Abigail R. Proffer, M.D. October 4, 2013

Abigail R. Proffer, M.D. October 4, 2013

Topics Human Papillomavirus (HPV) Vaccines Pap smears Colposcopy Contraception Polycystic Ovary Syndrome (PCOS) Can I get pregnant? Miscarriage Abnormal Uterine Bleeding Endometriosis Ovarian Cysts Libido Perimenopause, Menopause & Hormone Replacement Therapy

Human Papillomavirus (HPV) Most commonly diagnosed STD in the U.S. Over 100 types exist High- risk (Types 16 & 18) Low- risk (Types 6 & 11) Transmission Prevalence Natural course

HPV Vaccina4on First vaccine approved by FDA in 2006 Quadrivalent (Gardasil) Protects against types 6, 11, 16, 18 Bivalent (Cervarix) Protects against types 16, 18 Who should be vaccinated? Females - age 9-26 Males age 9-21 Is it working?

Pap Smears What exactly is a pap smear? What is the difference between a pap smear and a pelvic exam? Why are pap smears important? When should girls have their first pap smear? I used to get a pap smear every year, why has that changed? When can I stop getting pap smears altogether?

CIN 1 CIN 2 CIN 3 AIS Normal cervical cell 20 Years Cervical Cancer

What happens if my pap smear is abnormal? Colposcopy Looks at cervix using magnification Highlights abnormal cells Gives more definitive diagnosis What next? Observation without treatment LEEP Cone Biopsy Hysterectomy

Cervical Cancer Risk Factors HPV Infection* Smoking Immunosuppression

Contracep4on Birth control pills Combined estrogen- progesterone Progesterone- only Taken daily Patch Combined estrogen- progesterone Changed weekly Vaginal ring Combined estrogen- progesterone Changed monthly

Long- ac4ng Reversible Contracep4on Injection (Depo- Provera) Progesterone Dose every 3 months Implant (Nexplanon) Progesterone Lasts 3 years Intrauterine devices Progesterone (Mirena) lasts 5 years Copper (ParaGard) lasts 10 years Along with sterilization, most effective contraceptive methods available

Impact of Contracep4on on Fer4lity 70-95% became pregnant within 12 months after stopping: Birth control pills Intrauterine devices Condoms Natural Family Planning Progesterone implant: >90% ovulate within 3-4 weeks after removal Prolonged use of combined birth control (>5 years) does not decrease the odds of conception within 12 months Time to conception after stopping progesterone injections is delayed 50% conceive 6-7 months after last shot >90% conceive after 2 years

Polycys4c Ovary Syndrome (PCOS) Elevated levels of male hormones irregular or absent ovulation irregular periods 5-10% of women Excess hair growth, acne, male- pattern hair thinning, weight gain, difficulty becoming pregnant Higher than average risk of: Diabetes (insulin resistance) High cholesterol Sleep apnea

Polycystic ovary Normal ovary just before ovulation

How is PCOS diagnosed? Diagnosis may be based on symptoms, blood tests, or physical exam findings 2 of 3 of the following required for diagnosis: Irregular periods caused by anovulation Elevated androgens (male hormones) Polycystic ovaries on pelvic ultrasound

Treatments for PCOS Birth control pills = most common treatment Anti- androgen medications Progesterone Hair treatments Weight loss Metformin Clomid Gonadotropin injections

Can I get pregnant?

Miscarriage Pregnancy that ends before 20 weeks Common in early pregnancy 8-20% of women who know they re pregnant 80% occur in the first 12 weeks Causes Abnormal development Chromosome abnormalities Maternal medical problems

Miscarriage Risk factors Age Previous miscarriages Smoking Alcohol Fever Trauma Caffeine Other

Miscarriage Symptoms Treatment Observation Medication Surgery Prevention Recurrence *Most women go on to have healthy pregnancies*

Causes of Abnormal Bleeding Hormone changes Anovulation Fibroids Polyps Pregnancy Infection / Inflammation Blood clotting disorders Medical illnesses Pre- cancer / Cancer Perimenopause ( menopausal transition )

Abnormal Uterine Bleeding Birth control pills Progesterone IUD Lysteda/NSAIDS Surgery Myomectomy Treatment Uterine artery embolization Polypectomy Endometrial Ablation Hysterectomy

Endometriosis Definition Symptoms Pain Infertility Endometriomas Diagnosis Surgery Treating without definite diagnosis

Endometriosis: Treatment NSAIDS Hormonal birth control Other forms of hormone treatment GnRH Agonists Temporary Menopause Surgery *Best treatment depends on future fertility plans and what symptoms are most bothersome

Ovarian Cysts Common in women of all ages Vary in size Causes / Types Ovulation ( Functional cysts ) Dermoids PCOS Endometriosis Pregnancy Pelvic Infections Non- cancerous growths Cancer

Ovarian Cysts Treatment Watchful waiting Surgery Cyst drainage / removal Removal of entire ovary Prevention Potential causes of pain Rupture Torsion

Libido Libido is not essential to a satisfactory sex life Problems are common in both women and men 40% of women in the U.S. have sexual concerns Most common causes of problems: Relationship issues Poor physical or psychological well- being

Decreased Libido Risk Factors Childbirth Menopause Medical problems Medications Hysterectomy NOT a risk factor However, removal of ovaries at the time of surgery is

Decreased Libido Treatment Managing stress and relationship issues If pain is an issue, seek treatment Pelvic floor physical therapy Work with providers to reduce medication side effects Testosterone Studies have conflicting results No products approved in U.S. Side effects Herbal therapies

Hormone Replacement Therapy Perimenopause During this transition, ovarian production of estrogen decreases by over 90% Hormone Replacement Therapy (HRT) Estrogen and Progesterone Estrogen Replacement Therapy (ERT) Hormones comes in many varieties Vaginal estrogen Bioidentical hormones

Risks & Benefits of Hormone Therapy Women s Health Initiative (WHI) 15 years 161,000 women Would HRT reduce the risk of heart attacks after menopause? Well? Combination HRT actually increased the risk of heart attack, blood clots, breast cancer, stroke in older postmenopausal women Estrogen alone no increased risk of heart attack or breast cancer Small increase in risk of stroke and blood clots

Let s break this down a lisle Heart attacks Risk of having one related to HRT dependent on age No increased risk in women who: Became menopausal < 10 years before starting HRT OR Were between 50-59 when they took HRT Breast Cancer Small increased risk with combined HRT, less so with ERT HRT 5-6 years of use before risk goes up ERT 10+ years of use before risk goes up

Hormones affect more than that Osteoporosis & Fracture Dementia Depression Sleep problems Just to name a few

So what s the bosom line? Who should take HRT? Healthy women who have menopausal symptoms Shortest period of time, lowest dose possible Who should avoid hormones? Current or past history of breast cancer Coronary heart disease Women at higher risk for complications *Absolute risk of complications for healthy, young postmenopausal women taking HRT for 5 years is very low

Thank you!

References 1. Barbieri, RL. Patient information: Postmenopausal hormone therapy (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 2. Barbieri RL, Ehrmann DA. Patient information: Polycystic ovary syndrome (PCOS) (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 3. Darney PD. Etonogestrel contraceptive implant. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 4. Feltmate CM, Feldman S. Patient information: Colposcopy (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 5. Levy BS. Patient information: Endometriosis (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 6. Muto MG. Patient information: Ovarian cysts (Beyond the Basics). In: UpToDate, Basow (Ed), UpToDate, Waltham, MA, 2013. 7. Palefsky JM. Epidemiology of human papillomavirus infections. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 8. Shifren JL. Patient information: Sexual problems in women (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 9. Sirovich BE. Patient information: Cervical cancer screening (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 10. Tulandi T. Patient information: Miscarriage (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 11. Zacur HA. Patient information: Abnormal uterine bleeding (Beyond the Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. 12. Zieman M. Overview of contraception. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.