Women’s Health

Kristin Hahn-Cover, MD
Assistant Professor of Clinical
Medicine
Department of Internal Medicine
Osteoporosis prevention
By NHANES III data (1988-94), mean total
calcium intake below recommended level
in female teenagers
NHANES IV data (1999-2000)
Age 16-19: 779mg/d
Age 20-39: 797mg/d
Milk consumption is responsible for 46% of
calcium intake in 12-18 year old Americans
Milk consumption decreased by 36%
among female teenagers from the late
1970’s to the mid-1990’s
Osteoporosis prevention
Adequate calcium intake
1000-1500 mg/d
50-60% of older adults meet this
recommendation
Adequate Vitamin D intake
400-800 IU/d
Exercise, particularly resistance and
high-impact exercise
Osteoporosis screening
Indications
People who have had ”fragility” fractures
Most women by age 65
People with risk factors for secondary
osteoporosis
Other high-risk patients (by age 60?)
Methods
DXA scan at two sites most commonly
used
Folic acid intake

All women of reproductive age should

get at least 400mcg of folic acid daily
to reduce the risk of having a child
with a neural tube defect
Domestic Violence Screening
Routine screening recommended; no
clearly accepted best way to do so
Physicians are typically reluctant to ask
about domestic violence, for many reasons
“Expert” physicians were consulted
regarding screening methods
Include with other safety questions
Phrase generally: “this is a real problem in our
society…I want all my patients to know how to
get help…”
Have a high index of suspicion when a patient’s
story doesn’t fit with their exam
Depression Screening
Depression costs $43 billion in the U.S.
annually
Point prevalence of major depression in
primary care is 4.8-8.6%
“usual care” without formal screening misses
30-50% of depressed patients
Many well-validated screening tools
“Over the past 2 weeks, have you felt down,
depressed or hopeless?”
“Over the past 2 weeks, have you felt little
interest or pleasure in doing things?”
Vaccines
Td booster every 10 years
Consider Tdap substitution for ages 18-65
MMR vaccine if uncertain regarding prior
vaccination; contraindicated if pregnancy
anticipated within 4 weeks
Flu vaccine if pregnancy anticipated within
flu season
Varicella vaccine if uncertain immunity;
contraindicated in pregnancy
New vaccines: HPV and Herpes
zoster/shingles vaccines
HPV vaccine
Recommended routinely for girls 11-
12
May also be given in ages 13-26
Series of 3 injections
Targets 4 types of HPV
Cause up to 70% of cervical cancers
Cause about 90% of genital warts
Not recommended during pregnancy
$ 120 per dose (total $360)
Herpes zoster/shingles vaccine
Licensed in age > 60
64% reduction ages 60-69
18% reduction age > 80
Reduces risk of shingles by 50%
Duration of post-shingles pain reduced by vaccination
Live vaccine, so don’t give in
immunocompromised patients
Has not been studied in patients with history of
shingles
If patient has not had chicken pox, she should
have primary varicella vaccination series, not this
vaccine
Breast screening
Mammogram screening, age 40-49
USPSTF evaluated trials containing a total of
almost 200,000 participants
Relative risk 0.85 after 14 years’ observation
Need to screen 1792 to prevent one breast cancer
death
“…over 10 years of biennial screening among 40-
year-old women, approximately 400 would have
false-positive results on mammography, and 100
would undergo biopsy...for each death from breast
cancer prevented.”
Digital mammography performs better than
film in women under 50 and in
postmenopausal women on HT
Breast screening
Mammogram screening, age 50 or
older
USPSTF recommends annual or
biennial screening
No clearly-defined upper age limit;
evidence of benefit in women as old as
74 years of age
If patients 75 and older have co-morbidities
that limit life expectancy, mammogram of
less benefit
Breast screening

Clinical breast exam

Sensitivity 40-69%
Specificity 88-99%
13.4% of women will have false-positive
results at least once, over 10 years, with
screening every 2 years
Highest risk of false-positive results in
women under 50
Breast screening

Breast self-examination
No evidence of benefit in reducing
breast cancer morbidity, or in allowing
earlier detection
Breast cancer mortality no different in
subjects instructed in BSE vs. subjects
not instructed
Cervical Screening
Pap smears
Use lubricating gel
Do annually, unless 3 consecutive annual Pap
smears have been normal, and no change in
risk factors—then acceptable to do Pap smear
every 2-3 years
ASCUS Pap: triage by HPV DNA
Dysplasia: refer to Gyn
Some evidence that can follow LGSIL in young
women, since this is typically a marker for HPV
infection, rather than a warning for impending cervical
CA
If hysterectomy for benign cause, Pap smear
screening not indicated
Cervical Screening
Chlamydia trachomatis and Neisseria
gonorrhea screening
Routine screening for chlamydia is
recommended for all sexually active women
under 26 years of age
5-14% of screened females aged 16-20 are infected
3-12% of screened women aged 20-24 are infected
Screening for gonorrhea recommended in high-
risk women
Prevalence higher among African American patients
than other ethnic groups
0.43-5.3% of screened young adults infected
Colon cancer screening
Colonoscopy preferred to
sigmoidoscopy in average-risk
women
Study of 1463 asymptomatic women,
4.9% found with advanced neoplasia;
3.2% would have been missed by
sigmoidoscopy
Colonoscopy more sensitive and
specific than ACBE or CT
colonography for lesions > 6mm
Emergency Contraception
Appropriate for unprotected or under-protected
intercourse
Prevents pregnancy from starting
Does not interrupt an existing pregnancy
Many proposed mechanisms
Best if used within 72 hours of sex
No medical contraindications, but not indicated in
suspected or confirmed pregnancy
Progestin-only regimen is preferred method
0.75 mg levonorgestrel, two doses
Marketed as Plan B
Prevents 60-85% of predicted pregnancies
Contraception
26-35% of adolescents do not use
contraception with first intercourse
Girls under 15 less likely to use contraception
with first intercourse
20% of teenage pregnancies occur within a
month of first coitus
85% of sexually active women who do not
use contraception become pregnant in one
year
Treatment to prevent pregnancy with EC or
other contraception is a task separate from
cervical screening with Pap smears
Contraception
Combination hormonal contraceptives
Act primarily by inhibiting GnRH release,
which prevents ovulation
Safe and effective for most women, and
have non-contraceptive benefits
8 unintended pregnancies per 100 woman-
years with typical use
Initiate oral contraceptives by Sunday-
start method; if oligomenorrheic, start
after a negative pregnancy test
Contraception
Contraceptive patch (Ortho-Evra)
Comparable to COC’s in ideal effectiveness, but better
compliance
Less effective if patient weighs more than 200lbs/90kg
Adhesive reactions can be problematic
Higher estrogen levels of concern, consider equivalent to
COC with 50mcg of ethinyl estradiol
Contraceptive vaginal ring (NuvaRing)
Left in place for 3 weeks
Comparable to COC’s in ideal effectiveness, but
compliance may be better
Vaginal discharge and irritation can occur
Contraception
Progestin-only pills
Used when contraindication to COC
8 unintended pregnancies per 100 woman-
years with typical use
Depo-medroxyprogesterone acetate
IM injection every 3 months
Irregular bleeding common at first
Amenorrhea in 60% at 12 months
Weight gain common
Decreases in bone mineral density of concern,
with FDA black-box warning for use beyond 2
years
Postmenopausal hormone therapy
WHI disproved effectiveness of PremPro for preventive
therapy
No clear reason to presume this applies only to CEE + MPA
Less evidence of harm, but no net benefit with CEE alone
Only compelling reason to initiate systemic HT is to treat
vasomotor symptoms unresponsive to other treatments
Osteoporosis improves with treatment, but not sufficiently for
this to be the only reason to treat with HT
Urogenital atrophic symptoms improve, but vaginal estrogen is
presumably a safer way to treat
HT duration should be limited, as possible
There is a subgroup of women who have intolerable vasomotor
symptoms off of HT/ET—for them, a careful discussion of risks
and goals may lead to the joint decision of prolonged HT
FDA recommends that postmenopausal women “use CEE only
for menopausal symptoms at the smallest effective dose for the
shortest possible time.”
Hypertension

In the Women’s Health Initiative

Observational Study, mortality risk
from CVD was lowest in women on
diuretics, either alone or in
combination
Increased risk in women on CCBs
Nonfatal CVD risk not different between
groups
Cardiovascular risk
In the HOPE study including 2182 women with
cardiovascular disease, increasing waist-to-hip
ratio correlated with increasing rate of
cardiovascular outcomes
Ratio > 0.8 high risk
Evidence that women with diabetes are at higher
risk for cardiac death than women with prior
history of MI
In Women’s Health Study of low-risk women, ASA
100mg every other day did not alter risk of CVD
RR stroke 0.83
Still worthwhile to consider ASA for primary prevention if
10-year Framingham risk >6%