Linda Marie Wetzel, RN

Hysteroscopic removal of intrauterine devices (IUDs) during the first trimester is a viable option for patients who wish to continue their pregnancy, according to DI Nassie, MD, who presented on this topic at the 

2019 American Association of Gynecologic Laparoscopists (AAGL) Global Congress

 on minimally invasive gynecologic surgery (MIGS) in Vancouver, British Columbia.


	Dr. Nassie, of the Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tiqva, Israel, and the Sackler School of Medicine, Tel-Aviv University, noted that while use IUDs has increased in recent years over oral contraceptives, there continues to be inherent failure rates with IUDs, which result in women becoming pregnant with a device in place.

 (WHO) both recommend IUD removal in the face of pregnancy, specifically due to the possibilities of miscarriage, placental abnormalities, chorioamnionitis, and preterm delivery. However, when the strings are not visible, the consensus is less clear. The choices are to leave the device in situ, attempt to blindly remove it, remove it with sonographic guidance, or attempt removal via hysteroscopy.


	In Dr. Nassie’s study, seven women in the first trimester underwent IUD removal without anesthesia or cervical dilation utilizing a 3.5-mm 

. Prior to the procedure, they were all were given prophylactic antibiotics and received vaginal prep with antiseptic solution. The uterus was distended with 0.9% saline until a clear view was achieved and then the infusion was stopped or slowed to decrease risk of hydro-dissection of the gestational sac. When the strings of the IUD were located, they were grasped using semirigid SF grasping forceps, and the device was gently removed. After removal, the fetal pulse was verified by ultrasound. All the women were discharged on the operative day.


	Dr. Nassie reported that all patients went on to have spontaneous vaginal deliveries at term. All infants were reported to be of appropriate weight for their gestational ages. No complications of pregnancy or placentation were reported.

“Hysteroscopic removal of an IUD in the first trimester is a safe option when the strings are not visible. It is not associated, according to our data, with major adverse pregnancy outcomes,” said Dr. Nassie. “This procedure should be offered to gravid women in the first trimester who desire to preserve pregnancy.”

Articles

Hysteroscopic removal of intrauterine devices (IUDs) during the first trimester is a viable option for patients who wish to continue their pregnancy, according to a presentation at the AAGL 2019 Global Conference.

Hysteroscopic removal of IUD in first trimester viable option

Drs. Einarsson, Ascher-Walsh, Moawad, and Munro continue their conversation in a web-exclusive roundtable focused on the challenges associated with certification for today’s surgeons and how they differed from what surgeons faced in the past. The discussion also delves into the evaluation of surgical skills and how the surgical volume that today’s residents are graduating with impacts the specialty.

Click here for their original discussion on the role of surgical simulators.

What challenges are associated with certification in gynecologic surgery today and how do they differ from what surgeons faced in the past?  

One of the main challenges is that there is no objective evaluation of surgical skills built into the current system. We have excellent, well-monitored training programs. But when surgeons complete training and go into practice, they may not necessarily be able to maintain their skills. There is also no way of testing to determine if surgeons are maintaining as least the lowest acceptable standard of skills. I think objective evaluation is really needed. Surgery also has become much more complicated-more options, technology, and knowledge that surgeons have to acquire, adapt to, and maintain proficiency with. 

But I’m not sure that gynecologic surgeons are getting excellent training. The training an individual gets has more to do with who the instructor is in the particular medical center than with any specific standards. 

The Council on Resident Education in Obstetrics and Gynecology

 (CREOG) does set standards for certification, but many residents don’t even get to see many of the procedures that they’re asked to be competent in performing. When I was in training, we did five vaginal hysterectomies a day, most of them on normal uteri. Now hysterectomy is far more likely to be performed in very complicated circumstances because of the focus on alternatives to surgery. The public today also is far more likely to look up surgeons to see how many procedures they’ve done and what experience they’ve had. 

I think that most of the problems arise from increasing of working hours. Conversely, reducing hands-on time would have important ramifications for surgical training because it relies on development of fine-motor skills, dexterity, and coordination. The root of the problem is lack of standardization of training because in many places, surgeons still train in apprenticeships. Branding of physicians in the eyes of public, to which Dr. Munro alluded, places pressure on hospitals and also makes it even more challenging for newer learners.

One challenge of ob/gyn residency training is that our residents have to master not only gynecologic surgery but also obstetrics. So, they don’t get as much time training in the operating room as general surgeons, urologists, or physicians in other surgical specialties. I think in surgery, residents graduating today may outperform ob/gyns who have been in practice for 5 years. That is because residents have a fairly decent volume of surgical cases during their training but actual ob/gyn practices often are obstetrics heavy. So a clinician’s surgical skills actually may go regress a little bit, which is bit concerning to me.

I always remember shaking the hand of my outgoing senior resident, who had just done his 600

vaginal hysterectomy. Current residents perform a tiny fraction of that number. The notion that we’re graduating people who still need to get experience while they’re practicing on patients is embarrassing, suboptimal, and possibly dangerous. Juxtapose that with all of the data available about numbers and types of cases and the spectrum of procedures gynecologic surgeons need to perform and put that in context of a litigiousness society and you’ve got a pretty problematic situation.  

I really think the elephant in the room is that we aren’t training gynecologic surgeons properly. It’s really a specialty and obstetrics and gynecology residents can’t be adequately trained to do all the operations that are listed in the CREOG/ABOG guidelines during a 4-year program when they’re spending about 14 months in a surgical environment. We have a short training process and, in addition nationally, the training environment is diluted. In the United States, ob/gyn training is typically 4 years and there is one gynecologist for every 6,000 patients. Training is 5.7 years in Canada, 7 years in the UK, and 6 years in Australia, all of which have a ratio of approximately 1 gynecologist for every 25,000 individuals in the population. 

I completely agree with you but there are workload restrictions in Europe, and sometimes residents cannot work more than 48 hours a week. So, training is longer partially because of those restraints. 

In a lot of countries, an ob/gyn cannot operate without doing an additional surgical fellowship. In Germany, for example, those without additional training are limited to becoming a community gynecologist – it would generally take at least another couple of years in an apprenticeship-type program before they can operate.  

That may actually be happening in the United States as well, slowly but surely. We’re graduating 30 fellows per year in minimally invasive surgery, which I would really just call gynecologic surgery, and I think they’re gradually taking up more of the volume, which makes it harder for generalists to compete. We may see an evolution similar to what happened in gynecologic oncology, which became a subspecialty in the 1970s after volume had moved gradually away from generalists to gynecologic oncologists. Outcomes are better in the hands of high-volume surgeons and in my opinion, I think the same is probably going to hold true for advanced benign surgery.

I agree with Dr. Einarsson that we are naturally moving to a field where the majority of surgeries are being done by more high-volume surgeons. It is happening because patients are better educated and seeking out these surgeons. It is also happening because surgery is stressful in the best of hands but doing a dozen cases a year leaves the less experienced surgeons with greater anxiety when they do operate, and they therefore self-select to not do it. Also, dedicated OR time is difficult to come by at the larger institutions and the surgeons that rarely operate find it difficult to get OR time and it requires that they take off an entire day to do one or two cases. It isn’t financially worth it. All this said, though, we should not be letting this happen naturally but we should be driving this for the reason the others have been stating. Surgeries are safer in the hands of those with the experience. We should be tracking our residencies to generate surgeons by design, not by default.

The Role Of Simulation Training For Ob/Gyns

The complexity and the landscape of gynecologic surgery also is completely different today. Before ultrasound and other treatments became available, vaginal hysterectomy was performed for abnormal uterine bleeding and sometimes even as a method of sterilization. Removal of completely normal uteri was not unusual.   We have a moral imperative to ensure that our patients get the highest quality of care and they should not be treated by clinicians who have not demonstrated that they can operate safely and reliably. 

A web-exclusive discussion on the complexities and the current landscape of gynecologic surgery.

Challenges associated with surgical training

In gynecologic surgery, surgeons are expected to acquire high levels of experience before performing surgeries, but they need to perform surgeries in order to gain experience. One proposed solution to this paradox is using surgical simulators. Here, four physicians discuss the merits of incorporating simulators into surgical training.

Ms. Wetzel: How do surgical simulators work and can they take the place of actual surgical procedures in training and certification? 

: I think simulators have potential to be very useful in training. Low-fidelity simulators-box trainers-are perfectly adequate but the science of simulation is somewhat lacking. Studies show that learner skills do improve after practice with a simulator, compared with results prior to use of the technology.

 To me, that’s not very surprising. I would be much more interested in knowing whether learners retain knowledge and skills gained from simulators over the long term and if that translates into superior clinical outcomes. Those are important questions and I understand that in medicine, we use intermediate outcomes for teachability sake, but I think we need better science in simulation.

Using simulation technology to reduce maternal morbidity

: I agree that the science needs to be better. Many people think that surgical simulation means going into a virtual environment and simulating an entire operation.  However, we are nowhere close to having realistic immersive simulation in which a learner can actually work on a virtual patient with a spectrum of virtual anatomical and pathological circumstances. Instead much of what we have is simple technology that simulates parts of the task or skill that we believe are useful, circumstances that may reflect something about the physical abilities of the individual. And this sort of simulation doesn’t take into account surgical judgment. Truly meaningful outcomes with simulation would include the impact of simulation-based training on safety, efficacy, quality of life, cost reduction, or some combination of those. But assessing these outcomes would be quite expensive. So important questions facing us right now include: Who are the stakeholders for surgical simulation and where is the funding going to come from to study real-world outcomes?

: I have a different perspective on simulation. Simulations are not going to create the surgeon but they can help enhance hand/eye coordination and ambidextrous surgery, among other things, and facilitate the learning curve and help with team-building and managing complications. I believe that the value of simulation lies in shortening the learning curve for the learner and providing a safe environment in which it’s permissible to make mistakes, explore what went wrong, and ask questions.

: Where possible, we also have to try to determine outcomes for simulation training that are meaningful and that will guide us in designing the technology and the way in which it’s used. Simulation is a part of an overall change in the training paradigm that spans a range of components of care such as determining who to operate on and how the surgeon should be prepared to execute the technical aspects of performing the procedures. Our disease state management is basically that of uterine and adnexal disease so our training has to be in that context.

Ms. Wetzel: What kind of simulators are currently available and what do practitioners need to know about using them? Which simulators do you prefer and why? 

: A lot of different simulators are available. The simplest are low-fidelity trainers that are basically a box with a small camera and a light, into which instruments can be placed to practice. The box trainer most widely used right now is the 

And then you have virtual reality (VR) trainers that try to simulate more procedures than the actual intraoperative environment.

 I really like the box trainers because they’re relatively inexpensive and can be used in different places and under varying conditions to gain dexterity and experience with techniques such as intracorporeal and extracorporeal mopping. Developing VR trainers that are meaningful is money- and resource-intensive. We had a VR trainer at our simulation center and every time I used the ectopic pregnancy module, the patient bled to death. I’ve never had a patient bleed to death in real life from an ectopic pregnancy. So, I think that there’s still some developmental work that needs to be done on VR surgical trainers.

: I think the first consideration is framing what is it that you’re simulating. In gynecologic surgery, we have abdominal access, both laparotomic and laparoscopic approaches, the latter done with and without microprocessor assistance. Vaginal approaches include hysteroscopic technique and surgery on the cervix and, hysterectomy when removal of the uterus is necessary. Should all of those aspects be simulated for residency training? The 

American Board of Obstetrics and Gynecology

 (ABOG) has acknowledged the importance of simulation-based training in laparoscopy by requiring that residents in obstetrics and gynecology graduating after May 31, 2020 pass the 

 (FLS) examinations developed jointly by the 

Society of American Gastrointestinal and Endoscopic Surgeons

. Many residency programs, however, have trouble affording a surgical simulator unless it’s inexpensive. But there is really no evidence that VR laparoscopy trainers do a better job at what is being measured than the low-fidelity systems.

On the hysteroscopy side, VR is actually more realistic and more attainable. There are a number of quite decent VR systems for hysteroscopy and one of the reasons that it’s easier to engineer those in that the environment is like being in a small room. In the laparoscopy environment, in contrast, you have to simulate interaction with the bowel and the level of complexity is exponentially greater. Simulation is hardly being done for vaginal hysterectomy and it remains a very low morbidity procedure with no abdominal incisions, but one that requires certain skills. Simulation should be considered for the multiple approaches to and processes associated with vaginal hysteroscopy to see what the likely benefit of the procedure might be. We’ve examined two low-fidelity surgical simulation systems-one for hysteroscopy and one for laparoscopy. Both can be used reasonably well by novices, mid-level trainees, people without extra training in gynecologic surgery, and people who have done a 2-year fellowship in it. Low-fidelity simulation is quite feasible, and quite usable.

: If we’re going to devise surgical simulation, first we need to determine its goal. If we’re looking at training for depth perception, hand-to-hand coordination and ambidexterity, which are the basic principles of surgery, I believe that low-fidelity simulators are always the best. What they lack is the feel of real tissue and plane dissection. The latter can be learned by watching realistic videos. I think virtual simulation has a role if we’re looking at the efficiency of movements and how to maximize it. Calculations can be done about the number of unnecessary moves to establish how efficient a surgeon is.  

But virtual simulations are being marketed as depicting procedures so super-realistic that training on them will give someone the ability to do the real surgery in real life. But they’re very far away from reality in many metrics. I think each simulator adds something but we need a combination of them. For example, using a bell pepper for hysteroscopy, chicken for laparoscopy, and beef tongue for suturing or tissue extraction are really very valuable in terms of immersing trainees in actively performing surgical steps on real tissue.

: A few years ago, we started a research project with our insurance carrier with the eventual goal of trying to find a simulator for use for credentialing or for continuation of privileges. We tried a lot of simulators and decided on the 

 simulator because we thought it was as close to real life, at that time, as we could find. But, there’s really nothing that mimics real surgery, although some of the newer simulators have tactile feedback. My perception is that simulation is good for learning the steps of a procedure, and it may help people who didn’t grow up playing video games to develop the hand/eye coordination necessary for laparoscopy.   However, we’re far from using it learn the intricacies of surgery and create talented surgeons. Things like tissue planes, which experienced surgeons see innately don’t really exist within simulation at this point. 

The role of simulation training for ob/gyns

: I think we may potentially be able to use simulation to help identify who should or shouldn’t be admitted to surgical training programs. Ability to use a surgical simulator could be a criterion for entry, either into residency or into a fellowship. For years now, in North America, dentists have had to demonstrate manual dexterity in order to get into dental school. I don’t know what evidence the dentists had when that criterion was introduced, but it doesn’t matter how smart you are if you can’t do a good job with manual skills. Simulation-based testing also could function as a formative examination for surgical skill, a skill-based component of the CREOG in-training exam (ITE). The ITE is administered to residents annually to evaluate their cognitive knowledge but we have no equivalent for surgery. As was previously mentioned, ABOG will now be requiring that residents in obstetrics and gynecology pass the FLS examinations that were designed for general surgeons. But the only component of gynecologic surgery that’s tested under FLS is laparoscopy and, if we’re restricted to that, then we’re creating one-arm surgeons. There is no testing for hysteroscopy, vaginal surgery, or laparotomy. Maintenance of certification also is another possibility for simulation-based testing. And simulation could be used to train gynecologists on use of new equipment and new techniques that are introduced, much as is done by the US military or in civil aviation. For example when new fighter aircraft are built, training and credentialing systems also are created for that machinery and are used as critical and essential hurdles to the overall process of certification. In my opinion surgical simulation based training and testing should ultimately be used in a similar fashion for surgeons of any discipline. 

: I think the simulators that offer the biggest bang for the buck, so to speak, are the low-fidelity simulators, which could be used to help residents pass the FLS test that will soon be a requirement for graduation. I think both graduating residents and physicians in practice should become familiar with the low-fidelity simulators. They should be made available in every ob/gyn residency program rather than virtual reality trainers, which are more expensive.

: A number of inexpensive and portable low-fidelity simulators are available that incorporate iPhones or iPads as the camera and light source, in a fashion that allows for and supports manual skills training.  They aren’t exactly the FLS trainer that we’ve talked about, but they can be accessible to anyone who wants to learn or hone manual skills. 

: When I was a resident, I made my own simulator out of a cardboard box, a video camera - there were no iPhones then - and a flashlight.  And it worked quite well. So a simulator doesn’t have to be very fancy to be useful.

: I completely agree. I really don’t feel like we’ve come very far with simulation in the last 15 years or 20 years, because the devices we have are still just teaching the basic tools. The fancy simulators can walk you through the steps of a procedure, but you’re really still just using the basic tools of surgery. Simulators don’t create great surgeons but they can give you the simple tools that you need to then become a great surgeon.

: I feel that simulation could play a role in recertification, but unfortunately, recertification is now based on volume rather than multiple metrics that could lead to better outcome. The other thing we need to work on is the whole system. Recertification should enable us to triage people who would benefit the most from simulation or from a specific aspect of simulation to better their skills and make them have better surgical outcomes.

Ms. Wetzel: What other options for simulation are on the horizon and do you see simulators being integrated more completely into your own clinical practices?

: I think that the most exciting thing that’s on the horizon is really the launch of the Essentials in Minimally Invasive Gynecology (EMIG) test, which has been in development for some time now by 

. EMIG is a three-part program designed to aid and evaluate the acquisition of manual and cognitive skills in hysteroscopic and laparoscopic surgery. It includes a curriculum, written examination, and manual skills test. I hope EMIG will be integrated into clinical practice in the near future and hopefully represent a minimum standard of proficiency in hysteroscopy and laparoscopy that providers should have to meet to have the privilege of operating on patients.

: The laparoscopic component of EMIG is performed the FLS box trainer, with exercise and instructions that have been adapted in a way that we believe is appropriate for gynecologic trainees - from novices to mid-level trainees to board-certified ob/gyns and also those who are training for FMIGS and other surgical fellowships. We’ve also created a relatively simple box trainer for hysteroscopy but we’re still challenged by the expenses of having the scope, light source, and camera, and there is currently no way to adapt the trainer for the iPhone or similar easily accessible monitors. We don’t yet have a simulator for laparotomic or vaginal surgery. Hysteroscopy is strikingly missing from a lot of the discussions about simulation on a national level – an omission which is concerning. It is lesions in the endometrial cavity such as polyps and myomas that most often are responsible for infertility and abnormal uterine bleeding, and the hysteroscopic surgeon is the one often best equipped to deal with them in a minimally invasive fashion. And of course, the hysteroscopic surgeon and the laparoscopic surgeon should be one and the same, making decisions on the technique based upon optimal training and skill rather than what they are comfortable with based on limited training. As Dr. Einarsson has said, gynecologic surgeons need to be adept at hysteroscopic, laparoscopic, and vaginal procedures to call themselves gynecologic surgeons. So, the next step in introducing simulation to our trainees is to make them applicable to the two endoscopic approaches we use.

: For me the only way I see simulation getting integrated into clinical practice is for surgeons who don’t operate very much. For high-volume surgeons, simulation in its current state, which is really not very lifelike, doesn’t help us in our clinical practice. But for surgeons who do a dozen cases a year, simulation may be helpful in credentialing or assessing whether to continue privileges. For those low-volume surgeons, I would see simulation as part of their clinical practice in maintenance of skills.  

: Where I see simulation, not only for the novice surgeon but also for the experienced surgeon, is integration of case-specific simulation. For example, anatomy could be reconstructed in three dimensions (3D) based on imaging and then the trainer, the mentor and the learner could use it to review that specific case. We might use it to simulate models for incision of fibroids or to test scenarios for addressing a complex case in a different way. In the future, 3D printing and reconstruction combined with case-specific simulation may prove very helpful before the case itself.

: I agree. There are certain circumstances in which a case may be so challenging that 3D reconstruction could help identify who you need in the room, what resources, and even where to dissect. For example, for complex neurosurgery, surgeons are increasingly using 3D reconstruction using of MRI volumes and 3D printers have been used to assess vascularity and other factors, allowing the surgeons to understand how to dissect in a very difficult field.  As Dr. Ascher-Walsh said, we aren’t even remotely close to that but I think one of the potential advantages of a true virtual reality immersive experience, is the opportunity to actually practice the operation and be a little bit closer to what happens, like commercial or fighter aircraft simulation, where it really is a realistic immersive experience. In fact, the simulation systems for fighter aircraft are so sophisticated, that training planes are no longer made – the pilot goes straight from the simulator to solo flying in aircraft worth hundreds of millions of dollars.

: Until we are there, I think using low-fidelity simulators and watching videos can be very, very helpful for surgeons. I want to put a small plug in for the SurgeryU platform that the AAGL has developed. It has a lot of very high-quality surgical videos that AAGL members can access. There are other sources of surgical videos available as well. I think that those two components are most easily accessible currently and then hopefully this will evolve into a more sophisticated offering in the near future or maybe the far future.

: To go back to the EMIG program, I’d like to emphasize that it isn’t just manual skills. There is an entire cognitive program that comprises 80 training videos which encompass the spectrum of hysteroscopic and laparoscopic surgery procedures and patient preparation. There is an accompanying didactive component is designed to measure judgment that will be mounted on the AAGL’s 

. The cognitive exam that has been validated and, in an ongoing fashion is modified and revalidated using high quality, psychometrician supported methodology. This examination, meant to evaluate judgement, is paired with the manual skills exam to provide an overall assessment of progress. So the EMIG system is more comprehensive than just an assessment of manual skills.

Ms. Wetzel: In conclusion, please sum up for our readers where you see surgical simulation today and what’s on the horizon in terms of simulation science.

: Simulation is still somewhat in its infancy. The low-fidelity simulators are the most easily usable and are probably going to be more integrated with the FLS test and then hopefully the EMIG test. I think we need better science and also probably better technology in the area of surgical simulation. 

: The most important point about surgical simulation, for me, is that use of simulation in isolation from any teaching method will furnish the learner with some skills but the best time and place to learn most of the skills will still be the traditional way, in the operating room (OR). In addition, surgical judgment is really hard to learn and I think simulation could provide a safe environment in which to learn how things can go wrong and how to readdress them. Simulation could help gynecologic surgeons build  confidence to enable you to apply those kind of competencies in a real OR.

: Where we’ve had some early success with simulation is in establishing credentialing. We’ve done some projects with a very large health system looking at a few hundred attendings and correlating their surgical skills on the simulator with their case experience. We were able to find some correlation between the two and we’re now comparing it to actual surgical videos with the hope of being able to use it as a credentialing tool. I think, as everybody else was saying, we’re sort of far away in using simulation as an advanced surgical training tool. I agree that the low-fidelity simulators are the best tools for the surgeon early in training. For low-volume surgeons, it also may be a way to maintain their skills. I hope that in the next decade, as the science improves, we’ll be able to have more realistic simulation, but we’re not there now.

: In gynecology, we are awakening to the notion that we have an increasingly complex challenge in the disease states that we are entrusted to manage. That challenge has to be taken into consideration when developing a structured approach to training and evaluation of residents and fellows at a spectrum of benchmark times in the training process. It’s both a moral and legal imperative. We need to improve how we train gynecologic surgeons, and simulation is only  part of the answer. Right now, simulation is only a nascent adjunct to training, and, at least in present forms, the low-fidelity simulators are at least equivalent to expensive virtual reality systems. The future requires science, investment, creativity, and an understanding that ultimately the patient expects that her physician and surgeon have a consistent and predictable level of skills. The patient’s level of trust should be similar to that vested in the pilot of the commercial aircraft of her selected airline. Finally, simulation isn’t just for laparoscopy. Simulation and surgical training involves hysteroscopic, laparoscopic, laparotomic and vaginal approaches, because all are essential skills for the contemporary gynecological surgeon.

The participants report no potential conflicts of interest with regard to this article.

Alaker M, Wynn GR, Arulampalam T. Virtual reality training in laparoscopic surgery: A systematic review & meta-analysis. Int J Surg. 2016 May;29:85-94.

https://fls-products.com/fls/search/?searchTerm=fls-trainer-box-with-tv-camera-with-tasks

https://simbionix.com/simulators/lap-mentor/lap-mentor-vr-or/

Munro MG, Brown AN, Saadat S, et al. Essentials in minimally invasive gynecology manual skills pilot validation trial. J Minim Invasive Gynecol. 2019 Apr 26. pii: S1553-4650(19)30205-5.

Four ob/gyns discuss the merits of surgical simulators and what kind of future is in store for the tools.

What is the role of surgical simulators?

This quiz reviews some of the major takeaways from the February 2019 article, 

New tools for counseling on prenatal genetic testing

1. Which of the following are NOT elements of counseling prior to routine prenatal genetic testing?

a) Review of family history
	b) Review of medical history
	c) Review of the patient’s use of medication or controlled substances
	d) Discussion of patient’s values and preferences

Please click here for answer, discussion, and next question.

Answer: C. Review of the patient’s use of medication or controlled substances

2. ACOG recommends that all pregnant patients be offered which of the following?

a) Aneuploidy screening or diagnostic testing for fetal genetic disorders
	b) Carrier screening, including screening for cystic fibrosis and spinal muscular atrophy
	c) Additional testing based on the patient’s race and ethnicity
	d) All of the above

3. Which of the following statements are true regarding genetic screening?

a) Screening tests help the patient define her risks of passing along a genetic disorder.
	b) Screening tests usually involve an invasive procedure such as amniocentesis or chorionic villi sampling.
	c) Screening tests are more comprehensive and accurate than diagnostic tests.
	d) All of these statements are true.

Answer: A. Screening tests help the patient define her risks of passing along a genetic disorder.

Screening helps the patient define her risks of passing along a genetic disorder; diagnostic testing tells for certain whether a fetus is affected with a genetic disorder.
	 

4. All of the following statements are true with regard to aneuploidy screening except:

a) All pregnant women should be offered the option of screening regardless of age.
	b) Different providers and practices should all use the same testing options to promote consistency in testing results.
	c) Patients should be provided tools and informational resources prior to any screening procedures being performed.

Answer: B. Different providers and practices should all use the same testing options to promote consistency in testing results.

Different providers and practices may have access to many different testing options, which is why it is important that patients are offered educational resources and materials that compare and contrast the available options.

5. Which of the following statements are accurate with regard to prenatal carrier testing?

a) In pan-ethnic screening, a wide variety of conditions are tested for, owing to a growing admixture of ethnicities.
	b) Expanded carrier screening is the most comprehensive option, including over 100 recessively inherited conditions.
	c) The more comprehensive the panel the higher the rate--up to 60%--of a positive screening, necessitating testing of the biological father.
	d) All of these statements are true.

Answer: D. All of these statements are true. 

Advances in sequencing techniques have contributed to more comprehensive and less expensive screening options for patients.

6. When considering the patient’s preferences with regard to prenatal genetic testing:

a) The practitioner should draw blood for genetic testing as part of the routine prenatal visit and discuss the results with the patient afterwards.
	b) The practitioner should take steps to ensure that the patient understands the difference between genetic screening and diagnostic testing
	c) Some patients may decide that they wish to forego screening tests based on their values, needs, and desires.
	d) B & C only

Patients should never have blood drawn for prenatal genetic tests without a prior conversation and consent. If a patient decides she does not wish to undergo testing, that decision should be documented in the medical record.

This quiz reviews some of the major takeaways from the February 2019 article, New tools for counseling on prenatal genetic testing.

Quiz: How much do you know about genetic testing?

This month's quiz reviews some of the major takeaways from Dr. Lockwood's May 2018 editorial, 

Risks and benefits of hormonal contraception

Which of the following statements about combined oral contraceptives (OCPs) is not true?

a.   Risk of VTE is increased in users compared to non-users.

b.   Estrogen is the major influence on the effects of OCP use.

c.   There appears to be a modest link in incidence of breast cancer among women who use progestin-containing contraceptives. 

d.   Studies from the mid-1990s show that women who began OCPs after age 20 had a higher relative risk of breast cancer

Answer: D. Studies from the mid-1990s show that women who began OCPs after age 20 had a higher relative risk of breast cancer.

Studies conducted in 1996 by the Collaborative Group on Hormonal Factors and Breast Cancer noted that, although the absolute risk of cancer was low, women who showed a higher relative risk of developing breast cancer are those who began OCPs prior to age 20.

2. Benefits of hormonal contraception include:

a.   Lower overall rates of cancer, including colon, endometrial, and ovarian cancers.

b.   Treatment of dysmenorrhea, polycystic ovarian disease-associated hirsutism, acne, and anovulatory bleeding.

Benefits of hormonal contraception include all of the above. Progestin-containing IUDs are an effective treatment for menorrhagia.

3. Older studies of OCPs and breast cancer:

a.   Included patients who were taking higher-dose formulations of OCPs
	b.   Showed that cancers among OCP users tended to be later-stage, higher-risk lesions.
	c.   Are consistent in their observations that showed significant association between use of OCPs and breast cancer.
	d.   Reported that specific use of triphasic levonorgestrel formulations of OCPs was associated with a significantly lower risk of breast cancer.

Answer: A. Included pateints who were taking higher-dose formulations of OCPs

One of the major criticisms of older studies such as the Nurses’ Health Study  that showed elevated risks of breast cancer was that they included patients who were taking OCPs at higher doses than are in current products. In addition, other large observational and case-control studies have shown no association between current and past use of OCPs and breast cancer.

4. What do more recent studies of OCPs and breast cancer reveal?

a.   The risk of breast cancer increased with duration of exposure to OCPs
	b.   After stopping use of OCPs, risk of breast cancer decreased but did not disappear entirely.
	c.   The results were not altered when risks were adjusted for body mass index (BMI) or smoking.
	d.   A and B
	e.   All of the above

All of the choices are true according to a recent large prospective Danish study by MÃ¸rch and colleagues.

5. What important points should the practitioner keep in mind about use of OCPs?

a.    Studies have shown that there is a significant difference in breast cancer risks between different OCP formulations.

b.   Unfortunately, the increased incidence of breast cancer among users of progestin-containing contraceptives does not decrease even after a patient stops using OCPs.

c.    Switching from hormonal contraceptives to non-hormonal methods of birth control, such as copper IUDs, tubal ligation and barrier methods, is a prudent choice to help decrease incidence of breast cancer in women over 35.

Answer: C. Switching from hormonal contraceptives to non-hormonal methods of birth control, such as copper IUDs, tubal ligation and barrier methods, is a prudent choice to help decrease incidence of breast cancer in women over 35.

Because most breast cancers occur in women over age 40, switching to non-hormonal forms of birth control can be a good strategy for decreasing incidence of breast cancer in these patients.

Vessey M, Yeates D. Oral contraceptive use and cancer: final report from the Oxford-Family Planning Association contraceptive study. Contraception. 2013 Dec;88(6):678-83.

Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk of breast cancer. N Engl J Med. 2002 Jun 27;346(26):2025-32.

MÃ¸rch LS, Skovlund CW, Hannaford PC, Iversen L, Fielding S, Lidegaard Ã. Contemporary hormonal contraception and the risk of breast cancer.  N Engl J Med. 2017 Dec 7;377(23):2228-2239.

Since hormonal contraception was introduced in the 1960s, the risks and benefits of the drugs have been the topic of considerable debate. How much do you know about the subject?   

Quiz: Risks and benefits of hormonal contraception

This month's quiz reviews some of the major takeaways from the July 2019 article, "

Genitourinary syndrome of menopause: Underdiagnosed and undertreated

1. Which of the following statements is not true about genitourinary syndrome of menopause (GSM)?

a. GSM is a chronic disorder and not likely to improve without treatment.

b. GSM can be clinically detected in up to 70% of women experiencing menopause.

c. Symptoms of GSM may include vaginal dryness, itching, irritation, and dyspareunia.

d. Many women fail to link their symptoms with menopause and only about one-quarter of women discuss this problem with their providers.

Answer: B. GSM can be clinically detected in up to 70% of women experiencing menopause.

GSM can be detected in up to 90% of women. Census statistics imply that approximately 17 million women experience symptoms, a number that is likely to increase due to population demographics.

2. Lifestyle changes for the treatment of GSM include all of the following except:

d. Avoidance of fragrance-containing products in the vulvar region

Weight loss has no documented effect on the symptoms of GSM.

3. Which of the following statements are true about non-hormonal treatments for GSM?

a. Vaginal moisturizers such as hyaluronic acid and polycarbophil gel retain water and release it back slowly.

b. Hyperosmolar lubricants may be effective but can also cause irritation.

c. Black cohosh and soy have been shown to be effective treatments for the symptoms of GSM.

Non-hormonal options such as black cohosh and soy have not been shown to improve the symptoms of GSM and are not recommended for treatment.

4. All of the following are true about use of vaginal estrogen to treat GSM except :

a. Given at low doses, vaginal estrogen is the gold standard for patients who are not suffering from systemic symptoms.

b. Tablets and rings that contain low doses of the hormone result in increases in serum estradiol levels that are within normal postmenopausal range.

c. Rates of endometrial and invasive breast cancer and DVT are significantly increased with use of vaginal estrogen.

d. Use is contraindicated in women with unexplained uterine bleeding or endometrial hyperplasia or who are also taking aromatase inhibitors (AIs).

Answer: C. Rates of endometrial and invasive breast cancer and DVT are significantly increased with use of vaginal estrogen.

While the packaging for vaginal estrogen contains the same “black box” warning for endometrial cancer, breast cancer, cardiovascular disorders and dementia found on systemic estrogen, the data supporting these warnings involve hormone exposure at much higher levels. Because of this NAMS and other organizations have recommended the FDA remove the warning from topical estrogens.

5. All of the following statements about alternative treatments for GSM are true except:

a. Selective estrogen receptor modulators (SERMs) such as ospemifene, originally designed to treat breast cancer, are good choices for patients who are not candidates for estrogen therapy.

b. Patients receiving treatment with SERMs see immediate improvement in their symptoms

c. Ospemifene contains a black box warning regarding risk of VTE although the risk is not as much as seen with estrogen.

d. Vaginal dehydroepiandrosterone (DHEA), or prasterone, is a vaginal insert that has been shown to decrease dyspareunia in postmenopausal women in RCTs

e. Unlike estrogen treatments, alternative treatments to estrogen require daily administration to be effective.

Answer: B. Patients receiving treatment with SERMs see immediate improvement in their symptoms.

Many patients on SERMs may not see an improvement in their symptoms until about 6 months after the start of therapy.

6. Which of the following are true of factional carbon dioxide (CO

 laser therapy stimulates wound healing and tissue remodeling with increased collagen formation.

 laser therapy Is not FDA-approved and multiple treatments are recommended.

 laser treatment alone resulted in worsening of dyspareunia.

 laser treatments are of smaller sample size with no placebo-treated control groups.

This month's quiz reviews some of the major takeaways from the July 2019 article, "Genitourinary syndrome of menopause: Underdiagnosed and undertreated."