1. Hot Topics in Women’s Health MACHA October 4, 2013 Deborah Mathis, MSN, CRNP University of Pennsylvania

2. Objectives:  1. Explain the current guidelines for preventative well women care  2. List the common drug interactions with hormonal contraceptives and risk/benefits  3. Describe the new contraceptive options

3. Breast Health - CBE  Out with the monthly breast exams  In with Breast Self Awareness  Clinical breast exam every 1-3 yrs in the 20 to 39 age group (ACOG; ACS; National Comprehensive Cancer Network)  Why?  Low prevalence in 20-39 age women  False positives ACOG August 2012 Number 534

4. Breast Health – Mammogram Recommendations  American College of Obstetrics and Gynecology 2011 guidelines (ACOG)  American Cancer Society (ACS)  American College of Radiology (ACR)  Society of Breast Imaging (SBI)  All recommend that women receive an annual mammograms starting at age 40.

5. Breast Health  USPSTF 2009 guidelines recommends AGAINST routine Mammogram screening for women between ages 40 and 49  Whose guidelines do you follow?

6. Are We following the Guidelines?  2011 National Health Interview Survey  Between 2008-2011 mammogram rates increased from 51.9% to 53.6% In the 40-49 age group mammogram rates increased from 46.1% to 47.5% Why?  Providers disagree with USPSTF  Patients disagree with recommendations  5 yr survival rage is 98% if the cancer is discovered in the earliest stage.

7. ACOG Rationale  Three factors came into Play  1. the incidence of breast cancer 1 in 6 breast cancers occur in women 40-49  2. the sojourn time (time between when cancer is detected by mammogram and when it is big enough to become symptomatic) for breast cancer growth is shortest in women 40-49 (2-2.4 yrs)  3. Potential to reduce deaths

8. Cervical Cancer  2009 Data  12,357 US women were diagnosed with cervical cancer  3,909 women died from cervical cancer  US Cancer Statistics working group 1999-2009 Incidence and Mortality Web-based report, Atlanta, GA

9. New Cervical Cancer Screening Guidelines  American Society of Colposcopy and Cervical Pathology (ASCCP) (2012)  ACOG (2009)  ACS  USPSTF (2012)  American Society for Clinical Pathology (2012)  Everyone Agrees!!!!

10. Pap Test Recommendations  Start screening at age 21 regardless of sexual history.  Pap tests every 3 yrs from age 21 to 30  Pap and HPV testing for Types16 & 18 at age 30  Pap tests every 3-5 yrs over 30  > Age 65 based on sexual history  All recommendations are for women with no abnormal Pap history

11. Abnormal Pap Follow up  HPV Prevalence is high in ages 21 to 29 and 90% of cases will resolve spontaneously within 1-2 yrs*  UPENN We order:  21 to 25 yrs Surepath GS Pap  25-29 yrs Surepath GS Pap with reflex to High Risk HPV DNA  >30 yrs Surepath GS Pap AND HPV with reflex to 16-18  American Society for Colposcopy and Cervical Pathology Algorithms for Pap follow up  http://www.asccp.org/Portals/9/docs/Algorithms%207.3 0.13.pdf  * Plummer, Schiffman, et.al J. Infectious Diseases 2007;195 (11):1582- 158

12. Contraceptive Drug Interactions Medications that DECREASE the effectiveness of contraception.  Anti Seizure medications  Metabolism: both progestins and ethinyl estradiol are metabolized by the CYP450 enzymes in the liver  Drugs that can induce enzyme activity will decrease hormone levels and effectiveness of contraception include: o Phenytion(Dilantin o Carbamazepine (Tegritol) o Felbamate (Felbatol) o Primidone (Mysoline) o Barbituates o Topiramate (Topamax) o Oxcarbazepine (Trileptal)

13. Contraceptive Drug Interactions Medications that DECREASE the effectiveness of contraception. Antibiotics Only need to worry about these antibiotics:Only need to worry about these antibiotics: o Rifampin o Rifabutin o Griseofulvin  Miscellaneous : o St. John’s Wort

14. Contraceptive Drug Interactions Contraceptives will DECREASE the effective of medications  Lamotrigine (Lamictal) serum levels are decreased by 25 to 70 %  Levels not decreased during placebo period.  Consider continuous pill use  Phenobarbitol levels are reduced

15. Contraceptive Drug Interactions Contraceptives will POTENIATE the effective of some medications  Chlordiazepoxide (Librium)  Diazepam (Valium)  Tricyclics  Theophylline

16. Drospirenone Controversy  Risk of Blood Clots  First & Second generation progestin's Norethindrone & Levonorgestrel  3 in 10,000  Third generation progestin's  Desogestrel & Norgestimate  6 in 10,000  Drospirenone 10 in 10,000

17. US Medical Eligibility Criteria for Contraceptive Use, 2010 (US MEC) US Medical Eligibility Criteria for Contraceptive Use, 2010 (US MEC)  http://www.cdc.gov/reproductivehealth/U nintendedPregnancy/USMEC.htm http://www.cdc.gov/reproductivehealth/U nintendedPregnancy/USMEC.htm http://www.cdc.gov/reproductivehealth/U nintendedPregnancy/USMEC.htm  Excellent reference for safe prescribing

18. U.S. Selected Practice Recommendations for Contraceptive Use, 2013  http://www.cdc.gov/reproductivehealth/U nintendedPregnancy/USSPR.htm

19. U.S. Selected Practice Recommendations for Contraceptive Use, 2013  Appendix B: When to start specific contraceptive methods  Appendix C:  Appendix C: tests needed before initiating the various contraceptive methods   Appendix D:routine follow-up after initiating contraception   Appendix E: management of bleeding irregularities

20. Effectiveness of Method “ Women who used birth control pills, the patch or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer acting forms, such as IUD or implant” Winner B, Reipert JR. Zhao Q. et al. Effectiveness of long-acting reversible contraception/ New England Journal of Medicine 2012: 366(21):1,998-2,007

21. Typical Failure Rates No Method 85% Spermicides29% Diaphragm16% Condom (male) 15% Combined pill in obese women* 13% Combined pill and progestin-only pill 8% Contraceptive patch or vaginal ring 8% Copper IUD or LNG-IUS <1% Hormonal implant <1% Sterilization<1% *Includes data on combined oral contraceptives only; does not include progestin-only pills Trussell J. In: Contraceptive Technology. 2007.

24. Effectiveness of EC Methods If 1000 women have unprotected sex once during Week 2 or 3 of their cycle # of Pregnancies % Reduction No treatment 80- Combined ECPs 2075% Progestin-only ECPs 1088% IUD Insertion 199% Trussell J, Raymond EG. 2007.

30. Skyla  FDA approved January 2013  On the market February 2013

34. Origami Condom

35. References for Contraception  Association of Reproductive Health Professionals www.arph.org www.arph.org  Hatcher et.al Contraceptive Technology  Richard Dickey: Managing Contraceptive Pill Patients  Speroff & Darney: A clinical Guide for Contraception