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Join medical students Olivia Negris and Jen Romanello as they delve into the often-overlooked topic of female sexual health in health care. In this insightful podcast, Olivia and Jen discuss the challenges patients face when discussing sexual health with health care providers, the impact of the lack of education on female sexual medicine in medical training, and strategies for normalizing these discussions. With a focus on empowerment and advocacy, they share their experiences and initiatives aimed at bridging the gap in knowledge and improving patient care.

Olivia Negris and Jen Romanello are medical students.

They discuss the KevinMD article, “Empowering patients to discuss sexual health.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome Olivia Negris and Jen Romanello. They’re both medical students, and they are among the co-authors of the article “Empowering patients to discuss sexual health.” Olivia and Jen, welcome to the show.

Olivia Negris: Thanks so much for having us.

Kevin Pho: So I’m just going to start, briefly share your story and journey, then we’ll talk about the article. Olivia, why don’t you go first?

Olivia Negris: Yeah, of course. So I am an M4, actually graduating this weekend from Rush Medical College. I have had a long-standing interest in women’s health, starting with a minor in undergraduate studies in the study of the bioscience of gender and health. And kind of from there on, I’ve always looked for ways to engage with women’s health and kind of understudied issues as it relates to our health care.

And early on in my medical school career, I actually attended an event hosted by an organization that Jen here formed, and it was dedicated to female sexual medicine. And hearing patients’ stories about their time to diagnosis, and what they went through to kind of achieve their actual diagnosis for some conditions that have had really significant impacts on their quality of life.

So I recently matched into dermatology, but I have a special interest in vulvar dermatology, which is also really understudied, and is incorporated in the program I’m going to be continuing my training at, at UT Southwestern.

Kevin Pho: All right. And Jen, briefly share your story and journey.

Jen Romanello: So I’m also a fourth year, classmates with Olivia, graduating Saturday. I’m originally from New York City, and I came into med school knowing I was interested in sexual medicine.

I had met Dr. Rachel Rubin, she’s our mentor, and she is a urologist and sexual medicine specialist. And so I shadowed her even before I started medical school, and I found the work that she is doing really meaningful. She was seeing patients with pelvic pain, low libido, difficulty with arousal and orgasm, and these patients had seen many other doctors and weren’t really getting answers, and were getting better when they saw Dr. Rubin. So I found that very meaningful and very impactful.

So in 2020, moving to Chicago, I started the group Olivia alluded to, the Medical Student Forum on Female Sexual Medicine, where we have students from all the seven Chicago med schools on our team. Even students outside of Chicago attend our events.

And I am doing internal medicine at NYU. So talking about how interdisciplinary sexual medicine is is very important to me, because I knew the population I wanted to care for, but I came very certain into med school that I was going to do OB/GYN, and then I was thinking psychiatry, and I feel very happy with my decision to do internal medicine.

Kevin Pho: All right. So let’s talk about that article that you two are among the co-writers for. It’s titled “Empowering patients to discuss sexual health.” So Olivia, for those who didn’t get a chance to read that article, tell us what it’s about.

Olivia Negris: Yeah. So kind of just the backstory of how this article came to be is, our group has focused a lot on finding the gaps in what we actually learn as medical students, and publishing about these. So we’ve had a few prior publications and research presentations about the medical school curricula and what we learned in our preclinical and clinical years as it relates to female sexual medicine. Not surprisingly, there are a lot of gaps in this knowledge.

So it was really important for us to kind of follow up this work and have something that might be a little bit more patient-facing, and allow us to kind of embrace that humanism in medicine, and empower our patients to hopefully realize what they’re living through is valid. And it’s really unfortunate, but it’s not something that’s wrong with them, it’s kind of something that’s wrong with our education in many institutions.

So there’s this known gap in training, and I think that kind of furthers the stigma that patients experience. And so we wanted to try to formalize that and let them see that.

I think that in our generation there’s been a big push for groups like the one Jen started, as well as others, to fill these gaps, and hopefully have us become better clinicians for our future patients who do suffer with some of these conditions.

Kevin Pho: So Olivia, follow up on that. So tell us specifically, what kind of gaps are we missing when it comes to female sexual education?

Olivia Negris: Yeah, they’re kind of throughout the spectrum. We did a recent curricular review where we looked at all seven Chicago area medical schools, which includes both MD and DO, private and public institutions.

And seeing that we are not learning really anything about how to take a proper sexual history. There’s often learning objectives that point us to being able to define sexual medicine in our curricula and identify that and diagnose it, but then there’s really no corresponding lecture time that accompanies that.

So even how we lump these conditions, such as female sexual dysfunction, in the First Aid that we all use as our big reference for Step 1, a lot of that’s actually lumped in the psych section of that textbook. So I think it kind of perpetuates the stigma and leads us to think some of these things might be more psychiatric than have actual pathologies that we need to be paying attention to.

I’m curious if Jen has anything she wants to add as well to that.

Jen Romanello: I think just the fact that there’s delayed diagnosis for a lot of these conditions really speaks to itself. So one interesting piece of data from a recent study, for patients with vestibulodynia, so that’s a type of vulvar pain, was that 35 percent of patients attended more than 15 appointments to receive their diagnosis. And so that definitely creates a big question of, like, why is that happening?

Kevin Pho: So Jen, tell us about some of your initiatives. You mentioned that you formed an advocacy group bringing more attention to the issue. So tell us more about that.

Jen Romanello: So it’s called the Medical Student Forum on Female Sexual Medicine, and over the past four years we’ve had hundreds of students attend our lectures. So we’ll have different experts, for example Dr. Rachel Rubin, or Dr. Lauren Streicher, who’s an OB/GYN who started the sexual medicine and menopause clinic at Northwestern. And so it’s lectures where students can learn about these topics.

We also have an annual symposium, we had our fourth one recently, and it was on all these different types of doctors, so PM&R, urology, dermatology, internal medicine, and more, talking about how they do this work. So it’s also a way for students to find a way of how they can practice this, and connect to research projects and mentors.

Kevin Pho: So Jen, you mentioned that you’ve shadowed physicians who specialize in female sexual medicine even before medical school. So tell us about some of the dynamics in the exam room. What are some of the questions that are asked that you find are not typically asked by people who aren’t specialists? What are some of the missing questions, missing information, that goes on in the exam room that we should know about?

Jen Romanello: Well, the question that we’re taught in med school is, are you sexually active? And I think every patient, whether they saw their OB/GYN or their primary care doctor, could have been asked that. But that question actually can sometimes really be unhelpful, especially when we’re thinking of patients with sexual dysfunction.

So I’ll first go into why it’s not that helpful, and then what I’ve seen doctors do instead. So if someone’s asked, are you sexually active, and a patient is not, for example, intimate with anyone but they want to be, maybe it’s because they’re having pain, and if the patient then says no, that’s really the end of the conversation, and their questions and concerns were not addressed. Or maybe someone is having issues with orgasm but they’re not engaging in any sexual activity, and the answer is no, and it’s also the end of the conversation.

So what I’ve seen done, this is what Dr. Lauren Streicher does, she says, are you satisfied with your sexual function? Or she’ll say, many people have sexual concerns such as difficulty with orgasm, libido, arousal, or pain, are any of these concerns for you? That are just much more direct.

Kevin Pho: And then Jen, if the patient responds affirmatively, if they say yes to some of these follow-up questions, what are some of the next steps that you’ve seen?

Jen Romanello: So then, to build a differential, it could be important to ask, how long has this been going on for? Because some of these conditions people can be born with, or can be acquired, and the treatment can be different. Such as, if someone’s never had an orgasm, or then they did but then had issues like diabetes and cardiovascular disease, for example, that can cause issues with orgasm.

Kevin Pho: So Olivia, you are going to be a future dermatologist, and a lot of your interest certainly has that intersection between dermatology and female sexual conditions. So tell us more about that dermatology intersection. What are some dermatological conditions that intersect with female sexual health?

Olivia Negris: Yeah, so I think some of the big things that we learn about in medical school are like lichen sclerosus, lichen planus. But you can also have a lot of just common skin conditions, such as psoriasis, that can be localized to just the vulva, and patients will go on and on being told, it’s a yeast infection, it’s a yeast infection, because that’s what it looks like and what’s common. But kind of having that eye to actually look into it a little bit further, and have that suspicion, and also build that trust.

I think another big thing that kind of drew me to this field is, we know from recent data that about one in six women will experience an undiagnosed or undertreated vulvovaginal source of discomfort at some point in their lives. And then another recent study showed that only about 4 percent of academic dermatologists in the United States say that they always inspect the vulva during routine annual exams.

And if you think about that, they’re the ones that are trained in the skin, whereas OB/GYNs are kind of more internal. And so it’s kind of this no man’s land that I feel like both professions could kind of claim ownership of, but who really is doing that, and who do patients feel comfortable to bring those concerns to?

Kind of piggybacking off of your last question that you actually addressed to Jen, what have I seen done in the clinic that I think is really helpful for patients is having really straightforward patient-facing educational materials. I got to shadow in the specialized vulvar clinic with Dr. Melissa Mauskar at UT Southwestern, and she has all of these different handouts that she gives patients, and she annotates them and hands them to the patient and is like, read these, stay off of the Google doctor, don’t look on TikTok for your health care, read these. And this is what I’m seeing, this is what you have, these are the risks that come with it, and this is kind of what your prognosis looks like.

And I think even just having, there’s a lot of power in finally receiving a diagnosis, and having someone that takes that extra step to be like, I understand you are smart, you’ve been seeking this diagnosis for a long time, and now kind of putting that power in their hands. And they often come back with really great questions. And I think that informing in appropriate patient-facing language is something that we can all do better with, and that seems to be really beneficial for the patient and their experience with the health care system.

Kevin Pho: So Jen, one of the things that Olivia mentioned earlier was that there were a lot of gaps in terms of medical education. Just for some context, what is typically taught about female sexual health in a medical school curriculum? I guess from what you’ve seen, I know that you’ve only been at one medical school, but in general, what’s typically taught?

Jen Romanello: Definitely birth control and STDs, STIs, which is very important. I think there’ll be less on sexual dysfunction, especially for patients with vulvas and vaginas.

So in our curriculum review, we found that only three of the seven Chicago schools even highlighted the prevalence or epidemiology of female sexual dysfunction. Which is important, because then you’re highlighting that it is common, because it’s about 40 percent of patients with vulvas. Only three of the med schools address treatments for FSD.

And yes, this is medical school, we’re not practicing clinicians yet, but just to get this on someone’s radar I think is also important. And then we looked at what was also done in the First Aid book that students use for board exams, and the topics on sexual dysfunction for patients with vulvas versus penises was actually quite different. There was a lot more for the latter.

Kevin Pho: Have you seen the curriculum change in response to your advocacy efforts? Have you moved the needle when it comes to education? Have any of the medical schools in Chicago adjusted their curriculums?

Jen Romanello: So at Rush, we did reach out to the course director for the second year block on sexuality and reproduction, and she was very open to our feedback. And so she gave Olivia and I access to the document and we could insert our changes, and then it was brought to the curriculum committee.

And then at Loyola, one of the Chicago area schools, there is a doctor, Dr. Mary Lynn, who’s an OB/GYN, and she has really taken it upon herself to teach the medical students a lot about this. So it also matters who is at the institution. And in our curriculum review, out of the seven Chicago area schools, Loyola had the most comprehensive education on female sexual medicine.

Olivia Negris: I’d like to add, if I can, at Northwestern, actually this year, we got to talk with some of the Northwestern faculty at a conference last year when we presented our earliest data on this, and they this year had a guest speaker that actually kind of presented our paper there. And she goes by Gyno Girl on Instagram and other social media, but Dr. Rahman is her name, and she’s an OB/GYN in the area as well, and she was a guest lecturer and spoke to them for an hour on just this topic, on female sexual medicine.

So that’s been really cool to see. I think it is moving the needle a little bit. I think there’s a lot to be done, and so the work does not stop here.

Jen Romanello: Also, one of my interests as a future internist is menopause, and there really is not much we’re taught about menopause, even though this will be half of the population. And I think that says a lot, because is it going to be the perspective of, oh, this is something that just happens and these symptoms will eventually go away, or you have to deal with them? Or actually, are there treatments and interventions that we can be learning about for patients?

Kevin Pho: We’re talking to Olivia Negris and Jen Romanello. They’re both medical students, and we’re talking about the KevinMD article “Empowering patients to discuss sexual health.” So Olivia and Jen, I’m going to ask each of you just to share some take-home messages that you want to leave with the KevinMD audience. Olivia, why don’t you go first?

Olivia Negris: I’m going to start with saying that, again, nearly one in six women are going to have an underdiagnosed or undertreated vulvovaginal condition at some point in their lives. And again, half of our population is made up of women, and so we need to do a better job of caring for these concerns that can have incredible quality of life impacts.

I think for some of our clinical audiences, thinking about how we do a sexual history, that should be part of every H&P that we do, either as a student, resident, or attending. And something that we like to share is, we learned the five Ps in medical school, which is partners, practices, protection, past history of STDs, and then pregnancy prevention. But really what Jen and I have learned through some of our mentors and the presentations we’ve listened to is adding in, are you having pleasure, and is there pain? And so expanding that to the seven Ps.

I think that kind of puts this in a more holistic, and focusing on quality of life is really what we want at the end of the day. And these can be really emotionally distressing and affect these patients’ intimate relationships, and even just views of themselves.

So how can we just every day take that a step further and show that we care just a little bit more about these conditions? Whether or not we have received adequate training, I think just showing patients you’re willing to learn and willing to listen is what they’re looking for.

Kevin Pho: And Jen, we’ll end with you. Just please share your take-home messages.

Jen Romanello: My take-home message is that there’s a lot of work to be done, but if you’re collaborating and you’re working together, there’s so much more that you can achieve.

So with this group we’ve been able to do a lot, and also have a good time working together. And we’ve connected to mentors and to people doing research. And I think if you can find people with shared passions, it makes your work so much more effective and also enjoyable.

Kevin Pho: Olivia and Jen, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Jen Romanello: Thank you.