Women s Health: Take Home Messages Caren Solomon, MD Associate Physician, BWH Associate Professor of Medicine, HMS Deputy Editor, NEJM
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Contraception
Contraceptive Effectiveness Rates of unintended pregnancy with typical use: NO method- 85% Diaphragm 12% Condom 18% Pill/patch/ring 9% DepoProvera 6% IUD- Copper T 0.8%, LNG-IUS 0.2% Etonorgestrel Implant 0.05%
Long-Acting Reversible Contraception: IUDs and Implants Highly effective (immediately); forgettable IUDs Pregnancy rare (but ectopic pregnancy common if pregnancy occurs) Safe; Most women eligible (including nulliparous, prior h/o STD) Potential complications: expulsion, perforation (rare), malposition in uterus, PID (risk higher first 20 d after insertion 1-10/1000 women but after that, rare). Types Levonorgestrel (Mirena, Skyla, Liletta, Kyleena) Overall less bleeding ; often used in women with menorrhagia or dysmenorrhea; may have hormonal side effects Copper IUD (Paragard) increased bleeding (espec in first few months after insertion); more cramping/pain Can be inserted within 5 d after single act of unprotected intercourse as emergency contraception
Long-acting reversible contraception Implantable contraception (Etonogestrel (Nexplanon); progestin subdermal implant ) Highly effective, use up to 3 years approved (but effective longer) Must be inserted by trained provider Irregular bleeding common Contraindication: current breast cancer Potential complications: deep insertion /difficult removal (but inserter easy to use, infection at insertion site, expulsion (rare)
Medical Disorders Complicating Pregnancy
Pre-Existing Hypertension Generally good pregnancy outcomes unless superimposed preeclampsia develops Antihypertensive therapy generally can be tapered during pregnancy Goal SBP 120-160 mm Hg; DBP 80-105 mm Hg Stop ACEIs and ARBs prior to conception Methyldopa recommended 1 st line (long term outcomes data); or labetolol
Pre-existing diabetes mellitus Birth defect risk directly related to HbA1c at conception Other risks: macrosomia, iatrogenic prematurity, birth trauma, neonatal hypoglycemia; maternal: progression of DM complications, preeclampsia, increased risk of C-section ADA recommends goal of HbA1c < 6.5% at conception Goals during pregnancy: fasting blood sugar < 95 mg/dl; 1 h post prandial < 140 mg/dl; 2 h pp < 120 mg/dl: HbA1c < 6 % (if can be achieved without a lot of hypoglycemia) Treatment Human insulin recommended; most experience with NPH and regular (Category B); Lispro and Aspart also used Pump ok Insulin requirements typically increase in pregnancy but may decrease just before delivery
Gestational diabetes mellitus DM first diagnosed in pregnancy High risk of subsequent Type 2 DM Women with history of GDM should be screened for Type 2 DM
Hypothyroidism Diagnosis made by elevated TSH Possible risks: poor fetal growth; premature birth; pregnancy loss; possible effects on IQ; increased risk for preeclampsia and placental abruption in mother Requirement for thyroid hormone increases in pregnancy and returns to pre-pregnancy requirement postpartum Titrate thyroid hormone dose to maintain TSH <2.5 at conception and first 2 trimesters; < 3.5 third trimester
HPV-Related Disease and Vaccination
HPV 80% of people infected over lifetime Natural history: 80% clear infection in 12 months High risk types: HPV 16, 18, 31, 33, 45, 52, 58
HPV Vaccination Recommended starting age 11 or 12 (and through age 26, possibly older but off label.) Bivalent (16 and 18), quadrivalent, and 9 v vaccines can be used 3 doses STILL NEED cervical cancer screening
Cervical Cancer Screening Initiate screening at age 21 Age 21-29: Pap q 3 years (no HPV screening) Age 30-65 (and NOT high risk), may do: Combined Pap/HPV q 5 years if both tests negative Paps q 3 years HPV alone (Cobras HPV test) q 3 years over age 25 More frequent screening needed in high risk women (HIV infection, immunosuppressed, h/o DES exposure, previously treated CIN2 or 3 or adenoca in situ or CA )
Follow-Up of Various Pap Findings Absent Endocervical Cells Ages 21-29: Routine screening Age 30+ : HPV testing ASCUS If HPV negative, repeat co-testing in 3 years If HPV positive- colposcopy (except ages 21-24, where would repeat PAP in 1 y) ASC-H (ie cannot exclude high grade SIL) Colposcopy needed Endometrial cells No further evaluation in asymptomatic premenopausal women If postmenopuasal, need endometrial assessment
Menopause
Postmenopausal hormone therapy Improves vasomotor symptoms (and this remains indication for use) WHI data HRT: Increased risks of CHD, stroke, invasive breast cancer, DVT/PE, urinary incontinence; Reduced risks of fracture, colorectal cancer ERT: Increased risk of stroke, reduced risk of fx Both increased risk of dementia among women 65+
Postmenopausal hormone therapy: Endocrine Society Prescribing Recommendations Individualize therapy based on clinical features and patient preference Contraindications: h/o DVT/PE, breast CA, CVD, high risk endometrial cancer/unexplained vaginal bleeding, liver disease Assess CVD risk (10y) and breast cancer risk (5 y) before initiate; avoid where risk high (> 10% and > 3%, respectively)
Management of symptoms Vasomotor ERT/HRT- at lowest effective doses/generally not more than 5 years (though longer may be OK in low risk highly symptomatic women) Lifestyle- keep cool, weight control, exercise, don t smoke, avoid excessive alcohol.. Phytoestrogens- not generally effective in RCTs and potential concerns re estrogen agonist effects Other medications SSRIs, SNRIs (only paroxetine FDA approved for vasomotor symptoms; recommended that paroxetine be avoided in women taking tamoxifen) Gabapentin Clonidine (but use limited by side effects)
Management of symptoms GU (vulvovaginal atrophy) Local estrogen (creams, E2 tablets, vaginal ring) Lubricants Ospemifene: SERM approved for treatment of dypareunia in postmenopausal women (potential adverse effects: hot flashes, DVT/PE..)
Menstrual Irregularities
Amenorrhea Types Primary (Absence of menses by age 16) Secondary (Absence of menses for 3 months) Causes Pregnancy, Uterine or Outflow Tract Disorders,Ovulatory Disorders genetic and anatomic abnormalities more likely with primary amenorrhea Eval βhcg, FSH, PRL, TSH
Hypothalamic Amenorrhea Causes Energy Output > Energy Input Wt loss, eating disorders, excessive exercise Stress Psychological, Physical Eval: r/o other cause, MRI, BMD Treatment Weight gain, decrease exercise Oral contraceptives/hrt (?) Adequate calcium, vitamin D
Premature Ovarian Insuffiency Elevated FSH, age < 40 yrs Causes Turner s syndrome ; X chromosome deletions, translocations; Fragile X premutations Autoimmune, Chemotherapy or radiation therapy, other Evaluation Karyotype, Fragile X premutation screen, anti-thyroid and anti-adrenal antibodies Treatment OCPs/HRT; calcium/vit D
PCOS Rotterdam definition 2 out of 3 of the following: Oligo- or anovulation Clinical and/or biochemical signs of hyperandrogenism Polycystic Ovaries Exclusion of other causes (e.g. hyperprolactinemia, CAH, androgen secreting tumors) Other common features: obesity; insulin resistance; infertility
PCOS Management Weight loss /exercise OCP Metformin Ovulation induction/ivf Hair removal/spironolactone Follow up of glucose, lipids, bp
Osteoporosis and Metabolic Bone Disease
Calcium and vitamin D Supplementation with both may modestly reduce fracture risk Adverse effects (calcium) :GI upset, kidney stones; not strong evidence to support increased CVD risk Supplementation recommended in those with high risk for deficiency( frail elderly, malabsorption ) and those receiving osteoporosis treatment 25OH vit D levels do not need to be checked in elderly persons without osteoporosis or high fracture risk: vit D3 800 IU daily recommended
Bone density T-score BMD compared with young normal adults; ( number of standard deviations (SD) above or below the mean); Used to dx osteopenia (-1 to -2.5) osteoporosis (below -2.5) Z-score BMD compared with persons of same sex and age. A low Z-score indicates possible secondary cause of osteoporosis., BMD recommended in women age 65+, and men age 70+ without risk factors; earlier with risk factor or history of fracture
Risk Factors for Osteoporosis in Women Caucasian/Asian ALSO: Older age H/o falls (or risk factors for falls) Prior fx Mental illness or psychotropic meds Low weight Chronic hyponatremia Fam hx of fx Smoking Excess alcohol Glucocorticoids RA Hypogonadism IBD/malabsorption Organ tx Hyperthyroidism COPD Type 1 DM
Overall management strategy Minimize falls Exercise (strength and balance, gait training), vision assessment/treatment, environmental assessment/management, calcium/vit D recommended Increase bone strength
Treatment of Postmenopausal ACP recommends: Osteoporosis use bisphosphonate or denosumab (and NOT to use estrogen +/- progestin or raloxifene) treat for 5 years (without BMD monitoring) BUT there is controversy? better to treat to target (T score > -2.5) /Others recommend assessment to determine if bisphosphonate holiday appropriate DXA may indicate lack of response or?noncompliance Stopping denosumab at 5 y associated with rapid bone loss, rebound associated fxs reported