Women s s Health and Healthy Lifestyles Jennifer M. Hickman, M.D. Loudoun OB/GYN

Women s s Health and Healthy Lifestyles Jennifer M. Hickman, M.D. Loudoun OB/GYN

What is a Healthy Lifestyle? Health is defined as a state of complete physical, mental, and social well-being and not merely the absence of disease Key lifestyle factors Nutrition/diet Exercise Limiting weight gain Adequate sleep Prevention of disease Management/treatment of disease

Objectives Briefly discuss key health topics for Sleep Weight gain Menopause Osteoporosis Cardiovascular disease in women Commonly prescribed medications Combined oral contraceptives

Sleep Everybody wants it, not everybody gets it Most people require about 8 hours per night Recent survey: >1/3 get less than 7 hours Several causes of insufficient sleep Sleep deprivation Sleep disorders Insomnia

Sleep Deprivation Not enough sleep to allow for performance, alertness and health Acute or chronic Lack of quantity or quality of sleep Often work-related related In most cases considered volitional

Sleep Disorders Sleep-related breathing disorders obstructive sleep apnea Circadian rhythm sleep disorders Hypersomnias, i.e. narcolepsy Parasomnias Sleep-related movement disorders

Insomnia 3 criteria: Difficulty initiating or staying asleep or early waking Difficulty occurs despite adequate opportunity Resultant deficits in daytime function 7% of adults develop each year Common medical complaint Women > men with age

Consequences of Lack of Sleep Common complaints Fatigue Poor concentration Mood disturbance Social dysfunction Sleepiness Increased errors Headache, anxiety, gastrointestinal symptoms

Consequences of Lack Sleep Impaired performance reaction time, coordination accidents (motor vehicle & workplace) quality of life

Consequences of Lack of Sleep mortality Cardiovascular effects Some studies show risk HTN, MI, and stroke immune function appetite Hormone changes cause hunger especially for high carbohydrate foods

Treatment Sleep deprivation: Extend sleep time or eliminate sleep fragmentation Strategic napping Work schedule changes Sleep disorders: CPAP shown to be beneficial for OSA Insomnia: Treat underlying medical conditions Behavioral therapies (stimulus control therapy) Medications

Sleep Hygiene Sleep as long as necessary to feel rested Maintain a regular sleep schedule Try not to force sleep Avoid caffeinated beverages after lunch Avoid alcohol near bedtime Decrease bedroom stimuli Resolve concerns before bedtime Exercise regularly, > 4-54 5 hours before bed Avoid naps longer than 20 30 minutes

Stimulus Control Therapy Do not go to bed until sleepy Do not use bed to read, watch TV, eat, or worry Do not spend > 20 minutes in bed awake Do not eat or watch TV if awake at night; engage in relaxing activity away from bedroom Alarm clock to awaken at same time each day No daytime naps

Medications for Insomnia Over-the the-counter Diphenhydramine Valerian Melatonin Benzodiazepines (i.e. Ativan, Restoril) Nonbenzo-sedatives (i.e. Ambien, Lunesta) Melatonin agonists (i.e. Remelteon)

Sleep Key points: Exercise good sleep hygiene Identify underlying cause of poor sleep Talk with your healthcare professional to help guide therapy

Weight Gain Obesity is global epidemic 35.7% of U.S. adults are obese 17% of children are obese 26% of adults in Virginia are obese Body Mass Index (BMI) Weight (kg) height (m) squared BMI: 25 29.9 = overweight BMI: >30 = obese Waist circumference also important

Weight Gain Most likely times for to gain weight Although childhood obesity on rise, most gain after puberty College Pregnancy Menopause estrogen & progesterone = central fat deposition

Causes of Weight Gain calories in vs. calories expended Sedentary lifestyle Diet

Causes of Weight Gain Sleep deprivation Smoking cessation Drug induced Some antidepressants, steroids, diabetes meds Neuroendocrine Hypothyroid (<10% of population) Genetics Socioeconomic and ethnic factors

Consequences of Excess Weight BMI = rate of death from all causes risk of cardiovascular disease Hypertension Heart failure Stroke risk of diabetes risk of hypercholesterolemia

Consequences of Excess Weight risk of GERD osteoarthritis (major part of cost of obesity) risk respiratory dysfunction (esp. sleep apnea) risk of dementia risk certain cancers (endometrial) risk of death from cancer

Consequences of Excess Weight Fertility anovulatory cycles = fertility May not respond as well to ovulation induction agents Pregnancy risk gestational diabetes, preeclampsia risk cesarean delivery and infectious morbidity incidence of congenital anomalies, growth abnormalities and stillbirth

Prevention of Weight Gain Eat roughly the same amount of calories that you burn (regardless of the type of calorie) Use a food diary amount of physical activity each day TV watching & do not eat in front of TV It takes a of 3500 calories to 1 lb. To lose 1-21 2 lbs. per week, 500-1000 cal/day

Prevention of Weight Gain Breastfeeding may decrease obesity in offspring 1 study showed that having 1 obese parent more than doubled the risk of obesity as an adult Genetic factors Learned lifestyle and diet very important

Weight Gain Key points: Calories in need to = calories expended Limiting weight gain chances of developing many diseases Important to be a role-model for next generation

Menopause Defined by 12 months of amenorrhea after final menstrual period Menopausal transition: Lasts usually 2 8 yrs (avg. 5 yrs) Variation in menstrual cycle Average age = 51 Fluctuating levels of hormones common

Menopausal Transition: Clinical Manifestations Irregular bleeding Hot flashes Sleep disturbance Vaginal dryness Sexual dysfunction Urinary symptoms Depression?? Bone loss Also skin changes, poor balance

Menopausal Transition: Clinical Manifestations Irregular bleeding Chronic anovulation & progesterone lead to unopposed estrogen exposure Can cause irregular bleeding, endometrial hyperplasia Important to be evaluated to rule out hyperplasia or cancer Oral contraceptives very helpful to manage irregular bleeding during this time

Hot flashes Menopausal Transition: Clinical Manifestations 75% of experience, only 20% seek treatment Most common in late menopausal transition and early postmenopause (1 st 5 years after menopause) Usually resolve within 1-51 5 years Lifestyle changes Estrogen most effective therapy Alternative therapies: SSRI s, gabapentin Herbal: soy, black cohosh

Treatment of Menopausal Symptoms Lifestyle changes Regular exercise & weight loss may hot flashes Dress in layers & avoid wool clothing spicy foods, alcohol, smoking, caffeine

Treatment of Menopausal Symptoms Estrogen = gold standard for vasomotor symptoms Estrogen alone has better risk-benefit profile, however must use progestin if uterus intact Contraindications: Known coronary heart disease, breast cancer, previous venous thromboembolic event or stroke, active liver disease, or high risk for these events

Treatment of Menopausal Symptoms Lowest dose of hormone for shortest period Risks associated with hormone therapy: risk stroke Low risk of blood clot Slight risk of breast cancer in estrogen + progestin May risk of ovarian cancer, bronchospasm, lupus Risks are same for natural / bioidentical formulations

Treatment of Menopausal Symptoms Benefits of hormone therapy: Extremely effective in relieving hot flashes night sweats & sleep disturbance vaginal dryness and atrophy risk colorectal cancer risk osteoporotic fractures Improves balance = < falls

Treatment of Menopausal Symptoms Alternative therapies for hot flashes: SSRI s s have been shown to hot flashes in multiple trials Gabapentin hot flashes, but more side effects

Treatment of Menopausal Symptoms Herbal therapies: Safety & efficacy not well established Soy compounds May have estrogenic effects Some studies have shown hot flashes, but not consistent Black cohosh May be some benefit, however studies showing benefit were of poor design

Treatment of Menopausal Symptoms Key points: Hot flashes tend to be self-limited, limited, but if moderate severe can greatly impact quality of life For most healthy women close to the time of menopause, estrogen is a safe and effective therapy Talk to your healthcare professional to assess the best options for you

Osteoporosis Deterioration of bone tissue that leads to fragility 37 50% of aged > 50 with osteopenia 13 18% of aged > 50 with osteoporosis

Risk Factors for Osteoporosis Caucasian race Small frame / low weight Inadequate physical activity Poor nutrition Age Family history Smoking Alcohol intake Medications

Diagnosis of Osteoporosis DEXA most commonly used screening method T score used for diagnosis T score of -2.5 = osteoporosis When start screening (controversial) All postmenopausal > 65 years Start < 65 if 1 or more risk factors for fracture All postmenopausal with a fracture Certain diseases or medical conditions

Prevention of Osteoporosis Maximize peak bone mass Achieved by 3 rd decade of life 60 70% genetically determined, rest is environment Nutrition: adequate calcium & vitamin D Exercise increases bone accumulation cigarette smoking at all ages excess alcohol

Prevention of Osteoporosis Minimize bone loss Rate of loss about 0.5 1%/yr Calcium (1200 mg/day) & vit. D (800 IU/day) Weight bearing exercise Smoking cessation Moderation of alcohol intake

Treatment of Osteoporosis When to start treatment controversial National Osteoporosis Foundation recommends: Start treatment if T score -2 Start if T score -1.5 plus risk factors Bisphosphonates and raloxifene considered 1 st line therapy

Osteoporosis Key points: Know your risk factors Maximize bone mass Minimize bone loss Undergo screening if high risk

Cardiovascular Disease in Women Most common cause of death & disability in in the U.S. Responsible for more deaths per year than all other causes combined! Women are not referred as often as men for diagnostic testing/treatment; mortality in

Definition of Cardiovascular Disease (CVD) Coronary heart disease manifested by MI, angina, heart failure, and coronary death Cerebrovascular disease manifested by stroke or transient ischemic attack Peripheral artery disease manifested by intermittent claudication Aortic atherosclerosis and thoracic or abdominal aortic aneurysm

Risk Factors for CVD Age > 65 High LDL &/or low HDL Family history of early heart disease Diabetes Smoking Hypertension History of peripheral artery disease triglycerides, obesity, sedentary lifestyle also highly associated with risk

Signs & Symptoms of CVD in Chest pain (angina) Women Usually atypical, described as sharp, burning, radiating to back or jaw, pain in stomach Induced by rest, sleep or stress Shortness of breath and fatigue May be indicative of heart failure Fluttering in chest May be indicative of irregular heartbeat

Diagnosis of CVD EKG Stress testing Echocardiogram Chest x-rayx Coronary angiography & cardiac catheterization

Prevention of CVD Smoking cessation Moderate intensity exercise Low fat, low sodium diet Maintain normal weight with special attention to abdominal circumference Control diabetes Control hypertension Control cholesterol

CVD in Women Key points: Leading cause of mortality Know your risk factors and modify them Talk with your healthcare professional

Most Commonly Prescribed Medications in Lipid regulators Anti-depressants Narcotic pain killers Antibiotics Anti-ulcer Hormonal contraceptives Anti-hypertensives

Combined Oral Contraceptives Used by approximately 12 million in the U.S. With perfect use: > 99% effective in preventing pregnancy Actual use: 97% effective Contain both estrogen and progesterone

Combined Oral Contraceptives Side effects Nausea, bloating Breast tenderness Irregular bleeding NOT weight gain

Combined Oral Contraceptives Health benefits risk of ovarian & endometrial cancer ovarian cysts & uterine fibroids menstrual blood loss = anemia dysmenorrhea risk of colon cancer Regular menstrual cycle

Combined Oral Contraceptives Risks Hypertension Stroke Blood clot? Breast cancer May cervical cancer

Combined Oral Contraceptives Key points: Many health benefits Very effective with appropriate use Are some absolute contraindications, so talk with your healthcare provider

References Berek, Jonathon S. Novak s s Gynecology.. Philadelphia: Lippincott Williams & Wilkins, 2002. Speroff, Leon, and Marc A. Fritz. Clinical Gynecologic Endocrinology and Infertility. Philadelphia: Lippincott Williams & Wilkins, 2005. National Heart Lung and Blood Institute.. National Institutes of Health. 22 March 2012. http://www.nhlbi.gov. Pressman, Mark R. Definition and Consequences of Sleep Deprivation. UpToDate. 28 Feb. 2012. UpToDate. 19 March 2012. http://www.uptodate.com. Bonnie, Richard J., and Charles F. George. Performance and Safety risks of Sleep Deprivation and Sleep Disorders. UpToDate.. 28 Feb. 2012. UpToDate. 19 March 2012. http://www.uptodate.com. Bonnet, Michael H., and Donna L. Arand. Overview of Insomnia. UpToDate.. 31 Jan. 2012. UpToDate. 8 March 2012. http://www.uptodate.com. Martin, Kathryn A., and Robert L. Barbieri. Treatment of Menopausal Symptoms with Hormone Therapy. UpToDate.. 28 Feb 2012. UpToDate. 21 March 2012. http://www.uptodate.com.

References Bonnet, Michael H., and Donna L. Arand. Treatment of Insomnia. UpToDate.. 28 Feb. 2012. UpToDate. 21 March 2012. http://www.uptodate.com. Bray, George A. Screening for and Clinical Evaluation of Obesity in Adults. UpToDate.. 31 Jan. 2012. UpToDate. 8 March 2012. http://www.uptodate.com. Bray, George A. Etiology and Natural History of Obesity. UpToDate.. 31 Jan. 2012. UpToDate. 8 March 2012. http://www.uptodate.com. Bray, George A. Health Hazards Associated with Obesity in Adults. UpToDate. 31 Jan. 2012. UpToDate. 18 March 2012. http://www.uptodate.com. Casper, Robert F. Clinical Manifestations and Diagnosis of Menopause. UpToDate.. 28 Feb. 2012. UpToDate. 21 March 2012. http://www.uptodate.com. Casper, Robert F., and Richard J. Santen. Menopausal Hot Flashes. UpToDate. 28 Feb. 2012. UpToDate. 21 March 2012. http://www.uptodate.com. Rosen, Hillel N., and Marc K. Drezner. Overview of the Management of Osteoporosis in Postmenopausal Women. UpToDate.. 31 Jan 2012. UpToDate. 9 March 2012. http://www.uptodate.com.

References Lewiecki, E. Michael. Prevention of Osteoporosis. UpToDate.. 28 Feb. 2012. UpToDate. 21 March 2012. http://www.uptodate.com. Douglas, Pamela S. Clinical Features and Diagnosis of Coronary Heart Disease in Women. UpToDate.. 31 Jan. 2012. UpToDate. 8 March 2012. http://www.uptodate.com. Douglas, Pamela S., and Athena Poppas. Determinants and Management of Cardiovascular Risk in Women. UpToDate.. 31 Jan. 2012. UpToDate. 8 March 2012. http://www.uptodate.com. Douglas, Pamela S. Management of Coronary Heart Disease in Women. UpToDate.. 31 Jan. 2012. UpToDate. 18 March 2012. http://www.uptodate.com.