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

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!!!

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

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

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

Breast Cancer

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.

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.

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.

Detection

Signs of Breast Cancer

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

The Breast Exam

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.

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

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

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

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

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

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

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

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.

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.

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

Genital warts (HPV)

Normal Cervix

Cervical Cancer

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.

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.

Colposcopy

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.

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)

Endometrial Cancer

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

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)

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.

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

Menopause

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

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

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

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

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

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.

Heart Disease

Heart Disease

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.

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

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

Diabetes

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.

Diabetes in Pregnancy

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.

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

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

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

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.

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.

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.

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!!!

We Are Outta Here!