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Health maintenance for women of reproductive age includes counseling and screening tests that have been demonstrated to prevent disease and improve health. This article focuses mainly on conditions that are more common in women or have a unique impact on female patients. Family physicians should be familiar with evidence-based recommendations for contraception and preconception care and should consider screening patients for pregnancy intention. The American Academy of Family Physicians recommends against screening pelvic examinations in asymptomatic women; the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to make a recommendation for or against screening pelvic examinations. The USPSTF recommendations for women in this age group include screening for obesity and other cardiovascular risk factors, depression, intimate partner violence, cervical cancer, HIV, hepatitis C virus, tobacco use, and unhealthy alcohol and drug use as part of routine primary care. Breast cancer screening with mammography is recommended for women 50 years and older and should be individualized for women 40 to 49 years of age, although other organizations recommend earlier screening. Screening for sexually transmitted infections is based on age and risk factors; women younger than 25 years who are sexually active should be screened routinely for gonorrhea and chlamydia, whereas screening for syphilis and hepatitis B virus should be individualized. Immunizations should be recommended according to guidelines from the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices; immunizations against influenza; tetanus; measles, mumps, and rubella; varicella; meningococcus; and human papillomavirus are of particular importance in women of reproductive age. To have the greatest impact on health, physicians should focus on USPSTF grade A and B recommendations with patients.

Insomnia and sleep disorders affect one in four adults and significantly impact the quality of life of those affected. Older women face unique challenges to restorative sleep such as age-related changes to sleep architecture, perimenopausal symptoms, lower urinary tract symptoms, chronic medical conditions, mood disorders, and dementia. Sleep-related concerns should be explored by taking a detailed history, performing a relevant physical exam, and advising patients to keep a sleep diary for at least 2 weeks. Effective management of insomnia is multimodal and involves both nonpharmacologic and pharmacologic treatment strategies. Cognitive behavioral therapy for insomnia (CBT-I) should be offered as a first-line treatment strategy; sleep hygiene and relaxation training may have limited utility. The use of biofeedback is controversial. Medications can be incorporated with caution, keeping in mind the increased risk of side effects in older patients. Herbals/supplements may also be safely integrated as adjuvant therapies for interested patients. Medical providers should become familiar with available resources (websites, phone applications, patient handouts, and books) that can be utilized in the management of sleep-related complaints. It is important that medical providers employ shared decision-making and partner with the patient when choosing from various treatment strategies to optimize outcomes.

Introduction: Women’s health is only briefly explored in the preclerkship medical curriculum. Volunteering in student-run free clinics (SRFCs) increases clinical confidence; such service learning could bridge the gap between limited curricular offerings and student desire for exposure to women’s health topics. This study aimed to identify weaknesses in the women’s health preclerkship curriculum, build an educational intervention, and explore SRFCs as a teaching tool. Methods: We performed chart review of SRFC female patients to evaluate care. We held student focus groups to elicit feedback about the established curriculum. Based on this information, we devised a workshop to review practical skills. Participants attended the workshop, volunteered at SRFC, and completed surveys preintervention and at 3 months postintervention. A control group completed baseline and follow-up surveys. Results: We invited all 151 second-year students to participate; six attended the workshop and 21 served as control. There were no baseline differences between groups regarding age, prior experience with women’s health, confidence in relevant skills, and subjective readiness for clinical rotations; the control group had more men. After the workshop, intervention participants reported increased confidence in women’s health-related skills and in readiness for the OB/GYN rotation. Gains persisted at 3 months. Three of six students in the workshop group volunteered at SRFC; three of 12 in the control group volunteered. Conclusions: The addition of an interactive workshop to the existing preclinical curriculum on women’s health has lasting impact on subjective readiness for clinical clerkships. SRFC may be a useful addition to classroom learning. This initiative is student-led and reproducible, and could serve as an adjunct to established preclerkship curriculum.

Background and Objectives: Parenting during residency is increasingly common, and resident parents face unique demands on their time and emotional and cognitive resources. Physicians at all levels of training perceive negative impacts of parenting on career and family life. Surveys of program directors (PDs) in other specialties reveal concern about performance and quality of life of parenting residents. The primary aims of this study were to examine family medicine PDs’ perceptions of parenting residents’ performance and the adequacy of parenting support structures. Methods: Data were collected from the 2017 Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) Family Medicine Residency Program Directors survey. Directors provided the number and status of parenting residents and rated adequacy of parenting resources, resident performance, and impact of parenting on residents using a Likert scale. Results were compared between male/female PDs and male/female residents. Results: Response rate was 57.1%. Less than half of PDs reported adequate parenting support structures in their program (46%). Over 40% of PDs reported that 81%-100% of female residents who take parental leave end up extending their residency training, the most common response category. PDs did not report gender-based differences in performance of parenting residents. PDs most often reported significantly worse well-being for female parenting residents but perceived improved well-being of male parents. Conclusions: Less than half of family medicine PDs feel their program has adequate parenting resources. Female parenting residents commonly extend residency training. PDs perceive parenting negatively impacts well-being of female residents, but not male residents.

Background and Objectives: Adequate parental leave policies promote a supportive workplace environment. This study describes how US family medicine (FM) residency program parental leave policies compare to reported leave taken by residents and faculty. Methods: This is a descriptive study of questions from a 2017 Council of Academic Medicine Educational Research Alliance (CERA) survey of accredited US FM program directors. Results: The overall survey response rate was 54.6% (261/478). Paid maternity leave policies varied widely (0 to >12 weeks; mean=5.3 weeks for faculty and 4.5 weeks for residents); paid paternity leave ranged from 0 to 12 weeks (mean=2.7 weeks for faculty and 2.4 weeks for residents). Some FM programs reported offering residents (29.1%) and faculty (28.5%) no paid maternity leave; 37.2% offered residents and 40.4% offered faculty no paid paternity leave. Both female and male faculty took significantly less leave than was offered (maternity leave: faculty 0.6 weeks less, P

Rural communities in the United States have a shortage of primary care physicians. Women physicians are more likely than male physicians to choose primary care specialties but less likely to locate in rural areas. With an increasing proportion of women physicians, it is important to understand community characteristics that encourage their recruitment and retention. This qualitative study explored community characteristics that influenced successful rural practice. We conducted telephone interviews with 25 women family physicians in rural practice in the United States in 2012. Interviews continued until saturation of themes was reached. Data were analyzed using immersion and crystallization. Community themes associated with successful rural practice included: fit with the community; spouse/partner fit with the community; relationships with individuals; and relationships with the community. Family ties, training experience within the community, social networks, and investment in the community were positive factors, while political/cultural differences were negative. Community integration arose from compatibility between the physicians' goals and community characteristics, opportunities for a spouse/partner, friendships, and a feeling of community purpose. This information can be used by rural communities to recruit and retain physicians, and by physicians, medical students, and those who advise them to promote successful rural practice.

Atopic dermatitis (AD) is the most common skin disease encountered by pediatric primary care providers. To describe the knowledge, attitudes, and practices of primary care residents in the management of infectious aspects of pediatric AD, an anonymous web-based survey was offered to all residents in the pediatric and family medicine departments at 3 New York City hospitals. Eighty residents responded. Most (62%) reported seeing 5 to 14 patients with AD monthly. Twenty-seven percent reported obtaining cultures prior to prescribing oral antibiotics most of the time, while 8% reported doing so before giving topical antibiotics. Most respondents (60%) reported never/rarely recommending dilute bleach baths, and family medicine residents were significantly more likely to report never doing so (67% vs 16%, P < .001). Greater education on the use of cultures to guide treatment and potential benefits of dilute bleach baths is needed, especially given increasing antibiotic resistance.

PURPOSE Women family physicians experience challenges in maintaining work-life balance while practicing in rural communities. We sought to better understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction. METHODS Women family physicians practicing in rural communities in the United States were interviewed using a semistructured format. Interviews were recorded, professionally transcribed, and analyzed using an immersion and crystallization approach, followed by detailed coding of emergent themes. RESULTS The 25 participants described a set of strategies that facilitated successful work-life balance. First, they used reduced or flexible work hours to help achieve balance with personal roles. Second, many had supportive relationships with spouses and partners, parents, or other members of the community, which facilitated their ability to be readily available to their patients. Third, participants maintained clear boundaries around their work lives, which helped them to have adequate time for parenting, recreation, and rest. CONCLUSIONS Women family physicians can build successful careers in rural communities, but supportive employers, relationships, and patient approaches provide a foundation for this success. Educators, employers, communities, and policymakers can adapt their practices to help women family physicians thrive in rural communities.

Vaginitis is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Bacterial vaginosis is implicated in 40% to 50% of cases when a cause is identified, with vulvovaginal candidiasis accounting for 20% to 25% and trichomoniasis for 15% to 20% of cases. Noninfectious causes, including atrophic, irritant, allergic, and inflammatory vaginitis, are less common and account for 5% to 10% of vaginitis cases. Diagnosis is made using a combination of symptoms, physical examination findings, and office-based or laboratory testing. Bacterial vaginosis is traditionally diagnosed with Amsel criteria, although Gram stain is the diagnostic standard. Newer laboratory tests that detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity have similar sensitivity and specificity to Gram stain. Bacterial vaginosis is treated with oral metronidazole, intravaginal metronidazole, or intravaginal clindamycin. The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy; DNA probe testing is also available. Culture can be helpful for the diagnosis of complicated vulvovaginal candidiasis by identifying nonalbicans strains of Candida. Treatment of vulvovaginal candidiasis involves oral fluconazole or topical azoles, although only topical azoles are recommended during pregnancy. The Centers for Disease Control and Prevention recommends nucleic acid amplification testing for the diagnosis of trichomoniasis in symptomatic or high-risk women. Trichomoniasis is treated with oral metronidazole or tinidazole, and patients' sex partners should be treated as well. Treatment of noninfectious vaginitis should be directed at the underlying cause. Atrophic vaginitis is treated with hormonal and nonhormonal therapies. Inflammatory vaginitis may improve with topical clindamycin as well as steroid application.

Introduction The USA needs more rural physicians. Although women represent half of all US trained medical students, the rural physician workforce has remained predominantly male. Insight is needed into what makes rural practice attractive for women and which practice characteristics allow women physicians to practice successfully in rural areas. This study's purpose was to examine aspects of the practice environment that impact women physicians' professional satisfaction and commitment to rural medicine. Methods Twenty-five women family physicians practicing in rural areas of the USA were interviewed by phone using a semi-structured format. Transcribed interviews were analyzed using an immersion and crystallization approach. Emergent themes were identified, coded, and discussed until team consensus was attained. Interviews continued until saturation of themes was reached. Results Three themes emerged from the data, in relationship to practice and employment attributes that contribute to US women physicians' professional satisfaction and willingness to remain in a rural setting: professional relationships, practice characteristics, and support during times of transition. Participants placed high importance on professional relationships, both within and outside of their rural practice. Rural women physicians enjoyed practicing an expanded scope of care, valued loan repayment opportunities, and appreciated supportive practice partners. Importantly, women physicians who found themselves struggling to maintain rural careers often had experienced difficulty during times of practice transition, including maternity leaves. Conclusions Understanding practice attributes valued by successful rural women family physicians in the USA will help rural health systems, practices, and physicians-in-training to develop and evaluate opportunities that will best contribute to successful rural practice. Supporting women physicians during periods of practice transition may improve retention.

Electronic communication between physicians and patients is common but can carry risks to users--both patients and physicians. Little is known about electronic communication between physicians and patients and even less about electronic communication during residency. We studied knowledge and practices before and after a controlled test of a novel curriculum teaching e-mail communication with patients using residents and faculty in 16 family medicine residencies in the United States. Both faculty and residents showed a lack of knowledge of confidentiality and encryption, little familiarity with published guidelines for physician-patient e-mail, and noncompliance with documentation requirements before the curriculum was presented. Posttests revealed a greater improvement in knowledge and appropriate behaviors related to patient-physician e-mail in the intervention group compared to control sites (mean intervention increase is 13 points[t=-4.065, P.01], mean control increase is 5 points [t=-2.015, P.05]). An increased uncertainty about comfort with patient e-mail among intervention residents is an interesting result that could be due to heightened awareness of issues but limited time devoted to absorbing the topic. Suggestions for delivering the curriculum are provided.

Based on limited evidence, use of intrauterine devices (IUDs) is not contraindicated for women with HIV/AIDS (strength of recommendation [SOR]: C), multiple sexual partners (SOR: C), previous actinomyces colonization (SOR: C), most types of fibroids (SOR: C), or previous ectopic pregnancy (SOR: C). The risk to IUD users of pelvic inflammatory disease (PID) is similar to women using no contraception (SOR: B). Nulliparous women may experience increased insertion discomfort and higher rates of expulsion (SOR: B). IUD use of3.5 years is not associated with decreased fertility (SOR: B).

Question Is there an association between the amount and type of alcohol consumed during pregnancy and the risk of pre-term delivery? Study design Prospective cohort study. Main results Of 40, 892 pregnant women, 1880 (4.6%) had pre-term delivery. The adjusted relative risk of pre-term delivery in all women consuming 2–3.5 drinks per week was lower than in non-drinkers (RR 0.80, 95% CI 0.68 to 0.96). The risk was not statistically significant when only nulliparous women were included. Other levels of alcohol consumption were not associated with a statistically significant increased or decreased risk of pre-term delivery compared with non-drinkers except for nulliparous women who drank ⩾7 drinks per week (RR 2.91, 95% CI 1.29 to 6.55). There was no relationship between risk of pre-term delivery and the preferred type of alcohol (wine, beer, spirits or mixed). Authors’ conclusions Consumption of 7 or more drinks per week was associated with an increased risk of pre-term delivery in woman having their first child. Pre-term delivery was not affected by type of alcohol intake.