Women’s Health

Kristin Hahn-Cover, MDAssistant Professor of Clinical

MedicineDepartment of Internal Medicine

Osteoporosis prevention

By NHANES III data (1988-94), mean total calcium intake below recommended level in female teenagersNHANES IV data (1999-2000)

Age 16-19: 779mg/dAge 20-39: 797mg/d

Milk consumption is responsible for 46% of calcium intake in 12-18 year old AmericansMilk consumption decreased by 36% among female teenagers from the late 1970’s to the mid-1990’s

Osteoporosis prevention

Adequate calcium intake1000-1500 mg/d

50-60% of older adults meet this recommendation

Adequate Vitamin D intake400-800 IU/d

Exercise, particularly resistance and

high-impact exercise

Osteoporosis screening

IndicationsPeople who have had ”fragility” fractures

Most women by age 65

People with risk factors for secondary osteoporosis

Other high-risk patients (by age 60?)

MethodsDXA scan at two sites most commonly

used

Folic acid intake

All women of reproductive age should get at least 400mcg of folic acid daily to reduce the risk of having a child with a neural tube defect

Domestic Violence Screening

Routine screening recommended; no clearly accepted best way to do soPhysicians are typically reluctant to ask about domestic violence, for many reasons“Expert” physicians were consulted regarding screening methods

Include with other safety questionsPhrase generally: “this is a real problem in our society…I want all my patients to know how to get help…”Have a high index of suspicion when a patient’s story doesn’t fit with their exam

Depression Screening

Depression costs $43 billion in the U.S. annuallyPoint prevalence of major depression in primary care is 4.8-8.6%

“usual care” without formal screening misses 30-50% of depressed patients

Many well-validated screening tools“Over the past 2 weeks, have you felt down, depressed or hopeless?”“Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

Vaccines

Td booster every 10 yearsConsider Tdap substitution for ages 18-65

MMR vaccine if uncertain regarding prior vaccination; contraindicated if pregnancy anticipated within 4 weeksFlu vaccine if pregnancy anticipated within flu seasonVaricella vaccine if uncertain immunity; contraindicated in pregnancyNew vaccines: HPV and Herpes zoster/shingles vaccines

HPV vaccine

Recommended routinely for girls 11-12

May also be given in ages 13-26Series of 3 injections

Targets 4 types of HPVCause up to 70% of cervical cancers Cause about 90% of genital warts

Not recommended during pregnancy$ 120 per dose (total $360)

Herpes zoster/shingles vaccine

Licensed in age > 6064% reduction ages 60-6918% reduction age > 80

Reduces risk of shingles by 50%Duration of post-shingles pain reduced by vaccination

Live vaccine, so don’t give in immunocompromised patientsHas not been studied in patients with history of shinglesIf patient has not had chicken pox, she should have primary varicella vaccination series, not this vaccine

Breast screening

Mammogram screening, age 40-49USPSTF evaluated trials containing a total of almost 200,000 participants

Relative risk 0.85 after 14 years’ observationNeed to screen 1792 to prevent one breast cancer death“…over 10 years of biennial screening among 40-year-old women, approximately 400 would have false-positive results on mammography, and 100 would undergo biopsy...for each death from breast cancer prevented.”

Digital mammography performs better than film in women under 50 and in postmenopausal women on HT

Breast screening

Mammogram screening, age 50 or older

USPSTF recommends annual or biennial screeningNo clearly-defined upper age limit; evidence of benefit in women as old as 74 years of age

If patients 75 and older have co-morbidities that limit life expectancy, mammogram of less benefit

Breast screening

Clinical breast examSensitivity 40-69%

Specificity 88-99%

13.4% of women will have false-positive results at least once, over 10 years, with screening every 2 years

Highest risk of false-positive results in women under 50

Breast screening

Breast self-examinationNo evidence of benefit in reducing breast cancer morbidity, or in allowing earlier detection

Breast cancer mortality no different in subjects instructed in BSE vs. subjects not instructed

Cervical Screening

Pap smearsUse lubricating gelDo annually, unless 3 consecutive annual Pap smears have been normal, and no change in risk factors—then acceptable to do Pap smear every 2-3 yearsASCUS Pap: triage by HPV DNADysplasia: refer to Gyn

Some evidence that can follow LGSIL in young women, since this is typically a marker for HPV infection, rather than a warning for impending cervical CA

If hysterectomy for benign cause, Pap smear screening not indicated

Cervical Screening

Chlamydia trachomatis and Neisseria gonorrhea screening

Routine screening for chlamydia is recommended for all sexually active women under 26 years of age

5-14% of screened females aged 16-20 are infected3-12% of screened women aged 20-24 are infected

Screening for gonorrhea recommended in high-risk women

Prevalence higher among African American patients than other ethnic groups0.43-5.3% of screened young adults infected

Colon cancer screening

Colonoscopy preferred to sigmoidoscopy in average-risk women

Study of 1463 asymptomatic women, 4.9% found with advanced neoplasia; 3.2% would have been missed by sigmoidoscopy

Colonoscopy more sensitive and specific than ACBE or CT colonography for lesions > 6mm

Emergency Contraception

Appropriate for unprotected or under-protected intercoursePrevents pregnancy from starting

Does not interrupt an existing pregnancyMany proposed mechanisms

Best if used within 72 hours of sexNo medical contraindications, but not indicated in suspected or confirmed pregnancyProgestin-only regimen is preferred method

0.75 mg levonorgestrel, two dosesMarketed as Plan BPrevents 60-85% of predicted pregnancies

Contraception

26-35% of adolescents do not use contraception with first intercourse

Girls under 15 less likely to use contraception with first intercourse

20% of teenage pregnancies occur within a month of first coitus85% of sexually active women who do not use contraception become pregnant in one yearTreatment to prevent pregnancy with EC or other contraception is a task separate from cervical screening with Pap smears

Contraception

Combination hormonal contraceptivesAct primarily by inhibiting GnRH release, which prevents ovulationSafe and effective for most women, and have non-contraceptive benefits

8 unintended pregnancies per 100 woman-years with typical use

Initiate oral contraceptives by Sunday-start method; if oligomenorrheic, start after a negative pregnancy test

Contraception

Contraceptive patch (Ortho-Evra)Comparable to COC’s in ideal effectiveness, but better complianceLess effective if patient weighs more than 200lbs/90kgAdhesive reactions can be problematicHigher estrogen levels of concern, consider equivalent to COC with 50mcg of ethinyl estradiol

Contraceptive vaginal ring (NuvaRing)Left in place for 3 weeksComparable to COC’s in ideal effectiveness, but compliance may be betterVaginal discharge and irritation can occur

Contraception

Progestin-only pillsUsed when contraindication to COC8 unintended pregnancies per 100 woman-years with typical use

Depo-medroxyprogesterone acetateIM injection every 3 monthsIrregular bleeding common at firstAmenorrhea in 60% at 12 monthsWeight gain commonDecreases in bone mineral density of concern, with FDA black-box warning for use beyond 2 years

Postmenopausal hormone therapy

WHI disproved effectiveness of PremPro for preventive therapy

No clear reason to presume this applies only to CEE + MPALess evidence of harm, but no net benefit with CEE alone

Only compelling reason to initiate systemic HT is to treat vasomotor symptoms unresponsive to other treatments

Osteoporosis improves with treatment, but not sufficiently for this to be the only reason to treat with HTUrogenital atrophic symptoms improve, but vaginal estrogen is presumably a safer way to treat

HT duration should be limited, as possibleThere is a subgroup of women who have intolerable vasomotor symptoms off of HT/ET—for them, a careful discussion of risks and goals may lead to the joint decision of prolonged HTFDA recommends that postmenopausal women “use CEE only for menopausal symptoms at the smallest effective dose for the shortest possible time.”

Hypertension

In the Women’s Health Initiative Observational Study, mortality risk from CVD was lowest in women on diuretics, either alone or in combination

Increased risk in women on CCBs

Nonfatal CVD risk not different between groups

Cardiovascular risk

In the HOPE study including 2182 women with cardiovascular disease, increasing waist-to-hip ratio correlated with increasing rate of cardiovascular outcomes

Ratio > 0.8 high risk

Evidence that women with diabetes are at higher risk for cardiac death than women with prior history of MIIn Women’s Health Study of low-risk women, ASA 100mg every other day did not alter risk of CVD

RR stroke 0.83Still worthwhile to consider ASA for primary prevention if 10-year Framingham risk >6%