Interview with a Women's Health Nurse Practitioner
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Show notes:
One of the struggles for new nurse practitioners in primary care is managing women’s health topics, and knowing if and when to refer to an OBGYN specialist. We want to do things the right way and use resources we can trust.
Women's Health Nurse Practitioner Interview
In this week’s video, I’m interviewing Monica Carter, who is a family nurse practitioner who has practiced in the women’s health setting for the last 13 years. She dropped SO many pearls and pitfalls of practice, and is truly a gem of a human. We answered questions from the community for a women’s health provider, including:
Tips for finding cervixes on pap smears, when to do a pap post-hysterecomy, and how to assess the variable appearances of cervixes on exam
Tips and resources for managing menopausal symptoms, abnormal pap results, choosing contraceptives (such great insights!) and medications in pregnancy
Getting into GYN as a family nurse practitioner
When to refer to maternal fetal medicine
Initial workup for infertility and pearls of practice
Resources mentioned in this episode:
Menopausal symptoms
ACOG green journal (need an ACOG membership or you can purchase)
Menopro app (Not available currently - will activate when it comes back online)
Choosing birth control & best resources
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WEBVTT
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus, you'll find links to all the episodes
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with extra goodies over at realworldnp.com slash podcast. This week's video is an interview
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with Monica Carter, the nurse practitioner. If you don't follow her online already, she's on
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Instagram, she has her own website. She's a family nurse practitioner, and she has been
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practicing in the OB-GYN setting for the last 13 years. We took questions from the audience,
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including how she got into that setting, what her daily life looks like, her pet peeves and
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pearls of practice for nurse practitioners in the primary care setting to know, her favorite
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resources, and we touched on a lot of really common things that we see new nurse practitioners
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struggling with when it comes to women's health topics. She is just incredible and has so much
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wisdom and insight and so many pearls of practice to share with you. So I really hope
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you enjoy this interview. Without further ado, I'm going to share my interview with you.
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Well, welcome, Monica. Thank you so much for being here. Would you introduce yourself?
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All right. Hi, everyone. My name is Monica Carter. I'm a family nurse practitioner
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in Washington, D.C. I do live in Maryland, and I love it. I work in obstetrics and gynecology
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prior to becoming an MP in OB-GYN. I was a labor and delivery nurse, which I know is a
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common pathway to being an MP in OB-GYN, and I'm a mommy. I have three little ones,
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three two-and-a-half-year-olds, triplets, Bellamy, Kaden, and Kennedy. So when I'm not
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working full-time, I'm mommying full-time. It's nice to meet everyone.
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Thank you so much for being here. Oh, my gosh. I'm so excited. Monica and I have been talking
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about how we are both really chatty. There were so many questions, so many great questions.
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We'll try to answer as many as we can, and if we want to do a part two, we could always
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do that too. But cool. Why don't we jump in? So what is your regular, and I guess
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I think that there are a lot of nurse practitioners who are thinking about that,
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who really love women's health. So it sounds like you were already an LND,
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but going from family nurse practitioner to an OB setting, OB-GYN setting,
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and then what your kind of typical day is like, and what kinds of things you're seeing.
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Yeah. So I knew from the beginning of time that I wanted to work with women. I mean,
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I went to an all-girls high school. I'm like a girl girl. So all-girls high school,
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I was a cheerleader. I did dance in undergraduate. I had been a sorority.
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And so it was only natural. Of course, I went into LND, so labor and delivery. And even in
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LND, I knew I wanted to continue to work with women. I was seeing women at the end of their
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pregnancy. So if they had diabetes or high blood pressure or preeclampsia or cholestasis,
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if they had all these diagnoses, I never knew what all went on before they got to me.
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And seeing different health outcomes made me think, hmm, what if I could get in on the
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other side, the education side, the side where I'm guiding them and I'm holding their hand
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through their pregnancy and helping them, maybe I can help to improve some of these
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maternal health outcomes. So I thought I want to be a nurse practitioner. Interestingly enough,
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it sounds like, oh, well, why didn't you do WH&P, the Women's Health NP route, which I think is an
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incredible route, especially if you know you want to work with women. Interestingly enough,
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I think it's just the culture of the city, the culture of where you are sometimes can
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influence you. And everyone I knew, they were F&Ps. Simple enough. I worked at a hospital that
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had a scholarship program that fed into my alma mater, Georgetown University. And I wanted
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to go to Georgetown and I wanted that scholarship. And it was for F&P. Now to do WH&P, you had to do
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the dual nurse midwife program. And I knew I didn't want to deliver babies for lifestyle
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reasons. I didn't want to be on call. I didn't want to work nights and weekends. I knew I
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wanted to have a family of my own. So I really didn't want to do that part of it. But
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so I couldn't do that program and that would have been full time. So really it was kind of
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F&P just worked for me. And I plan to use and leverage my experience as an L&D nurse,
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my passion for the specialty to market myself for a position in obstetrics and gynecology.
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Also, I had heard at the same time that some places only accept F&Ps. And at the time I'm
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like, am I going to move? Am I going to go somewhere like Hawaii where the only choice
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might be like a retail clinic and I have to have an F&P or if I can't find a job.
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So for me, it was just a marketability thing. So as we said, I'm chatty. So this is why.
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See, Liz, this is the problem. I'm going to be too chatty. To make a long story short,
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I love working with women. I want to improve health outcomes and the way women live their
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lives. So I knew I wanted to be in obstetrics and gynecology. But the F&P, it just kind of
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that route fell in my lap. I wish it was more thought provoking, but it was kind of like
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my mentors were F&Ps. The program that had the scholarship was F&P. F&P it was.
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I think that's super also encouraging though, because I think that there are a fair number of
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F&Ps who love women's health. And it almost feels like that's a closed door. But it,
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I mean, it sounds like it's really regional and very job by job dependent. So.
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There's three MPs in my practice were all F&Ps. And there was an MP that I worked with prior
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who left, she moved to San Francisco and she was a women's health MP. And I will say
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looking at her curriculum, just hearing her talk about certain things, it is more robust.
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It is more paid. It's more women's health centered. So I can't pretend it's not, but
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there are so many opportunities for F&Ps to learn, to improve skills. I mean, the
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these days are incredible. If you're in a supportive environment on the job training,
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and that's with any specialty, there's going to be on the job training. So I definitely do not
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think it's a stretch to be an F&P wanting to be in a specialty. That's awesome. And that
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kind of ties into what are, what are the kind of, and I feel like you also, it's so
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wonderful that you have the F&P perspective too, in terms of the context of this conversation,
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because one of the things that I'm obsessed with as part of this platform is like, what is
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the scope of primary care? And what is the specialty side? And what are they saying about
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primary care being like, oh my god, can you just not, can you just not send me one more
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of that thing? So I'd love to hear about the context of what you see in a regular day,
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like what your kind of day to day looks like. And then that kind of ties into those like
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what you wish primary care providers knew and like stop sending you or like did more first.
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Well, first I'll say, I love that the NPs in primary care and the NPs in GYN, we have become
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besties and it's like, there's no judgment. So it's like, okay, you know, it can, because
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I ask things too. I ask them like, oh, should I be managing this or should I be
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checking her back up to you? I would say so on a regular day, I'm seeing
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all types of gynecologic conditions and I see OB patients up until 36 weeks. So that last month
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of pregnancy, we have them just see the obstetricians so they can really get comfortable
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and get prepped for delivery. So I'm seeing acute visits like UTI, vaginitis. I'm seeing
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irregular bleeding, abnormal uterine bleeding. I'm seeing birth control consults. I see
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fertility consults. I see medication consults. Of course, I see annual exams, breast pain,
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breast lump. I actually, this is outside of, I would say, what a NP would normally see in
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obstetrics and gynecology, but I joined a hereditary breast and ovarian cancer screening
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team at Georgetown and I'm a part of the genetic counseling team specifically for
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breast and ovarian cancer. So I'm really uniquely knowledgeable about that kind of stuff and I,
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anyway, I'm a little bit of a nerd. So I see all kinds of things and I love it. You know,
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do I ever get bored? I'll say there are days and I'm like, I've seen a lot of yeast infections.
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I mean, literally something in the water, literally and figuratively, there's something
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in the water. I mean, it's yeast everywhere. I've seen it all day. I can't see 100% get
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bored of it because I think if you're a person who likes a specialty, you love to be
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proficient and you love to be an expert at a small subset of conditions. So I actually
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don't get bored because I like knowing what I'm doing. And I tip my hat off to the primary
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care and piece because it's like, you have to know a lot about a lot. And, you know,
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they say you've done a little bit a lot about a lot. No, you have to know a lot about a lot
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or how to find it or who to refer to. So I always tip my hat off to the primary
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care and piece because I look at their charts and I'm like, oh, eight cheap complaints.
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Cool. Wow. But so no, I don't get bored. And I will say that often as an MP in obstetrics
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and gynecology, you'll see patients who are coming in for their annual exams. So
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that's like your breast exam, your public exam, your pap smear if it's due, maybe
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sexually transmitting infection screening. Maybe we'll talk about birth control or
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menopausal treatment. And you'll find that during those visits, there are acute
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problems that come up. So it might be a preventative care visit that turns into
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plus an acute visit. So there are plenty of things that are interesting enough.
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And I think if you love the specialty itself, you won't really get bored. And
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if you ever get bored, and this is for any new nurse practitioner within the
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first five years of practicing, if you ever get bored, learn a new skill.
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I know it sounds corny and nerdy. Go to a conference, learn how to insert
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IUDs or next one on, which is that subdermal implant that goes in your arm or,
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you know, talk to your boss about colposcopies. Look at the scope of
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your state, see if that's something you can do. Vulvar biopsies, you know,
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suturing. I mean, learn a new skill and it really does get things, it spices it up.
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Me doing the genetic counseling now, it allows for me to do more telehealth,
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which means I get to be home. Which I love, don't tell anyone. Okay,
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everyone's gonna know soon. I mean, this is going on the internet, so.
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It'll just be everyone who knows, hopefully know what you're supposed to know,
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or that's supposed to know. But I'll say learn a new skill. If you get bored, learn a new skill,
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learn a new challenge, try something new, because as nurse practitioners,
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I mean, there's just so much we can do. Totally, totally.
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But what do I wish primary care providers knew? I know that's what you mean.
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Yes, I want to know. You're like, oh my god, you're, I mean, you're super nice,
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so I don't feel like you would be mad about anything, but like,
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do you hear that from your colleagues or like, I think that like sometimes,
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like I know for me personally, like with with fertility workups,
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I never really know where the line is for primary care. And I'm like you, like I kind of,
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I'm a professional nerd and I try to push the scope as much as I can,
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but at the same time, like I don't want them to get mad at me. So I'm like,
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I don't want to do the wrong thing. So I'm going to do step one. I think you need like
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I don't know if you call it that, but hysterosalpingogram for like part of your
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workup, but like I'm not going to order that. Okay, good.
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Women's health imposter. I like try really hard. But yeah, like I'm not going to order
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those tests, but I might do some labs, but I just, anyway, if there's like things that you
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wish people would do or you're really pleased when they do those things,
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that would be, that would be super helpful. Yeah, I would say, I mean, so let's use,
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first I'm going to start with your example with the fertility workup. You know, I wouldn't even,
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I wouldn't judge at all if a primary care said, Hey, why don't you go to your GYN and talk about
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this? And let me tell you why. Some people, they are not great candidates for pregnancy
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at baseline. So I have some patients, they might be a little bit older. They might have
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significant chronic conditions and we do the fertility workup and we send them to the
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reproductive endocrinologist or for lack of better words, fertility specialist, like
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and they're like, why did you send this person? She's uncontrolled. She's a brittle diabetic
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or, you know, she, she is, she has uncontrolled diabetes. That's what I should say. She has
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uncontrolled diabetes. Her blood pressure is high. Her BMI is 45. We're not going to treat
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her and she's going to get a big fat bill. So, you know, I do like them sending them to
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us because we kind of pre-screen for the fertility center. So, you know, we say, you
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have three chronic conditions and I really do want you to get pregnant. Do you mind doing
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a consult with one of our maternal fetal medicine specialists first? So we can optimize
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pregnancy for you because unfortunately right now, none of the fertility centers in DC
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are going to accept you as a patient, which is the truth. You know, they want good
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outcomes as well. So, you know, they'll turn you away away from BMI. They might turn you
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away for certain chronic medical conditions. And that took a while for me to learn
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because I was like, bright-eyed and bushy-tailed. I'm like, look, her AMH is good. She's
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going to get pregnant. Off you go. And they're like, Monica, you do realize she's a
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transplant patient, right? We can talk about this. I'm like, oh, okay.
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What kind of transplant?
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I'm sorry?
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What kind of transplant?
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I mean, we've had, I mean, so we do high risk in our practice. So I've had
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kidney transplant patients. I've had patients on dialysis who are pregnant. We have,
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yeah, we see some really high risk patients. That being said, this patient wasn't actually
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transplant patient, but it's an exaggeration to say that sometimes, you know, the big picture
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is not something that we see because it's just not what we do every day. So I wouldn't expect
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primary care to do a workup. That being said, often, you know, baseline labs to see
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does the person have PCOS or maybe a thyroid condition or something like that, or maybe they
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have an elevated prolactin, that's where their periods are off, or maybe they're not ovulating
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because of their BMI. You know, I do believe primary care has a great role in kind of saying,
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from our standpoint, you're pretty healthy. Let's send you to GYN and just see from their
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standpoint what it's looking like. The other thing is I would say, and this is like my
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favorite answer, if you're not sure, call a fertility center that's local. See if you can
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talk to one of the docs, which is what I did. And I wrote down everything she said,
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and I basically made a copy and sent it to everyone in our practice. This is what they want us to
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order. This is what they want us to stay away from. This makes me so happy you're saying this,
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Monica. And I did not ask you to say that, just to be clear, because I feel like a broken
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record being like, just call the specialist, just call them, just pick up the phone.
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Yeah, I mean, and I would consider a specialty, we call the specialist. So I'll say,
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you know, they might want me to do, maybe they want an FSH, or maybe they'll want
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estradiol, or maybe they'll want an AMH, which is the anti-mullerian hormone in the
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new, you know, craze of fertility testing. They might want me to do day three labs,
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but they might say, hey, can you go ahead and order an HSG? You can have it done here. Or
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can you go ahead and order an HSG? She can have it done in radiology at your office.
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And then I've had some say, honestly, we would rather you just send to us.
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For me personally, as a provider, my hard fast rule is if the patient has, and I mean,
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these are the weeds of it. So I don't want to see, I'm going to talk too much, but you know,
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unfortunately, most fertility centers around the country don't accept Medicaid.
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Yeah, I think that's the tricky part. I never know where the line is. And I'm like,
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I can do some, but I don't know where the hard stop is going to be and how much you're
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going to be on the hook for. So I'd rather you just talk to somebody else who knows the
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whole process. So for some of those patients who, their insurance won't be covered at all
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at the Fertility Center, I find myself doing more. I order all the labs, I'm doing the HSG,
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I order the semen analysis, and I'm doing literally everything possible to try to get them
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pregnant. And if you know, six months or so goes by, I'm like, I've really exhausted
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everything I can do. Unfortunately, they'll have to pay out of pocket. Now for patients,
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otherwise, I say you look at look at their age, you know, if they're 30, and they've
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been trying a year, send them. You really don't have to do a workout, just send them
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because of time. And really, we don't want to waste their time. And I always think about
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that. Am I causing harm to the patient? Am I doing well by the patient? They've been
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trying to get pregnant for a year. Let's go ahead and send them. If they're 35 and
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they've been trying for six months, send them. If they're 40, I just send them because
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time is truly of the essence. So I find a lot of fertility centers, they based on age,
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they just want us to send them. If they've been trying a certain amount of time. Now,
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if it's my 33 year old has been trying six months and she's anxious, that was me.
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Yeah. Well, I wasn't 33. Actually, I was actually younger. But the point is,
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I was 27 and I was anxious. So I was 31. Oh my gosh. Six months went by and I
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went to the other MP. I was like, Casey, I need labs because something's wrong with me.
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And nothing ended up being wrong. Everything was fine. It was a timing thing. So,
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you know, for those patients, I say do the labs, do an initial workup. But I would I
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wish primary care providers knew, I mean, we're a team. So I'll definitely say that,
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kind of lean on each other. As far as it goes with public exams, I always tell primary care
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MPs, if you're going to do a public exam, go for it. If they have a GYN, you don't have
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to. I mean, it depends on your own personal practice, but if they're going to see their
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GYN that year, we can do the breast and pelvic exam. And I share a lot of patients
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with our primary care MPs and they don't do breasts or public exam on those patients.
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Because they know that I'm going to see those patients. But if you are everything for that
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patient and you're doing head to toe, if they have never had their cervix removed, it's there.
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You have cervix. It's there. Just take a deep breath. If you're thinking of a circle,
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kind of a circle, as the vagina go way deep, deep, low, low, low, and kind of slowly put
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the speculum up. So if the speculum looks like this, you want to go low, open it up,
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you're going to see the cervix. And I tell my students, I'm like, there's a cervix in there.
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Don't worry. Just take your time. Sometimes you need a longer speculum. Sometimes you need
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them to put their fist under their bottom. Sometimes they need to scoot closer down the
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table. But if you're doing exams, there's a cervix unless it's been taken out.
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Yes. And actually that brings to one of the questions from people, which is,
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I'm going to reference it specifically. So do you still perform PAPS on women that I've had
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either a full or partial hysterectomy? It's like the question of the ages.
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This is the perfect segue. We're doing speculum, cervix, and now we're talking
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either cervix. That is truly, that's the question of the year. It's the question of
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the decade. It really is. I talked about this when I was a brand new grad. Yes. And it's
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still like in the air. Yes. The answer is twofold. So do I perform PAPS mirrors on women
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who have had a full or partial hysterectomy? If the woman had a hysterectomy and they took
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everything, uterus, tubes, ovaries, cervix, everything's gone. But she had the
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hysterectomy because she was diagnosed with cancer that you are still doing PAPS mirrors.
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You can look at current guidelines to see how often you can talk to gynecology, oncology,
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the gynoch on service to see if anything's changed. Should I do a PAP? When in doubt,
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you can do one. The insurance company is going to still cover it yearly still at this
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point. It's 2021. I don't know when you're watching this. Just in case this age is well
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and people are watching this in 2020. If the hysterectomy was for cancer, they still
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need PAPS mirrors. It's going to be a PAP of the vaginal tissue, vaginal, or some people
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call it vaginal cuff or cervical little stump. Just get in there with the spatula. You don't
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really need a brush. If you want to do two spatulas just to make sure you have enough cells,
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go for it. I would not use lubricant because it's probably going to skew the results
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because those cells are probably atrophic. If the patient's a little bit older,
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there's less cellularity. It's scant. You really want to make sure whatever you can get,
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you can get. Maybe you put a little water on the speculum if you want to be super nice
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in case they're a little bit dry, but no gel for those patients. Yes, you're doing a PAP for them.
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If they had a hysterectomy for the reason that most people do, bothersome fibroids,
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heavy menstrual bleeding, or maybe they had it due to a birth issue through pregnancy,
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find out if they have a cervix. A lot of people don't know if they have a cervix. They
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say, oh, I had a total hysterectomy. I go in there and I'm like, you have a cervix. They're
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like, I do? I've had PAPS for 20 years. They never know. I always ask, do you know if they
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removed the cervix? And they're just like, no. Do you have any records? No. It's either they
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don't know or they say they have nothing left. And I go in and I'm like, oh, there's
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a cervix here. And they're like, get out of town. I have a cervix. I'm like, yes,
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we need to do a PAPS here. We're 10 years behind. They leave it in place for a reason,
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right? It's kind of for like the pelvic floor support. Is that the main rationale?
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Okay. Exactly. And it's the same thing. A lot of people say I have a total hysterectomy and
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they don't realize they have ovaries. So I often say, you got your hysterectomy. Did you start
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having hot flashes or did you notice vaginal dryness or mood changes? I start asking
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questions to say, did you go into menopause? Because if we take the ovaries, we're taking
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the estrogen, and menopause starts. So I ask those questions because a lot of people
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don't know. And when in doubt, get a pelvic ultrasound. Pelvic ultrasounds, I mean,
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really low cost, low fuss, and it'll give you a lot of information. And you need to know if
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a person has their ovaries, especially if they have a family history of breast cancer or
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ovarian cancer, pancreatic cancer. You want to know, do they have their ovaries? So
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yes, for the PAPS smear, for hysterectomy, no matter what, if they had cancer.
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Yes, if they have hysterectomy where they spared the cervix, so cervical sparing
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hysterectomy. If they had a hysterectomy and they took the cervix and it was for fibroids
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or bleeding or any other reason besides cancer, no, they never need a PAPS smear again.
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And often, guys, you're going to be the ones that tell the patient that they're
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going to come to you and they're going to say, I don't know, check my chart.
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I don't know. Can you look? I don't know. Tell me if it's in there when you get down
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there. And you're going to be nervous because it might be your third PAP ever.
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And it's okay to say, Hey, can you look at this really quickly? Or, you know, you say,
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okay, Mrs. Johnson, hold tight for one moment. I'm going to have Dr. So-and-so
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come in and just look behind me really quickly just to make sure that's fine.
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You know, you want to get it right. So if you have to get a second pair of eyes,
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do not feel embarrassed. Totally. Oh my God. I love that so much.
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So a question about managing menopausal symptoms, choosing birth control, interpreting
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PAP results and medications and pregnancy. That is a lot of topics, but I think that
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there's a bottom line that you and I talked about. So what do you, what do you think
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about that? Yeah, I think what it boils down to is when you're new, you want to make sure
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you're managing people correctly. And to do that, I think it's really important to know
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where to find information and also to be okay asking, be okay asking for help. So
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I'll start with menopausal symptoms. You know, menopause is such a,
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it's kind of a little bit of a taboo topic in this country. I find people are scared to
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treat menopausal patients. People are scared to prescribe hormone therapy.
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They're scared to start patients on it. They don't want them to get breast cancer.
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You know, back in the day, the medications are, were not as sophisticated and safe as
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they are today. And a lot of people are nervous. They're like, she's having hot
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flashes. No, no, no, no, no. Cool down the room, drop you to spicy food and go to your GYN.
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But you know, I found that, so ACOG, the American College of Organic Colleges, they have
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an excellent green journal article on menopause. It's very long, but it's excellent. And
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really everything you need to find, it's in there. Up to date. I'm sure if you're
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watching this, you've used up to date, your preceptor is used up to date. You've heard of
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it. It has incredible algorithms about menopausal symptoms, different preparations of
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menopausal hormone replacement therapy in general. I tell my students and new MPs,
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if they're just having local symptoms, like just vaginal dryness or just pain during
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intercourse, you can treat locally. And local treatment is super safe. It's well studied.
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And we should be helping our women to feel better and live full lives. And for a lot of
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women, a full life includes intimacy. So, you know, we don't want to block them from
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that because we're scared to prescribe it. So a local topical preparation of estrogen
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cream or a little tablet or something like that, completely safe. And you can talk to
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the patient about the risks and benefits. But the studies are so great that we're not scared
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to prescribe those. You're also going to have patients who are having high flashes. I'm talking
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hot. You don't have time for this story. But the fast, the quick and dirtiest, I had a patient
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who was so miserable from her high flashes. And I'm smiling because in retrospect,
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she's like, oh my gosh, I was really off the deep end with that. But I mean, she really was
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wanting to end it all. I mean, she was talking like this. She's like, Monica,
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I can't live anymore. And we got her feeling better so fast. So, you know, you're going to
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have women with systemic symptoms and you're going to want to treat them systemically. You
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can treat them with a combination patch. You can treat them with hormone replacement therapy
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pills. But, you know, the ACOG Green Journal, up to date. And there's actually a free app
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called Menopro. So M-E-N-O-P-R-O, Menopro. It's completely free from the North American
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Menopausal Society. And it's like, it's like... Menopause for dummies?
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I was like, how do I say that? I was like, menopause 101. It's like menopause for dummies.
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And the thing is, don't feel embarrassed because this is like, these are, when you're in a
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specialty, there's just going to be stuff that, it's impossible to be taught the intricacies
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of every single thing while in school. And on the job training is important. But what school
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does teach you is generally what you should be doing, how to find information and who to ask.
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You know when something's wrong. You know that a person shouldn't be
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depressed because they're so hot. You know what I mean? So I love those three resources.
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As far as birth control, choosing birth control, it comes with time. As you
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become more comfortable prescribing, you're going to feel more comfortable
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kind of tweaking medications. You're going to learn more about the different progestins.
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Every birth control pill has the same estrogen, ethanol, estradiol. They're all the same. But
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every birth control pill has a different progestin. And they come in generations,
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I think they're still called generations, but anyway. And depending on the birth control
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progestin content, it's going to have a different effect on patients. So you might
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have a patient with PCOS, there might be a birth control pill that's better for her
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because it's going to help to block some of those like androgens.
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Androgenic effects, anti-androgen.
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You either laugh about it or edit it out. But you know,
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either way, I honestly am fine with either. But there might be birth control pills that
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are better for her. If a person's having breakthrough bleeding, maybe you're going to
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need to switch their birth control or increase the dose or change the progestin.
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Generally, there are certain progestins. And like I said, up to date is a great resource.
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If you go through it, you can look and say, okay, the progestin norethendron,
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it's going to make your periods much lighter. It's going to decrease bleeding.
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If you have a patient who wants a birth control pill where they're not going to
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have a period or they're going to have a lighter period. Oh, I want one with
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norethendron. I remember Monica talking about that. That's your low estrogen,
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your microgestin, your Junel, et cetera. No disclaimers here. These are not sponsored.
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No affiliations here. No. That's what it is. No affiliation. This is just
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complete facts. So as you learn those things, you're going to become more comfortable.
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I do share decision-making with my patients. So when we're talking about which
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birth control is my go-to, it's up to the patient. I go through all the options and
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studies have shown that we should start with the long-acting reversible contraceptives and
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go down. So we should start with the IUDs and the subdermal implant, the next one on.
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We should technically the depo. Yeah, I'm not a fan. Yeah, I'm not a big fan.
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I will tell you guys a little, you know, clinical pearl. Depo does have about an
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average of a nine month return to fertility. So please don't start your patients who are
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thinking about getting pregnant within the next year on Depo because it's a sad, sad story.
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When they're a period, it's not coming back and then it's irregular, et cetera. So that's
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a little clinical pearl. I love the book Contraceptive Technology.
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A bunch of dots in the front in a circle. Sure is. Yes, I remember that. I love that book.
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I love it. And in the middle, there are pictures of each pill pack. And I mean,
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first of all, I love this book. And I got the Contraceptive Technology book at the
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Contraceptive Technology Conference. Again, no affiliations. It's just that great. It's a
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DC and Boston. Every year they have it in those four cities. And I think they're probably
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doing it virtually now. And it's PCOS, menopause, birth control. You can get certified
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to place next one on. That's where I was certified. You learn how to place IUDs. I mean,
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it's incredible. And I bought the book there and the author signed it and everything.
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So that book is great. So Contraceptive Technology book, up to date,
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reproductive health access. It's a website. It's great for your patients. Bedsider.org,
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another great resource. Great to do patient handouts, patient info handouts.
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Awesome. And I'll link to all of those below the video too.
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Yeah, I know. I'm saying a lot of resources, but I just want you guys to know that you have
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what it takes. You have what it takes. I was gonna say that's the bottom line is
377
00:31:45.390 --> 00:31:49.770
resources and trusting yourself. Because I mean, clearly you are a wealth of knowledge with
378
00:31:49.770 --> 00:31:56.590
many clinical pearls. And also they have what it takes too, to practice. Get the practice to
379
00:31:56.590 --> 00:32:01.810
do it for sure. I love those resources. That's awesome. Yeah. So Liz will link those because
380
00:32:01.810 --> 00:32:04.770
that Contraceptive, I mean, the fact that she even knows it has a little dots around
381
00:32:04.770 --> 00:32:08.270
the outside. I love it. And it has every pill pack inside. So if your patient says,
382
00:32:08.930 --> 00:32:13.590
well, if you tell them, okay, you're gonna take three weeks of pills and then that last
383
00:32:13.590 --> 00:32:17.570
week is a placebo, then they get the pill pack and there's only three lines. And they're
384
00:32:17.570 --> 00:32:21.510
like, well, wait a minute. So sometimes I'll just check and say, oh, actually this is one that has
385
00:32:21.510 --> 00:32:26.810
three weeks and you have to just break for a week. And that's so good. I clearly did not
386
00:32:26.810 --> 00:32:30.790
utilize that book. I bought it for grad school, but I was like, I don't know what to do with
387
00:32:30.790 --> 00:32:34.990
this. But I love that book. And there's like headlines like your patient's having
388
00:32:34.990 --> 00:32:39.590
breakthrough bleeding. Do this. Your patient's having, you know, breast tenderness or pelvic
389
00:32:39.590 --> 00:32:44.950
pain. Do this. Your patient's having acne. Switch to this. I love it. That's so good.
390
00:32:44.950 --> 00:32:50.190
This is a good book. Oh, that's so good. Thank you. Hat results, ASCCP guidelines. Yes.
391
00:32:50.430 --> 00:32:56.320
It costs $10, I think either $10 a year or $10. But yeah, there's an app for that.
392
00:32:59.070 --> 00:33:02.590
And that's one thing I'll say for primary care providers. One thing I think in GYN,
393
00:33:02.750 --> 00:33:06.810
we want you all to know is to check the guidelines because often patients are sent to
394
00:33:06.810 --> 00:33:10.370
me for a colposcopy who don't need a colposcopy. They just need to repeat the
395
00:33:10.370 --> 00:33:15.550
year. And they get there and they're like, I drove all the way here and I paid a copay for
396
00:33:15.550 --> 00:33:19.050
you to tell me I don't need to be here. And I'm like, we can talk about something else. Like,
397
00:33:19.050 --> 00:33:23.550
I feel terrible. I don't know. So I want primary care providers to just check the
398
00:33:23.550 --> 00:33:28.430
guidelines too and feel okay saying like, you know, these are the guidelines we use. This
399
00:33:28.430 --> 00:33:32.250
is your PAP result. Looks like we can repeat in a year. If you want, you're welcome to see
400
00:33:32.250 --> 00:33:36.610
your GYN for that repeat or come back to me. Something like that. Awesome. Awesome.
401
00:33:37.170 --> 00:33:40.370
Yeah. And then medications and pregnancy. I think that was the other one. And I'll say
402
00:33:40.370 --> 00:33:45.430
the medications and pregnancy, broken record, of course, like up to date stuff like that.
403
00:33:45.710 --> 00:33:51.710
There's a site called Reprotox. You do need a subscription. But the great thing is like our
404
00:33:51.710 --> 00:33:58.210
whole practice uses the same login and password that our boss got the prescription. Look at me.
405
00:33:58.530 --> 00:34:04.050
Subscription. And that basically you put the medication in and it brings up all the data as
406
00:34:04.050 --> 00:34:09.730
pertains to pregnancy. Excellent. And I like that because, you know, medications and pregnancy,
407
00:34:09.770 --> 00:34:14.050
everyone says Monica, what's safe? Can I use this? Can I use this? It's again, it's a
408
00:34:14.050 --> 00:34:19.370
discussion. It's a discussion with your patient because there are not a lot of clinical trials
409
00:34:19.370 --> 00:34:23.630
with pregnant patients who are volunteering to try medication. So a lot of these are
410
00:34:23.630 --> 00:34:26.670
retrospective. We're looking back at pregnant women who were on those medications.
411
00:34:27.330 --> 00:34:31.610
I mean, how did it look? Some of them are animal studies, but it's just to say that
412
00:34:32.330 --> 00:34:36.969
that's a little bit more sophisticated. And sometimes we refer to maternal fetal medicine
413
00:34:36.969 --> 00:34:41.310
and say, you know, this is the medication she's on. Her psychiatrist needs her to stay on it.
414
00:34:42.070 --> 00:34:46.949
We want her to stay on it because we want her to have a mentally healthy pregnancy as well.
415
00:34:47.330 --> 00:34:52.750
We would like for you to counsel her about risks to the fetus, you know. So as far as
416
00:34:52.750 --> 00:34:57.450
medications and pregnancy, don't feel bad asking, you know, don't feel bad being a
417
00:34:57.450 --> 00:35:03.270
specialist, asking a real specialist. I mean, MFM is like a whole, I mean, they are like,
418
00:35:03.530 --> 00:35:08.730
in the GYN world, they're like, they're like, God, I mean, they're like the smartest
419
00:35:08.730 --> 00:35:16.030
people ever. They're so smart. That's awesome. And this is maybe the silly question,
420
00:35:16.110 --> 00:35:22.330
but do you ever get people like, do people see you first and then you refer to maternal
421
00:35:22.330 --> 00:35:26.450
fetal medicine or do people directly go to maternal fetal medicine in your experience?
422
00:35:26.450 --> 00:35:33.530
It just depends on the practice, not practice standard, but the flow of the practice.
423
00:35:33.870 --> 00:35:38.290
In our practice, they love, of course, for them to see the nurse practitioners first
424
00:35:38.290 --> 00:35:43.030
because we're so detailed and we do have longer slots with patients. So I'm able to do
425
00:35:43.030 --> 00:35:47.270
a really, so sometimes I'll see a patient for onboarding into our practice as a pregnant
426
00:35:47.270 --> 00:35:50.890
patient who is a really high risk patient and I'm going to go through their records
427
00:35:50.890 --> 00:35:58.350
and I do their history. I do their physical. I really make the chart nice and put on a silver
428
00:35:58.350 --> 00:36:02.630
platter and then say to them, here you go. And they do the counseling. I'm kind of kidding,
429
00:36:02.630 --> 00:36:07.010
but you get what I'm saying. They want them to see us first because we're one that it's
430
00:36:07.010 --> 00:36:11.730
going to be easier to get in with us. And because they're doing consults all day or they're
431
00:36:11.730 --> 00:36:15.710
doing ultrasounds all day. So we're going to check the baby. We're going to talk to them
432
00:36:15.710 --> 00:36:22.770
the practice, our practice model that we have men and women and students as a teaching hospital.
433
00:36:23.090 --> 00:36:29.010
So they do see us first. Now, a lot of times primary care will refer to MFM, which is fine.
434
00:36:29.270 --> 00:36:35.950
And the MFM's administrative assistant just says, okay, you'll see Dr. So-and-so on
435
00:36:35.950 --> 00:36:40.410
Thursday and you'll see Monica on Monday just to kind of get in and get all your
436
00:36:40.410 --> 00:36:43.590
information because those consults are long. I'm not going to lie. You know, the MFM,
437
00:36:43.590 --> 00:36:50.950
they're talking for, I mean, when I was pregnant with triplets, my MFM consult and these are,
438
00:36:51.130 --> 00:36:54.130
I mean, I've been there 13 years. So these are people I've known forever.
439
00:36:54.530 --> 00:36:59.010
My MFM consult was an hour. They talked to me for an hour. And I'm going to be honest,
440
00:36:59.010 --> 00:37:04.570
some of that stuff, I'm like, you don't say, am I supposed to have ever heard this? What
441
00:37:04.570 --> 00:37:11.870
is this? You know, so I will say their job is to counsel. So it is nice for them to
442
00:37:12.810 --> 00:37:17.270
kind of be established in the practice first. But as for primary care, just go ahead and refer
443
00:37:17.270 --> 00:37:22.430
them to the specialist. And if their practice has them see the gynecologist or obstetrician first
444
00:37:22.430 --> 00:37:26.370
or, you know, you can let them worry about that. But referring them to a specialist says,
445
00:37:26.470 --> 00:37:30.330
this is a high risk pregnancy and I need a high risk doctor to see this patient at some
446
00:37:30.330 --> 00:37:36.930
point. So last question. One of the common questions that I get for new grads that I
447
00:37:36.930 --> 00:37:45.210
myself was when I would find the cervix, finally, sometimes it looks like a textbook cervix where
448
00:37:45.210 --> 00:37:50.370
it's like pink and smooth and nothing else is going on. And then there's other times where
449
00:37:50.370 --> 00:37:56.350
there's like redness or it seems like irregular margins, or maybe there's some growths on.
450
00:37:56.610 --> 00:38:00.570
And I think for me, it would freak me out. I think anything would freak me out as a new
451
00:38:00.570 --> 00:38:04.890
grad with physical findings that didn't like match a textbook, like ears, like all that
452
00:38:04.890 --> 00:38:08.710
stuff. But like, what is the guidance that you have for new grads about looking at different
453
00:38:09.950 --> 00:38:14.130
cervixes in terms of like, should they like, I think the question that people have is,
454
00:38:14.250 --> 00:38:18.510
do I do a pap every time to see if it's like cancerous looking? Do I send them to
455
00:38:18.510 --> 00:38:23.710
GYN every time? Like, what are, yeah, what guidance do you have about assessing
456
00:38:24.230 --> 00:38:31.910
cervixes? Yeah, I will say I have seen some services where I was like, oh, wow.
457
00:38:37.870 --> 00:38:42.270
We now have the capture app at my job where you could take a picture, which I,
458
00:38:42.650 --> 00:38:45.530
I'm going to be honest, you could take a picture and it flows straight into the chart.
459
00:38:46.410 --> 00:38:50.830
And it's like, it goes straight into the chart. And it's like a thing that the patient
460
00:38:50.830 --> 00:38:55.290
could say, they can watch it. And it goes out of your phone. To this day, I haven't
461
00:38:55.290 --> 00:39:00.890
used it because pulling out my phone to take a picture down there. I'm just not comfortable yet.
462
00:39:01.050 --> 00:39:07.010
But if your practice has that, you can always do that and it can capture and you
463
00:39:07.010 --> 00:39:10.510
But if it's, if you're like me and you don't want to pull your phone out, take a picture.
464
00:39:11.810 --> 00:39:17.330
I would say as far as like red flags, so any lesions on the cervix can be thought of as a
465
00:39:17.330 --> 00:39:23.890
red flag. But some of them are normal. So think of a cervix like a face. If a person has a
466
00:39:23.890 --> 00:39:28.750
pimple, it's something on the face, but it's not harmful. If they have freckles, it's
467
00:39:28.750 --> 00:39:36.150
something on the face, but it's not harmful. Your pimples and your freckles are kind of
468
00:39:36.550 --> 00:39:41.990
on the cervix or flesh tone and they're completely normal and they're benign and
469
00:39:41.990 --> 00:39:45.490
they're not problematic. But a lot of PCPs will send the patient to me and say, hey,
470
00:39:45.570 --> 00:39:48.330
she has lesions on her cervix, check it out. And they're just in the both the assist.
471
00:39:48.830 --> 00:39:53.190
Another thing I see often that does look kind of scary is called ectropion. So
472
00:39:53.190 --> 00:39:58.250
when the cervix looks like a donut and just like a donut, it has a little donut hole.
473
00:39:59.330 --> 00:40:02.730
The endocervix or the inside of the cervix, those cells are kind of beefy red
474
00:40:02.730 --> 00:40:07.450
and they're immature, they're young. So when they express themselves on the outside,
475
00:40:07.910 --> 00:40:14.910
it looks like cervicitis or it looks like an inflamed cervix or cervix that's red and angry
476
00:40:14.910 --> 00:40:19.850
and you're like, spicy meatballs, something's wrong. I know this is not right. It's
477
00:40:19.850 --> 00:40:23.890
ectropion and it's normal. Patients who have ectropion sometimes have bleeding during
478
00:40:23.890 --> 00:40:27.870
intercourse. So they might come to you and say, hey, I'm having spotting during intercourse,
479
00:40:28.030 --> 00:40:31.250
but I don't have pelvic pain and everything else is normal. You look for
480
00:40:31.250 --> 00:40:35.890
transmitted infections, you look for vaginitis, everything's normal and you look at the cervix
481
00:40:35.890 --> 00:40:40.030
like, oh, there's ectropion there. So that makes a little bit of sense and birth control
482
00:40:40.030 --> 00:40:44.870
pills can help. So putting them on some hormones, birth control period can help with
483
00:40:44.870 --> 00:40:49.130
ectropion, but it's kind of like they'll grow out of it. So when they get into their
484
00:40:49.130 --> 00:40:52.730
thirties, it should be on. So these are the kinds of things that are normal. But to
485
00:40:52.730 --> 00:41:01.230
answer your question, if you see anything on the cervix, I would do a pap smear. If they
486
00:41:01.230 --> 00:41:06.590
send them to GYN because it's always better to be safe than sorry. And it gives the
487
00:41:06.590 --> 00:41:11.510
patient some reassurance. You can say, you know, this is probably completely normal,
488
00:41:12.690 --> 00:41:16.750
but you know, I know the gynecologist they see, you know, they deal with this every
489
00:41:16.750 --> 00:41:20.370
single day, all day, just, you know, make an appointment with them and just have them do
490
00:41:20.370 --> 00:41:23.870
a quick exam just to make sure. And you can reassure the patient, I'm not really worried.
491
00:41:23.870 --> 00:41:28.730
I did a pap smear. When the results come back, I'll call you, but maybe just to have
492
00:41:28.730 --> 00:41:32.950
extra set of eyes. And I think that that's fine. But I would say do a pap if they haven't
493
00:41:32.950 --> 00:41:36.030
had it. Now, if they had a pap smear within the last year and you see an abnormality,
494
00:41:36.070 --> 00:41:40.630
I would just send them. Yeah, I would send them because I mean, often that's our first
495
00:41:40.630 --> 00:41:45.690
screening too over in GYN. And you know, if we see something really abnormal, we might
496
00:41:45.690 --> 00:41:51.390
treat with antibiotics. If you see something that is like, oh my gosh, I think I
497
00:41:51.770 --> 00:41:55.370
heard of this in school. It looks like strawberry. So, you know, like strawberries
498
00:41:55.370 --> 00:42:00.510
have those little seeds. A strawberry cervix. I mean, it truly looks like a strawberry.
499
00:42:00.950 --> 00:42:04.170
And you might start thinking it might be, you know, trichomonas or it might be
500
00:42:05.490 --> 00:42:11.390
an infection. So, you know, things like that. So, yes, send to us. Don't feel bad. I have
501
00:42:11.390 --> 00:42:16.490
personally seen things that I'm like, well, do a pap smear. I'm going to do some vaginal
502
00:42:16.490 --> 00:42:21.490
cultures. We're going to just, a lot of times everything comes back normal. Yes. And it's
503
00:42:21.490 --> 00:42:26.010
just like everyone's face is a little bit different. It's just their cervix.
504
00:42:26.770 --> 00:42:30.730
And I think that's like kind of almost a rite of passage for nurse practitioners to like,
505
00:42:31.350 --> 00:42:34.470
not be able to sleep at night because you're thinking about that cervix that you should have
506
00:42:34.470 --> 00:42:39.890
done a pap on. I mean, not speaking from experience at all, but like just do what helps
507
00:42:39.890 --> 00:42:43.970
you sleep at night and what is the safest option for that patient because doing a pap is
508
00:42:43.970 --> 00:42:49.830
a very relatively non-invasive low cost test overall. So, I love that. I actually have,
509
00:42:49.830 --> 00:42:54.570
I just sent somebody, I wish we worked close by, I just sent somebody for a vulva lesion
510
00:42:54.570 --> 00:42:59.410
that I wasn't sure what it was. So, I'm looking forward to those results. I need to talk to my
511
00:42:59.410 --> 00:43:03.390
local GYN because I have a newer practice that I work with. So, I get a call them.
512
00:43:03.930 --> 00:43:07.790
And I would say that as far as like if you see something on the vulva on the skin,
513
00:43:08.330 --> 00:43:13.290
vulva biopsies, I mean, I tell people just do it, just do it because a lot of times
514
00:43:13.290 --> 00:43:16.310
another issue is, you know, we start treating what we think it is. So, you're seeing
515
00:43:16.310 --> 00:43:19.590
something and you're like, you know what, this is lichens sclerosis. I know lichens
516
00:43:19.590 --> 00:43:25.950
sclerosis. I'm seeing some loss of architecture of the clitoris and it's fusing and it's a
517
00:43:25.950 --> 00:43:30.150
little bit harder and it's hypopigmented. Like this is textbook lichens sclerosis and you
518
00:43:30.150 --> 00:43:34.530
start treating with clobidazole, which is a really strong steroid, which will skew up
519
00:43:34.530 --> 00:43:37.930
vulva biopsies. So, say you start treating with that and it gets worse and worse and worse
520
00:43:37.930 --> 00:43:43.790
and you're like, uh-oh, spaghetti. So, you know, I'd say people, you know what, biopsy,
521
00:43:43.790 --> 00:43:47.310
there are old school docs. A lot of them, they will not start treating without a biopsy.
522
00:43:47.310 --> 00:43:52.070
They want to know what it is, you know, because we do see vulva cancer and it does
523
00:43:52.070 --> 00:43:57.990
mirror other, you know, vulva dermatosis. So, never feel bad for sending for vulva
524
00:43:58.450 --> 00:44:04.910
biopsy. Never, you know, at all, at all. So, yeah. I love that. And I will also
525
00:44:04.910 --> 00:44:08.870
say this is one more clinical pearl, which is something that I kind of, I learned it
526
00:44:08.870 --> 00:44:12.530
earlier on, but I started really realizing it later. When people come in for a regular
527
00:44:12.530 --> 00:44:18.050
bleeding, part of the workup can be a pap smear. So, cervical cancer, one of the symptoms
528
00:44:18.050 --> 00:44:22.870
is a regular bleeding. Ovarian cancer, one of the symptoms is bloating and increased
529
00:44:22.870 --> 00:44:26.610
discharge. So, you might have someone who's like, yeah, I've been kind of bloated and
530
00:44:27.070 --> 00:44:30.410
I'm like, oh, how's your appetite? You know what, I haven't really been that hungry.
531
00:44:30.570 --> 00:44:34.090
Or I'll take a bite and it's like, I'm full. And I'm like, okay. And I'm like,
532
00:44:34.190 --> 00:44:38.410
in any vaginal discharge and they're like, how did you know? Like, I've been,
533
00:44:38.410 --> 00:44:41.310
I've been driving for years and now I've discharged. So, these are kind of things
534
00:44:41.310 --> 00:44:46.190
that, you know, as you start learning conditions in those symptoms, it'll help to tailor
535
00:44:47.110 --> 00:44:50.690
your history. But until then, when you're new, you just ask every single question you
536
00:44:50.690 --> 00:44:55.010
could think of. Oh my God. I love this. I did not tell you to say that.
537
00:44:57.150 --> 00:45:03.590
Because I say the same thing. I totally like ask all, just ask it. Ask it. You'll be
538
00:45:03.590 --> 00:45:07.730
surprised. And I mean, I've had patients where I just happen to ask a couple extra
539
00:45:07.730 --> 00:45:13.270
questions and I'm like, oh my, really? Okay. Well, let's, okay. Well, we got to start
540
00:45:13.270 --> 00:45:18.350
over because now we have, there's something else going on, you know? So, yeah. So that's
541
00:45:18.350 --> 00:45:23.150
kind of like my, my tips for, as far as when you see the cervix, never be afraid to do
542
00:45:23.150 --> 00:45:27.490
a pap smear. If you've done it within last year or you have normal results within last
543
00:45:27.490 --> 00:45:37.570
year, send them. If you see something abnormal, the vulva, biopsy, you know, if you, if you
544
00:45:37.570 --> 00:45:42.510
treat it and say, come back if it's not better or come back in a month and let me re-evaluate.
545
00:45:42.810 --> 00:45:49.050
And I, and I say, and I'm, this is going to be my parting words, I promise. For,
546
00:45:49.050 --> 00:45:52.510
for though, for nurse practitioners who are within the first few years of practice,
547
00:45:53.450 --> 00:45:58.330
it's always a good idea to have a follow-up plan. It's always good to say, you know,
548
00:45:58.330 --> 00:46:03.250
if you're not feeling better in a week, if it's getting any worse, I want you to
549
00:46:03.250 --> 00:46:08.590
come back in. I want you to send me an email. Document that follow-up plan. Document. This
550
00:46:08.590 --> 00:46:13.050
is the plan. Patient verbalizes, understand she's going to call me if it's getting worse
551
00:46:13.050 --> 00:46:16.770
or if it's not better in a week. And then have a plan. Say, you know what, we treated you,
552
00:46:17.970 --> 00:46:25.110
we're treating you empirically for BV and yeast. Your results come in, they're normal,
553
00:46:25.110 --> 00:46:28.530
but she's like, oh, but I'm feeling much better with the medication. Great. She might
554
00:46:28.530 --> 00:46:32.230
start taking the medications. Like I've, it's getting worse down there. And we're like,
555
00:46:32.230 --> 00:46:37.550
stop the medication. Come in. So make sure patients understand that they're not on their own.
556
00:46:37.670 --> 00:46:41.240
You know, they were, we're, we're trying something, you know, we're not always right.
557
00:46:42.630 --> 00:46:46.890
As you grow in practice, often you'll be right, but sometimes you'll be shocked. I've had
558
00:46:46.890 --> 00:46:51.770
patients I've treated that it's like clearly general herpes. Like it's, there's no,
559
00:46:52.430 --> 00:46:55.390
there's no doubt, but because I've been doing this long enough, I always tell people,
560
00:46:56.050 --> 00:47:00.690
this is what it looks like clinically. And this is a, this is the treatment and it does
561
00:47:00.690 --> 00:47:05.270
hurt to start this treatment. It can only help. But if you're not getting significantly better,
562
00:47:05.950 --> 00:47:09.450
we have to start thinking some other way. So, and I've had patients with some serious
563
00:47:09.450 --> 00:47:14.750
staph infections that it wasn't herpes. So sometimes when I look and I'm like,
564
00:47:14.770 --> 00:47:18.630
this is on the mons pubis or in the inner thigh. And I'm like, this is
565
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kind of aggressive for herpes, but it looks like herpes. I'm like, okay,
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here's what we'll do. We're going to do this one for herpes. We're going to treat
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you with Valtrex or acyclovir or whatever you want to do. And then I'm going to also
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do a general culture just to see what grows. And sometimes I'm like, oh my gosh,
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you have like a skin infection and we treat them for skin infection and like, you know,
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with Kevflex or whatever or Bactrim, if you want to cover for me. And it's like better.
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And they were like, okay. And they're like, oh my God, I'm so happy. And I'm like,
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I am too. I'm shocked. So just to say that, you know, sometimes it might not be what you
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think it is, but as long as your patient knows how to reach you and knows that they
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can contact you and follow up if it's not getting better or if it's getting worse,
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it really optimizes their health. It covers you as a clinician and it really makes for a good
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provider, patient relationship. That's awesome. Monica, you're the best. I wish I could work
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with you and be your patient. I would love to work with you. I feel like you're the best,
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Liz. Oh, thank you. You're so sweet. Thank you so much for being here. Where can people
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find you? So I am at Monica, the NP on all channels. So on Instagram at Monica, the NP,
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Facebook, Monica, the NP, and my website is Monica, the NP.com reach out to me. If you need
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anything, my specialty is teaching our practitioners, how to negotiate teaching
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those practitioners, how to transition into the business of being an NP, which
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gets me so excited. So as you start interviewing and reach out to me. Yes. I mean,
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you have the compensation course. I talk about it like all the time, but if you want to tell
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people about that too, go for it. Sure. So I created the compensation course. So it's a guide
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for nurse practitioners to learn how to negotiate their dream job. We go through the job hunt,
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the job search, interviewing, and then we get really into the thick of salaries, how to
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compute your salary, how to ask for a raise, what are RVUs, what are AVUs, how is my bonus
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calculated, how do I create a bonus. It's a lot about compensation and it's not just about money.
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A great job will pay you well, but a great job also, it provides longevity. So maybe it's good
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hours, money for CMEs, maybe you have a supportive workplace. There are other things
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that are part of that compensation package that matter, that's not necessarily salary. So
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we go through all of that and I do review contracts. So my students will bring me their
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offers, their contracts, we'll go through them. We'll do counter offers, my favorite.
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I do a lot of word for word scripts for people just because I know what you guys want,
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but no one knows how to say it. So I help you to feel confident to ask for more
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so that we as a profession, all of us as MPs can continue to push the envelope.
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Yeah, so good. And your students' results are just so amazing. It gives me chills. It's so good.
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You're amazing. That's how I feel about your students with everything you do.
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Oh, you're so sweet. You're so sweet. Well, thank you so, so much.
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I hope you enjoyed that interview as much as I did. If you haven't grabbed the Ultimate
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00:50:25.610 --> 00:50:31.310
Resource Guide for the new NP, head over to realworldnp.com slash guide. You'll also get
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00:50:31.310 --> 00:50:35.670
these videos sent straight to your inbox every week with notes from me, patient stories,
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00:50:35.670 --> 00:50:40.170
and bonuses I really just don't share anywhere else. Thank you so very much for watching.
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Hang in there and I'll see you soon. That's our episode for today. Thank you so much
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for listening. Make sure you subscribe, leave a review, and tell all your NP friends so
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00:50:56.900 --> 00:51:02.140
together we can help as many nurse practitioners as possible give the best care to their patients.
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00:51:02.440 --> 00:51:06.660
If you haven't gotten your copy of the Ultimate Resource Guide for the new NP,
609
00:51:06.660 --> 00:51:13.040
head over to realworldnp.com slash guide. You'll get these episodes sent straight to your inbox
610
00:51:13.040 --> 00:51:18.100
every week with notes from me, patient stories, and extra bonuses I really just
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00:51:18.100 --> 00:51:22.740
don't share anywhere else. Thank you so much again for listening. Take care and talk soon.
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