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Women's Health

by

Kristen Pellegrino

on 23 April 2015

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Transcript of Women's Health

Cardiovascular disease:
Still kills 1 in 4 women
34
10 things you need to know in 30 minutes
Women's Health:
10 Things to Know
in 30 Minutes

Hormone Replacement Therapy: start low and
perhaps
end early
Vitamin D:
Think about targeted screening
Obesity
and its
effects
on
Emergency

Contraception
What Can We Agree On?
Know your pap guidelines
Common issues:
Screening for cervical cancer: a systematic review and meta-analysis. Peirson L, et al. Syst Rev. 2013;2:35. Epub 2013 May 24.
The experts agree:
DON'T pap teens--even pregnant ones, no matter when they became sexually active.

DON'T require a pap before birth control.

DON'T order HPV cotesting routinely on women under 30 with no prior history of abnormal paps.

DO consult guidelines for algorithmic management of abnormal results.
Reproductive Life Planning
Contraception: implants and IUDs are the most effective methods
Melanoma:
Increasing rates
among young women
For low risk, immunocompetent women:
Screening
saves lives.

-cervical stenosis
-pregnancy loss
-preterm delivery
-perinatal mortality
-psychosocial costs
-economic costs
-opportunity costs
Worse maternal and fetal outcomes when pregnancies are unintended
-low birth weight (OR 1.36)
-premature delivery (OR 1.31)
-PPROM (OR 1.37)
-postpartum depression (OR 1.98)
- Higher rates of
all cause mortality
for both mothers and infants

Women face a worse prognosis than men
following a primary cardiovascular event.
Uncertainties

Optimal level of vitamin D
Commercial assay variability
Racial differences
Who should be screened?
Indications for BRCA Testing

Go AS et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013.
Smoking confers a 25% higher risk of CHD in women when compared to men.
Huxley RR et al. Lancet. 2011;398(9799):1297-1305.
Women receive fewer preventive services for CHD and less treatment intensification than men.
Yoon PW et al. Prev Chronic Dis. 2011;8(2):A43.
Prevention is key. Manage risk factors aggressively.
Over-screening
has risks.

American Congress of Obstetricians and Gynecologists
U.S. Preventive Services Task Force
American Cancer Society
American Society for Colposcopy and Cervical Pathology
Heart disease
kills more women than all cancers
combined
.
SOURCE: Final Recommendation Statement: Menopausal Hormone Therapy: Preventive Medication. U.S. Preventive Services Task Force. February 2014


Individualization is key

Start low
0.3mg/d oral CE
0.5mg/d oral micronized estrogen, 0.014-0.0375mg/week transdermal estradiol

Consider discontinuation after 3-5 years for combined hormone replacement

The North American Menopause Society
2012 Position Statement:
Think of those who are high risk for vitamin D deficiency:
-Osteoporosis
-Cirrhosis
-Chronic Kidney
-Malabsorption
-Hyperparathyroidism
-Dark skin
-Fall risk
-Non-traumatic fracture
-Pregnancy
-Obesity
40% increase in BRCA testing occurred
4 months after Angelina Jolie's op-ed
"I can tell my children that they
don't need to fear they will lose
me to breast cancer".

Angelina Jolie in "My Medical Choice", NY Times, May 2013
-AARP Public Policy Institute
National Cancer Institute
Identify individuals who may be at risk:
-At least one family member with breast,
ovarian, fallopian, or peritoneal cancer
Use a screening tool to further access

risk
www.breastcancergenescreen.org
How to decide who to screen in three steps:
From 1970 to 2009, the incidence of melanoma
increased by 8 fold among young women aged 18-39.
Nearly 1 in 3 young women (18-25) report using a tanning bed.
2010 National Health Interview Survey
What is One Key Question?
A brief, free, office-based intervention designed to help a patient identify her Reproductive Life Plan.
Find out more about the original initiative at
www.onekeyquestion.org.
In the next year, do you or your
partner plan on becoming
pregnant?
YES
NO
Preconception
Care
Contraceptive needs
assessment
Women with a positive screen should be offered genetic counseling
Reed, KB. Increasing Incidence of Melanoma Among Young Adults: An Epidemiological Study in Olmsted County, Minnesota. Mayo Clinical Proceedings. 2012; 87(4): 328-334
Incidence rates of the trunk among young
women is rising.
Use of tanning beds increase the risk of melanoma by 75%.
American Academy of Dermatology
New options for dyspareunia:
Viagra for women?
Studies in Family Planning . Population Council. Vol 39 No 1 Mar 2008

CDC MMWR. 1999 Apr 2; 48(12):241-3.
Shah et al. Intention to become pregnant and low birth weight and preterm birth: a systematic review [published online December 10, 2009] Matern Child Health J.
Mohllajee et al. Obstet Gynecol. 2007 Mar;109(3):678-86.


Cheng D et al. Contraception. 2009;79(3):194–198
Pregnancy planning has many advantages
Individual social and economic advantages
Alignment with patient's personal life goals
Opportunities for preconception counseling and screening
Optimize control of chronic diseases
Diabetes
Hypertension
Obesity
Depression
Bipolar disorder
Coagulopathies
Seizure Disorders
Reduce high risk behaviors
Early entry into prenatal care
Tobacco use
Substance abuse
Exposure to chemicals
Vaccines
Folic Acid
(But don't forget about condoms for STI prevention.)
Change the birth control conversation from
re
active to
pro
active
Trussell J et al. Contraceptive Technology. 20th revised ed. New York: Ardent Media; 2011.
Guttmacher (2012). "Contraceptive Use in the United States".
1 Nexplanon = 1 Skyla= 1,095 pills
1 Mirena = 1826 pills
1 Paragard = 4383 pills

Emergency Contraception: Birth control used after sexual intercourse to prevent pregnancy.
Levonorgestrel (Plan B)
Ullipristal Acetate (Ella)
Copper IUC (Paragard)
Here's the problem:
-Levonorgestrel EC is equivalent to not taking any action at all in women with a BMI >26.
-Ullipristal is significantly less effective in women with a BMI >35.
Glasier A, e al. Contraception. 2011;84:363-7.
Emergency contraception key points
BMI 26-35
: can use ullipristal or copper IUD


BMI > 35
: can use copper IUD
BMI < 26
: can use levonorgestrel (Plan B), ullipristal (Ella), or copper IUD (Paragard)
Most effective (99%) EC for all women: Copper IUD
Bradford, PT. Rising melanoma incidence rates of the trunk among young women in the US. Cancer Epidemiol Biomarkers Prev. 2010 Sept; 19(9): 2401-6
1. Increase opportunities for sun protection in outdoor settings
2. Provide individuals with the information they need to make informed, healthy choices about UV
exposure
3. Promote policies that promote the national goal of preventing skin cancer
4. Reduce harms from indoor tanning
5. Strengthen research, surveillance, monitoring, and evaluation related to skin cancer prevention strategies




Nearly 3/4 of women older than 60 report difficulty with intercourse or painful intercourse (dyspareunia).

Diokno AC. Sexual function in the elderly. Arch Inter Med 1990; 150: 197-200
Diminishing estrogen in menopause, leading to vulvovaginal atrophy, at least partly contributes to dyspareunia.
Meston CM. Aging and sexuality. West J Med 1997; 167: 285-290
FDA approves Osphena (Ospemifene) for the use of moderate to severe dyspareunia in 2013.
Risks have not been studied in long term trials

Most common side effect is hot flashes

Has not been studied head-to-head against topical estrogen
Systemic hormone therapy, with estrogen alone or in combination with progestin, is the most effective therapy for vasomotor symptoms.
What is Ospemifene?
Estrogen receptor agonist/antagonist

Exerts a strong agonist effect on vaginal
epithelium
Concerns....
McLendon, AN. Ospemifene for the Treatment of Vulvovaginal Atrophy and Dyspareunia in Postmenopaual Women. Pharmacology 2014; 34: 1050-1060
Number needed to screen to avoid
one death from cervical cancer
= 1140

Gates T. Am Fam Physician 2001.
WWW
-Saslow D, et al. ACS, ASCCP, and ASCP screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin 2012; 62:147.
-Moyer VA. Screening for cervical cancer: USPSTF recommendation statement. Ann Intern Med 2012; 156:880.
-Cervical cytology screening. ACOG Practice Bulletin No. 131. American Congress of Obstetricians and Gynecologists. Obstet Gynecol 2012; 120:1222.
Objectives:

At the end of this presentation, participants will be able to:

1. Identify appropriate screening candidates for 3 preventable diseases
2. Use reproductive life planning to discuss fertility and patient-centered contraception
3. Educate patients on choices of treatment for menopausal concerns

The presenters have no disclosures to report.
Management of menopausal symptoms. Practice Bulletin No. 141. ACOG. Obstet Gynecl 2014; 123: 202-16.
USPSTF 2014 Recommendation Statement:
2014 ACOG Practice Bulletin:
Management of Menopausal Symptoms
Pap guidelines
Hormone replacement therapy
New options for dyspareunia
Shannon Connolly MD
Kristen Pellegrino MD

Vitamin D Screening
Cardiovascular Disease
Reproductive Life Planning
IUDs and implants
BRCA Screening
Melanoma
Obesity and Emergency Contraception
High Continuation Rates
Advantages of IUDs and Implants
Highly Effective:
Failure rates in first year of use (%)
0.05
Implant
LNG IUD
Sterilization
Copper IUD
DMPA
Pill/Patch/Ring
Male Condom
Very Convenient
Ospemifene at 60mg/day is an effective
option for the treatment for moderate to severe dyspareunia.
Full transcript