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ETSU Internal
Medicine Board
Review:
Women’s Health
Deidre Pierce, MD
Goals and Objectives
• US Preventive Task Force Recommendations Specific to Women
• Cardiovascular Health in Women
• Ischemic Heart Disease
• Hypertension • Female Sexual Dysfunction
• Approach to the Patient
• Classification • Contraception and Preconception Counseling
• Pregnancy and Disease
• Cardiovascular Disease and Pregnancy
• Thyroid Disease and Pregnancy
• Other Diseases and Pregnancy
Goals and Objectives
• Geriatrics and Women
• Menopause
• Overview
• Vasomotor Symptom Management
• Urogenital Symptom Management
• Osteoporosis
• Clinical Presentation/Evaluation
• Treatment and Monitoring
• Breast masses
• Clinical Presentation
• Evaluation
• Breast Pain (Mastodynia)
• Clinical Presentation
• Evaluation
Goals and Objectives
• Other reproductive health issues
• Vaginitis‐ diagnosis and treatment
• Abnormal Uterine Bleeding
• Chronic Pelvic Pain
• Dysmenorrhea
• High Value Care Recommendations
What are Specific History Points for Women’s Health
• Reproductive Health (contraception, menstrual history and current and past sexual activity and habits, PAP smear history‐abnormal results & interventions)
• Obstetric History (gestational DM, HTN, large infants (>9lbs), miscarriages, delivery method)
• Breast Health‐ (fibrocystic disease, biopsies)
• Family history of female cancers, osteoporosis
• Domestic Violence
USPTF Recommendations for Non‐Pregnant Women
• http://epss.ahrq.gov/ePSS/
• Aspirin ‐ages 55 to 79 years Stroke reduction‐
Grade A • Breast Cancer Screening‐screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women age 50‐74 years‐ Grade B USPTF Recommendations for Non‐Pregnant Women
• Cervical Cancer Screening‐ages 21 to 65 years‐
Grade A
• cytology (Pap smear) every 3 years • women ages 30 to 65 years who want to lengthen the screening interval with a combination of cytology and human papillomavirus (HPV) testing every 5 years
• Chlamydia Screening‐ screening for <24 years of age or older if risk factors‐ Grade A
USPTF Recommendations for Non‐Pregnant Women
• Cholesterol Screening for women
• <45 years of age if risk factors for CV Disease‐Grade B
• >45 years of age if risk factors CV Disease‐ Grade A
• Domestic Violence Screening‐ Grade B
• Folic Acid Supplementation‐all women planning or capable of becoming pregnant‐ Grade A
• Osteoporosis‐osteoporosis in women age ≥65 years or younger if fracture risk ≥ 65‐year‐old white woman with no additional risk factors.‐Grade B Case Question
• A 57yo female patient who has PmHx of HTN, obesity, DM2 and HPL with family history of heart disease comes to your office complaining of fatigue and dyspnea. She reports no chest pain or pressure either with activity or rest. You:
• 1. Exclude cardiac as etiology as she has no chest pain
• 2.Recommend exercise regimen be increased
• 3. Consider depression, I mean, with her health issues who would not be depressed.
• 4. Consider further evaluation of cardiac status
Ischemic Heart Disease (IHD) and Women
• Cardiovascular Disease leading cause of death in women
• Less obstructive CAD and more preserved LVF, but
• More frequent symptoms
• More frequent ischemia
• Higher mortality
• Evidence that women benefit from same therapies but still having less aggressive treatment and worse outcomes
Traditional and Novel Risk Factors‐ Women IHD
• Framingham underestimates risk of women (consider Reynolds Risk Score)‐ adds CRP, A1C and other info
• Dysfunctional ovulation with functional hypothalamic amenorrhea associated with premature CAD
• Polycystic Ovarian Syndrome‐ increased CAD risk
• Hormone therapy with SERM or aromatase inhibitors may increase risk
• WISE Study‐ HRT initiated in women <55yo with natural, not surgical menopause less angiographic CAD‐ so type of menopause affects CAD and HRT?
How do Traditional Risk Factors Differ among Sexes
• Lipids
• Low HDL (<50) more predictive of heart disease in women than high LDL‐so treatment goal women >50mg/dl (only treatment difference)
• Elevated triglycerides more predictive in older women, total cholesterol only seems important in younger women
• Lipoprotein is a determinant in women <66yo whether pre or post menopausal
• Family history present more often in female patients with CAD
• Minimal smoking by women affects risk more (relative risk 2.4 for 1.4 cigarettes per day
Pathophysiology and Clinical Manifestations
• Symptomatic women without obstructive CAD
• ½ demonstrated microvascular dysfunction as impaired flow reserve
• Many factors can predispose to functional ischemia so may need different therapeutic paradigms
• Symptoms differ
• Women more likely to have atypical chest pain at rest or persist for longer periods after exercise
• Fatigue and dyspnea more common presentation
• If ACS, less often typical ischemic symptoms and more often without chest pain but with one other typical component
Hypertension and Women
• Thiazides may reduce bone loss and hip fracture so consider in post menopausal women
• More often experience stroke when HTN uncontrolled
• Higher incidence of diastolic dysfunction in women
• Women more likely to develop LVH but experience less regression of hypertrophy in response to anti‐
hypertensive treatment
Sexual Dysfunction
• A 42yo married monogamous female comes to PCP office reporting sexual issues with her husband. Intercourse is painful and she is now avoiding sexual intercourse. She asks what could be causing the issue. Diagnosis is likely
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A. Vaginismus
B. Depression
C. Dyspareunia
D. Sexual Arousal Disorder
Female Sexual Dysfunction
• sexual difficulties that are persistent and personally distressing to the patient
• affects up to 35% of sexually active women, peaking in middle‐age • the practitioner should routinely ask about sexual function • query if a patient is sexually active
• if there are any related problems, including pain with intercourse (if so detailed sexual hx)
Physical Examination and Testing
• A pelvic examination is important
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specific areas of pain
vaginal atrophy
inadequate lubrication
vaginismus
• Laboratory testing only if suspicion for particular diagnosis
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prolactinoma
thyroid abnormalities
adrenal disease.
no approved any medication for the treatment of female HSDD. Individual and couples sex therapy or psychotherapy may be beneficial.
Sexual Desire Disorders‐
HSDD
• Hypoactive sexual desire disorder (HSDD) ‐persistent lack of sexual thoughts or desire for or receptiveness to sexual activity
• most common female sexual disorder, affecting 12% to 19% of U.S. women
• Desire encompasses three separate components—drive, cognition, and motivation. • Drive‐sexual interest, is biological based on neuroendocrine functions
• Cognition‐belief and value framework patient has regarding sex
• Motivation ‐willingness to engage in sexual activity‐
psychosocial factors.
Sexual Desire Disorders‐
SAD
• Sexual aversion disorder (SAD)‐persistent or recurrent aversion to any genital contact with a sexual partner
• usually experience feelings abhorrence and revulsion
• panic may accompany specific sexual situations. • Avoidance of sexual behavior typically reinforces the aversion, treatment often involves:
• graduated re‐introduction of sexual behavior
• relaxation exercises
• may be augmented by therapy with a selective serotonin reuptake inhibitor (SSRI)
Sexual Arousal Disorders
• Female sexual arousal disorder –inability to complete sexual activity • with adequate lubrication
• absent or impaired genital responsiveness to sexual stimulation
• Cognitive‐behavioral therapy with sensate focus and training to improve partner communication are effective strategies
• Inadequate Lubrication‐
• Systemic or local estrogen therapy can increase lubrication in postmenopausal women provided no contraindications (see Menopause section)
• Premenopausal women‐vaginal moisturizers can be helpful
Sexual Pain Disorders‐
Dyspareunia
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Dyspareunia‐persistent urogenital pain
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Therapy is aimed at identifying and treating the underlying cause, which may include
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occurs around intercourse not related exclusively to inadequate lubrication or vaginismus
Coexisting vaginal atrophy and inadequate lubrication may worsen the pain syndrome and usually can be diagnosed on physical examination. vulvodynia
interstitial cystitis
pelvic adhesions
infections
Endometriosis
pelvic venous congestion
Treatment •
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Vaginal estrogen frequently improves atrophy symptoms
systemic estrogen or estrogen‐progesterone therapy can increase vaginal blood flow and lubrication Successful treatment strategies must address: •
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complex psychological and behavioral changes desire and arousal disorders that often develop as a result of the painful sexual experience.
Sexual Pain Disorders‐
Vaginismus
• Vaginismus‐ involuntary, recurrent, and persistent spasm of the outer third of the vagina, preventing desired vaginal penetration • situation‐specific, for example, pelvic examinations or intercourse
• anticipation of pain with vaginal entry underpins this diagnosis and may result in sexual avoidance
• Treatment involves: • cognitive‐behavioral therapy • Systematic desensitization teaches • deep muscle relaxation • dilators
Orgasmic Disorder
• Female orgasmic disorder is the persistent or recurrent delay or absence of orgasm following a normal excitement phase. • Cognitive‐behavioral therapy is most effective for teaching a woman to be comfortable, minimizing negative attitudes, and decreasing anxiety.
Contraception
• A 25‐yo female smoker comes to establish care and requests the most reliable contraception with the least side effects. What should be recommended?
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A. Condoms
B. Oral Contraceptives C. IUD
D. Sterilization
Contraception
• Women >35 who smoke >15 cigarettes/day‐ NO ESTROGEN
• Nearly ½ of pregnancies in US unintended
• Adherence can be improved with counseling
• Risk overview of each method
• Barrier methods rely on user skill/technique
• Pills have issues with adherence especially low dose as must be at same time daily
• Combo Patches increased dose bigger VTE risk/local Rx
• Surgical for the most part irreversible
• Long acting preparations delay return to ovulation
BEWARE‐ Hormonal Contraceptive Users
• CYP3A inducers can reduce effectiveness
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Barbiturates
Carbamazepine
Anti‐seizure medications
Rifampin
Some Anti‐retroviral agents
• Antibiotics and other neurologic medications can alter via other mechanisms
• Additional barrier methods should be used concurrent and 4 weeks after discontinuation
Combined oral contraceptives (COCs)‐
Oral, Patch and Ring
BENEFITS (decreased issue with following)
RISKS
• VTE
(RR 3‐6 x)
• Dysmenorrhea
• Hypertension
• Menorrhagia & Anemia
• Stroke
• Symptomatic ovarian cysts
• Cervical cancer (>5 years of use)
• Endometrial and ovarian cancer
• Liver cancer
• PMDD
• Pregnancy category X
• Non‐adherence (ring and patch)
• Hirsutism (oral)
• Myocardial infarction (1/100,000; none after years 10 years w/o)
• Lower systemic estrogen (ring)
• Breast cancer (none > 10 yrs w/o)
(RR 2‐6 if migraines)
• Increases triglycerides
• Worsen acne
• Breakthrough bleeding
• Increased vaginitis (ring)
Progestin‐only Formulations • Use if estrogen contraindicated (uncontrolled HTN, liver disease, hx thrombosis, breast cancer, migraine w aura)
• May worsen acne
• Mini‐pill must have precise daily dosing
• Long‐acting (depot or implant) have own issues (besides delayed ovulation resumption)
• Irregular bleeding, amenorrhea, decreased bone density (especially adolescents)
• BUT benefits with long effectiveness, improved endometriosis, decreased endometrial CA & PID (?)
Intrauterine Devices (IUD)
• Low cost and least user dependent
• Lowest failure rate (even typical use much less than 1% per year)
• Copper is non‐hormonal and good for up to 10 years and can be implanted within 5 days of unprotected intercourse for emergency contraception
• Levonorgestrel effective up to 5 years and decreased blood loss and anemia
• No STI protection, bleeding, pain and expulsion are big risks
Barrier Methods
• Highest failure rate and most user dependent
• Do provide protection from STIs
• Often need spermicide
• Old friend the male condom least failure rate among these methods (2% perfect/15 %typical use)
• Others included female condom and diaphragm, cervical cap and vaginal sponge
Emergency Contraception (4 in US )‐
within 5 days of concerning sexual encounter • Levonorgestrel‐ single dose (1.5mg) available OTC (Rx if <17yo)‐ most used, most effective
• Levonorgestrel‐two‐dose (0.75mg x2‐12 hrs apart)
• High Dose Combo OCP (100mcg ethinyl estradiol x2‐
12 hrs apart)‐common to have N/V, dizziness and H/A
• Copper IUD
Sterilization
• Complications a big risk
• Regret also an issue as typically irreversible
• Tubal ligation may reduce ovarian cancer risk but increased risk of ectopic pregnancy if occurs
• Vasectomy costs less, fewer complications and more effective
Absolute Contraindications to Pregnancy‐ CV
• Pulmonary and arterial hypertension‐ any cause
• Severe systemic ventricular dysfunction (NYHA III‐IV and/or LVEF <30%)
• Previous postpartum cardiomyopathy with any residual impairment
• Severe mitral stenosis
• Severe symptomatic aortic stenosis
• Marfan Syndrome with aorta dilated >45mm
• Aoric dilation >50 mm in aortic disease associated with bicuspid aortic valve
• Native severe coarctation
Preconception Counseling
• Office Visit‐ each time ask reproductive age women if considering pregnancy (if not, how preventing)
• Lifestyle Counseling (ETOH, drugs, nutrition, tobacco, activity level, obesity)
• Immunization status
• Varicella and rubella‐ wait 4 wks prior to conception if vaccinated
• Flu if pregnant during season
• DPT if not vaccinated as adult
Preconception Counseling (more issues)
• Medication Review‐minimize/discontinue contraindicated meds
• If a question of chronic disease/ health condition and pregnancy contraindications, may require specialist referral (genetics, etc.)
• Environmental hazard/toxin counseling
• Consider infectious dx screening/health maintenance up to date (PAP, ?HIV)
• Folic acid (400mcg/day) for all reproductive age‐more if
• hx of neural tube defect • Obese
• anti‐seizure medication
• 35yo AAF with PMHx lupus and hypothyroidism presents because of polyuria, polydypsia & fatigue. She has gained approx. 30 lbs. over the past 7 years. Her mother and father both have DM. On exam, her BP is 150/90 and you note acanthosis. FBG is 150, hba1c is 8, LDL 160, and Cr 0.9. You want to start her on metformin, lisinopril, and atorvastatin. Current medication is levothyroxine only. She is sexually active with her significant other and uses no contraception.
• What additional critical historical information do you need to know before proceeding?
Things doc should know every time…
• Can she be pregnant?
• Implications for meds, procedures, dx.
Can she get pregnant?
‐Implications for meds and dx.
‐What birth control options are best?
Medication Considerations
• HTN:
• Avoid: Ace, ARBs (enalapril only ACE post partum if breastfeeding by AAP)
• Preferred: Methyldopa, labetalol, nifedipine
• Forget hydralazine used to use but linked to poor outcomes‐ no longer first line
• Hyperlipidemia:
• Avoid: Statins
• Preferred: Lifestyle modifications
• DM:
• Avoid: TZDs
• Preferred: Insulin (?metformin, ??glyburide)
Reminder of some changes during pregnancy
• Increased progesterone leads to relative hyperventilation and mild respiratory alkalosis
• Reduces bicarbonate by average of 4
• Mild bilateral hydronephrosis‐ physiologic‐
>90% of women
• Prothrombotic changes
• Increased fibrinogen, vWF and Factor VIII
• Decreased vWF cleaving protease (ADAMTS13)
• CV changes on subsequent slides
Cardiovascular Disease and Pregnancy
• Most common cause of death during pregnancy in industrialized nations
• Increased survival with congenital heart disease
• Older maternal age
• Increased atherosclerosis during childbearing years
• Increased obesity and DM2
• Maternal Death Rate (2006‐2008)
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11.3 per 100k caucasian/34.8 per 100K A‐A
CVD 14.6%/Cardiomyopathy 12.4%
Hemorrhage 11.5%
Hypertensive Disorder 10.5%
Thrombotic PE 10.3%
Other (infection/sepsis 11.1%/ non‐CVD 11.9%)
More CV Disease and Pregnancy
• Changes during pregnancy
• 1st 24 weeks Blood volume increases, SVR decreases
• 30‐50% augmentation of cardiac output
• Early in pregnancy related to increased stroke volume
• 3rd trimester due to increased heart rate
• Labor and Delivery
• 300‐500ml of blood into circulation with each uterine contraction
• Relief of vena‐caval compression increases venous return
• Cardiac output up to 180% of pre‐pregnancy
• Vaginal delivery preferred usually if CV disease
• Caesarian increased risk of hemorrhage, infection, thrombosis
• Hemodynamic stress limited with epidural anesthesia
MI in Pregnancy
• Relative to median risk
• Women >40 yo 30x risk
• African American 8X risk
• Risk factors
• >35yo, HTN, smoking, DM2
• Pre‐eclampsia, thrombocytosis, infection, previous OCP use
• Evaluation‐ Treadmill testing w/w‐o Echo (radionuclide contraindicated)
• Intervention
• STEMI‐ choose stent to minimize length of dual antiplatelet Tx
• NSTEMI‐ supportive care unless intermediate or high risk
• Shock, acute MR, acute VSD
Cardiomyopathy in Pregnancy
• Peripartum‐ common final month to 5 months post partum
• >50% recover normal size and function within 6 months
• Recurrence risk 30‐50%‐especially if residual symptoms‐ so no additional pregnancies
• Hypertrophic cardiomyopathy‐ generally well‐
tolerated in pregnancy
Thyroid Disease in Pregnancy
• Hypothyroidism
• Can adversely affect maternal health
• Establish diagnosis in first trimester
• Fetal brain and thyroid develop at this time
• No clear screening guidelines but “should be avoided”
• Women with known hypothyroidism often require dose increase up to 50%
• Hyperthyroidism
• Can occur when HCG stimulates TSH‐ often no treatment needed
• Graves Disease‐ TSH receptor stimulating AB can cross placenta
• PTU 1st trimester treatment
• Methimazole remaining trimesters
Preeclampsia and HELLP Syndrome
• Preeclampsia‐ new onset after gestational week 20 of persistent HTN and proteinuria >300mg/24hr‐ in previously normotensive woman
• Oliguria, epigastric and RUQ pain, impaired liver fx
• Cerebral and visual disturbances, AKI (1‐5%)
• Pulmonary edema, thrombocytopenia and fetal growth retardation
• HELLP Syndrome‐peak incidence weeks 27‐37, 70% develops prior to delivery (15‐20% no HTN or proteinuria)
• Microangiopathic anemia, elevated liver enzymes and low platelets, 15% AKI (if have 46% will need dialysis)
• Additional Sx: nausea/vomiting, epigastric/RUQ pain
• Treatment for both: Delivery and Supportive Care
TMA (TTP‐AHUS)
• TMA‐ fibrin and/or PLT thrombi in multiple organs
• TTP‐ develops 2nd‐3rd trimester‐ADAMTS13 deficiency
• Ultralarge multimers of vWF promote plt aggregation
• Fever, thrombocytopenia, neurologic symptoms, microangiopathic hemolytic anemia
• Differentiate from HELLP and preeclampsia by LFT elevation
• Atypical HUS‐21% occurs pre/79% post‐partum
• Protein mutations in the alternate complement pathway spontaneously stimulate excessive stimulation of alternate pathway factors causing endothelial damage
• Symptoms same as TTP but less neuro symptoms
• Treatment for both‐ plasma exchange and other treatment as for non‐pregnant
Acute Fatty Liver of Pregnancy (AFLP)
• Characterized by acute liver failure and coagulopathy
• Symptoms: a continuum but involve
• Nausea, vomiting, anorexia
• Epigastric pain and jaundice develops after several days, hypoglycemia, AKI in 60%
• Differentiate from HELLP in this case with • Coagulopathy
• Hypoglycemia‐ may need 10% dextrose treatment
• Not usually thrombocytopenia here
• Treatment: low carb, high protein diet, lactulose and delivery
Lupus and Pregnancy
• Pregnancy exacerbates especially if lupus nephritis (Crea >1.4 mg/dl) or proteinuria >0.5g/24hr
• Treatment: steroids and azathioprine, hydroxychloroquine
associated with improved outcome and no fetal toxicity
• Treatments to avoid
• Cyclophosphamide‐ detrimental fetal effects
• Mycophenolate‐ teratogenic
• Stop 6 weeks prior to conception
• Bone marrow suppression
• Developmental anomalies
• Cleft palate, microtia, short fingers, nail abnormalities
Case Question
• A 55‐yo female smoker comes into your office requesting treatment for her menopausal symptoms and preventive care. She has not seen an physician in about 10 years. Last menstrual cycle was 18 months ago. You recommend
• A. Dexa scan to assess bone density
• B. HRT for her lifetime to prevent menopause symptoms
• C. Preventive health measures to include lab testing, colonoscopy, CT scan
• D. A and C only
• E. All of the above
Menopause
• Retrospective/Clinical Dx‐ cessation menses 12 months
• Hormonal changes early menopause but not needed for diagnosis
• FSH >40 units/L
• Estradiol <20ng/ml
• Average age ‐51
• Vasomotor and Urogenital Symptoms big issues
Vasomotor Symptom Management
• “Hot Flashes” and night sweats ‐50% women experience but spontaneously resolve within few years of onset
• Smoking, obesity and sedentary lifestyle risk factors for increased issue
• Behavioral changes can help • Treatment
• Hormonal‐ most‐effective‐FDA approved (mod‐severe sx)
• not longer 5 yrs
• Lowest dose, shortest period of time possible • Taper or stop abruptly‐ no change in sx recurrence
• Non‐hormonal
Hormone Replacement Therapy (HRT)
• Absolute Contraindications
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Pregnancy (don’t forget to consider in Diff Dx)
Unexplained vaginal bleeding
Hx CAD, stroke or VTE
Hx Breast or endometrial CA
Hypertriglyceridemia
Immobilization
• Cardiovascular Risk
• No increased risk among women 50‐59 if menopause at median age
• May think twice if elevated Framingham Risk • Do not start if >60yo, median age menopause, and no previous HRT
More about HRT
• Systemic treatment for vasomotor symptoms
• Limited data less VTE risk with transdermal avoids hepatic 1st pass effect
• Common adverse effect
• Breast tenderness
• Uterine bleeding
• Women with intact uterus
• must have combination estrogen/progesterone • Helps prevent endometrial hyperplasia/cancer
• Benefits (besides sx relief)
• Combination Tx –decreased osteoporotic fractures and colorectal cancer
• Risks
• Combination Tx‐increased invasive breast cancer, CAD, stroke, VTE, may increase lung cancer risk among older smokers (need more study)
• Estrogen only‐ only stroke increased
Non‐Hormonal Therapy
• Antidepressants
• Studies support SNRIs (venlafaxine and desvenlafaxine)
• One SSRI‐ paroxetine
• Mixed results with other SSRIs
• Soy Isoflavone‐ mixed studies
• Forget the herbs‐ no data to support
• Red clover extract
• Black cohosh
• Random medications that may also reduce symptoms
• Gabapentin
• Clonidine Urogenital Symptoms • Vaginal atrophy and thinning epithelium‐ usually ongoing
• Dyspareunia, dryness and itching of vagina
• Dysuria and frequent UTIs
• Hormonal Therapy‐ local does not need progesterone
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Conjugated and estradiol creams
Vaginal estradiol tablets (10‐25mcg)
Estradiol vaginal ring
Ring and tablets preferred as less systemic absorption
• Non‐Hormonal Therapy‐ moisturizers and lubricants
Osteoporosis
• Risk Factors
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Advancing Age
History of steroid use
Previous fracture
Parental history of fracture
Smoking
Low body weight
Heavy ETOH consumption
Secondary osteoporosis
• Diagnosis with fragility fracture or Dexa Scan of bone density
• If a fracture do not need BMD to diagnose
• T score less than 2.5 indicates osteoporosis
• Frax Tool can be used to assess fracture risk‐ 10 year
• http://www.shef.ac.uk/FRAX/
Osteoporosis‐ Treatment
• Lifestyle/ Dietary measures
• Calcium 1200 mg/day and Vitamin D 800U /day minimum
• Exercise‐ weight bearing (walking) 30 minutes‐
3x per week
• Smoking cessation
• Fall prevention
• Limited alcohol use
Osteoporosis‐ Drug Therapy‐ 1A recommend • Bisphosphonates first line therapy
• Daily, weekly, annual preparations available
• Daily or weekly preferred unless not tolerated‐
alendronate‐insurance prefers‐
generic/inexpensive
• Side effects usually related to GI upset
• Ensure patient instructions clear as absorption a problem
Osteoporosis‐ Other treatments
• Raloxifene‐ inhibits bone resorption and prevents vertebral fractures
• Good to use if invasive breast cancer risk
• 8 year safety and efficacy data
• Tamoxifen‐ not used for this alone but if receiving after breast cancer some bone protection
• Denosumab‐ if cannot tolerate bisphosphonates and impaired renal function
• Skin infections greater than placebo
• Must correct hypocalcemia prior to starting
• PTH therapy
• Severe osteoporosis who cannot tolerate bisphosphonates
• Those who continue to fracture after one year of bisphosphonates
• Contraindications to bisphosphonates and cannot tolerate other therapies
Case Question:
24 year old female presents for an “annual exam.” She has had a pap last year which was normal. She is sexually active with one partner, using condoms. You decide that she is not yet due for a repeat. You tell her:
• 1. She needs chlamydia screening.
• 2. She should consider additional contraceptive options. • 3. She should start a prenatal vitamin. • 4. All of the above.
• She also reports some yellowish vaginal discharge associated with irritation x 3 days. Her partner is without symptoms. She denies a prior history of STDs.
• You:
• 1. Check a nitrazine ph. test, a wet mount and check for GC/chlamydia.
• 2. Tell her the most likely diagnosis is candidiasis.
• 3. Give her a Fluconazole pill so you don’t have to do a pelvic exam
Vaginitis
a spectrum of infectious and noninfectious conditions that produce characteristic vulvovaginal symptoms, including vaginal discharge, vulvar itching, burning, and irritation
Etiology
• Most Common (Infectious)
• Less Common (Non‐infectious)
• Bacterial Vaginosis
• Vaginal atrophy
• Vulvovaginal Candidiasis
• Certain Dermatologic conditions
• Trichomoniasis
• Allergic Reactions
Bacterial Vaginosis (BV)
• Risk Factors: douching, lack of condom use, and multiple or new sexual partners (although BV may also be diagnosed in women who have never been sexually active)
• BV can be diagnosed by the presence of three of the four Amsel criteria:
• 1. abnormal discharge that is thin, gray/white, and homogeneous
• 2. vaginal pH greater than 4.5
• 3. positive “whiff” test
• 4. the presence of clue cells on saline microscopy.
Trichomoniasis
• profuse malodorous yellow‐green discharge with vulvar itching, burning, and postcoital bleeding
• Vaginal pH >4.5 • presence of motile trichomonads on saline microscopy
• Sensitivity/ specificity of pH and the saline microscopy are low so can culture
• Treat partner as well
Vulvo‐vaginal Candidiasis (VVC)
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1/3 of women will have two or more infections in their lifetime (10‐20% colonized)
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Hallmark symptoms:
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vulvar pruritus
external dysuria
thick, “cottage‐cheese” discharge
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history alone is insufficient for reliably establishing the diagnosis
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VVC is confirmed:
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if sx are accompanied by the presence of yeasts, hyphae, or pseudo hyphae on microscopy
Gram stain, or if a vaginal culture is positive for yeast
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Vaginal pH is normal in VVC
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As the sensitivity of microscopy may be as low as 65%, empiric treatment for VVC can be considered •
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if vaginal culture is unavailable
symptoms are accompanied by characteristic physical examination findings.
Microscopic Examination of Vaginal Samples
Infectious Vaginitis Treatments
‐Bacterial Vaginosis: oral or vaginal metronidazole, 500 mg twice daily 5‐7 d
‐Trichomoniasis: single 2‐g oral dose metronidazole
‐Candidiasis: single 150‐mg oral dose of fluconazole or less costly miconazole or clotrimazole creams or vaginal suppositories
Complicated (pregnant, DM, HIV, immunosuppressed) ‐topical imidazole treatment for up to 14 days or
‐two doses of oral fluconazole given 3 days apart
‐pregnant women, VVC is treated with a 7‐day course of topical imidazole
Recurrent (>4 episodes with symptoms in 1 yr)‐7‐ to 14‐day course of topical imidazole therapy or oral fluconazole every third day for a total of three doses, followed by oral fluconazole weekly for 6 months
‐Non‐C. albicans Candidiasis (15‐20% recurrent)‐Tx 2 weeks intravaginal boric acid
• 56 yo AAF w/ PMH of DM with 2 days of scant vaginal spotting. She has been taking lots of aspirin lately for a strained rotator cuff. She denies other abnormal vaginal discharge or irritative symptoms. Her LMP was at age 50. She is sexually active with the same partner for the past 30 yrs. No dyspareunia or prior post‐
coital bleeding. No HT/tamoxifen hx. No FMH ca. She is G0P0. Her last pap was two years ago and normal with a neg. HPV digene. BMI 35.
• 1. Reassure her, as it was likely related to all of the nsaids & tell her to return if it recurs.
• 2. Do a pelvic, evaluate for infections, order TVUS.
• 3. Do a pelvic, dx. pap, evaluate for infections, order TVUS & refer her for EMBx.
Abnormal Uterine Bleeding (AUB)
• Any bleeding that is excessive:
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<21 day interval
Volume/ duration
> 25 pads or flooding (>80 mL)
Outside of the normal menstrual cycle
After 6 months of amenorrhea
Any uterine bleeding in a post‐menopausal female is abnormal and must be evaluated (endometrial cancer)
Quick Definitions
• Polymenorrhagia‐ more than q24 days
• Oligomenorrhea – less than q35 days
• Metorrhagia‐irregular or intermenstrual bleeding
• Menorrhagia‐excess bleeding in normal cycle
• Metomenorrhagia‐ irregular interval cycle with excessive bleeding
Initial Evaluation AUB
• Stressors, diet, exercise, weight change, trauma, substance abuse
• Changes in blood loss
• Flow pattern or amount
• Presence of clots
• Chronic disease considerations
• Liver, kidney, thyroid, autoimmune
• Bleeding disorders
Further Evaluation/Etiologies
• Pregnancy Test
• PAP smear
• STI screening
• Pelvic Ultrasound
• Most common etiologies: PALM
• polyp • adenomyosis
• leiomyoma/fibroids*
• malignancy/ hyperplasia
Pelvic Ultrasound
• Structural abnormalities on exam
• Abnormal bleeding despite evidence of ovulatory cycles
• New onset intermenstrual bleeding
• >35 years old (assess stripe thickness) • prior to therapy initiation
• >5mm warrants endometrial biopsy
Risk Factors for Endometrial Ca
•
50‐70 have 1.4 % risk
2
Treatments for Premenopausal AUB
• NSAIDs*
• OCPs*
• Progesterone‐releasing intrauterine device (Mirena®)
• Cyclical progesterone therapy Medroxyprogesterone
• Tranexamic acid (Lysteda®)
• Endometrial ablation
• Uterine artery embolization *also txs. For dysmenorrhea
Case Question
• A 19yo college freshman comes to your clinic requesting help with painful periods. The pain and cramping starts several days prior to start of period and continues for the first 3 days. Periods are q28 days, regular and last 5 days. She has never been sexually active. You recommend:
• A. NSAIDS
• B. Pelvic Ultrasound
• C. PAP Smear and chlamydia screening
• D. Cognitive behavioral therapy
Dysmenorrhea
• Most common gynecologic symptom in adolescents and young adults
• Complicated or painful menstruation
• Cramps, H/A, N/V
• 90% primary
• Unless pathology suspected in hx can begin Tx
• NSAIDS and Cox‐2 inhibitors
• COCP if these not effective
• 10 % secondary
• Endometriosis most common (cyclic and non‐cyclic pain big clue)
• Treatment options similar
• Add GNRH agonists and aromotase inhibitors
• Both require Vitamin D and Calcium Supplementation
Chronic Pelvic Pain (CPP)
Non‐Cyclic pelvic pain >6 months duration
• Endometriosis‐ 2/3 of CPP
• Worsens with menstruation, dyspareunia
• Eval‐ Empiric GnRH agonist/Diagnostic Lap
• Tx: GnRH agonist or COCP, surgical destruction
• Pelvic Adhesions‐1/4 to ½ with CPP have adhesions
• History of PID, endometriosis or abd/pelvic surgery
• Eval‐ Diagnostic Lap
• Tx: Adhesiolysis
• Pelvic varices
• Dull, chronic pain worse with standing, improved with lying down
• Eval‐
Transabdominal/Transvaginal U/S
• Tx: Medroxyprogesterone acetate
• Interstital cystitis
• Dysuria, urgency, frequency with negative urine cultures
• Eval:interstitial cystitis sx index and cystoscopy
• Tx: Pentosan polysulfate sodium, TCAs, GnRH agonist may be helpful
Bra “Burning”
• 48 y WF w/ irregular periods presents with a 1 week history of a right breast lump. It is non‐tender and has not changed. She has not noticed any overlying skin changes. She denies a history of trauma. She has never felt it before. • You tell her to:
• 1. Return if it is still present after her next menstrual cycle.
• 2. Return for a clinical breast exam by you after two menstrual cycles.
• 3. Get an ultrasound.
• 4. Get a diagnostic mammogram.
Breast mass
• Discrete, distinctly different
• Diff dx: •
•
•
•
•
Cyst
Fibro adenoma
fibrocystic disease
fat necrosis
DCIS/ invasive cancer What to do next?
• The diagnostic mammogram does not show anything at the site of the palpable abnormality. She calls you, anxious about her test result, and asks you what is the next step? She still feels the lump.
• You tell her:
• 1. Good news, not to worry.
• 2. Return after 1‐2 menstrual cycles for a re‐
exam.
• 3. She needs a referral for a biopsy.
If palpable mass, a negative mammogram does NOT EXCLUDE breast ca!
Benign Lesions
• MORE LIKELY IF:
•
•
•
•
•
•
•
younger age absence of breast cancer risk factors
normal overlying skin
a milky (vs. bloody) nipple discharge
change in size during menstrual cycles
round, mobile, and soft
Painful but presence of pain doesn’t R/O malignancy
Clinical Breast Exam
• most breast masses (up to 90%) are benign cysts or fibro adenomas
• H &P cannot definitively rule in or rule out underlying malignancy with sufficient accuracy
• In a study of 201 referral patients with palpable solid breast masses
• sensitivity of the physical exam for the detection of breast cancer was 88%
• PPV and NPV breast cancer were 73% and 87%, respectively
Breast Mass Evaluation
• When imaging a palpable breast mass,
• ultrasonography is preferred for pregnant women or women younger than 30 to 35 years
• mammography is preferred for women older than 30 to 35 years
• 10% to 20% of palpable breast cancers are undetected by ultrasonography or mammography
Tissue Sampling of Breast Masses
• fine needle aspiration‐generally reserved for cystic lesions, is operator‐dependent and requires an experienced cytopathologist for interpretation
• core needle biopsy with or without stereotactic or ultrasound guidance
• more costly, higher risk for post‐procedure hematoma, but better tissue sampling for pathologic examination and hormone receptor status (if positive for cancer) • can distinguish in situ versus invasive cancer
• the test of choice for most solid lesions
• excisional biopsy‐used when core needle biopsy is non‐diagnostic or if biopsy and imaging studies are not in agreement Mastodynia
• Breast pain may be characterized as :
• cyclical‐ mastalgia typically lasts for several days and is moderate to severe in intensity
• Noncyclical‐ no relationship to the menstrual cycle and may be caused by pregnancy, medications (nicotine, hormone therapy), stretching of Cooper ligaments (secondary to large breasts), or cancer
• Extra‐mammary‐may be caused by:
• Musculoskeletal (Chest wall inflammation, a common cause typically presents with unilateral, localized, burning discomfort)
• cardiac
• gastrointestinal
• spinal disorders
Evaluation/Treatment of Breast Pain
• Clinical Breast Examination
• Diagnostic Imaging
• Treatment is based on etiology
• cyclical mastalgia benefit from education and reassurance, as most will experience spontaneous resolution of their symptoms.
• Medical treatment may be considered for women with severe and persistent pain that interferes with quality of life
• Danazol (100 mg twice daily) is the only therapy that has been FDA‐
approved for the treatment of cyclical mastalgia, but side effects, including menorrhagia and weight gain, often limit its use
• Patients with cyclical mastalgia experience benefit with tamoxifen (10 mg/d), and treatment‐associated hot flushes and menstrual irregularities are relatively infrequent Final Note………..
High Value Care Recs‐
Women’s Health
• Evidence lacking for screening mammograms >75 yo
• ACS does not recommend breast MRI for average risk women and breast self‐exam data found to be insufficient
• Due to poor specificity, cervical cancer screening with HPV DNA testing alone not recommended but can be used with cytology in women >30 to assess frequency of testing
• IUDs have lowest failure rate for contraception combined with lowest cost
References
•
Agency for Healthcare Research and Quality “Treatment of osteoporotic Fractures: an Update” http://effectivehealthcare.ahrq.gov/ehc/products/160/1048/lbd_clin_fin_to_post.pdf‐ accessed May 1, 2012 •
Ahmad, Shema, Stephen A. Geraci, and Christian A. Koch. "Thyroid Disease in Pregnancy." Southern Medical Journal 106.9 (2013): 532‐38. Web.
•
Ashley, Kellan E., and Stephen A. Geraci. "Ischemic Heart Disease in Women." Southern Medical Journal 106.7 (2013): 427‐33. Web.
•
Geraci, Therese S., and Stephen A. Geraci. "Considerations in Women with Hypertension." Southern Medical Journal 106.7 (2013): 434‐38. Web.
•
Gyamlani, Geeta, and Stephen A. Geraci. "Kidney Disease in Pregnancy." Southern Medical Journal 106.9 (2013): 519‐25. Web.
•
"MKSAP 16 Digital." MKSAP 16. American College of Physicians, n.d. Web. 29 Apr. 2014.
•
Nickens, Myrna Alexander, Robert Craig Long, and Stephen A. Geraci. "Cardiovascular Disease in Pregnancy." Southern Medical Journal 106.11 (2013): 624‐30. Web.
•
Sanders, Suzanne, MD, and Stephen A. Geraci, MD. "Osteoporosis in Postmenopausal Women." Southern Medical Journal 106.12 (2013): 698‐706. Web.
•
Sikon, Andrea, MD. "Webcast: Women's Health Internal Medicine Board Review." Webcast: Women's Health Board Review 2012. Cleveland Clinic, 2012. Web. 29 Apr. 2014. •
"Yale Office‐Based Medicine Curriculum." Yale Office‐Based Medicine Curriculum. Yale University Department of Medicine, n.d. Web. 19 Apr. 2015. <http://www.yobm.yale.edu/>.