Proactive Health Management for Women in High Stress Careers April 4, Eirwen M. Miller, MD Division of Gynecologic Oncology

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1 Proactive Health Management for Women in High Stress Careers April 4, 2018 Eirwen M. Miller, MD Division of Gynecologic Oncology 1

2 Annual Well-Woman Care Blood pressure Weight Physical exam (including pelvic exam) Tobacco use Alcohol use Illicit drug use Risky behavior Intimate partner violence 2

3 PREVENTION OF CORONARY HEART DISEASE (CHD) 2011 AHA GUIDELINES 3

4 CHD Risk Factors Age 55 (or premature menopause without HRT) Family history: heart attack in male < age or female < age 65 (1 st degree relative) High blood pressure (>140/90) or an antihypertensive medication High cholesterol (total cholesterol >200 or HDL cholesterol <40) Cigarette smoking Diabetes Obesity (BMI >30) End-stage renal disease 4

5 Prevention of CHD Lifestyle modification Physical activity: Goal: >150 minutes/week of moderately intense physical activity or >75 minutes per week of vigorous physical activity Diet - sea food, fish, fruits, nuts, whole grains, high fiber, vegetables and low salt Weight loss Goal: BMI < 25, Waist < 35 cm 5

6 Prevention of CHD Smoking cessation Blood pressure management Goal BP < 120/80 DASH diet Exercise Medications High cholesterol management Diet/lifestyle interventions Omega-3 fish oil (1800mg/day) Medications Diabetes management (HbA1c < 7%) 6

7 DASH Diet Eat vegetables, fruits, and whole grains Fat-free/low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils Limit foods high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils Limit sugar-sweetened beverages and sweets 7

8 Interventions not Effective for CHD Prevention Hormone replacement therapy Antioxidant supplementation (vitamin C, B, and beta-carotene) Folic acid (with or without vitamin B6 and B12) Aspirin Routine use of aspirin in healthy women less than 65 years of age is not recommended to prevent MI 8

9 Cholesterol Screening Screening test: fasting lipid profile Age 20 and over Screening frequency: Screen every 5 years if no CHD and LDL cholesterol < 160mg/dL (0-1 CHD risk factor) or < 130mg/dL ( 2 CHD risk factors) Screen every 1-2 years if borderline-high cholesterol and 0-1 CHD risk factors Screen yearly if CHD or borderline-high cholesterol and 2 CHD risk factors 9

10 Framingham Risk Score 10

11 Diabetes Definition: disease affecting your body s ability to produce/use insulin resulting in too much sugar in the blood 30 million Americans (9% of US population) 1.5 million Americans are diagnosed annually 7 th leading cause of death in US in

12 Diabetes Risk Factors Family history of diabetes in a 1 st degree relative Sedentary lifestyle Race: African-American, Hispanic, Native American, Asian- American, and Pacific Islanders Prior baby weight > 9 lbs History of gestational diabetes High blood pressure High cholesterol Glucose intolerance 12

13 Diabetes Screening Screen all adults with BMI 25 kg/m2 and one or more additional risk factors If no risk factors, screen everyone beginning at age 45 Screening tests: hemoglobin A1C (preferred), fasting plasma glucose, or 2-h OGTT Retest in three years if normal 13

14 Screening test: TSH Hypothyroidism Screening Screen everyone with symptoms of hypothyroidism Screening in absence of symptoms is controversial USPSTF insufficient data to recommend American Thyroid Association - screen every 5 years starting at age 35 14

15 Osteoporosis Definition: reduction in bone mass and disruption of bone architecture, resulting in reduced bone strength and increased fracture risk 50% of postmenopausal women will have an osteoporotic fracture in their lifetime 1.5 million fractures annually 15

16 Bone Health: Nutrition & Exercise Age group Calcium Vitamin D mg 600 IU mg 600 IU > mg 800 IU Weight bearing exercise (not biking or swimming) Slide courtesy of Dr. Beth Prairie 16

17 Osteoporosis Risk Factors Intrinsic: age, race, small frame, family history, prior fracture, early menopause Modifiable: smoking, light weight, alcohol consumption, sedentary lifestyle, poor nutrition Medical: hyperthyroidism, renal disease, steroid use, hyperparathyroidism Slide courtesy of Dr. Beth Prairie 17

18 Osteoporosis Screening DXA measures bone mineral density (BMD) 18

19 DXA Results T score compares BMD to young, healthy women Normal: > -1 Osteopenia: -1 to -2.5 Osteoporosis: < -2.6 Slide courtesy of Dr. Beth Prairie 19

20 Osteoporosis Screening All women should have baseline by age 65 Earlier screening before age 65 if they have additional risk factors FRAX risk assessment tool Cannot repeat more often than every 2 years Slide courtesy of Dr. Beth Prairie 20

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22 Osteoporosis Treatment Exercise and nutrition Bisphosphonates Daily, weekly, monthly, yearly Decrease fractures Side effects: esophagitis, GI upset, osteonecrosis of jaw (rare), atypical femur fractures Hormone therapy prevents fracture Raloxifene (Evista) Side effects: venous thromboembolism, vasomotor symptoms, leg cramps Others: Calcitonin, Forteo (teriparatide) 22

23 Immunizations 23

24 Pneumococcal Vaccine All adults over age 65 (single dose) Vaccinate at any age if Chronic lung disease (including asthma) Diabetes Chronic liver disease Alcoholism Asplenia Renal failure Immunocompromise (HIV, transpolant) Residents of nursing homes/long-term care facilities Tobacco use One-time re-dose for those >65 if they were vaccinated >5 years previously and were <65 at time of primary vaccination 24

25 Sexually Transmitted Disease & Other What When How often HIV Age Age < 15 if at risk Age > 64 if at risk Gonorrhea Chlamydia Sexually active women age < 25 Sexually active women > 25 if at risk Syphilis Those at increased risk Unclear Hepatitis B High risk groups (central or southeast Asia, sub-saharan Africa, China; HIV positive; intravenous drug use; hemodialysis; immunosuppresive drugs) Hepatitis C Born High risk groups (intravenous drug use, blood transfusion before 1992, hemodialysis, incarceration, health care workers, high risk sexual behavior) One time screening Repeated screening for those at ongoing risk of infection and those engaged in risky behavior One time screening Repeated screening for those whose sexual history reveals new or persistent risk factors since last negative test Periodic screening in those with ongoing risk Once Periodic screening in those with ongoing risk 25

26 Pregnancy Considerations Folic acid supplementation 400 ug/day Screening at first prenatal visit Urine culture HIV Hepatitis B Rh type Syphilis Blood pressure at each visit Gestational diabetes after 24 weeks 26

27 Lung Cancer Second most common cancer in women 100,000 new diagnoses in US women in 2014 Will affect 6% of men and women during lifetime Leading cause of cancer death in men and women 27

28 Lung Cancer Screening Who? Age pack-year smoking history Currently smoke or quit within past 15 years Screening test: CT scan Screening frequency: annual 28

29 Colon Cancer Third most common cancer in women will affect 4% of women Third most common cause of cancer death in women 25% of adults aged years have never been screened Incidence declining 29

30 Colon Cancer Screening Age (+/- age 76-85) Screening options Annual fecal occult blood testing Colonoscopy every 10 years CT colonography every 5 years Flexible sigmoidoscopy every 5 years 30

31 Cervical Cancer 1940s: major cause of death in US women 1950s: introduction of Pap smear : >60% decline in cervical cancer incidence and death rates 31

32 Cervical Cancer rd most common cancer in women worldwide 2 nd most common cause of cancer death in women worldwide 14 th most common cancer in US women (rare) 13,000 estimated new cases Compare with breast cancer (250,000) 4,000 estimated cancer related deaths Pap smear identifies treatable precancerous lesions 32

33 Cervical Cancer Almost exclusively caused by 1 of 15 types of high-risk HPV 70% due to HPV16 or HPV18 Sexually transmitted 33

34 Cervical Cancer Screening Pap smear Age Not if prior hysterectomy Frequency Pap only: every 3 years Pap + HPV testing: every 5 years (after age 30) Exceptions: Prior cervical dysplasia or cancer In utero DES exposure Immunocompromised (HIV) 34

35 HPV Vaccine Gardasil Protective HPV6, HPV11 (genital warts) and HPV16, HPV18 (cervical cancer) Gardasil 9 HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58 Who? Boys and girls age (2 shots 6-12 months apart) Young women up to age 26 Young men up to age 21 35

36 Breast Cancer Most common cancer in women Lifetime risk: 1 in 8 2 nd most common cause of cancer death in US women 36

37 Breast Cancer Symptoms Palpable lump painless, hard Breast swelling Skin dimpling Breast/nipple pain Nipple retraction Nipple discharge 37

38 Increasing Age Breast Cancer Risk Factors 38

39 Breast Cancer Risk Factors BRCA mutations 80% lifetime risk of ovarian cancer Menarche before age 12 Menopause after age 55 Late childbearing (after age 29) First degree relative with breast cancer (number of relatives with breast cancer) Personal history of breast biopsy History of hormone replacement therapy (estrogen + progesterone) White race Obesity Increased alcohol intake Sedentary lifestyle Tobacco use 39

40 Breast Cancer Screening Mammogram controversial USPSTF Biennial age Consider age > 40 if first degree relative with breast cancer ACOG and ACS Age 40 and above Annual Clinical breast exam USPSTF insufficient evidence to recommend ACOG and ACS Age every 1-3 years Age > 40 annual Breast self awareness 40

41 Breast Cancer Chemoprevention Medications to reduce breast cancer risk Tamoxifen and raloxifene reduce breast cancer risk by 50% Recommended in high risk populations (5 year risk >1.66%) Gail Model estimates 5 year incidence of breast cancer 41

42 National Cancer Institute Breast Cancer Risk Assessment Tool Frequency of assessment: repeat when significant change in risk factors 42

43 Ovarian Cancer Second most common gynecologic malignancy Lifetime risk 1.4% (1 in 70) 43

44 Ovarian Cancer Symptoms Silent killer - symptoms are vague Abdominal fullness or distension Abdominal or back pain Decreased energy Lethargy Urinary frequency No screening test available 44

45 Ovarian Cancer Protective Factors Prophylactic oophorectomy Prophylactic salpingectomy? Use of OCPs Tubal ligation 45

46 Age Ovarian Cancer Risk Factors Risk increases until age 70 then decreases 46

47 Ovarian Cancer Risk Factors Caucasian race Nulliparity Infertility Endometriosis Family History 5% if one affected 1 st degree relative 20-30% if two affected 1 st degree relatives 47

48 Familial Ovarian Cancer Breast/ovarian familial cancer syndrome BRCA1 mutation associated with 5-10% of cases BRCA1/BRCA2 confers 15-45% lifetime risk Lynch II syndrome Families with 1 st and 2 nd degree relatives with colon, endometrial, ovarian, or breast cancers 3-fold risk 48

49 Genetic testing 49

50 Endometrial Cancer Most common gynecologic malignancy 50

51 Endometrial Cancer Symptoms Abnormal uterine bleeding (90%) Menstrual age women: heavier, more frequent menses Postmenopausal women: postmenopausal bleeding Abdominal/pelvic pain Abdominal bloating Early satiety Change in bowel/bladder function 51

52 Increasing age Endometrial Cancer Risk Factors 52

53 Endometrial Cancer Risk Factors Unopposed estrogen Endogenous Chronic anovulation (PCOS) Obesity - linear increase in endometrial cancer risk when BMI > 25 > 30 lb: RR 3.0 > 50 lb: RR 10.0 Hormone replacement therapy Concomitant progestin mitigates risk Tamoxifen Reduced risk of breast cancer 50% Increased risk of endometrial cancer (RR 3.3), predominantly in women aged 50 years or older (RR 5.3) 53

54 Endometrial Cancer Risk Factors 54

55 Lynch syndrome Familial Endometrial Cancer Autosomal dominant Colon, endometrial, ovarian cancer 2.5% of endometrial cancer associated with Lynch syndrome 5-9% of endometrial cancer in women < age % endometrial cancer risk by age 70 Cowden Syndrome Autosomal dominant Breast, thyroid, endometrial cancer 55

56 Endometrial Cancer Protective Factors Contraceptives OCP RR 0.5 with > 1 year of use, effect lasts 10 yrs Depo-Provera Mirena IUD Smoking: 30% risk reduction 56

57 THANK YOU 57

58 QUESTIONS? 58