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Allentown Cmeconference ALLENTOWN CME CONFERENCE Sam Study Group - Early Childhood Illness............................................................................................. Menopause and Post Gynecological Reproductive Care ....................................................................... Pulmonary Function Tests – Basic Interpretation for Primary Care ...................................................... Dyslipidemia – New Guidelines .............................................................................................................. Transitioning Patients with Autism from Pediatric to Adult Practices ................................................... Herbs, Supplements and Athletes .......................................................................................................... Tools to Treat Adult Patients with Obesity: An Update on Bariatric Surgery and Pharmacologic Agents Case Studies of Common Behavioral Health Scenarios.......................................................................... Opioid Prescribing: Safe Practice, Changing Lives ................................................................................. Act 31 Child Abuse Recognition .............................................................................................................. Integrating Genetic Testing into Family Medicine - Part I, an Overview .............................................. Drugs of Abuse ........................................................................................................................................ VTE: Beat the Clot! ................................................................................................................................. Pre-Operative Assessment in the Office ................................................................................................ ENT Review ............................................................................................................................................. CSI (Clinical Skin Investigation) Introduction to Dermoscopy ............................................................... Integrating Genetics into Family Practice – Part II ................................................................................. Achieving Glycemic Control: When Optimized Basal Insulin Isn’t Adequate......................................... Physician Burnout ................................................................................................................................... Tackling the Top Three Most Common Ailments…Low Back Pain, Depressed Mood and “I Think I Have Bronchitis” .............................................................................................................................................. Return to Top Sam Study Group – Early Childhood Illness Sam Study Group - Early Childhood Illness Americo Fraboni, MD, East Carolina University & David Weismiller, MD, ScM, FAAFP, East Carolina University Disclosures: Speakers have no disclosures and there are no conflicts of interest. The speaker has attested that their presentation will be free of all commercial bias toward a specific company and its products. The speaker indicated that the content of the presentation will not include discussion of unapproved or investigational uses of products or devices. Because of the content of this presentations, handouts are not allowed to be posted online. Register at PAFP.com for the next SAM session at Pittsburgh CME Conference scheduled for March 10-13, 2016. Return to Top Menopause and Post Gynecological Reproductive Care Menopause and Post Gynecological Reproductive Care Nguyet-Cam Vu Lam, MD, St. Luke’s FMR Disclosures: Speaker has no disclosures and there are no conflicts of interest. The speaker has attested that their presentation will be free of all commercial bias toward a specific company and its products. The speaker indicated that the content of the presentation will not include discussion of unapproved or investigational uses of products or devices. Menopause and Post Gynecological Reproductive Care Nguyet-Cam Vu Lam, MD, FAAFP Associate Program Director St. Luke’s Family Medicine Residency 1 Disclosure Dr. Nguyet-Cam Vu Lam has no conflict of interest, financial agreement, or working affiliation with any group or organization. 2 Objectives Understand the physiologic changes that happen to women as they move through the menopausal transition. Understand routine preventive care for post- reproductive women. Recognize common gynecologic issues in post- reproductive women with some understanding of diagnosis and treatment options Know the indications, contraindications, risks and benefits of hormone replacement therapy. 3 1 Definition Menopause is defined as the permanent cessation of menses. 12 months of amenorrhea. Median age at menopause is 51 years old (range 40-58). With life expectancy approaching 80 years, the average women is postmenopausal for 1/3 of her life. Family physician can address both management of menopausal symptoms as well as preventive health care measure. 4 Perimenopause Most women start to have physiologic changes associated with menopause in years prior to the final menstrual period. Menopausal transition has fluctuated hormone levels as ovarian function starts to decrease. Serum estradiol and progesterone decrease and follicle-stimulating hormone levels increase. These changes result in menopausal symptoms such as vasomotor (hot flushes) and vaginal symptoms. 5 Case: 54 years old woman come for routine visit Tearful, afraid that her marriage of 20 years is falling apart. She and her husband argue frequently; patient alternates between tearful and angry for no apparent reason. Last menstrual period 2 years ago 6-7 hot flashes daily—disrupt her sleep several nights/week. Intercourse is painful, decreased interest Exam: thin pale vaginal epithelium, all other exam within normal limit 6 2 What do you want to do as her family physician? Many women with menopausal symptoms that significantly impair their quality of life never report them to their physician. Approaching the subject with perimenopausal women, rather than waiting for them to initiate the discussion is an important first step. Common menopausal symptoms including hot flushes, atrophic vaginitis, insomnia, diminished libido, and hair loss, can be treated successfully with a variety of hormonal and non-hormonal agents. Many women find it challenging to deal with both the physical and emotional ramifications of this new phase in life. 7 Hot flushes: How often? How severe? Sudden sensation of extreme heat in upper body, face, neck, chest lasting 1-5 minutes. In up to 75% of menopausal women. Most severe in the first 2 years of menopause. (lasting a median 4-10.2 years) Broad spectrum of frequency and severity. Risk factors for greater severity and frequency: Surgically or chemically induced menopause Elevated body mass index History of tobacco use African American ethnicity 8 What is the most effective treatment for perimenopausal vasomotor symptoms? A. Compounded bioidentical hormones B. SSRI’s C. Estrogen or Estrogen/progesterone combination D. Gabapentin 9 3 Options for treating hot flashes Hormone therapy (HT): Estrogen alone or estrogen-progesterone combination Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) or selective serotonin- norepinephrine reuptake inhibitors (SNRIs) Antiepileptic: gabapentin (900mg/day) Antihypertensive: Clonidine, Methyldopa Herbal supplements: Black cohost, Mg, Omega-3- fatty acid, Red clover, St. John’s wort. Lifestyle/alternative: Acupuncture, avoidance of triggers, physical activity, yoga 10 Systemic HT-Level A evidence Systemic HT, with estrogen alone or in combination with progestin, is the most effective therapy for vasomotor symptoms related to menopause. Low-dose and ultra low systemic doses of estrogen are associated with a better adverse effect profile than standard doses and may reduce vasomotor symptoms in some women. 11 Systemic HT-Level A evidence Given the variable response to HT and the associated risks, it is recommended that health care providers individualize care and treat women with the lowest effective dose for the shortest duration that is needed to relieve vasomotor symptoms. The risks of combined systemic HT include thromboembolic disease and breast cancer. 12 4 A critical look at HT Estrogen/progesterone combination for women with intact uterus, and estrogen alone for those who’ve had a hysterectomy is highly effective, alleviating hot flushes and other menopausal symptoms 80-90% of the time. Women health initiative in 2002 reported increased risk of breast cancer, coronary heart disease, stroke, and venous thromboembolism in women aged 50-77 years after 5 years of combined HT. 13 HT-reanalysis of the WHI Women <60 years old and within 10 years of the onset of menopause, HT appeared to be a safe short-term treatment. Women >60years old and at risk for cardiovascular disease or breast cancer or both, should not take HT. Cochrane review of HT in 2012 stated that HT should not be used for primary or secondary disease prevention because the risks of use outweigh the benefits. 14 Ways to minimize risk with HT Limit duration of HT to the shortest treatment required Use a transdermal delivery system (lower risk of thromboembolism) Prescribe low-dose HT regimen. 15 5 Discontinuation Discontinuation of HT may associated with recurrent vasomotor symptoms in 50% women. ACOG recommends against
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