Post on 25-Dec-2015
Menarche to Menopause:What’s New in Women’s
Health?
Cheryl A. Fuller, CRNP, PhD
NEW CERVICAL SCREENING GUIDELINES
FREQUENCY OF SCREENING
ACOG Revised Cervical Cancer Screening Guidelines (11/09)
Begin Pap Tests at age 21Age 21 – 29 years old – every 2 years (LBC)Age 30 years and older – every 3 years (if history of 3 consecutive normal paps & negative HPV)Age 70 and older (if 3 consecutive normal paps & no abnormal results in 10 years)Hysterectomy for benign conditions and no history of high grade CIN
Rationale for New Guidelines
Invasive cancer rare in women under age of 25 yeas oldAdolescents have higher incidence of HPV-related precancerous dysplasia because of immature cervixMost of these lesions resolve spontaneously without treatmentWomen with history of excisional procedures for dysplasia have significant increase in premature births
Don’t Forget . . . .
Sexually active adolescents and high risk women need to be counseled and tested for STIs
Counseling on smoking cessation
Exceptions
Women with a history of CIN 2, CIN 3, or cancer treatment (continue annual screenings for 20 years)Women with a hysterectomy with removal of cervix & a history of CIN 2 or CIN 3 (continue to screen after period of post-treatment surveillance)HIV positive and immunocompromised women (annually)DES exposure (annually)
FREQUENCY OF SCREENING
CDC and American Cancer Society Guidelines
Agree with ACOG with one exception:
First pap about three (3) years from first vaginal intercourse, but no later than 21 years old
Management of Abnormal Pap Tests
Management of Abnormal Pap Tests
Management of Abnormal Pap Tests
Management of Abnormal Pap Tests
The Challenge of DES Exposure
History of DESDiethylstilbestrol
Given as treatment for the prevention of spontaneous abortions, prematurity, intrapartal bleeding, and diabetes
Between 1938 – 1971
Estimated 10 million women & children exposed
78 branded DES products have been identified
www.cdc.gov/DES
DES
Known Risks of DES Exposure:Women who took DES have a 30% higher than average risk for breast cancerDES daughters:
50% higher than average risk for breast caHigher risk for clear cell adenocarcinoma (CCA) of vagina or cervixHigher risk for cervical dysplasia, CIN, and SILAt twice the risk of HSIL of vagina. Vulva, and cervixAnatomical abnormalities of the reproductive tract
DES GranddaughtersMore irregular menstrual cycles, infertility, fewer live births
DES
Follow Up of DES Daughters & Granddaughters:
Annual four quadrant pap
Annual clinical breast exams starting in adolescence
At least once – iodine staining of cervix and vagina to identify adenosis
Prenatal visits – follow closely for early dilation & effacement of cervix and prematurity
Avoid hormone exposure (OCs & HRT)
Anal Pap Smears
Relationship between HPV infection and the development of anal cancer
HPV 16 and 18 have been identified in 80% anal cancers
Anal cancer more common in women430 deaths/ year in women260 deaths/ year in men
Incidence increased past 30 years4650 case in U.S.
Anal Pap Smears
At-risk groups:MSM
HIV infected men and women
Immunocompromised men and women
Women with history of HGSIL of cervix and/or vulva
Women participating in anal receptive intercourse
Anal Pap Smears
No national recommendationsScreening NOT recommended byCDC, USPSTF, ACS, ISDA or National Guidelines ClearinghouseRecommended Annually by New York Dept of Health for following:
HIV +MSMHistory of genital wartsHistory of CIN
Anal Pap Smears
ProcedurePosition patient on side or in GYN stirrups
Use Dacron swab pre-moistened with tap water
Insert 2 inches and use a spiral motion
Gradually withdraw over 10 seconds (rotating)
Agitate in liquid fixative for 15 seconds
Oropharyngeal Cancer
Oral cancers develop through 2 pathways
Those initiated by sexual behaviors (HPV positive cases) (60%)
Those initiated by tobacco and alcohol use (HPV negative cases)
M. Gillison. (2008) Journal of the American Cancer Institute.
Oropharyngeal Cancer
Screening Techniques:Current
Annual clinical exam by visual inspection
FutureOral cytology
Oral HPV testing
Brush biopsy
Visual assistance devices
VACCINATION ISSUES IN A WOMEN’S HEALTH
PRACTICE
Vaccinations
Until recently, women’s health care providers viewed the topic of immunizations as the responsibility of Primary Healthcare Providers (PCPs)Two events have changed this:
Many women’s health care providers are functioning as PCPs The development and successful marketing of HPV vaccines
Immunizations
The challengeWhile we have an experience and a comfort level in dealing with STDs and the need for immunizations in pregnancy
Our Pediatric, Family and Adult Practice colleagues have been integrating immunizations in the practice
Immunizations
GardasilManufactured by MerckQuadrivalent, recombinant vaccine designed to reduce HPV strains 6, 11, 16 & 18 6 & 11 associated with ano/genital warts16 and 18 associated with cervical CA (60-70% of all cervical cancersJune 2006 FDA approved for girls & women age 9 to 26 (do not give if pregnant)Shown to be 100% effective in preventing cervical dysplasia related to HPV infectionVaccine seroconversion rate = 99.7%Administered at 0 – 2 – 6 monthsCost $125/ dose or $375 total
Immunizations
Gardasil (cont.)October 2009 FDA approved for boys and men aged 9 to 26Has been tested in women 24 to 45
Study was done during 24 month period91% reduction of incidence (95%CI)83% prevention rate for 16 & 18 (95%CI)Not yet approved by FDA
– FDA requesting a 48 month study
Immunizations
CervarixManufactured by GalaxoSmithKline
Approved late 2009
Bivalent vaccine: Protects against HPV 16 & 18
Recent evidence that it protects against 31, 33, & 35 ( other cancer causing HPV strains)
96.9% effective in prevention of infection with HPV 16 & 18
100% effective in prevention of cervical CIN 1 related to HPV 16 & 18
Immunizations
TwinrixManufactured by GalaxoSmithKline (1/08)
Hepatitis A Inactivated & Hepatitis B (Recombinant) Vaccine
Standard dosing = 0 -1 -6 months with booster at 12 months
Accelerated dosing = 0 -7days – 21 to 30 days with booster at 12 months
Immunizations (Adult)
VACCINE RECOMMENDATIONTd/Tdap 19yo and above: Td booster every 10 years
19-64yo : 1 dose Tdap then Td q 10 years
HPV 19-26yo ; 3 doses (0,2,6 months)
Varicella Over 19yo: 2 doses (0, 4-8 weeks)
Zoster Over 60yo: 1 dose
MMR 19-49yo: 1 or 2 doses
Over 50yo: 1 dose
Influenza 19-49yo: 1 dose annually
50 and over: 1 dose annually
Pneumoccal (polysaccharide)
19-64yo: 1 or 2 doses
Over 65yo: 1 dose
Immunizations (Adult)
Hepatitis A 19 and above: 2 doses (0, 6-12 months or
0, 6-18mos)
Hepatitis B 19 and above: 3 doses (0, 1-2, 4-6 months)
Meningococcal 19 and above: 1 or more doses
Immunizations
http://www.immunize.org/immschedules/immschedule_adult.pdf
BIOIDENTICAL HORMONE USE IN MENOPAUSE
What We Know
HTRelieves hot flashes
Relieves vaginal dryness
Preserves bone mineral density/reduces fracture risk
What We Know
There are 3 classes of estrogens used in HT:
Native or bioidentical estrogensEstradiol, estrone, and estriol
Natural estrogensConjugated estrogens
Synthetic estrogensEthinyl estradiol and quinestrol
Women’s Health Initiative
What the FDA said about the WHI study results: Treatment of menopausal symptoms such as
hot flashes and vaginal dryness, remains the main use for HT
HT should be used at the lowest effective dose for the shortest time period
HT should not be used for primary or secondary prevention of coronary heart disease (CHD)
Current GYN exam, pap test, mammogram
North American Menopause Society (NAMS)
Most recent statement July, 2008Women most likely to benefit from HT = around the time of menopause (preferably before age 60)
Benefit of HT decreases with advancing age and increasing time since menopause
Decreased risk of CHD in women starting HT within 10 years of menopause
Diagnosis of breast cancer increases with EPT use beyond 3 to 5 years
Effects of WHI Results on Patients
Women’s faith in conventional HT has been shaken
Search for a safer alternative to ease their menopausal symptoms
Accessibility of information on the internet, TV, and books
“Natural”/”Customized” formulations
Became appealing
Effects of WHI Results on Patients
Bioidentical Hormones
Derived from plant sources (Soy or wild Mexican yam root)Synthetic processing is used to derive the hormones usedThere is currently no central oversight on the production, prescribing or dosing of bioidentical hormonesCommercially available in Europe, South Africa, Australia, and New ZealandNot approved by FDA
Bioidentical Hormones
No large, prospective, well-controlled clinical trialsEstriol
Limited data suggest that it improves menopausal symptomsSome studies show improvements in BMDImpact on cardiovascular outcomes is unknownConflicting results of breast cancer risk
EstroneShown to relieve vasomotor symptoms and increase BMD (randomized, double-blind, placebo-controlled studies)Low potency (1/10 of estradiol)
Bioidentical Hormones
Take home messages:Need for RCTs
Patient education is keySee handout
Mammograms, RTIs & Recurrent BV
Mammograms
U.S. Preventive Services Task Force (USPSTF) 2009 Recommendations Regarding Mammograms
All recommendations are for women not at increased risk for breast cancer.
USPSTF Recommendations
No routine screening of women aged 40 to 49 years (C recommendation) The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
USPSTF Recommendations
Biennial screening mammography for all women aged 50 to 74 years
The current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older
Against teaching BSE
The evidence for CBE continues to be assessed as insufficient
Recommendations
1000 women in their 40's with annual mammograms for 10 yearsMore than ½ of them (500) will need repeat mammograms for concerning findingsNearly 1/5 (200) will get breast biopsies 2 deaths from breast cancer will be prevented
The American College of Obstetricians and Gynecologists (ACOG)
Maintains its current advice that women in their 40s continue mammography screening every one to two years Women age 50 or older continue annual screening. Continue to counsel women that BSE has the potential to detect palpable breast cancer and can be performed.
American Cancer Society
Yearly mammograms starting at age 40 and continuing for long as the woman is in good health.
Clinical breast exams (CBE) every 3 years ages 20 to 39 and anually thereafter
Breast self exam (BSE) is an option for women starting in there 20s.
American Academy of Nurse Practitioners (AANP)
Supports the USPSTF recommendations
Reproductive Tract InfectionsCDC Guidelines 2006
Retest all women 3 months after treatment for chlamydia (NOT a TOC)
Concern that women with repeated infections are more at risk for PID
Cefixime 400mgm more effective that Ceftriaxone 125mgm IM in treatment for gonorrhea
Reproductive Tract InfectionsCDC Guidelines 2006
Persistent Bacterial VaginosisInitial treatment
Followed by metronidazole 0.75% gel 2X a week for 6 weeks
Trichomoniasis VaginalisAlternate to metronidazole 2 grams stat:
Tinidazole 2 grams at once
Conclusions
New Guidelines based upon Evidence Based Research:
Cervical cancer screening and treatment guidelines
Breast cancer screening guidelines
Vaccinations
Hormone Replacement Treatment
STDs