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Faculty Gabriele Darch, CRNP Menopause: The Third Stage Nurse Practitioner Senior in a Woman’s Life Ramona Hawkins, CRNP Nurse Practitioner Senior
Satellite Conference and Live Webcast Beth Nichols, CRNP Nurse Practitioner Director Wednesday, July 28, 2010 2:00-4:00 pm Central Time Grace Thomas, MD Women’s Health Medical Director
Produced by the Alabama Department of Public Health Video Communications and Distance Learning Division Alabama Department of Public Health
Objectives Menopause/Clinical Definition
• Describe the signs and symptoms • Absence of menstrual cycle for of menopause 12 consecutive months
• Discuss treatment regimens related • Average age is 51-52 to symptom relief • FSH testing is no longer • Identify women’s health issues recommended to diagnose related to aging menopause
Menopause/Clinical Definition Menopause/Clinical Definition • Menopause can be • When menopause occurs before – Surgically induced by TAH-BSO age 40 – Caused by disruption of ovarian – Premature menopause ftifunction through : – Premature ovarian failure (or • Medication insufficiency) • Chemotherapy • Radiation
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Perimenopause Perimenopause • Refers to the years preceding the • What’s happening? end of menses marked by: – The number of ovarian follicles – Irregular menstrual cycles decreases – Vasomotor syypmptoms – FSH (follicle -stimulating hormone) – Vaginal dryness levels increase, causing ovarian – Sleep deprivation follicles to be lost at an accelerated – Mood changes rate until they are depleted • Lasts approximately 2-8 years – LH (luteinizing hormone) increases
Perimenopause Perimenopause • Most of the endogenous estradiol • Estrogen levels are markedly after menopause results from reduced due to decrease in ovarian peripheral conversion of estrone function from androstenedione secreted by • The ovary secretes low levels of the adrenals androgen • Because of these hormone fluctuations, FSH testing does not provide a true picture of a woman’s menopausal status
Perimenopause Contraception After 50 • LH or estradiol levels are also not indicated “. . . And then she • Pregnancy can still occur, although a asked, “What’s the best form of birth woman’s fertility is lessened control after 50?” • 77% of pregnancies in the age range “I said, “Nudity.” of 40-44 are unintended (second only to adolescents) • Important for women to be on SOME form of birth control during this time
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Perimenopause/Contraception Perimenopause/Contraception
• COCs can be used by healthy (no • Paragard IUD and sterilization medical conditions) perimenopausal provide contraception without women who are non-smokers and of hormones normal weight • Barrier methods can also be • Progestin only methods (Mirena IUD, considered although not optimal POPs, and DMPA) can be used for • Emergency contraception should be women who have health conditions provided routinely in this age group that preclude the use of estrogen
Most Commonly Most Commonly Reported Symptoms Reported Symptoms • Vasomotor • You sell your home heating system – Hot flushes, night sweats at a yard sale • Sleeppp disruption • YouhavetowritepostYou have to write post-it notes with • Urogenital atrophy your kids’ names on them
– Vaginal dryness • You change your underwear after a – Dyspareunia sneeze – Urinary difficulties
Vasomotor Symptom Relief Vasomotor Symptom Relief
• Vasomotor symptoms, including • North American Menopause Society both hot flushes and night sweats, (NAMS) recommends lifestyle are the primary reason women seek changes alone or in combination care at the time of menopause with nonprescription remedies for women with mild vasomotor symptoms
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Symptom Relief A Little History of Hormone Therapy • However • Estrogen has been utilized since the – Vasomotor symptoms are most 1960s with the advent of Conjugated effectively treated with systemic Eqqguine Estrogen made from hormone therapy (HT) pregnant mare’s urine • Estrogen alone was found to contribute to endometrial cancer
A Little History A Little History of Hormone Therapy of Hormone Therapy
• Progestin added to estrogen therapy I • From the 1980s to 1990s hormone • Estrogen/progestin combination therapy was widely prescribed proved protective against • IfIn fact , est rogen/ progesti tithn therapy endometrial cancer was considered to be the fountain of youth
Why Older Women Shouldn’t Women’s Health Initiative WHI Sunbathe in the Nude • WHI enrolled 16,000 women nationwide between the ages of 50 and 70
• One major question of the study: Does HT prevent heart disease?
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Women’s Health Initiative WHI Women’s Health Initiative WHI • WHI trial of combined estrogen and • In 2004, the “estrogen alone” arm of the study was discontinued progestin therapy demonstrated that • Estrogen alone did not appear to EPT did not prevent heart disease in affect coronary heart disease ↔ (as healthy women comparedtd to pl aceb o) • CHD was actually slightly increased • Estrogen alone appears to • Use of HT decreased markedly after – ↑ risk of stroke the results of the WHI were made – ↓ risk of hip fracture public – ↔ breast cancer
Women’s Health Initiative WHI Symptom Relief • Recent reanalysis of data • Vasomotor symptoms are most – Increased risk of CHD in older effectively treated with systemic women and those a number of hormone therapy years beyond menopause • Use the lowest dose for the shortest – No increased risk of CHD in duration women between the ages of 50 and 59 or within 10 years of menopause
Vasomotor Symptom Relief Vasomotor Symptom Relief Hormone Therapy • Progestin therapy alone can • What are the most commonly used effectively treat hot flushes and may combinations of HT either ET or remain an option E/PT? • Medroxy-progesterone acetate, either • Can’t make a general statement oral or as a 3 month IM injection • Treatment is based on individual patient symptoms/risk factors
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Alternatives to Hormone Alternatives to Hormone Therapy for Treatment of Therapy for Treatment of Vasomotor Symptoms Vasomotor Symptoms • Lifestyle changes – Manage stress with meditation, – Eat a healthy diet exercise, and yoga – Limit caffeine and alcohol – Get support by talking about your menopausal symptoms with like- – Quit smoking minded friends, family, and health – Exercise regularly care professionals – Maintain a healthy weight
Meno-paws Alternatives to Hormone Therapy • Nonprescription medications
– Isoflavone supplements – Soy products
– Black cohosh
– Vitamin E I Meditate, I do Yoga, I chant …and I still want to smack someone!!
Vasomotor Symptom Vasomotor Symptom Relief Non-hormonal Relief Non-hormonal Prescription Medications Prescription Medications
• Antidepressants /SSRIs • Anticonvulsants
– Paroxetine (Paxil) – Gabapentin (Neurontin) – Venlaxafine (Effexor) • Antihypertensives
– Fluoxetine (Prozac) – Clonidine and Methyldopa • Bellergal
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Sleep Disturbance: Symptom Relief Symptom Relief Non-hormonal Medications Non-hormonal Prescription Medications • Sleep Aids • Sleep Aids • Nonprescription
– Eszopiclone (Lunesta) • Diphenhydramine hydrochloride (Benadryl) – Zolpidem tartrate (Ambien) • Dimenhydrinate (Dramamine) – Benzodiazepines (Xanax, Valium, Ativan, Klonopin)
Urogenital Atrophy Urogenital Atrophy • Affects 75% of postmenopausal • On exam, vaginal changes may women include – Vaginal dryness • Petechiae – Pruutusritus • Erythema – Bleeding • Pallor – Dyspareunia • Loss of elasticity and rugal folds – Dysuria • Diminished secretions • Urinary urgency/incontinence • Vaginal shortening and narrowing
Symptom Relief Symptom Relief Urogenital Atrophy Urogenital Atrophy • Vaginal estrogen preparations found • Non-hormonal alternatives equally effective – Creams (0.5 g) used one to three – Vaginal moisturizers times weekly • Over the counter - KY jelly, – Tablets (25 mcg) inserted vaginally Replens and Astroglide twice weekly – Regular sexual activity – Rings (7.5 mcg/d) slow release- placed vaginally every 3 months)
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“Bio-identical” What Does it Mean? What’s the Buzz on Bio-identical Hormones? • Medications containing estrogen, progesterone, and other hormones that are chemicallyyp exact duplicates of hormones produced by women, primarily in the ovaries • Bio-identical is a marketing term, not a medical term
Bio-identical Hormone Bio-identical Hormone Therapy Therapy FDA Approved • Confusing to consumers and some Bio-identical Hormones health professionals • Oral
• Some “bio-identical hormones” are – Estrace (1975) FDA-approved brand-name – Estradiol generic (1997) prescription drugs – Prometrium (1998) • Made from plants (or plant-derived) compounds
Bio-identical Hormone Bio-identical Hormone Therapy FDA Approved Therapy FDA Approved Bio-identical Hormones Bio-identical Hormones • Transdermal (gels, lotion, spray) • Transdermal (Patches)
– EstroGel gg(el (2004), Estrasorb – Estraderm (1985) lotion (2006) – Vivelle (1995) – Divigel gel (2007), Elestrin gel – Climara (1995) (2008) – Vivelle Dot (1998) – Evamist spray (2008)
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Bio-identical Hormone Bio-identical Therapy FDA Approved Hormone Therapy Bio-identical Hormones • Some bio-identical hormones are • Vaginal “custom-compounded” recipes – Estrace cream (1984) prepared by a pharmacist
– Estring ring (1996) – Not FDA approved – Prochieve 4% gel (1997) • Contain not only the active – Vagifem tablets (1998) hormone(s) but other ingredients – Femring ring (2003) that bind everything together
Bio-identical Bio-identical Hormone Therapy Hormone Therapy • Benefits • Potential risks - not government approved – Individualized doses and mixtures ofdtddff products and dosage forms th thtat – Individually mixed recipes may not are not available commercially be absorbed appropriately or provide predictable levels in blood and tissue
Bio-identical Why the Surge in Prescriptions Hormone Therapy for Bio-identicals from a Patient POV? • No scientific evidence about the effects of these compounded • Response to widely publicized medications on the body results form 2002 WHI
– Either good or bad • Suspicion of “traditional” medicine • Saliva and blood testing of hormone • Dislike of big pharmaceutical levels is not evidence-based companies
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Why the Surge in Prescriptions Midlife Health Issues for Bio-identicals from • Osteoporosis a Patient POV? • Obesity • Perception it is a safer alternative • Cancer • “Natural” is equated with safer – Breast • Wider and more aggressive – Endometrial advertising, via internet and other media – Ovarian • Testimony from celebrities – Colorectal
Midlife Health Issues Midlife Health Issues • Coronary Vascular Disease Osteoporosis • Affects 44 million Americans/80% • Diabetes are women • Depression • Rapid bone loss for 5-7 years at time of menopause
• Bone density may decrease by 15-30%
Midlife Health Issues Midlife Health Issues Osteoporosis Osteoporosis • Non-modifiable risk factors include • BMD (Bone Mineral Density test) – Age appropriate for women who are at least 50 years old and also have one – Asian or white race or more ofthf the fo llow ing r is kfk fact ors – Family history for fracture – History of a prior fracture – History of fracture after – Early menopause menopause • Oophorectomy – Body Mass Index (BMI) < 21
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Midlife Health Issues Midlife Health Issues Osteoporosis Osteoporosis – Parental history of hip fracture • Drug therapy (bisphosphonates are 1st line agents) is appropriate in – Current smoking, rheumatoid postmenopausal women who have arthritis, or excessive alcohol intake any of the following • Three or more drinks per day – A history of osteoporotic hip or – In absence of these risk factors, vertebral fracture BMD testing should begin at age 65
Midlife Health Issues Midlife Health Issues Osteoporosis Osteoporosis – DXA T-score lower than -2.5 – FRAX score that indicates a (indicating osteoporosis) 10 year risk of hip fracture of at – T-score from -10to1.0 to -2. 5 (low bone least 3% or a 10-year overall risk mass or osteopenia) plus a FRAX of osteoporotic fracture of at score least 20%
Midlife Health Issues Midlife Health Issues Osteoporosis Osteoporosis
• FRAX = Fracture Risk Algorithm Treatment with Biphosphonates – Developed by WHO (World Health Fosamax Daily or Weekly Fosmax Plus D Weekly Organization) to determine 10 year Actonel Daily/Weekly/Monthly risk of hip fracture and 10 year Actonel With Calcium 7 Day Regimen overall risk of osteoporotic fracture Boniva Monthly for Oral Route/IV Q 3 Months Reclast IV Annually
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Midlife Health Issues Midlife Health Issues Osteoporosis Osteoporosis
Other Bone-Specific Prescription Drugs • Recommendations for Calcium and Approved for Postmenopausal Osteoporosis Vitamin D supplementation SERMS (raloxifene) Evista po Daily ClitCalcitoni n (l(nasal spray) • Calcium 1200-1500 mg daily
Fortical or Miacalcin Daily • Vitamin D 800-1000 IU daily Parathyroid hormone
Forteo subQ injection Daily (High Fx Risk)
Midlife Health Issues Midlife Health Issues Obesity Obesity • BMI > 30 and waist circumference • Increased risk for insulin resistance > 35 inches –↑ cardiovascular disease • Average of 5 lbs weight gain in – ↑ diabetes midlife
• Change in fat distribution from “pear” to “apple”
Midlife Health Issues Midlife Health Issues Obesity Obesity • Obese women more prone to: • Obesity also linked to cancer
– Osteoarthritis – Breast – Cho lecysti c disease – EdEndomet tilrial
– Urinary incontinence – Colorectal
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Midlife Health Issues Midlife Health Issues Obesity Breast Cancer • Where Alabama ranks • Breast cancer is the most frequently – Alabama is the second most obese diagnosed cancer in women state, behind Mississippi • The lifetime risk of developing – Alabama ranks third for adult invasive breast cancer for women diabetes and high blood pressure rates is 12% – Alabama is the fifth-most physically inactive state
Midlife Health Issues Midlife Health Issues Breast Cancer Breast Cancer • Risk factors – Hyperplasia (biopsy confirmed) – Female gender – Exposure to high dose radiation – Increasing age to chest – Inherited genetic mutations – Recent hormone use (BRCA 1 and BRCA 2) – Overweight after menopause – Personal or family history of – Physical Inactivity breast cancer – Alcohol – High breast tissue density
Midlife Health Issues Midlife Health Issues Breast Cancer Breast Cancer • An increased risk (26%) of breast • No increased risk of breast cancer in cancer is seen after 5 years of short-term HT use combined estrogen and progestin • Benefits generally out weigh the therapy use (WHI) risks for “healthy women” who want/need HT for treatment of vasomotor symptoms
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Midlife Health Issues Midlife Health Issues Breast Cancer Breast Cancer • Hormone therapy should not be • Current data from WHI and Heart and prescribed to women with a history Estrogen/Progestin Replacement of breast cancer Studyy( (HERS ) su pport a link between
• HT should be used cautiously by HT use and breast cancer risk women at high risk for breast cancer • EPT/ET should be prescribed at the lowest dose for symptom relief for the shortest possible amount of time
Midlife Health Issues Breast Cancer • Most cancers are detected after age 50
• Monthly self-breast examination is recommended
• Annual clinical breast exams and mammograms can reduce breast Yes, I did have my mammogram today… cancer mortality Why do you ask?
ABCCED Program Breast Facts ABCCED Program 2009 • Alabama Breast and Cervical Cancer • Clinical breast examinations: 9,170 Early Detection Program Statistics • January 2009-December 2009 for • Abnormal clinical breast exams: Women Ages 40-64 610 (normal mammograms) • Total number of women screened: 12,241 • (Mammo, USS or both) – First screen: 6,097 (49.8%) – Second screen: 6,346
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ABCCED Program ABCCED Program January-December 2009 • Of the 10,109 mammograms • Abnormal Mammograms: 1,257 performed
BIBI--RADSRADS 0 1,065 • Women diagnosed with Breast BI-RADS 1 4, 221 Cancer: 127 BIBI--RADSRADS 2 4,117 – Cancer, invasive: 106 BIBI--RADSRADS 3 410 – Ductal Carcinoma, in situ: 18 BIBI--RADSRADS 4 138 BIBI--RADSRADS 5 46 – Lobular Carcinoma, in situ: 3
Midlife Health Issues Midlife Health Issues Endometrial Cancer Endometrial Cancer • Endometrial cancer is the most • WHI data
common GYN malignancy in the U.S. – No risk of endometrial cancer with • Risk factors combined EPT when compared to
– Obesity, HTN, diabetes, tamoxifen placebo and unopposed estrogen (PCOS), early menarche, late menopause
Midlife Health Issues Midlife Health Issues Endometrial Cancer Endometrial Cancer • Women who use E+P hormone • Any woman who uses sequential therapy should take the progestin progestin over the long term should continuously rather than sequentially undergo regular endometrial monitoring via transvaginal ultrasonography, endometrial biopsy or both
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Midlife Health Issues Midlife Health Issues Endometrial Cancer/AUB Abnormal Uterine Bleeding • Patients report • Any vaginal bleeding after cessation – Frequent episodes of bleeding of menstruation for one year is > 7 days considered highly suspicious for – Bleeding between menses “CANCER” until proven otherwise – Bleeding after coitus – Passing large or excessive number of clots – Bleeding after menopause
Midlife Health Issues Midlife Health Issues Abnormal Uterine Bleeding Abnormal Uterine Bleeding • Other causes of abnormal uterine – Medications
bleeding • Including OTC and herbal – Uterine fibroids remedies, anti psychotic drugs,
– Medical conditions: thyroid blood thinners and problems, blood clotting problems, contraceptives liver disease
Midlife Health Issues Midlife Health Issues Abnormal Uterine Bleeding Abnormal Uterine Bleeding • Diagnostic testing includes • Treatment modalities most
• Pelvic/transvaginal ultrasound commonly used are • EdEndomet tilbirial biopsy – Hormonal contraceptives • Oral, IUD, or ring – Nonsteroidal anti-inflammatory drugs
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Midlife Health Issues Midlife Health Issues Abnormal Uterine Bleeding Abnormal Uterine Bleeding – Antifibrinolytic medications • Surgical treatments
(Amicar) – Endometrial ablation – GnRH agonists – D&C
• Danazol – Uterine Artery Embolization – Myomectomy
– Hysterectomy
Midlife Health Issues Midlife Health Issues Ovarian Cancer Ovarian Cancer • Ovarian cancer is 5th leading cause • WHI data
of cancer death in U.S. – No significant difference in risk of • Risk factors ovarian cancer seen in EPT as
– Increasing age and family history compared to placebo
• Oral contraceptives are protective in premenopausal women
Midlife Health Issues Midlife Health Issues Ovarian Cancer Ovarian Cancer • Symptoms – Loss of appetite, increased feeling
– Abdominal bloating or increased of fullness, urinary frequency or abdominal size , abdominal pain or recent onset of incontinence pelvic pain – Unexplained weight loss – Fatigue, indigestion, constipation, back pain
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Midlife Health Issues Midlife Health Issues Ovarian Cancer Colorectal Cancer • Diagnosis • Colorectal cancer is the third leading – Patient presents with vague but cause of death for women persistent symptoms • Risk factors – Physical examination may reveal pelvic mass – Increased age, family history, – Referral to PMD for Imaging history inflammatory bowel studies/vaginal USS disease – CA 125
Midlife Health Issues Midlife Health Issues Colorectal Cancer Colorectal Cancer • Screening should begin at age 50 • WHI trial of estrogen alone, • Colonoscopy every 10 years (shorter demonstrated no effect on colorectal cancer in women with hysterectomy interval after detection of polyps) • HT should not be prescribed for • WHI data prevention of colorectal cancer – Reduced risk of colorectal cancer in women randomly assigned EPT compared to placebo
This is What We Have to Midlife Health Issues Cognition Look Forward To • Cognition is disturbed by sleep disruption brought on by vasomotor symptoms
• By treating vasomotor symptoms you indirectly improve cognitive function – i.e. short term memory and attention
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Midlife Health Issues Midlife Health Issues Cognition Depression • WHI Memory Study • Perimenopausal transition is a time
– A significant twofold increased risk of increased emotional vulnerability of dementia (most commonly • Massachusetts Women ’s Health Alzheimer’s disease) with HT Study (2 years of observation) showed a high rate of depression largely explained by the presence of menopausal symptoms
Midlife Health Issues Midlife Health Issues Depression Depression • Suicide rate for women peaks at age • Therapeutic intervention for 45-54 and again after age 75 depression includes • American Foundation for Suicide – Antidepressant medication Prevention ranks Alabama 24th in – Psychotherapy the U.S. – Counseling
Midlife Health Issues Midlife Health Issues Cardiovascular Disease CVD • WHI trial demonstrated a small • Cardiovascular disease is the increased risk for heart disease number one cause of death in • Results indicated that HT should not postmenopausal women be initiated or continued for primary • Risk factors prevention – Age, family history, smoking, • Results led to the restriction of HT obesity and a sedentary lifestyle use even for healthy women with bothersome vasomotor symptoms
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Midlife Health Issues Midlife Health Issues CVD CVD • Reanalysis of WHI Study – No increased risk of CVD in women
– Confirmed that the increased risk between ages 50-59 of CVD occurs mostly in older – No increase in women within 10 women and a number of years years of menopause beyond menopause
Midlife Health Issues Midlife Health Issues Stroke Stroke • Stroke was not increased in WHI • Hers Study (Heart and study in the 50-59 age group Estrogen/progestin Replacement Study) no significant increase of • Increased rate of first strokes in stroke women initiating HT over age 60 • WEST Study (Women’s Estrogen for Stroke Trial) no significant increase
Midlife Health Issues Midlife Health Issues Venous Thromboembolus Venous Thromboembolus • WHI Trial demonstrated an increased • Increased risk for women with a prior risk of VTE with oral HT history of VTE or who possess • VTE risk increases relative to BMI Factor V Leiden (> 30) • Limited observational studies suggesting lower risk of VTE with transdermal as opposed to oral administration
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Midlife Health Issues Midlife Health Issues Diabetes Diabetes • Aging is associated with an – Inadequate evidence to increased risk of adult onset DM recommend HT as the sole or ((ypType 2 DM ) primary indication for prevention – HT may be associated with an of DM improvement in insulin resistance in postmenopausal women
Summing It Up! Summing It Up! Benefits of Hormone Therapy Benefits of Hormone Therapy • Hormone therapy is the most – HT reduces the risk of effective treatment for osteoporosis – Hot flashes , night sweats and – HT reduces the risk of colon fatigue cancer
– Vaginal dryness, discomfort with sex and urogenital symptoms, in general
Summing It Up! Benefits/Risks Benefits of Hormone Therapy of Hormone Therapy Out of 10,000 Postmenopausal No Risk/ HT • HT may or may not help with Women Over A 10 Year Period HT Benefit Number will get invasive breast cancer 30 38 8 more depression or Alzheimer’s Disease cases Number will have a heart attack 30 37 7 more – May increase risk of AD when HT cases Number will have a serious blood clot 16 34 18 more started in women over 65 years cases Number will have stroke 21 29 8 more of age cases Number will have a hip fracture 15 10 5 fewer cases Number will get colon cancer 16 10 6 fewer cases
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Health Screenings Health Screenings During Midlife During Midlife • Thyroid screen • Urine screen, • Breast and pelvic examination
• Fasting glucose when indicated including rectovaginal
• Fasting lipid • ClColonoscopy • BMI panel • STI, when • Pap smear as indicated • Mammogram indicated • Stool Hemoccult testing • Bone density
Health Screenings Periodic Health Screenings During Midlife Thyroid Every 5 years beginning at age 50 • Screening for specific chronic conditions Diabetes Every 3 years beginning at age 45 Lipids Every 5 years beginning at age 45 – EhltlEKGtEx: cholesterol, EKGs, etc. Colorectal One of the following: • Appropriate immunizations • FOBT yearly at age 50 • Sigmoidoscopy every 5 years – Td, Herpes Zoster, flu, pneumonia • Barium enema every 5 years • Colonoscopy every 10 except sooner for AA women or family Hx
Periodic Health Screenings Recommended Adult
Mammography Every 1-2 years beginning at Immunization Schedule age 40, yearly at age 50 BMD Every woman 65 and older, Bone Mineral Density younger if at risk for osteoporosis. Repeat every 1-2years2 years Immunizations CDC – 2010 MMWR Quick Guide Pap smear ACS – screening table
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Cervical Cancer Where Do We Go From Here? Screening Guidelines • Healthy symptomatic women should be offered the option of HT for menopausal symptoms because HT provides an overall improvement in Quality of Life • Our clients are using and are interested in bio-identical hormones, so we as NPs need to have some knowledge about them
Where Do We Go From Here? Why Older Women Shouldn’t • Continuing research is essential in Sunbathe in the Nude identifying long term benefits and risks of traditional HT and the safety and efficacy of bio-identical hormones • NPs are in a position to educate these women to take steps to reduce health risks and improve their overall well-being through the aging process
Aerobics Class References • Shifren, JL & Schiff, Isacc. Obstetrics & Gynecology Vol. 115, No. 4, April 2010 • Schuling, KD & Likis, FE. Women’s Gynecologic Health, Jones & Bartlett, c. 2006 • NAMS (North American Menopause Society) Position Statement re: Estrogen & progestogen use in postmenopausal women, Menopause , Vol 17, No . 2, 2010 • OBG Management, May 2010. Vol 22, No5 • ACOG – Guidelines for Women's Health Care: A Resource Manual, Third Edition • Clinical Challenges in Women’s Health in the 21st Century: A Practice Handbook for Nurses Practitioners. 2008
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Prevention is the Key! 10 Ways To Know If You Have “Estrogen Issues” 1. Everyone around you has an attitude problem 2. You’re adding chocolate chips to your cheese omelet 3. The dryer has shrunk every last pair of your jeans 4. Your husband is suddenly agreeing to everything you say
10 Ways To Know If You 10 Ways To Know If You Have “Estrogen Issues” Have “Estrogen Issues” 5. You’re using your cellular phone to 9. You’re sure that everyone is dial up every bumper sticker that scheming to drive you crazy says, “How’s my driving?” 10. The Ibuprofen bottle is empty and 6. Everyone’s head looks like an you bought it yesterday Yes, we forgot number 8 כ invitation to batting practice 7. Everyone seems to have just landed here from “outer space”
• 52 year old female; G6 P3; Ht 63”; Wt 253; BMI=45; BP 130/80; HGB 14.9; UCG negative; Smokes Case Study #1 • 1 ppd; No pap smear or MD care ~ 20 years; Family Hx: Mom uterine Ca • Presenting s/s: C/o occasional pelvic pain and irregular vaginal bleeding with light to heavy flow for 1 year. Reports no sexual activity for 4 months due to bleeding and pain
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• Hx of Gestational Diabetes • Labs: Pap smear; GC/CT; FOBT not • Surgical Hx: BTL 1983; C-Section x 3 performed due to contamination from vaginal bleeding • Physical Exam: Posterior bilateral breast and inguinal skin with • Diagnosis: AUB, Obesity R/o erythematous, irregular borders; Dia bet es Pelvic: vaginal mucosa without • Plan: Refer to GYN for evaluation and erythema or lesions; uterus and endometrial bx. (Pap results: AGC adnexae are without palpable favor neoplastic ) Refer for colpo. masses
• 45 y/o female G2 P 1; LMP 2008; BMI=26 Case Study #2 • Non-smoker, presently in Nursing school • Nliif1No sexual activity for ~15 years • Family Hx: Mom and Dad CVA • Surgical Hx: TAH, BSO 2008 for uterine fibroids
• Presenting s/s: C/o “Major • What does she need? hotflashes” used HT for one month – Pap? Visual exam? Pelvic? post Hyst. Experiences ~ “10 “ GC/CT? Mammogram? • Hotflashes /day – Rx for HT or OTC or None??? • PE: Breast: No pa lpa ble masses, wi th • Lifestyle modifications • Extramammary tissue bilaterally in – What screenings are indicated? axilla
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