key: cord-0077961-uhiielyh authors: Grimes, Cara L.; Balk, Ethan M.; Dieter, Alexis A.; Singh, Ruchira; Wieslander, Cecilia K.; Jeppson, Peter C.; Aschkenazi, Sarit O.; Kim, Jin Hee; Truong, Mireille D.; Gupta, Ankita S.; Keltz, Julia G.; Hobson, Deslyn T.G.; Sheyn, David; Petruska, Sara E.; Adam, Gaelen; Meriwether, Kate V. title: Guidance for gynecologists utilizing telemedicine during COVID‐19 pandemic based on expert consensus and rapid literature reviews date: 2020-07-16 journal: Int J Gynaecol Obstet DOI: 10.1002/ijgo.13276 sha: d04cdf59887d3e6e23c60a81720791fdd36ad275 doc_id: 77961 cord_uid: uhiielyh BACKGROUND: COVID‐19 has impacted delivery of outpatient gynecology and shifted care toward use of telemedicine. OBJECTIVE: To rapidly review literature and society guidelines and create expert consensus to provide guidance regarding management of outpatient gynecology scenarios via telemedicine. SEARCH STRATEGY: Searches were conducted in Medline and Cochrane databases from inception through April 15, 2020. SELECTION CRITERIA: Literature searches were conducted for articles on telemedicine and abnormal uterine bleeding, chronic pelvic pain, endometriosis, vaginitis, and postoperative care. Searches were restricted to available English language publications. DATA COLLECTION AND ANALYSIS: Expedited literature review methodology was followed and 10 943 citations were single‐screened. Full‐text articles and relevant guidelines were reviewed and narrative summaries developed. MAIN RESULTS: Fifty‐one studies on the use of telemedicine in gynecology were found. Findings were reported for these studies and combined with society guidelines and expert consensus on four topics (abnormal uterine bleeding, chronic pelvic pain and endometriosis, vaginal discharge, and postoperative care). CONCLUSIONS: Guidance for treating gynecological conditions via telemedicine based on expedited literature review, review of society recommendations, and expert consensus is presented. Due to minimal evidence surrounding telemedicine and gynecology, a final consensus document is presented here that can be efficiently used in a clinical setting. On January 30, 2020, WHO declared a worldwide state of emergency due to the coronavirus SARS-CoV-2 (COVID- 19) pandemic. Social distancing has become the primary behavioral modification to minimize viral transmission and control the pandemic. 1, 2 During the initial surges of infection, telehealth and telemedicine were used as a way of protecting patients and providers from exposure to COVID-19 while continuing care. Telehealth is a more global term that refers to any healthcare process that occurs remotely. Telemedicine is a term that describes technology used to connect a patient to provider to administer care through telephone or video interactions. 3 As we enter a "new normal" phase of the pandemic, it is highly likely that telemedicine will continue to be important due to new waves of disease, patient anxiety, and healthcare system resources. A systematic review published in February 2020 examined the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes. 4, 5 This work emphasized the importance of remote monitoring and virtual visits in settings where there are barriers to facility-based care, a situation that now feels prescient. Evidence-based guidance for telemedicine in gynecological conditions will be critical during this time. The Society of Gynecologic Surgeons (SGS) recently released guidelines on the use of telemedicine in female pelvic medicine and reconstructive surgery (FPMRS) to help steer FPMRS providers in their care of patients during COVID-19 and the present review hopes to offer similar guidance for gynecologists. 6 The aim of the present study was to perform a systematic, rapid review of the literature and combine it with society guidelines and expert consensus to provide guidance regarding management of common outpatient gynecology scenarios via telemedicine. This guidance will assist the specialty in delivering the most effective and safe healthcare during the COVID-19 pandemic and for future global crises. developed for articles about telemedicine (technology to connect a patient to a provider) and each clinical topic (see Appendix S1). Formal literature searches were run in PubMed, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews and were conducted from database inception through April 15, 2020. All searches were restricted to English language publications regarding human patients. Searches that yielded over 1500 citations had exclusion of case reports, and any articles that were not original exception of narrative reviews. For all topics, existing systematic reviews, primary studies, and pertinent narrative reviews were sought. Further details of clinical research questions, including specific eligibility criteria and literature flow, are reported in Appendix S1. Due to the rapid nature of the project, articles reviewed were limited to those that could be retrieved from group member libraries within 24 hours. The combined searches yielded 2375 citations with partial removal of duplicate citations (partially deduplicated). These were screened singly by eight team members. Among these, 44 citations were initially accepted, which were rescreened by a single team member who selected 17 for further review. One article could not be retrieved and another was a duplicate publication. Fourteen articles were extracted for pertinent data to offer the following guidance. These included four randomized controlled trials (RCTs), [9] [10] [11] [12] two existing systematic reviews, 13,14 seven cross-sectional or survey studies, [15] [16] [17] [18] [19] [20] [21] and one retrospective cohort study. 22 • The quality of information on online sites about bleeding disorders and AUB is limited. 18, 20 Women should be given professional guidance to websites that are useful and accurate (EC), such as pamphlets from the American College of Obstetricians and Gynecologists (ACOG) 23 at acog.org/patient-resources/faqs or misforwomen.com. 24 • Social media platforms have been shown to increase awareness of undiagnosed bleeding disorders. 17 Women could be directed to social media groups or platforms that might increase their awareness (EC). • Telephone or video chat counseling of patients has been demonstrated to increase patient satisfaction, lower anxiety score, and not alter treatment complication or outcomes. 12 Telephone or video counseling with patients is encouraged to help manage their care (EC). • Acute heavy bleeding is more likely to occur in women with ovulatory dysfunction 14 ; therefore, women with anovulatory bleeding are optimal candidates for telemedicine management as first-line management is hormonal treatment (EC). • Bleeding timing and quantity can be collected through text message or mobile applications (such as Glow™, Clue™, GP™ apps, Period tracker Free Menstrual calendar™, and Pink Pad Period Tracker & Fertility Tracker Pro™) rather than paper forms, facilitating evaluation by telemedicine. 10, 11, 21 • Standard physical exam or testing components for assessment of AUB 14 can be accomplished by home urine pregnancy test, guiding patients to take their own pulse and blood pressure, capillary refill time with a stopwatch, home pad weight or photos of pad saturation, or sending photos or video assessment to look for conjunctival pallor 19 as an indicator of anemia (EC). • If lab services are not the safest option during the pandemic, a reliable alternative is smartphone-based evaluation of conjunctival pallor. 19 • There is no literature available regarding the accuracy of screening for anemia with symptoms, but screening assessment of the patient is recommended with questions regarding common symptoms of anemia (shortness of breath, dizziness, chest pain, headache, lightheadedness, etc.) (EC). • Most physicians advocate for at least two medical treatments before considering hysterectomy. 15 Medical treatment should be given priority, particularly during this pandemic (EC). • The progestin-only regimen of oral medroxyprogesterone acetate 20 mg three times per day for 1 week, then 20 mg daily for 3 weeks is effective in acute bleeding (based on one RCT), 14 [25] [26] [27] • No data guide the role of GnRH agonists in the management of AUB. 14 During the current pandemic, oral GnRH agonists with add-back therapy could be considered for patients awaiting surgery, specifically in patients with known fibroids (EC). • Endometrial sampling is not necessary for all women with acute AUB but should be considered in women aged 45 years and over, who have risk factors for hyperplasia, or women who have failed conservative management. 14 Even among patients with these risk factors, urgent sampling is not needed in hemodynamically stable patients and could be postponed during the pandemic (EC). • Less invasive and safer office-based or outpatient procedures for AUB, including magnetic resonance-guided focused ultrasound and uterine artery embolization, are equally efficacious from the patients' perspective to hysterectomy and may be offered to women who require urgent interventions to address acute bleeding during this pandemic (EC). • Hysterectomy for stable patients with AUB is not currently advocated due to restrictions on elective surgery during the COVID-19 pandemic (EC). 28 Two separate searches were conducted for pelvic pain and endometrio- • There is no literature guiding the initiation or use of narcotics for CPP or other pelvic pain disorders via telemedicine, but we recommend against initiation of narcotics for CPP without guidance from a pain specialist (EC) due to the fact that narcotics are generally considered a controversial last resort therapy for this disorder. 72 The combined searches yielded 1209 citations. These were screened singly in full by five team members. Among these, 62 citations were screened in, which were rescreened by two team members who selected 15 for further review, all of which were successfully retrieved. Four articles were rejected for being populations not of interest. In total, 11 articles were extracted for pertinent data. These included one prospective cohort study, 73 two comparative studies, 74,75 one retrospective cohort study, 76 five cross-sectional studies, 77-81 one qualitative study, 82 and one literature review. 83 We further extrapolated treatment strategies from expert reviews on standard clinical evaluation and treatment that could be used in telemedicine. 84-86 • If there is concern for STIs based on sexual history or symptoms, consider empiric therapy for chlamydia, gonorrhea, and possible coinfection with Trichomonas vaginalis (EC). • • HSV is the most common cause of genital ulcers. 83 The combined searches yielded 2641 citations. These were • In lieu of the ability to perform a physical examination, telemedicine may provide a safe and cost-effective option for providers to be able to assess pain, need for analgesia, return to normal function (urinary, gastrointestinal, activities of daily living), and identify complications needing an in-person visit (EC). • Based on limited evidence, telemedicine may lead to similar or improved patient-related outcomes compared to in-person postoperative care. 99 Telemedicine could be utilized to supplement usual postoperative care and limit the number of visits during the pandemic. • Internet-based programs to assist in postoperative recovery after hysterectomy and laparoscopic adnexal surgery are cost-effective and may shorten recovery time. 93, 98 • Surgical pathology results can be reviewed over the telephone/video (EC). • Providers may consider extending pelvic rest in patients who are not able to be seen in person for evaluation of vaginal cuff and/or vaginal/vulvar incision (EC). The strengths of the present review include the use of standardized expedited evidence review methods as well as the author team's experience conducting systematic reviews and developing clinical practice guidelines and their varied and advanced expertise in gynecologic practice. The main limitations to the present review are its rapid nature, the small number of high-quality studies, the sparse evidence regarding many of the pertinent clinical questions arising in these unprecedented times, and the fact that the expedited review methods may have missed some important studies. Further, the expedited review did not formally assess the quality of evidence and risk of bias as is routine in a more formal systematic review. The reviews were focused on telemedicine, which largely did not consider special circumstances related to care during pandemics. For practical reasons, the reviewed evidence base was restricted to English-language publications that were readily available. The preponderance of recommendations is based on expert consensus and/or on one or two studies only. Literature and expert-based guidance has been provided for gynecologists as they navigate the use of telemedicine. However, the COVID-19 pandemic is evolving rapidly and, as more data become available, it is impossible to forecast how this will impact the management of common gynecologic conditions in the months to come. It is clear that telemedicine can play a key role in infection prevention and continuity of care in the administration of quality gynecologic care during the pandemic. CLG, EMB, AAD, RS, CKW, PCJ, SOA, JHK, MDT, ASG, JGK, DTGH, DS, SEP, and KVM were responsible for protocol, project development, data collection or management, data analysis, manuscript writing/editing; GA was responsible for project development, data collection or management, data analysis, manuscript writing/editing. Collaborative Research in Pelvic Surgery Consortium (SGS CoRPS) and Systematic Review Group (SRG). Funding provided by the Society of Gynecologic Surgeons (SGS) supports assistance by methods experts in systematic reviews and other logistics. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) Telemedicine, telehealth, and mobile health applications that work: Opportunities and barriers Telehealth interventions to improve obstetric and gynecologic health outcomes: A systematic review Implementing telehealth in practice. ACOG committee opinion summary, number 798 A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: Review of existing evidence Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement Effective treatment of heavy and/or prolonged menstrual bleeding with an oral contraceptive containing estradiol valerate and dienogest: A randomized, double-blind Phase III trial A randomized controlled trial of daily text messages versus monthly paper diaries to collect bleeding data after intrauterine device insertion Mobile application vs paper pictorial blood assessment chart to track menses in young women: A randomized cross-over design Health education using telephone and WeChat in treatment of symptomatic uterine myoma with highintensity focused ultrasound Surgical intervention versus expectant management for endometrial polyps in subfertile women Acute uterine bleeding unrelated to pregnancy: A Southern California Permanente Medical Group practice guideline Current management of endometrial hyperplasia-a survey of United Kingdom consultant gynaecologists Disposable platform provides visual and color-based point-of-care anemia self-testing Let's Talk Period! Preliminary results of an online bleeding awareness knowledge translation project and bleeding assessment tool promoted on social media Quality of medical information about menorrhagia on the worldwide web Non-invasive detection of anaemia using digital photographs of the conjunctiva Quality information about uterine fibroids on the internet Evaluation of smartphone menstrual cycle tracking applications using an adapted APPLICATIONS scoring system Quality-of-life assessment of fibroid treatment options and outcomes Thromboembolic risk and anticoagulant therapy in COVID-19 patients: Emerging evidence and call for action Prominent changes in blood coagulation of patients with SARS-CoV-2 infection Changes in blood coagulation in patients with severe Coronavirus Disease 2019 (COVID-19): A meta-analysis Joint Statement on Elective Surgeries Providing a mindfulness app for women with chronic pelvic pain in gynaecology outpatient clinics: qualitative data analysis of user experience and lessons learnt Internet-based guided self-help for vaginal penetration difficulties: Results of a randomized controlled pilot trial Effectiveness of appbased self-acupressure for women with menstrual pain compared to usual care: A randomized pragmatic trial Can menstrual health apps selected based on users' needs change health-related factors? A double-blind randomized controlled trial Development and evaluation of an E-health system to care for patients with bladder pain syndrome/interstitial cystitis Health education and symptom flare management using a videobased m-health system for caring women with IC Reliability and validity of self-reported symptoms for predicting vulvodynia The cost-effective, but forgotten, medical endometriosis therapy: A prospective, quasirandomized study on progestin therapy. Facts Views Vis Obgyn Quality of information on the internet related to bladder pain syndrome: A systematic review of the evidence Googling endometriosis: A systematic review of information available on the Internet Evaluation of a multisite telehealth group model for persistent pain management for rural/remote participants Should you search the Internet for information about your acute symptom? Online information on dysmenorrhoea: An evaluation of readability, credibility, quality and usability Therapeutic affordances of online support group use in women with endometriosis Towards remote assessment and screening of acute abdominal pain using only a smartphone with native accelerometers Endometriosis resources Kennedy Shriver National Institute of Child Health and Human Development The Endometriosis Association. Myths & Facts About Endometriosis Hormone treatment for endometriosis symptoms -what are my options? Interstitial Cystitis -IC Symptoms Treatments, Pain And Causes Home -Interstitial Cystitis Association Validating the SF-36 health survey questionnaire: new outcome measure for primary care Measuring health-related quality of life Health-related quality of life measurement in women with common benign gynecologic conditions: A systematic review Quality of life instruments in studies of chronic pelvic pain: A systematic review Development of the Short Form Endometriosis Health Profile Questionnaire: the EHP-5 The Endometriosis Impact Questionnaire (EIQ): a tool to measure the long-term impact of endometriosis on different aspects of women's lives Mindfulness-based stress reduction as a novel treatment for interstitial cystitis/bladder pain syndrome: a randomized controlled trial Intra-vaginal diazepam for high-tone pelvic floor dysfunction: a randomized placebo-controlled trial of Obstetricians and Gynecologists' Committee on Gynecologic Practice, American Society for Colposcopy and Cervical Pathology (ASCCP) Chronic pelvic pain. ACOG practice bulletin, number 218 Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder: A Double-Blind, Randomized, Placebo-Controlled Trial American Urological Association. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment Pentosan Polysulfate-Associated Macular Disease in Patients With Interstitial Cystitis Phenotypic Spectrum of Pentosan Polysulfate Sodium-Associated Maculopathy. A Multicenter Study 760: dysmenorrhea and endometriosis in the adolescent 110: noncontraceptive uses of hormonal contraceptives Practice bulletin no. 114: management of endometriosis Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion ESHRE guideline: management of women with endometriosis Chronic pelvic pain in women Home screening compared with clinic-based screening for sexually transmitted infections Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis Home Self-Collection by Mail to Test for Human Papillomavirus and Sexually Transmitted Infections Telephone triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms The diagnosis of chlamydia, gonorrhoea, and trichomonas infections by self obtained low vaginal swabs, in remote northern Australian clinical practice Can e-technology through the Internet be used as a new tool to address the Chlamydia trachomatis epidemic by home sampling and vaginal swabs? Chlamydia trachomatis age-specific prevalence in women who used an internet-based self-screening program compared to women who were screened in family planning clinics Trichomonas vaginalis infection in women who submit self-obtained vaginal samples after internet recruitment Female users of internet-based screening for rectal STIs: descriptive statistics and correlates of positivity The use of focus groups to design an internet-based program for chlamydia screening with self-administered vaginal swabs: what women want Determining the cause of vulvovaginal symptoms Noncandidal vaginitis: a comprehensive approach to diagnosis and management Recurrent vulvovaginal candidiasis Expedited partner therapy Everlywell: Home Health Testing Made Easy -Results You Can Understand Clinical characteristics of 138 hospitalized patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan Personalised perioperative care by e-health after intermediate-grade abdominal surgery: A multicentre, single-blind, randomised, placebo-controlled trial A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: Results of a multicentre randomised trial Telephone advice to gynaecological surgical patients after discharge Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: Cluster controlled trial with randomised stepped-wedge implementation Evaluation of surveillance for surgical site infections in Thika Hospital Process evaluation of a multidisciplinary care program for patients undergoing gynaecological surgery Automated patient assessments after outpatient surgery using an interactive voice response system Diagnosis of adverse events after hysterectomy with postoperative self-care web applications: A pilot study Cost-effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: Economic evaluation alongside a steppedwedge cluster-randomised trial The effect of perioperative E-health interventions on the postoperative course: A systematic review of randomised and non-randomised controlled trials ACOG. COVID-19 FAQs for Obstetrician-Gynecologists, Gynecology ACOG. COVID-19 FAQs for Obstetrician-Gynecologists Onc Considerations During COVID-19 ASBrS and ACR Joint Statement on Breast Screening Exams During the COVID-19 Pandemic Recommendations for Prioritization, Treatment and Triage of Breast Cancer Patients During the COVID-19 Pandemic: Executive Summary Society of Breast Imaging Statement on Breast Imaging during the COVID-19 Pandemic ASGE. Gastroenterology professional society guidance on endoscopic procedures during the COVID-19 PANDEMIC COVID-19) infection and abortion care Joint Statement on Abortion Access During the COVID-19 ?_id=43CF0 73F75 B0407 88256 7D8C2 50A2A 76&_z=z. Accessed Contraception in the Time of COVID-19 -Health Reproductive No Touch Medication Abortion Workflow -Reproductive Health Access Project Contraceptive Care During COVID-19 | Beyond the Pill What Family Planning Providers Can Do to Meet Client Needs During COVID-19. Family Planning National Training Center Appendix S1. Literature review methods.Appendix S2. Postoperative telemedicine questionnaires.