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Women's Health 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 Please check where applicable and sign below. Provide additional pages as necessary. 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. B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care goods or services. Please check the relationship(s) that applies. Research Grants Stock/Bond Holdings (excluding mutual funds) Speakers’ Bureaus* Employment Ownership Partnership Consultant for Fee Others, please list: Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper: Organization With Which Relationship Exists Clinical Area Involved 1. 1. 2. 2. 3. 3. 4. 4. *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% 1 8/13/2018 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. 2 8/13/2018 ASC-US Follow Up ASC-US Follow up 3 8/13/2018 Atypical Glandular Cells 4 8/13/2018 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 5 8/13/2018 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 6 8/13/2018 Treatment of PMDD Nonpharmacologic: Pharmacologic: Patient education SSRIs (First line) daily symptom diary Estrogen 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 menopause. What is the most effective treatment option? Combined Hormone replacement therapy 7 8/13/2018 Menopause - Diagnosis Retrospective diagnosis based on >12 months of amenorrhea occurring at a mean age of 51 years. Typical symptoms include: Hot flashes, night sweats, vulvovaginal atrophy, sleep disturbances associated with the cessation of menses Menopause - treatment Combined estrogen/progestogen 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) 8 8/13/2018 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
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