Introduction

The COVID-19 pandemic has represented a major impact to health systems and the society in general all around the world, and it has forced many changes that will affect our practice for an amount of time that is still hard to predict.

With obstetrics comprising a major component of priority healthcare, most gynecology patients who are planned for elective surgery can be offered medical treatment, with exceptions in the form of patients with menorrhagia, causing severe anemia, postmenopausal bleeding or malignancy.

Routine screening of patients for COVID-19 with clinical, laboratory and radiological investigations is essential before consulting any gynecologic patient in person.

In this article, we have mainly reviewed the guidelines provided by American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetrics and Gynecology (RCOG), as the guidelines specific to gynecology practice are limited.

Triaging Gynecological Patients

ACOG recommend prioritizing gynecologic patients based on local availability of resources and patient population.1

Patients with conditions like severe gynecologic infections, suspected ectopic pregnancy, and major postoperative complications requiring admission should be advised to consult in person.

Women who require contraception advice, follow-up of asymptomatic ovarian cyst, and routine postoperative checkup can avail of these services via teleconsultation.1

Routine Gynecologic Checkup

Patients requesting for a routine gynecologic check up can be deferred until the burden of the pandemic subsides.1

Recommended Outpatient Practices

The recommendations to modify routine practice are as follows1:

• Universal mask policy for healthcare professionals, patients, and visitors.

• Restricting the number of attendants.

• Social distancing to be practiced in elevators, waiting rooms, and during examination clinic spaces.

• Hand sanitizing options for patients and staff members to be used before entering the clinic.

• Offering teleconsultation wherever possible.

• Planning patient visits by prior appointment to prevent crowding of waiting area.

• Minimize visits by preplanning the investigations the patient might need and addressing them in the same visit.

Benign Gynecological Conditions

Postmenopausal Bleeding

Women with postmenopausal bleeding (PMB) can be managed through telecommunication to confirm the symptom and assess the urgency of in person consultation. The patient can be assessed for symptoms of COVID-19 and advised accordingly.

Women who have suspected or confirmed COVID-19 should be advised to access appropriate care and consult further after they are not infectious and retested. However, the risk of delayed treatment should be considered, especially in high risk of malignancy.

Evaluation of postmenopausal women should comprise a speculum examination as a normal cervix in women with a negative cervical smear excludes cervical cancer.

Transvaginal ultrasound (TVS) with measurement of the endometrial thickness (ET) should be performed, and women with an ET of < 4 mm on TVS can be reassured, as the risk of endometrial malignancy is very minimal. If the ET is > 4 mm, endometrial sampling should be advised, based on the resources available. If the histopathology is inadequate or benign, patient can be reassured.

There is no increased risk of transmission of SARS-CoV-2 to healthcare professionals during a hysteroscopy, blind endometrial biopsy, and polypectomy. Best practice is to minimize contamination from blood, urine, genital tract fluids, and feces during any genital tract procedure.

Simultaneous insertion of levonorgestrel intrauterine device can be considered during endometrial biopsy or hysteroscopy in selected cases.2

Cancer Cervix Screening by Colposcopy

During the COVID-19 crisis, only women with a recent cervical smear suggesting high grade, moderate neoplasia in endocervical cells or possible glandular neoplasia/invasive disease should be seen for colposcopy.

RCOG consensus states that in asymptomatic women, gloves, apron and an appropriate mask be worn for colposcopy consultation and examination.

A minimum number of staff should be present during procedures. A serviced smoke evacuator must be used for laser loop excision procedures. Laser ablation and excision should not be used due to vaporization and aerosol generation.

In women with suspected or confirmed COVID-19 infection, colposcopy assessment should be postponed until symptoms resolve or the woman has tested negative. Precautions should be taken by instructing women not to cough during the procedure to facilitate bringing the cervix into view.

If women have symptoms suggestive of cervical cancer and are symptomatic of COVID-19, patient should be seen at the end of OPD and preferably in a separate COVID designated area. The colposcopy team should wear full personal protective equipment (PPE) during consultation and examination.3

Elective Gynecological Surgeries

Elective procedures should be postponed and patients offered alternative conservative measures when possible. Patients with abnormal uterine bleeding and menorrhagia, resulting in severe anemia, can be taken up for surgery after appropriate screening for COVID-19 infection. All operating room staff should be following universal precautions with adequate PPE to minimize exposure and risk of infection.1 2

Contraception

Contraception care needs to be simplified in accordance with the current pandemic demanding enormous resources. Teleconsulting can be done in women who can self-administer medication and who need refill of their prescription.

For patients requesting emergency contraception, long-acting reversible contraceptive methods (LARC) should be offered like intrauterine contraceptive device; implants and permanent contraception can be offered when possible. If there is inability to immediately offer the above, the patient can be given oral contraceptives for self-administration during this period of delay. Women with LARC scheduled for removal can be postponed and counselled for extended usage and benefits.1 4

Gynecologic Oncology

The Society of Gynecologic Oncology recommends continuing evaluation and treatment of patients who are newly diagnosed with malignancy, prioritizing higher grade pathology, patients with recurrent cancer and symptoms that require immediate treatment.5

Among patients with ovarian cancer, neoadjuvant therapy can be considered to delay surgery. The dose of chemotherapy needs to be carefully adjusted to minimize neutropenia.

Women diagnosed with endometrial cancer, who are at a higher risk of perioperative morbidity, can be offered alternative treatment options like hormonal therapy for intraepithelial neoplasia/low-grade malignancy.

The treatment of patients diagnosed with preinvasive cervical malignancy can be deferred. Women with operable disease can be taken up for surgery, as planned, and patients with inoperable disease should be treated with therapeutic chemoradiation as required

Conclusion

To conclude, the current COVID-19 pandemic has significantly changed our day-to-day practice. In this scenario, safety of the healthcare staff is as important as the patient’s safety. Therefore trying to implement the above mentioned guidelines in out patient can reduce the risk of exposure to covid 19 for the treating physician, hospital staff and other patients attending the clinic. Proper screening, both clinical and by laboratory, and radiological investigations are essential in triaging patients with high risk of active COVID-19 disease. The take-home message is that whenever applicable, medical or nonsurgical treatment should be preferred, and surgery should be postponed while balancing the risk of disease progression with treatment delay.