillomavirus (hrHPV) testing data were abstracted. All women included in the study had documentation of at least 1 cervical cytologic assessment after SOT. Cumulative incidence of abnormal cytology or histology was estimated using the Kaplan-Meier method. RESULTS: In total, 459 women (mean age at SOT, 43.9 years) were included in the study. Pre-SOT cytology was benign in 226 (97.4%) of 232 patients with available results. During follow-up, 9 women had cervical intraepithelial neoplasia grade 3 or higher (CIN3) histology. The cumulative incidence of CIN3 was 0.2% (95% confidence interval [CI], 0%-0.6%) at 1 year after SOT, 0.7% (95% CI, 0%-1.5%) at 2 years, 1.9% (95% CI, 0.5%-3.3%) at 5 years, and 3.1% (95% CI, 0.4%-5.7%) at 10 years. At the time of the first post-SOT cervical cytology, a greater proportion of women who were hrHPV positive had abnormal findings compared with hrHPV-negative women (10/15 [66.7%] vs 1/71 [1.4%]; p < .001). CONCLUSIONS: The cumulative incidence of CIN3 in the first 5 years after SOT approximates the level of risk for which annual cytologic assessment has been recommended.

Female Sexual Function Improves After Endometrial Ablation.

BACKGROUND: Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods. METHODS: Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF-12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test. RESULTS: A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 (p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 (p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF-12 scores improved for global physical function (p < .001) and mental function (p = .002). CONCLUSIONS: Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.