History & Physical:

ObGyn H&P1

ObGyn H&P2

 

Site Evaluation Presentation Summary:

For my site visits, I presented one patient each time and went over the drug cards. For my first site visit, I presented a patient there for her initial prenatal visit but also complained of RLQ pain and very light spotting, so she was sent for a workup to r/o an ectopic, but also for routine first trimester labs. For my second site visit, I presented a patient who complained of “smelly vaginal discharge that is worse after sex” and she was treated for BV. I then presented my journal article. See below.

 

Journal Article & Summary:

Treatment of Endometriosis-Associated Pain with Elagolix, an Oral GnRH Antagonist

This article comprised of 2 randomized, double-blind, multicenter, placebo-controlled phase III trials done to evaluate the efficacy of elagolix, an oral GnRH antagonist, for controlling both dysmenorrhea and nonmenstrual pelvic pain. Subjects eligible to participate were premenopausal women between the ages of 18 and 49 years who had received a surgical diagnosis of endometriosis in the previous 10 years and who had moderate or severe endometriosis-associated pain. Two double-blind, randomized, 6-month phase 3 trials (Elaris Endometriosis I and II [EM-I and EM-II]) were performed to evaluate the effects of two doses of elagolix — 150 mg once daily (lower-dose group) and 200 mg twice daily (higher-dose group) — as compared with placebo in these women.

Women underwent randomization for Elaris EM-I at 151 sites in the United States and Canada from July 2012 through May 2014 and for Elaris EM-II at 187 sites on five continents from November 2013 through July 2015. Each trial was divided into four intervals: a washout of hormonal therapies (if applicable); a screening period of up to 100 days, including two menstrual cycles, during which women switched from the use of usual analgesic agents to receive allowed rescue medication of an NSAID (500 mg of naproxen), an opioid according to country (e.g., 5 mg of hydrocodone plus 325 mg of acetaminophen), or both; a 6-month treatment period; and a follow-up period of up to 12 months, unless the woman was enrolled in the corresponding 6-month extension study.

The two primary outcomes were the proportion of women who had a clinical response with respect to dysmenorrhea and the proportion who had a clinical response with respect to nonmenstrual pelvic pain at 3 months. The key secondary outcomes were the mean changes from baseline to 3 months or 6 months, which were tested in the following order: the score on the Numeric Rating Scale (0 [no pain] to 10 [worst pain ever]) at 3 months, dysmenorrhea at 6 months, nonmenstrual pelvic pain at 6 months, use of rescue analgesic agents (both NSAID and opioid pill counts) at 3 months and 6 months, dyspareunia (0 [none] to 3 [severe] or not applicable) at 3 months, and the use of a rescue opioid at 3 months.

A total of 872 women underwent randomization in Elaris EM-I and 817 in Elaris EM-II; of these women, 653 (74.9%) and 632 (77.4%), respectively, completed the intervention. The results showed that those who received two different doses of elagolix had significantly lower scores for dysmenorrhea and nonmenstrual pelvic pain than did those who received placebo after 3 months and 6 months of treatment. This was based on the significantly better scores for endometriosis-associated pain on the Numeric Rating Scale at 3 months among those who received elagolix than those who received placebo. In addition, women who received the higher dose of elagolix (200 mg twice daily) had significantly better results with respect to the use of rescue analgesic agents at 3 months and 6 months, dyspareunia at 3 months, and rescue opioid use at 3 months than did those receiving placebo. However, the women who received elagolix experienced the hypoestrogenic effects of the drug. They had higher rates of hot flushes, higher levels of serum lipids, and greater decreases from baseline in bone mineral density than did those who received placebo. The shift in the lipid profile with elagolix treatment included both increased HDL cholesterol levels but also increased LDL cholesterol levels, which may raise concern for long-term cardiovascular risk. There were no adverse effects on the endometrium after 6 months of elagolix treatment. Results also showed that women in the higher-dose group had a greater reduction in pain and more severe hypoestrogenic adverse effects than those in the lower-dose group, which suggests the possibility of individual tailoring of these two doses to balance efficacy with hypoestrogenic effects. Although these results were promising, further evaluation is warranted to better assess the risk–benefit profiles of each dose.

 

Typhon:

ObGyn Typhon Logs

 

Mini-CAT #2:

Mini-CAT 2

 

Self-Reflection:

On the first day of this rotation, I received my schedule and was expecting to be in the ObGyn clinic but I was assigned to L&D. This made me a little anxious because it had been a while since I studied Ob and I now had to care for patients that are pregnant and about to deliver, so there was a lot I had to refresh my memory with in order to help as best I can. What added to my anxiety was that this was the first rotation back after being off for 3 months due to COVID-19 and I was not sure what I am allowed/not allowed to do as a student with all the new rules that come out. One experience I don’t think I will forget was from my first shift when a midwife dismissed me from the room of a patient who was in labor and about to deliver because I was “not with the patient the whole time she was in labor.” I was frustrated because no one had told me what my responsibilities were as a student in COVID-19 times. I did not think being with a patient for a long period of time (labor could be for HOURS) was something that was allowed/recommended with the current situation. However, this taught me that I should always ask those on shift what my responsibilities are beforehand and now I knew better for the future patients/deliveries what I had to do for a patient to be comfortable with me and to create that bond of being with someone during something so painful yet beautiful. A couple of hours later after being dismissed from one delivery, I got to be bedside of another patient with another midwife and help with the labor and delivery. Another memorable L&D experience for me was on my last L&D shift at midnight when a patient who had been there all week was going in for a C-section after failing all attempts at induction of labor. I got to scrub into the C-section with PA Melendez and assist him and the attending working that night. This also made me realize that I really need to practice closing up/suturing.

Clinic weeks were a lot more enjoyable for me because I would see ~20 patients a day with the provider I got to work with that day. Some providers were better than others in terms of teaching and letting students get more hands on. I learned how to do fundal height measurements and use the doppler to find the FHR depending on the GA (got better at it the more I did it). At first, I was not given the opportunity to do speculum exams until I got lucky enough to work with a Dr. Jones who loves teaching and allowed me to a do a couple of them. Having never done with on a real person (since we learned with mannequins), I thought I would struggle with them, but both the doctor and I were impressed with how well I did. Clinic week taught me how to ask the pertinent questions depending on the presentation and how to make an uncomfortable exam as comfortable as possible for the patient.

During clinic week, I also had the opportunity to scrub into a “Laporoscopic assisted vaginal hysterectomy, bilateral laparoscopic salpingectomy, cystoscopy” with Dr. Jones and another medical student. I was terrified when I was asked to scrub in because this would be my first time in the OR for a surgery (besides the C-section), but I got over it because it was a learning opportunity that I had to take. I got to use the uterus manipulator and assist with the hysterectomy after.

A patient that I feel like I’ll always remember is a young female who came in after getting a call that she needs to come in person for STI test results. While waiting for the provider to come discuss the results and it was just her and I in the exam room, she cried asking me “Please tell me what’s going on.” I felt helpless because I didn’t want to discuss anything until the provider came so I started talking to her about her educational background and work until the provider came to reassure her that she just needs some antibiotics and that there is nothing to be that concerned about. At the end of this visit, the patient put her hand on my shoulder and thanked me for trying to get her mind off of worrying for those couple of minutes and it was a very good feeling to help in that manner.

Overall, I think this has been my favorite rotation so far, even though it was not as best as it could get due to COVID. What I want to improve on in future rotations, though this rotation has helped with it already, is taking the initiative to see patients on my own before the provider and forming my own assessment and plan. PA Melendez was great to work with because he makes you feel like the provider and not just a student observing the provider.