1. Bryan E. Mosora D.O. Intern/IM Resident
Women’s Health
Bryan E. Mosora D.O.
Intern/IM Resident

2. Women in your Practice
Special considerations with regards to health maintenance and prevention
Important to understand cultural issues
Women are not the same as a men!!!

3. Women in your Practice
Typically more involved with there healthcare then men. This equals more opportunity to play a preventative role
Usually will be armed with information from various sources, i.e. magazines, internet, television.
Important role of the physician is to help her sort through the garbage and address meaningful issues

4. Issues Breast cancer Ovarian Cancer Cervical Cancer Uterine cancer
Menopause/HRT
Heart Disease
Diabetes
Depression

5. Statistics 213,000 cases of breast cancer per year with 41,000 deaths.
9,700 cases of cervical cancer per year with 3,700 deaths
41,200 cases of uterine cancer per year with 7,350 deaths
20,200 cases of ovarian cancer per year with 15,310

6. Breast Cancer

7. Breast Cancer
The most common cancer in women, no matter your race or ethnicity.
The most common cause of death from cancer among Hispanic women.
The second most common cause of death from cancer among white, black, Asian/Pacific Islander, and American Indian/Alaska Native women.

8. Risk Factors
Research has shown that the following conditions increase a woman's chances of getting breast cancer:
Personal history of breast cancer.
Family history..
Certain breast changes.
Genetic alterations.
5% to 10% of all breast cancer.

9. Warning Signs New lump in the breast or underarm (armpit).
Thickening or swelling of part of the breast.
Irritation or dimpling of breast skin.
Redness or flaky skin in the nipple area or the breast.
Pulling in of the nipple or pain in the nipple area.
Nipple discharge other than breast milk, including blood.
Any change in the size or the shape of the breast.
Pain in any area of the breast.

10. Detection

11. Signs of Breast Cancer

12. Detection
Regular self breast exam is nearly as good as mammography in terms of the size of the lesion that can be detected.
Second only to regular breast exam by a skilled physician

13. The Breast Exam

14. The Breast Exam
Women should undergo breast examination by a clinician as part of their normal health maintenance program.
This should be done every two to three years from age 20 to 40, and annually after the age of 40.

15. Breast cancer
Over 50 years: All women over the age of 50 years should have annual mammography examinations.
40-50: The National Cancer Institute recommends that these women get a mammogram every 1-2 years.
Under 40 years: Most women under the age of 40 years do not need annual mammograms

16. Prognosis
STAGE 0. In Situ ("in place") disease in which the cancerous cells are in their original location within normal breast tissue. STAGE I. Tumor less than 2 cm in diameter with no spread beyond the breast
STAGE IIA. Tumor 2 to 5 cm in size without spread to axillary (armpit) lymph nodes
STAGE IIB. Tumor greater than 5 cm in size without spread to axillary lymph nodes
STAGE IIIA. Tumor smaller than 5 cm in size with spread to axillary lymph nodes which are attached to each other or to other structures,
STAGE IIIB. The tumor has penetrated outside the breast to the skin of the breast or of the chest wall or has spread to lymph nodes inside the chest wall along the sternum
STAGE IV. A tumor of any size with spread beyond the region of the breast and chest wall, such as to liver, bone, or lungs

17. Prognosis
The clinical stage of breast cancer is the best indicator for prognosis (probable outcome).
Five-year survival rates for individuals with breast cancer who receive appropriate treatment are approximately:
95% for stage 0
88% for stage I
66% for stage II
36% for stage III
7% for stage IV

18. Ovarian Cancer
Ovarian cancer is the fifth leading cause of cancer death in women
The leading cause of death from gynecological malignancies.
The second most commonly diagnosed gynecologic malignancy

21. Ovarian Cancer
The risk for developing ovarian cancer appears to be affected by several factors:
Early age of first pregnancy
Multiparity
Later age of final pregnancy
Tubal Ligation

22. Symptoms digestive symptoms, bloating, distention or cramping
abdominal or low-back discomfort
pelvic pressure or frequent urination
unexplained changes in bowel habits
nausea or vomiting
pain or swelling in the abdomen
loss of appetite (anorexia)
unexplained weight gain or loss
pain during intercourse
vaginal bleeding in post-menopausal women

23. Diagnosis a complete medical history to assess all the risk factors
a thorough bi-manual pelvic examination
CA-125 assay
one or more various imaging procedures
a lower GI series, or barium enema
diagnostic laparoscopy

24. Prognosis Stage I: Cancer is confined to one or both ovaries.
Stage II: Cancer is found in one or both ovaries and/or has spread to the uterus, fallopian tubes, and/or other body parts within the pelvic cavity.
Stage III: Cancer is found in one or both ovaries and has spread to lymph nodes or other body parts within the cavity
Stage IV: Cancer is found in one or both ovaries and has spread to other organs such as the liver or lung.

25. Prognosis Stage I cancer 95% survival rate at 5 years post diagnosis
Stages III and IV may have a survival rate of 17-30% at five years post-diagnosis.

26. Cervical Cancer
Worldwide, it is the second-most common cancer of women.
Human papilloma virus (HPV) infection is responsible for >90% of the cases of cervical cancer
An effective vaccine for the two most common strains of HPV has recently been licensed

27. Genital warts (HPV)

28. Normal Cervix

30. Cervical Cancer

31. Diagnosis
The early stages of cervical cancer may be completely asymptomatic
Vaginal bleeding, contact bleeding or (rarely) a vaginal mass may indicate the presence of malignancy
In advanced disease, metastases may be present in the abdomen, lungs, or elsewhere.

32. Diagnosis Diagnosis is made by doing a biopsy of the cervix.
Often involves colposcopy, or a magnified visual inspection of the cervix aided by using an acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix.
A Pap smear is insufficient for the diagnosis.

33. Colposcopy

34. Treatment Prevention may be the best treatment
Merck has developed a vaccine against four strains of HPV, called Gardasil.
Targeted at girls and women of age 9 to 26.
Vaccine only works if given before infection occurs.
They are targeting girls before they begin having sex.

35. Uterine Cancer
Uterine cancer is the most common cancer of the female reproductive system
There are two different types of uterine cancer:
endometrial cancer
uterine sarcoma (less common)

36. Endometrial Cancer

37. Risk Factors Obesity Use of Tamoxifen Use of unopposed estrogen
Hypertension (high blood pressure)
Polycystic ovarian syndrome and/or skipping menstrual periods for months at a time
Family history of endometrial, ovarian or colon cancer
Never having had children
Menopause at a late age
Endometrial hyperplasia (excessive build up of the uterine lining)
Diabetes

38. Signs and Symptoms
Bleeding after menopause (experienced by over 90% of endometrial cancer patients)
Change in bowel or bladder habits and/or pain during intercourse
A thickened endometrial lining (which can be seen on an ultrasound of the uterus)

39. Prognosis
The American Cancer Society estimates that 41,200 women will be diagnosed with uterine cancer in 2006, and of those 7,350 will die.
A woman’s chance of developing this cancer through out her life time is about 1 in 38.
This cancer is 40% more prominently found in white women.
On average the five-year survival rate is at 84%, and this percentage increases if the cancer is detected in early stages.

40. Menopause/HRT
Menopause occurs as the ovaries stop producing estrogen, causing the reproductive system to gradually shut down.
Technically, menopause refers to the cessation of menses
The average onset of menopause is 50.5 years

41. Menopause

42. Sign and Symptoms
The clinical features of menopause are caused by the lessening in the amount of estrogen in the woman's body.
hot flashes, hot flushes, including night sweats
sleep disturbances

44. Sign and Symptoms Urogenital atrophy dyspareunia itching dryness
bleeding
urinary frequency
urinary urgency
urinary incontinence

45. Sign and Symptoms Skeletal Skin, soft tissue osteoporosis
joint, muscle pain
back pain
Skin, soft tissue
breast atrophy
skin thinning
decreased elasticity

46. Sign and Symptoms Psychological mood disturbance irritability fatigue
decreased libido
memory loss

47. Treatment Options
While menopause is a natural stage of life, some symptoms may be alleviated through medical treatments.
Most notably, Hormone Replacement Therapy (HRT), has been used to reduce osteoporosis.
A large, randomized, controlled trial (the Women's Health Initiative) found that women undergoing HRT had an increased risk of:
Alzheimer's disease
Breast cancer
Heart disease
Stroke

48. Heart Disease Heart disease isn't just a man's disease.
Heart attack, stroke and other cardiovascular diseases are devastating to women, too.
Coronary heart disease, is the leading cause of death for American women.
Nearly twice as many women in the United States die of heart disease and stroke as from all forms of cancer, including breast cancer.

49. Heart Disease

50. Heart Disease

51. Heart Disease Risk Factors
Increasing age — As women grow older, their risk of heart disease and stroke begins to rise and keeps rising with age.
Heredity (family history) — Both women and men are more likely to develop heart disease or stroke if their close blood relatives have had them.
Race is also a factor.
Black women have a greater risk of heart disease and stroke than white women.
Previous heart attack
Women who've had a heart attack are at higher risk of having a second heart attack.

52. Risk Factors Tobacco smoke High blood cholesterol High blood pressure
Research has shown that low levels of HDL cholesterol seem to be a stronger risk factor for women than for men.
High blood pressure 
Physical inactivity
Obesity and overweight
Diabetes mellitus
Compared to women without diabetes, women with diabetes have from two to six times the risk of heart disease and heart attack

53. Diabetes mellitus About 10 million American women have diabetes
3 million of them don’t even know it
Diabetes increases a woman’s risk of developing heart disease 3- to 7-fold, compared with 2- to 3-fold in men
Women with diabetes are 2 to 5 times more likely to die of heart disease than women without diabetes

54. Diabetes

55. Diabetes in Pregnancy
Nearly all pregnant women should be tested for gestational diabetes during the 24th to 28th weeks of pregnancy.
Gestational diabetes occurs in about 4% of pregnancies
Causes macrosomia which can lead to:
shoulder injuries during birth,
breathing problems,
higher risk of developing obesity and type 2 diabetes later in life.

56. Diabetes in Pregnancy

57. Depression Women experience depression twice as often as men
Women with depression more frequently experience guilt, anxiety, increased appetite and sleep, weight gain and comorbid eating disorders.

58. Risk Factors Family history of mood disorders
Personal past history of mood disorders Loss of a parent before the age of 10 years
Childhood history of physical or sexual abuse
Use of an oral contraceptive, especially one with a high progesterone content
Use of gonadotropin stimulants as part of infertility treatment
Persistent psychosocial stressors (e.g., loss of job)
Loss of social support system or the threat of such a loss

59. Diagnosis Psychological Symptoms Depressed mood
Reduction of interest and/or pleasure in activities, including sex
Feelings of guilt, hopelessness and worthlessness
Suicidal thoughts (recurrent)

60. Diagnosis Physical Symptoms
Sleep disturbance (insomnia or hypersomnia)
Appetite/weight changes
Attention/concentration difficulties
Decreased energy or unexplained fatigue
Psychomotor disturbances

61. Treatment Strategies
Identify any relationship between depression and menstruation, pregnancy, the perinatal period or the perimenopausal period.
A possible relationship between depression and medications such as birth control pills or agents used in hormone replacement therapy must also be explored.
If there is a link to any treatable cause of depression, it should be addressed first.

62. Treatment Considerations
Absorption of antidepressants may be enhanced in women because they secrete less gastric acid than men.
In addition, gastrointestinal transit time may be slower in women, especially during high progesterone phases of the reproductive cycle, thus enhancing the absorption of antidepressant medications.
Another difference is the higher ratio of body fat to muscle in women;
this ratio becomes even greater with age and increases the volume of distribution for many drugs.

63. Treatment Considerations
Because of these biologic differences, antidepressant plasma concentrations may be higher in women.
Thus, female patients with depression may require lower dosages of antidepressants than their male counterparts.
Also, women frequently experience sexual side effects, they generally do not report these effects unless specifically asked.

64. Summary
Women have many issues that of course require special attention.
Important not to forget about the similar disease processes that could affect them as equally as their male counterparts.
And finally……..My favorite woman!!!

65. We Are Outta Here!