Women's Health After 40: comprehensive overview, honest discussion, latest updates & helpful tips

Parker Adventist Hospital | Health Seminar | April 22, 2014
Women’s Health after 40
comprehensive overview, honest discussion,
latest updates & helpful tips
Vandna Jerath, MD, FACOG
April 22, 2014
optimawomenshealthcare.com
drjerath.com

Vandna Jerath, MD, FACOG
 FACOG - Board-Certified
 Private practice - 15+ years
 Optima Women’s Healthcare
 Located at Parker Adventist Hospital
 Full-scope obstetrics & gynecology
 Enjoy education and community outreach
 Disclosure – no affiliations
 Healthcare social media pioneer & expert locally
 Educate, engage, and empower women
 Website /Blog

Optima Women’s Healthcare
 Services
 Low and high risk obstetrics
 Minimally invasive gynecologic surgery
 Novasure and Thermachoice Endometrial ablation
 Essure sterilization
 Family planning and infertility
 Menopause and hormone replacement therapy
 Bladder retraining and incontinence surgery
 Women’s health resource/expert
 Female empowerment
 Spa-like setting
 Individualized, personalized, and compassionate care
 optimawomenshealthcare.com

Learning Objectives
 General overview of women’s health after age 40
 Review of current healthcare screening guidelines for
women with latest updates
 Learn the latest research, news, and updates related to
women’s health issues in this age category
 Discuss age related gynecological clinical conditions
such as infertility, family planning, sexual health,
menstrual disorders, PMS, menopause, incontinence,
osteoporosis, and cancer

Global Women’s Health & Rights
1. The right to be full and responsible citizens of their countries, with equal property,
economic, voting and freedom of movement rights.
2. The right to equal education.
3. The right to work and earn a living with equal pay for equal work.
4. The right to be free of all forms of gender based violence such as domestic violence,
sexual assault, incest, female infanticide, honor killings, female genital cutting and self-
immolation at a husband’s death.
5. The right to the best available, scientifically based healthcare, including health and
sexuality education.
6. The right to autonomous decision-making, informed consent, privacy and confidentiality
regarding their own health care.
7. The right to participate equally in ethically conducted clinical and other research.
8. The right to decide when and if to have sex, including choosing one’s partner, and freedom
from coerced marriage and sex trafficking.
9. The right to decide whether to have children, the number and spacing of their children,
and to have the information, education and access to health services to make these
choices.
10. The right to safe childbearing, with resources available to reduce maternal and infant
morbidity and mortality.
ACOG Statement of Policy, July 2012 (endorses FIGO resolutions)

To pap or not to pap?
 Based upon current ACOG screening guidelines, at
what interval should a woman age 45 obtain a pap
smear, if her last pap smear and HPV testing was
negative and she has had no history of prior
abnormal pap smears?
 A. Annually
 B. Every 2 years
 C. Every 3 years
 D. Every 5 years

The Basics - Screening
 Cervical Cancer Screening
 Start age 21, regardless of sexual activity
 Age 21-29 – every 3 years
 No HPV testing
 Age 30-64 – every 3-5 years
 HR HPV testing
 No paps after hysterectomy if low-risk
 Stop age 65 – if normal for 10 years
 If history of abnormal paps – need to be normal for at least 20 years
 USPSTF/ACS/ASCCP 3/2012 guidelines and ACOG Practice Bulletin, Number 131, November
2012
 Breast Cancer Screening
 Self-breast awareness or exams monthly
 Clinical breast exam annually
 Mammograms annually starting at age 40
 Or 10 years before relative with breast cancer
 ? Dense breasts - ?Ultrasound/MRI
ACOG Practice Bulletins, Committee Opinions and Guidelines for Women’s Healthcare – No 534, August 2012; No
131, November 2012; No 554, February 2013; No 122, August 2011; No 482, March 2011

The Basics - Screening
 Colon Cancer Screening
 Fecal occult blood stool cards yearly starting age 50
 Colonoscopy start at age 50 – every 10 years, every 5 years with risk factors
 Start 10 years before relative with colon cancer and every 5 years
 Medical Screening
 Labs every 5 years – CBC, Chem 20, Lipid, TSH; glc every 3 years
 Heart disease, thyroid disease, anemia, liver disease, metabolic syndrome
 BP, Skin, Eyes, Teeth – annually
 Reproductive and Sexual Coercion
 Osteoporosis Screening
 Bone Density (DEXA) starting age 65 – every 2 years
 Or as indicated clinically
 Or by FRAX risk
ACOG Practice Bulletins, Committee Opinions and Guidelines for Women’s Healthcare – No 534, August 2012;
No 131, November 2012; No 554, February 2013; No 122, August 2011; No 482, March 2011

The Basics - Immunizations
cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm?s_cid=mm6104a9_w

Fertility by Age
Rba-online.com
ACOG Committee Opinion – Female Age Related Fertility Decline, No 589, March 2014

Infertility
 Common
 Low success rate after 40
 Increased risk of congenital anomalies or miscarriage
 Healthy lifestyle is important
 Male factor vs Female factor
 Basic Testing
 Day 3 Labs
 Estrogen
 Follicle Stimulating Hormone (FSH)
 Anti-Mullerian Hormone (AMH)
 Clomid Challenge Test
 Pelvic Ultrasound
 Pelvic Anatomy
 Antral Follicle Count
 Hysterosalpingogram or Sonohysterogram
 Check for tubal patency
 Check for uterine abnormalities
 Semen Analysis
 Laparoscopy
 Anxiety/Depression
 Mental Health Specialist
ASRM Committee Opinion – Diagnostic Evaluation of the Infertile Female, Fertility & Sterility - Vol 98, No 2, August 2012, 302-307

Reproductive Endocrine Infertility
 Referral to REI specialist
 Options
 Clomid
 Clomid-Intrauterine Insemination (IUI)
 In-vitro Fertilization (IVF)
 Gamete Intrafallopian Tube Transfer (GIFT)
 Egg Donor
 Surrogacy
 Adoption
 Genetic Testing

Family Planning
 Unintended pregnancy
 Rates high (50%) over age 40
 Over 50% result in termination
 Guttmacher Institute data
 Contraception
 Options
 How to decide
 What is best over 40?
 Political Firestorm
 ACA Preventative Coverage
 ACOG recommends OCPs and EC
should be available OTC
ACOG Committee Opinions, No 542/No 544, November/December 2012
ASRM Practice Committee – Hormonal Contraception,Fertility & Sterility – Vol 90, Suppl 3, November 2008, S103-S113

Contraception – Short Term
 Barrier
 Condoms
 Diaphragm
 Hormonal
 Oral Contraceptives “the pill”
 Estrogen/Progesterone combination or Progesterone only
 Daily
 Patch
 Weekly
 Vaginal Ring
 Monthly
 Depo-Provera injection
 Progesterone only
 Every 3 months

Contraception – Long Term
 Reversible
 Implanon – implantable device
 Every 3 years
 Etonorgesterol hormone – 68 mg
 Intrauterine Device (IUD)
 ParaGard
 Non-hormonal, copper
 10 years
 Benefits – no hormones, use until menopause
 Risks – pain, cramping, discharge
 Mirena
 Levonorgesterol hormone – 52 mg
 5 years
 Benefits - decrease heavy periods, stabilize fibroids
 Risks – breakthrough bleeding, acne, weight gain
 Skyla
 Levonorgesterol hormone – 13.5 mg
 3 years
 Benefits – smaller, nulliparous women, used in between pregnancies
 Risks – breakthrough bleeding
ACOG Practice Bulletin – LARC: Implants and IUDs, No 121, July 2011

Contraception - Permanent
 Non-reversible
 Sterilization
 Traditional surgery (L/S or Lap)
 Tubal ligation
 CREST Study 1996 – 13/1000 5 year failure rate
 In-office
 ESSURE
 Metal coils
 In-office Adiana (off the market now)
 Silicone plugs
 No cutting
 No general anesthesia
 No hormones
 Quick recovery
ACOG Practice Bulletin – Benefits and Risks of Sterilization, #133, February 2013

Contraception - Permanent
Method 5 year
(per 1000
procedures)
10 year
(per 1000
procedures)
Ectopic
(per 1000
procedures)
Postpartum partial
salpingectomy
6.3 7.5 1.5
Bipolar Coagulation 16.5 24.8 17.1
Silicone band
methods
10.0 17.7 7.3
Spring Clip 31.7 36.5 8.5
Essure
(hysteroscopy)
1.64 ---- ----
Vasectomy 11.3 no association
ACOG Practice Bulletin – Benefits and Risks of Sterilization, #133, February 2013
US Collaborative Review of Sterilization -Crest Study, 1996

Sexually Transmitted Infections
 STI/STD
 Women over 40 getting divorced
 Infidelity
 New partners
 Anxiety
 Condoms
 Regular testing
 Treatment
 CDC 8/2012 new GC Rx guidelines
 Ceftriaxone 250mg IM + Azithromycin 1gm PO or Doxycycline 100mg PO BID
 Most common
 HPV – Human Papilloma Virus
 HSV - Herpes
 GC/CT – Gonorrhea/Chlamydia
 HPV vaccine
 FDA approved
 Girls ages 9-26, ideal age 11-12, boys too
CDC STD Treatment Guidelines 2010: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf

Sexual Dysfunction
 Marked distress and interpersonal difficulty
 Anxiety and fear - difficulty discussing with healthcare provider
 Desire Problems
 Most common – 8% prevalence; peak women age 40-60
 Decreased libido
 Arousal Problems – 5%
 Orgasmic Problems – 3.4-5.8%
 Inability to orgasm
 Sexual Pain Disorders
 Dyspareunia – 8-22%; recurrent painful sex
 Vaginismus – 1-6%; involuntary spasm of lower 1/3 vagina
 Vestibulitis
 Vulvodynia
ACOG Practice Bulletin – Female Sexual Dysfunction, No 119, April 2011

Sexual Dysfunction
 Causes
 Physiologic - Menopause, atrophic vaginitis, lack of estrogen, chronic disease
 Psychological - Dysfunctional interpersonal relationship, depression, traumatic life event, history of
abuse
 Meds – SSRI, OCPs, steroids, anti-hypertensives, histamine blockers
 Treatment
 Physiologic – ERT, testosterone, lubricants
 Physical – Pelvic floor therapy, masturbation, muscle relaxation, vaginal dilators, clitoral therapy
 Therapy - Psychotherapy, couples counseling, communication exercises, decrease stress
 Meds – Sildenafil (Viagra), Testosterone, ERT, antidepressants, adjust SSRI, change OCPs, analgesics,
xylocaine
 Date Night
 Validate and reassure patient
ACOG Practice Bulletin – Female Sexual Dysfunction, No 119, April 2011

Clinical Conditions
 Premenstrual Syndrome – PMS/PMDD
 Heavy periods/AUB
 Perimenopause/Menopause
 Urinary Incontinence
 Pelvic Organ Prolapse
 Osteoporosis
 Cancers

Premenstrual Syndrome

Premenstrual Syndrome
 Cyclic occurrence of symptoms with physical, emotional,
and/or psychological manifestations
 Occur 5-7 days before menses and subside within 4 days
after onset
 Common age 25-45; may worsen in perimenopause
 Imbalance of neurotransmitters
 Premenstrual Syndrome (PMS)
 75-85% women have one symptom
 20-30% moderate to severe symptoms
 Premenstrual Dysphoric Disorder (PMDD)
 3-5% have debilitating symptoms with impairment of lifestyle
http://drjerath.com/2011/06/13/pms--a-womans-monthly-madness.aspx

PMS - Symptoms
 Emotional/Mood
 Crying
 Angry outbursts
 Mood Swings
 Depressed
 Irritable
 Social Withdrawal
 Poor Concentration
 Physical
 Breast tenderness
 Bloating
 Constipation
 Weight gain
 Swelling
 Acne
 Headache
 Fatigue
 Sleep disturbances
 Appetite changes/food cravings
 Keep mood and menstrual diary
 Distinguish from medical
conditions
 Hypothyroidism
 IBS
 Chronic fatigue/fibromyalgia
 Mood disorders
 Migraines

PMS - Treatment
 Lifestyle Modifications
 Stress reduction
 Exercise
 Healthy diet
 Reduce caffeine, alcohol, tobacco
 Alternative/Natural Therapies
 Vitamins – Calcium, B6, Magnesium, Vit E
 Herbs – Black Cohosh, Gingko, St. John’s Wort, not FDA approved
 Acupuncture
 Psychotherapy
 Light therapy
 Medications
 NSAIDs – Motrin, Aleve, Ponstel
 OCPs – Yaz, Yasmin
 Diuretics
 Ovarian Suppression – Danacrine, Lupron
 Antidepressants – SSRI – Prozac, Sarafem, Zoloft, Celexa, Effexor, Cymbalta

Heavy Periods/AUB
 Menorrhagia – heavy periods, >80ml blood loss
 Excessive, prolonged, heavy bleeding
 1 in 5 women affected
 In the U.S. 10 million women suffer
 Takes physical, social, emotional, and psychological toll
 70% of women suffer in silence
 Causes
 Anatomical
 Endometrial Polyp
 Fibroids
 Adenomyosis
 Hyperplasia
 Cancer
 Hormonal
 Ovulatory
 Anovulatory
 Polycystic Ovarian Syndrome (PCOS)
 Other
 Coagulopathy
 Iatrogenic
ACOG Practice Bulletin – Diagnosis of AUB, No 128, July 2012

Heavy Periods - Treatment
 Expectant Management
 Oral Contraceptives (OCPs) – birth control pills
 Provera withdrawal
 Hormones
 Dilation and Currettage (D&C)
 Hysteroscopy
 Endometrial Ablation
 Novasure
 Thermachoice
 Hydrothermablation(HTA)
 Her Option cryotherapy
 Microwaveendometrialablation
 Myomectomy
 Hysteroscopic
 Laparoscopic
 Laparotomy
 Uterine Artery Embolization
 Hysterectomy
 Laparoscopic – LAVH, TLH, DaVinci
 Vaginal
 Abdominal
ACOG Practice Bulletin – Endometrial Ablation, No 81, May 2007

Menopause

Menopause
 Pre, Peri, and Post-Menopause
 No period for 1 year
 Average age in U.S. is 51; range age 45-55
 Increased FSH > 30
 Symptoms
 Hot flashes – 75%
 Vaginal dryness
 Mood swings
 Decreased libido
 Decreased concentration
 Insomnia/Sleep Disturbances
 Hair loss
 Weight gain
 Metabolic Syndrome
 Risk CVD & diabetes
 Natural aging vs medical disorder

Menopause - Symptoms
Symptom What you can do
Hot Flashes/Night Sweats Dress in layers
Keep Thermostat down
Avoid hot drinks
Use a cold, wet washcloth against neck
Use a fan
Quit smoking, if you smoke
Vaginal Dryness Use lubricants before sex
Use a vaginal moisturizer
Do your kegel exercises
Sleep Problems Keep a circadian rhythm
Avoid naps
Avoid caffeine
Avoid alcohol
Relaxation
Try sleep aid
Depression Exercise and stay active
Seek social support
Talk about it

Menopause - Treatment
 Hormone Replacement Therapy
(HRT)
 Types
 Estrogen
 Estrogen/Progestin
 Pills, patches, creams, vaginal
suppositories, shots, pellets,
intranasal (EU), progestin IUD
 Bioidentical hormones
 Cyclic or daily
 Benefits
 Reduction and improvement of
symptoms
 Protect bones
 May reduce risk of colon CA
 ?CV benefit HRT close to onset
 Risks
 Side Effects – bleeding, breast
tenderness, bloating, abnormal
uterine bleeding (AUB)
 Anxiety
 Stroke
 Heart attack
 Blood clot (less transdermal)
 Breast cancer
 Women’s Health Initiative (WHI)
results
 Contraindications
 Breast Cancer
 Blood clots – PE, DVT
 CV disease
 Liver disease
 History of stroke or heart attack
 NAMS Statement 2012

Menopause - HRT
 No longer recommended as primary prevention or treatment of
disease
 Acceptable and safe option for the relatively young (up to age 59
or within 10 years of menopause)
 Reduce total mortality by 30% when initiated in women younger
than 60 years
 Lowest dose for shortest duration that is effective
 Currently fewer than 1 in 3 women take
 Most women discontinue within 1 year
 Breast cancer risk increases with use beyond 3 to 5 years
 Many FDA approved HRT products are in fact bioidentical
NAMS Statement 2012

Menopause – Other Treatment
 Low Dose Oral Contraceptive Pills
 Antidepressants
 SSRI or SNRI – Venlafaxine (Effexor), Citalopram (Celexa), Escitalopram (Lexapro),
Paroxetine (Paxil)
 FDA approved Brisdelle
 Clonidine
 Gabapentin
 Duavee
 Phytoestrogens/Botanicals
 Bioidentical Hormones
 Vaginal Moisturizers and Lubricants
 Quality of life issue
 Duration of Treatment
NAMS: Menopause.org

Menopause – Alternative Therapy
 Holistic or natural approach – not
an assurance of safety or efficacy
 Used by more than 30% of women
 Significant costs
 Bioidentical Hormones
 Not FDA approved
 Compounding variance
 Herbal
 Not FDA approved
 High degree of variation
 Hot flashes – soy, black cohosh,
evening primrose, dong quai
 Mood disturbances – St. John’s
wort, valerian root
 Sexual dysfunction – chasteberry,
ginseng
 AUB – wild yam
 Soy
 Phytoestrogen - isoflavones
 Avoid in Breast CA?
 Acupuncture
 Lifestyle modification
 Nutrition
 Exercise
 Yoga
ACOG Committee Opinion – Compounded Bioidentical
Menopause HRT, No. 532, August 2012
ACOG Practice Bulletin – Use of Botanicals for Management of
MenopausalSymptoms, No 28, June 2001
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying
Misconceptions,Vol 78, No 12, December 2011

Vaginal Atrophy - Treatment
 Affects 20-40% of menopausal women
 May lead to dyspareunia and sexual dysfunction
 Moisturizers and lubricants
 Replens, Me Again, Vagisil Feminine, Feminease, K-Y Silk-E
 Water soluble - Astroglide, Slippery Stuff, K-Y Jelly
 Silicone based - Pjur Eros, ID Millennium
 Oil based - Elegance Women’s Lubricant
 Mechanical Measures
 Sexual activity
 Vaginal dilators
 Vaginal Estrogen Therapy
 Cream – Premarin, Estrace
 Ring – Femring, Estring
 Tablet – Vagifem
 Selective Estrogen Receptor Modulators (SERM)
 Oral tablet – Ospemifene (Osphena)
 Other
 Smoking cessation
 Oral Vit D
 Vaginal Vitamin E
 ?Testosterone – may help libido, but not vaginal atrophy

Menopause – WHI
 Women’s Health Initiative
 Launched in 1991, 15+ year study
 Clinical trials and an observational study,
 161,808 generally healthy postmenopausal women
 Age 50-79
 Test the effects of postmenopausal hormone therapy,
diet modification, calcium and vitamin D supplements
on heart disease, fractures, and breast and colorectal
cancer.
 Some follow-up studies ongoing
 nhlbi.nih.gov/whi/

Menopause – WHI Data
 Compared with the placebo, estrogen plus
progestin resulted in:
 Increased risk of heart attack
 Increased risk of stroke
 Increased risk of blood clots
 Increased risk of breast cancer
 Reduced risk of colorectal cancer
 Fewer fractures
 Increased risk of dementia (study included
only women 65 and older)
 Stopped 2002
 30/10,000
 Compared with the placebo, estrogen alone
resulted in:
 No difference in risk for heart attack
 Increased risk of stroke
 Increased risk of blood clots
 Uncertain effect for breast cancer
 No difference in risk for colorectal cancer
 Reduced risk of fracture
 Stopped 2004
 8-10/10,000
NAMS 2012 Statement on HRT, Menopause, Vol 19, No 3, 257-271

Urinary Incontinence
 Video
 Whoopi Goldberg - Poise

Urinary Incontinence
 Urinary Incontinence
 Involuntary leakage / loss of urine
 Spontaneously
 Response to a stimulus
 Dribble
 Overflow from full bladder
 Urgency
 Neurologic
 More than 50% of women with symptoms do not discuss it with their doctor or seek help
 Can lead to stigma, embarrassment, isolation, sexual dysfunction, depression, and decreased
quality of life
 Estimated 50 million women
 Twice as common in women than men
 Affects 10-70% of all women
 > 50% of nursing home women
 25% premenopausal
 40% postmenopausal
ACOG Practice Bulletin – Urinary Incontinencein Women, No 63, June 2005 (Reaffirmed 2011)

Urinary Incontinence - Etiology
 Pelvic Floor Damage
 Pregnancy and childbirth
 1 delivery 2 x risk of POP
 50% of incontinence
 75% of prolapse
 Stretching, compression, tearing of nerve, muscle, tissue
 Episiotomy
 Pudendal nerve damage
 Weak evidence to support elective c-section
 Can occur in nulliparous women
 Diabetes
 Back Surgery
 Neurologic disease
 Menopause

Urinary Incontinence - Types

Pelvic Organ Prolapse (POP)
 Vaginal support tissue
 Weakening
 Results in protrusions
 “Bump” or “Falling out”
 Pelvic pressure
 Uterine
 Cystocele (bladder)
 Rectocele (rectum)
 Enterocele (bowel)
 Vaginal or paravaginal defect
 Coexist in 15 to 80 % of women
 80% with severe POP have SUI due to urethral obstruction
 Corrective surgery for POP can result in SUI
ACOG Practice Bulletin – Pelvic Organ Prolapse, No 85, September 2007 (Reaffirmed 2011)

Incontinence and POP - Treatment
 Incontinence products
 Lifestyle Modification
 Kegel Exercises
 Pelvic Floor Rehab and Physical
Therapy
 Biofeedback
 Ultrasound
 Electrical stimulation
 Acupuncture
 Pessary
 Medications
 No oral ERT/HRT
 Anticholinergics – Detrol LA,
Enablex, Vesicare
 New FDA approvals for OAB
 Oxytrol OTC
 Botox
 Periurethral injections
 ISD – intrinsic sphincter (urethral)
deficiency
 Surgical
 Older procedures
 MMK, Pyrera, KKP, Raz
 Burch Retropubic Urethropexy
 Fascial sling
 Mid-urethral Sling
 TVT – tension free vaginal tape
 TOT – trans obturator tape
 Mesh – erosion, FDA safety
concerns
 FDA Safety Statement, July 2011 -
http://www.fda.gov/MedicalDevices/
Safety/AlertsandNotices/ucm262435.
htm

Osteoporosis

Osteoporosis
 Bones become thin and brittle due to more bone loss than bone formation
 WHO – disorder characterized by
 Deterioration of bone microarchitecture
 Skeletal fragility
 Increased risk of fracture
 Osteopenia – low bone mass, not yet osteoporosis
 Affects 200 million worldwide
 55% of the population over 50 have a fracture and risk increases 3% for each year of advancing age
 Peak bone mass by age of 30
 Greatest risk for postmenopausal women
 2-5% bone loss per year
 Underdiagnosed and undertreated
 Two types of bone
 Cortical – hard outer shell, 75%
 Trabecular – inner spongy structure, 25%, first to lose and first to respond to therapy
 Fractures can cause chronic pain, deformity, disability, depression, inability to walk, deconditioning,
debilitation, long-term care, and death
 FRAX
ACOG Practice Bulletin – Osteoporosis, No 129, September 2012

Osteoporotic Brittle Bones

Osteoporosis – Risk Factors
 History of prior fracture
 Family history of osteoporosis
 Caucasian race
 Poor nutrition
 Smoking
 Low BMI
 Estrogen deficiency
 Long-term low calcium intake
 Alcoholism
 History of falls or fall hazards
 Sedentary lifestyle
 Certain diseases – eating disorders, IBS, Cushing’s, AIDS, Diabetes
 Certain medication use – anticonvulsants, steroids, heparin, thyroxine, lithium,
tamoxifen

Osteoporosis - Fractures

Osteoporosis - Treatment
 Lifestyle modification
 Decreasing fall risks
 Hip protectors
 Medication
 Calcium – 1200-1500 mg/day
 Vit D – 800 IU/day
 Combo therapy 12% reduction fractures
 HRT –
 24-34% reduction fractures
 Biphosphonates –
 30-50% reduction fractures
 Selective Estrogen Receptor Modulators
 35-50% decrease in vertebral fractures
 Calcitonin
 Parathyroid Hormone
 Other
 Fluoride, Testosterone, Soy
 Prolia
 Treatment based T<= -2.5 on FRAX risk
 3% hip fracture or 20% major fracture

Cancers - Breast
 Breast
 Family history – 1st degree (parent, sibling, child)
 Lifetime risk 1 in 8
 20-30% BRCA 1 & 2
 70% no family h/o or known genetic risk
 Breast cancer mortality decreasing since 1990
 Earlier detection – 50-70% self-detected
 Improved treatment
 Gail Model – risk assessment tool; cancer.gov/bcrisktool
 Detection
 Self-breast exam vs awareness
 Clinical breast exam
 Mammography
 Ultrasound - dense breasts ?
 MRI – greater than 20% lifetime risk
 Thermography – Not Recommended, Not FDA approved
ACOG Practice Bulletin – Breast Cancer Screening, No 122, August 2011

Breast Cancer Screening Guidelines
Organization Mammo Clinical Exam SBE SBA
ACOG
American College of
Ob/Gyn
Age 40+
annually
Age 20-39: 1-3
yrs; age40+:
annually
Consider for
high-risk patients
Recommended
ACS
American Cancer Society
Age 40+
annually
Age 20-39: 1-3
yrs; age40+:
annually
Optional for
age 20+
Recommended
NCCN
National Comprehensive
Cancer Network
Age 40+
annually
Age 20-39: 1-3
yrs; age40+:
annually
Recommended Recommended
NCI
National Cancer Institute
Age 40+ 1-2yrs Recommended Not
Recommended
N/A
USPSTF
U.S. Preventative Services
Task Force
Age 50-74
biennially
Insufficient
Evidence
Not
Recommended
N/A

Breast Cancer Risk Factors
Relative Risk Factor Factor
>4.0 Female
Age 65+
Genetic mutation
Personal h/o Breast CA
2+ 1st degree relatives
High breast tissue density
Biopsy – Atypical Hyperplasia
2.1-4.0 1 first degree relative
High-does radiation
High bone density (postmenopausal)
1.1-2.0 1st pregnancy > age 30
Onset of menses < age 12
Late menopause > age 55
No full-term pregnancies
No h/o breastfeeding
Recent use of oral contraceptives
Recent & long-term use of HRT
Obesity (postmenopausal)
Other H/O uterine or ovarian CA
Alcohol
Tall height
High socioeconomic status
Ashkenazi Jewish heritage

Cancers - Colorectal
 Facts
 Diagnosed in more women than all gyn cancers combined
 70,000 women in the U.S. yearly
 24,000 women die yearly
 3rd leading cause of CA death in women
 Screening
 Colonoscopy every 10 years starting age 50
 Earlier or more frequent with family history
 With polypectomy reduces incidence by 76-90%
 Miss rate polyp – 6-12% and CA – 5%
 Fecal occult blood or fecal immunochemical testing annually starting age 50
 Flexible sigmoidoscopy
 Double contrast barium enema
 Virtual Colonoscopy
ACOG Committee Opinion – Colonoscopy and Colorectal Cancer Screening, No 482, March 2011

Colorectal Cancer Screening
Test Interval Key Issues
Colonoscopy Every 10 years Complete bowel prep
Conscious sedation
Need transportation
Risks – perforation, bleeding, and death
Flexible
Sigmoidoscopy
Every 5 years Complete or partial bowel prep
No sedation, some discomfort
Limited view of colon
If positive colonoscopy
Double Contrast
Barium Enema
Every 5 years Complete bowel prep
If positive colonoscopy
Risks – very low
Expertise to interpret

Gyn Cancer - Endometrial
 Uterine
 In U.S. – 40,000 cases, 7,310 deaths annually
 Most common gyn CA – 8th most common CA death
 Precursor – endometrial hyperplasia
 Risk Factors
 Obesity
 Early menses
 Late menopause
 Nulliparity
 Infertility
 White race
 Tamoxifen use
 ERT
 Diabetes
 Symptoms – abnormal uterine bleeding (AUB)
 Diagnosis – Endometrial biopsy or Dilation & Curettage (D&C)
 Treatment – surgery, radiation, progestin (hyperplasia)
ACOG & SGO Practice Bulletin – Managing Endometrial Cancer, No 65, August 2005

Gyn Cancer - Ovarian
 Ovarian/Fallopian Tube
 In U.S. – 22,430 cases, 15,280 deaths annually
 Lifetime risk 1 in 70
 2nd most common gyn CA
 20% diagnosed Stage 1 with 90% 5 year survival rates
 70% diagnosed advanced stage with 5 year survival rates 30-55%
 Risk factors
 Older age
 Post-menopausal
 Family h/o breast or ovarian cancer
 BRCA 1 (60x) & BRCA 2 (30x)
 Nonpolyposis colorectal CA or Lynch II (13x)
 Nulliparity (never pregnant)
 Infertility
 Endometriosis
 Prophylaxis
 Oopherectomy
 Combined oral contraceptives (OCPs)
 Evaluation/Diagnosis – pelvic exam, ultrasound, doppler, CT scan, CA-125, OVA-1, surgery
 Treatment – surgery, chemo
 No routine screening USPSTF 9/2012 & 1/2013
ACOG & SGO Committee Opinion - Role of Ob/Gyn in Early Detection of Ov CA No 477, March 2011

Gyn Cancer - Cervical
 Cervical
 In U.S – 12,900 cases, 4,400 deaths annually
 Decreased due to effective screening – 16% of gyn CA
 Precursor – cervical dysplasia
 Risk Factors
 HPV
 Early onset of sexually activity
 History of STD/STI
 Multiple sexual partners
 Smoking
 Symptoms – watery vaginal discharge, post-coital and intermittent
spotting
 Diagnosis – pap/colposcopy
 Treatment – surgery, radiation, chemo
ACOG Practice Bulletin – Cervical Cancer Screening, No 131, November 2012

Helpful Links
 General Women’s Health
 Acog.org
 Contraception
 Plannedparenthood.org
 Essure.com
 Nexplanon-USA.com
 Paraguard.com
 Mirena-us.com
 Skyla-us.com
 Infertility
 Resolve.org
 ASRM.org
 Sexually Transmitted Infections/Diseases
 cdc.gov/std
 Heavy Periods
 Novasure.com
 Pelvichealthsolutions.com
 Menopause
 Menopause.org
 Knowmenopause.com
 nhlbi.nih.gov/whi/
 Incontinence
 AUGS.com
 Mypelvichealth.com
 NAFC.org
 Osteoporosis
 NOF.org
 WHO.int/en
 shef.ac.uk/FRAX/tool.jsp
 Heart Disease
 Goredforwomen.org
 Cancer
 Foundationforwomenscancer.org
 Cancer.org

Healthcare Social Media
 Facebook
 Facebook.com/drjerath
 Facebook.com/optimawhc
 Twitter
 Twitter.com/drjerath
 Twitter.com/optimawhc
 YouTube
 Youtube.com/doctorjerath
 Linked In
 Linkedin.com/in/drjerath
 Google +
 Gplus.to/drjerath
 Gplus.to/optimawhc
 Pinterest
 Pinterest.com/drjerath
 Pinterest.com/optimawhc
 Blog
 Drjerath.com
 Website
 Optimawomenshealthcare.com

Contact Information
Vandna Jerath, MD
Optima Women’s Healthcare
Sierra Medical Office Building
Parker Adventist Hospital Campus
9399 Crown Crest Blvd, Suite 450
Parker, CO 80138
303.805.1807 P | 303.595.5390 F
optimawomenshealthcare.com
drjerath.com
Email - staff@optimawomenshealthcare.com
Presentation - http://www.slideshare.net/vandnaJerathMD/

Women's Health After 40: comprehensive overview, honest discussion, latest updates & helpful tips

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