1. WOMEN’S HEALTH UPDATE CAPA C ONFERENCE 25 O CTOBER 2014 Heather McLaughlin BN RN NP MN

3. O VERVIEW 1. Contraception and birth control 2. Pap screening 3. Infertility/ fertility 4. Prenatal care 5. Menopause

4. 1. B IRTH CONTROL AND CONTRACEPTION Oral contraceptives: So many generics!!! Newer OCP’s: Yasmin - Zamine, Zarah generics) Yaz- 24 days of hormone pills MYA generic

5. 1. B IRTH CONTROL AND CONTRACEPTION My old favorites: Minovral : Portia, Ovima Marvelon : Apri, Freya, Mirvala, Reclipsen Others: Tricyclen, Tricyclen- Lo: Tricira, Tricira- Lo Alesse : Aviane, Alysena, Lutera, ESME

6. 1. B IRTH CONTROL AND CONTRACEPTION New”ish” but becoming more popular: EVRA patch- one dose only still Seasonale OCP- 84 pills of Minovral/ Portia/ Ovima Nuvaring - one dose only, < 90kg

7. 1. B IRTH CONTROL AND CONTRACEPTION Mirena IUD/ IUS- since 2000 in Canada Levonorgestrel 52 mg Jaydess IUD/ IUS- since Feb 2014 in Canada 25% smaller IUD and insertion device Good for 3 years Levonorgestrel 13.5 mg Less expensive Lower dose, less amenorrhea

8. 1. B IRTH CONTROL AND CONTRACEPTION Plan B- emergency contraception- one tab levonorgestrel 1.5 mg (One step) or two tabs 0.75 mg Next Choice – generic

9. 2. P AP SCREENING / CERVICAL CANCER There are more than 100 HPV types, 40 of which have been found in the cervicovaginal area. There are high-risk types (oncogenic HPV-16 and HPV-18) and low-risk, non–cancer-causing types, including those responsible for common genital warts (HPV-6 and HPV-11). Human papillomavirus infections of the genital tract might be clinical (condyloma acuminatum, or genital warts) but most are subclinical and can only be diagnosed by Pap testing Every week in Ontario approximately 10 women are diagnosed with cervical cancer and 3 women die from cervical cancer.

10. 2. P AP SCREENING / C ERVICAL CANCER PAP screening now every 3 years for low risk women ( no past dysplasia) in most provinces, annually for life if hx dysplasia Initiate pap screening 3 yrs after first sexual contact, or age 21 Gardasil vaccine has been in Canada since 2006. Still $400 for series of 3 vaccines, most provinces immunizing 12 yr old girls in school Newer guidelines recommend Gardasil for women up to age 45, men up to age 26

11. 3. I NFERTILITY / FERTILITY Fertility decreases 50% by age 35, poorer oocyte quality as well, increased aneuploidy First time mothers > 35 increased from 4% in 1987 to 11% 2005 – so age is common cause of infertility If subfertile couple, do not hesitate to refer earlier if close to mid 30’s (6 months of trying is lots) Assisted reproductive technology success is lower (except with egg donation) in late 30’s and 40’s. Controlled ovarian hyperstimulation (Clomid) low success rates > 40 yrs of age

12. 3. I NFERTILITY / FERTILITY Lab tests: TSH should be < 2.5 Day 3 FHS greater than 7.5 indicates ovarian aging, decreasing ovarian reserve- can help guide counselling of women Weight should be as close to healthy BMI as possible (overweight or obese = precocious menarche, irregular menses, oligo/ amenorrhea, ovulatory dysfunction, IVF/ ICSI failure, increased spontaneous abortion)

13. 3. I NFERTILITY / FERTILITY Infertile young couple- refer after one year/ 12 cycles of unprotected intercourse (will likely need HSG, +/- laparoscopy) Co-enzyme Q 10 (ubiquinone) may be recommended – may increase egg quality, chance of success with IVF- no great evidence yet IVF still not available at public expense except in Quebec.

14. 4. P RENATAL CARE Maternal serum testing- all provinces Nuchal fold ultrasound, Early Pregnancy review, Intergrated Screen- only for high risk women in some provinces Weight management: new recommendations for weight gain based on BMI BMI <20 28-40 lbs BMI 20-27 25-35 lbs BMI 27- 29 15-25 lbs BMI >30 15 lbs In Canada 51.9% of people are currently overweight or obese (BMI >25), 61.2 % in NS

15. R ISKS OF E XCESS M ATERNAL W EIGHT Antenatal complications : GDM 2-8 X higher, gestational HTN/ preeclampsia (2-7X), indicated preterm birth, dizygotic twins, thromboembolism (2-4.3 X), OSA, infections Maternal death- 35% are in obese women Fetal complications : congenital anomalies, stillbirth/ IUFD (2X in obese mom), uteroplacental insufficiency, suboptimal fetal imaging

16. R ISKS OF E XCESS M ATERNAL W EIGHT Intrapartum : shoulder dystocia (1.5X), operative vag delivery, cesarean (1.5-3 X) due to dysfunctinal labour/ fetal distress, increased OR time, increased blood loss Anesthesia problems Neonatal complications: neonatal death, NICU admission, birth trauma, sepsis, resp distress, hypoglycemia **OBS +/- Anesthesia consult if obese

17. 5. M ENOPAUSE HRT - “quality of life” medicine No evidence supporting benefit of bio-identicals. They are still hormones so no safer! Assess risks/ benefits- Still not uncommon!

18. 5. M ENOPAUSE Bone density screening : All women (and men) 65years or older

19. 5. M ENOPAUSE Postmenopausal women ( and men 50 – 64) with risk factors for fracture including: Fragility fracture after age 40 Vertebral fracture or low bone mass identified on x-ray Parental hip fracture High alcohol intake Current smoking Low body weight, i.e. less than 132 lbs or 60 kg Weight loss since age 25 greater than 10% High risk medication use: prolonged glucocorticoid use, aromatase inhibitors for breast cancer, androgen deprivation therapy for prostate cancer Rheumatoid arthritis Other disorders that may contribute to bone loss

20. 5. M ENOPAUSE Mammogram screening: 40-49 no clear evidence to support it, so assess risk Age 50-69 screening every 2 years recommended Women who don’t screen: 1 in 155 chance of dying of breast cancer (of 100,000 women, 640 will die) With regular screening: 1 in 196 chance of dying of breast cancer (of 100,00 women screened, 510 will die)