; Professor and Chair of Obstetrics and Gynecology; and Gillette Professorship of Obstetrics and Gynecology at 

Catherine Y. Spong, MD

It has been one hot summer, especially here in the Dallas-Fort Worth, Texas, area. We saw a record-breaking streak of consecutive days over 100 °F and without rain. 

With the summer months sweltering on, the editors and contributors of Contemporary OB/GYN® have been hard at work carefully crafting a great issue that touches upon a variety of subjects within obstetrics and gynecology. 

There are several excellent must-read articles this month:

 is an article by Melissa M. Mauskar, MD; Hunter J. Pyle, BBA; and Audrey K. Rutherford, MD, on vulvovaginal dermatology essentials needed every day to accurately identify various vulvar conditions and determine the appropriate treatment. the authors also provide information on how to best approach patients with vulvovaginal concerns in the clinic. 

, written by Danielle M. Alm, PharmD, BCPs, BCPPs; Reina Puri; and Christine Payne, takes a deep dive into the various contraceptives on the market and describes some best practices for discussing birth control with adolescent patients.

by Brian K. Iriye, MD; and James D. Keller, MD, provides thoughtful and informative tips on how to make meetings both effective and efficient.

 explains the latest phase 3 data for fezolinetant (Astellas Pharma) to treat moderate to severe vasomotor symptoms associated with menopause. The data were presented at the American College of Obstetricians and Gynecologists' Annual Clinical and Scientific Meeting in May 2022 in san Diego, California. 

 features an article by Bertie Geng, MD; and Alla Vash-Margita, MD, about cervical cancer screening guidelines in adolescents. And although average-risk adolescents don’t need Papanicolaou tests, this article gives an update on special populations of adolescent patients who do.

So, as you sit back, relax, and read this August issue of Contemporary OB/GYN® (I hope by a pool or in the shade), please let me know whether there are any topics you would be interested in reading about. Email me at cspong@mjhlifesciences.com. 

Articles

Beating the heat

It’s a growing specialty within our field and often is underappreciated.

In this issue, you’ll find articles (some of which are detailed below) on gynecologic care for the adolescent, including care of the transgender adolescent patient, common pediatric vulvar conditions, the second part of our pediatric adolescent gynecologic emergencies series, and more.

We tapped experts in the field to address these topics and—appreciating the political nature of some—worked to ensure that the data and expertise were shared across the specialty to provide the best possible coverage.

Appointments specifically for adolescent gynecology are limited in
many areas of the US. As we provide coverage for these needs and topics,
it is essential that we communicate the importance of addressing
concerns, as well as critical support, for the adolescent going through a
medical situation.

Care for transgender patients may need to extend beyond the medical scenario if their care is affected by political agendas. It is vital for obstetrician-gynecologists (ob-gyns) to advocate for the care of our patients and ensure appropriate, evidence-based care.

Pediatric vulvar conditions are often hidden, unrecognized, or unacknowledged. Our advocacy to ensure they are evaluated and addressed is critical.

Adolescent gynecologic care may be provided through pediatric adolescent medicine clinics or ob-gyn adolescent gynecology clinics (after subspecialty training). It is vital to ensure appropriate expertise, interest, and support are provided.

Ultimately for the ob-gyn, these individuals are the future of our
field, and providing the best care now ensures a bright future for the patient population. 

Catherine Y. Spong, MD,editor in chief, is professor and chair in the Department of Obstetrics and Gynecology at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology. Email her at cspong@mjhlifesciences.com.

This month we focus on pediatric adolescent gynecologic topics, which are critical to our practices (and our families). 

The world of the pediatric adolescent patient

Thrust into the front lines of the pandemic, we were called upon to not only care for patients with COVID-19 but to do so against the backdrop of ongoing nonelective care. Put simply, obstetrics never stopped. As we reflect on the heroic work of our colleagues and friends, it is interesting to frame our experiences through ebbs and flows of case counts for the past 2 years. 

We saw community burden through a unique lens given constant patient volume, access to COVID-19 testing in outpatient and inpatient areas with integrated electronic health records, early universal testing at delivery for mothers and exposed infants, and screening for those admitted during antepartum care.

Indeed, being in the labor and delivery department the past 2 years often felt like one was the canary in the coal mine. As COVID-19 surges came and went, we felt that the day-to-day rise in number of positive cases we diagnosed foreshadowed the rise in hospitalizations. 

Taking this to our statisticians, we asked them to see whether they could prove our hypothesis. The statistics were more complex than we expected.

At Parkland Hospital in Dallas, Texas, where there are nearly 12,000 births per year, the service was testing as many as 50 women a day. A time series analysis was used to compare the number of new COVID-19 cases in obstetrics and the number of new COVID-19 cases hospitalized in the Dallas–Fort Worth trauma service area. 

The Kwiatkowski-Phillips-Schmidt-Shin test was used to test the assumption of stationarity in both data sets. This assumption indicates that each time series has no dependence on the time it is being observed (no trend, seasonality, etc). 

Figure: Obstetrics COVID-19 Case Volume vs Hospital COVID-19 Census

The data were determined to be stationary, and the Granger causality test was used to determine whether the obstetrics COVID-19 counts at differing lags in addition to the changing hospital census counts were useful for forecasting the hospital census count in the future. 

A lag of 1 would indicate using obstetrics counts 1 day prior, a lag of 2 would be using the obstetrics counts 2 days prior, and so on. We tested to see how far out the obstetric case counts became the “canary.” Lags of 1 to 7 days were tested to assess the usefulness of the prior week of obstetrics data in forecasting the Dallas–Fort Worth hospital census. 

 values were adjusted using the Bonferroni method to control the inflated type I error rate due to multiple testing. Statistical significance is indicated
by 

Interestingly, the data proved our point. The obstetric COVID-19 cases 1 day prior forecasted hospital census increases in our metroplex (

Table: Do Obstetric COVID-19 Case Counts Predict Future Rises in Hospital Census?

We believe the same could be done with continued ongoing local surveillance, but that is not yet a reality because most community testing is done for an indication rather than universally. That is, community testing availability waxes and wanes in response to a recognized surge. 

Although these data are limited in predicting a surge far in advance, the labor and delivery department statistics did serve as a safety signal for the community. Ob-gyns were the canaries in the coal mines of COVID-19 community burden. We hope to use this insight and similar data in the future to guide targeted responses to disease spread. 

Obstetrics and gynecologists (ob-gyns) are tough.

Ob-gyns: canaries in the coal mine for COVID-19

Endometriosis is a topic that is relevant to both our patients and providers, judging by the number of page views on our website (

). Endometriosis is estimated to affect over 6 million women in the United States.

 Symptoms include pain, bleeding between menses, gastrointestinal problems (such as diarrhea, constipation, bloating, and nausea), and infertility. Although the most common symptom is pain, more than one-third of women with grade IV endometriosis present without pain, suggesting the need to keep endometriosis in the differential, even if pain free.

TABLE. Contemporary OB/GYN Endometriosis Articles

National awareness months are useful not only to bring awareness to a particular disease or disorder but also to raise interest, provide knowledge, and offer a better understanding of the condition. With this month being National Endometriosis Awareness Month, 

® is featuring an article on how patients use social media to learn more about the condition.

FIGURE. National Institutes of Health Funding—Endometriosis

Research on endometriosis includes understanding the etiology or cause; the role of genetics, hormones, and the immune system; and management options. Interestingly, funding for endometriosis from the National Institutes of Health has fluctuated from $6 million to $15 million since 2008 (

 Compared with other diseases with similar 2020 and estimated 2021 funding, endometriosis affects a much greater proportion of the population than the funding might suggest.

Endometriosis is diagnosed when endometrial tissue—which typically is inside and lines the uterus—is present outside the uterus, most commonly in the ovaries, fallopian tubes, and the tissue lining the pelvis. Although history and physical exam may be helpful with the diagnosis, definitive diagnosis often requires laparoscopy. Given the common symptoms, on average it takes more than 7 for a woman to get the diagnosis.

Scholarly peer-reviewed articles about endometriosis in PubMed have risen almost every year and now top 2000 per year. Despite this, more studies need to be done. For an illness that affects 1 in 10 women, this month, let’s up the ante on support, research, and commitment to an issue that significantly and adversely affects women’s health—and that of their families. 

Fuldeore MJ, Soliman AM. Prevalence and symptomatic burden of diagnosed endometriosis in the United States: national estimates from a cross-sectional survey of 59,411 women. 

. 2017;82(5):453-461. doi:10.1159/000452660

Gordon HG, Mooney SS, Conroy IC, Grover SR. When pain is not the whole story: presenting symptoms of women with endometriosis. 

. 2022;10.1111/ajo.13482. doi:10.1111/ajo.13482

National Institutes of Health. Estimates of funding for various research, condition, and disease categories. (RCDC). June 25, 2021. Accessed February 8, 2022. https://report.nih.gov/funding/categorical-spending#/

National awareness months and days span a variety of topics, from celebrated foods (think National Ice Cream Day, National Bagel Day, National Pizza Day) to businesses (free Slurpee at 7-Eleven) to our terrain: health issues. March alone is a national health awareness month for over 10 conditions, one of which is endometriosis. 

Bringing awareness to endometriosis

Vaccinations for measles, mumps, rubella, and pertussis, to name a few, are routinely administered to children. Influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines should be administered in pregnancy, as recommended by professional organizations including the American College of Obstetricians and Gynecologists and the Advisory Council on Immunization Practices. Both vaccines are standard inoculations in pregnancy, decreasing the risk of influenza and pertussis in pregnant women and their infants.

COVID-19 Full Vaccination Rates in US and US Pregnant Populations. 

SOURCE: Centers for Disease Control and Prevention

COVID-19 vaccination is also recommended for pregnant women; however, to date, vaccinations lag in this group (

). Because of the Omicron surge, infection in pregnancy has skyrocketed. We are seeing a more than 500% increase in COVID-19 diagnoses. Thankfully, the severity with Omicron is much lower than with the Delta variant.

 It is not, however, without an impact on our field, as the donning and doffing of personnel protective equipment and the deluge of patients are not insignificant and are further taking a toll on providers—both physicians and nurses. With this new surge in cases, the light at the end of the tunnel for this pandemic seems more distant than ever.

The latest COVID-19 vaccination numbers from the Centers for Disease Control and Prevention (CDC) reveal that, as of this writing, 62.5% of the US population are fully vaccinated, 74.3% have received at least 1 dose, and 36.3% have received booster doses.

 This is in contrast to pregnant women (aged 18-49 years), who are at less than one-third the rate, with just 41.5% fully vaccinated; of these, about half received their vaccinations prior to pregnancy.

US Immunization Rates in Children, Pregnant Women, and Adults Over 65 Years

Despite demonstrated effectiveness and—for Tdap—benefits that extend to the infant, a 2021 survey by the CDC reports disappointing uptake of even non–COVID-19 vaccination in pregnancy.

 Of 1795 pregnant women between October 2020 and January 2021, just 55% received influenza and 53.5% received Tdap vaccinations. Furthermore, just 30.7% received both influenza and Tdap vaccines. These rates are relatively stagnant, as data from 2017 report Tdap vaccination in pregnancy at 50.4%.

 These rates pale in comparison with vaccinations in children: More than 80% are vaccinated for diphtheria, tetanus, and pertussis, and more than 90% are vaccinated for polio, measles, mumps, rubella, hepatitis B, and chickenpox.

 Furthermore, 46.8% of adults are vaccinated for influenza, and 68.9% over age 65 years have received a pneumococcal vaccination (

Despite numerous efforts to advocate for including pregnant and lactating women in research, both groups were again excluded from research on the COVID-19 vaccines and therapeutics. Even with official recommendations for COVID-19 vaccination in pregnancy, it has been difficult to implement. Importantly, influenza and Tdap vaccinations in pregnancy were highest in women when the provider offered or referred for vaccination (influenza, 68.1%; Tdap, 69.9%).

 This opens an avenue forward: We as providers can make a difference for our patients by advocating and encouraging vaccination, providing the data on efficacy and impact on the health of both the woman and her infant. It is imperative that we break through the political issues associated with COVID-19 vaccination and directly provide the guidance to our patients.

Adhikari EH, SoRelle JA, McIntire DD, Spong CY. Increasing severity of COVID-19 in pregnancy with Delta (B.1.617.2) variant surge. 

. 2022;226(1):149-151. doi:10.1016/j.ajog.2021.09.008

COVID-19 vaccinations in the United States. Centers for Disease Control and Prevention. March 28, 2020. Accessed January 10, 2022. 

https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total

COVID-19 vaccination among pregnant people aged 18-49 years overall, by race/ethnicity, and date reported to CDC – vaccine safety datalink United States. Centers for Disease Control and Prevention. January 15, 2021. Accessed January 10, 2022. 

https://covid.cdc.gov/covid-data-tracker/#vaccinations-pregnant-women

Tdap vaccine. Centers for Disease Control and Prevention. Updated August 15, 2017. Accessed January 10, 2022. 

https://www.cdc.gov/vaccines/pregnancy/hcp-toolkit/tdap-report.html

Immunization. Centers for Disease Control and Prevention. Updated August 3, 2021. Accessed January 10, 2022. https://www.cdc.gov/nchs/fastats/immunize.htm

Influenza. Centers for Disease Control and Prevention. Updated August 3, 2021. Accessed January 10, 2022. https://www.cdc.gov/nchs/fastats/flu.htm

Flu and Tdap vaccination coverage among pregnant women – United States, April 2021. Centers for Disease Control and Prevention. Updated October 7, 2021. Accessed January 10, 2022. https://www.cdc.gov/flu/fluvaxview/pregnant-women-apr2021.htm

For more than 70 years, vaccination has been a public health strategy for disease mitigation. Even in populations often considered “vulnerable”—children and pregnant women—vaccination is strongly recommended and commonly embraced.

Vaccination: Protecting our most vulnerable

Strain from medical and home demands, along with furloughs as a result of reduction of elective medical care early during the pandemic altered the professional trajectory of many in nursing careers. As a result, there has been an increase in retirements, career changes, and separation from the workforce.

The nationwide shortage of nurses is a crisis that is especially felt in obstetrics and gynecology. Even with incentive pay and critical staffing pay, money cannot overcome the fatigue associated with increased workload on a reduced staff. This has forced facilities to turn to travel or agency nurses. Rates for travel nurses have tripled.1 For example, nurses in Houston, Texas, were being paid up to $12,000 a week.

 Furthermore, hospital nursing staff working alongside travel/agency nurses created conflict given the disparate compensation.

FIGURE. National Health Care Expenditures

Hospitals critically need nursing staff to care for their patients and thus are forced to pay these rates to ensure care. The American Hospital Association sent an open letter to the Federal Trade Commission to investigate this issue, specifically anticompetitive pricing by nurse staffing agencies.

 The higher salaries and greater flexibility in the travel positions, as well as the ability to be a travel nurse without leaving home, have led to a surge of hospital nurses leaving their positions to travel positions, further compounding the problem.

US health care expenditures exceed those of other developed countries, with similar or worse outcomes.

 The national health expenditures grew
4.6% to $3.8 trillion in 2019, accounting for 17.7% of gross domestic product and is projected to grown annually approximately 5.4% through 2028, reaching $6.2 trillion by 2028 (

 However, these calculations do not account for the nursing shortages seen with the pandemic and the reliance on agency nurses at a higher cost. The health care system is at a crossroads with how to handle the critical nursing shortage without further increasing the national health care expenditures.

One option is to enforce via regulation, holding down the cost of travel nurse compensation. However, regulation such as this in other areas has not been successful. For example, ensuring housing is available to people who in live certain areas led to the creation of rent-controlled dwellings. Although incredibly useful to the families who can obtain this housing, the benefits for those who build and own these facilities are limited. Thus, developers’ interest in further creating these dwellings ceases and often, they move to other markets for a better margin of profit.

Ultimately, the path forward requires not only the education and training of more nurses but also the creation of an environment where they are valued and inherently want to work because of the mission, vision, and goals of the institutions. People who go into nursing commonly do so because of their passion to help others and to work closely with people. If we hope to avert this nursing crisis in our facilities, we must empower our nursing colleagues to address the pipeline and concerns and identify solutions. 

1. AHA urges FTC to examine anticompetitive behavior for nurse-staffing agencies and commercial insurers. American Hospital Association. February 4, 2021. Accessed December 7, 2021. https://www.aha.org/lettercomment/2021-02-04-aha-urges-ftc-examine-anticompetitive-behavior-nurse-staffing-agencies-and

2. Ackerman T. Job offers of up to $12,000 a week lure Houston nurses to COVID-19 hot spots. 

. January 16, 2021. Accessed December 7, 2021. https://www.houstonchronicle.com/news/houston-texas/health/article/Job-offers-of-up-to-12-000-a-week-lure-Houston-15875348.php

3. NHE fact sheet. Centers for Medicare & Medicaid Services. Accessed December 7, 2021. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet

4. How U.S. healthcare costs compare to other countries. Investopedia. Accessed December 7, 2021. https://www.investopedia.com/articles/personal-finance/072116/us-healthcare-costs-compared-other-countries.asp

The impact of hospitalization from COVID-19, especially severe disease, has greatly impacted our health care system—particularly the nursing staff. 