1 / 25

Women’s Health

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

alaura
Télécharger la présentation

Women’s Health

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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%

More Related