Gynecology Clinic

Women’s Health (Complex Gynecology) Referral Guidelines for MAP Handbook

1. Appropriate Referrals:

Condition/DX: Chronic pelvic pain or dysmenorrhea.

• • 1. PCP documentation: has condition lasted longer than 6 months? Has the condition not responded to 3 months of medical therapy, i.e. NSAIDs, OCPs.
    2. Medication list: documenting 3 months of medical therapy
    3. Diagnostic: pelvic sonogram within one year
    4. Labs: Recent urine culture, and STD testing within 6 months

Condition/DX:   Vulvodynia (painful vulva), vaginismus, or vaginal/vulvar dermatoses

1. PCP documentation: has the condition not responded to medical therapy. Any clinic visits where the patient was evaluated for vulvar complaints
2. Labs: has any skin/allergy testing been performed? has any prior testing that could exclude or confirm a vaginal infection, such as wet prep, PCR or culture for the following: gonorrhea, chlamydia, trichomonas, yeast, bacterial vaginosis STI screening within the past 6 months.

Condition/DX:   The patient is experiencing bothersome frequency and/or leakage of urine.

1. Labs: Urinalysis and culture (+/- micro) within the past 3 months

Condition/DX: The patient has pelvic organ prolapse and/or is complaining that something is falling out of their vagina.

1. PCP Documentation: In the past month, the patient has experienced accidental bowel leakage (gas or stool).
2. Procedure: Colonoscopy >=50 yo, 40 yo with fam hx, blood in stool (encouraged but not required) OR current occult blood screening

Condition/DX: The patient has bladder pain with negative urine cultures and symptoms that are consistent with interstitial cystitis.

1. Lab: Urinalysis and culture (+/- micro) within the past 3 months

Condition/DX: The patient is older than the age of 60 with a history of smoking and has more than 3 red blood cells per high-power field that has been documented by a urine dip followed by a urinalysis. (If there is visible blood in the urine, then the patient should be referred to a Urologist instead)

1. Labs: Urinalysis with greater than 3 red blood cells per high-power field, Micro UA
2. Diagnostics: CT Urogram

Condition/DX: The patient is a low-risk, never smoking woman between the ages of 35 – 50 years old with more than 25 red blood cells per high-power field that has been documented by a urine dip followed by a urinalysis (If there is visible blood in the urine, then the patient should be referred to a Urologist instead)

1. PCP documentation: Urinalysis with greater than 25 red blood cells per high-power field.
2. Lab: Micro UA
3. Diagnostic: CT Urogram

Condition/DX: The patient has a history of two or more urinary tract infections in the past six months or three or more urinary tract infections within the past year that is documented with urine cultures and treatments.      

1. PCP documentation: Minimum of 2 UTIs within 6 months or 3 UTIs in 12 months.
2. Labs: All urine culture results for the preceding year
3. Diagnostic: CT Urogram

2. Documentation required for scheduling referral

• The Demographics page: name, address, phone numbers (home, mobile, daytime and alternate as applicable), email address if available, DOB, preferred language, insurance with policy number, requesting provider (include address, phone number, and fax number), primary care provider (include address, phone number, and fax number)
• Clinical Information/Comments
• The (Master IM) Last Summary Note from Referring Provider
  Current Medication List (Medication name, Dose, Sig)
  Problem List (Onset date, Chronic y/n, Notes)
  Obstetrical/Gynecologic History (# of pregnancies, Results of pregnancy, Complications)
  Menses (Age at menses, Status of menses, Days b/w periods, Days of menstrual flow, Pain with periods)
  Family History (Cause of death, Disease detail, Family member, Name, Age, Comments)
  Past Medical/Surgical History (Disease/disorder, Onset date, Procedure/surgery, Year)
  Behavioral Health history (Condition, Treatment, Diagnosing provider, Result)
  Social history (Relationship status, # in household, Exercise frequency, Caffeine intake, Smoking, Alcohol intake, Recreational drug use, Dietary description)
• Diagnostics/Imaging History within the last 12 months (Test, Date ordered, Date completed, Status, Interpretation, Result)
• Lab/pathology history within the last 12 months (Test, Date ordered, Date completed, Status, Interpretation, Result), current pap test according to ASCCP guidelines
• If applicable, pelvic floor physical therapy reports
• If a patient has postmenopausal/abnormal uterine bleeding, a current endometrial biopsy is encouraged, not required.