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Complete Care for Every Woman: An Evidence Based Approach for Clinicians in Women’s Health

Complete Care for Every Woman: An Evidence Based Approach for Clinicians in Women’s Health. Amy Loden, M.D. April 5, 2014 Department of Internal Medicine Washington University in Saint Louis. Case 1. 18y G0 presents for pre-college physical “because my mom is making me” PMH: acne

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Complete Care for Every Woman: An Evidence Based Approach for Clinicians in Women’s Health

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  1. Complete Care for Every Woman: An Evidence Based Approach for Clinicians in Women’s Health Amy Loden, M.D. April 5, 2014 Department of Internal Medicine Washington University in Saint Louis

  2. Case 1 • 18y G0 presents for pre-college physical “because my mom is making me” • PMH: acne • PSH: tonsillectomy • SHx: • ½ ppd tobacco, no alcohol or illicit drugs • Sexually active with 1 lifetime partner, uses condoms “sometimes” • FHx: hypertension (father), obesity (mother) • Meds: metronidazole gel

  3. What are your recommendations? • Pap smear with HPV • Pap smear without HPV • No pap smear • Advise smoking cessation • Measure BP and waist • Screen for HIV and Chlamydia • Screen for glycemic and lipid abnormalities • Screen for depression

  4. Case 2 • 23y G0 presents for “irregular periods” • ROS: gained 60lbs during college and law school • PMH: acne • PSH: tonsillectomy • SHx: occasional beer, 1/2ppd, no illicits; currently in law school, sexually active with 2 lifetime partners • FHx: hypertension (father), obesity (mother) • Meds: metronidazole gel • Vitals: BP:130/80, BMI 38 with waistline of 35 inches (89cm) • Exam: acanthosis nigracans in the axillae, skin tags, hirsutism, no adnexal masses

  5. What are your recommendations? • Advise weight loss • Start oral contraceptive for presumed polycystic ovarian syndrome • Start metformin for presumed insulin resistance • Fasting insulin, lipids and hemoglobin a1c • AM cortisol, 24 hour urine cortisol • TSH, free T4 and free T3 • AM DHEA, free and total testosterone • 17-hydroxyprogesterone level • Transvaginal ultrasound

  6. Case 3 • 28y G1P0010 presents “because I want to start a family” • PMH: polycystic ovarian syndrome (PCOS), hypertension (HTN), hyperlipidemia (HLD) • PSH: tonsillectomy, elective AB (1) • SHx: occasional beer, no tobacco or illicits; associate at a local law firm, sexually active with 3 lifetime partners, married and monogamous • FHx: hypertension (father), obesity & diabetes (mother) • Meds: lisinopril, simvastatin, metformin • Vitals: BP:125/75, BMI 33 • Exam: obese, otherwise normal

  7. What are your recommendations? • Advise weight loss • Start folic acid • Continue lisinopril • Stop linsinopril • Continue metformin • Stop metformin • Continue simvastatin • Stop simvastatin • Screen for HIV • Check A1c

  8. Case 4 • 33y G3P2012 presents to your office for “heavy periods” • Periods are every 30 days, bleeding lasts 8-12 days, she passes clots the size of a lemon, and she has no inter-mentstrual bleeding • PMH: PCOS, HTN, HLD, gestational diabetes (GDM) • PSH: tonsillectomy, elective AB (1) • SHx: no toxic habits; married & monogomous • FHx: HTN, CAD, (father); obesity, DM (mother); HTN (sister) • Meds: lisinopril, simvastatin, metformin • Exam: BMI 28, normal pelvic and breast exams

  9. What are your recommendations? • Pregnancy test, • Prolactin level, TSH • FSH, LH • Ferritin and iron panel • CBC • Coagulation panel • Transvaginal ultrasound • Endometrial biopsy • Hysteroscopy • Endometrial ablation • Hysterectomy

  10. Case 5 • 38y G4P2022 presents to “to be sure I don’t get cancer” • PMH: PCOS, HTN, HLD, gestational diabetes (GDM) • PSH: tonsillectomy, elective AB (1) • SHx: no toxic habits; married & monogomous • FHx: HTN, CAD, and colon cancer at age 55 (father); obesity, DM and breast cancer at age 60 (mother); HTN (sister) • Meds: lisinopril, simvastatin, metformin • Vitals: BP 130/80, BMI 28 • Exam: normal

  11. What are your recommendations? • Annual skin exam • Mammogram now • Mammogram starting age 40-50 • Colonoscopy now • Colonoscopy starting age 45 • Colonoscopy starting age 50 • CA-125 level • Transvaginal ultrasound • Endometrial Biopsy • CXR • Low radiation chest CT

  12. Case 6 • 48y G4P2022 presents to your office for “hot flashes” • ROS: irritability, insomnia and vaginal dryness • PMH: PCOS; HTN; HLD; GDM • PSH: tonsillectomy, elective AB (1), endometrial ablation • SHx: no toxic habits; attorney; married and monogomous • FHx: HTN, DM, CAD, colon and breast cancer • Meds: lisinopril, simvastatin, metformin • Vitals: BP 140/80, BMI 35 • Exam: vaginal atrophy, anxious affect, appears fatigued

  13. What are your recommendations? • Advise increased physical activity • Measure FSH • Start hormone replacement therapy • Start venlafaxine (Effexor) • Start paroxetine (Paxil) • Start gabapentin (Neurontin)

  14. Case 7 • 58y post-menopausal G4P2022 presents for “shortness of breath” and “fatigue” • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, normal mammograms & colonoscopies • PSH: tonsillectomy, elective AB (1), endometrial ablation • SHx: no toxic habits; attorney; married & monogomous • FHx: HTN, DM, CAD, colon and breast cancer • Meds: lisinopril, simvastatin, metformin • Vitals: BP 150/90, HR 70, BMI 35 • Exam: obese, otherwise unremarkable

  15. What are your recommendations? • Start a rigorous exercise program to lose weight • Diet modification • Increase blood pressure medication • Screen for renal disease • Screen for diabetes • Screen for thyroid disease • Assess lipids • EKG • Stress test • PFTs • CXR • Start low dose aspirin therapy

  16. Case 8 • 63y post-menopausal G4P2022 presents “to be sure I don’t have osteoporosis” • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, GERD, normal mammograms & colonoscopies • PSH: tonsillectomy, elective AB (1), endometrial ablation • SHx: no toxic habits; attorney; married & monogomous • FHx: HTN, DM, CAD, colon and breast cancer • Meds: lisinopril, metoprolol, simvastatin, metformin, aspirin, omeprazole • Vitals: BP 120/80, HR 60, BMI 30 • Exam: obese, otherwise normal

  17. What are your recommendations? • Reassure • Advise calcium carbonate supplement only • Advise calcium citrate supplement only • Advised calcium-magnesium and vitamin d combined supplement • Advise vitamin d supplement only • Measure vitamin d level • Measure urinary NTX level • DEXA testing now • DEXA testing at age 65

  18. Case 9 • 68y post-menopausal G4P2022 presents for “urine leaking” • Occurs mostly with laughing, coughing, sneezing; +urgency, nocturia and frequency; denies fecal incontinence or hematuria; occurs daily and she has stopped going out due to embarrassment about leaking • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, normal mammograms & colonoscopies • PSH: tonsillectomy, elective AB (1), endometrial ablation • SHx: no toxic habits; attorney; married & monogomous • FHx: HTN, DM, CAD, colon and breast cancer • Meds: lisinopril, metoprolol, simvastatin, metformin, aspirin, omeprazole • Vitals: BP 120/80, HR 60, BMI 30 • Exam: normal

  19. What are your recommendations: • Advise kegel exercises and bladder training • Advise weight loss • Advice avoidance of irritants (eg, alcohol, caffeine) • Start oxybutynin (Ditropan) or tolteradine (Detrol) • Urinalysis & urine culture • Measure hemoglobin A1c • Bladder stress test • Measure post-void residual volume • Urodynamic testing • Cystoscopy • Schedule for surgical intervention

  20. Case 10 • 78y G4P2022 presents for “ bloating” • ROS: dyspepsia, early satiety, and increased constipation, abdominal girth • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, GERD normal mammograms & colonoscopies • PSH: tonsillectomy, elective AB (1), endometrial ablation • SHx: no toxic habits; retired attorney; widowed • FHx: HTN, DM, CAD, colon and breast cancer • Meds: lisinopril, metoprolol, simvastatin, metformin, aspirin, omeprazole, tolteradine • Vitals: BP 120/80, HR 60, BMI 30 • Exam: vaginal atrophy; no cervical lesions, bleeding or discharge; no appreciable uterine tenderness or adnexal mass on bimanual examination; guaiac negative • Labs: CBC, chemistries, TSH all normal

  21. What are your recommendations? • Reassure • Advise simethicone for flatus • Advise ranitidine for worsening acid reflux • Advise increased water consumption and otc stool softners, laxatives for constipation • Refer for EGD and colonoscopy • CA-125 level • Transvaginal ultrasound • Abdominal CT Abdomen/Pelvis

  22. Contact Information Amy Loden, M.D. aloden@dom.wustl.edu

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