Clinical Applications of Telemedicine in Gynecology and Women’s Health

Telemedicine and telehealth (TM/TH) are beneficial for patients living in remote and rural areas with limited medical resources. It is also practical for patients with rare or complex medical problems for which only subspecialists can recognize and treat. Local practitioners can get guidance and advice from a distant expert.

The definition of telehealth is different from telemedicine because it contains a broader spectrum of distant healthcare services that involves remote “nonclinical” services. For example, training health care providers, administrative meetings, medical education to providers and patients, in addition to clinical services, are examples of telehealth, whereas telemedicine only involves remote clinical services.

The American Telemedicine Association and the World Health Organization (WHO) use the 2 terms interchangeably, focusing on the “remote” delivery of health care services as a critical factor. The history of telemedicine dates back to the 1950s.

WELL WOMAN’S VISIT AND PREVENTIVE CARE

Important features of a well-woman visit are a discussion of reproductive plans, care for women across her lifespan, and regular care for the perimenopausal and postmenopausal woman. The well-woman visit consists of a screening for underlying medical conditions, maintenance of healthy life with preventive care, management of women at reproductive age with PCC, and referral to another specialist as needed.

Indications for referral would include medical problems that require monitoring, history of pregnancy-related complications, and infertility. PCC is an excellent opportunity to counsel the patient on how to maintain a healthy lifestyle, improve her overall well-being, and provide preventive services.

A head-to-toe physical examination was traditionally required during the wellwoman visit. There are several instances whereby telemedicine can be a beneficial adjunct to the traditional physical examination. For example, the patient’s history and review of system (ROS), follow-up of blood work, and additional screening tests are ideal for telemedicine.

PRECONCEPTION COUNSELING

An important component of the well-woman visit for a reproductive-aged woman is a discussion about her life plan on reproduction. The patient can undergo screening and tests depending on her history, symptoms, and risk factors. This time is the ideal time when PCC, infertility assessment, health care related to sexually transmitted diseases, and a discussion on the full range of contraceptive options that are available can take place.

The goal of PCC is not just to help a patient achieve pregnancy but to establish a favorable pregnancy outcome with a healthy mother and a baby PCC is an extension of a well-woman visit. A detailed discussion on lifestyle habits, body weight and nutrition, screening tests for antibody status that require vaccination as well as screening for a medical condition should be done in addition to routine gynecology testing.

FAMILY PLANNING

Family planning is another essential component of the well-woman visit. When a woman reaches an age when contraception is important, it is crucial to counsel, educate, and provide the ideal form of contraception to each woman to maintain her optimal reproductive health.

Nonetheless, getting an oral contraceptive (OCP) prescription has been the one of the greatest barriers to this population because of the difficulty in accessing physicians. According to a study in 2016, about 29% of women had difficulties in obtaining OCP prescriptions or refills. The most common reasons were difficulty meeting a doctor, having no PCP or gynecologist, busy work schedule, and high medical costs.

Efforts to expand OCP prescription availability could be achieved by allowing a pharmacist to prescribe an OCP or making OCPs nonprescription drugs. Making OCPs nonprescription is realistically not possible because of the risks that could be caused by uncontrolled use of hormonal agents.A newer effort to expand accessibility to OCPs is by using TM/TH to screen for medical conditions and provide a prescription.

INFERTILITY WORKUP

Team work is important for a comprehensive infertility workup. Reproductive endocrinology and infertility (REI) specialists, and PA, NP, embryologist, endocrine laboratory technician, nutritionist, psychiatrist, or psychologist are all part of the team that assists the women dealing with the physical and emotional aspects of infertility.

Infertility treatment can involve multiple office visits, especially when patients are undergoing assisted reproductive technology. Currently, infertility management is generally not covered by most insurance carriers, which imposes a heavy burden in terms of time and money on the infertile couple.

TM/TH can be helpful by reducing on-site visits when the physical encounter with the health care provider is not necessary. Infertility management not only involves the general health management of the infertile woman but also may involve a genetic evaluation, mental illness counseling, detailed discussion about treatment options, laboratory tests, hysterosalpingography (HSG), ultrasound (US), and prescriptions for medications and injections before egg retrieval or embryo transfer procedures.

TELERADIOLOGY: ULTRASOUND

US is by far the safest, least invasive, and cost-effective imaging modality in gynecology. Conventional transvaginal 2-dimensional (2D) US is used to evaluate pelvic anatomy for suspected abnormalities in the uterus, fallopian tubes, and ovaries. Uterine leiomyoma, endometrial polyps, and ovarian or fallopian tube pathologic conditions can be detected with US. Recent advances in 3-dimensional and real-time 4-dimensional (3D/4D) US have added value to the evaluation of uterine anomalies or endometrial lesions.

Telesonography has been used with obstetric US since 1997. Recent technology has made the assessment of the fetal heart remotely with real-time fetal echocardiogram using 4D spatiotemporal image correlation possible. In gynecology, telesonography has had limited use.

Although it may be early to incorporate TM/TH into routine clinical gynecologic practice, there has been a recent move toward using self-operated endovaginal telemonitoring and 3D/4D US for the assessment of the uterus in place of the traditional HSG in infertility patients. These studies have shown that using TM/TH technique was as accurate as the conventional in-person method although more evidence-based studies need to be conducted to be applied in clinical practice.

CERVICAL CANCER SCREENING AND COLPOSCOPY

Cervical cancer was the leading cause of cancer death for women in the Unites States. However, in the past 40 years, the number of cases and the number of deaths from cervical cancer have decreased significantly. This decline is the result of many women getting regular pap tests and human papillomavirus (HPV) testing, which can find a cervical precancerous lesion before it turns into cancer.

However, in developing countries with low medical resources, cervical cancer is still a major health challenge, with a high incidence and a high number of cancer-related deaths. The problems in the developing countries are due to a lack in cervical cancer screening and follow up, problems with interpretation of the results of screening, and a lack of preventative education.

Following screening for cervical cancer with pap smears and/or HPV testing, colposcopy with or without biopsy may be indicated in some patients. Colposcopy is a simple method to diagnose cervical pathologic condition with a low-power binocular microscope and a high-intensity light source that can magnify the cervix.

MEDICAL ABORTION

Another essential aspect of family planning is the termination of pregnancy (TOP). According to WHO, the first-trimester TOP can be achieved on an outpatient basis by midlevel providers and by having the patient self-administer the medication and self-assess the abortion completeness at home There are limited data on the safety of medical abortion using TM/TH, but that data showed reassuring safety outcomes.

ACOG defines a medical abortion as the TOP before 10 weeks of gestation using mifepristone and misoprostol.The efficacy of this regimen is approximately 92% in women with a gestation up to 49 days.

The first medical abortion using telemedicine occurred in 2008 at the Planned Parenthood of the Heartland facility in Iowa.Using telemedicine as a means of TOP has increased the proportion of medical abortions undertaken before 12 weeks of gestation. TOP before 12 weeks is more likely to result in a complete abortion. Studies have reported that medical abortions via telemedicine are as likely to be successful and to have a similar risk for adverse events as procedures done on site.

MENTAL ILLNESSES IN GYNECOLOGY

Mental illness in gynecology can benefit from the use of TM/TH. The prevalence of depression/anxiety is common in infertile women. Infertile women have comparable levels of anxiety and depression to those with heart disease, human immunodeficiency virus, or metastatic cancer.

Interventions that have included emotional support have been well researched and have shown favorable outcomes in this population. Psychological interventions may be offered in many forms, including individual counseling and therapy.

Programs for infertile women that have provided counseling, personal attention, and support have shown a reduction in depression/anxiety and an increase in the pregnancy rate. Recently, psychological interventions offered online have become popular. Studies comparing patients who received psychoeducational support through the Internet with patients who received no intervention showed that the intervention group had lower levels of depressive/anxiety symptoms and improved pregnancy rates after the intervention. This finding suggests that TM/TH maybe helpful in treating for mental illness in gynecology.

PREOPERATIVE COUNSELING, POSTOPERATIVE CARE, AND TELESURGERY

TM/TH is currently used for preoperative and postoperative consultations, education on surgical procedures to patients, and teleconferencing locations with limited medical resources, which has enabled patients to be able to make decisions on site rather than having to be transferred to larger facilities for education and consultations. Routine postoperative care, using telemedicine, has been reported to be safe and effective.

TM/TH has allowed patients to be seen by specialists in distant sites without traveling to those sites, saving significant time and expense and resulting in increased patient satisfaction and reducing overall total medical cost. Telemedicine, using videoconferencing, could also help physicians to assess minor complications and reduce unnecessary hospital visits.

 

Author: Siwon Lee, MD, PhD, Wilbur C. Hitt, MD, FACOG FACOEM

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