No. Pelvic exams have stayed in person. But my practice is staying online.
Despite my early misgivings, the pandemic has now convinced me that telemedicine has a definitive role in health care, including gynecology.
I have been a practicing OB/GYN for almost five decades and have spent the past 20 years specializing in menopausal medicine, which means most of my patients are middle-aged or older women. Research showed that the majority of my patients — who’d had normal Pap smears for at least 30 years — no longer needed annual Pap smears or pelvic exams, which opened a door to my online practice.
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Thanks to telemedicine, even at the height of the pandemic, I could review patients’ histories, address their more immediate health problems, discuss other relevant clinical information, renew or change their prescriptions, and email them an order for a yearly mammogram or a bone density test. They could print these documents and take them to any test facility near them, with the results promptly faxed to me.
Still, without examining each woman physically, I feared I was doing an incomplete job of being their gynecologist. But several months of positive experiences with virtual care, and a review of the relevant medical literature published by the American College of Obstetricians and Gynecologists (ACOG), reinforced my belief that, in many women’s health visits, routine pelvic exams and Pap smears contribute nothing to the ultimate treatment of the patient.
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The best uses of telemedicine in gynecology are for menopausal consultation, suspected urinary tract infections, renewal of oral contraceptives, treatment of vaginal yeast infections and consultation for premenstrual syndrome, said Cynthia Abraham, an associate professor at Icahn School of Medicine at Mount Sinai in New York. She officially reviewed the March 10 ACOG report.
The ACOG report further defines situations in which only in-office consultations are appropriate, such as fever with a vaginal infection; symptoms of an ectopic pregnancy, including pain in the pelvis, abdomen or back; and severe vaginal bleeding. Another indication for a live visit is the failure of the remote encounter to solve the problem. If telemedicine isn’t working, the default mode is always an in-person examination.
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More generally, anyone who is hemorrhaging, or having severe chest pain, a seizure or other new symptoms that are frightening, or potentially serious coronavirus symptoms, should go to a doctor, in person, or to the nearest emergency room or urgent care facility.
I’ll admit that there have been some surprises online. Once, I didn’t recognize a longtime patient online in her living room without her makeup. Another woman had a large, white bird on each shoulder and asked if I minded that she had her pets with her during the visit. I agreed that the Health Insurance Portability and Accountability Act probably didn’t extend to companion animals.
A few patients said I looked different without my white coat and tie. I also learned that, for privacy reasons, many people conduct their appointments from their car — which is fine, as long as they aren’t driving. And one woman sent me a “selfie” of her genital wart but accidentally used the email address I share with my wife.
Telemedicine also demands a higher degree of patient responsibility than standard, in-office visits.
Several months ago, a woman I’d been treating for decades called complaining of intermittent vaginal bleeding several years after menopause. I referred her to a colleague’s office for evaluation and treatment. But she was unvaccinated against covid-19 and decided to wait several months before finally seeing the doctor. When she finally made it in for a visit, she was diagnosed with uterine cancer.
Luckily for her, the cancer had not spread outside her uterus, and she was treated successfully with robotic surgery.
Telemedicine has worked well for my time-crunched patients, many of whom have aging parents or in-laws who need their attention, an ill spouse or partner who requires emotional support, children to raise and often a full-time job; they were happy to avoid driving to the office, parking and sitting in a waiting room. For those patients who were reluctant to give up their annual in-person exam, I referred them to another women’s health specialist for further care.
Online medicine has proved so beneficial in the pandemic that the American Medical Association and Medicare support continuing coverage for remote visits even post-pandemic. Other insurers often follow Medicare’s lead.
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Before taking the full telemedicine plunge, I’d advise that patients do some research on options, including checking their health insurance provider’s policies, preferably before any health crisis.
But in this new world of cyber appointments, patients now have the option of a screening visit from their home to determine the severity of a problem, with either immediate reassurance and treatment virtually, or timely referral to an emergency facility. This can save anxiety, time and money for both the consumer and the health-care system.
Jerrold H. Weinberg is a physician in suburban Detroit and a Fellow of the American College of Obstetricians and Gynecologists. He is working on a book titled “A Male Gynecologist Goes Through Menopause.”