Current Recommendations in Women’s Healthcare - PowerPoint Presentation

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Current Recommendations in Women’s Healthcare

Dr. Maria Lin, DO FACOOG

Premier OB/GYN, LLCSlide2

Background Information

Medical school - Nova Southeastern University School of Osteopathic Medicine in Fort Lauderdale, FL

OB/GYN Residency – Mount Clemens Regional Medical Center in Detroit, MISlide3

Background Information

Employed at Premier OB/GYN, LLC

5323 4

th

Ave Circle East Bradenton, FL. 34208

Married and mother of 2 young children

No Disclosures

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Mia Lin age 4 years and Nicholas Lin age 9 monthsSlide5

Nicholas Lin age 21 months and Mia Lin age 5Slide6
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Cervical cancer screening and preventionSlide8

Pap TestingSlide9

Papanicolaou Test

Method of cervical screening used to detect potentially pre-cancerous and cancerous processes in the cervix

Involves collecting cells from the cervix

Detecting abnormal cells early with a pap smear is the first step in halting the possible development of cervical cancer.Slide10

Patients will ask “How beneficial is this really? I hate going…”Slide11

The Benefits

The incidence of cervical cancer in the U.S. has decreased more than 50% in the past 30 years because of screening.

In 1975, rate was

14.8

per 100,000. By 2011, it decreased to

6.7

per 100,00.

Cervical cancer is much more common worldwide, mainly in countries without screening programs, with an estimated 527,624 new cases of disease and 265,672 resultant deaths each year.

When cervical cancer screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed. Slide12

The scary truth

MOST CASES OF CERVICAL CANCER OCCUR IN WOMEN WHO WERE EITHER NEVER SCREENED OR WERE SCREENED INADEQUATELY

50% OF THE WOMEN IN WHOM CERVICAL CANCER IS DIAGNOSED NEVER HAD SCREENING

ANOTHER 10% HAD NOT BEEN SCREENED WITHIN THE 5 YEARS BEFORE DIAGNOSISSlide13

What causes cervical Cancer ?Slide14

Human Papillomavirus (HPV)Slide15

Human Papillomavirus

Double stranded DNA tumor virus

45 – 55 nm

icosohedral

capsid

More than 100 typesSlide16

Types of infection

Mucocutaneous

Verruca

plantaris

1,2,4

Verruca

vulgaris

2,4,29,38

Verruca

plana

3,10,28

Anogenital

Condyloma

6,11

Dysplasia and cancer 16,18,31,33,35,45,51,56Slide17

Incidence

It is estimated that 80% of men and women will be exposed to the virus by the age of 50

Median duration of any HPV infection – 8 months

70% cleared in 1 year

90% cleared in 2 yearsSlide18

HPV and cervical cancer

1995 study Bosch et al., 932 cases of cervical cancer from around the world

Using PCR reactions, his group amplified HPV DNA from the tumor and found that

93%

of cervical carcinoma had HPV DNA

1999

Walboomers

et al. repeated Bosch’s experiment using new PCR primers. Those cancers that failed to test positive for HPV DNA were retested with these new primers and results showed that

99.7%

of Bosch’s original cases tested positive for HPV DNA. Slide19

HPV and oncogenesis

Viral DNA E6 and E7 are the main force in stimulating cellular proliferation

E6 inhibits p53. p53 is a crucial cell protein involved in apoptosis (cell death).

E7 binds the retinoblastoma (

Rb

) protein. Once bound,

Rb

releases E2F transcription factor which causes cellular proliferation.Slide20

Screening guidelines

Cervical cancer screening should begin at age 21 years.

Women younger than 21 years should not be screened regardless of sexual initiation.Slide21

Screening guidelines

Women aged 21-29 years should be tested with cervical cytology alone, and should be performed every 3 years.Slide22

Screening guidelines

For women aged 30-65 years,

cotesting

with cytology and HPV testing every 5 years is preferredSlide23

Screening guidelines

Women aged 65 years and older – no screening is necessary after adequate negative prior screening results

Women with history of

CIN 2, CIN 3 or AIS

should continue screening for at least 20 yearsSlide24

What about women who have had a hysterectomy?

No screening is necessary

Applies to women without a

cervix

Applies to women without a history of

CIN 2, CIN 3, AIS, or cancer

for the past 20 years

IF HYSTERECTOMY WAS DONE BECAUSE OF ABNORMAL PAP – STILL NEED SCREENING!!!Slide25

Cervical cancer screening for specific populations

Women who have HIV

– first year diagnosed should have pap every 6 months, then it should be done annuallySlide26

Cervical cancer screening for specific populations

Women who are

immuncocompromised

(transplant patient)

– Annual pap testSlide27

Cervical cancer screening for specific populations

Women who were exposed to DES in

utero

– Annual pap testSlide28

Breast cancer screening and preventionSlide29

1 in 8 women living in the U.S. will be diagnosed with breast cancer in her lifetime…Slide30

3 out of 4 of those diagnosed with breast cancer have no known risk factors.Slide31

25% of women who die from breast cancer are diagnosed in their forties

.Slide32

But if the cancer is detected before it has spread, the chance for a cure is nearly 100%.Slide33

Breast cancer screening has typically involved 3 elements

Breast imaging

Clinical breast examination

Patient self-screeningSlide34

Breast Imaging – MammogramSlide35

Screening Mammography

Obtains routine images of asymptomatic women to detect cancer at a preclinical stage

Consists of 2 views of each breast (

craniocaudal

and

mediolateral

oblique)

Breast compression is a necessary part of the examinationSlide36

Screening Mammography – why?

The smallest breast mass that can be palpated is about 1 cm, but most do not notice it until about 2 cm.

89% of tumors measuring 1cm or less are cured by primary surgery

By mathematical estimation a typical

ductal

adenocarcinoma

with a constant mean doubling time of 100 days would have been present for more than 11 years before it grew to a generally palpable size of 2 cm.

Mammography screening can identify a

nonpalpable

mass measuring 1mm to 1cm during its preclinical phase,

3 years before it becomes palpableSlide37

Breast Imaging - Ultrasonography

Established adjunct to mammogram

Useful in evaluation inconclusive mammogram findings, in evaluating young patients and women with dense breast tissue, in guiding tissue core-needle biopsy and other biopsy techniques, and in differentiating a cyst from a solid mass.

NOT RECOMMENDED AS A SCREENING MODALITYSlide38

Breast Imaging - MRI

Useful adjunct to mammography

Cost, duration of examination, and injection of IV contrast prohibit its use as routine screening technique

MRI screening is recommended for women with a 20% or greater lifetime risk of developing breast cancer

BREAST MRI IS NOT RECOMMENDED FOR SCREENING WOMEN AT AVERAGE RISK OF DEVELOPING BREAST CANCERSlide39

Breast Imaging - other

Color Doppler

ultrasonography

, computer-aided detection, positron emission tomography,

scintimammography

, and digital breast

tomosynthesis

have shown promise in selected clinical situations as adjuncts to mammography. However, these techniques are not considered alternatives to mammography.Slide40

Clinical Breast examination

Performed by a healthcare professional who is trained to recognize many different types of abnormalities and warning signs. Slide41
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Patient self-screening

Evolution away from teaching self-breast examination toward the concept of breast self-awareness

Breast self-awareness – a woman’s awareness of the normal appearance and feel of her breasts

Approximately 50% of all cases of breast cancer in women >50 and 70% of cases of cancer <50 are detected by women themselvesSlide43

How often and when do I start?Slide44

When can I stop screening?

A consensus of recommendations on this issue does not exist

Medical

comorbidity

and life expectancy should be considered in a breast cancer screening program for women aged 75 years or olderSlide45

Screening guidelines in High-risk groups

BRCA 1/BRCA 2 mutation

–

-TWICE YEARLY CLINICAL BREAST EXAM

-ANNUAL MAMMOGRAM starting at least 10 years prior

to the earliest age cancer diagnosed, and no later

than age 25

- ANNUAL BREAST MRI Slide46

Screening guidelines in High-risk groups

Women who are estimated to have a lifetime risk of breast cancer of 20% or greater (based on risk models such as the Gail model, Claus model,

T

yrer

C

uzick

model)

–

- TWICE

YEARLY CLINICAL BREAST EXAM

-ANNUAL MAMMOGRAM starting at least 10 years prior

to the earliest age cancer diagnosed, and no later

than age 25

- ANNUAL BREAST MRI

Slide47

Screening guidelines in High-risk groups

Women who have had prior thoracic radiation therapy (typically as treatment for lymphoma)

–

- CLINICAL BREAST EXAMS EVERY 6-12 MONTHS

- ANNUAL MAMMOGRAM starting at age 25

- ANNUAL BREAST MRI starting at age 25Slide48

Screening guidelines in High-risk groups

Women with personal history of high-risk breast biopsy results, including atypical hyperplasia and lobular carcinoma in situ

–

-

CLINICAL BREAST EXAMS EVERY 6-12 MONTHS

- ANNUAL MAMMOGRAM starting at age 25

- ANNUAL BREAST MRI

has been recommended for

women with history of lobular carcinoma in situ by

some organizations Slide49

What about women with Breast Implants?

ANNUAL MAMMOGRAM

X-rays used in mammograms cannot go through silicone or saline implants well enough to show the tissue under them. So women with breast implants have 4 extra pictures done (2 on each breast). These extra pictures are called implant displacement views in which the implant is pushed back against the chest wall and the breast is pulled forward over it.

Very rarely mammograms can rupture an implantSlide50

Colorectal cancer screening and prevention Slide51

Worldwide, colorectal cancer is the second most commonly diagnosed cancer in womenSlide52

In the United States, colorectal cancer is the second leading cause of cancer death

Approximately one in three people who develop CRC die of this disease.Slide53

90 percent of cases occur after the age of 50 years.Slide54

Tests used for screening

Stool-based tests:

Fecal occult blood test

Immunochemical-based fecal occult blood test (FIT)

Cologuard

(fecal DNA testing)Slide55

Tests used for screening

Endoscopic and radiologic exams

:

Flexible

sigmoidoscopy

Colonoscopy

CT

colonographySlide56

Guidelines for screening

Multi-Society Task Force guidelines (joint guidelines from the American Cancer Society, the United States Multi-Society task force on Colorectal Cancer, and the American College of Radiology)

United States Preventive Task Force

American College of GastroenterologySlide57

Multi-Society Task Force guidelines

Offer screening beginning at age 50 years

No single test is of unequivocal superiority : Colonoscopy every 10 years or Computed

Tomographic

Colonography

every 5 years or Flexible

Sigmoidoscopy

every 5 years or Fecal occult blood testing annually or Fecal immunochemical-based testing annuallySlide58

The United States Preventive Services Task Force guidelines

Three screening options for adults 50-75 years old

1. Annual fecal occult blood testing

2. Flexible

Sigmoidoscopy

every 5 years

3. Colonoscopy every 10 yearsSlide59

Are you confused yet?Slide60

GOLD STANDARD

Colonoscopy – has the benefit of high detection rate and lesions can often be removed during the same procedureSlide61

American College of Gastroenterology

Recommends colonoscopy as the preferred screening/prevention test

Recommends colonoscopy starts at age 45 for African Americans and age 50 for the rest of the population

The fecal immunochemical test is the preferred screening/detection test for those patients who absolutely refuse colonoscopySlide62

The Benefits

Both the incidence of and mortality rates from colorectal cancer have been declining in the United states.

Approximately 250,000 to 500,000 colorectal cancer cases may have been prevented from 1987 to 2010, along with a shift from late to early stage disease.Slide63

Osteoporosis ScreeningSlide64

Osteoporosis

Osteoporosis is a skeletal disorder characterized by loss of bone mass, deterioration of

microarchitecture

, and a decline in bone quality – all of which lead to increased risk of FRACTURESlide65

Osteoporosis

Bone is a dynamic tissue

Remodeling and repair of bone is accomplished through

resorption

and formation processes controlled by

osteoclasts

(

resorption

) and

osteoblasts

(formation).Slide66

Bone remodeing

Osteoclasts

breaking down old bone and

osteoblasts

building new boneSlide67

Osteoporosis

In the young adult years, net gain or loss of bone mineral content is minimal

In midlife, this bone turnover process shifts to greater

resorption

than formation, resulting in a net loss of bone mineral content

THE TIME OF MOST RAPID BONE LOSS IN WOMEN COINCIDES WITH THE MARKED DECLINE IN ESTROGEN LEVELS ASSOCIATED WITH MENOPAUSE. Slide68

Definition of Osteoporosis: WHO based on T score

Z-score – reference population is same sex, age, race

T-score – reference population is normal young adult

Osteopenia

– T score -1 to -2.5 (standard deviation below the mean)

Osteoporosis – T score < - 2.5Slide69

Why do we care so much?Slide70

Morbidity and mortality are especially high with hip fractures.

Of women older than 80 years who have had a hip fracture, only 56% could walk independently after 1 year.Slide71

Approximately 3-6% of women die

of complications while hospitalized for hip fracture.Slide72

Why do we care so much?Slide73

Spinal compression

fractures can permanently alter the strength and shape of

the spine. Most

compression fractures occur in the front of the vertebra, which causes the front part of the bone to collapse creating a wedge-shaped vertebra. The back of the bone is unchanged because it's made of harder bone. This creates the stooped posture called

kyphosis

,

or dowager's hump.

About two-thirds of spinal compression fractures are never diagnosed because many patients and families think the

back pain is

merely a sign of aging

and arthritis.

But

if

osteoporosis isn't

treated, it can lead to future fractures -- and possibly more severe compression fractures. Slide74

Diagnosing Osteoporosis

The most widely recommended method of diagnosing osteoporosis in the U.S. is bone densitometry.

DXA of the lumbar spine and hip is the preferred methodSlide75

When should bone density screening be initiated?

DXA screening should begin at age 65 years for women

DXA screening can be used selectively for women younger than 65 years if they are postmenopausal and have other risk factors for fractureSlide76

When to screen before age 65 years – Postmenopausal and…

Medical history of a fragility fracture

Body weight less than 127lb

Medical causes of bone loss (medications or diseases)

Parental medical history of hip

fracture or osteoporosis

Current smoker

Alcoholism

Rheumatic and autoimmune diseasesSlide77

Conditions, Diseases, and Medications that cause or contribute to Osteoporosis and Fractures

Ankylosing

spondylitis

, Lupus, Rheumatoid arthritis, Adrenal insufficiency, Cushing’s

syndrome, Diabetes mellitus, Hyperparathyroidism,

Thyrotoxicosis

, Celiac disease,

Gastric Bypass, GI surgery, Inflammatory bowel disease,

Malabsorption

, Pancreatic

disease, Primary

biliary

cirrhoisis

, low calcium intake, high caffeine intake, alcohol (3 or

more drinks/day), Smoking, Vitamin D insufficiency, High salt intake, Inadequate

physical activity, Falling, Excess Vitamin A, Aluminum in antacids, Immobilization,

Thinness, Anticoagulants, Anticonvulsants,

Aromatase

inhibitors,

Barbituates

, Cancer

Chemotherapeutic drugs, cyclosporine A and

tacrolimus

,

Depo

-

medroxyprogesterone

,

Glucocorticoids

,

Gonadotropin

releasing hormone agonists, Lithium, Cystic

fibroisis

, Ehlers-

Danlos

,

Gaucher’s

disease, Glycogen storage disease,

Hemochromatosis

,

Homocystinuria

,

Hypophosphatasia

, Idiopathic

hypercalciuria

,

Marfan

syndrome,

Menkes

steely hair

syndrome,

Osteogenesis

imperfecta

,

parenal

history of hip fracture,

Porphyria

, Riley-Day

syndrome, Androgen

insensivity

, Anorexia nervosa and

bulemia

,

atheletic

amenorrhea,

hyperprolactinemia

,

panhypopituitarism

, Premature ovarian failure, Turner’s syndrome and

Klinefelter’s

syndrome, Alcoholism,

Amyloidosis

, Chronic metabolic acidosis, Congestive

heart failure, Depression, Emphysema, End stage renal disease, Epilepsy, idiopathic

scoliosis, Multiple sclerosis, Muscular Dystrophy,

Parenteral

nutrition, Post-transplant bone

disease, Prior fracture as an adult,

Sarcoidosis

, Hemophilia, Leukemia and lymphomas,

Multiple myeloma, Sickle cell disease, Systemic

mastocytosis

,

ThalassemiaSlide78

After menopause, start thinking about screening!Slide79

What about uterine cancer and ovarian cancer screening?

Unfortunately there is no standard or routine screening test for uterine cancer or ovarian cancer.

These cancers are usually diagnosed based on evaluation of symptoms – which is just another reason it is so important to have a yearly female wellness exam.Slide80
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QuestionsSlide82

References

Chelmow

MD, David. “Cervical Cancer Screening and Prevention.” ACOG Practice Bulletin Number 157, January 2016

Griffin MD, Jennifer,

Gemignani

MD, Mary, Pearlman MD, Mark. “Breast Cancer Screening.” AGOG Practice Bulletin Number 122, August 2011

Gass

, MD, Margery. “Osteoporosis.” ACOG Practice

Bulletn

Number 129, September 2012

Doubeni

MD,

Chyke

. “Screening for colorectal cancer: Strategies in patients at average risk.”

Uptodate

. April 8, 2016.Slide83

Quick Board Review for Medical Students

FETAL HEART RATE TRACING IS ALWAYS, ALWAYS, ALWAYS on boards!!!!Slide84
Slide85

Early Decelerations

Caused by fetal head compression

Generally seen in active labor

No associated with fetal hypoxia, acidosis or low

Apgar

scoresSlide86
Slide87

Late Decelerations

Results from fetal hypoxia

Non-reassuring when persistent

BUZZWORD –

uteroplacental

insufficiencySlide88
Slide89

Variable Decelerations

Caused by umbilical cord compression

Persistent mild umbilical cord compression – may cause mild respiratory acidosis from CO2 retention

Prolonged, repetitive umbilical cord compression – progressive fetal hypoxia and metabolic acidosis