Intern Ready: Ob/Gyn

Placing an IUD is one of the most common procedures you'll be asked to help with as an intern — and one of the easiest to feel unprepared for if you haven't reviewed the device differences ahead of time. In this episode, Dr. Lillian Chen breaks down the five IUDs you'll encounter, how their insertion mechanics differ, what changes in the postpartum and postabortion setting, and the high-yield points you're likely to be tested on. IUD Types at a Glance Mirena — LNG-IUD, 52 mg levonorgestrel, FDA-approved for 8 years (effective 8+ years), 4.4 mm tube, 6–10 cm uterine sound range. Lighter bleeding/amenorrhea common. FDA-approved for heavy menstrual bleeding (HMB). Liletta — LNG-IUD, 52 mg levonorgestrel, FDA-approved for 8 years (effective 8+ years), 4.8 mm tube, 6–10 cm uterine sound range. Lighter bleeding/amenorrhea common. Uses a different inserter than the Bayer products. Kyleena — LNG-IUD, 19.5 mg levonorgestrel, FDA-approved for 5 years, 3.8 mm tube, 6–10 cm uterine sound range. Less bleeding and less amenorrhea than Mirena; smaller frame. Skyla — LNG-IUD, 13.5 mg levonorgestrel, FDA-approved for 3 years, 3.8 mm tube, 6–10 cm uterine sound range. Regular menses more common; good option for smaller uterine cavities. Paragard — Copper T380A (hormone-free), FDA-approved for 10 years (effective 12+ years), ~4.7 mm tube, 6–9 cm uterine sound range. Heavier menses/cramping. Insertion Pearls Mirena, Kyleena, and Skyla use the Bayer one-handed slider system and have very similar deployment mechanics. Liletta has a unique loading sequence and should be reviewed separately before insertion. Paragard requires loading the arms into the insertion tube and is often considered the least intuitive inserter for trainees. Always confirm fundal placement before release. Routine antibiotic prophylaxis is not recommended. Postplacental & Postabortion Pearls Immediate postpartum insertion is safe and effective but has higher expulsion rates. IUDs can be placed immediately after first- or second-trimester abortion when no contraindication exists. Counsel patients that expulsion risk is higher after postpartum placement. Board-Style High-Yield Points Copper IUD is the most effective form of emergency contraception. LNG-IUDs reduce menstrual blood loss and dysmenorrhea. Mirena is FDA-approved for heavy menstrual bleeding. Amenorrhea rates increase with higher-dose LNG-IUDs. Same-day insertion is appropriate when pregnancy can reasonably be excluded. Resources: Mirena — Insertion and Removal Kyleena — Insertion and Removal Skyla — Insertion and Removal Liletta — Insertion and Removal Paragard — Placement and Removal ACOG Paragard Insertion Animation ACOG Kyleena Insertion Animation Topics to Review Over Time: IUD removal technique and management of a lost or malpositioned string Managing IUD-related bleeding and cramping complaints Contraindications and medical eligibility criteria (US MEC) for IUD placement Counseling on non-contraceptive benefits (HMB, dys...

Preeclampsia complicates roughly 10% of pregnancies and accounts for up to 9% of pregnancy-related deaths in the U.S. — which makes it one of the highest-stakes diagnoses you'll manage as an intern. In this episode, Dr. Anna Jarvis walks through the hypertensive spectrum, how to get the diagnosis right, when to worry about severe features or HELLP syndrome, how to rule out the mimics, and how fast you need to move when things get acute. Resources: ACOG Practice Bulletin No. 222 — Gestational Hypertension and Preeclampsia (2020) Magee LA, Nicolaides KH, von Dadelszen P. "Preeclampsia." N Engl J Med. 2022;386:1817–1832 Sibai BM. "Imitators of Severe Preeclampsia." Obstet Gynecol. 2007;109(4):956–66 ACOG/SMFM Practice Advisory — Low-Dose Aspirin Use for Prevention of Preeclampsia (2021, reaffirmed) Topics to Review Over Time: Chronic hypertension in pregnancy: antihypertensive selection and BP targets Low-dose aspirin prophylaxis — who qualifies and when to start Eclampsia: seizure management and post-seizure stabilization Postpartum antihypertensive management and medication safety in lactation Long-term cardiovascular risk counseling after a hypertensive pregnancy disorder About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Anna Cardall Jarvis, MD – First-year Maternal-Fetal Medicine fellow at The Johns Hopkins Hospital, where she completed her residency in Obstetrics and Gynecology. Her clinical and research interests focus on hypertensive disorders of pregnancy, maternal cardiovascular disease, and improving outcomes for pregnant patients with chronic medical conditions. She is also actively involved in medical education, teaching and mentoring medical students and residents. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

Gynecologic oncology clinic can feel intimidating for a new intern — the patients are complex and the terminology is dense. In this episode, Dr. Liang breaks down the three visit types you'll encounter (new patient, chemo clearance, and surveillance), what to prechart, and what your role is as the resident in each one. Visit Type 1: New Patient Visits BEFORE CLINIC — PRECHARTING Ask: Why are they here? Confirmed cancer diagnosis (pathology in hand)? Concern for cancer only — no pathology yet? Seeking second opinion after treatment elsewhere? Hereditary cancer syndrome (Lynch, BRCA)? HPI — how did the patient present? What symptoms? Workup by primary cancer type: Uterine: endometrial sampling, TVUS, CT abdomen/pelvis Ovarian: CA-125, imaging Cervical/vulvar: Pap history, colposcopy, biopsies, LEEP, CKC Medical & surgical history — comorbidities, medications, prior abdominal surgeries Family history — relatives affected, cancer type, age at diagnosis Preventive screening — Pap, mammogram, colonoscopy up to date? DURING THE VISIT Ask the patient: what is their understanding of why they're here and of next steps? Confirm and fill in gaps from chart review Assess functional status → ECOG performance status (impacts candidacy for surgery/treatment) Exam: heart, lungs, abdomen — defer pelvic exam until attending is present "The tissue is the issue" — cancer cannot be confirmed without pathology (endometrial sampling, biopsy, or surgical pathology) Visit Type 2: Chemo Clearance Visits KEY TERMINOLOGY Cytotoxic agents (e.g., carboplatin, paclitaxel) — target rapidly dividing cells Immunotherapy / checkpoint inhibitors (e.g., pembrolizumab) — immune system targets cancer PARP inhibitors (e.g., olaparib) — prevent DNA repair; used in ovarian cancer Hormonal therapy (e.g., letrozole, an aromatase inhibitor) — for ER/PR+ tumors Adjuvant — chemo after surgery (most common) Neoadjuvant — chemo before surgery (to downsize disease; often used in advanced ovarian cancer) Maintenance therapy — additional treatment after initial surgery + chemo to delay recurrence (PARP inhibitors, bevacizumab) BEFORE THE VISIT — FOCUSED CHART REVIEW Pull up last clinic note → one-liner + oncologic summary Cancer type, stage, date of diagnosis Prior surgeries and procedures Current regimen — cycle #, date of last treatment First regimen or has there been a prior line? Review prior side effects and tolerance Labs: ANC, Hgb, Plts, Cr, electrolytes, tumor markers Imaging: no evidence of disease? Partial response? Progression? DURING THE VISIT How did they tolerate the last cycle? Ask about previously reported side effects — better or worse? Any new ones? Look up key side effects for their specific regimen ahead of time Brief ROS: fatigue, appetite, nausea/vomiting Exam: heart, lungs, abdomen Goal: confirm labs are acceptable, patient is tolerating treatment, and disease is not progressing. You are not expected to manage the regimen as a resident. Visit Type 3: Surveillance Visits PURPOSE Patients who have completed treatment and currently have no evidence of disease (NED) Monitor for signs of recurrence — frequency and duration vary by cancer type and stage Example: early-stage endometrial cancer → H&P every 3–6 months for first 2–3 years, then every 6–12 months up to 5 years BEFORE & DURING THE VISIT Use last clinic note: cancer type, surgeries/treatments, du...

Walking into your first infertility clinic visit and not sure what to expect? In this episode, Dr. Valdez-Sinon walks through the definition of infertility, how to take a thorough history for both partners, the key workup for ovulatory, tubal, uterine, and male factors, and when to refer to REI. Definition What is infertility? Failure to achieve pregnancy after 12 months of regular unprotected intercourse — for patients under 35 Shorten to 6 months for patients 35 and older Anyone 40+ should be seen as soon as they start trying — don't wait Immediate evaluation warranted for: Oligomenorrhea or amenorrhea Known uterine or tubal disease Stage III/IV endometriosis Resource: ACOG Committee Opinion No. 781 and ASRM guidelines History & Exam HISTORY — PATIENT Comprehensive medical and surgical history Menstrual history — are cycles regular? (regular cycles suggest ovulation, but ~1/3 of regular cyclers can still be anovulatory) Full GYN history — pelvic infections, STIs, known fibroids, endometriosis Prior pregnancies with previous partners? (establishes primary vs. secondary infertility) Ask about: thyroid disease, galactorrhea, hirsutism, pelvic/abdominal pain, dyspareunia Family history: developmental delay, early menopause, reproductive problems Social history: tobacco, alcohol, recreational drugs HISTORY — PARTNER Obtain medical and reproductive history — pregnancy takes two Prior pregnancies with previous partners? Intercourse frequency — ideally unprotected sex ~2x/week PHYSICAL EXAM Vitals, weight and BMI — extremes affect fertility Thyroid exam; breast exam (look for galactorrhea if indicated) Signs of androgen excess — acne, hirsutism, male-pattern hair Pelvic exam — uterine size, shape, mobility; adnexal masses or tenderness Ovarian & Ovulatory Evaluation COMMON CAUSES PCOS — most common cause of ovulatory-related infertility Primary ovarian insufficiency (POI) Thyroid disease, hyperprolactinemia WORK-UP Mid-luteal progesterone — obtain ~day 21 of a 28-day cycle; value >3 ng/mL suggests ovulation For PCOS evaluation: LH, FSH, testosterone Thyroid function studies and prolactin as indicated Ovarian reserve: Antral follicle count on early-cycle ultrasound AMH — value <1 ng/mL suggests diminished ovarian reserve A low AMH does not mean infertility — it only takes one egg. AMH estimates ovarian reserve and responsiveness to gonadotropins for IVF/oocyte preservation. TREATMENT FOR ANOVULATION Ovulation induction with clomiphene (estrogen receptor antagonist) or letrozole (aromatase inhibitor) Tubal Evaluation HSG (hysterosalpingogram) — gold standard for tubal patency Radio-opaque dye injected through cervix; X-ray visualizes "fill and spill" through tubes Low positive predictive value — non-patency needs follow-up Hydrosalpinx: salpingectomy often recommended before IVF — fluid impairs implantation Known tubal factor → IVF required for conception Uterine Evaluation Look for: polyps, fibroids, septum, adhesions (synechiae) — >16% of patients with infertility have a uterine abnormality on sono Saline infusion sonogram (SIS) — preferred over standa...

Headed into the OR for your first hysteroscopy? In this episode, we walk through everything you need to know before you scrub in — from indications and pre-op preparation to OR equipment, distension media, fluid deficit management, and how to handle complications when they arise. I. Introduction & Learning Goals Purpose: Guidance for an intern's first hysteroscopy in the OR. Objectives: Review indications, pre-op preparation, OR setup/equipment, fluid media, and complications. II. Indications for Hysteroscopy Diagnostic Hysteroscopy: Abnormal uterine bleeding (AUB) or postmenopausal bleeding Infertility workup Evaluation of abnormal imaging findings Operative Hysteroscopy: Polypectomy (removal of polyps) Myomectomy (removal of submucosal fibroids) Septum resection Lysis of adhesions (Asherman syndrome) Foreign body removal (e.g., "lost" IUD) III. Pre-Operative Preparation Chart Review Checklist: Indication: Understand the clinical reason for the procedure Imaging (US/MRI): Confirm uterine size (to avoid over-dilating) and location of pathology Comorbidities: Check cardiac, renal, and pulmonary history to set fluid management thresholds Cervical History: Assess risk for stenosis (prior procedures or menopause) Menstrual Cycle: Check current phase (bleeding can obscure visualization) Patient Counseling (Benefits & Risks): Benefits: Superior diagnostic sampling and therapeutic symptom relief Standard Risks: Pain, bleeding, infection (low risk) Specific Risks: Uterine perforation (may require laparoscopy if energy was used or if there is concern for bowel injury) IV. Equipment & OR Setup The Hysteroscope Components: Telescope: The lens (0-degree for forward viewing vs. 30-degree for lateral angles) Sheaths: Inner and outer sheaths to house the telescope and allow fluid flow Inflow/Outflow Ports: For fluid delivery and drainage (use under-the-butt drapes to catch fluid for deficit calculation) Light Source: Warning — becomes extremely hot; keep away from drapes/patient Camera System & Monitor Working Channel: For operative instruments (graspers, scissors) V. Distension Media (Fluids) Isotonic Solutions (Preferred): Normal Saline: Compatible with bipolar electrosurgery; same osmolality as blood Hypotonic Solutions: Glycine (1.5%), Sorbitol (3%), Mannitol (5%) Used only for monopolar surgery; higher risk of hyponatremia Fluid Deficit Management: Definition: The difference between fluid into the uterus vs. fluid recovered ACOG Threshold: Max 2,500 mL for isotonic; however, many surgeons stop at 1,500 mL (or 750–1,000 mL for high-risk patients) VI. Procedural Steps & Tips Cervical Dilation: Can use mechanical dilators or "hydrodilation" using fluid pressure through the scope Tenaculum Tip: Take a "sturdy bite" of the cervix to prevent tearing/lacerations Pressure Management: Keep intrauterine pressure lower than the patient's Mean Arterial Pressure (MAP) to limit fluid extravasation into the body VII. Complications Uterine Perforation: Often occurs during dilation; recognized by a "loss of resistance" Fluid Overload: Can lead to hyponatremia, distributive shock, or flash pulmonary edema Hemorrhage: More common in operative cases (3% for myomectomy); manage with massage, uterotonics, or intrauterine balloons Vasovagal Reaction: Can occur during cervical manipulation or distensio...