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132 Cards in this Set
- Front
- Back
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Stages of Adolescence
Early? Middle? Late? |
Early: age 11-14 elementary and middle school
Middle: age 15-17 high school Late: age 17-21 college or employed |
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HEADSS Is Very Good
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Home
Education Activities Drugs Sexuality Suicide Internet Violence Gangs |
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what are indications for a pelvic exam?
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pelvic pain/mass
severe dysmenorrhea amenorrhea pregnancy unexplained vaginal bleeding reported sexual activity assault trauma STI |
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FNP counseling for adolescents
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-info on normal sexual development
-abstinence -safe sex -S&S of STIs -contraception options -high risk situations (alcohol, drugs, sex) |
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Healthy People 2010 Leading Health Indicators
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-physical activity
-overweight -tobacco use -substance abuse -responsible sexual behavior -mental health -injury and violence -environmental health -immunizations -access to care |
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what is dysmenorrhea?
primary? secondary? |
Dysmenorrhea: pain with mensturation; cramping centered in lower abdomen
primary: menstrual pain without pathology secondary: menstrual pain with pathology |
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Dysmenorrhea affects ___% of menstruating women.
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50%
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when does pain begin and end with primary and secondary dysmenorrhea?
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Primary: begins a few hours prior to or just after the onset of menses and lasts 48-72 hrs
Secondary: begins 1-2 weeks prior to menses and persists until after menses stops |
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what are symptoms of Primary dysmenorrhea?
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-pain (usually colicky)
-suprapubic cramping (labor like) -mild suprapubic tenderness -N/V/D -headache -syncopal episodes (rare) -normal VS and Normal pelvix exam -systemic symptoms from prostaglandin to release -mild uterine tenderness on exam during menses |
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How do you confirm diagnosis of primary dysmenorrhea?
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Rule out pathology!
-normal pelvic exam and normal VS -not pregnant -no acute/chronic abdominal pain -no chronic pelvic disorders (non-cyclic, adhesions, salpingo-oophoritis, cancer) -no GI, GU, neuro problems |
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Treatment for primary dysmenorrhea?
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Prostaglandin inhibitors
-ponstel (mefennamic acid) 500mg stat, 250mg q6 -ibuprofen 400mg q4-6, start 4 days prior to menses -Naproxen sodium 550mg stat, 275mg q 8 (take prior to or onset of pain)- 80% effective -NSAIDs for 4-6 mo. Change after 2-4 cycles if no relief. -OCPs- 90% have some relief -if nothing helps, refer! |
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Patient education for pts with primary dysmenorrhea.
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-medication compliance
-exercise- esp when pain is worst -heading pads/warm baths -relaxation -good diet -follow-up |
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What is secondary dysmenorrhea?
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menstrual pain with pathology
-imperforate hymen -transverse vaginal septum -cervical stenosis -uterine anomalies -endometrial polyps -adenomyosis -uterine leiomyomas (fibroids) -endometriosis -IUD -chronic ectopic, chronic functional cyst -GI, GU, Neuro, GYN- adhesions, infection |
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what is endometriosis?
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presence of endometrial tissue outside of uterus
-often includes glands and stroma -most frequent sites are pelvic viscera and peritoneum -extra pelvic sites are intestines (colon and rectum), ureteral, lungs, umbilicus |
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what is the etiology of endometriosis?
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-estrogen
-ectopic transplantation of endometrial tissue (retrograde menses) -immune system factors -genetic (7x greater risk if mother/sister effected; 75% incidence in homozygotic twins) |
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associated symptoms of endometriosis
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dysmenorrhea
pelvic pain infertility dyspareunia abdominal back pain GI and Gu problems |
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how do you diagnose endometriosis?
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laparoscopy
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Management of endometriosis
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-surgery (laser ablation, hysterectomy with oophrectomy)
-continuous OCPs -depo provera for pain management -GNRh agonists (lupron) -danazol |
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STD history
5 P's |
partners
prevention of pregnancy protection from STDs sexual practices past history of STDs |
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Cardinal rule: a woman of reproductive age with a complaint of abdominal/pelvic pain has an ____ _____ until proven otherwise
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ectopic pregnancy
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STD workup
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DNA probe
cultures rpr hiv hbsag wet mount |
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clinical manifestations of chlamydia
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-cervicitis
-pharyngitis -bartholinitis -proctitis -endometritis -urethritis |
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serious sequelae of chlamydia
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PID
ectopic pregnancy infertility |
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risk factors of chlamydia
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young age (15 – 21 highest prevalence)
multiple sex partners non-white race low Socioeconomic status cervical eversion OCP’s New partner Unprotected sex |
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signs and symptoms of chlamydia
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-asymptomatic
-abnormal vag discharge -postcoital or intermenstrual spotting/bleeding -dysuria, frequency -dyspareunia -pelvic/abdominal pain -usually normal, elevated temp -abdomen usually normal, RUQ pain -cervix may be friable w/ mucopurulent discharge -fundus may be tender if endometritis present -adnexae may be tender; mass may be present |
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diagnosis of chlamydia
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DNA probe gold standard
NAATs- nucleic acid amplified test |
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treatment of chlamydia
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azithromycin 1gm po x1 dose or
doxycycline 100mg po bid x7d alternatives: erythromycin, ofloxacin, or levofloxacin x7 days |
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Test of cure of chlamydia is not indicated except for ____.
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pregnancy, test of cure in 3-4 weeks after completing therapy
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how do you manage partners of a patient with chlamydia?
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-partners must be evaluated, tested, and treated
-all partners with sexual contact 60 days prior to onset of symptoms -most recent partner should be evaluated even if >60 days |
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what is the recommended treatment of chlamydia in pregnant patients?
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azithromycin 1gm po x1 dose or
amoxicillin 500mg po tid x 7d alternates: erythromycin |
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sites of gonorrhea infection
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-endocervix-primary site for women
-urethra-primary site for men; usual site in women with hysterectomy -skene's and bartholin's -rectum -pharynx |
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gonorrhea sequelae
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PID-15 to 20%
infertility ectopic pregnancy disseminated gonococcal infection |
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symptoms of gonorrhea
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-asymptomatic- women may not have symptoms until PID
-vulvar pruritus, irritation, labial edema -abnormal vag discharge -abnormal vag bleeding -dysuria, urgency/frequency, dyspareunia, dysmenorrhea -males have drippy discharge- purulent creamy -painful to urinate |
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signs of gonorrhea
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-temp may be elevated
-pharyngeal injection, cerivcal node -volar aspects of arms, hands, fingers -joint tenderness, swelling, erythema, effusion -abdomen wnl; tender if PID -external genitalia-erythema, edema, excoriation -vagina abnl discharge, blood, pus -cervix-purulent, mucopurulent discharge; friable -uterus tender if PID -adnexa- tender, mass if PID |
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how do you diagnose gonorrhea?
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nucleic acid amplifed tests- dna
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treatment of uncomplicated gonorrhea of cervix, urethra, rectum
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cephalosporins only!
ceftriaxone 125mg IM x1 dose or Cefixime 400mg PO x1 dose PLUS txt for chlamydia if not ruled out altenatives: spentinomycin 2gm IM x1 dose (only UK) or cephalosporin single dose |
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how do you manage sexual partners of your pt with gonorrhea?
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treat sex partners with sexual contact 60 days prior to onset of symptoms (treat both chlamydia and gonorrhea)
-most recent sexual partner should be treated even if sexual contact is >60 days |
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how do you treat gonorrhea in pregnant women?
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NO quinolones or tetracyclines!
use recommended or alt. ceftriaxone 125mg IM x1 dose or Cefixime 400mg PO x1 dose PLUS txt for chlamydia if not ruled out |
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what are STDs characterized by lesions?
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ULCERS
-genital herpes (most prevalent) -syphilis -chancroid all 3 are associated with increased risk for HIV Warts -HPV (condyloma) |
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diagnosis of STD lesions
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diagnosis based only on HPI, PMH, and PE is often inaccurate
serology testing should be done on all pts with lesions |
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what are specific tests for evaluation of genital ulcers?
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-darkfield examination or direct immunofluorescence test for treponema pallidum
-culture or antigen test for HSV -culture for haemophilus ducreyi (where chancroid is prevalent) |
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1st episode of HSV
incubation period? timeline of healing of lesions? viral shedding? |
incubation 2-10 days
healing of lesions after 1-2 wks completely healed 2-4 wks viral shedding 11-14 days severe systemic symptoms |
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Ulcer stages of genital herpes
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-vesicles or pustules
-crusting -healing -adjacent pustules often coalesce to form areas of ulceration -deep necrotic ulcers |
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symptoms of genital herpes
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-multiple genital lesions
-itching, burning, tingling -dysuria, retention -inguinal adenopathy with tenderness |
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Signs of genital herpes
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-fever, extragenital lesion
-pharnyx erythematous, white exudate, cervical lymph nodes enlarged -abdomen tender, enlarged inguinal lymph nodes -females: vaginal outlet tender, lesions in various stages, friable cervix -males: may have ulcers around glans, on shaft, pubic area, scrotum, or perianal |
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diagnosis of genital herpes
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clinical presentation
culture tzanck smear serology- glycoprotein g assays (may have false +) -cytology: pap giant, multinucleated cells; not diagnostic |
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Treatment of genital herpes
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-acyclovir 400mg PO TID x7-10 days
-or acyclovir 200mg PO 5x/d x7-10 days -or famciclovir 250mg PO TID x7-10 days -or valcyclovir 1gm PO BID x7-10 days treatment may be extended if healing is not complete |
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patient educations to pts with genital herpes
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-nature of disease, potential for recurrence, asymptomatic viral shedding
-abstain from sexual activity when lesions are present or prodromal symptoms present -encourage to inform partners -use condoms with all new sexual contacts -transmission can occur during asmptomatic periods- viral shedding -neonatal infection risk -antiviral therapy can shorten duration of episodes or ameliorate/prevent outbreaks |
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symptoms of recurrent episodes of HSV
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-prodrome 1-2 days
-painful, localized genital sore(s)- single or cluster -external dysuria -systemic symptoms absent -resolve in 7-10 days |
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treatment for recurrent HSV
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acyclovir 400mg TID x 5 days
or famciclovir or valcyclovir |
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daily suppressive regimens for HSV
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-Acyclovir 400 mg po bid, or
-Famciclovir 250 mg po bid, or -Valacyclovir 500 mg po qd, or (less effective inpatients with >10 episodes yr) -Valacyclovir 1000 mg po qd *if pt has 10 outbreaks/yr- start thinking about why this pt is immunocompromised |
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chancroid is often a cofactor for ____ transmission
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HIV
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20-40% of pts with chancroid have _____
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inguinal lymphadenitis-often unilateral
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diagnosis of chancroid
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-no commercial tests available
-painful genital ulcer and tender suppurative -negative darkfield exam or RPR, HSV testing of ulcer negative |
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symptoms of chancroid
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-multiple, painful, punched out ulcers with undetermined borders on vulva
-painful ulcer with marked surrounding erythema and edema |
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Treatment of chancroid
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-Azithromycin 1 gm po x1 dose or
-Ceftriaxone 250 mg IM in a single dose, or -Ciprofloxacin*500 mg po bid x 3 days, or -Erythromycin base 500 mg po tid x 7d *Ciprofloxacin is contraindicated for pregnant and lactating women and for persons aged < 18 yo |
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followup for chancroid
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-reexamine pt 3-7 days after treatment
-healing >2 weeks -fluctuant lymphadenopathy may required I&D -treat partner regardless of symptoms if contact within 10 days prior to symptoms |
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how is syphilis transmitted?
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Treponema palladium
-primary: sexually -nonsexual intimate contact -blood transmission |
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what are the stages of syphilis?
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primary
secondary early latent<1 yr late latent >1 yr late/tertiary 1-20 yr after infection, usually CNS involvement |
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risk factors for syphilis
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-heterosexual
-young age 15-24 -black race -low socio-economic status -drugs, sex, multiple partners -increasing incidence in homosexuals -unprotected sex |
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signs of primary syphilis
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genital lesion 10-90 days, usually 3 wks
-lesion indurated, painless -inguinal or cervical lymphadenopathy 7-10 days after chancre, nontender, bilateral with genital chancre -no systemic symptoms |
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secondary syphilis
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-onset 3-6wks to 6 mo after primary
-may overlap with primary -may be asymptomatic -flu-like symptoms in 50% -maculopapular rash 80%- trunk, extremities, palms, soles, pruritic -condyloma lata- large, raise, broad papules, resemble warts, vulva perineum anus -split papule- eroded, fissured papules-nasolabila folds, angles of mouth, behind ears -mucosal lesions -alopecia- patchy on scalp, eyebrows, lashes -lymphadenopathy- rubbery, nontender, mod enlarged -systemic symptoms, CNS involvement |
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Latent syphilis
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late benign syphilis
-cardiovascular syphilis -CAD |
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Late syphilis
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-neurosyphilis
occurs 2-35 yrs after infection -rare -reactive VDRL from CSF -3 types -meningiovascular 2-10 yrs -tabes dorsalis 5-30 yrs -general paresis 15-30 yrs |
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Diagnosis of syphilis
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-Presumptive Diagnosis: VDRL or RPR, Fluorescent Treponema Antibody-Absorbed (FTA-ABS), Microhemaglutination-T. pallidum (MHA-TP)
-Definitive Diagnosis: Early syphilis - Darkfield exam; direct fluorescent antibody test -Rule out HIV and other STD’s |
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What are causes of a false positive RPR or VDRL?
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-mononucleosis
-leprosy, malaria -lupus, other autoimmune diseases -viral pneumonia, viral infections -immunizations |
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What is the treatment for primary and secondary Syphilis?
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-Benzathine pencillin G
allergy to PCN? doxycyline 100mg PO BID x2 weeks or tetracycline 500mg PO QID x 2weeks |
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what are complications of syphilis in pregnancy?
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fetal hepatomegaly, stillborn
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what is the follow-up plan for pts with syphilis?
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in pregnancy, monthly quantitative titers
for all others, quantitative nontreponemal tests at 6 and 12 months, titers should drop 4 fold within 6 months If HIV+, follow-up is every 3 months |
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How do you manage partners of pts with syphilis?
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-If exposed within 90 days before diagnosis of primary, secondary, or early latent--> treat presumptively even if seronegative
-If exposed >90 days before diagnosis of primary, secondary, or early latent--> treat presumptively if serology not available or poor f/u -long term partners of patients who have late syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of findings. |
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Granuloma Inguinale
Donovanosis |
-Organism: Klebsiella granulomatis (formerly: Calymmatobacterium granulomatis) -
-Intracellular Gram-negative bacterium. -Incubation: 1-4 weeks (up to 6 months) -Rare in the USA: Approx 100 cases per year -Endemic in tropical and sub-tropical areas, central and northern Australia, southern India, Viet-Nam, Guyana, & New Guinea |
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how does a patient with Donovanosis present?
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-Painless, progressive, ulcerative lesion
-Lesions are highly vascular -Beefy red appearance> bleed easily on contact |
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how do you diagnose donovanosis?
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Darkfield examination for donovan bodies (intracytoplasmic rod shaped organisms)
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what is the treatment for donovanosis?
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Doxycycline 100mg BID x 3 weeks
alternatives: azithromycin, ciproflocacin, erythromycin, or Trimethoprim-sulfamethoxaloe |
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how do you manage partners of pts with donovanosis?
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Treat partners within 60 days before onset of patient symptoms
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Lymphogranuloma Venerium
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-ORGANISM: Chlamydia trachomatis serovars L1, L2, or L3
-INCUBATION: 3 – 30 days for a primary lesion -Rare in the USA: prevalent in tropical and semi-tropical climates. -Endemic in parts of Asia and Africa. -Recent increased incidence in Men Who Have Sex With Men (MSM) |
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How does a patient with lymphogranuloma Venerium (LGV) present?
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-Unilateral tender inguinal and/ or femoral lymphadenopathy.
-Self limiting genital ulcer or papule at site of innoculation -Rectal exposure may result in proctocolitis |
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what is the treatment for LGV?
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-Doxycycline 100mg PO BID x21 days
-alternative: erythromycin for pregnancy |
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what is the management of partners of pts with LGV?
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treat all partners within 60 days before onset of symptoms..
also test for urethral or cervical chlamydia infection-- if infected, treat with azithromycin or doxycycline |
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Human Papillomavirus (HPV)
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-ORGANISM – Over 100 types idenitfied, more than 30 types of HPV can infect the genital tract
-Most common types causing genital lesions are 6 and 11 -High Risk Types: 16, 18, 31, 33, 35 associated with cervical dysplasia |
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how do you diagnose HPV?
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-Clinical appearance, response to treatment
-Biopsy - rarely needed -DNA typing (not routine), but becoming more common (standard of care for cervical dysplasia) |
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which HPV strains are most common, causes genital lesions, and are associated with genital squamous intraepithelial cancer?
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HPV type 6 and 11
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what is the patient applied treatment for Genital Warts?
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-Podofilox 0.5% solution or gel (BID x 3 days then 4 days off. May repeat up to 4 cycles)
OR -Imiquimod 5% cream (Once daily at bedtime for up to 16 weeks. Wash area with soap and water 6 – 10 hours after application) -The safety of Podofilox and Imiquimod has not been established in pregnancy. |
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with is the provider applied treatment for Genital Warts?
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-Cryotherapy
-Podophyllin resin -Surgical removal -Laser or Electrocautery (surgical plume may contain viral particles) |
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how do you educate pts who have genital warts?
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Use condoms- it will decrease risk of exposure but does not eliminate risk of transmission
Pt may remain infectious even though there are no visible warts. All women should have routine cervical screening. |
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Vaccine for HPV
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-Gardasil (protection against HPV type 6,11,16, 18)
-recommended for females age 9-26 -recommended prior to start of sexual activity -does not eliminate HPV infection once acquired |
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what are common causes of Vaginitis?
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-Vulvovaginal candidiasis
-Bacterial vaginosis -Trichomoniasis -Dual infections -Vaginal Atrophy |
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what are other less common infectious causes of vaginitis?
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-Streptococcoal infections
-Cytolytic vaginosis/vaginal lactobacillosis -Recurrent herpes simplex -Genital warts -Cervicitis |
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what are noninfectious causes of vaginitis?
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-Contact dermatitis
-Erosive lichen planus -Diabetic vulvodynia -Lichen sclerosis -Vulvar hyperplasia -Other dermatologic conditions -Carcinoma |
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Factors that influence physiolgic discharge?
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-AGE (prepubertal, reproductive, post-menopausal)
-HORMONES (the pill, cyclical hormonal changes, pregnany) -LOCAL FACTORS (menstruation, post partum, malignancy, semen, personal habits and hygiene) |
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what are questions to ask women who complain of vaginal discharge?
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DISCHARGE (onset, duration, amount, color, blood staining, consistency, odor, previous episodes)
ASSOC. SYMPTOMS (itching, soreness, dysuria, intermenstrual or post-coital bleeding, lower abdominal pain, pelvic pain, dyspareunia--superficial or deep) |
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what does the physical exam of a patient c/o vaginal discharge include?
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Complete pelvic exam
-determine source of discharge -check for foreign bodies -evaluation of discharge -wet mount prep Saline: clue cells, WBC, and Trich KOH: yeast Amine (whiff) test: BV, Trich |
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what is vulvovaginal candidiasis (VVC)?
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-A fungal infection
-caused by Candida albicans, but can be caused by other yeast forms -75% of all women report at least 1 episode of VVC, and 40-45% will have 2 or more occurrences -About 10% of women will have recurrent/complicated VVC |
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what are precipitating factors of VVC?
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-Immunocompromised
-Diabetics or high sugar intake -Recent antibiotic use -Douching -Diaphragm/cervical cap users -Spermicide users -Chronic conditions or poor diet -Pregnancy |
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how does a patient with VVC present clinically?
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-Pruritus and erythema in vulvovaginal area
-White discharge, may be “cheesy” or “curd like” in consistency |
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How do you diagnose VVC?
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-ph is <4.5 (normal)
-10% KOH prep will show peudohyphae, yeast spores -Can culture for a yeast species, if recurrent |
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what are Intra-vaginal treatments for VVC?
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-Miconazole
-Butaconazole -Clotrimazole -Terconazole |
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what is the oral treatment for VVC?
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Fluconazole (Diflucan) 150mg PO x1 dose
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what are other helpful treatments for VVC?
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-2% hydrocortisone cream for pruritus
-Acijel or "boric acid" suppositories |
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what is Bacterial Vaginosis?
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-Caused by replacement of normal vaginal flora with anaerobic micoorganisms
-Characterized by vaginal discharge, vulvar itching and irritation, and vaginal odor -Most frequent causes: Gardnerella vaginalis and Mycoplasma |
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How do you diagnose BV?
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Requires 3 out of 4:
-Homogenous, white, noninflammatory D/C coating the walls of the vagina -Vaginal pH of >4.5 -Fishy odor (+Whiff/Amine test) -Clue cells on microscopic exam other adjuncts -DNA probe for Gardnerella Vaginalis -Fem Exam card: detect high PH and trimethylamine |
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what is the treatment for BV?
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-Metronidazole (vag or PO)
-Clindamycin cream consider f/u eval in 1 month for high risk pregnancies |
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Thrichomoniasis
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-Results from infection with Trichomonas vaginalis, a flagellated protozoan
-Incubation 5-10 days, range 1-28 days -3-5 million women infected annually -Comprises 15% of STI clinic visits -Non-sexual transmission rare, but possible |
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Symptoms of Trichomoniasis
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-Malodorous yellow vaginal D/C
-Vaginal soreness -Vulvar itching -Dyspareunia, dysuria -10% may have abdominal symptoms -Asymptomatic infection is not uncommon |
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Clinical signs of Trichomoniasis?
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-Copious, thin, homgenous pools of yellow or green D/C
-D/C may be frothy, since this is an anaerobe -May be confused with candidiasis or mucopurulent cervicitis -Wiping the cervix clean to see if D/C is oozing from the cervix may be helpful -strawberry cervix -abdominal and bimanual exams show mild lower quadrant discomfort |
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Diagnosis of Trichomoniasis
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-pH>4.5
-Positive amine test -Wet prep demonstrates protozoa in only 60% of women -Pear-shaped with undulating flagella -Increased WBCs -recommend cultures if: high risk, negative wet prep but very suspicious, or persistent infection despite treatment -ELISA sensitive but expensive |
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what is the treatment for Trichomoniasis?
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Metronidazole 2gm PO x1 dose
treat partner! |
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what are complications of Trichomoniasis in pregnancy?
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-premature rupture of membranes
-preterm delivery -low birth weight |
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what are some causes of recurrent and peristent vaginitis?
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-partner not treated- reinfection/reappearance of trich
-STD of the cervix (GC, chlamydia, syphilis) -atrophic vaginitis -irritant or allergic contact dermatitis |
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Cardinal rule about abdominal pain
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Any woman of reproductive age who presents with abominal pain has an ectopic pregnancy until proven otherwise
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what are the statistics of PID?
how many outpatients visits annually? how many hospitalizations annually? |
-Accounts for approximately 2.5 million outpatient visits annually
-Accounts for approximately 200,000 hospitalizations per year. |
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Clinical signs of PID
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-lower abdominal pain (can be subtle)
-abnormal uterine bleeding (1/3 of pts) -associated signs: new vaginal discharge, urethritis, proctitis, fever, and chills |
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Risk factors for PID
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-Age less than 35 years
-Non barrier contraception -New, multiple, or symptomatic partners -Previous episode of PID -Oral contraceptives -African – American ethnicity (higher reported incidence) |
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Physical examinations findings of a pt with PID
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-Purulent endocervical discharge and / or acute cervical motion tenderness and adnexal tenderness by bimanual examination is highly suggestive of PID
-Rectovaginal examination should reveal the uterine adnexal tenderness |
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what is the CDC minimum criteria for empirical treatment for PID?
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-lower abdominal tenderness
-adnexal tenderness -cervical motion tenderness minor determinants: fever>101, vag d/c, documented STD, elevated ESR, C reactive protein, systemic symptoms, dyspareunia |
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what is the laboratory tests for PID workup
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-Pregnancy test !!!!!
-Microscopic exam of vaginal discharge (wet mount) -Complete Blood Count (CBC) -Test for Gonorrhea and Chlamydia -Urinalysis -Fecal Occult Blood- r/o diagnoses that cause abd pain -C-reactive protein (optional) |
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Ultrasounds should be reserved for which pts?
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for the acutely ill patient with PID in whom you suspect a pelvic abscess
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what are differential diagnoses for PID?
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-Ectopic Pregnancy
-Appendicitis -Hemorrhagic ovarian cyst -Ovarian torsion -Endometriosis -Urinary tract infection -Irritable Bowel Syndrome -Gastroenteritis -Cholecystitis -Nephrolithiasis -Somatization (abuse) |
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Treatment for PID (outpatient)
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-Ceftriaxone 250 mg IM in a single dose PLUS
-Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT -Metronidazole 500 mg orally twice a day for 14 days |
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what other serology testing should be done for women with PID?
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-HIV
-Hep B and C -Syphilis |
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Define rate
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number of events per number of individuals per timer interval
example: 44 events in 10,000 people per year |
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Define Relative Risk (ratio)
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-rate of disease in exposed group divided by rate of disease in unexposed group
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Define Absolute risk
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-difference between incidence rates in exposed and unexposed groups (risk difference)
-more clinically useful -addresses number of new cases |
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what are the 1998 CIOMS risk levels for RARE and VERY RARE?
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RARE: < or = 10/10,000 per year
VERY RARE: < or = 1/10,000 per year |
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Results of HERS I
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-2763 postmenopausal women with CAD (average 67 years), were randomized to receive either 0.625 mg/day of CEE plus 2.5 mg/day of MPA or placebo.
-After 4.1 years of follow-up, there were no significant differences between groups in the primary outcome of CHD events, including nonfatal MI or CHD death. -But there was a significant difference in that the treatment group had more CHD events the 1st year, and fewer in the 3-5 year. |
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Results of HERS II
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-a continuation of HERS I to confirm trend to improvements in Cardiovascular profile in treatment group
-2.7 year unblinded, private physician prescribed -results of study: no continuing improvement |
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Results of WHI
CEE/MPA ? |
-study was stopped 2 years early due to excess risk
- high risk for VTE: hazard ratio 111%, 18 more cases |
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Results of WHI
CEE only findings? |
-12 more cases of stroke compared to placebo
-6 fewer cases of hip fractures -7 fewer cases of breast cancer -bottom line: CEE should not be used to prevent chronic disease overall and heart disease in particular |
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Results of WHI
Similarities and differences between CEE vs. CEE/MPA? |
Similarities: Increased stroke and decreased fractures
Differences: CEE did not increase breast cancer or decrease colorectal cancer. CEE/MPA did increase breast cancer and decrease colorectal cancer. |
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Secondary Analysis of WHI
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- study of effect of age and years since menopause
-CHD risk decreased in ET vs HT -younger group 50-59 had a decreased mortality -If <10 yrs since menopause, there was no difference in total mortality -If >20 yrs since menopause, HT increased risk for CHD -stroke risk increased across all categories |
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NAMS position statement 2010
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"The benefit-risk ratio for menopausal hormone therapy (HT) is favorable for women beginning HT close to menopause but decreases in older women and with time since menopause in previously untreated women."
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alternatives for HRT
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-bioidentical hormones
-oral/IM progesterone -antidepressants -anticonvulsants -antihypertensives -soy & black cohosh |
