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Women’s Health Update

Women’s Health Update. John Hickner, MD, MS Editor-in-Chief, Journal of Family Practice. Objectives. 1. Summarize recent USPSTF updates on screening recommendations for women 2. Review the evidence regarding the association between hormone replacement therapy and chronic diseases

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Women’s Health Update

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  1. Women’s Health Update John Hickner, MD, MS Editor-in-Chief, Journal of Family Practice

  2. Objectives 1. Summarize recent USPSTF updates on screening recommendations for women 2. Review the evidence regarding the association between hormone replacement therapy and chronic diseases 3. Review two recent publications on breast cancer risk 4. Review recent studies on osteoporosis and fracture prevention

  3. Screening and prevention 1. Intimate partner violence screening recommended by USPSTF • Screening recommended (B recommendation) • 3 screening RCT negative • However, if effective programs in place, improved outcome 2. Ovarian cancer screening not recommended • D recommendation; harms outweigh benefits 3. Cervical cancer screening: new recommendation (A) • Added high risk HPV screening ALONE q 5 years for low risk women age 30 to 65

  4. Screening and prevention 4. HPV testing alone will detect most cases of cervical cancer and precancer • 1.2 million women, 30 years and older, screened q 3 years • In 10 years 623 women developed cervical cancer and 5369 women had precancers (CIN 3 or adenocarcinoma in situ) • Only 6% (38) with cancer and 4% with precancer had neg HPV 5. Most women older than 60 do not need cervical cancer screening • Cohort of 569,132 women in Sweden age 51 and older • Cancer incidence for women aged 61 to 80 was 1.6/1000 for those with adequate normal screening in their 50s, and 2.5/1000 for those with inadequate screening yet normal results

  5. Cervical cancer prevention 6. HPV vaccine reduces the incidence of cervical cancer • Compare invasive cervical cancer rates before and after HPV immunization introduced in US in 2006 • 2003–2006 vs. 2011-2014 • 29% reduction (6.0 vs 8.4 per 1,000,000) age 14-24, and 13% reduction ages 25-34 • In 2017, 66% of adolescents aged 13-17 years received the first dose to start the vaccine series, and 49% percent finished, up 5% per year from 2013-2017

  6. HRT and chronic disease 7. HRT not recommended to prevent chronic disease in postmenopausal women • USPSTF 2017: D recommendation • Increased risk of: invasive breast cancer, VTE, CAD, stroke, dementia, gallbladder disease, and urinary incontinence 8. Meta-analysis of HRT for cardiovascular disease prevention: Cochrane 2015 • LOWER risk of CVD in women within 10 years of menopause • HIGHER risk of CVD if greater than 10 years from menopause • (see abstract for details)

  7. HRT and chronic disease 9. 18-year follow-up of the Women’s Health Initiative Study: mortality • conjugated equine estrogens (CEE, 0.625 mg/d) plus medroxyprogesterone acetate (MPA, 2.5 mg/d) (n = 8506) vs placebo (n = 8102) for 5.6 years (median) or CEE alone (n = 5310) vs placebo (n = 5429) for 7.2 years (median) • All cause mortality: 27.1% vs 27.6% placebo; no diff for CV, cancer and other mortality • Age 50-59 lower mortality compared to 70-79; 0.61 HR during intervention and 0.83 HR at 18 years (hazard ratios)

  8. Topical rx for menopausal sx 10. Vaginal moisturizer as good as estrogen for postmenopausal vaginal symptoms • RCT 302 women • vaginal estradiol 10 mcg vs. lubricant vs. both • moderate to severe symptoms of vulvovaginal itching, pain, dryness, irritation, or pain with penetration • Similar results for all 3 groups, decreasing the average score (on a scale of 0 to 3) from 2.4 ("moderate" severity) at the beginning of treatment to 1.0 ("mild") • Sexual function improved comparably in all groups

  9. Breast 11. Hormonal contraception associated with slight increase in breast cancer risk • Modern data that includes the newer progestins • 1.2 million Danish women, mean 11 year follow up • Recent or current users 1.2 RR of breast cancer; dose response • Absolute risk small, NNH 7,690; likely benefits>harms 12. Breast biopsy rate much higher after breast MRI than mammography • 812,164 women undergoing a total of 2,048,994 digital mammographies, breast MRIs, or both between the years of 2003 and 2013 • 8.47% versus 1.49% biopsy rate for women s. hx breast ca

  10. Osteoporosis 13. Calcium and Vitamin D supplements do not prevent fracture in community dwelling adult women • USPSTF statement: inadequate evidence to support value; most studies negative or tiny effect • Another meta-analysis agrees (Zhao JG, Zeng XT, Wang J, Liu L. Association Between Calcium or Vitamin D Supplementation and Fracture Incidence in Community-Dwelling Older Adults: A Systematic Review and Meta-analysis. JAMA. 2017 Dec 26;318(24):2466-2482.) • Other studies show value in nursing home women 14. Romosozumab plus alendronate reduces fractures in women with osteoporosis • More effective than alendronate alone • 9.7% vs 13.0%; P < .001; NNT = 30 over 2

  11. Osteoporosis 15. Zoledronic acid reduces fracture risk in women with osteopenia • RCT: 2000 women, 65 years or older with osteopenia • 5-mg zoledronate infusion every 18 months or a saline infusion; 1861 completed the 6-year follow-up • 28.2 vs 18.6 per 100/women/6 yr; NNT 10 over 6 years 16. Long-term use of biphosphonates does not appear to increase fracture risk • FLEX and HORIZON trial follow up for up to 10 years • Overall reduced incidence of hip fractures RR 0.73

  12. Bottom Lines 1. Screen for intimate partner violence if comprehensive support services are available. 2. Do not screen average risk asymptomatic women for ovarian cancer; refer for genetic counseling women who are high risk. 3. hrHPV testing q 5 years alone is an option for cervical cancer screening for average risk asymptomatic women age 30-65. 4. VACCINATE against HPV. Recommend it like you mean it. It prevents cervical cancer. 5. For women within 10 years of menopause and < age 60, there is lower mortality with use of HRT for up to 5 years.

  13. Bottom Lines 6. Hormonal contraception is associated with a slight increased risk of breast cancer. 7. Biopsy rate after breast MRI is much higher than after mammograms in women without prior cancer 8. Vitamin D plus calcium in community dwelling women not decrease fracture risk. 9. Romosozumab reduces fracture risk in women with osteoporosis, and zoledronic acid reduces fracture risk in women with osteopenia. 10. Biphosphonates use for up to 10 years does not increase fracture rates.

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