Women's Health Topics Covered at Luncheon
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A discussion of women's health issues over age 40 including fertility, infertility, family planning, contraception, PMS, menopause, hormones, urinary incontinence, and osteoporosis, and cancer for the Illuminate women's luncheon.
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Women's Health Topics Covered at Luncheon
- 3. Illuminate | Women’s Luncheon | March 9, 2012 Vandna Jerath, MD, FACOG FACOG - Board-Certified Private practice - 13 years Located at Parker Adventist Hospital Full-scope obstetrics & gynecology Enjoy education and community outreach Disclosure – no affiliations Healthcare social media pioneer & expert locally Educate, engage, and empower women Blog – drjerath.com
- 4. Illuminate | Women’s Luncheon | March 9, 2012 Optima Women’s Healthcare Services Low and high risk obstetrics Minimally invasive gynecologic surgery Novasure and Thermachoice Endometrial ablation Essure sterilization Family planning and infertility Menopause and hormone replacement therapy Bladder retraining and incontinence surgery Women’s health resource/expert Female empowerment Spa-like setting, patient pampering Individualized, personalized, and compassionate care optimawomenshealthcare.com
- 6. Illuminate | Women’s Luncheon | March 9, 2012 The Basics - Screening Cervical Cancer Screening Start age 21, regardless of sexual activity Age 21-29 – every 2 years Age 30-64 – every 1-3 years Stop age 65 – if normal for 10 years Breast Cancer Screening Self-breast exams monthly Clinical breast exam annually Mammograms annually starting at age 40 Or 10 years before relative with breast cancer Colon Cancer Screening Fecal occult blood stool cards yearly starting age 50 Colonoscopy start at age 50 – every 10 years, every 5 years with risk factors Start 10 years before relative with colon cancer and every 5 years Medical Screening Labs every 5 years – CBC, Chem 20, Lipid, TSH; glc every 3 years Heart disease, thyroid disease, Anemia, liver disease, metabolic syndrome BP, Skin, Eyes, Teeth – annually Osteoporosis Screening Bone Density (DEXA) starting age 65 – every 2 years Or as indicated clinically
- 7. Illuminate | Women’s Luncheon | March 9, 2012 The Basics - Immunizations cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm?s_cid=mm6104a9_w
- 8. Illuminate | Women’s Luncheon | March 9, 2012 The Basics - Immunizations cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm?s_cid=mm6104a9_w
- 10. Illuminate | Women’s Luncheon | March 9, 2012 Fertility by Age Rba-online.com
- 11. Illuminate | Women’s Luncheon | March 9, 2012 Infertility Common Low success rate after 40 Increased risk of congenital anomalies or miscarriage Healthy lifestyle is important Male factor vs Female factor Basic Testing Day 3 Labs Estrogen Follicle Stimulating Hormone (FSH) Anti-Mullerian Hormone (AMH) Clomid Challenge Test Pelvic Ultrasound Hysterosalpingogram Check for tubal patency Semen Analysis Laparoscopy Anxiety/Depression Mental Health Specialist
- 12. Illuminate | Women’s Luncheon | March 9, 2012 Reproductive Endocrine Infertility Referral to REI specialist Options Clomid Clomid-Intrauterine Insemination (IUI) In-vitro Fertilization (IVF) Gamete Intrafallopian Tube Transfer (GIFT) Egg Donor Surrogacy Adoption Genetic Testing
- 13. Illuminate | Women’s Luncheon | March 9, 2012 Family Planning Unintended pregnancy rates high over age 40 40-50% result in termination Contraception Options How to decide What is best over 40? Political Firestorm Preventative Coverage
- 14. Illuminate | Women’s Luncheon | March 9, 2012 Contraception – Short Term Barrier Condoms Diaphragm Hormonal Oral Contraceptives “the pill” Estrogen/Progesterone combination or Progesterone only Daily Patch Weekly Vaginal Ring Monthly Depo-Provera injection Progesterone only Every 3 months
- 15. Illuminate | Women’s Luncheon | March 9, 2012 Contraception – Long Term Reversible Implanon – implantable device Every 3 years Intrauterine Device (IUD) Paraguard Non-hormonal 10 years Benefits – no hormones, use until menopause Risks – pain, cramping, discharge Mirena Progesterone hormone 5 years Benefits - decrease heavy periods, stabilize fibroids Risks – breakthrough bleeding, acne, weight gain
- 16. Illuminate | Women’s Luncheon | March 9, 2012 Contraception - Permanent Non-reversible Sterilization Traditional surgery Tubal ligation In-office ESSURE Metal coils In-office Adiana Silicone plugs No cutting No general anesthesia No hormones Quick Recovery
- 17. Sexual Health
- 18. Illuminate | Women’s Luncheon | March 9, 2012 Sexually Transmitted Infections STI/STD Women over 40 getting divorced Infidelity New partners Anxiety Condoms Regular testing Treatment Most common HPV – Human Papilloma Virus HSV - Herpes GC/CT – Gonorrhea/Chlamydia HPV vaccine FDA approved Girls ages 9-26, ideal age 11-12, boys too
- 19. Illuminate | Women’s Luncheon | March 9, 2012 Sexual Dysfunction Marked distress and interpersonal difficulty Anxiety and fear - difficulty discussing with healthcare provider Desire Problems Most common – 8% prevalence; peak women age 40-60 Decreased libido Arousal Problems – 5% Orgasmic Problems – 3.4-5.8% Inability to orgasm Sexual Pain Disorders Dyspareunia – 8-22%; recurrent painful sex Vaginismus – 1-6%; involuntary spasm of lower 1/3 vagina Vestibulitis Vulvodynia Causes Physiologic - Menopause, atrophic vaginitis, lack of estrogen, chronic disease Psychological - Dysfunctional interpersonal relationship, depression, traumatic life event, history of abuse Meds – SSRI, OCPs, steroids, anti-hypertensives, histamine blockers Treatment Physiologic – ERT, testosterone, lubricants Physical – Pelvic floor therapy, masturbation, muscle relaxation, vaginal dilators, clitoral therapy Therapy - Psychotherapy, couples counseling, communication exercises, decrease stress Meds – Sildenafil (Viagra), Testosterone, ERT, antidepressants, adjust SSRI, change OCPs, analgesics, xylocaine Date Night Validate and reassure patient
- 20. Gyn Conditions
- 21. Illuminate | Women’s Luncheon | March 9, 2012 Clinical Conditions Premenstrual Syndrome – PMS/PMDD Heavy periods Perimenopause/Menopause Urinary Incontinence Pelvic Organ Prolapse Osteoporosis Cancers
- 22. Illuminate | Women’s Luncheon | March 9, 2012 Premenstrual Syndrome
- 23. Illuminate | Women’s Luncheon | March 9, 2012 Premenstrual Syndrome Cyclic occurrence of symptoms with physical, emotional, and/or psychological manifestations Occur 5-7 days before menses and subside within 4 days after onset Common age 25-45; may worsen in perimenopause Imbalance of neurotransmitters Premenstrual Syndrome (PMS) 75-85% women have one symptom 20-30% moderate to severe symptoms Premenstrual Dysphoric Disorder (PMDD) 3-5% have debilitating symptoms with impairment of lifestyle
- 24. Illuminate | Women’s Luncheon | March 9, 2012 PMS - Symptoms Emotional/Mood Crying Angry outbursts Mood Swings Depressed Irritable Social Withdrawal Poor Concentration Physical Breast tenderness Bloating Constipation Weight gain Swelling Acne Headache Fatigue Sleep disturbances Appetite changes/food cravings Keep mood and menstrual diary Distinguish from medical conditions Hypothyroidism, IBS, chronic fatigue, fibromyalgia, mood disorders, and migraines
- 25. Illuminate | Women’s Luncheon | March 9, 2012 PMS - Treatment Lifestyle Modifications Stress reduction Exercise Healthy diet Reducecaffeine, alcohol, tobacco Alternative/Natural Therapies Vitamins – Calcium, B6, Magnesium, Vit E Herbs – Black Cohosh, Gingko, St. John’s Wort, not FDA approved Acupuncture Psychotherapy Light therapy Medications NSAIDs – Motrin, Aleve, Ponstel OCPs – Yaz, Yasmin Diuretics Ovarian Suppression – Danacrine, Lupron Antidepressants – SSRI – Prozac, Sarafem, Zoloft, Celexa, Effexor, Cymbalta
- 26. Illuminate | Women’s Luncheon | March 9, 2012 Heavy Periods Menorrhagia – heavy periods, >80ml blood loss Excessive, prolonged, heavy bleeding 1 in 5 women affected In the U.S. 10 million women suffer Takes physical, social, emotional, and psychological toll 70% of women suffer in silence Causes Anatomical Endometrial Polyp Fibroids Hyperplasia Cancer Hormonal Ovulatory Anovulatory Polycystic Ovarian Syndrome (PCOS) Other
- 27. Illuminate | Women’s Luncheon | March 9, 2012 Heavy Periods - Treatment Expectant Management Oral Contraceptives (OCPs) – birth control pills Provera withdrawal Hormones Dilation and Currettage (D&C) Hysteroscopy Endometrial Ablation Novasure Thermachoice Hydrothermablation (HTA) Her Option cryotherapy Microwave endometrial ablation Myomectomy Uterine Artery Embolization Hysterectomy Laparoscopic – LAVH, TLH, DaVinci Vaginal Abdominal
- 28. Illuminate | Women’s Luncheon | March 9, 2012 Menopause
- 29. Illuminate | Women’s Luncheon | March 9, 2012 Menopause Pre, Peri, and Post- Menopause No period for 1 year Average age in U.S. is 51; range age 45-55 Symptoms Hot flashes – 75% Vaginal dryness Mood swings Decreased libido Decreased concentration Insomnia Hair loss Weight gain Metabolic Syndrome Risk CVD & diabetes Natural aging vs medical disorder
- 30. Illuminate | Women’s Luncheon | March 9, 2012 Menopause - Treatment Hormone Replacement Therapy Types Estrogen Estrogen/Progestin Pills, patches, creams, vaginal suppositories,shots, pellets Bioidentical hormones Cyclic or daily Benefits Reduction and improvement of symptoms Protect bones Risks Side Effects – bleeding, breast tenderness, bloating, abnormal uterine bleeding (AUB) Anxiety Stroke Heart attack Blood clot Breast cancer Women’s Health Initiative (WHI) results Lowest dose for shortest duration that is effective Currently fewer than 1 in 3 women take Antidepressants SSRI or SNRI Gabapentin Quality of life issue Duration of Treatment
- 31. Illuminate | Women’s Luncheon | March 9, 2012 Menopause – Alternative Therapy Holistic or natural approach – not an assurance of safety or efficacy Used by more than 30% of women Significant costs Bioidentical Hormones Not FDA approved Herbal Not FDA approved High degree of variation Hot flashes – soy, black cohosh, evening primrose, dong quai Mood disturbances – St. John’s wort, valerian root Sexual dysfunction – chasteberry, ginseng AUB – wild yam Soy Phytoestrogen - isoflavones Avoid in Breast CA? Acupuncture Lifestyle modification Nutrition Exercise Yoga
- 32. Illuminate | Women’s Luncheon | March 9, 2012 Menopause – WHI Women’s Health Initiative Launched in 1991, 15+ year study Clinical trials and an observational study, 161,808 generally healthy postmenopausal women Age 50-79 Test the effects of postmenopausal hormone therapy, diet modification, calcium and vitamin D supplements on heart disease, fractures, and breast and colorectal cancer. Some follow-up studies ongoing nhlbi.nih.gov/whi/
- 33. Illuminate | Women’s Luncheon | March 9, 2012 Menopause – WHI Data Compared with the placebo, estrogen plus progestin resulted in: Increased risk of heart attack Increased risk of stroke Increased risk of blood clots Increased risk of breast cancer Reduced risk of colorectal cancer Fewer fractures Increased risk of dementia (study included only women 65 and older) Stopped 2002 30/10,000 Compared with the placebo, estrogen alone resulted in: No difference in risk for heart attack Increased risk of stroke Increased risk of blood clots Uncertain effect for breast cancer No difference in risk for colorectal cancer Reduced risk of fracture Stopped 2004 8-10/10,000
- 34. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence Video Whoopi Goldberg - Poise Http://youtu.be/Ih7lI2IhJao
- 35. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence Urinary Incontinence Involuntary leakage / loss of urine Spontaneously Response to a stimulus Dribble Overflow from full bladder Urgency Neurologic More than 50% of women with symptoms do not discuss it with their doctor or seek help Can lead to stigma, embarrassment, isolation, sexual dysfunction, depression, and decreased quality of life Estimated 50 million women Twice as common in women than men Affects 10-70% of all women > 50% of nursing home women 25% premenopausal 40% postmenopausal
- 36. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence - Etiology Pelvic Floor Damage Pregnancy and childbirth 1 delivery 2 x risk of POP 50% of incontinence 75% of prolapse Stretching, compression, tearing of nerve, muscle, tissue Episiotomy Pudendal nerve damage Weak evidence to support elective c-section Can occur in nulliparous women Diabetes Back Surgery Neurologic disease Menopause
- 37. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence - Types
- 38. Illuminate | Women’s Luncheon | March 9, 2012 Pelvic Organ Prolapse (POP) Vaginal support tissue Weakening Results in protrusions “Bump” or “Falling out” Pelvic pressure Uterine Cystocele (bladder) Rectocele (rectum) Enterocele (bowel) Vaginal or paravaginal defect Coexist in 15 to 80 % of women 80% with severe POP have SUI due to urethral obstruction Corrective surgery for POP can result in SUI
- 39. Illuminate | Women’s Luncheon | March 9, 2012 Incontinence and POP - Treatment Incontinence products Lifestyle Modification Kegel Exercises Pelvic Floor Rehab and Physical Therapy Biofeedback Ultrasound Electrical stimulation Acupuncture Pessary Medications No oral ERT/HRT Periurethral injections ISD – intrinsic sphincter (urethral) deficiency Surgical Older procedures MMK, Pyrera, KKP, Raz Burch Retropubic Urethropexy Fascial sling Mid-urethral Sling TVT – tension free vaginal tape TOT – trans obturator tape Mesh – erosion, FDA safety concerns
- 40. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis
- 41. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis Bones become thin and brittle due to more bone loss than bone formation WHO – disorder characterized by Deterioration of bone microarchitecture Skeletal fragility Increased risk of fracture Osteopenia – low bone mass, not yet osteoporosis Affects 200 million worldwide 55% of the population over 50 have a fracture and risk increases 3% for each year of advancing age Greatest risk for postmenopausal women 2-5% bone loss per year Underdiagnosed and undertreated Peak bone mass by age of 30 Two types of bone Cortical – hard outer shell, 75% Trabecular – inner spongy structure, 25%, first to lose and first to respond to therapy Fracturescan cause chronic pain, deformity, disability, depression, inability to walk, deconditioning, debilitation, long-term care, and death
- 42. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporotic Brittle Bones
- 43. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis – Risk Factors History of prior fracture Family history of osteoporosis Caucasian race Poor nutrition Smoking Low BMI Estrogen deficiency Long-term low calcium intake Alcoholism History of falls or fall hazards Sedentary lifestyle Certain diseases – eating disorders, IBS, Cushing’s, AIDS, Diabetes Certain medication use – anticonvulsants, steroids, heparin, thyroxine, lithium, tamoxifen
- 44. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis - Fractures
- 45. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis - Treatment Lifestyle modification Decreasing fall risks Hip protectors Medication Calcium – 1200-1500 mg/day Vit D – 800 IU/day Combo therapy 12% reduction fractures HRT – 24-34% reduction fractures Biphosphonates – 30-50% reduction fractures Selective Estrogen Receptor Modulators 35-50% decrease in vertebral fractures Calcitonin Parathyroid Hormone Other Fluoride, Testosterone, Soy Prolia
- 46. Cancer
- 47. Illuminate | Women’s Luncheon | March 9, 2012 Cancers - Breast Breast Family history – 1st degree (parent, sibling, child) Lifetime risk 1 in 8 20-30% BRCA 1 & 2 70% no family h/o or known genetic risk Breast cancer mortality decreasing since 1990 Earlier detection – 50-70% self-detected Improved treatment Gail Model – risk assessment tool; cancer.gov/bcrisktool Detection Self-breast exam vs awareness Clinical breast exam Mammography MRI – greater than 20% lifetime risk Thermography – Not Recommended, Not FDA approved
- 48. Illuminate | Women’s Luncheon | March 9, 2012 Breast Cancer Screening Guidelines Organization Mammo Clinical Exam SBE SBA ACOG American College of Ob/Gyn Age 40+ annually Age 20-39: 1-3 yrs; age40+: annually Consider for high-risk patients Recommended ACS American Cancer Society Age 40+ annually Age 20-39: 1-3 yrs; age40+: annually Optional for age 20+ Recommended NCCN National Comprehensive Cancer Network Age 40+ annually Age 20-39: 1-3 yrs; age40+: annually Recommended Recommended NCI National Cancer Institute Age 40+ 1-2yrs Recommended Not Recommended N/A USPSTF U.S. Preventative Services Task Force Age 50-74 biennially Insufficient Evidence Not Recommended N/A
- 49. Illuminate | Women’s Luncheon | March 9, 2012 Breast Cancer Risk Factors Relative Risk Factor Factor >4.0 Female Age 65+ Genetic mutation Personal h/o Breast CA 2+ 1st degree relatives High breast tissue density Biopsy – Atypical Hyperplasia 2.1-4.0 1 first degree relative High-does radiation High bone density (postmenopausal) 1.1-2.0 1st pregnancy > age 30 Onset of menses < age 12 Late menopause > age 55 No full-term pregnancies No h/o breastfeeding Recent use of oral contraceptives Recent & long-term use of HRT Obesity (postmenopausal) Other H/O uterine or ovarian CA Alcohol Tall height High socioeconomic status Ashkenazi Jewish heritage
- 50. Illuminate | Women’s Luncheon | March 9, 2012 Cancers - Colorectal Facts Diagnosed in more women than all gyn cancers combined 70,000 women in the U.S. yearly 24,000 women die yearly 3rd leading cause of CA death in women Screening Colonoscopy every 10 years starting age 50 Earlier or more frequent with family history With polypectomy reduces incidence by 76-90% Miss rate polyp – 6-12% and CA – 5% Fecal occult blood or fecal immunochemical testing annually starting age 50 Flexible sigmoidoscopy Double contrast barium enema Virtual Colonoscopy
- 51. Illuminate | Women’s Luncheon | March 9, 2012 Colorectal Cancer Screening Test Interval Key Issues Colonoscopy Every 10 years Complete bowel prep Conscious sedation Need transportation Risks – perforation, bleeding, and death Flexible Sigmoidoscopy Every 5 years Complete or partial bowel prep No sedation, some discomfort Limited view of colon If positive colonoscopy Double Contrast Barium Enema Every 5 years Complete bowel prep If positive colonoscopy Risks – very low Expertise to interpret
- 52. Illuminate | Women’s Luncheon | March 9, 2012 Gyn Cancer - Uterine Uterine In U.S. – 40,000 cases, 7,310 deaths annually Most common gyn CA – 8th most common CA death Precursor – endometrial hyperplasia Risk Factors Obesity Early menses Late menopause Nulliparity Infertility White race Tamoxifen use ERT Diabetes Symptoms – abnormal uterine bleeding (AUB) Diagnosis – Endometrial biopsy or Dilation & Curettage (D&C) Treatment – surgery, radiation, progestin (hyperplasia)
- 53. Illuminate | Women’s Luncheon | March 9, 2012 Gyn Cancer - Ovarian Ovarian/Fallopian Tube In U.S. – 22,430 cases, 15,280 deaths annually Lifetime risk 1 in 70 2nd most common gyn CA 20% diagnosed Stage 1 with 90% 5 year survival rates 70% diagnosed advanced stage with 5 year survival rates 30-55% Risk factors Older age Post-menopausal Family h/o breast or ovarian cancer BRCA 1 (60x) & BRCA 2 (30x) Nonpolyposis colorectal CA or Lynch II (13x) Nulliparity (never pregnant) Infertility Endometriosis Prophylaxis Oopherectomy Combined oral contraceptives (OCPs) Evaluation/Diagnosis – pelvic exam, ultrasound, doppler, CT scan, CA-125, OVA-1, surgery Treatment – surgery, chemo
- 54. Illuminate | Women’s Luncheon | March 9, 2012 Gyn Cancer - Cervical Gynecological Cervical In U.S – 12,900 cases, 4,400 deaths annually Decreased due to effective screening – 16% of gyn CA Precursor – cervical dysplasia Risk Factors HPV Early onset of sexually activity History of STD/STI Multiple sexual partners Smoking Symptoms – watery vaginal discharge, post-coital and intermittent spotting Diagnosis – pap/colposcopy Treatment – surgery, radiation, chemo
- 55. Resources
- 56. Illuminate | Women’s Luncheon | March 9, 2012 Helpful Links General Women’s Health Acog.org Drjerath.com Contraception Plannedparenthood.org Essure.com Adiana.com Paraguard.com Mirena-us.com Infertility Resolve.org Sexually Transmitted Infections/Diseases cdc.gov/std Heavy Periods Novasure.com Pelvichealthsolutions.com Menopause Menopause.org Knowmenopause.com nhlbi.nih.gov/whi/ Incontinence AUGS.com Mypelvichealth.com NAFC.org Osteoporosis NOF.org WHO.int/en Heart Disease Goredforwomen.org Cancer Foundationforwomenscancer.org Cancer.org
- 58. Illuminate | Women’s Luncheon | March 9, 2012 Contact Information Optima Women’s Healthcare Vandna Jerath, MD Sierra Medical Office Building Parker Adventist Hospital Campus 9399 Crown Crest Blvd, Suite 450 Parker, CO 80138 303.805.1807 P | 303.595.5390 F optimawomenshealthcare.com drjerath.com Email - vjerathmd@optimawomenshealthcare.com
- 59. Illuminate | Women’s Luncheon | March 9, 2012 Social Media Facebook Facebook.com/drjerath Facebook.com/optimawhc Twitter Twitter.com/drjerath Twitter.com/optimawhc LinkedIn Linkedin.com/in/drjerath Pinterest Pinterest.com/drjerath Pinterest.com/optimawhc Google Plus profiles.google.com/Vandna Jerath, M.D. YouTube Youtube.com/doctorjerath
- 60. Illuminate | Women’s Luncheon | March 9, 2012 Thank You Many thanks to Julie Groves for this wonderful Illuminate luncheon series Definitely a wonderful way for women to learn and grow For more info Grovesllc.com/illuminate