Menarche to Menopause: What’s New in Women’s Health?

1. Menarche to Menopause:What’s New in Women’s Health? Cheryl A. Fuller, CRNP, PhD

2. NEW CERVICAL SCREENING GUIDELINES

3. FREQUENCY OF SCREENING ACOG Revised Cervical Cancer Screening Guidelines (11/09) • Begin Pap Tests at age 21 • Age 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

4. Rationale for New Guidelines • Invasive cancer rare in women under age of 25 yeas old • Adolescents have higher incidence of HPV-related precancerous dysplasia because of immature cervix • Most of these lesions resolve spontaneously without treatment • Women with history of excisional procedures for dysplasia have significant increase in premature births

5. Don’t Forget . . . . • Sexually active adolescents and high risk women need to be counseled and tested for STIs • Counseling on smoking cessation

6. 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)

7. 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

8. Management of Abnormal Pap Tests

9. Management of Abnormal Pap Tests

10. Management of Abnormal Pap Tests

11. Management of Abnormal Pap Tests

12. The Challenge of DES Exposure • History of DES • Diethylstilbestrol • 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

13. DES • Known Risks of DES Exposure: • Women who took DES have a 30% higher than average risk for breast cancer • DES daughters: • 50% higher than average risk for breast ca • Higher risk for clear cell adenocarcinoma (CCA) of vagina or cervix • Higher risk for cervical dysplasia, CIN, and SIL • At twice the risk of HSIL of vagina. Vulva, and cervix • Anatomical abnormalities of the reproductive tract • DES Granddaughters • More irregular menstrual cycles, infertility, fewer live births

14. 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)

15. 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 women • 430 deaths/ year in women • 260 deaths/ year in men • Incidence increased past 30 years • 4650 case in U.S.

16. 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

17. Anal Pap Smears • No national recommendations • Screening NOT recommended by CDC, USPSTF, ACS, ISDA or National Guidelines Clearinghouse • Recommended Annually by New York Dept of Health for following: • HIV + • MSM • History of genital warts • History of CIN

18. Anal Pap Smears • Procedure • Position 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

19. 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.

20. Oropharyngeal Cancer • Screening Techniques: • Current • Annual clinical exam by visual inspection • Future • Oral cytology • Oral HPV testing • Brush biopsy • Visual assistance devices

21. VACCINATION ISSUES IN A WOMEN’S HEALTH PRACTICE

22. 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

23. Immunizations • The challenge • While 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

24. Immunizations • Gardasil • Manufactured by Merck • Quadrivalent, recombinant vaccine designed to reduce HPV strains 6, 11, 16 & 18 • 6 & 11 associated with ano/genital warts • 16 and 18 associated with cervical CA (60-70% of all cervical cancers • June 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 infection • Vaccine seroconversion rate = 99.7% • Administered at 0 – 2 – 6 months • Cost $125/ dose or $375 total

25. Immunizations • Gardasil (cont.) • October 2009 FDA approved for boys and men aged 9 to 26 • Has been tested in women 24 to 45 • Study was done during 24 month period • 91% reduction of incidence (95%CI) • 83% prevention rate for 16 & 18 (95%CI) • Not yet approved by FDA • FDA requesting a 48 month study

26. Immunizations • Cervarix • Manufactured 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

27. Immunizations • Twinrix • Manufactured 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

28. Immunizations (Adult)

29. Immunizations (Adult)

30. Immunizations • http://www.immunize.org/immschedules/immschedule_adult.pdf

31. BIOIDENTICAL HORMONE USE IN MENOPAUSE

32. What We Know • HT • Relieves hot flashes • Relieves vaginal dryness • Preserves bone mineral density/reduces fracture risk

33. What We Know • There are 3 classes of estrogens used in HT: • Native or bioidentical estrogens • Estradiol, estrone, and estriol • Natural estrogens • Conjugated estrogens • Synthetic estrogens • Ethinyl estradiol and quinestrol

34. 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

35. North American Menopause Society (NAMS) • Most recent statement July, 2008 • Women 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

36. 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

37. Effects of WHI Results on Patients

38. Bioidentical Hormones • Derived from plant sources (Soy or wild Mexican yam root) • Synthetic processing is used to derive the hormones used • There is currently no central oversight on the production, prescribing or dosing of bioidentical hormones • Commercially available in Europe, South Africa, Australia, and New Zealand • Not approved by FDA

39. Bioidentical Hormones • No large, prospective, well-controlled clinical trials • Estriol • Limited data suggest that it improves menopausal symptoms • Some studies show improvements in BMD • Impact on cardiovascular outcomes is unknown • Conflicting results of breast cancer risk • Estrone • Shown to relieve vasomotor symptoms and increase BMD (randomized, double-blind, placebo-controlled studies) • Low potency (1/10 of estradiol)

40. Bioidentical Hormones • Take home messages: • Need for RCTs • Patient education is key • See handout

41. Mammograms, RTIs & Recurrent BV

43. Mammograms • U.S. Preventive Services Task Force (USPSTF) 2009 Recommendations Regarding Mammograms • All recommendations are for women not at increased risk for breast cancer.

44. 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.

45. 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

46. Recommendations • 1000 women in their 40's with annual mammograms for 10 years • More than ½ of them (500) will need repeat mammograms for concerning findings • Nearly 1/5 (200) will get breast biopsies • 2 deaths from breast cancer will be prevented

47. 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.

48. 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.

49. American Academy of Nurse Practitioners (AANP) • Supports the USPSTF recommendations

50. 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