Menarche to Menopause:What’s New in Women’s

Health?

Cheryl A. Fuller, CRNP, PhD

NEW CERVICAL SCREENING GUIDELINES

FREQUENCY OF SCREENING

ACOG Revised Cervical Cancer Screening Guidelines (11/09)

Begin Pap Tests at age 21Age 21 – 29 years old – every 2 years (LBC)Age 30 years and older – every 3 years (if history of 3 consecutive normal paps & negative HPV)Age 70 and older (if 3 consecutive normal paps & no abnormal results in 10 years)Hysterectomy for benign conditions and no history of high grade CIN

Rationale for New Guidelines

Invasive cancer rare in women under age of 25 yeas oldAdolescents have higher incidence of HPV-related precancerous dysplasia because of immature cervixMost of these lesions resolve spontaneously without treatmentWomen with history of excisional procedures for dysplasia have significant increase in premature births

Don’t Forget . . . .

Sexually active adolescents and high risk women need to be counseled and tested for STIs

Counseling on smoking cessation

Exceptions

Women with a history of CIN 2, CIN 3, or cancer treatment (continue annual screenings for 20 years)Women with a hysterectomy with removal of cervix & a history of CIN 2 or CIN 3 (continue to screen after period of post-treatment surveillance)HIV positive and immunocompromised women (annually)DES exposure (annually)

FREQUENCY OF SCREENING

CDC and American Cancer Society Guidelines

Agree with ACOG with one exception:

First pap about three (3) years from first vaginal intercourse, but no later than 21 years old

Management of Abnormal Pap Tests

Management of Abnormal Pap Tests

Management of Abnormal Pap Tests

Management of Abnormal Pap Tests

The Challenge of DES Exposure

History of DESDiethylstilbestrol

Given as treatment for the prevention of spontaneous abortions, prematurity, intrapartal bleeding, and diabetes

Between 1938 – 1971

Estimated 10 million women & children exposed

78 branded DES products have been identified

www.cdc.gov/DES

DES

Known Risks of DES Exposure:Women who took DES have a 30% higher than average risk for breast cancerDES daughters:

50% higher than average risk for breast caHigher risk for clear cell adenocarcinoma (CCA) of vagina or cervixHigher risk for cervical dysplasia, CIN, and SILAt twice the risk of HSIL of vagina. Vulva, and cervixAnatomical abnormalities of the reproductive tract

DES GranddaughtersMore irregular menstrual cycles, infertility, fewer live births

DES

Follow Up of DES Daughters & Granddaughters:

Annual four quadrant pap

Annual clinical breast exams starting in adolescence

At least once – iodine staining of cervix and vagina to identify adenosis

Prenatal visits – follow closely for early dilation & effacement of cervix and prematurity

Avoid hormone exposure (OCs & HRT)

Anal Pap Smears

Relationship between HPV infection and the development of anal cancer

HPV 16 and 18 have been identified in 80% anal cancers

Anal cancer more common in women430 deaths/ year in women260 deaths/ year in men

Incidence increased past 30 years4650 case in U.S.

Anal Pap Smears

At-risk groups:MSM

HIV infected men and women

Immunocompromised men and women

Women with history of HGSIL of cervix and/or vulva

Women participating in anal receptive intercourse

Anal Pap Smears

No national recommendationsScreening NOT recommended byCDC, USPSTF, ACS, ISDA or National Guidelines ClearinghouseRecommended Annually by New York Dept of Health for following:

HIV +MSMHistory of genital wartsHistory of CIN

Anal Pap Smears

ProcedurePosition patient on side or in GYN stirrups

Use Dacron swab pre-moistened with tap water

Insert 2 inches and use a spiral motion

Gradually withdraw over 10 seconds (rotating)

Agitate in liquid fixative for 15 seconds

Oropharyngeal Cancer

Oral cancers develop through 2 pathways

Those initiated by sexual behaviors (HPV positive cases) (60%)

Those initiated by tobacco and alcohol use (HPV negative cases)

M. Gillison. (2008) Journal of the American Cancer Institute.

Oropharyngeal Cancer

Screening Techniques:Current

Annual clinical exam by visual inspection

FutureOral cytology

Oral HPV testing

Brush biopsy

Visual assistance devices

VACCINATION ISSUES IN A WOMEN’S HEALTH

PRACTICE

Vaccinations

Until recently, women’s health care providers viewed the topic of immunizations as the responsibility of Primary Healthcare Providers (PCPs)Two events have changed this:

Many women’s health care providers are functioning as PCPs The development and successful marketing of HPV vaccines

Immunizations

The challengeWhile we have an experience and a comfort level in dealing with STDs and the need for immunizations in pregnancy

Our Pediatric, Family and Adult Practice colleagues have been integrating immunizations in the practice

Immunizations

GardasilManufactured by MerckQuadrivalent, recombinant vaccine designed to reduce HPV strains 6, 11, 16 & 18 6 & 11 associated with ano/genital warts16 and 18 associated with cervical CA (60-70% of all cervical cancersJune 2006 FDA approved for girls & women age 9 to 26 (do not give if pregnant)Shown to be 100% effective in preventing cervical dysplasia related to HPV infectionVaccine seroconversion rate = 99.7%Administered at 0 – 2 – 6 monthsCost $125/ dose or $375 total

Immunizations

Gardasil (cont.)October 2009 FDA approved for boys and men aged 9 to 26Has been tested in women 24 to 45

Study was done during 24 month period91% reduction of incidence (95%CI)83% prevention rate for 16 & 18 (95%CI)Not yet approved by FDA

– FDA requesting a 48 month study

Immunizations

CervarixManufactured by GalaxoSmithKline

Approved late 2009

Bivalent vaccine: Protects against HPV 16 & 18

Recent evidence that it protects against 31, 33, & 35 ( other cancer causing HPV strains)

96.9% effective in prevention of infection with HPV 16 & 18

100% effective in prevention of cervical CIN 1 related to HPV 16 & 18

Immunizations

TwinrixManufactured by GalaxoSmithKline (1/08)

Hepatitis A Inactivated & Hepatitis B (Recombinant) Vaccine

Standard dosing = 0 -1 -6 months with booster at 12 months

Accelerated dosing = 0 -7days – 21 to 30 days with booster at 12 months

Immunizations (Adult)

VACCINE RECOMMENDATIONTd/Tdap 19yo and above: Td booster every 10 years

19-64yo : 1 dose Tdap then Td q 10 years

HPV 19-26yo ; 3 doses (0,2,6 months)

Varicella Over 19yo: 2 doses (0, 4-8 weeks)

Zoster Over 60yo: 1 dose

MMR 19-49yo: 1 or 2 doses

Over 50yo: 1 dose

Influenza 19-49yo: 1 dose annually

50 and over: 1 dose annually

Pneumoccal (polysaccharide)

19-64yo: 1 or 2 doses

Over 65yo: 1 dose

Immunizations (Adult)

Hepatitis A 19 and above: 2 doses (0, 6-12 months or

0, 6-18mos)

Hepatitis B 19 and above: 3 doses (0, 1-2, 4-6 months)

Meningococcal 19 and above: 1 or more doses

Immunizations

http://www.immunize.org/immschedules/immschedule_adult.pdf

BIOIDENTICAL HORMONE USE IN MENOPAUSE

What We Know

HTRelieves hot flashes

Relieves vaginal dryness

Preserves bone mineral density/reduces fracture risk

What We Know

There are 3 classes of estrogens used in HT:

Native or bioidentical estrogensEstradiol, estrone, and estriol

Natural estrogensConjugated estrogens

Synthetic estrogensEthinyl estradiol and quinestrol

Women’s Health Initiative

What the FDA said about the WHI study results: Treatment of menopausal symptoms such as

hot flashes and vaginal dryness, remains the main use for HT

HT should be used at the lowest effective dose for the shortest time period

HT should not be used for primary or secondary prevention of coronary heart disease (CHD)

Current GYN exam, pap test, mammogram

North American Menopause Society (NAMS)

Most recent statement July, 2008Women most likely to benefit from HT = around the time of menopause (preferably before age 60)

Benefit of HT decreases with advancing age and increasing time since menopause

Decreased risk of CHD in women starting HT within 10 years of menopause

Diagnosis of breast cancer increases with EPT use beyond 3 to 5 years

Effects of WHI Results on Patients

Women’s faith in conventional HT has been shaken

Search for a safer alternative to ease their menopausal symptoms

Accessibility of information on the internet, TV, and books

“Natural”/”Customized” formulations

Became appealing

Effects of WHI Results on Patients

Bioidentical Hormones

Derived from plant sources (Soy or wild Mexican yam root)Synthetic processing is used to derive the hormones usedThere is currently no central oversight on the production, prescribing or dosing of bioidentical hormonesCommercially available in Europe, South Africa, Australia, and New ZealandNot approved by FDA

Bioidentical Hormones

No large, prospective, well-controlled clinical trialsEstriol

Limited data suggest that it improves menopausal symptomsSome studies show improvements in BMDImpact on cardiovascular outcomes is unknownConflicting results of breast cancer risk

EstroneShown to relieve vasomotor symptoms and increase BMD (randomized, double-blind, placebo-controlled studies)Low potency (1/10 of estradiol)

Bioidentical Hormones

Take home messages:Need for RCTs

Patient education is keySee handout

Mammograms, RTIs & Recurrent BV

Mammograms

U.S. Preventive Services Task Force (USPSTF) 2009 Recommendations Regarding Mammograms

All recommendations are for women not at increased risk for breast cancer.

USPSTF Recommendations

No routine screening of women aged 40 to 49 years (C recommendation) The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.

USPSTF Recommendations

Biennial screening mammography for all women aged 50 to 74 years

The current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older

Against teaching BSE

The evidence for CBE continues to be assessed as insufficient

Recommendations

1000 women in their 40's with annual mammograms for 10 yearsMore than ½ of them (500) will need repeat mammograms for concerning findingsNearly 1/5 (200) will get breast biopsies 2 deaths from breast cancer will be prevented

The American College of Obstetricians and Gynecologists (ACOG)

Maintains its current advice that women in their 40s continue mammography screening every one to two years Women age 50 or older continue annual screening. Continue to counsel women that BSE has the potential to detect palpable breast cancer and can be performed.

American Cancer Society

Yearly mammograms starting at age 40 and continuing for long as the woman is in good health.

Clinical breast exams (CBE) every 3 years ages 20 to 39 and anually thereafter

Breast self exam (BSE) is an option for women starting in there 20s.

American Academy of Nurse Practitioners (AANP)

Supports the USPSTF recommendations

Reproductive Tract InfectionsCDC Guidelines 2006

Retest all women 3 months after treatment for chlamydia (NOT a TOC)

Concern that women with repeated infections are more at risk for PID

Cefixime 400mgm more effective that Ceftriaxone 125mgm IM in treatment for gonorrhea

Reproductive Tract InfectionsCDC Guidelines 2006

Persistent Bacterial VaginosisInitial treatment

Followed by metronidazole 0.75% gel 2X a week for 6 weeks

Trichomoniasis VaginalisAlternate to metronidazole 2 grams stat:

Tinidazole 2 grams at once

Conclusions

New Guidelines based upon Evidence Based Research:

Cervical cancer screening and treatment guidelines

Breast cancer screening guidelines

Vaccinations

Hormone Replacement Treatment

STDs