Though theoretical, the threat of aerosolized viral particles places health care providers at risk. Certain safety measures can be taken. View the full, peer-reviewed article, and more, in this month's edition of Contemporary OB/GYN.

July 2020 | Vol 65 No 07

The writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. 

A total of 40 statements were assessed and divided into 5 categories: (1) patient criteria; (2) health care provider criteria; (3) efficacy; (4) safety; and (5) treatment considerations.

In a July 2018 Safety Communication, the U.S. Food and Drug Administration (FDA) issued a public warning about the use of EBDs to perform vaginal rejuvenation or vaginal cosmetic procedures.

The statement highlighted the imprecision of the term “vaginal rejuvenation” and emphasized that, although the FDA is aware that devices such as lasers are used for a variety of surgical applications, the agency has not approved their use for any specific gynecologic indication.

Health care providers who subspecialize in female pelvic medicine and reconstructive surgery are positioned to evaluate and manage genitourinary syndrome of menopause (GSM) and vulvovaginal atrophy (VVA), and some of these clinicians deliver patient services using the EBDs that are discussed in the FDA Safety Communication. The vulvovaginal EBD devices that will be addressed in this document include laser and radiofrequency (RF) devices.

Concurrent with the FDA’s Safety Communication, a December 2018 International Urogynecological Association Writing Group Opinion summarized the small, but growing, body of evidence as well as concerns about vulvovaginal EBD.

This document explored evidence for the use of laser-based devices for GSM, vaginal laxity, and stress urinary incontinence (SUI). 

An International Continence Society/International Society for the Study of Vulvovaginal Disease Best Practice Consensus Statement published in February of 2019 concluded that, based on the currently available literature, laser is not recommended for routine treatment of VVA or SUI except as part of a well-designed clinical trial or with special arrangements for clinical governance, consent, and audit.

The primary author, Dr. Alshiek, stated that AUGS found it timely to provide guidance by convening a panel of experts to compile a clinical consensus statement (CCS). In the absence of strong Level I evidence, this CCS was created based on rigorous criteria to compile the most important agreed upon expert opinion statements supported by the available literature as it pertains to use of vulvovaginal EBDs.

The long-term safety and efficacy of these treatments needs to be evaluated. The increase in vascularity that has been shown in short-term studies is likely part of an injury-repair phenomenon similar to what happens with healing incisions. 

Just as an incision looks red for the first several months but turns white and avascular over time, it is possible that the increased vascularity produced by the laser could transform into devascularized scar later. 

If this scarring develops once the original injury repair is completed, irreversible scarring could take its place. Proof that this does not occur is needed.

Target devices were defined as all vulvovaginal EBDs applied to treat the conditions listed above, including:

Non-ablative Er:YAG lasers: A solid-state infrared light laser whose active laser medium is erbium-doped yttrium aluminum garnet (Er:Y3Al5O12), which typically emits light with a wavelength of 2.94 μm.

Fractional microablative CO2 laser: A CO2 laser that produces a beam of continuous infrared light with the principal wavelength bands centering on 9.4 and 10.6 micrometers (μm).

HYBRID -- Combination of non-ablative and ablative approaches

Hybrid fractional lasers: A laser device that applies tunable non-ablative (1.47 μm) and ablative (2.94 μm) wavelengths to the same microscopic treatment zone.

 This allows for simultaneous ablation and coagulative effects.

Radiofrequency (RF):A device that uses RF energy to heat tissue and stimulate subdermal collagen production in order to reduce the appearance of fine lines and loose skin. The technique induces tissue remodeling and production of new collagen and elastin. RF treatment also causes apoptosis of fat cells, which leads to fat layer reduction in the treated area.

Absence of consensus on many statements about EBD therapy practices currently in clinical use without preliminary scientific evidence exposes a significant knowledge gap about the efficacy and safety profile of the vulvovaginal EBD therapies, their indications, contraindications, maintenance regimens, comparison with available current treatments, and long-term benefits.

This was created in partnership with the American Urogynecologic Society (AUGS). AUGS was established in 1979 and represents more than 1,900 members, including practicing physicians, nurse practitioners, physical therapists, nurses and health care professionals, and researchers from many disciplines.

Full text of AUGS’ Clinical Consensus Statement on Vaginal energy-based devices can be found at: 

AUGS.ORG/ASSETS/1/6/VAGINAL_ENERGY_BASED_DEVICES.3.PDF

1.US Food and Drug Administration. FDA Warns Against Use of Energy-Based Devices to Perform Vaginal 'Rejuvenation' or Vaginal Cosmetic Procedures: FDA Safety Communication. August, 1 2018 

https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic#:~:text=To%20alert%20patients%20and%20health,associated%20with%20serious%20adverse%20events.

2.Shobeiri SA, Kerkhof MH, Minassian VA, Bazi T, IUGA Research and Development Committee. IUGA committee opinion: laser-based vaginal devices for treatment of stress urinary incontinence, genitourinary syndrome of menopause, and vaginal laxity. 

. 2019 Mar;30(3): 371-376. doi: 10.1007/s00192-018-3830-0.

3.Preti M, Vieira-Baptista P, Digesu GA, Bretschneider CE, Damaser M, Demirkesen O, et al. The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document. 

. 2019 Mar;38(3): 1009-1023. doi: 10.1002/nau.23931.

4.Tadir Y, Gaspar A, Lev-Sagie A, Alexiades M, Alinsod R, Bader A, et al. Light and energy based therapeutics for genitourinary syndrome of menopause: Consensus and controversies. 

. 201 Feb7;49(2):. 137-159. doi: 10.1002/lsm.22637.

Articles

This clinical consensus statement on vaginal energy-based devices (EBDs) reflects statements drafted by content experts from the American Urogynecologic Society’s (AUGS) EBD writing group. 

AUGS: Vaginal Energy-Based Devices

suggests that, among others, insulin resistance is a contributing factor in the association between race and poor prognosis in US women with breast cancer.

Although mortality rates have declined in some ethnic populations, the overall cancer incidence among African American and Hispanic populations continue to grow.

 The lack of data on the possible connection between race and breast cancer prognosis is what led a group of Mount Sinai researchers to conduct this new multicenter, cross-sectional study.

They used data from 10 hospitals across the country and patients included self-identified black women and white women with newly diagnosed invasive breast cancer. According to the authors, metabolic syndrome disproportionately affects more black women than white women.

The primary goal of the study was to determine if insulin resistance, determined by the homeostatic model assessment of insulin resistance (HOMA-IR), mediated the effect of race on prognosis. Researchers also included demographic data, anthropometric measurements, and fasting blood.

In total, 515 women participated (83% white, 17% black). Researchers ultimately found that MetS was more prevalent in black women than in white women (40% vs. 20%, 

The study also found that the mediation model, when adjusted for age, revealed that HOMA-IR was higher in black women than in white women (1.9± 1.2 vs. 1.3 ± 1.2, 

1. Gallagher EJ, Fei K, Feldman, SM, et al

 Insulin resistance contributes to racial disparities in breast cancer prognosis in US women. 

https://doi.org/10.1186/s13058-020-01281-y

2. Yedjou CG, Sims JN, Miele L, et al. Health and racial disparity in breast cancer. 

. 2019;1152:31‐49. doi:10.1007/978-3-030-20301-6_3

The lack of data on the possible connection between race and breast cancer prognosis is what led a group of Mount Sinai researchers to conduct this new multicenter, cross-sectional study. 

Insulin resistance contributes to racial disparities in breast cancer prognosis in US women

Dr. Spong is Chief of the Pregnancy and Perinatology Branch at the National Institute of Child Health and Human Development (NICHD), and Program Scientist for the Maternal-Fetal Medicine Unit Network. A Maternal-Fetal Medicine Specialist with INOVA Alexan

Women’s health research continues to be marginalized. To address and reverse this trend requires committed, accountable leadership, inclusion of diversity of thought and critical social science issues, in addition to the more well-funded basic traditional and clinical research.

There are several areas that contribute to this marginalization, first, with respect to pregnant women. Optimizing pregnancy outcome would significantly improve world health, as babies, if born early – and often thus small – have higher risks of heart disease, diabetes, and asthma. 

Therefore, a baby born without complications, at the right time and weight, has the potential for a healthier life. Similarly, optimizing a woman’s health – both for a healthier pregnancy and outcome and for her long-erm health – also has the potential to improve world health. A woman’s health is known to impact her family, including both younger and older generations, thus strategies to address women’s health are essential.

Funding for women’s health research is limited. The National Institutes of Health (NIH) categorizes research funding to provide consistent and transparent information on the categories of disease, conditions, and research areas. 

The categorization uses sophisticated text data mining based on scientific experts to define a research category. Incredibly, 

2019 was the first year that federal funding for women’s health research was classified based on scientific relevance

, rather than based on the percentage of female subjects included in the studies.

The rationale for using the percentage of females enrolled in a study to count as “women’s health research” is unclear, and unfounded, as women certainly are enrolled in studies that are not focused on women’s health.In 2019, the NIH funded $4,749M in women’s health research, with the largest percent (26%) by the National Cancer Institute (Figure 1). 

As examples, the genetics, neurosciences, biotechnology, brain disorders, pediatrics, and aging research categories all had more NIH funding in 2019 than women’s health. 

Although COVID-19 has impacted research across the board, its negative impact on women’s research cannot be underestimated. 

To prevent transmission of the virus, all non-essential visits and encounters have been appropriately stopped, thus all ongoing clinical research has effectively ceased aside from that impacting clinical care. As I mentioned in my editorial in April, when there were only 51 studies

 - pregnant and breastfeeding women are yet again excluded from research, notably from participating in COVID-19 clinical trials during this pandemic. 

This is a major missed opportunity as results with therapies studied in men and nonpregnant women may not be generalizable. Furthermore, therapies are potentially not being offered to women, or if they are offered, are not being systematically studied in this population to provide needed data with which to guide therapy. 

The impact of COVID-19 on women’s health research highlights the long-standing inequities in including this population in research. Only in the last few decades were women required to be included in clinical research. 

Only in 1993, with the passage of the National Institutes of Health Revitalization Act, were women mandated to be included in NIH-funded research. 

Yet even with this mandate, subsets of women remain excluded.

Despite mandated inclusion of women in research, women’s health research remains marginalized, as are women researchers and physician-scientists. Although data suggest that women submitting NIH research project grant (RO1) applications for the first time have the same grant success rate as men

, they are half as likely to apply for those grants

, despite the fact that just as many women as men are receiving advanced degrees. 

A natural history experiment using the investigator-initiated Canadian Institutes of Health Research Grant Programmes demonstrated that gender gaps in funding were due to female principal investigators being evaluated less favorably than male principal investigators - and not related to the quality of their research proposals.

This marginalization of women researchers is rampant. As reported in numerous studies, women are less likely to be promoted, achieve tenure, or be selected for leadership roles (Supplemental figure). 

Similarly, women with equal stature are less likely to be selected to participate in “think tanks” than men. As an example, a recent article outlining a research strategy for women’s health with 17 authors included only 4 (24%) women.

Furthermore, of the nine physician authors, only one is an ob/gyn and four are pediatricians. The themes from the “think tank” neglect critical areas of research, focusing on traditional sciences and emphasize genetics, overlooking the role of racial disparities and health inequities.

As noted by the 2018 NIH Gender Inequality Task Force Report, “Sustainable change in representation of women, and of all individuals from underrepresented groups, requires committed, accountable leadership along with effective tools to accomplish this important goal.”

 It is troubling that gender diversity in leadership positions is lacking nationally. 

Using 2019 data, only 19% of department chairs (both interim and permanent) are held by women. Extrapolating the trend lines suggests another 50 years are needed to attain parity of department chairs and medical school deans by gender (Figure 2). 

This diversity is not due to a lack of qualified women, as since 2002, women have earned the majority of all doctorates

 and in 2019, women comprise the majority of enrolled US medical students.

Underrepresentation creates a culture that perpetuates inequalities. For our patients, for ourselves, for our families, we must correct this course. This is not easy, and will require a change of culture led by a committed, accountable, proactive leadership. 

Equally important will be the inclusion of diversity and broadening of the research agenda to include critical social science issues, health disparities, and social determinants of health.

One ray of hope to address these pressing issues is the formation of the Womxn’s Health Collaborative, a group determined to identify and initiate actionable steps. 

If you are interested in participating, I encourage you to contact Dr. Michal Elovitz at 

, editor in chief, is Professor and Vice Chair in the Department of Obstetrics and Gynecology and Chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology.

https://report.nih.gov/categorical_spending.aspx

https://www.contemporaryobgyn.net/view/heralding-new-era-timely-topics-and-guidance

Constantine MM et al. Obstetrics & Gynecology: 

Pohlhaus JR et al. Acad Med. 2011; 86(6):759-67.

https://report.nih.gov/nihdatabook/report/132?showm=Y&chartId=176&catId=

Witteman HO et al. Lancet 2019; 393:10171:531-540

Sadovsky Y et al. AJOG 2020. PMID: 32565236

https://diversity.nih.gov/sites/coswd/files/images/2018-05/Gender%20Inequality%20Task%20Force%20final%20AD%20may%2030%202018.pdf

https://ncses.nsf.gov/pubs/nsf20301/report/u-s-doctorate-awards#sex

https://www.aamc.org/news-insights/press-releases/majority-us-medical-students-are-women-new-data-show

In this month's issue, Contemporary OB/GYN Editor-in-Chief Dr. Catherine Y. Spong talks about the ways in which women's health research has and continues to be marginalized. Addressing these inequalities, Dr. Spong says, demands a change of culture led by committed and accountable leadership.

Addressing inequalities in women's health research

The double impact of the pandemic and protests have placed a spotlight on what could otherwise be ignored corners and crevices. 

Starting on page 6, Editor-in-Chief Catherine Y. Spong, MD, tackles the topic of the inequities in women’s health research and has a call to action.

As is pointed out by Dr. Spong, correcting inequities demands a change of culture that requires committed and accountable leadership.

And so it goes that we must demand more from ourselves and organizations. Dr. Washington Clark Hill, who has been a practicing ob/gyn for 55 years, provides a wake-up call in his 

He addresses the difference between equity and equality. Watch our 

 that supplements his written piece. Sharing the cover story space with Dr. Hill are Vanessa Rogers, MD, and Shawna Nesbitt, MD, MS.

Dr. Rogers, a practicing ob/gyn, interviews Dr. Nesbitt, who is renowned for her work in diagnosing hypertensive disorders and also serves as Associate Dean of Student Diversity and Inclusion at the University of Texas Southwestern Medical Center in Dallas. 

We want your thoughts on other groups that could be covered in similar ways. Please email Senior Editor Angie DeRosa at 

This month’s issue takes on the pervasive problem of implicit bias and systemic racism in health care. 

Chairman's message: Implicit bias and racism

Dr. Hill is a Maternal-Fetal Medicine specialist with CenterPlace Health and Sarasota Memorial Hospital and has been an obstetrician-gynecologist for 55 years, almost 30 in Sarasota, Fla., within the Sarasota Memorial Health Care System.

We are in a cultural moment of awareness and change because of moral outrage by people of all colors. As was said at George Floyd’s eulogy, “What happened to Mr. Floyd happens every day in this country, in education, in health services, and in every area of American life, it’s time for us to stand up in Mr. Floyd’s name and say 

In obstetrics and gynecology, it’s way past the time to provide better and improved health care for all, not just for the haves but for the vulnerable in our communities as well.

Systematic and institutional racism result in many if not all of the 

 (SDoH) our patients face. The SDoH play a major role in numerous health disparities in our specialty and poorer outcomes that we see, whether in the death of pregnant mothers or infants or rates of cancer, heart disease, or worse outcomes in black and brown individuals with COVID-19. 

This is as a result of long-standing racism that is interpersonal, systemic, institutional, structural, and exemplary of racial bias and which adversely affects healthcare.

Physicians and healthcare workers (us) see this every day. We know racial bias and racism when we encounter it and that over the years, it leads to poorer health status and outcomes. 

The COVID-19 pandemic disproportionately affects and targets black and brown people more than whites because of racism. 

. The coronavirus has placed a bright spotlight on the long-existing poor health in black and brown people and the worse outcomes when they get COVID-19.

Clearly, there are demonstrated disparities in outcomes based solely on implicit bias and racism. A midwife said to me on rounds that there is no reason for a black or brown pregnant woman to die or be very sick more so than her white counterpart other than long-standing and present racism. Think about that. She is right. There is no genetic or biological reason for this tragedy! 

We can eliminate racial disparity by eliminating racial inequity.

Racism is an insidious cultural disease with many manifestations. Privilege is one and has to be admitted. Access to healthcare and healthcare injustice are others. Not getting a deserved promotion is another. Being assigned an insurance plan that does not provide for needed services is another. And so on. You know them.

Around the country, medical students, physicians, nurses, and their families have recently knelt in remembrance of George Floyd’s death to say “yes” we know there is racism in the provision of healthcare services and “yes” we admit it and “yes” now let’s use our platforms and do something about it. 

This is a great start but that alone is not enough! Letters and events of support are meaningful, but the systemic racism continues. 

All of us providing healthcare services have a role and must speak out. What should empower you to speak out? Better outcomes for your patients.

Dr. Hill is a Maternal-Fetal Medicine specialist with CenterPlace Health and Sarasota Memorial Hospital and has been an obstetrician-gynecologist for 55 years, almost 30 in Sarasota, Fla., within the Sarasota Memorial Health Care System. He can be reached at 

Steps to advance and address racial justice and healthy equity in ob/gyn

So where do we go from here? What can you as a clinician or administrator do?

 within your organization diversity and inclusion among your learners, faculty, staff, and most importantly the leadership within your organization. Change starts from the top. Is your “med exec” group truly diverse and reflective of your medical staff or group?

Have those difficult and sometimes uncomfortable, real, open conversations about racism and racial equity at your institution and their effects locally and within policies and practices in your organization.

and teach the importance of SDoH and structural racism in health services as part of the curriculum for trainees.

 for more diversity of staff, employees, management, faculty, and leadership. These people need your help. Use your platform and speak out wherever and whenever you can.

 health equity knowledge and advocacy where you work. Remember that equality is not equity. The service may be available to all; i.e., “equality,” but are all really able to access it, i.e., “equity?”

 Examine your own group, clinic or office. Is it really diverse? Who is at the front desk and who is doing the procedures? Any blacks or Latinos?

your meetings, mouth, ears, devices, and contacts to advocate and speak out for a more accountable, diverse and inclusive “healthcare system.” Compliment when you see something done well and hold those accountable when it needs to improve.

 your leadership, staff, and employees to use their influence and push forward with diversity and inclusion initiatives. Encourage them to partner with community organizations, suppliers, businesses, and diverse communities, not just those that look like them.

questions like, “How diverse is our workforce and management?” “What do the data show?” Look at the metrics over time. You know the importance of data. Eenie, Meenie, Minie, Mo...What Do the Data Really Show?

 your own institution. Does it appear that your hospital is welcoming to all forms of promoting diversity? What more can be done? Speak up if you see an injustice committed. Your organizations should encourage and support their staff to confront overt racism and implement efforts to address the implicit biases of coworkers and senior staff members.

 We can no longer remain silent and not speak up. That’s complicity. Your voice has power!

For those of you who choose to do it, this is not easy work. There will be lots of resistance and lots of words. It will take a lot of energy, but do not become dismayed or give up. It can be very frustrating. 

We have come a ways in including diversity, inclusion, and equity in our healthcare organizations but we still have a very long way to go in really being diverse. Healthcare organizations cannot rest on their laurels. 

Your hospital should be just as proud of being one of the top diverse hospitals in your area or country as it is about being a top cardiovascular center putting in valves. Use your platform to get there.

In the past 55 years since I became a physician, progress has been made but we still have so much more to do and a long way to go. Those gatherings in front of medical schools, hospitals, and clinics kneeling to remember George Floyd in support of the Black Lives Matter movement will make sure of that. 

They are not going away nor is the community. 

 wire story, dated March 26, 1966, contains the first known published reference to Dr. Martin Luther King’s famous quotation regarding injustice in health care, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” 

Dr. King’s remarks were made at a Chicago press conference held the day before in connection with the annual meeting of the Medical Committee for Human Rights. These words still ring true today.

I graduated from medical school in 1965 and remember marching the next summer for racial equity. It is now the summer of 2020 and people of color are still marching for racial equity. There is something wrong with that picture and many of you have pointed that out. 

—has changed. We must all do, expect, and demand better of ourselves and those in power who provide healthcare services and teach about it.

We have a lot of work and a long way to go to get the knee up and improve healthcare services for all of our patients, but we can do it if we really want to. 

A change has to come! I hope that this commentary rings clear as a clarion call touse our platforms, work together, stronger and better to eliminate racial inequity in our specialty and all of healthcare.

Racial and ethnic disparities in obstetrics and gynecology

. Committee Opinion No. 649. American College of Obstetricians and Gynecologists Obstet Gynecol 2015;126:e130–4.

Importance of social determinants of health and cultural awareness in the delivery of reproductive health care

. ACOG Committee Opinion No. 729. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e43–8.

The Joint Commission Stands for Racial Justice and Equity

SMFM Issues a Statement to its Membership on 

Reduction of Peripartum Racial/Ethnic Disparities

“In the past 55 years since I became a physician, progress has been made but we still have so much more to do and a long way to go.”

Ensuring racial justice and health equity in ob/gyn

Among lactating women during the first postpartum year, the contraceptive efficacy and safety of the 3-month progesterone vaginal ring (PVR) is comparable to the Copper-T380A intrauterine device (IUD), which lasts up to 12 years, according to a multicenter study in India.

The open-label study enrolled 789 healthy, married lactating women (aged 20 to 35 years; mean age 24) at 20 centers in India. All the women were 6 to 9 weeks postpartum following the birth of a normal, healthy infant, exclusively breastfeeding and willing to continue breastfeeding at least four times daily for 1 year. 

Participants also had not used any contraceptives since delivery, but were at risk for pregnancy.

Of the women, 459 used the PVR and 330 the IUD. No significant difference was seen between the two groups in 1-year pregnancy rates using either the Pearl Index (PI) for incidence of pregnancy per 100 women-years nor Kaplan-Meier (K-M) life tables. (PI: 0.62 for PVR and 0.35 for IUD vs. for K-M: 0.7 for PVR and 0.4 for IUD (

Overall, 99.3% of PVR users and 99.6% of IUD users avoided pregnancy. But contraceptive continuation rates at 12 months were 78.5% for IUD compared to only 56.9% for the PVR (

“This outcome was due primarily to expulsions that occurred during toileting and other squatting activities within the first three months and non-replacement of lost rings consistent with the protocol, a stipulation that limited comparisons and comparability of the two study arms,” the authors wrote.

Ring expulsions and menorrhagia were the two most common reasons for discontinuation among PVR and IUD users, respectively. However, few women (4 PVR users and 0 IUD users) reported weaning as a reason for discontinuation.

Median duration of amenorrhea among PVR users was 405 days versus 120 days for IUD users (

 < 0.001). Infants from both groups were fed seven to 12 times daily and grew at expected rates. The study underscores the value of PVR as a method that promotes breastfeeding as being beneficial to infant health.

Both groups reported similar treatment-emergent adverse events (TEAEs): 24.2% of PRV users and 23.0% of IUD users. Five PVR users experienced severe TEAEs: three cases of menorrhagia and one case each of dizziness and vaginal ulceration. This compared to three IUD users with severe TEAEs: one each of extremity pain, seizure and menometrorrhagia/menorrhagia.

Ensuring access to safe and effective contraception for postpartum women is an important national goal for India because only one-quarter of the country’s postpartum population is using contraception. In addition, short pregnancy intervals increase the risks of adverse maternal and infant outcomes.

In 2015, the World Health Organization (WHO) said that women who breastfeed and are 4 or more weeks postpartum can use the PVR without restriction. The authors concluded that a user-controlled device like the PVR “offers an additional contraceptive choice for lactating women for one-year postpartum use and can help to address the unmet need for contraception among postpartum women while encouraging breastfeeding to enhance infant growth and well-being.”

Roy M, Hazra A, Merkataz R, et al. Progesterone vaginal ring as a new contraceptive option for lactating mothers: evidence from a multicenter non-randomized comparative clinical trial in India. Contraception. Published online May 1, 2020. doi:org/10.1016/j.contraception.2020.04.016

Ensuring access to safe and effective contraception for postpartum women is an important national goal for India because only one-quarter of the country’s postpartum population is using contraception. 

Progesterone vaginal ring for contraception during lactation 

Videos

Senior Editor Angie DeRosa and Associate Editor Lindsey Carr sat down with Drs. Vanessa Rogers and Shawna Nesbitt to discuss racism and unconscious bias in ob/gyn practice. 

Overcoming racism and unconscious bias with Drs. Vanessa Rogers and Shawna Nesbitt

Partner Perspectives allows marketers to connect directly with the Contemporary OBGYN audience by enabling them to share their content. This content does not necessarily reflect the views of Contemporary OBGYN editorial staff or MJH Life Sciences.

Given the threat of cervical cancer to women’s health, guidelines for cervical cancer screening by the American College of Obstetricians and Gynecologists recommend screening with the Pap test and human papillomavirus (HPV) test together every 5 years for women age 30 to 65 years and cytologic testing alone every 3 years for women age 21 to 29 years.

 A wealth of data—including a recently published longitudinal Quest Diagnostics Health Trends™ study—affirm cotesting as the most effective screening strategy for women age 30 to 65 years.

 But to what extent do obstetrician/gynecologists (ob/gyns) agree with and follow guidelines, and how do they differ or deviate from women’s healthcare providers (HCPs) as a whole?

Through a survey of ob/gyns, nurse practitioners, and primary care physicians conducted by the National Association of Nurse Practitioners in Women’s Health (NPWH) and HealthyWomen, we find Ob/gyns, as well as all of these HCPs combined, are unified in their support for and continued use of the Pap test and cotesting for cervical cancer screening.

 We found similar support was noted from patients, which is important to consider when providing them care. There are differences, however, in perception of the effect of guidelines on women’s health, preferences for screening frequency, report of patient screening practice, and perceived patient knowledge about cervical cancer by ob/gyn experience.

Ob/gyns more likely to use Pap test compared to all HCPs

Ob/gyns recognize the value of the Pap test in screening for cervical cancer (94% ob/gyns, 95% all HCPs combined). Additionally, 94% of ob/gyns and 92% of all HCPs combined say the Pap test is an effective tool for managing the risk of cervical cancer (

). As well, 87% of ob/gyns say the Pap test itself is a primary reason their patients receive annual health checkups. Moreover, ob/gyns are more concerned that eliminating the Pap test from frontline cervical cancer screening will have a negative impact on women’s health (66% vs 61%).

Less than 1% of HCPs screen using HPV alone, demonstrating nearly universal agreement across all types of HCPs that screening with HPV alone is less effective than use of the Pap test and/or cotesting. In considering risks associated with HPV only testing without a Pap test, ob/gyns are most fearful about a positive diagnosis with no treatment options offered to patients (58%), more recommendations for colposcopies (57%), and higher rates of missed diagnoses (52%). These concerns are not surprising given previous research showing that screening with HPV alone could miss up to 1 in 5 cervical cancer cases.4 Considering the high prevalence of HPV, particularly among women younger than age 30 years, it is critical to discern which cases are most likely to progress to invasive disease to avoid unnecessary treatment. All of these concerns culminate in ob/gyns saying they are more likely (88% vs 82%) to continue using the Pap test as part of their cervical screening practices for the foreseeable future (

Ob/gyn and combined HCP support for the Pap test mirrors that of their patients. It was found that 84% of women are familiar with the Pap test and 90% believe the Pap test is important to managing their overall health and well-being. Women value the Pap test and believe it’s an important preventive health tool warranting regular visits with their ob/gyn.

Like the Pap test, both ob/gyns and all HCPs combined agree that cotesting has positive effects on women’s health. The extent to which HCPs trust and value the role of cotesting has increased to an even higher level since they were last surveyed by us 5 years ago. Ob/gyns are particularly strong in their support for the value of cotesting. Overwhelmingly, 91% of ob/gyns and 89% of combined HCPs believe cotesting is valuable for their patients’ health (

). These findings demonstrate clear agreement that cotesting remains the best way to protect women’s health.

Ob/gyns are also more likely to use cotesting than all HCPs combined and are taking the lead on what is considered standard practice in the United States. For patients who are age 30 to 65 years, more than 8 in 10 ob/gyns (81%) are likely to use cotesting for screening (compared to 74% of all HCPs combined). Moreover, ob/gyns are more likely to believe that cotesting provides the most assurance that a patient is not at risk for cervical cancer (83% vs 74% among HCPs) (

). Confidence in cotesting is inversely related to the experience with newer practitioners who are quick to adopt it. Ob/gyns with 10 years or less of experience are most confident in cotesting (93%), compared to those with 11 to 19 years of experience (80%) and those with 20 or more years of experience (79%).

Familiarity with guidelines does not equate to total compliance

Compared to all combined HCPs, ob/gyns are more familiar with consensus screening guidelines as you may expect. In fact, 87% of ob/gyns are familiar with these guidelines, as compared with only 69% of combined HCPs. However, less than half of ob/gyns (42%) believe the consensus guidelines have had a positive effect on overall women’s health compared to 55% among all HCPs combined (

). This lack of support may be due to the lengthening of screening intervals, given the overwhelming support for screening strategies involving the Pap test.

Divergence exists between ob/gyn preferences for screening frequency and patient practice

Regardless of personal perceptions of screening guidelines, ob/gyns and all HCPs combined most often recommend that their patients age 30 to 65 years be tested every 5 years after an initial test (44% of ob/gyns, 43% of HCPs).

Patients seem to prefer more frequent testing, with only 19% of patients tested every 5 years. However, 81% of patients are tested more frequently, with 1% tested every 4 years, 27% tested every 3 years, 12% tested every 2 years, 38% tested annually, 1% tested every 6 months, and 2% tested at some other frequency (

). Ob/gyns are more likely to report their patients being concerned about less frequent screenings (81%) than all HCPs combined (71%).

Ob/gyn confidence in patients’ awareness about cervical cancer screening varies

Ob/gyns report that a large majority of their patients are familiar with cervical cancer screening methods and the collection process. In fact, ob/gyns recognize how much women value the Pap test as part of their overall health and well-being. When asked whether they believe their patients are familiar with the Pap test, more than 3 in 4 (76%) report their patients are familiar. Further, all HCPs combined report similarly high rates of familiarity. As well, more than 6 in 10 ob/gyns (63%) and all HCPs combined (64%) report their patients as being aware that the Pap test and HPV test are collected in the same way, adding no extra time or frequency to visits with their HCPs. Ob/gyns with longer tenures are more confident their patients are aware of this. Of ob/gyns with 20 years or more experience, 73% report the majority of their patients are aware, compared to 64% of ob/gyns with 11 to 19 years of experience and just 45% of ob/gyns who have 10 years or less of experience.

Despite strong patient awareness of the different screening methods, most ob/gyns report that their patients are unaware of the link between HPV and cervical cancer. Although 98% of ob/gyns report being comfortable discussing an HPV diagnosis with their patients (96% typically discuss HPV with patients as part of their wellness exams, and 76% believe it is important to discuss HPV with their patients), only 39% of ob/gyns report that their patients are aware HPV can cause cervical cancer. Again, there is divergence in attitudes by ob/gyn experience. Nearly 47% of ob/gyns (1 in 2) with 20 or more years of experience report their patients are aware, compared to 41% of ob/gyns with 11 to 19 years of experience and just 22% of ob/gyns with 10 or less years of experience.

The varied confidence that ob/gyns have in their patients’ awareness of screening methods and cervical cancer risks may be due in part to a conversation gap between providers and patients. Although 76% of all HCPs combined claim to discuss cervical cancer and HPV frequently as part of their routine exams, patients say that they do not discuss these conditions as frequently as HCPs believe. Only 27% say they talk about cervical cancer with their HCP most or all of the time, while 25% say they never discuss it and 20% say they rarely do. These conflicting perceptions highlight the importance of ensuring cervical cancer screening is prioritized as a point for discussion during regular exam visits.

Implications for ob/gyns and patient health

Ob/gyns play a critical role in helping protect their patients’ health against the threat of cervical cancer by providing screening and education. There is strong agreement among ob/gyns that both the Pap test and cotesting are valuable cervical cancer screening methods. More than 8 in 10 report that they will continue to use Pap testing and cotesting with their patients. This unified support is reinforced by nearly universal agreement that HPV alone screening presents a number of risks, as evidenced by less than 1% of HCPs reporting that they screen using HPV alone.