Well-patient care (GYN): Clinical sciences

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Introduction0:00–0:43

Well-patient gynecologic care focuses on screening and prevention of disease in otherwise healthy individuals. All patients benefit from basic preventative care, which is focused on counseling on a variety of topics including substance use, mental health, contraception, interpersonal and domestic violence, obesity, urinary incontinence, sexually transmitted infections or STIs, and age-appropriate immunizations and cancer screenings.
Additional recommendations are based on the patient’s age and health risks. When a patient presents for well-patient care, begin with a complete history and physical exam.This includes your patient's obstetrical, gynecological, menstrual, and contraceptive history, along with their family and social history.

General screening and counseling0:43–7:55

Key factors that will guide your screening include age, past and current sexual activity, smoking status, and review of medical conditions like hypertension, dyslipidemia, diabetes mellitus, and cancers like cervical, breast, colorectal, and skin cancer.
Next, complete an age-appropriate physical exam including height, weight, and vital signs. Now let’s talk about the recommended screening and counseling that applies to all patients.
Screening for alcohol, tobacco, and substance abuse can be completed either through a direct conversation with your patient or by using a validated questionnaire.
Regarding alcohol use, the recommended limits for alcohol are one drink or less per day or seven drinks per week. Additional alcohol use beyond this is a common cause of preventable diseases such as alcoholic liver disease, injuries from events like motor vehicle crashes, and overall premature mortality.
Likewise, tobacco use and substance abuse are significant preventable causes of disease, disability, and death. As needed, provide counseling for patients and connect them to resources and referrals for further intervention and support.
Next, screen for anxiety and depression - both of which are common conditions - using a validated questionnaire. A positive screening for either condition should prompt further evaluation.
Counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, can be effective, as well as medical management.
Also discuss birth control for your patients of reproductive age, which allows patients to control their reproductive health and prevent unintended pregnancy.
Provide education and counseling on contraceptive options, including the benefits and risks of each. Also, provide education on daily folic acid supplementation before and during pregnancy to prevent neural tube defects like spina bifida.
Then, screen for interpersonal and domestic violence, which is common but often goes undetected. Be alert for certain risk factors that can increase the risk of violence, such as economic hardships, social isolation, and substance abuse.
Provide counseling and referrals, as needed.Moving on, complete blood pressure screening for all patients, and assess for risk factors for high blood pressure, such as excess weight and lifestyle factors, including smoking, lack of physical activity, and high fat and high sodium diet.
Provide counseling to reduce the incidence of cardiovascular and kidney disease. Similarly, screen for elevated lipids, calculate your patient’s 10-year risk of a cardiovascular event, and prescribe a statin to prevent cardiovascular disease, as needed.Also, screen for obesity, which is defined as a body mass index, or BMI, of 30 or greater.
Obesity increases the risk of chronic health conditions like cardiovascular disease, type 2 diabetes, gallstones, and certain types of cancers, such as endometrial cancer.
As needed, provide individualized counseling on weight reduction and healthy eating.Next screen for urinary incontinence, which is often unreported or ignored but adversely impacts quality of life.
There are several types of urinary incontinence, which are managed differently, but the first step is to identify the issue.
Then, provide counseling, as well as referrals for further diagnostic evaluation, as needed.Finally, screen for STIs. Most STIs, like gonorrhea, chlamydia, hepatitis B, hepatitis C, HIV, and syphilis can be asymptomatic.
Screening is key, as these can cause serious issues including pelvic inflammatory disease, infertility, and cervical cancer.
Counsel on safe sexual practices to prevent STIs and prescribe treatment, as needed. Okay, now let’s review additional topics to cover for high-risk patients.
A patient is considered high-risk and is in need of increased screening and counseling if they have certain risk factors.
Diabetes screening is indicated every 3 years beginning at age 35 for patients who have risk factors like being overweight, obese, or a history of gestational diabetes.
Next, patients who would benefit from tuberculosis screening include those who have immigrated from countries with increased prevalence of tuberculosis, and those living in high-risk congregate settings such as homeless shelters, correctional facilities, or long-term care facilities.
Other risk factors include being in close contact with individuals who have active tuberculosis, or having a medical condition that weakens the immune system, like diabetes or HIV, as well as conditions that require treatment with corticosteroids or chemotherapy.
Screening can pick up a small percentage of individuals with latent tuberculosis before it progresses to active disease.
Moving on, let’s discuss healthy diet and physical activity counseling. While all patients can benefit from a healthy diet and physical activity, those with risk factors for cardiovascular disease have the greatest benefits.
Lastly is risk assessment for BRCA 1 and 2. Screening is recommended for patients with a known family history of breast or ovarian cancer; those who previously had breast or ovarian cancer and are now considered cancer free; as well as patients with an ancestry known to be at a higher risk, such as Ashkenazi Jewish ethnicity.

Age 18-207:55–9:15

Okay, now let’s initiate individualized care based on your patient’s age. For those aged 18 to 20, start by reviewing age-appropriate immunizations.
All patients should be up-to-date on their pediatric vaccinations as recommended by the Centers for Disease Control and Prevention, or CDC.
Here’s a clinical pearl! Annual influenza vaccines are recommended for all healthy patients, regardless of age.
Also be sure your patent’s COVID 19 vaccination status is up to date based on CDC guidelines! Additionally, recommend the human papillomavirus, or HPV, vaccine, unless previously received, as immunization against HPV is the main intervention to prevent cervical cancer.
Also encourage meningococcal B vaccine and Tdap or tetanus-diphtheria-pertussis, which is administered every 10 years. Encourage periodic vision and hearing tests along with skin cancer screening for high-risk patients, which includes those with fair skin, light hair and eye color, freckles, and or those who sunburn easily.For patients aged 21 to 39, review their immunization status per the CDC, including HPV vaccination through age 26, unless previously vaccinated.

Age 21-399:15–10:00

Also continue to recommend skin cancer screening for high-risk patients. Next, focus on completing a Pap test for cervical cancer screening, starting at age 21.
Cytology alone is typically used for screening from age 21 to 29, every 3 years. Although this is the most common approach, primary HPV testing every 5 years may also be considered for average-risk patients starting at age 25.For patients aged 40 to 64, confirm that they’re up-to-date on immunizations per the CDC, including the herpes zoster vaccine, starting at age 50.

Age 40-6410:00–12:48

In addition, the respiratory syncytial virus or RSV vaccine can be considered starting at age 60 using shared clinical decision-making.
Cervical cancer screening continues every 5 years, and breast cancer screening begins at age 40 with annual mammograms. If your patient has a family history of a first-degree relative with breast cancer diagnosed before the age of 50, then recommend starting screening 10 years prior to that relative’s age at the time of diagnosis.
For example, if your patient’s mother was diagnosed with breast cancer at age 45, then your patient should begin screening at age 35.
Colorectal cancer screening starts at age 45, with the same caveat about first-degree relatives as breast cancer. There are different screening modalities, but the gold standard is colonoscopy, which if normal, is repeated every 10 years for non-high-risk patients.
Also, be sure to screen for osteoporosis. Specifically, all biological females require screening via dual-energy-X-ray absorptiometry, or DEXA scan, beginning at age 65.
Additionally, postmenopausal patients younger than age 65 who have at least one risk factor for osteoporotic fractures can be evaluated with a clinical risk assessment tool, such as the fracture-risk-assessment-tool, or FRAX.
Risk factors include a parental history of hip fracture, smoking, White race, excess alcohol consumption, and/or low body weight.
In these individuals, use the FRAX to calculate their 10-year probability of a major osteoporotic fracture. If greater than 8.4%, a DEXA scan is indicated.
This is because in these individuals the risk of fracture is equivalent to the risk in a 65 year old White female without major risk factors!
Finally, recommend lung cancer screening for your patients via an annual low-dose CT scan starting at age 50 if they have a 20 pack-year history and currently smoke or have quit smoking in the last 15 years.For those aged 65 or older, begin by confirming that immunizations are up-to-date, including the pneumococcal vaccine.

Ages 65+12:48–13:36

Cervical cancer screening can be stopped at age 65 if your patient has had adequate negative prior screening results. Breast cancer screening with yearly mammograms continues until at least age 75 and colorectal screening also continues until at least age 75.
Patients aged 65 and older should be screened for osteoporosis. Finally, lung cancer screening for patients with a 20 pack-year history should continue until age 80, but can be discontinued as early as 15 years after they've stopped smoking.Alright, as a quick recap… Well-patient gynecologic care focuses on screening and prevention of disease in otherwise healthy individuals.
After completing history and physical examination, move on to screening and counseling. Individualized recommendations are based on your patient's age and risk factors.

Review13:36–13:55

in otherwise healthy individuals After completing history and physical examination move on to screening and counseling Individualized recommendations
Well-patient care (GYN): Video, Steps, Indications | Osmosis