Ob-Gyns Provide Essential Care for Sexual Assault Survivors
Washington, DC – Sexual assault is a significant public health problem affecting millions of adults and children in the United States. Approximately one in five women in the U.S., an estimated 23 million, experience completed or attempted rape over their lifetime. As public discourse advances toward a more open and robust discussion about the prevalence of sexual assault, the development of resources to support survivors and strategies to prevent this violence, the American College of Obstetricians and Gynecologists (ACOG) today released updated guidance focusing on ob-gyns’ role in supporting sexual assault survivors.
Given the continued high rates of sexual assault, ob-gyns should understand individual experiences with sexual assault are likely to vary widely in nature and circumstance. Working from this understanding, the Committee Opinion emphasizes the importance of screening all individuals for a history of sexual assault. It should never be assumed that a patient has not experienced an assault simply because they have not mentioned it.
Awareness of a history of sexual assault is especially pertinent in reproductive health care settings, as gynecologic procedures and examinations may trigger panic and anxiety for survivors. To assist ob-gyns in taking a sensitive and thoughtful approach to sexual assault screening, the Committee Opinion outlines a suggested protocol for questions to be asked.
“For sexual assault survivors, the emotional complexity and vulnerability of issues discussed and exams performed during reproductive health care visits may be particularly difficult,” says Serina Floyd, M.D., MPH, Committee Opinion author. “This guidance aims to give ob-gyns a framework to approach sexual assault screening and care in a compassionate and comprehensive fashion, so that every individual who walks through our office doors feels heard, cared for and safe.”
The guidance recommends a trauma-informed approach to care for survivors of sexual assault. This framework acknowledges the effects of trauma, recognizes signs and symptoms of trauma, responds by integrating knowledge about trauma into practices and aims to resist retraumatization. It helps establish trust, understanding and open communication between patients and clinicians, reinforcing the foundation of the relationship.
Individuals who have experienced sexual assault are likely to face both immediate and long-term physical and mental health consequences, but they are also unlikely to spontaneously discuss a history of sexual assault. Consistent screening, early identification, and a trauma-informed approach to care increases the likelihood survivors receive proper and complete care to address immediate concerns like bodily injuries, sexually transmitted infection and pregnancy.
These protocols are also important to minimizing or addressing the long-term effects of sexual assault, both physically and mentally. Ob-gyns should be particularly aware of those reproductive health care related symptoms and conditions that may manifest from sexual assault in the long term, like chronic pelvic pain, dysmenorrhea, and sexual dysfunction.
The Committee Opinion overviews the complex legal and evidentiary protocols surrounding care for sexual assault survivors at their first point of contact following an assault. These vary from state to state and ob-gyns should familiarize themselves with the specifics of their state and local requirements and resources. The guidance directs ob-gyns to resources from the United States Department of Justice and International Association of Forensic Nurses for more information.
Committee Opinion #777, “Sexual Assault,” is published in the April edition of Obstetrics & Gynecology.
The Use of Antimüllerian Hormone in Women Not Seeking Fertility Care
Committee Opinion #773
Antimüllerian hormone is produced by the granulosa cells surrounding each oocyte in the developing ovarian follicle. The production and serum levels of antimüllerian hormone at any given time are reflective of a woman’s ovarian reserve, and multiple studies have demonstrated that antimüllerian hormone levels decline across the reproductive lifespan. Data exist to support the use of antimüllerian hormone levels for the assessment of ovarian reserve in infertile women and to select ovarian stimulation protocols in this population; however, using serum antimüllerian hormone levels for fertility counseling in women without a diagnosis of infertility is not currently supported by data from high-quality sources. The obstetrician–gynecologist should exercise caution when considering the predictability of serum antimüllerian hormone levels in any population of women with a low prevalence of infertility, including reproductive-aged women who either have never tried to become pregnant or have become pregnant previously without assistance. Based on the current information, a single serum antimüllerian hormone level assessment obtained at any point in time in a population of women with presumed fertility does not appear to be useful in predicting time to pregnancy and should not be used for counseling patients in this regard. At this time, routine antimüllerian hormone testing for prediction of pregnancy loss is not recommended. More data are needed to determine the utility of antimüllerian hormone as a predictor of time to menopause, a biomarker for polycystic ovary syndrome, or a predictor of future menses in women who have received gonadotoxic therapy
Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention
Committee Opinion #774
Opportunistic salpingectomy may offer obstetrician–gynecologists and other health care providers the opportunity to decrease the risk of ovarian cancer in their patients who are already undergoing pelvic surgery for benign disease. By performing salpingectomy when patients undergo an operation during which the fallopian tubes could be removed in addition to the primary surgical procedure (eg, hysterectomy), the risk of ovarian cancer is reduced. Although opportunistic salpingectomy offers the opportunity to significantly decrease the risk of ovarian cancer, it does not eliminate the risk of ovarian cancer entirely. Counseling women who are undergoing routine pelvic surgery about the risks and benefits of salpingectomy should include an informed consent discussion about the role of oophorectomy and bilateral salpingo-oophorectomy. Bilateral salpingooophorectomy that causes surgical menopause reduces the risk of ovarian cancer but may increase the risk of cardiovascular disease, cancer other than ovarian cancer, osteoporosis, cognitive impairment, and all-cause mortality. Salpingectomy at the time of hysterectomy or as a means of tubal sterilization appears to be safe and does not increase the risk of complications such as blood transfusions, readmissions, postoperative complications, infections, or fever compared with hysterectomy alone or tubal ligation. The risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization. Additionally, ovarian function does not appear to be affected by salpingectomy at the time of hysterectomy based on surrogate serum markers or response to in vitro fertilization. Plans to perform an opportunistic salpingectomy should not alter the intended route of hysterectomy. Obstetrician–gynecologists should continue to observe and practice minimally invasive techniques. This Committee Opinion has been updated to include new information on the benefit of salpingectomy for cancer reduction, the feasibility of salpingectomy during vaginal hysterectomy, and long-term follow-up of women after salpingectomy.
Nonobstetric Surgery During Pregnancy
Committee Opinion #775
The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice acknowledges that the issue of nonobstetric surgery during pregnancy is an important concern for physicians who care for women. Because of the difficulty of conducting large-scale randomized clinical trials in this population, there are no data to allow for specific recommendations. It is important for a physician to obtain an obstetric consultation before performing nonobstetric surgery and some invasive procedures (eg, cardiac catheterization or colonoscopy) because obstetricians are uniquely qualified to discuss aspects of maternal physiology and anatomy that may affect intraoperative maternal–fetal well-being.
Immune Modulating Therapies in Pregnancy and Lactation
Committee Opinion #776
Because autoimmune conditions occur more often among women of childbearing age, continuation of these medications during pregnancy is often considered to optimize disease management in the woman and pregnancy outcomes, without placing the fetus at undue risk. Many commonly prescribed drugs can be used safely during pregnancy, without risk of teratogenicity or pregnancy complications, whereas a few are strictly contraindicated. The decision to use any agent during pregnancy should be based on the clinica lcontext, risks associated with individual medications, and gestational age. For immunomodulators considered appropriate to use during pregnancy, the common clinical practice of stopping use at approximately 32 weeks of gestation because of theoretic concerns regarding the immune system of the fetus is not supported bycurrently available data. Low-risk medications typically are continued in pregnancy, or initiated during pregnancy as needed, because the benefits of therapy and disease control far outweigh any theoretic risks associated with the medication. Use or initiation of medications with intermediate risk or little or no data during pregnancy or lactation (or both) should be individualized. High-risk medications are typically not continued or initiated in pregnancy. However, it is critical that counseling occur, ideally in the prepregnancy and interpregnancy periods, to review the individual risks and benefits as they relate to disease management and pregnancy-associated risks with high-risk medication. There may be select circumstances when continued treatment is the safest option. In general, immunomodulating drugs that are not contraindicated in pregnancy are compatible with breastfeeding.
Practice Bulletin #210
Fecal incontinence, or the involuntary leakage of solid or loose stool, is estimated to affect 7–15% of communitydwelling women. It is associated with reduced quality of life, negative psychologic effects, and social stigma, yet many women do not report their symptoms or seek treatment. Less than 3% of women who do self-report fecal incontinence will have this diagnosis recorded in their medical record. Obstetrician–gynecologists are in a unique position to identify women with fecal incontinence because pregnancy, childbirth, obstetric anal sphincter injuries (OASIS), and pelvic floor dysfunction are important risk factors that contribute to fecal incontinence in women. The purpose of this Practice Bulletin is to provide evidence-based guidelines on the screening, evaluation, and management of fecal incontinence to help obstetrician–gynecologists diagnose the condition and provide conservative treatment or referral for further work up and surgical management when appropriate. For discussion on fecal incontinence associated with OASIS, see Practice Bulletin No. 198, Prevention and Management of Obstetric Lacerations at Vaginal Delivery.
The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. www.acog.org