Hot Topics in Women’s Hot Topics in Women’s HealthHealthMACHA MACHA

October 4, 2013October 4, 2013

Deborah Mathis, MSN, Deborah Mathis, MSN, CRNPCRNP

University of University of PennsylvaniaPennsylvania

Objectives:Objectives:

1. Explain the current guidelines for 1. Explain the current guidelines for preventative well women carepreventative well women care

2. List the common drug interactions with 2. List the common drug interactions with hormonal contraceptives and risk/benefitshormonal contraceptives and risk/benefits

3. Describe the new contraceptive options3. Describe the new contraceptive options

Breast Health - CBEBreast Health - CBE

Out with the monthly breast examsOut with the monthly breast exams In with Breast Self Awareness In with Breast Self Awareness Clinical breast exam every 1-3 yrs in the 20 to Clinical breast exam every 1-3 yrs in the 20 to

39 age group (ACOG; ACS; National 39 age group (ACOG; ACS; National Comprehensive Cancer Network)Comprehensive Cancer Network)

Why?Why? Low prevalence in 20-39 age womenLow prevalence in 20-39 age women False positives False positives

ACOG August 2012 Number 534 ACOG August 2012 Number 534

Breast Health – Mammogram Breast Health – Mammogram RecommendationsRecommendations

American College of Obstetrics and American College of Obstetrics and Gynecology 2011 guidelines (ACOG)Gynecology 2011 guidelines (ACOG)

American Cancer Society (ACS) American Cancer Society (ACS) American College of Radiology (ACR)American College of Radiology (ACR) Society of Breast Imaging (SBI) Society of Breast Imaging (SBI) AllAll recommend that women receive an recommend that women receive an

annual mammograms starting at age 40.annual mammograms starting at age 40.

Breast HealthBreast Health

USPSTF 2009 guidelines recommends USPSTF 2009 guidelines recommends AGAINSTAGAINST routine Mammogram routine Mammogram screening for women between ages 40 screening for women between ages 40 and 49and 49

Whose guidelines do you follow?Whose guidelines do you follow?

Are We following the Guidelines?Are We following the Guidelines?

2011 National Health Interview Survey 2011 National Health Interview Survey Between 2008-2011 mammogram rates Between 2008-2011 mammogram rates

increased from 51.9% to 53.6%increased from 51.9% to 53.6%In the 40-49 age group mammogram rates In the 40-49 age group mammogram rates

increased from 46.1% to 47.5%increased from 46.1% to 47.5%Why?Why? Providers disagree with USPSTFProviders disagree with USPSTF Patients disagree with recommendationsPatients disagree with recommendations 5 yr survival rage is 98% if the cancer is 5 yr survival rage is 98% if the cancer is

discovered in the earliest stage.discovered in the earliest stage.

ACOG RationaleACOG Rationale

Three factors came into PlayThree factors came into Play1. the incidence of breast cancer 1 in 6 1. the incidence of breast cancer 1 in 6

breast cancers occur in women 40-49 breast cancers occur in women 40-49 2. the sojourn time (time between when 2. the sojourn time (time between when

cancer is detected by mammogram and cancer is detected by mammogram and when it is big enough to become when it is big enough to become symptomatic) for breast cancer growth is symptomatic) for breast cancer growth is shortest in women 40-49 (2-2.4 yrs) shortest in women 40-49 (2-2.4 yrs)

3. Potential to reduce deaths3. Potential to reduce deaths

Cervical CancerCervical Cancer

2009 Data2009 Data 12,357 US women were diagnosed with 12,357 US women were diagnosed with

cervical cancercervical cancer 3,909 women died from cervical cancer3,909 women died from cervical cancer

US Cancer Statistics working group 1999-2009 Incidence and Mortality US Cancer Statistics working group 1999-2009 Incidence and Mortality Web-based report, Atlanta, GA Web-based report, Atlanta, GA

New Cervical Cancer New Cervical Cancer Screening GuidelinesScreening Guidelines

American Society of Colposcopy and American Society of Colposcopy and Cervical Pathology (ASCCP) (2012)Cervical Pathology (ASCCP) (2012)

ACOG (2009)ACOG (2009) ACSACS USPSTF (2012)USPSTF (2012) American Society for Clinical Pathology American Society for Clinical Pathology

(2012)(2012) Everyone Agrees!!!!Everyone Agrees!!!!

Pap Test Pap Test Recommendations Recommendations

Start screening at age 21 regardless of sexual Start screening at age 21 regardless of sexual history.history.

Pap tests every 3 yrs from age 21 to 30Pap tests every 3 yrs from age 21 to 30 Pap and HPV testing for Types16 & 18 at age Pap and HPV testing for Types16 & 18 at age

3030 Pap tests every 3-5 yrs over 30 Pap tests every 3-5 yrs over 30 > Age 65 based on sexual history> Age 65 based on sexual history All recommendations are for women with no All recommendations are for women with no

abnormal Pap history abnormal Pap history

Abnormal Pap Follow upAbnormal Pap Follow up

HPV Prevalence is high in ages 21 to 29 and 90% of HPV Prevalence is high in ages 21 to 29 and 90% of cases will resolve spontaneously within 1-2 yrs*cases will resolve spontaneously within 1-2 yrs*

UPENN We order:UPENN We order: 21 to 25 yrs Surepath GS Pap 21 to 25 yrs Surepath GS Pap 25-29 yrs Surepath GS Pap with reflex to High Risk HPV DNA 25-29 yrs Surepath GS Pap with reflex to High Risk HPV DNA >30 yrs Surepath GS Pap >30 yrs Surepath GS Pap AND AND HPV with reflex to 16-18HPV with reflex to 16-18

American Society for Colposcopy and Cervical Pathology American Society for Colposcopy and Cervical Pathology Algorithms for Pap follow upAlgorithms for Pap follow up

http://www.asccp.org/Portals/9/docs/Algorithmshttp://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf%207.30.13.pdf

**Plummer, Schiffman, et.al J. Infectious Diseases 2007;195 (11):1582-158Plummer, Schiffman, et.al J. Infectious Diseases 2007;195 (11):1582-158

Contraceptive Drug InteractionsContraceptive Drug InteractionsMedicationsMedications that that DECREASE DECREASE the the effectiveness of contraception. effectiveness of contraception. Anti Seizure medicationsAnti Seizure medications

Metabolism: both progestins and ethinyl estradiol are Metabolism: both progestins and ethinyl estradiol are metabolized by the CYP450 enzymes in the liver metabolized by the CYP450 enzymes in the liver

Drugs that can induce enzyme activity will Drugs that can induce enzyme activity will decreasedecrease hormone levels and hormone levels and effectivenesseffectiveness of contraception of contraception include:include:o Phenytion(DilantinPhenytion(Dilantino Carbamazepine (Tegritol)Carbamazepine (Tegritol)o Felbamate (Felbatol)Felbamate (Felbatol)o Primidone (Mysoline)Primidone (Mysoline)o BarbituatesBarbituateso Topiramate (Topamax)Topiramate (Topamax)o Oxcarbazepine (Trileptal)Oxcarbazepine (Trileptal)

Contraceptive Drug InteractionsContraceptive Drug Interactions Medications Medications thatthat DECREASE DECREASE the the effectiveness of contraception. effectiveness of contraception. AntibioticsAntibiotics

• Only need to worry about these Only need to worry about these antibiotics:antibiotics:o RifampinRifampino RifabutinRifabutino GriseofulvinGriseofulvin

MiscellaneousMiscellaneous::o St. John’s WortSt. John’s Wort

Contraceptive Drug InteractionsContraceptive Drug InteractionsContraceptives Contraceptives willwill DECREASE DECREASE the the effective of medicationseffective of medications

Lamotrigine (Lamictal) serum levels are Lamotrigine (Lamictal) serum levels are decreased by 25 to 70 %decreased by 25 to 70 %

Levels not decreased during placebo Levels not decreased during placebo period.period.

Consider continuous pill useConsider continuous pill use Phenobarbitol levels are reduced Phenobarbitol levels are reduced

Contraceptive Drug InteractionsContraceptive Drug InteractionsContraceptives Contraceptives willwill POTENIATE POTENIATE the the effective of some medicationseffective of some medications

Chlordiazepoxide (Librium)Chlordiazepoxide (Librium) Diazepam (Valium)Diazepam (Valium) TricyclicsTricyclics TheophyllineTheophylline

Drospirenone Drospirenone ControversyControversy

Risk of Blood ClotsRisk of Blood Clots First & Second generation progestin's First & Second generation progestin's

Norethindrone & Levonorgestrel Norethindrone & Levonorgestrel 3 in 10,0003 in 10,000

Third generation progestin'sThird generation progestin's Desogestrel & NorgestimateDesogestrel & Norgestimate 6 in 10,0006 in 10,000

Drospirenone 10 in 10,000Drospirenone 10 in 10,000

US Medical Eligibility Criteria for Contraceptive Use, 2010 (US MEC)

http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

Excellent reference for safe prescribingExcellent reference for safe prescribing

U.S. Selected Practice Recommendations for Contraceptive Use, 2013

http://www.cdc.gov/reproductivehealth/http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htmUnintendedPregnancy/USSPR.htm

U.S. Selected Practice Recommendations for Contraceptive Use, 2013

Appendix B: When to start specific Appendix B: When to start specific contraceptive methodscontraceptive methods

Appendix C: Appendix C: tests needed before initiating the various contraceptive methods

Appendix D:routine follow-up after initiating contraception

Appendix E: management of bleeding irregularities

Effectiveness of MethodEffectiveness of Method

““Women who used birth control pills, Women who used birth control pills, the patch or vaginal ring were 20 times the patch or vaginal ring were 20 times more likely to have an unintended more likely to have an unintended pregnancy than those who used longer pregnancy than those who used longer acting forms, such as IUD or implant”acting forms, such as IUD or implant”

Winner B, Reipert JR. Zhao Q. et al. Effectiveness of long-Winner B, Reipert JR. Zhao Q. et al. Effectiveness of long-acting reversible contraception/ New England Journal of acting reversible contraception/ New England Journal of Medicine 2012: 366(21):1,998-2,007Medicine 2012: 366(21):1,998-2,007

Typical Failure RatesTypical Failure RatesNo MethodNo Method 85%85%

SpermicidesSpermicides 29%29%

DiaphragmDiaphragm 16%16%

Condom (male)Condom (male) 15%15%

Combined pill in obese women*Combined pill in obese women* 13%13%

Combined pill and progestin-only pillCombined pill and progestin-only pill 8%8%

Contraceptive patch or vaginal ringContraceptive patch or vaginal ring 8%8%

Copper IUD or LNG-IUSCopper IUD or LNG-IUS <1%<1%

Hormonal implantHormonal implant <1%<1%

SterilizationSterilization <1%<1%

*Includes data on combined oral contraceptives only; does not include progestin-only pills*Includes data on combined oral contraceptives only; does not include progestin-only pills

Trussell J. In: Trussell J. In: Contraceptive Technology. Contraceptive Technology. 2007.2007.

Effectiveness of EC Effectiveness of EC MethodsMethods

If 1000 women have unprotected sex once If 1000 women have unprotected sex once during Week 2 or 3 of their cycleduring Week 2 or 3 of their cycle

# of # of PregnanciesPregnancies % Reduction% Reduction

No treatmentNo treatment 8080 --

Combined ECPsCombined ECPs 2020 75%75%

Progestin-only ECPsProgestin-only ECPs 1010 88%88%

IUD InsertionIUD Insertion 11 99%99%

Trussell J, Raymond EG. 2007.Trussell J, Raymond EG. 2007.

SkylaSkyla

FDA approved January 2013FDA approved January 2013

On the market February 2013On the market February 2013

Origami CondomOrigami Condom

References for References for Contraception Contraception

Association of Reproductive Health Association of Reproductive Health Professionals Professionals www.arph.org

Hatcher et.al Contraceptive TechnologyHatcher et.al Contraceptive Technology Richard Dickey: Managing Contraceptive Richard Dickey: Managing Contraceptive

Pill PatientsPill Patients Speroff & Darney: A clinical Guide for Speroff & Darney: A clinical Guide for

Contraception Contraception