Women’s Health

1. Women’s Health Kristin Hahn-Cover, MD Assistant Professor of Clinical Medicine Department of Internal Medicine

2. Osteoporosis prevention • By NHANES III data (1988-94), mean total calcium intake below recommended level in female teenagers • NHANES IV data (1999-2000) • Age 16-19: 779mg/d • Age 20-39: 797mg/d • Milk consumption is responsible for 46% of calcium intake in 12-18 year old Americans • Milk consumption decreased by 36% among female teenagers from the late 1970’s to the mid-1990’s

3. Osteoporosis prevention • Adequate calcium intake • 1000-1500 mg/d • 50-60% of older adults meet this recommendation • Adequate Vitamin D intake • 400-800 IU/d • Exercise, particularly resistance and high-impact exercise

4. Osteoporosis screening • Indications • People who have had ”fragility” fractures • Most women by age 65 • People with risk factors for secondary osteoporosis • Other high-risk patients (by age 60?) • Methods • DXA scan at two sites most commonly used

5. 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

6. Domestic Violence Screening • Routine screening recommended; no clearly accepted best way to do so • Physicians are typically reluctant to ask about domestic violence, for many reasons • “Expert” physicians were consulted regarding screening methods • Include with other safety questions • Phrase 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

7. Depression Screening • Depression costs $43 billion in the U.S. annually • Point 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?”

8. Vaccines • Td booster every 10 years • Consider Tdap substitution for ages 18-65 • MMR vaccine if uncertain regarding prior vaccination; contraindicated if pregnancy anticipated within 4 weeks • Flu vaccine if pregnancy anticipated within flu season • Varicella vaccine if uncertain immunity; contraindicated in pregnancy • New vaccines: HPV and Herpes zoster/shingles vaccines

9. HPV vaccine • Recommended routinely for girls 11-12 • May also be given in ages 13-26 • Series of 3 injections • Targets 4 types of HPV • Cause up to 70% of cervical cancers • Cause about 90% of genital warts • Not recommended during pregnancy • $ 120 per dose (total $360)

10. Herpes zoster/shingles vaccine • Licensed in age > 60 • 64% reduction ages 60-69 • 18% 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 patients • Has not been studied in patients with history of shingles • If patient has not had chicken pox, she should have primary varicella vaccination series, not this vaccine

11. Breast screening • Mammogram screening, age 40-49 • USPSTF evaluated trials containing a total of almost 200,000 participants • Relative risk 0.85 after 14 years’ observation • Need 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

12. Breast screening • Mammogram screening, age 50 or older • USPSTF recommends annual or biennial screening • No 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

13. Breast screening • Clinical breast exam • Sensitivity 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

14. Breast screening • Breast self-examination • No 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

15. Cervical Screening • Pap smears • Use lubricating gel • Do 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 years • ASCUS Pap: triage by HPV DNA • Dysplasia: 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

16. 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 infected • 3-12% 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 groups • 0.43-5.3% of screened young adults infected

17. 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

18. Emergency Contraception • Appropriate for unprotected or under-protected intercourse • Prevents pregnancy from starting • Does not interrupt an existing pregnancy • Many proposed mechanisms • Best if used within 72 hours of sex • No medical contraindications, but not indicated in suspected or confirmed pregnancy • Progestin-only regimen is preferred method • 0.75 mg levonorgestrel, two doses • Marketed as Plan B • Prevents 60-85% of predicted pregnancies

19. 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 coitus • 85% of sexually active women who do not use contraception become pregnant in one year • Treatment to prevent pregnancy with EC or other contraception is a task separate from cervical screening with Pap smears

20. Contraception • Combination hormonal contraceptives • Act primarily by inhibiting GnRH release, which prevents ovulation • Safe 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

21. Contraception • Contraceptive patch (Ortho-Evra) • Comparable to COC’s in ideal effectiveness, but better compliance • Less effective if patient weighs more than 200lbs/90kg • Adhesive reactions can be problematic • Higher estrogen levels of concern, consider equivalent to COC with 50mcg of ethinyl estradiol • Contraceptive vaginal ring (NuvaRing) • Left in place for 3 weeks • Comparable to COC’s in ideal effectiveness, but compliance may be better • Vaginal discharge and irritation can occur

22. Contraception • Progestin-only pills • Used when contraindication to COC • 8 unintended pregnancies per 100 woman-years with typical use • Depo-medroxyprogesterone acetate • IM injection every 3 months • Irregular bleeding common at first • Amenorrhea in 60% at 12 months • Weight gain common • Decreases in bone mineral density of concern, with FDA black-box warning for use beyond 2 years

23. Postmenopausal hormone therapy • WHI disproved effectiveness of PremPro for preventive therapy • No clear reason to presume this applies only to CEE + MPA • Less 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 HT • Urogenital atrophic symptoms improve, but vaginal estrogen is presumably a safer way to treat • HT duration should be limited, as possible • There 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 HT • FDA recommends that postmenopausal women “use CEE only for menopausal symptoms at the smallest effective dose for the shortest possible time.”

24. 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

25. 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 MI • In Women’s Health Study of low-risk women, ASA 100mg every other day did not alter risk of CVD • RR stroke 0.83 • Still worthwhile to consider ASA for primary prevention if 10-year Framingham risk >6%