Annual Gyn Exam

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Annual Gyn Exam

• Shane Prettyman, MD
• University of Virginia

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Overview

• Who and why
• HP
• Screening/Prevention
• PAP, HPV
• Breast disease
• Osteoporosis
• Colon Cancer
• CV disease
• Substance Abuse/Cessation
• Exercise/Nutrition
• Immunizations
• Domestic Violence

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Why Important

• 38 patients see ob/gyn as primary care provide
• survey of 158 women at university ob/gyn clinic -
  Women Health, 2003

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Who needs them?

• Most importantly, need provider to provide
  confidential dialogue for age-appropriate issues
• Annual pelvic exam when sexually active or age 18
  (ACOG)
• PAP smear 3 years after initiation sexual
  intercouse or at age 21 even if abstinent (ACOG)

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Who get them?

• 20 women between 25 - 54 yrs receive annual
  exams
• 10 women 55 64 yrs
• 5 gt 65 yrs receive annual exam

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History Physical

• HPI (menstrual history)
• Medical history
• Surgical history
• Obstetric history
• Gyn history
• Medications
• Allergies
• Social history
• Family history
• Health Care Maintenance

• Physical Exam
• Assessment/Plan
• Pap
• Breast Screening
• Contraception
• Other Screening

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History Present Illness

• Menstual Hx
• LMP
• menarche
• cycle length, duration, flow
• change in periods
• dysmenorrhea
• irregular bleeding

• recurrent UTIs incontinence
• fecal incont
• vag irritation, d/c
• hx STDs, PID
• sex history currently, multiple partners,
  protection
• contraception

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Gynecologic History

• Menarche
• Cycles
• Pap
• Abnormal PAPs, colpo, bxs, LEEP
• Surgeries

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Screening/Prevention

• Pap
• STD screening
• HPV prevention
• Breast Screening
• Osteoporosis
• HRT
• CV disease prevention
• Colon Cancer Screening
• Immunizations
• Exercise
• Nutrition
• Substance Abuse/Cessation
• Domestic Violence

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George N. Papanicolaou (1883-1962)

• described the role of vaginal smear in cancer in
  1928

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PAP smear

• When start?
• PAP smear 3 years after initiation sexual
  intercouse or at age 21 even if abstinent (ACOG)
• How often?
• Annually
• After 3 consecutive neg Paps, if gt 30 yrs old,
  can do Pap q 2-3 yrs
• After neg Pap neg HPV, if gt 30 yrs old, can do
  Pap q 3 yrs
• When stop?
• Consider stopping age 65 if low risk
• if no hx CIN 2-3, immunosuppresion, HIV, DES in
  utero

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HPV Prevention

• CDC 80 women by age 50 will have contracted HPV
• Gardasil Human Papillomavirus Quadrivalent
  Vaccine
• HPV 6, 11, 16, 18 (70 cvx cancer 90 warts)
• Contains recombinant Virus Like Particles that
  trigger Ab response
• Rec for all females b/t 13-26 yrs, even if hx
  genital warts, abnormal Paps, or HPV b/c
  different strains
• 3 doses (0, 2, 6 months)
• Currently know protected 5yrs unsure long-term
  protection
• Not recommended in pregnant patients

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Breast Cancer

• 2nd leading cause cancer deaths in women
• 1 in 8 women develop
• Risk Factors
• Age
• Family history
• Early menarche/late menopause
• Late age 1st preg
• No breastfeeding
• Obesity
• Alcohol
• HRT

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Breast Screening

• Self Breast Exam
• Sensitivity 20-30
• Prospective study 600 pts w/ breast ca found only
  7.6 who did reg self exams found own cancer, and
  those that did had NO survival advantage
• More biopsies benign lesion more anxiety, etc
• USPSTF 2002 found insufficient evidence to render
  opinion
• Clinical Breast Exam
• Annually
• Start age 18???
• Sensitivity 59 Specificity 94
• 1000 exams to feel 5 cancers

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Breast Screening

• Mammogram
• 10 yrs less than age of diagnosis of youngest
  family member
• Age 40, q 1-2 yrs
• Age 50, yearly
• No specified age to stop screening
• Meta-analysis concluded screening women 70-70 is
  moderately cost-effective and provides small
  increase life expectancy

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Bone Mineral Density

• 1318 U.S. women gt 50 yrs have osteoporosis
  while 3750 have osteopenia
• Bone mass peaks age 30, then lose 0.4 per yr b/t
  30-50 yrs. First 58 years after menopause, lose
  2 cortical bone and 5 trabecular bone per year.

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Bone Mineral Density

• Largest factor (80) of peak bone mass is
  genetics
• Corticosteroids at high doses associated with 10
  bone loss in first yr of treatment

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Bone Mineral Density

• Screening Who?
• All women 65 yrs or greater
• Postmenopausal women lt 65 if have one or more
  risk factors
• Any postmenopausal women with fracture to confirm
  diagnosis and severity and track treatment
  efficacy
• Screening How often?
• No more than q 2 yrs (in absence of new risk
  factors)

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Bone Mineral Density

• Dual-Energy X-ray Absorptiometry (DEXA)
• - T score - standard deviation from mean density
  of a reference population of normal, young adult
  women
• Z score - standard deviation from mean density of
  reference population of same sex, race, age

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Bone Mineral Density(World Health Org)
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Bone Mineral Density

• Decrease of 1 standard deviation associated with
  2-fold increase in fracture risk
• Treatment threshold
• National Osteoporosis Foundation recs
• T score of -2 without risk factors
• T score of -1.5 with additional risk factors

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Bone Mineral Density

• Treatment methods
• reverse modifiable risk factors
• weight-based exercise
• Ca, Vit D
• HRT
• SERMs
• Bisphosphonates

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Bone Mineral Density

• Calcium (NIH recommendations)
• Pre-menopausal 25-50 yrs
• 1000 mg/day
• Postmenopausal lt 65
• 1500 mg/day
• Postmenopausal lt 65 yrs using estrogen
• 1000 mg/day
• All women gt 65
• 1500 mg/day
• Vit D assists Ca absorption from intestines
• 400-800 IU/day

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Bone Mineral Density

• Hormone Replacement Therapy
• Womens Health Initiative
• conjugated equine estrogen (0.625 mg/d) with
  medroxyprogesterone acetate (2.5 mg/d) reduced
  the risk of hip and clinical vertebral fractures
  by 34 and reduced overall fractures by 24.

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Bone Mineral Density

• SERMs Raloxifene (Evista)
• Acts as estrogen in bones to prevent osteoporosis
  
• acts as anti-estrogen in breast and uterus ? will
  not increase cancer risk (some studies show it to
  be protective of breast cancer)
• Side-effects - hot flashes, leg cramps,
  thromboembolism

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Bone Mineral Density

• Bisphosphonates
• Fosamax (alendronate), Actonel (risedronate),
  Boniva (ibandronate)
• Inhibit osteoclasts
• increase bone mineral density in spine and hip
• reduce fractures in women with osteoporosis by
  approximately 3050

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Colon Cancer

• Cancer Deaths among Women
• Lung (68,000/yr)
• Breast (40,000/yr)
• Colon (26,000/yr)

• - Age 50, have 5 lifetime risk being diagnosed
  with colorectal cancer and 2.5 chance of dying
  from it
• - Less than 50 U.S. women older than 50 yrs are
  screened by any of the recommended methods

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Colon Cancer

• Risk Factors
• gt 50 yrs, red meat, phys inactivity, obesity,
  DM2, alcohol, smoking, African Americans
• High risk 1st degree relative dx lt 60 yrs old
  two 1st degree relatives of any age, personal or
  family hx adenomatous polyps
• Very high risk HNPCC, familial adenomatous
  polyposis (FAP), ulcerative colitis, Crohns
• 80 occur w/o family history

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Colon Cancer Screening

• AVERAGE RISK pt screening begins age 50 with one
  of
• Yearly FOBT (2-3 samples)
• Flexible sigmoidoscopy q 5 yrs
• Yearly FOBT flex sig q 5 yrs
• Double contrast barium enema q 5 yrs
• Colonoscopy q 10 yrs
• ACOG recs age 45 African American women
• May not need screen past age 80

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Colon Cancer Screening

• HIGH RISK pt screening begins age 40 or 10 yrs
  before youngest case
• Repeat c-scope q 4 yrs
• VERY HIGH RISK
• Suspected FAP - yearly flex sigs begin age 10-12
  genetic screening
• Suspected HNPCC c-scope q 1-2 yrs begin age 20
  or 10 yrs before youngest case
• IBD c-scope q 1-2 yrs begin 8 yrs after
  pancolitis or 12-15 after left-side colitis

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Colon Cancer Screening

• FOBT
• Requires 3 samples
• Dig rectal exam and in-office stool sample
  collection for fecal occult blood testing are NOT
  recommended screening methods
• sensitivity of single sample obtained during an
  office visit by DRE was 4.9, compared with 23.9
  for the recommended at-home fecal occult blood
  testing series
• Flex Sig FOBT
• Combined gives better sensitivity

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Colon Cancer Screening

• Double contrast barium enema
• Sensitivity 86-90
• Specificity 85-95, but National Polyp Study,
  detected only 48 percent of polyps greater than 1
  cm
• Colonoscopy
• Sensitivity 75 (lt1cm polyp) to 90
• preferred method for screening women at either
  average risk or high risk
• gives access to right-sided lesions, which
  comprise 65 of advanced lesions that would be
  missed by other screening methods

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Cardiovascular Disease Prevention

• Fasting Lipid Profile (USPSTF recs)
• q 5 yrs starting at age 45 in women
• Screen age 20-45 if any risk factor
• Fam Hx CV disease in male lt 55 or female lt 65
• Smoking
• Diabetes
• HTN
• HDL lt 40
• Familial hyperlipidemia

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Cardiovascular Disease Prevention

• Lipid Goals
• Total cholesterol lt 200
• Triglyceride lt 150
• HDL gt 50
• LDL lt 160 if no risk factors
• lt 100 if 2 risk factors or CAD or equivalent
• (DM, peripheral artery dz, AAA)
• lt 70 very high risk (hx MI, poorly controlled
  risk
• factors)

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Cardiovascular Disease Prevention

• Hypertension
• ACOG rec screening starting age 13

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Substance Abuse/Cessation

• Smoking
• causes CAD, the leading cause of death in US.
  Cigarette smokers are 24 times more likely to
  develop CAD
• causes CVA - 2x more likely have stroke than
  nonsmokers risk of stroke decreases steadily
  after smoking cessation - former smokers have the
  same stroke risk as nonsmokers after 5 to 15
  years.

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Substance Abuse/Cessation

• Varenicline (Chantix)
• Method of action partial agonist for nicotinic
  acetylcholine receptors binding produces agonist
  activity (at lower levels than nicotine) while
  simultaneously preventing nicotine binding
• Dosing comes in weekly dose packs
• Week 1 0.5 mg qd on day 1-3 and bid on day 4-7
• Week 2-12 1mg bid
• Stop smoking on start of week 2
• Side effects nausea, sleep disturbance,
  constipation, gas, vomiting, vivid dreams
• At the end of 12 wks, 44 were able to quit
  smoking
• Not studied in pregnancy or breast feeding

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Exercise

• 61 of adult population are either obese or
  overweight with half being obese (2002)
• In a 1993 study, 14 percent of all deaths in the
  United States were attributed to activity
  patterns and diet.
• A weight gain of 11 to 18 pounds increases a
  persons risk for developing type 2 diabetes to
  twice that of individuals who have not gained
  weight
• Rec at least 30 minutes of moderate activity on
  at least five days per week, or 20 minutes of
  vigorous physical activity at least three times
  per week (American Heart Association)

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Nutrition

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Nutrition

• Folic acid 400 µg/day
• Calcium 1000-1500 mg/day
• Calories/day
• Sedentary 1800-2000 cal/day
• Moderate 2000-2200 cal/day
• Active 2400 cal/day

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Immunizations

• Influenza
• Yearly
• 6mo-5yrs, 50yrs, pregnancy (2nd-3rd tri),
  pulmonary, chronic disease (diabetes, renal,
  immunosupp/ deficiency, hemoglobinopathy),
  nursing home, health care workers,
• Pneumococcal
• Single vaccine consider 5 yr booster for highest
  risk
• 65yrs, chronic disease (pulmonary, diabetes,
  diabetes, renal, liver, immunosupp/deficiency,
  hemoglobinopathy, asplenic, alcoholism, organ
  transplant)

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Immunizations

• Tdap
• Primary vaccine series for adults 2 doses 4-8
  wks apart 3rd dose 6-12 months later
• booster q 10 yrs, but Tdap only once, then Td for
  later boosters
• Pregnant and last Td gt 10 yrs ago, give Td during
  2nd-3rd trimester
• Postpartum Tdap immediate postpartum if Td lt 10
  yrs ago, but wait at least 2 yrs since last Td
• All adults
• MMR
• adults born before 1957 and have not received
• Another dose if health care worker, travel,
  college, or exposed to outbreak, women rubella
  nonimmune

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Immunizations

• Varicella
• 2 doses 4-8 wks apart
• All adults without immunity/prior infection
• Not give during pregnancy (live vaccine)
• Hep B
• 3 doses at 0, 1, 6 months
• ESRD, chronic liver dz, HIV, health-care workers,
  polygamous
• Meningitis
• Asplenia, college dorms, military, international
  travel

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Domestic Violence

• 0.9 - 21 of pregnant women are battered. (CDC,
  1997)
• 31 women report being sexually or physically
  abused by husband/boyfriend during life
• 20 high school females report phys or sex abused
  by boyfriend

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Domestic Violence

• ACOG recs screening all patients
• Annual exams, preconception counseling
• Pregnant first prenatal, each trimester,
  postpartum visit
• 3 questions
• Past year have you been hit, slapped, kicked or
  physically hurt by someone?
• Are you in a relationship with a person who
  threatens or physically hurts you?
• Has anyone forced you to have sexual activities
  that made you feel uncomfortable?"