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Holistic Gynecologist

UterusUnity

Seeking consensus framework for an evidence‑based “holistic gynecology” consult pathway within conventional practice

Patient demand for “holistic” or integrative gynecologic care is rising, but offerings are highly variable and sometimes unsafe or unsupported. I am proposing a standardized, evidence‑graded consult pathway that can be implemented within general gynecology, MFM, REI, and urogynecology settings, and I am seeking critique and contributions from colleagues who practice integrative medicine, pelvic pain, sexual medicine, and primary care.

Proposed components

Intake and screening (structured, EHR‑embedded)
- Menstrual/reproductive history; contraceptive/HT use; pain and sexual function (FSFI, PFDI, Vulvar Pain Functional Questionnaire).
- Mental health and trauma screen (PHQ‑9, GAD‑7, PCL‑5 where appropriate); insomnia/sleep apnea screen (ISI, STOP‑BANG).
- Nutrition/weight history; disordered eating screen (SCOFF); physical activity; substance use.
- GI and bladder symptom overlap (IBS‑SSS, ICIQ).
- Environmental/occupational exposures (endocrine disruptors, heat stress).
- Supplement/herbal/CBD use captured with structured vocabulary and dose/frequency fields.
Minimal lab/imaging set (indication‑driven; avoid low‑value testing)
- Iron studies (ferritin with CBC) for HMB/fatigue; 25‑OH vitamin D where deficiency risk; TSH/TPO by clinical context.
- Avoid nonstandard micronutrient panels without clear indication; document rationale for any advanced testing (e.g., AMH, inflammatory markers).
- Vaginal ecosystem: use microscopy/Nugent/NAATs; reserve microbiome sequencing for research.
Nonpharmacologic care bundles (evidence‑graded)
- Dysmenorrhea/chronic pelvic pain: pelvic floor PT; exercise program; TENS; heat; mindfulness‑based stress reduction/CBT for pain; sleep optimization; anti‑inflammatory dietary pattern (Mediterranean‑style).
- Endometriosis support: as above plus pain neuroscience education; flare management plan; nutrition consult for GI overlap.
- PMS/PMDD: CBT; sleep/circadian regularity; exercise; light therapy for late luteal insomnia.
- PCOS: structured nutrition focusing on glycemic load; resistance training; sleep apnea evaluation when indicated; consider CGM for behavior feedback (non‑diagnostic) in shared decision‑making.
- Menopause: individualized discussion of HT vs nonhormonal options; paced breathing; exercise; sexual pain pathway with lubricants/moisturizers and PFPT.
- Sexual dysfunction: AASECT‑certified sex therapy, PFPT, dyspareunia desensitization protocols.
Supplements/herbals (standardized evidence and safety table with stoplight coding)
- Green (evidence for benefit; favorable safety in nonpregnant adults): omega‑3 for dysmenorrhea; ginger for N/V; magnesium for dysmenorrhea/constipation; myo‑inositol for PCOS metabolic features; CoQ10 for diminished ovarian reserve (limited but favorable safety).
- Yellow (mixed evidence or context‑dependent; monitor): chasteberry for mastalgia/PMS; cranberry for rUTI prevention; D‑mannose (conflicting data); soy isoflavones for vasomotor symptoms.
- Red (avoid or specialist oversight): St John’s wort (CYP3A4 induction; contraceptive failure risk); black cohosh (hepatotoxicity signals); high‑dose green tea extract (liver); kava (hepatotoxicity); CBD (broad CYP interactions); any proprietary blends with undisclosed constituents.
- Pregnancy/lactation: default to avoidance unless robust safety data (use LactMed/TERIS); maintain a “not recommended” list accessible in EHR.
Interaction and perioperative safety protocols
- EHR clinical decision support to flag CYP3A4/2C9/UGT interactions with OCPs, anticoagulants, perioperative anesthetics.
- Preop hold list (e.g., ginkgo/garlic/ginseng/fish oil/high‑dose turmeric) 7-10 days prior; explicit documentation.
Vaginal ecosystem care
- Probiotics: limit to strains with RCT support and known safety; acknowledge that L. crispatus CTV‑05 shows promise post‑BV treatment but is not widely available/approved.
- Avoid high‑risk intravaginal botanicals or essential oils; emphasize harm‑reduction.
Documentation, consent, and coding
- GRADE the evidence for each modality; document goals, expected effect size, and monitoring plan.
- Distinct informed consent for non‑FDA‑regulated supplements and off‑label use.
- Time‑based or complexity‑based billing; consider group visits for education.
Team‑based care and credentialing
- Referral network standards: PFPT with WCS; RDN with women’s health focus; NCCAOM‑certified acupuncturists; AASECT‑certified sex therapists; IBCLC for lactation; behavioral health.
- Clinician training: ABMS‑recognized integrative medicine certification or CME equivalent; maintain formulary knowledge.
Outcomes and quality metrics
- Core outcome set: pain (NRS), function (PROMIS‑PF), menstrual symptoms (MSQ), sexual function (FSFI), mood (PHQ‑9/GAD‑7), sleep (ISI), quality of life (PROMIS‑GH), medication burden, opioid sparing, ED visits, unplanned surgeries.
- Safety monitoring: adverse events, LFTs when indicated, contraceptive failures, periop complications.
- Equity metrics: access by language/insurance; culturally safe care.

Open questions for the group

1) Minimum viable dataset: Which screeners and labs are essential vs optional to keep the visit under 60 minutes and the lab bill reasonable?
2) Supplements formulary: What would you include/exclude from green/yellow/red lists for dysmenorrhea, endometriosis, PCOS, menopause, and pregnancy? Any center‑developed monographs you can share?
3) EHR build: Has anyone implemented supplement interaction alerts tied to contraceptives and perioperative orders? Pitfalls and alert fatigue mitigation?
4) Perioperative policy: Consensus on hold times and documentation for common botanicals; any anesthesia department protocols to share?
5) Vaginal probiotic guidance: Practical criteria for when to consider, which strains, and how to counsel on commercial product quality (USP/NSF/ConsumerLab)?
6) Outcomes: Which patient‑reported measures are most feasible in busy clinics, and what change thresholds are clinically meaningful?
7) Reimbursement: Experience with coding/group visits/shared medical appointments for integrative gynecology; payer acceptance in value‑based contracts.
8) Training and credentialing: Minimum training for clinicians marketing “holistic gynecology”; how do you vet external partners to avoid misinformation?
9) Research: Interest in a multicenter pragmatic registry with common data elements to evaluate effectiveness, safety, and cost of this pathway?

If there is interest, I can share draft EHR templates (intake questionnaire, supplement inventory, consent language), a preliminary stoplight formulary, and a starter order set for labs/referrals. Contributions of existing materials and constructive critique would help move this from concept to a safe, scalable, and measurable care pathway.