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��1 &#x/MCI; 0 ;&#x/MCI; 0 ; &#x/MCI; 1 ;&#x/MCI; 1 ; &#x/MCI; 2 ;&#x/MCI; 2 ;AAFP Reprint No. 282Recommended Curriculum Guidelines for Family Medicine ResidentsWomen’s HealthGynecologic Caredocument wasendorsed by the American Academy of Family Physicians(AAFP) ��2 &#x/MCI; 0 ;&#x/MCI; 0 ;Program requirements specific to family medicine residencies may be found on the ACGME website. Current AAFP Curriculum Guidelines may be found online at www.aafp.org/cg. These guidelines are periodically updated and endorsed by the AAFP and, in many instances, other specialty societies, as indicated on each guideline.Please note that the term “manage” occurs frequently in AAFP Curriculum uidelines. “Manage” is used in a broad sense indicating that the family physician takes responsibility that optimal and complete care is provided to the patient. To manage does not necessarily mean that all aspects of care need to be directly delivered personally by the family physician and may include appropriate referral to other healthcare providersincluding other specialists for evaluation and treatment.Each residency program is responsible for its own curriculum. This guideline provides a useful strategy to help residency programs form their curricula for educating family physicians.PreambleWhile we recognize a nonbinary gender spectrum, this curriculum guideline addresses care of patients of the female sex. Issues specifically related to caring for transgender patients can be found under the LGBT curriculum guidelines. For the sake of clarity, the words woman and womn’s health should be assumed to be synonymous with individuals of female sex. Women’s health care addresses the unique, multidisc

iplinary aspects of issues affecting women. In providing a wide range of medical services, the family physician can provide reventive and wellness care, diagnosgeneral medical illnessesanddisease processes unique to womenand care for women and their families.The goal of these guidelines is to familiarize the family medicine resident with attitudes, knowledgeand skills that are important for the care of women and their families.Family physicians must be trained to care for women throughout the life cycle and must appreciate challenges such as adolescence, sexuality, family planning, balance of family life and careernd aging within the female patient’s culture. Health promotionincluding screening, counseling, and vaccinationis a foundation of family medicine. or the majority of their reproductive livesmost women try to prevent pregnancy, so we highlight this aspect of care.The psychological and physiologic changes of menarchcontraceptionpregnancylactation,and menopause impactwomen in many aspects of their lives, requiring clinical skills on the family physician’s part to provide education, diagnostic testingtreatment, and appropriate referralthat is safe and effective. Women are living to an advanced age more frequently than their malecounterpartstherefore cognitive, affective,and functional assessments, as well as endlife discussionsare important aspects of care. ��3 &#x/MCI; 0 ;&#x/MCI; 0 ; &#x/MCI; 1 ;&#x/MCI; 1 ;This AAFP Curriculum Guideline provides an outline of the attitudes, knowledge,and skills that family physicians should attain during residency training to provide high quality care to their female patients.ee also AAFP Curriculum Guideline No. 261 Maternity Care.CompetenciesAt the completion of residency trainin

g, a family medicine resident shouldbe able toDiagnose and develop treatment plans for common conditions affecting female patients at different stages throughout the reproductive lifespan (Medical Knowledge, Systemsbased Practice, Practicebased Learning and Improvement)Perform appropriate preventive servicesincluding screening tests and wellness counseling based on the patient’s age and risk factors(Patient CareMedical Knowledge)erform routine gynecologic procedures, includingbut not limited topap smear, endometrial biopsy, collection and interpretation of vaginal and cervical samplesand placement of longacting reversible contraception (LARC) (Patient Care, Medical Knowledge)Offerpatientcentered comprehensive contraceptive counseling and optionsincluding longacting reversible contraception (LARC) (Patient Care, Medical Knowledge)Understand the risks and appropriately counsel patients about nongynecologic medical problems that may manifest differently or more frequently in womenincludingheart diseasestroke, osteoporosis, anxiety/depression, and intimate partner violence Patient Care, Medical KnowledgeConsult with bstetricianynecologists(OBGYNs), other physician specialists,and allied health care professionalsto provide optimal health services for women (Medical KnowledgeSystemsbased Practice)Communicate respectfully and effectively with women of all ages to act as patient advocate and coordinator of care for female patients across the continuum of outpatient, inpatient,and assisted care (Systemsbased Practice)Attitudesand BehaviorsThe resident should develop attitudes and behaviors that encompass:A caring, compassionate,and respectful approach to the female patient’s role as an informed participant in her own health care decisions and those affecting he

r family ��4 &#x/MCI; 2 ;&#x/MCI; 2 ;• Recognition of the need to empower the female patient in the decisionmakingprocess and provide information to enable the female patient to make informed decisionsecognition that a woman’s health is affected not only by medical problems, but also by family, career, life cycle, relationshipsand communityAppreciation of the role that many women play in the health of the family by selecting health care professionals, providing family careand making lifestyle decisions for the familyAwareness of the effects of public perception and media representation of women and body image on female patients Awarenessof implicit bias, particularly in relationship to race and ethnicityAwareness of issues facing heterosexual, lesbian, bisexualand transgender patientsee AAFP Curriculum Guideline No. 289D Lesbian, Gay, Bisexual, Transgender Health)Awareness of the widespread and complex health effects of physical, emotional, and sexual abuse on women Awareness of the issues of female circumcision/female genital mutilation when caring for females from cultures that carry out suchpracticesKnowledgeIn the appropriate setting, the resident should demonstrate the ability to apply knowledge ofee also AAFP Curriculum Guideline No. 261 Maternity CareHealth romotionisease reventionand eriodic ealth valuationBasic aspects of normal growth and development of females from puberty to adulthood(and variants of normal)Normal physiology of reproduction in healthy women from puberty to menopauseNormal physiological sexual responses and diagnosis of sexual dysfunction (including initial treatment and referral to appropriate resources)ervical dysplasiascreeningguidelines(including HPV), colposcopic evaluation, biopsy, treatment, and ref

erralAppropriate evaluation and counseling using evidencebased guidelines for:Nutritional needs through the female lifecycleCancer screening guidelinesVaccinationiv.ExerciseprescriptionOsteoporosispreventionand treatmentvi.Smoking cessationvii.Weight management ��5 &#x/MCI; 3 ;&#x/MCI; 3 ;viii.Risks and unique presentations of cardiovascular disease in women (including appropriate testing and treatment strategies for symptomatic women)ix.Mental health and substance abuse screening recommendationsWomen’s unique risks in the community (including poverty, violence, access to health care for pregnant and nonpregnant women, and teen pregnancyand the impact of these factors on infant morbidity and mortalityBasic understanding of complementary/integrative therapiesMenstruationPhysiology of puberty, menarche, and menstrual cycles, including normal variationsEvaluation and treatment for conditions of abnormal menstruation Amenorrhea: evaluation and management of both primary and secondaryetiologiesAbnormal uterine bleeding Postcoital bleedingiv.Dysmenorrhea Family planning Preconception counseling for women of all reproductive age groupsAppropriate evaluation and counseling using evidencebased guidelines for contraception for women in all reproductive age groupsPermanentReversibleOralInjectablePatchesIntravaginal contraceptive ringacting reversible contraception (LARC)Intrauterine devices (IUDs)ImplantsNatural family planningBarrier methodsPostcoital (emergency) contraceptionEtiologies of female infertility, as well as a familycentered approach to evaluation, testing, counseling, and referral resources (including counseling regarding assisted reproductive technology and adoption)Early pregnancy evaluation and managementDating of early pregnancy

Counseling for unintended pregnancincluding options of adoption, abortion(medication and aspiration), and continuing the pregnancy to term ��6 &#x/MCI; 2 ;&#x/MCI; 2 ;c. Assessment and management of first trimester bleeding, including ectopic pregnancy diagnosis and managementAssessment and management of early pregnancy loss, including expectant, medication, and aspiration optionsAssessment and management of postmiscarriage and postabortion symptoms and complications, including mental health implicationsInfertilityDiagnosisof infertility and appropriate referral.Familycentered maternity care (so AAFP Curriculum Guideline No. 261 Maternity Care)General gynecologic pathologyBenign and malignant neoplasms of the external and internal genitaliaUterine and adnexal pathology, evaluation, treatmentand appropriate referralfibroids, endometrial hyperplasia, postmenopausal vaginal bleeding, malignant uterine lesions, and adnexal masses.Pelvic pain: evaluation and differential diagnosis of acute and chronic pelvic pain, including recognition of emergencies (e.g., ovarian torsion)awareness of association between historical or ongoing sexual or domestic abuse, and indications for referral(e.g.infection, endometriosis, tumors)Polycystic ovarsyndrome: presenting symptoms, evaluation and initial treatment, as well as association with ype 2 diabetes mellitusFemale sexual dysfunction: evaluation, counseling, and management, including problems of libido, dyspareunia, and anorgasmiaTrauma: patientcentered, sensitive evaluation of both accidental trauma to the genital region and trauma in victims of intimate partner violence and sexual assaultUrogynecologyUrinary tract infections (UTIs): diagnosis and management of uncomplicated acute UTI, as well as recurrent

or complicated UTI; indicationsforand management of prophylactic antibioticsIncontinence: screening, evaluation, and treatment options for stress incontinence and overactive bladder, including medications, pelvic floor therapies, behavioral modifications, and referral for surgeryInterstitial cystitis: presenting symptoms,evaluation, management, and referraliv.Pelvic rgan rolapse (POP): recognition, diagnosis, manment and referralnfections of the genital tract ��7 &#x/MCI; 2 ;&#x/MCI; 2 ;a. Sexually transmitted infections, cervicitis, and pelvic inflammatory disease: pidemiology, screeningpresentation, evaluationand treatment(outpatient versus inpatient management)Vaginitis: riskfactors, presenting symptomsevaluation, and treatmentRisksfactors for, screening testsfor,and presentations of HIV in women, as well initial evaluation, counselingand referral to resources in the community for both pregnant and nonpregnant female patients who have HIV Breast ealthAnatomy and physiology of benign diseases of the breast (including cysts, adenomasand fibrocystic changes through the menstrual cycle)Evaluation and management of breast diseaseincluding mastodynia, galactorrheaand nipple discharge. Counseling and indications for referral for breast reduction surgery Recommendations based on evidence and controversies related to screening for breast cancer using clinical breast examination(CBE)breast selfexaminations(BSE), imagingand genetic testingInitial recommendations for treatment modalities, referral resourcesand primary care followup for patientswho have breast cancerTypes, risks, and psychological impact of breast implantsMental ealthUnique risks and presentations of mental health problems in women, including:Major depressive disorder Peripartum blue

s, anxiety,depression, and psychosisAnxiety disorders and stress managementiv.Problems with selfesteemEating disorders vi.Obesityvii.Alcohol and substance abuseviii.Chronic pain and disabilityhysiology and diagnostic criteria of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)and available treatments for eachPhysical, emotional,exualand intimate partner iolenceEpidemiology, riskfactorsand red flags for identifying intimate partner violenceand resources available to assist affected women and children. Components of the evaluation and treatment of survivors of rapesexual assaultand sexual harassment (including psychosocial and legal issuesas well as mandatory reporting regulations ��8 &#x/MCI; 2 ;&#x/MCI; 2 ;12. Careof the older womenopausediagnosis, physical, emotional, and sexual impact of the transition, risks/benefits of hormone replacement therapy, complementary alternativesPelvic floor dysfunction: presenting symptoms (urinary incontinence and pelvic floor prolapse), medicaland surgical treatment options, appropriate referralostmenopausal bleeding: workup, management and referral.Cognitive, affective, and functional assessmentEnd of life planningSkillsIn the appropriate setting, the resident should demonstrate the ability to independently perform the following skills (when this is not available or appropriate, the resident should have exposure to the opportunity to practice these skills):Offering comprehensive contraceptive optionsCounseling and prescribing for all forms of birth control (including all hormonal hormonal methods as described above)IUD insertionand removalImplantable contraceptive insertion and removal Diaphragm fittingPrescription of emergency contraceptionQuickstart approach to prescribing contrace

ption, allowing most women with a negative pregnancy test to start a contraceptive method at any point in the menstrual cycleOutpatient gynecologic procedures, interpretation, and appropriate referralFemale breast exam, when indicatedGynecologic exam, including atraumatic speculum and bimanual examsVaginal and cervical cytology collection (with HPV testing, as indicated)Endometrial biopsy Interpretation of urinalysis, vaginal wet mount,KOH prep,vaginal culturesVaginal foreign body removalBiopsy of vulvar lesionsCervical polypectomyCounseling ��9 &#x/MCI; 0 ;&#x/MCI; 0 ;a. Results of cervical cytology, mammography, osteoporosis screening, sexually transmitted infection screening, and other testsAppropriate referralsFamily and relationship stresses Intimate partner and family violenceContraceptive choicesPregnancy options including adoption, abortionand parentingPregnancy loss, ectopic pregnancy, and molar pregnancynfertilityHealthy lifestyle choicesPregnancy managementee also AAFP Curriculum Guideline No. 261 Maternity Care)Prenatal counseling about aspects of normal pregnancy, deliveryand family adaptationEvaluation of gestational age and pregnancy risks in early pregnancyReferral for first trimester termination if desired by patientrisk prenatal careIdentification of highrisk pregnanciesLaborand delivery management (also AAFP Curriculum Guideline No. 261 Maternity CareAdvanced kills in obstetrics and ynecology for family medicine residents who wish to include these in their practicesColposcopycervical biopsy, and endocervical curettage Cervical cryosurgery Bartholin duct cyst management Vulvovaginal biopsyBreast cyst aspirationLoop electrosurgical excisionprocedure with paracervical blockFirst trimester termination: surgical or medicalBila

teral tubal ligationUterine aspiration for incomplete or missed first trimester abortionPessary fittingDilation and curettage ��10 &#x/MCI; 0 ;&#x/MCI; 0 ; &#x/MCI; 1 ;&#x/MCI; 1 ;7. Gynecologic surgery Assisting with common major surgical procedures, including hysterectomy Postoperative management following gynecologic or obstetric surgeryImplementationCore cognitive ability and skills require experience in structured rotations n obstetrics and gynecology.Emphasis on the ambulatory care of patients including counseling, examination,and outpatient proceduresis crucialand can be taught in both continuity clinics and highvolume specialty clinicsWorkshops in gynecologic procedures, didactics,and communication seminars can enhance clinical experience.aculty role models and family physicians who provide comprehensive reproductive healthcare should be available to teach residents and observe their interactions with female patients. Residentsof both genders should care for an adequate number of female patients of all agesalong with their familiesto learn the full spectrum of issues affecting women.ResourcesApgar BS, Brotzman GL, Spitzer M. Colposcopy, Principles and Practiceed. Philadelphia, PSaunders; 2008.Berek JS. Berek and Novak’s Gynecologyed. Philadelphia, .: Lippincott Williams & Wilkins; 2012.Carlson KJ, Eisenstat SA, Frigoletto FD, Schiff I. Primary Care of Womened. Philadelphia, .: MosbyFritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertilityed. Philadelphia, P.: Lippincott Williams & Wilkins; 2011.Gabbe SG, Niebyl JR, Simpson JL, et. al.Obstetrics: Normal and Problem Pregnanciesed. Philadelphia, Elsevier; 2017.Lentz G, Lobo RA, Gershenson D, Katz VL. Comprehensive Gynecologyed. Philadelphia, P.: Mosby Elsevie

r; 2012.Manetta A. Cancer Prevention and Early Diagnosis in Women. Philadelphia, Mosby; 2004. ��11 &#x/MCI; 0 ;&#x/MCI; 0 ;Mansel RE, Webster DJT, Sweetland, HM. Hughes, Mansel & Webster’s Benign Disorders and Diseases of the Breasted. Philadelphia, Pa.: Saunders; 2009.Mayeaux EJ, Cox JT. Modern Colposcopy: Textbook and Atlas. 3rd ed. Phildelphia, .: Lippncott Williams and Wilkins; 2012.Melmed S, Polonsky KS, Larsen PR, Kronenberg HM. Williams Textbook of Endocrinology. 13ed. Philadelphia, PElsevier; 2016.Website ResourcesAmerican Society for Colposcopy and Cervical Pathology (ASCCP). www.asccp.org/ Centers for Disease Control and Prevention (CDC). www.cdc.gov Centers for Disease Control and Prevention. US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html National Osteoporosis Foundation. www.nof.org/ Reproductive Health Access Project. www.reproductiveaccess.org/ Training in Early Abortion for Comprehensive Healthcare. http://www.teachtraining.org/ U.S. Department of Health and Human Services Office on Women’s Health. www.womenshealth.gov/ U.S. Preventive Services Task Force Recommendations for Primary Care Practice.www.uspreventiveservicestaskforce.org/Page/Name/recommendations Published: 4/94Revised: 2/97Revised 1/04Revised 1/08by University of Mississippi Family Medicine Residency Program and the Society of Teachers of Family Medicine (STFM) Group on Oral HealthRevised 11/by Family Medicine Residency of IdahoRevised/Retitled 6/14 by Bayfront Health St. Petersburg Family Medicine Residency, FLRevised 8/16 by Contra Costa Family Medicine Residency, Martinez, CARevised 08/8 by Sutter Health Family Medicine Residency Program, Sacram