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 21
Age 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 old
Adolescents have higher incidence of HPVrelated precancerous dysplasia because of
immature cervix
Most of these lesions resolve
spontaneously without treatment
Women 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 posttreatment 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 DES
Diethylstilbestrol
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 cancer
DES daughters:
50% higher than average risk for breast ca
Higher risk for clear cell adenocarcinoma (CCA) of
vagina or cervix
Higher risk for cervical dysplasia, CIN, and SIL
At twice the risk of HSIL of vagina. Vulva, and cervix
Anatomical abnormalities of the reproductive tract
DES Granddaughters
More 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 women
430 deaths/ year in women
260 deaths/ year in men
Incidence increased past 30 years
4650 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 recommendations
Screening NOT recommended by
CDC, USPSTF, ACS, ISDA or National
Guidelines Clearinghouse
Recommended Annually by New York
Dept of Health for following:
HIV +
MSM
History of genital warts
History of CIN
Anal Pap Smears
Procedure
Position 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
Future
Oral 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 challenge
While 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
Gardasil
Manufactured by Merck
Quadrivalent, recombinant vaccine designed to reduce
HPV strains 6, 11, 16 & 18
6 & 11 associated with ano/genital warts
16 and 18 associated with cervical CA (60-70% of all
cervical cancers
June 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 infection
Vaccine seroconversion rate = 99.7%
Administered at 0 – 2 – 6 months
Cost $125/ dose or $375 total
Immunizations
Gardasil (cont.)
October 2009 FDA approved for boys
and men aged 9 to 26
Has been tested in women 24 to 45
Study was done during 24 month period
91% 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
Cervarix
Manufactured 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
Twinrix
Manufactured 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
RECOMMENDATION
Td/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/immschedul
es/immschedule_adult.pdf
BIOIDENTICAL HORMONE
USE IN MENOPAUSE
What We Know
HT
Relieves 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 estrogens
Estradiol, estrone, and estriol
Natural estrogens
Conjugated estrogens
Synthetic estrogens
Ethinyl 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, 2008
Women 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 used
There is currently no central oversight on
the production, prescribing or dosing of
bioidentical hormones
Commercially available in Europe, South
Africa, Australia, and New Zealand
Not approved by FDA
Bioidentical Hormones
No large, prospective, well-controlled clinical trials
Estriol
Limited data suggest that it improves menopausal
symptoms
Some studies show improvements in BMD
Impact on cardiovascular outcomes is unknown
Conflicting results of breast cancer risk
Estrone
Shown 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 key
See 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 years
More than ½ of them (500) will need
repeat mammograms for concerning
findings
Nearly 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 Infections
CDC 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 Infections
CDC Guidelines 2006
Persistent Bacterial Vaginosis
Initial treatment
Followed by metronidazole 0.75% gel 2X
a week for 6 weeks
Trichomoniasis Vaginalis
Alternate 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