INTENSIVE UPDATE AUGUST 24 - 26, 2018 & BOARD REVIEW Loews Chicago O’Hare Hotel Rosemont, IL

INNOVATIVE • COMPREHENSIVE • HANDS-ON

Focus on Women's Health

Martha Metzgar, DO

The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians.

The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content. ACOFP FULL DISCLOSURE FOR CME ACTIVITIES

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Name of CME Activity: ACOFP Intensive Update & Board Review in Family Medicine Dates and Location of CME Activity: August 24-26, 2018, Loews Chicago O'Hare Hotel, Rosemont, IL, United States

Name of Faculty/Moderator: Martha Metzgar, DO

DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary X entity producing health care goods or services.

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*If you checked “Speakers’ Bureaus” in item B , please continue: • Did you participate in company-provided speaker training related to your proposed topic? Yes: No: • Did you travel to participate in this training? Yes: No: • Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No: • Did the company pay the travel/lodging/other expenses? Yes: No: • Did you receive an honorarium or consulting fee for participating in this training? Yes: No: • Have you received any other type of compensation from the company? Please specify: Yes: No: • When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation and/or lecture handout materials? Yes: No: • Will your topic involve information or data obtained from commercial speaker training? Yes: No:

DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS

A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or X investigational uses of products or devices.

B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated below:

I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement.

Signature: Martha Metzgar, DO Date: 7/9/18

8/13/2018

WOMEN’S HEALTH

Martha Metzgar, DO, FAAFP

Women’s Health on AOBFP exam

 OB/GYN – 4%

 Women’s Issues – 4%

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Case 1  27 yo G1P1 who presents for “my yearly pap”

 Her last pap was one year ago and was ASC-US and HPV was not able to be done. You repeat the pap and it is again ASC-US with +HPV.

 What is the next step?

 Colposcopy

Pap Screening

 Start at age 21(no pap, no HPV <21)

 21-29 - cytology alone every 3 years

 30-65 – HPV and cytology “cotesting” every 5 years (can do cytology alone every 3 years)

 >65 – No screening assuming adequate negative prior screening (history of CIN 2 or > should continue screening)

 No screening after hysterectomy  No change in these if HPV vaccinated.

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ASC-US Follow Up

ASC-US Follow up

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Atypical Glandular Cells

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Case 2  22 yo complains of fatigue, anxiety, emotional lability, concentration problems, difficulty sleeping. On ROS she does admit to breast tenderness, abdominal bloating, food cravings. No menstrual irregularities. She thinks this is more prevalent during the week prior to her period and resolves within 3 days of starting menses. She does start to cry and admits that this is affecting her life.  Most likely diagnosis?  PreMenstrual Dysphoric Disorder

PMS

 At least one of the following affective and somatic symptoms during the 5 days before menses in each of the three previous cycles:  Affective symptoms: depression, angry outbursts, irritability, anxiety, confusion and withdrawal  Somatic symptoms: breast tenderness, abdominal bloating, HA, swelling of extremities  Symptoms relieved from days 4 through 13 of the menstrual cycle

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Premenstrual Dysphoric Disorder

 In most menstrual cycles during the past year, five or more of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase and were absent in the week after menses with at least one of the symptoms being1,2,3 or 4  Markedly depressed mood, feelings of hopelessness or self-deprecating thoughts  Marked anxiety, tension or feelings of being “keyed up” or “on edge”  Marked affective lability  Persistent and marked anger or irritability or increased interpersonal conflicts  Decreased interest in usual activities  Subjective sense of difficulty concentrating  Lethargy, easy fatigability or marked lack of energy  Marked change in appetite, overeating or specific cravings  Hypersomnia or insomnia  Subjective sense of being overwhelmed or out of control  Other physical symptoms such as breast tenderness or swelling, HA or joint/muscle pain, sensation of bloating or weight gain

 The disturbance markedly interferes with work or school or with usual social activities and relationships

 The disturbance is not merely an exacerbation of another disorder

 Criteria ABC must be confirmed by prospective daily ratings during at least 2 consecutive symptomatic cycles.

PMDD – International Society for the Study of Premenstrual Disorders

 During a majority of menstrual cycles within the past year  a pattern of mood symptoms (depressed mood, irritability)  somatic symptoms (lethargy, joint pain, overeating)  or cognitive symptoms (concentration difficulties, forgetfulness)  begin several days before the onset of menses  start to improve within a few days after the onset of menses  become minimal or absent within approximately 1 week following the onset of menses.  The temporal relationship of the symptoms to the luteal and menstrual phases may be confirmed by a prospective symptom diary.  The symptoms are severe enough to cause significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning  do not represent the exacerbation of a mental disorder

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Treatment of PMDD

 Nonpharmacologic:  Pharmacologic:  Patient education  SSRIs (First line)  daily symptom diary  therapy/COCs  adequate rest and  Androgen therapy and structured sleep schedule GnRH agonists(limited by  sodium restriction side effects)  caffeine restriction  CBT/mindfulness  aerobic exercise  NSAIDS (physical symptoms except breast tenderness  Supplements/herbal  Diuretics (spironolactone  Calcium carbonate effective for breast 1200mg/day tenderness and bloating)  Vit B6, Vit E, chasteberry, Evening primrose oil

Case 3  51 yo with hot flashes that you determine to be from . What is the most effective treatment option?

 Combined Hormone replacement therapy

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Menopause - Diagnosis

 Retrospective diagnosis based on >12 months of occurring at a mean age of 51 years.

 Typical symptoms include:  Hot flashes, night sweats, vulvovaginal , sleep disturbances associated with the cessation of menses

Menopause - treatment

 Combined estrogen/ therapy, but not estrogen alone, increases the risk of breast cancer after three to five years of use (B)

 Systemic estrogen, alone or in combination with a progestogen, is the most effective therapy for menopausal hot flashes, and is approved by the U.S. Food and Drug Administration for this indication (A)  Because of the potential risks with long-term use of hormone therapy, clinicians should prescribe the lowest effective dosage for the shortest duration necessary to improve symptoms (C)

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Menopause - treatment

 There is no high-quality, consistent evidence that black cohosh, botanical products, omega-3 fatty acid supplements, or lifestyle modification alleviates hot flashes. (B)

 The decision to continue combined hormone therapy for more than three to five years should be made after reviewing the risks, benefits, and symptoms and with the patient. (C)

 Effective nonhormonal therapies for genitourinary syndrome of menopause include vaginal moisturizers and oral ospemifene (osphena)

Case 4  14 yo with 6 month history of lower mid- abdominal pain. The pain is colicky begins with the onset of menses and lasts for 2 to 4 days. She has missed school due to the pain. Menarche was 18 months ago and she has had regular periods for 6 months. Denies sexual activity. Physical exam is normal and she has had normal secondary sexual development.  What is the etiology of this patient’s condition?  Increased levels of prostaglandins

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Dysmenorrhea

 Most common GYN complaint of young women

 Primary usually begins within 6 to 12 months of menarche.  Secondary dysmenorrhea is defined as dysmenorrhea with identifiable pelvic etiology (PID, ).

 Increased prostaglandin (PGF2a)

 First line is NSAIDS (decrease prostaglandins)  May add OCPs if NSAIDs not effective

Case 5  35 yo complains of heavy menstrual periods for the past year. She states her period occurs at irregular intervals (between 2 weeks and 2 months between periods). Her menses last 7- 10 days. Physical exam is normal.

 How would you describe this pattern of menstruation?

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Patterns

 Menorrhagia – heavy bleeding

 Metrorrhagia – Irregular periods

 Menometrorrhagia – irregular, heavy bleeding

 Amenorrhea – no menses

– >35 days between periods

 Polymenorrhea - <21 days between periods

Abnormal Uterine Bleeding

 PALM-COEIN

 PALM – Structural causes  Polyp, , leiomyoma, malignancy

 COEIN – Nonstructural  Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified

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Abnormal Uterine Bleeding

 Evaluation:  pregnancy test  TSH  Prolactin (Pituitary imaging if prolactin high)  endometrial biopsy in perimenopausal patients or postmenopausal patients receiving HRT or if endometrial stripe >5mm  Transvaginal ultrasound if abnormal or inadequate pelvic exam  Usually anovulatory

Abnormal Uterine Bleeding

 NSAIDS

 Oral contraceptives

 Progestins

 IUD

 Surgical treatment (ablation/hysterectomy)

12 8/13/2018

Case 5  27 yo who is 7 months post partum is asking about contraception. She is currently .

 Which of the following is a reasonable option for contraception?  Combined Oral Contraceptive pills  Transdermal contraceptive patch  Progestin-only IUD  She won’t get pregnant while breastfeeding

Contraception

 OCP/COCP –  may be used for treatment of other conditions  Avoid in estrogen dependent malignancies, migraines with aura, history of VTE and >35 yo and  May cause HTN, VTE, hepatic adenoma

 Progestin only – (Pills, depo, progestin IUD, single rod)  Can be used in breastfeeding or other contraindications to estrogen  Depo may have a delayed return to fertility  IUD can be used in nulliparous patients

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Case 6 • 23 yo pregnant patient with . Sexually active. Pelvic exam reveals: • Thin gray-white discharge, pH 5, a strong fishy odor is present when KoH is added to the discharge. Treatment? BV – metronidazole 500mg BIDx7days

Bacterial Vaginosis

 Anaerobic bacteria  (gardnerella, prevotella, mobiluncus, ureaplasma, mycoplasma)  Fishy odor, thin homogenous discharge, may worsen after intercourse, pelvic discomfort  pH >4.5, clue cells  Increased risk of HIV, gonorrhea, chlamydia, herpes  Metronidazole 500mg BIDx7days (same in pregnancy)  Or metronidazole or clindamycin gel intravaginally  Multiple recurrences  Metronidazole gel intravaginal twice weekly for 4-6 months  Routine treatment of partners not recommended

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Vulvovaginal Candidiasis

 Candida albicans  White thick cheesy or curdy discharge, vulvar itching or burning, no odor  Vulvar erythema and edema  pH <4.5  Topical azole therapy (preferred in pregnancy x7 days)  Fluconazole 150mg orally single dose  If recurrent  Oral fluconazole weekly for six months  Routine treatment of partners not recommended unless symptomatic.

Vaginitis

Trichomoniasis Atrophic

 Trichomonas vaginalis  Estrogen deficiency  Green or yellow, frothy discharge; foul odor; vaginal pain  Thin, clear discharge,  Inflammation; strawberry vaginal dryness,  Increased risk of HIV infection, , itching Increased risk of preterm labor  Should be screened for other STIs  Inflammation, thin,  Treat with metronidazole 2g orally (same in pregnancy) friable vaginal mucosa  Treatment of partner is recommended  Estrogen topically

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Vaginitis

Physiologic Irritant/allergic

 Clear to white, not  Contact irritation or malodorous allergic reaction  No discomfort or  Burning/soreness pruritus  Vulvar erythema  Quantity varies during menstrual cycle  Remove irritant

 Often WBCs on wet mount

Case 7  51 yo complaining of a lump in her right breast that she noticed in the shower a week ago. Located in the upper outer quadrant. Mobile, 4 cm in diameter, hard mass palpated on exam. Lymph nodes in the axilla palpated as well.  First diagnostic test?  mammogram

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Breast Disease

 Palpable mass – indeterminate features (discrete margins, no skin changes, smooth, mobile)  Patient younger than 30 – Ultrasound  Patient >30 – diagnostic mammogram and +/- US

 Palpable mass – suspicious features (hard, immobile, fixed, poorly defined margins)  Diagnostic Mammogram +US, likely biopsy

Nipple Discharge

 Pathologic – spontaneous, unilateral, single duct, clear, serous or bloody, assoc with a mass  Diagnostic mammogram and ultrasound  Intraductal papilloma, duct ectasia, malignancy  Physiologic – bilateral or milky  Pregnancy test  Galactorrhea work up – meds, TSH, prolactin  Meds – methyldopa, verapamil, cimetidine, metoclopramide, estrogen, doceine, morphine, antipsychotics, SSRIs, TCAs  Physiologic discharge – bilateral, milky, expressed only, multiduct, yellow, green, grey or black  Observe, avoid nipple stimulation repeat exam or if bothersome refer for possible duct excision.

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References

 “Vaginitis:Diagnosis and Treatment” Paladine, H. and Desai, U. Amer Fam Phys. Vol 97, no 5 March 2018.

 “Dysmenorrhea” Latthe, P. Champaneia, R. Khan, K. Amer Fam Phys. Vol85 No.4, Feb 2012.

 ACOG guidelines on management of abormal uterine bleeding associated with ovulatory dysfunction

 “Sexually transmitted Infections: Recommendations from the USPSTF” Lee et al. Amer Fam Phys. Vol 94 no11 December 2016.

 US Medical Eligibility Criteria for Contraceptive Use. Centers for disesase control, 2017.

 “Diagnosis and Initial Management of Dysmenorrhea” Osayande, A. and Mehulic, S. Amer Fam Phys. Vol 89 No 5 March 2014.

 “ and Premenstrual Dysphoric Disorder” Hofmeister, S. DO and Bodden, S. Amer Famy Phys. Vol 94 No3. August 2016.

 “Hormone Therapy for the Primary Prevention of Chronic conditions in Postmenopausal Women” Tracer, H. McKee, D. Am Fam Physician. 2018 Apr 15; 97(8):541-542.

 Swanson’s Family Medicine Board Review. Talia Et al. 2014

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