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Women Veterans Health LAURA LAWRENCE, MPAS, PA-C Then and Now… Women Veterans Health Care 1988: Women Veterans Health Program 4.4% women veterans 8% More cost-effective medical and psychosocial care 2007: Strategic Health Care Group Office of Public Health and Environmental Hazards Increased scope of activities to include all services, including supplies (DEXA scans, mammography machines, u/s and biopsy equipment) 2011: Women’s Health Office of Patient Care Services (PCS) 2012: Women’s Health Services Increased collaboration between Women’s Health and programs including Primary Care, Mental Health, Specialty Care (cardiology, pain management) Increase in VA Health Care Use by Women Veterans of OEF/OIF/OND 8/13/2016 http://abc13.com/health/houston-va-expanding-programs-to-help-female-veterans/1491791/ Women Veterans Health Care Program Mission Comprehensive primary care by a proficient and interested PCP Privacy, safety, dignity, and sensitivity to gender-specific needs The right care in the right place and time State of the art health care equipment and technology High-quality preventive and clinical care, equal to that provided to male Veterans Women Veterans Health Care Strategic Priorities Comprehensive Primary Care Women’s Health Education Reproductive Health Communication and partnerships Women’s health research Special populations Reproductive Health Implement safe prescribing measures for women Veterans of childbearing age Improve follow-up of abnormal mammograms Track the timeliness of breast cancer treatment Ensure coordination of care for women receiving non-VA, maternity and emergency department care. BREAST DISORDERS History Masses Skin changes Nipple discharge Nipple inversion Mastalgia Family history OBGYN history Medications Social history Previous imaging/biopsies Physical Exam Inspection Skin appearance, skin thickening, size/symmetry, contour, nipple characteristics Arm movement: Overhead, to the sides, on the hips, leaning forward Palpation Supine and sitting Systematic Vertical Strip Pattern Breast and surrounding nodal basins NCCPA BLUEPRINT TOPICS Fibroadenoma Fibrocystic Disease Gynecomastia Galactorrhea Mastitis Carcinoma Fibroadenoma Most common etiology of breast “lump” Most common in young women Benign Discrete mass Mobile Non-tender to palpation Can change in size May have increased pain with menstruation or increased caffeine intake Fibroadenoma Diagnostic Evaluation Mammogram Ultrasound Possible biopsy Fibroadenoma Treatment Monitor every 6 months with ultrasound in addition to annual mammogram (if over 40 y/o) x 2 years If stable, no further treatment or monitoring needed If increasing size, consider surgical excision Fibrocystic Disease Benign Most common of all benign breast conditions Most common in women of reproductive age Occasionally seen with hormone replacement Fibrocystic Disease Clinical Manifestations Mastalgia Engorgement Increased breast nodularity Cysts Dense/thick breast tissue Diagnostics Mammogram Ultrasound Consider MRI if clinically indicated Fibrocystic Disease Treatment First Line: NSAIDs Second Line: OCPs Alternative: Primrose oil Galactorrhea Milky nipple discharge not associated with gestation Age: 15-50 y/o Causes: Pituitary gland overproduction, hypothalamic region dysregulation, medications that suppress dopamine, hypothyroidism Galactorrhea Diagnostic Evaluation Labs: Prolactin, TSH, pregnancy test, LFTs, renal function, FSH, LH, GH, adrenal function Imaging: Pituitary MRI with gadolinium enhancement if elevated serum prolactin Treatment Treat underlying cause Breast Cancer Second most common cause of cancer death in women 1:9 lifetime risk Risk factors: age > 60, first degree family history, nulliparity, 1st pregnancy after 30, menarche < 12, menopause > 50, obesity, tobacco use, previous radiation, hormone therapy Imaging Screening mammogram Diagnostic mammogram Ultrasound MRI Imaging: Mammogram Imaging: BIRADS Genetic Testing BRCA1, BRCA2, BART 5-10% of breast cancer cases 1% of population Indications: personal breast hx <45, dx any age with 1 close relative breast <50 or ovarian at any age, two breast primaries with first <50, triple negative <60, personal breast history <60 with limited family history, personal hx at any age with > 2 close relatives with breast at any age/pancreatic/prostate, close male relative, Ashkenazi Jewish, personal hx ovarian Breast and ovarian implications P53 Young women High risk for several cancers Breast Cancer: Clinical Manifestations Can be asymptomatic Breast or axillary mass Nipple discharge Nipple retraction or inversion Skin changes- peau d’orange Types of Breast Cancer Ductal Carcinoma In Situ (DCIS) Invasive Ductal Carcinoma (IDC)* Invasive Lobular Carcinoma (ILC) Inflammatory Breast Cancer (IBC)* Prognostic Factors Tumor Markers Estrogen Progesterone Her2/neu Ki67 Grade Oncotype Genetic test Breast Cancer Staging Tumor Node Metastasis (TNM) c = clinical p = pathologic Breast Cancer Staging: T TX: Primary tumor cannot be assessed Tis: DCIS T0: No evidence of primary tumor T1: Tumor < 20 mm in greatest dimension T2: Tumor >20 mm but <50 mm in greatest dimension T3: Tumor >50 mm in greatest dimension T4: Tumor of any size with direct extension to the chest wall and/or to the skin Breast Cancer Staging: N NX: Regional lymph nodes cannot be assessed (ex. Previously removed) N0: No regional lymph node metastases N1: Metastases to moveable ipsilateral level I, II axillary node(s) N2: Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted; or in clinically detected apparent ipsilateral internal mammary nodes in absence of clinically evident axillary lymph node metastases N3: Metastases in ipsilateral infraclavicular (level III) node(s) with or without level I, II axillary node involvement; or in clinically detected ipsilateral internal mammary nodes with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral supraclavicular node(s) with or without axillary or internal mammary node involvement Breast cancer staging: M Mx: Not assessed M0: No clinical or radiographic evidence of distant metastases M1: Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven larger than 0.2 mm Breast Cancer Staging Most common sites of metastasis are lymph nodes, bone, liver, and lung Indicated in patients with positive lymph nodes or >T3 Bone Scan CT Abdomen/Pelvis Chest Xray +/- PET/CT +/- Brain MRI Types of Treatment Surgical Oncology Segmental/Partial Mastectomy (Lumpectomy/Breast conservation therapy) Total Mastectomy Modified Radical Mastectomy Sentinel Node Biopsy Axillary Node Dissection Radiation Oncology Medical Oncology Chemotherapy Endocrine therapy (Hormone therapy) Radiation Therapy Whole breast radiation Daily for 4-6 weeks Partial breast radiation (APBI) Daily for 5 days Targeted therapy Side effects: skin discoloration, fatigue, breast shrinkage, increased risk of lymphedema Contraindications: collagen vascular disorders Chemotherapy Indications Positive lymph nodes Her2/neu+ Triple negative Large tumor size, shrink prior to surgery Oncotype Chemotherapy Taxol Adriamycin/ (AC) Weekly x 12 cycles Every 3 weeks x 4 cycles Herceptin Every 3 weeks x 1 year Most Common Side Effects: Hair loss, fatigue, nausea, diarrhea, neuropathy Possible contraindication: heart disease Hormone Therapy Tamoxifen Premenopausal 5-10 years Side effects: risk of DVT, RARE endometrial cancer, menopause Arimidex Postmenopausal Treatment Timeline Surgery Upfront 1 month before or after chemo Chemotherapy 6 months 1 month before or after surgery Radiation Final treatment 5 days or 4-6 weeks 1 month after surgery or chemo Plastic Surgery Local tissue rearrangement Tissue expander Contraindications: DM, smoking, possibly heart disease Implant Autologous Nipple reconstruction Gynecology Gs and Ps Leiomyoma Fibroids Benign Smooth Muscle tumor - Often multiple NOT Sarcoma (don’t confuse leiomyosarcoma 1/1000) Most common benign tumors More common in African Americans Middle to late reproductive years Heavy menstruation/urinary frequency Often cited for reason for Hysterectomy Treatment NSAIDs ? Levonorgestrel IUD Refer to GYN for other hormonal rx Uterine artery embolization/ligation RFA Myomectomy Hysterectomy Uterine Prolapse Uterine prolapse Aging Loss of support structures Obesity Traumatic /multiple vaginal births Painful/Loss of function Kegel exercises +/- Biofeedback/PT HRT Pessaries Surgery Uterine Prolapse Grading of prolapse 1st degree: To the ischial spine 2nd degree: To the introitus 3rd degree: Just beyond the introitus 4th degree: Complete uterine and vaginal inversion involving bladder and bowel Cystocele Cysts Ovarian Cysts Common Majority of women have at some point Can be severe Pelvic pain most common symptom Diagnose with pelvic ultrasound * Fluid filled Due to hormonal fluxes – treatments surround this Surgery can be performed - typically laproscopic Types Follicular – Corpus Luteum cysts – heterogenous – hair, teeth, etc. Cystadenomas after egg released Up to 4 in. usually last only a few weeks Dermoid – failure to release egg 1-2 in. last 2-3 mo. On outside of ovary – can be large and cloudy PCOS Multiple cysts mature sacs but no release Hirsuitism Other Cysts Plugging of gland PE diagnostic Can be painful or Or painless Watchful waiting Compresses Screen for STI Drain - Marsupialization vs. balloon Menopause Vaginitis Most common types • • • • Bacterial vaginosis Yeast infections Trichomoniasis Vaginal atrophy Vulvovagintis Vaginitis Trichomoniasis Vaginalis Cause pH (norm is 3.8-4.2) Discharge characteristics KOH (whiff test) T. vaginalisflagellated protozoan >4.5 Malodorous, yellow-green, copious, frothy +/- Bacterial Vaginosis (BV) Inbalance of vaginal florareplaced by Gardenerella vaginalis >4.5 Malodorous, thin, gray or white, sticky +; “fishy odor” Vaginal Candidiasis 90% Candida albicans <4.5 White, “cottage cheese” Absent (odorless) Other diagnostic factors Motile flagellelated Clue Cells on wet prep WBCs Pseudohyphae with buds (spaghetti and meatballs) Other S/S Vulvar irritation Worse after sex, pruritis Pruritis, burning, dysuria, dyspareunia Tx Flagyl 2g po x 1 Flagyl 500 mg po bid x 7d, clinda Fluconazole (oral or topical) Comments STD- 7.4 million/yr Common in PG Inc risk PID PG, DM, steroids, OCP, Abx, immuno 2010 WebMD Contraceptive Methods http://www.womenshealth.va.gov/WOMENSHEALTH/outreachmater ials/GeneralHealthandWellness/maternity.asp Human Papillomavirus (HPV) HPV DNA virus AKA venereal or anogenital warts Most common STD in US – 20 million* “HPV is so common that most sexually active adults become infected at some point in their lives” – CDC HPV occurs in 50-80% of sexually active women by the age of 50 ~100 recognized human papillomaviruses; 30+ can infect the genital area Most patients (90%) will clear virus on their own but persistence of ongocenic types can lead to cervical cancer 99% of cervical cancers contain at least 1 high-risk (oncogenic) type of papillomavirus 70% cervical cancers are HPV 16 and 18 HPV types 6 & 11 (condyloma acuminata) Most typical form Rarely associated with invasive SCC HPV types 16, 18, 31, 33, & 45 + 8 more Associated with SCC HPV Treatment 1° goal – removal Chemical treatments Patient-applied: Podofilox 0.5% gel/solution Imiquimod 5% cream Provider-applied: Podophyllin resin 15-25% - standard treatment Trichloroacetic acid (TCA) Ablative treatment Cryotherapy Laser treatment Excisional HPV Complications Women Cervical dysplasia – 1,000,000 cases / yr Cervical Cancer – 12,357 cases / yr Vulvar, Vaginal and Anal Carcinoma Men- “the carriers” Penile Cancer – 1,570 cases / yr Anal Cancer Both men and women Condyloma acuminata Studies link HPV with some H&N cancers HPV: Prevention June 2006 – Gardasil approved by the FDA for HPV serotypes 6, 11, 16, & 18 Recommended by the CDC in females 9-26 y/o Gardasil now recommended in males 9-26 y/o These 4 types of HPV cause 70% of Cervical Ca and 90% genital warts Administered in 3 doses at 0, 2, & 6 months Only ¼ of adolescent girls in 2007 vaccinated New vaccination released Feb. 2015 – Gardasil 9