4 GYN Cases

For a basic description of what happens during the annual exam, see this post. Below I am going to add things that are slightly different than normal.

Case A: 18yr old, in for an annual exam - her first. BMI 31. Family history of hypertension, diabetes, and hypercholesterol. Having casual sex for one year, using condoms "always." Wants to add oral contraceptives.

I always ask a general "how is everything?" and then a specific "how is school? how is home? how are things with your friends?" She's here for an annual exam, so that was first: because it was her first exam, I talk about the parts of the exam (external inspection, insert speculum, pap and STD exam, bimanual exam, etc) I show her the speculum. If she looks really nervous, I remind her that she does not have to have a physical exam to get birth control, and ask if she's still ready to have the exam. Then I tell her we can stop at any time. I ask all first timers if they want to see their cervix when I find it, and if they seem unsure I err on the side of them wanting to see it. She asked a few questions, and we proceeded.

I spent more time on nutrition and exercise counseling because of her BMI. I pointed out where her BMI falls on the chart, and what the number represents. I pointed out my BMI on the chart, and told her how I felt about my category, and then asked her how she felt about her BMI. She said she thought it was "too high," and so I made some recomendations. 1. Because she was only doing cardio twice a week, upper body toning once a week, and lower body toning once a week, I suggested that she up her cardio to every time she goes to the gym, which is about 4 times a week. 2. lay off the soda 3. switch her amounts of refined carbs with her amounts of vegetables (ie: less white bread, more green beans). I then talked to her about getting her cholesterol and glucose checked because of her BMI and family history. She agreed. Then we got to contraceptive counseling and safer sex conversations. I ask her again about her condom use. Turns out it's NOT everytime. Ok, so, now I suggest a full STD and HIV screening. I ask her to give me a scenario where she didn't manage to use any protection. ("Didn't have it with me, and we really wanted to") Then we role played what she could say and do next time. The main question...Do I want to bad enough to risk HIV? (or any other infection) But of course no one is thinking of HIV (or anything else) when they're trying to get to it, so the next question she can ask herself is can I wait 15 minutes? (hopefully that's long enought to find something) and if all else fails, "don't be rough (trying to avoid abrasions), make sure you're eroused (ie: 'wet') again with the abrasions, and withdraw." Last note: "Please be safe. We're here on Thursdays, if you want to talk." She left with a prescription for birth control pills.



Case B: 17yr old in for first annual exam, and full STD screening. Complains of vaginal itch and discharge. I notice on the chart that she came in last week for urine gonorrhea and chylamydia testing.

The exam was pretty much the same as the above, but without extensive counseling on diet and exercise or lipid/glucose testing. We talk to every woman about eating healthy and exercising in general though. Here's what was different for this woman:

I asked she was coming in only a week later for repeat STD testing? "I don't know I just feel like I should get checked."

"OK. Let's talk about it. Are you currently in a relationship, having casual sex...or how would you define your current activities surrounding sexuality?"

"I'm in a monogamous relationship."

"OK. It's excellent that you're trying to stay on top of your health by getting checked for STDs...are you using protection every time?"

"Yes."

"OK, well we do not normally recommend STD testing so frequently if your having sex, protected, with the same partner long term. But sometimes people, understandably so, don't completely trust the person they're with and would like testing more often and we can certainly test you...You were here last week...has anything changed since last week?"

"Yeah I have a different partner." ding ding ding. This makes me look at the chart where people list their sexual "numbers"...how many partners in the last year? Lifetime? Age when first had sex. I usually don't look at these numbers because I don't really agree with them being on the form in the first place...it seems like a way to be judgemental...and if the provider feels that it's important, they can always ask...this is another post...so anyway, I looked and she wrote that she had just become sexually active this year, but had already had 17 partners. Something else that stuck out in my mind was rape. Why? She was just here last week...a week later she thinks she might be infected...even though she was fine last week...she's being vague about the situation...she's drinking quite a bit on weekends (4-5 drinks in one sitting, 2-3 times over the weekend)...which puts her at risk simply becaus of the college campus environment and her behaviors. So I ask the hard question: "I'm going to ask you a question that I ask a lot of women I see...Have you been sexually assaulted?"

"No."

"Ok, do you feel safe with the people you party with?"

"Yes."

"OK. Well, I want you to know that if you ever want to talk about anything, I'm here. And when I'm not, the other midwives are here. And when we're not, there's free services at the mental health clinic next door - and people go there even when they just want to talk." And then the exam commenced. Her itch? Was really on the outer upper labia and mons pubis...from shaving. Her discharge? Normal. I looked at her mucus under the microscope to make sure there was no yeast (or not a lot of yeast) before I told her it was normal.


(BTW, This was new to me...that midwives looked under microscopes to diagnose STDs and other changes in vaginal flora...I had no idea before I came to school that we would be doing this!)

That's all I'm going to say for now for that day of patients, but I did want to say something quick about another patient I had on a different day:

This woman did not have anything out of the ordinary for her going on. She was a little stressed with school and work, but was doing ok. We talked a lot about her career goals because she is a junior in college, and considering graduate school. So we talked about that, and she asked me about the GREs and about what it's like to be in graduate school. It was such an unexpected conversation. But it made me remember that it's about so much more than pap smears, STDs, and pregnant bellies. Even though I say it on this blog all the time, I forget...sometimes you just want to see someone who looks like who's doing any smidgen of something you want to do....someone who says "YES! I took the GREs, let me tell you about it..." or "NO! you don't have to have had been on the dean's list the whole time to considered a good applicant...and YES! You can do this!" The reality is that this woman might not have known anyone who was trying to do what she's doing before coming to the clinic. It was good to be there.

I'm stopping now because something else has started to occupy my mind...