OB/Gyn OSCE
The three most effective reversible methods of contraception available today are the two
intrauterine devices, or IUDs, and the implant. The two IUDs are the hormonal IUD, which is
known as the Mirena, and the non-hormonal copper IUD, known as the Paragard. The implant is
called Implanon or Nexplanon. All three of these methods are over 99% effective and are just as
effective as getting your tubes tied or sterilization, but reversible so that if you did want to
become pregnant you could just have the device removed and your fertility will return.
HORMONAL IUD The hormonal IUD is a five-year contraceptive method that is inserted into
your uterus by a clinician. Although it lasts for five years, you can have it removed sooner. As
you can see, it is T-shaped and releases the hormone progestin primarily into your uterus.
Some women have irregular bleeding and cramping after the hormonal IUD is inserted. The
irregular bleeding is greatest in the first 3-6 months, but usually improves. After this period of
time, your period is typically much lighter and shorter. Twenty percent of women stop having
their periods altogether after the first year. There are strings connected to the hormonal IUD that
become soft and usually do not cause any discomfort to you or your partner during sex. A
woman may choose the hormonal IUD because it is highly effective, convenient, safe, and long
lasting. She would understand that irregular bleeding may occur, especially within the first six
months after insertion, but eventually her periods may become shorter, lighter and may even
stop altogether. She would know that this method does not protect against sexually transmitted
infections.
It's possible to get pregnant right away after your doctor removes your IUD. Women
usually begin to ovulate within 1 month after removal. For most, pregnancy happens
within 6 months to a year
Hormonal IUDs don't contain estrogen, so they typically have fewer hormonal side
effects than methods that do contain estrogen. Many people who start using a
hormonal IUD have irregular bleeding for the first 3-6 months after placement. This
bleeding is usually more like spotting—light and not painful
Mirena
Mirena is the hormonal IUD that’s been around the longest, and it’s one of the longest
lasting (it’s been proven effective for up to 7 years in practice, though it’s officially
FDA-approved for up to 5 years). It’s perfectly safe and effective for people who’ve never
given birth. Mirena is commonly recommended to help manage heavy or painful periods. It
may also help reduce bleeding caused by fibroids and endometriosis. For many people who
use it, their periods get significantly lighter or go away completely. About 1 in 5 Mirena
users stop having a period after a year, and 1 in 3 people who use it for longer stop having
a period. A 2016 study found that you may be able to predict how likely it is that Mirena will
make your period go away based on how heavy your pre-IUD cycle is.
LILETTA
LILETTA is a lot like Mirena—same dose of hormone, same lighter or nonexistent periods.
One difference is that it’s FDA-approved for use for longer than Mirena—up to 6 years (as
compared to Mirena’s 5 years), but in practice, it’s been proven effective for up to 7 years,
just like Mirena. It’s also explicitly approved for people who have not given birth. The main
benefit of LILETTA is that it is more affordable than the other hormonal IUDs, especially for
those with grandfathered health insurance plans and those without health insurance.
Skyla
There’s a reason we’ve referred to Skyla as Mirena’s little sister. It’s slightly smaller, has a
lower dose of hormones, and lasts up to 3 years instead of up to 7. Skyla can make periods
lighter, but most Skyla users won’t have their period go away altogether. Only 1 in 17 stop
having a period after a year, and about 1 in 8 have no period if they use it for longer.
Because Skyla is slightly smaller, it has a narrower inserter, so in theory insertion may be
less uncomfortable for those who haven’t had a child.
Kyleena
If Skyla is the baby of the family, Kyleena is the middle sister. It’s the same size as Skyla
but releases 17.5 micrograms/day of levonorgestrel—more than Skyla’s 14 micrograms/day
and less than Mirena’s and LILETTA’s 20. Kyleena lasts up to 5 years, and about 1 in 8
people who use it will stop having periods after a year.
NON-HORMONAL COPPER IUD The non-hormonal IUD is a 10-year contraceptive
method that is inserted into your uterus by a clinician. Although it lasts for ten years, you
can have it removed sooner. As you can see, it is T-shaped and made of plastic and
copper. Some women have spotting for the first few months after the copper IUD is
inserted. In some women, periods may be heavier or crampier, especially within the first
3-6 months after insertion, although this may get better over time. There are strings
connected to the non-hormonal copper IUD that become soft and usually do not cause
discomfort to you or your partner during sex. A woman may choose the copper IUD
because it is highly effective, safe, convenient and long-lasting. She may desire a form
of birth control that contains no hormones and may want to have her period. She would
understand that her periods may become heavier and crampier, although this may get
better over time. She would also know that the copper IUD does not protect her from
sexually transmitted infections. Both of these IUDs are inserted in essentially the same
way. First, the clinician will perform a pelvic exam to determine the size and position of
your uterus. Next, he or she will insert a speculum like when you have a pap smear and
wash off your cervix. The clinician will then place the IUD through the cervix and into the
uterus. The insertion of an IUD can be crampy, but usually it takes less than five
minutes. You can take ibuprofen or other medications to help with the cramping.
How about the non-hormonal IUD?
The Paragard non-hormonal IUD prevents pregnancy thanks to a tiny copper filament
wrapped around the T. Paragard contains no hormones of any kind—it’s the only
super-effective non-hormonal birth control method around (besides sterilization). Paragard
also works as highly effective emergency contraception, so if you’re considering an IUD and
have had unprotected penis-in-vagina sex in the last 5 days but don’t want to be pregnant,
that could be another point in its favor.
Most people who use Paragard have heavier, longer, or crampier periods, especially for the
first few months. After 6 months, many Paragard users’ periods return to normal. If you
already have really heavy or uncomfortable periods, or you are anemic (too little iron in
your blood), you might prefer a hormonal IUD.
IMPLANT The implant is the other most effective method of contraception and it lasts
for 3 years. Like the IUDs, it is also more than 99% effective. Although the implant lasts
for three years, you can have it removed sooner. It is a small rod that is placed under the
skin of your arm between your bicep and tricep. You can feel it but you usually can’t see
it. The implant releases the hormone progestin, which can cause irregular bleeding.
Some women have irregular bleeding for a month, six months, a year, or even the entire
three years. Some women using the implant have no bleeding at all. The implant is
inserted easily. The clinician will wash off your arm, inject some numbing medicine, and
then place the implant under your skin. You will need to wear a bandage on your arm for
24 hours. A woman may choose the implant because it is highly effective, safe,
convenient and long lasting. She would understand that irregular bleeding is the most
common complaint among women using the implant and that this is normal. She would
also know that this method does not protect her from sexually transmitted infections.
BIRTH CONTROL SHOT The birth control shot, which is also known as Depo or
Depo-Provera, is another very effective method. It is an injection of the hormone
progestin. The shot is 94% effective, which means that typically 6 out of 100 women will
become pregnant using this method in the first year. The shot is given every 3 months.
This means you will need to return to your provider on a regular basis to get your shot.
The shot can cause some irregular bleeding and spotting which usually improves over
time. After a year, almost half of all women using this method stop having their period
altogether. Some women are concerned that the use of the shot may lead to weight
gain. You can help control weight gain by being aware of your food choices and keeping
an exercise routine. A woman may choose the birth control shot because it is very
effective, safe, easy to use, and may improve menstrual symptoms. She would
understand that irregular bleeding may occur with the shot but eventually her periods
may stop altogether. She would be willing to go to a clinic or doctor every 3 months. She
would also know that this method does not protect against sexually transmitted
infections
[Combined Hormonal Contraception] The pill, the patch, and the vaginal ring are all
effective methods that contain the hormones estrogen and progestin. These methods
are 91% effective with typical use, meaning up to 9 out of 100 women will become
pregnant within the first year of use. All of these methods require the user to ‘do’
something on a daily, weekly, or monthly basis. Women usually will have regular, lighter,
and shorter periods with these methods. Some women may experience irregular
bleeding or spotting, nausea, bloating or breast tenderness during the first few months
after starting these methods, but these side effects will usually get better.
BIRTH CONTROL PILL The birth control pill needs to be taken every day and should be
taken at the same time to make it effective.
-Ethinyl Estradiol and Norgestimate:
tablet, triphasic (Ortho Tri-Cyclen, Tri-Estarylla, TriFemynor, Tri-Mili, Trinessa,
Tri-Sprintec, Tri-Previfem) 0.25mg/35mcg
Sunday starter: 1 hormonally active tablet daily for 21 days, then 1 inert tablet daily for
7 days; cycle repeated; start Sunday after onset of menstruation; if menstrual period
occurs on Sunday, start that very same day; take additional method of contraception
until after first 7 days of consecutive administration
Day 1 starter: Take first dose on the day of the menstrual cycle and continue to take 1
tablet daily
21-tablet package: Take 1 tablet for 21 days followed by 7 days off the medication
28-tablet package: Take 1 tablet daily without interruption
-levonorgestrel/ethinyl estradiol:
tablet, monophasic (Aubra, Aviane, Delyla, Falmina, Falessa, Falessa Kit, Larissia, Lessina,
Lutera, Orsythia, Vienva) 0.1mg/20mcg
1 active tablet PO daily for 21 days, then 1 inert tablet PO daily for 7 days
(follow manufacturer's color-coding for sequence)
PATCH The patch is an adhesive that you place on the skin. It needs to be
changed once a week for three weeks, and then during the fourth week you leave it off
and have your period.
VAGINAL RING The ring is a plastic ring that you insert yourself into your vagina. It
needs to be changed every 4 weeks. Most women leave the ring in for three weeks and
then take it out for the fourth week to have a period. 4 There is no perfect way to insert
the ring; you just place it into your vagina to where you can no longer feel it. The ring is
supposed to be comfortable for both partners during sex.
A woman may choose birth control pills because they are safe, may improve menstrual
symptoms, may help control irregular bleeding, and may improve acne. She also may
want to predict when she will have her period. She would need to remember to take her
pill every day. A woman may choose the patch or the ring because they are safe,
comfortable and may help regulate a woman’s menstrual cycle. The woman would need
to remember to change the patch every week or the ring every month. The patch and the
ring may offer the same general health benefits as those offered by the birth control pill.
She would also know that none of these methods protect against sexually transmitted
infections
PROGESTIN ONLY PILLS (POPs) There are also pills with no estrogen called
progestin-only pills, minipills, or POPs. Some women with medical problems such as
high blood pressure or migraine headaches should avoid estrogen. These pills are 91%
effective with typical use, meaning that up to 9 out of 100 women will become pregnant
using this method in the first year. With the progestin-only pills, women take an active
pill every day of the month. Women using progestin-only pills may experience irregular
bleeding, spotting, or no period at all. POPs must be taken every day at the same time. If
you are 3 or more hours late taking your pill, you must use a back-up method, such as
condoms for 48 hours. A woman may choose progestin-only pills because they are safe
and she may want to avoid using a method that contains estrogen. She would need to
remember to take a pill at the same time every day. She would also know that this
method does not protect her from sexually transmitted infections.
-Norethindrone (PROGESTERONE ONLY PILL) → 1 tablet (0.35mg) PO qDay
Take at same time each day; use additional contraception x48 hours if dose >3 hours
late. Administration is continuous; no interruption between pill packs. Initiate first pill
pack on 1st day of menses or day after miscarriage or abortion
CONDOMS Condoms, when used alone, are 82% effective at preventing pregnancy.
Typically, 18 out of 100 women using just condoms become pregnant in one year.
However, when used with another method, condoms can further decrease your risk for
pregnancy. Condoms are the only method that protect against sexually transmitted
infections. Some women use condoms and another birth control method together to
prevent infections and pregnancy. There are a few things you should always remember
when using a condom: • Always check for an air pocket in the condom’s packaging. If
you can’t squeeze an air pocket, then the condom could be damaged and you should
throw it away. • Also, look for an expiration date. An expired condom should never be
used, just throw it away. • Only use water-based lubrication with latex condoms. • Store
condoms in a cool, dry place out of direct sunlight. 5 • A new condom should be used
for each act of sexual intercourse—including oral, anal or vaginal. Never use the same
condom twice. A woman may use condoms because she is concerned about reducing
her risk for sexually transmitted infections and pregnancy. EMERGENCY
CONTRACEPTION Emergency contraception can be used after unprotected sex to
decrease the risk of pregnancy. Emergency contraception includes pills such as Plan B,
Next Choice, and EllaOne, as well as the nonhormonal copper IUD. Emergency
contraceptive pills can be taken up to 5 days after unprotected sex, although the sooner
you take them the more effective they can be. The copper IUD can be placed up to 5
days after unprotected sex and is 99% effective at preventing pregnancy. Women who
are 17 years or older can purchase Plan B or Next Choice without a prescription at their
local pharmacy. A woman may use emergency contraception because she had
unprotected sex, the condom broke, she missed her birth control pills, or was late for
her birth control shot. She would know that emergency contraceptive pills may not be as
effective as other forms of birth control and should not be used as a primary method.
She would understand that the copper IUD is the most effective form of emergency
contraception, and if she chose this, she could continue to use it to provide highly
effective contraception. She would also know that emergency contraception does not
protect her from sexually transmitted infections.
HPV and cervical cancer screening
Two doses of HPV vaccine are recommended for children at ages 11–12; the
vaccine can be given starting at age 9 years.
Children who start the HPV vaccine series on or after their 15th birthday need
three doses given over 6 months.
HPV vaccination is also recommended for everyone through age 26 years, if they
were not adequately vaccinated already.
HPV vaccination is not recommended for everyone older than age 26 years.
However, some adults age 27 through 45 years who were not already vaccinated
may decide to get HPV vaccine after speaking with their doctor about their risk
for new HPV infections and the possible benefits of vaccination. HPV vaccination
in this age range provides less benefit, as more people have already been
exposed to HPV.
Cervical cancer screening is used to find changes in the cells of the cervix that could lead to
cancer. The cervix is the opening to the uterus and is located at the top of the vagina.
Screening includes cervical cytology (also called the Pap test or Pap smear) and, for some
women, testing for human papillomavirus (HPV).
Most cases of cervical cancer are caused by infection with HPV. HPV is a virus that enters
cells and can cause them to change. Some types of HPV have been linked to cervical
cancer as well as cancer of the vulva, vagina, penis, anus, mouth, and throat. Types of HPV
that may cause cancer are known as “high-risk types.”
HPV is passed from person to person during sexual activity. It is very common, and most
people who are sexually active will get an HPV infection in their lifetime. HPV infection often
causes no symptoms. Most HPV infections go away on their own. These short-term
infections typically cause only mild (“low-grade”) changes in cervical cells. The cells go
back to normal as the HPV infection clears. But in some women, HPV does not go away. If a
high-risk type of HPV infection lasts for a long time, it can cause more severe (“high-grade”)
changes in cervical cells. High-grade changes are more likely to lead to cancer.
It usually takes 3–7 years for high-grade changes in cervical cells to become cancer.
Cervical cancer screening may detect these changes before they become cancer. Women
with low-grade changes can be tested more frequently to see if their cells go back to
normal. Women with high-grade changes can get treatment to have the cells removed.
● Women age 21 to 29 should have a Pap test every 3 years. HPV testing is not
recommended.
● Women age 30 to 65 should have both a Pap test and an HPV test every 5 years.
You also can talk with your ob-gyn about having a Pap test alone every 3 years.
● After age 65, you can stop having cervical cancer screenings if you have never
had abnormal cervical cells or cervical cancer, and you’ve had three negative Pap
tests in a row. (You also can stop screening if you’ve had two negative Pap and
HPV tests in a row in the past 10 years, with at least one test in the past 5 years.).
You may need more frequent screenings if you
● have a history of cervical cancer
● are HIV positive
● have a weakened immune system,
● were exposed before birth to diethylstilbestrol (DES, a hormone given to pregnant
women between 1940 and 1971)
● If you have had a hysterectomy, you still may need screening. And if you’ve had
the HPV vaccine, you should still follow the guidelines. The vaccine doesn’t
protect you against every type of HPV.
If you have had a hysterectomy, you still may need screening. The decision is based on
whether your cervix was removed, why the hysterectomy was needed, and whether you have
a history of moderate or severe cervical cell changes or cervical cancer. Even if your cervix
is removed at the time of hysterectomy, cervical cells can still be present at the top of the
vagina. If you have a history of cervical cancer or cervical cell changes, you should continue
to have screening for 20 years after the time of your surgery.
Mammography and Other Screening Tests for
Breast Problems
For women at average risk of breast cancer, screening mammography is recommended
every 1–2 years beginning at age 40 years. If you have not started screening in your 40s,
you should start having mammography no later than age 50 years. Screening should
continue until at least age 75 years.
How often should I have a clinical breast exam?
For women who are at average risk of breast cancer and who do not have symptoms, the
following are suggested:
● Clinical breast exam every 1–3 years for women aged 25–39 years
● Clinical breast exam every year for women aged 40 years and older
What are the benefits of a routine pelvic exam?
● The potential benefits of a routine pelvic exam include:
○ Possible early detection of treatable conditions, such as infections or
cancer
○ Detection of other problems, such as changes to the skin in your pelvic
area
○ A better understanding of your body
○ Reassurance about your sexual and reproductive health
Osce General Questions- well woman
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Introduction
Confirmation of patient information
What brings you in today?
Do you have any concerns at the moment?
o OLDCARTS if yes
Past medical history
o Adult/childhood illnesses- migraine!
Surgical history
Hospitalizations
Screenings
o PCP
o Ever had a pelvic exam
o Last pap smear
o Immunizations/Vaccinations (HPV)
Any hx of factor 5 leiden, or blood clots
Medications
o Prescribed or OTC
Allergies
Family history
o Family history of breast cancer, cervical cancer, ovarian cancer, uterine
cancer? Fibroids? Endometriosis?
Social history
o Etoh
o Tobacco
o Drugs
o Home/environment
o Safety at home
o Relationship/marriage/safety
o Diet/exercise
o Employment/education
Sexual history
o Currently sexually active?
o How many partners? Male, female or both?
o Unprotected sex?
o Currently using any form of birth control; i.e condoms?
o Pain with sex
o Sexual functioning
o History of sexually transmitted infections?
o Seeking pregnancy?
Spiritual history
ROS
o General: fever, fatigue, weight changes, changes in sleep pattern
o Head: headaches, head injury
o Breast: lumps in breast, pain or discomfort, nipple discharge,
self-examinations
o Respiratory: shortness of breath, cough, wheezing
o Cardiac/PV: chest pain, palpitations, high blood pressure, HX OF
CLOTTING
o GI: abdominal pain, nausea, vomiting, diarrhea, change in appetite,
regurgitation, indigestion, changes in stools, blood in stool, pain with
defecation
o GU: pain/burning with urination, increased frequency of urination,
urinating more at night, blood in urine, flank pain, frequent UTIs,
- Age of first period, last menstrual period, how long do periods last,
regularity, pain with menstruation, amount of bleeding (pad count),
bleeding between periods
-ever been pregnant (if yes, how many times, how many times given
birth, full term or preterm, type of deliveries, abortions,
complications)
- vaginal discharge, vaginal odor, vaginal sores/lesions, exposure to
HIV
- IF OLDER: age of menopause, postmenopausal bleeding, hot
flashes, vaginal dryness
o Psychiatric: mood changes, depression, nervousness, memory changes,
suicidal ideation or past attempts
o Endocrine: thyroid trouble, heat or cold intolerance, excessive sweating
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SUMMARY
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PHYSICAL EXAM
o Vital signs
o Thyroid
o Heart/PV
o Lungs
- Abdomen exam
o Poss breast exam
o Pelvic exam
+- pap smear, +-HPV testing
● Leave room→ labs 5 mins
○ URINE PREGNANCY!!! (beta hcg)
○ Poss pap (cervical cytology)
○ Poss HPV
○ Poss gonorrhea/chlamydia
○ Poss cbc, cmp
○ Poss tsh
○ Poss urinalysis
● Return → patient education/anticipatory guidance 15 mins
● Treatment plan CANVAS 15 mins
○ Student will write out any radiologic or laboratory studies the patient
should have performed prior to the next scheduled follow up. Student
should be detailed in their orders as if submitting for EMR ordering.
○ · Student will then provide three (3) components of patient education
related to the patient’s condition.
○ · Student will then provide a prescription to the patient being sure to
include all necessary components of a complete prescription.
○ · Student will identify the appropriate next follow up visit for patient’s
condition.
○ · Reference must be peer-reviewed scientific source (i.e. journal article,
meta-analysis, etc) and cited in APA format.
● SOAP note 10 mins - subjective, objective, assessment and plan.
Pre-natal screening