Behaviors

Pelvic ultrasound should be included in a well-woman exam and requested for pelvic pain, suspected endometriosis, or evaluation of PCOS morphology, fibroids, septum, cysts, and possible endometrioma. If a doctor refuses to order it for pain, seek another doctor or another imaging site.

She presents sex 3–4 times per week as the benchmark trying-to-conceive frequency, noting that in her example about 50% conceive within 6 months and 90% within 1 year.

For people with PCOS trying to get pregnant, ask a doctor about letrozole as a first-line treatment before Clomid.

For people with PCOS trying to get pregnant, ask a doctor about Clomid after letrozole.

Treat painful periods as a possible sign of endometriosis rather than normal menstrual discomfort, especially if the pain disrupts daily life or school.

Painful sex with deep penetration may be a sign of endometriosis.

Persistent bloating around and beyond periods may be a sign of endometriosis.

Painful bowel movements may be a sign of possible endometriosis and should be considered in evaluation.

If recurrent bladder symptoms are repeatedly treated with antibiotics despite negative cultures, consider endometriosis until proven otherwise.

Laparoscopic excision/resection is the gold-standard diagnosis and treatment for endometriosis, especially when pain is severe or hormonal suppression fails.

Cut out lesions rather than burning them, since burning is only a temporary fix and the pain can return.

Avoid estrogen-containing birth control for endometriosis, because estrogen can cause the implants to grow.

Limit estrogen-suppressing pills to no more than 2 years because of the risk of bone loss.

After endometriosis surgery, she places a progesterone IUD before sending patients home.

For stage 3 or 4 endometriosis, she may add GnRH antagonists after surgery for 6 months up to 2 years, depending on stage and symptoms.

For patients with endometriosis after delivery, place a progesterone IUD at the postpartum visit, around 6 weeks postpartum, to help suppress recurrence.

Women should calculate their lifetime breast cancer risk using the Tyrer-Cuzick tool, and this should be known routinely. The result can guide decisions about earlier imaging.

If lifetime breast cancer risk is 20% or higher, start breast imaging at age 30 instead of waiting until age 40.

For women with dense breasts and a high risk of breast cancer, add breast ultrasound to mammography.

Women with a lifetime breast cancer risk of 20% or more should ask for a breast MRI in addition to a mammogram and ultrasound.

Women with family history of breast, ovarian, pancreatic, prostate, and related cancers should ask whether they qualify for genetic cancer testing.

For very high breast cancer risk, undergo imaging every 6 months, alternating mammogram/ultrasound with MRI.

She presents prophylactic double mastectomy as an option for women at very high breast cancer risk, described as north of 35% lifetime risk.

In young patients with PCOS, include ApoB testing as part of cardiovascular risk assessment.

In young patients with PCOS, check lipoprotein(a) status.

For perimenopausal women, check APOE4 status to assess dementia risk.

Discuss or check bone density as part of a proper well-woman exam.

She includes colonoscopy discussion as part of comprehensive well-woman care.

If you have endometriosis and are trying to get pregnant, have had a miscarriage, or have a personal or family history of autoimmune disease, ask for a full autoimmune panel.

Refer patients with PMDD to a psychiatrist to assess for underlying chronic anxiety or depressive disorders.