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Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
Women's Health After 40:  comprehensive overview, honest discussion, latest updates & helpful tips
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Women's Health After 40: comprehensive overview, honest discussion, latest updates & helpful tips

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Insightful discussion by Vandna Jerath, MD on Women's Health after 40 including a comprehensive overview, honest discussion, latest updates & helpful tips. Topics include basic healthcare screening, …

Insightful discussion by Vandna Jerath, MD on Women's Health after 40 including a comprehensive overview, honest discussion, latest updates & helpful tips. Topics include basic healthcare screening, infertility/fertility, contraception, sexual health, Sexually Transmitted Diseases (STD), Sexually Transmitted Infections (STI), Premenstrual Syndrome (PMS), Abnormal Uterine Bleeding (AUB), menorrhagia, menopause, vaginal atrophy, Hormone Replacement Therapy (HRT), Women's Health Initiative (WHI), urinary incontinence, pelvic organ prolapse, osteoporosis, breast, uterine, ovarian, cervical, and colon cancers, and gynecology.

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  • 1. Parker Adventist Hospital | Health Seminar | April 22, 2014 Women’s Health after 40 comprehensive overview, honest discussion, latest updates & helpful tips Vandna Jerath, MD, FACOG April 22, 2014 optimawomenshealthcare.com drjerath.com
  • 2. General Information
  • 3. Parker Adventist Hospital | Health Seminar | April 22, 2014 Vandna Jerath, MD, FACOG  FACOG - Board-Certified  Private practice - 15+ years  Optima Women’s Healthcare  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  Website /Blog
  • 4. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Individualized, personalized, and compassionate care  optimawomenshealthcare.com
  • 5. Parker Adventist Hospital | Health Seminar | April 22, 2014 Learning Objectives  General overview of women’s health after age 40  Review of current healthcare screening guidelines for women with latest updates  Learn the latest research, news, and updates related to women’s health issues in this age category  Discuss age related gynecological clinical conditions such as infertility, family planning, sexual health, menstrual disorders, PMS, menopause, incontinence, osteoporosis, and cancer
  • 6. Parker Adventist Hospital | Health Seminar | April 22, 2014 Global Women’s Health & Rights 1. The right to be full and responsible citizens of their countries, with equal property, economic, voting and freedom of movement rights. 2. The right to equal education. 3. The right to work and earn a living with equal pay for equal work. 4. The right to be free of all forms of gender based violence such as domestic violence, sexual assault, incest, female infanticide, honor killings, female genital cutting and self- immolation at a husband’s death. 5. The right to the best available, scientifically based healthcare, including health and sexuality education. 6. The right to autonomous decision-making, informed consent, privacy and confidentiality regarding their own health care. 7. The right to participate equally in ethically conducted clinical and other research. 8. The right to decide when and if to have sex, including choosing one’s partner, and freedom from coerced marriage and sex trafficking. 9. The right to decide whether to have children, the number and spacing of their children, and to have the information, education and access to health services to make these choices. 10. The right to safe childbearing, with resources available to reduce maternal and infant morbidity and mortality. ACOG Statement of Policy, July 2012 (endorses FIGO resolutions)
  • 7. Basic Overview
  • 8. Parker Adventist Hospital | Health Seminar | April 22, 2014 To pap or not to pap?  Based upon current ACOG screening guidelines, at what interval should a woman age 45 obtain a pap smear, if her last pap smear and HPV testing was negative and she has had no history of prior abnormal pap smears?  A. Annually  B. Every 2 years  C. Every 3 years  D. Every 5 years
  • 9. Parker Adventist Hospital | Health Seminar | April 22, 2014 The Basics - Screening  Cervical Cancer Screening  Start age 21, regardless of sexual activity  Age 21-29 – every 3 years  No HPV testing  Age 30-64 – every 3-5 years  HR HPV testing  No paps after hysterectomy if low-risk  Stop age 65 – if normal for 10 years  If history of abnormal paps – need to be normal for at least 20 years  USPSTF/ACS/ASCCP 3/2012 guidelines and ACOG Practice Bulletin, Number 131, November 2012  Breast Cancer Screening  Self-breast awareness or exams monthly  Clinical breast exam annually  Mammograms annually starting at age 40  Or 10 years before relative with breast cancer  ? Dense breasts - ?Ultrasound/MRI ACOG Practice Bulletins, Committee Opinions and Guidelines for Women’s Healthcare – No 534, August 2012; No 131, November 2012; No 554, February 2013; No 122, August 2011; No 482, March 2011
  • 10. Parker Adventist Hospital | Health Seminar | April 22, 2014 The Basics - Screening  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  Reproductive and Sexual Coercion  Osteoporosis Screening  Bone Density (DEXA) starting age 65 – every 2 years  Or as indicated clinically  Or by FRAX risk ACOG Practice Bulletins, Committee Opinions and Guidelines for Women’s Healthcare – No 534, August 2012; No 131, November 2012; No 554, February 2013; No 122, August 2011; No 482, March 2011
  • 11. Parker Adventist Hospital | Health Seminar | April 22, 2014 The Basics - Immunizations cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm?s_cid=mm6104a9_w
  • 12. Parker Adventist Hospital | Health Seminar | April 22, 2014 The Basics - Immunizations cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm?s_cid=mm6104a9_w
  • 13. Infertility/Fertility
  • 14. Parker Adventist Hospital | Health Seminar | April 22, 2014 Fertility by Age Rba-online.com ACOG Committee Opinion – Female Age Related Fertility Decline, No 589, March 2014
  • 15. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Pelvic Anatomy  Antral Follicle Count  Hysterosalpingogram or Sonohysterogram  Check for tubal patency  Check for uterine abnormalities  Semen Analysis  Laparoscopy  Anxiety/Depression  Mental Health Specialist ASRM Committee Opinion – Diagnostic Evaluation of the Infertile Female, Fertility & Sterility - Vol 98, No 2, August 2012, 302-307
  • 16. Parker Adventist Hospital | Health Seminar | April 22, 2014 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
  • 17. Parker Adventist Hospital | Health Seminar | April 22, 2014 Family Planning  Unintended pregnancy  Rates high (50%) over age 40  Over 50% result in termination  Guttmacher Institute data  Contraception  Options  How to decide  What is best over 40?  Political Firestorm  ACA Preventative Coverage  ACOG recommends OCPs and EC should be available OTC ACOG Committee Opinions, No 542/No 544, November/December 2012 ASRM Practice Committee – Hormonal Contraception,Fertility & Sterility – Vol 90, Suppl 3, November 2008, S103-S113
  • 18. Parker Adventist Hospital | Health Seminar | April 22, 2014 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
  • 19. Parker Adventist Hospital | Health Seminar | April 22, 2014 Contraception – Long Term  Reversible  Implanon – implantable device  Every 3 years  Etonorgesterol hormone – 68 mg  Intrauterine Device (IUD)  ParaGard  Non-hormonal, copper  10 years  Benefits – no hormones, use until menopause  Risks – pain, cramping, discharge  Mirena  Levonorgesterol hormone – 52 mg  5 years  Benefits - decrease heavy periods, stabilize fibroids  Risks – breakthrough bleeding, acne, weight gain  Skyla  Levonorgesterol hormone – 13.5 mg  3 years  Benefits – smaller, nulliparous women, used in between pregnancies  Risks – breakthrough bleeding ACOG Practice Bulletin – LARC: Implants and IUDs, No 121, July 2011
  • 20. Parker Adventist Hospital | Health Seminar | April 22, 2014 Contraception - Permanent  Non-reversible  Sterilization  Traditional surgery (L/S or Lap)  Tubal ligation  CREST Study 1996 – 13/1000 5 year failure rate  In-office  ESSURE  Metal coils  In-office Adiana (off the market now)  Silicone plugs  No cutting  No general anesthesia  No hormones  Quick recovery ACOG Practice Bulletin – Benefits and Risks of Sterilization, #133, February 2013
  • 21. Parker Adventist Hospital | Health Seminar | April 22, 2014 Contraception - Permanent Method 5 year (per 1000 procedures) 10 year (per 1000 procedures) Ectopic (per 1000 procedures) Postpartum partial salpingectomy 6.3 7.5 1.5 Bipolar Coagulation 16.5 24.8 17.1 Silicone band methods 10.0 17.7 7.3 Spring Clip 31.7 36.5 8.5 Essure (hysteroscopy) 1.64 ---- ---- Vasectomy 11.3 no association ACOG Practice Bulletin – Benefits and Risks of Sterilization, #133, February 2013 US Collaborative Review of Sterilization -Crest Study, 1996
  • 22. Sexual Health
  • 23. Parker Adventist Hospital | Health Seminar | April 22, 2014 Sexually Transmitted Infections  STI/STD  Women over 40 getting divorced  Infidelity  New partners  Anxiety  Condoms  Regular testing  Treatment  CDC 8/2012 new GC Rx guidelines  Ceftriaxone 250mg IM + Azithromycin 1gm PO or Doxycycline 100mg PO BID  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 CDC STD Treatment Guidelines 2010: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
  • 24. Parker Adventist Hospital | Health Seminar | April 22, 2014 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 ACOG Practice Bulletin – Female Sexual Dysfunction, No 119, April 2011
  • 25. Parker Adventist Hospital | Health Seminar | April 22, 2014 Sexual Dysfunction  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 ACOG Practice Bulletin – Female Sexual Dysfunction, No 119, April 2011
  • 26. Gyn Conditions
  • 27. Parker Adventist Hospital | Health Seminar | April 22, 2014 Clinical Conditions  Premenstrual Syndrome – PMS/PMDD  Heavy periods/AUB  Perimenopause/Menopause  Urinary Incontinence  Pelvic Organ Prolapse  Osteoporosis  Cancers
  • 28. Parker Adventist Hospital | Health Seminar | April 22, 2014 Premenstrual Syndrome
  • 29. Parker Adventist Hospital | Health Seminar | April 22, 2014 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 http://drjerath.com/2011/06/13/pms--a-womans-monthly-madness.aspx
  • 30. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Migraines
  • 31. Parker Adventist Hospital | Health Seminar | April 22, 2014 PMS - Treatment  Lifestyle Modifications  Stress reduction  Exercise  Healthy diet  Reduce caffeine, 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
  • 32. Parker Adventist Hospital | Health Seminar | April 22, 2014 Heavy Periods/AUB  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  Adenomyosis  Hyperplasia  Cancer  Hormonal  Ovulatory  Anovulatory  Polycystic Ovarian Syndrome (PCOS)  Other  Coagulopathy  Iatrogenic ACOG Practice Bulletin – Diagnosis of AUB, No 128, July 2012
  • 33. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Microwaveendometrialablation  Myomectomy  Hysteroscopic  Laparoscopic  Laparotomy  Uterine Artery Embolization  Hysterectomy  Laparoscopic – LAVH, TLH, DaVinci  Vaginal  Abdominal ACOG Practice Bulletin – Endometrial Ablation, No 81, May 2007
  • 34. Parker Adventist Hospital | Health Seminar | April 22, 2014 Menopause
  • 35. Parker Adventist Hospital | Health Seminar | April 22, 2014 Menopause  Pre, Peri, and Post-Menopause  No period for 1 year  Average age in U.S. is 51; range age 45-55  Increased FSH > 30  Symptoms  Hot flashes – 75%  Vaginal dryness  Mood swings  Decreased libido  Decreased concentration  Insomnia/Sleep Disturbances  Hair loss  Weight gain  Metabolic Syndrome  Risk CVD & diabetes  Natural aging vs medical disorder
  • 36. Parker Adventist Hospital | Health Seminar | April 22, 2014 Menopause - Symptoms Symptom What you can do Hot Flashes/Night Sweats Dress in layers Keep Thermostat down Avoid hot drinks Use a cold, wet washcloth against neck Use a fan Quit smoking, if you smoke Vaginal Dryness Use lubricants before sex Use a vaginal moisturizer Do your kegel exercises Sleep Problems Keep a circadian rhythm Avoid naps Avoid caffeine Avoid alcohol Relaxation Try sleep aid Depression Exercise and stay active Seek social support Talk about it
  • 37. Parker Adventist Hospital | Health Seminar | April 22, 2014 Menopause - Treatment  Hormone Replacement Therapy (HRT)  Types  Estrogen  Estrogen/Progestin  Pills, patches, creams, vaginal suppositories, shots, pellets, intranasal (EU), progestin IUD  Bioidentical hormones  Cyclic or daily  Benefits  Reduction and improvement of symptoms  Protect bones  May reduce risk of colon CA  ?CV benefit HRT close to onset  Risks  Side Effects – bleeding, breast tenderness, bloating, abnormal uterine bleeding (AUB)  Anxiety  Stroke  Heart attack  Blood clot (less transdermal)  Breast cancer  Women’s Health Initiative (WHI) results  Contraindications  Breast Cancer  Blood clots – PE, DVT  CV disease  Liver disease  History of stroke or heart attack  NAMS Statement 2012
  • 38. Parker Adventist Hospital | Health Seminar | April 22, 2014 Menopause - HRT  No longer recommended as primary prevention or treatment of disease  Acceptable and safe option for the relatively young (up to age 59 or within 10 years of menopause)  Reduce total mortality by 30% when initiated in women younger than 60 years  Lowest dose for shortest duration that is effective  Currently fewer than 1 in 3 women take  Most women discontinue within 1 year  Breast cancer risk increases with use beyond 3 to 5 years  Many FDA approved HRT products are in fact bioidentical NAMS Statement 2012
  • 39. Parker Adventist Hospital | Health Seminar | April 22, 2014 Menopause – Other Treatment  Low Dose Oral Contraceptive Pills  Antidepressants  SSRI or SNRI – Venlafaxine (Effexor), Citalopram (Celexa), Escitalopram (Lexapro), Paroxetine (Paxil)  FDA approved Brisdelle  Clonidine  Gabapentin  Duavee  Phytoestrogens/Botanicals  Bioidentical Hormones  Vaginal Moisturizers and Lubricants  Quality of life issue  Duration of Treatment NAMS: Menopause.org
  • 40. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Compounding variance  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 ACOG Committee Opinion – Compounded Bioidentical Menopause HRT, No. 532, August 2012 ACOG Practice Bulletin – Use of Botanicals for Management of MenopausalSymptoms, No 28, June 2001 Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions,Vol 78, No 12, December 2011
  • 41. Parker Adventist Hospital | Health Seminar | April 22, 2014 Vaginal Atrophy - Treatment  Affects 20-40% of menopausal women  May lead to dyspareunia and sexual dysfunction  Moisturizers and lubricants  Replens, Me Again, Vagisil Feminine, Feminease, K-Y Silk-E  Water soluble - Astroglide, Slippery Stuff, K-Y Jelly  Silicone based - Pjur Eros, ID Millennium  Oil based - Elegance Women’s Lubricant  Mechanical Measures  Sexual activity  Vaginal dilators  Vaginal Estrogen Therapy  Cream – Premarin, Estrace  Ring – Femring, Estring  Tablet – Vagifem  Selective Estrogen Receptor Modulators (SERM)  Oral tablet – Ospemifene (Osphena)  Other  Smoking cessation  Oral Vit D  Vaginal Vitamin E  ?Testosterone – may help libido, but not vaginal atrophy
  • 42. Parker Adventist Hospital | Health Seminar | April 22, 2014 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/
  • 43. Parker Adventist Hospital | Health Seminar | April 22, 2014 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 NAMS 2012 Statement on HRT, Menopause, Vol 19, No 3, 257-271
  • 44. Parker Adventist Hospital | Health Seminar | April 22, 2014 Urinary Incontinence  Video  Whoopi Goldberg - Poise
  • 45. Parker Adventist Hospital | Health Seminar | April 22, 2014 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 ACOG Practice Bulletin – Urinary Incontinencein Women, No 63, June 2005 (Reaffirmed 2011)
  • 46. Parker Adventist Hospital | Health Seminar | April 22, 2014 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
  • 47. Parker Adventist Hospital | Health Seminar | April 22, 2014 Urinary Incontinence - Types
  • 48. Parker Adventist Hospital | Health Seminar | April 22, 2014 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 ACOG Practice Bulletin – Pelvic Organ Prolapse, No 85, September 2007 (Reaffirmed 2011)
  • 49. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Anticholinergics – Detrol LA, Enablex, Vesicare  New FDA approvals for OAB  Oxytrol OTC  Botox  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  FDA Safety Statement, July 2011 - http://www.fda.gov/MedicalDevices/ Safety/AlertsandNotices/ucm262435. htm
  • 50. Parker Adventist Hospital | Health Seminar | April 22, 2014 Osteoporosis
  • 51. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Peak bone mass by age of 30  Greatest risk for postmenopausal women  2-5% bone loss per year  Underdiagnosed and undertreated  Two types of bone  Cortical – hard outer shell, 75%  Trabecular – inner spongy structure, 25%, first to lose and first to respond to therapy  Fractures can cause chronic pain, deformity, disability, depression, inability to walk, deconditioning, debilitation, long-term care, and death  FRAX ACOG Practice Bulletin – Osteoporosis, No 129, September 2012
  • 52. Parker Adventist Hospital | Health Seminar | April 22, 2014 Osteoporotic Brittle Bones
  • 53. Parker Adventist Hospital | Health Seminar | April 22, 2014 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
  • 54. Parker Adventist Hospital | Health Seminar | April 22, 2014 Osteoporosis - Fractures
  • 55. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Treatment based T<= -2.5 on FRAX risk  3% hip fracture or 20% major fracture
  • 56. Cancers
  • 57. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  Ultrasound - dense breasts ?  MRI – greater than 20% lifetime risk  Thermography – Not Recommended, Not FDA approved ACOG Practice Bulletin – Breast Cancer Screening, No 122, August 2011
  • 58. Parker Adventist Hospital | Health Seminar | April 22, 2014 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
  • 59. Parker Adventist Hospital | Health Seminar | April 22, 2014 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
  • 60. Parker Adventist Hospital | Health Seminar | April 22, 2014 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 ACOG Committee Opinion – Colonoscopy and Colorectal Cancer Screening, No 482, March 2011
  • 61. Parker Adventist Hospital | Health Seminar | April 22, 2014 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
  • 62. Parker Adventist Hospital | Health Seminar | April 22, 2014 Gyn Cancer - Endometrial  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) ACOG & SGO Practice Bulletin – Managing Endometrial Cancer, No 65, August 2005
  • 63. Parker Adventist Hospital | Health Seminar | April 22, 2014 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  No routine screening USPSTF 9/2012 & 1/2013 ACOG & SGO Committee Opinion - Role of Ob/Gyn in Early Detection of Ov CA No 477, March 2011
  • 64. Parker Adventist Hospital | Health Seminar | April 22, 2014 Gyn Cancer - Cervical  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 ACOG Practice Bulletin – Cervical Cancer Screening, No 131, November 2012
  • 65. Resources
  • 66. Parker Adventist Hospital | Health Seminar | April 22, 2014 Helpful Links  General Women’s Health  Acog.org  Contraception  Plannedparenthood.org  Essure.com  Nexplanon-USA.com  Paraguard.com  Mirena-us.com  Skyla-us.com  Infertility  Resolve.org  ASRM.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  shef.ac.uk/FRAX/tool.jsp  Heart Disease  Goredforwomen.org  Cancer  Foundationforwomenscancer.org  Cancer.org
  • 67. Contact Information
  • 68. Parker Adventist Hospital | Health Seminar | April 22, 2014 Healthcare Social Media  Facebook  Facebook.com/drjerath  Facebook.com/optimawhc  Twitter  Twitter.com/drjerath  Twitter.com/optimawhc  YouTube  Youtube.com/doctorjerath  Linked In  Linkedin.com/in/drjerath  Google +  Gplus.to/drjerath  Gplus.to/optimawhc  Pinterest  Pinterest.com/drjerath  Pinterest.com/optimawhc  Blog  Drjerath.com  Website  Optimawomenshealthcare.com
  • 69. Parker Adventist Hospital | Health Seminar | April 22, 2014 Contact Information Vandna Jerath, MD Optima Women’s Healthcare 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 - staff@optimawomenshealthcare.com Presentation - http://www.slideshare.net/vandnaJerathMD/

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