Transcript Women Veteran`s Health

Women Veterans Health
LAURA LAWRENCE, MPAS, PA-C
Then and Now…
Women Veterans Health Care
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1988: Women Veterans Health Program
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4.4% women veterans  8%
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More cost-effective medical and psychosocial care
2007: Strategic Health Care Group
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Office of Public Health and Environmental Hazards
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Increased scope of activities to include all services, including supplies (DEXA
scans, mammography machines, u/s and biopsy equipment)
2011: Women’s Health
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Office of Patient Care Services (PCS)
2012: Women’s Health Services
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Increased collaboration between Women’s Health and programs including
Primary Care, Mental Health, Specialty Care
(cardiology, pain management)
Increase in VA Health Care Use by
Women Veterans of OEF/OIF/OND
8/13/2016

http://abc13.com/health/houston-va-expanding-programs-to-help-female-veterans/1491791/
Women Veterans Health Care
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Program Mission
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Comprehensive primary care by a proficient and interested PCP
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Privacy, safety, dignity, and sensitivity to gender-specific needs
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The right care in the right place and time
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State of the art health care equipment and technology
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High-quality preventive and clinical care, equal to that provided to
male Veterans
Women Veterans Health Care
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Strategic Priorities
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Comprehensive Primary Care
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Women’s Health Education
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Reproductive Health
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Communication and partnerships
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Women’s health research
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Special populations
Reproductive Health
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Implement safe prescribing measures for women Veterans of
childbearing age
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Improve follow-up of abnormal mammograms
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Track the timeliness of breast cancer treatment
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Ensure coordination of care for women receiving non-VA, maternity
and emergency department care.
BREAST DISORDERS
History
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Masses
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Skin changes
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Nipple discharge
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Nipple inversion
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Mastalgia
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Family history
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OBGYN history
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Medications
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Social history
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Previous imaging/biopsies
Physical Exam
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Inspection
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Skin appearance, skin thickening, size/symmetry, contour, nipple
characteristics
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Arm movement: Overhead, to the sides, on the hips, leaning forward
Palpation
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Supine and sitting
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Systematic
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Vertical Strip Pattern
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Breast and surrounding nodal basins
NCCPA BLUEPRINT TOPICS
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Fibroadenoma
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Fibrocystic Disease
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Gynecomastia
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Galactorrhea
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Mastitis
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Carcinoma
Fibroadenoma
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Most common etiology of breast “lump”
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Most common in young women
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Benign
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Discrete mass
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Mobile
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Non-tender to palpation
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Can change in size
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May have increased pain with menstruation or increased caffeine
intake
Fibroadenoma
 Diagnostic
Evaluation
 Mammogram
 Ultrasound
 Possible
biopsy
Fibroadenoma
 Treatment
 Monitor
every 6 months with ultrasound in addition to
annual mammogram (if over 40 y/o) x 2 years
 If
stable, no further treatment or monitoring needed
 If
increasing size, consider surgical excision
Fibrocystic Disease
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Benign
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Most common of all benign breast conditions
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Most common in women of reproductive age
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Occasionally seen with hormone replacement
Fibrocystic Disease
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Clinical Manifestations
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Mastalgia
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Engorgement
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Increased breast nodularity
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Cysts
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Dense/thick breast tissue
Diagnostics
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Mammogram
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Ultrasound
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Consider MRI if clinically indicated
Fibrocystic Disease
 Treatment
First
Line: NSAIDs
Second
Line: OCPs
Alternative:
Primrose oil
Galactorrhea
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Milky nipple discharge not associated with gestation
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Age: 15-50 y/o
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Causes: Pituitary gland overproduction, hypothalamic region
dysregulation, medications that suppress dopamine, hypothyroidism
Galactorrhea
 Diagnostic
Evaluation
 Labs:
Prolactin, TSH, pregnancy test, LFTs,
renal function, FSH, LH, GH, adrenal
function
 Imaging:
Pituitary MRI with gadolinium
enhancement if elevated serum prolactin
 Treatment
 Treat
underlying cause
Breast Cancer
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Second most common cause of cancer death in
women
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1:9 lifetime risk
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Risk factors:
 age
> 60, first degree family history, nulliparity, 1st
pregnancy after 30, menarche < 12, menopause > 50,
obesity, tobacco use, previous radiation, hormone
therapy
Imaging
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Screening mammogram
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Diagnostic mammogram
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Ultrasound
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MRI
Imaging: Mammogram
Imaging: BIRADS
Genetic Testing
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BRCA1, BRCA2, BART
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5-10% of breast cancer cases
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1% of population
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Indications: personal breast hx <45, dx any age with 1 close relative breast
<50 or ovarian at any age, two breast primaries with first <50, triple negative
<60, personal breast history <60 with limited family history, personal hx at any
age with > 2 close relatives with breast at any age/pancreatic/prostate,
close male relative, Ashkenazi Jewish, personal hx ovarian
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Breast and ovarian implications
P53
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Young women
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High risk for several cancers
Breast Cancer: Clinical
Manifestations
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Can be asymptomatic
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Breast or axillary mass
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Nipple discharge
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Nipple retraction or inversion
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Skin changes- peau d’orange
Types of Breast Cancer
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Ductal Carcinoma In Situ (DCIS)
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Invasive Ductal Carcinoma (IDC)*
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Invasive Lobular Carcinoma (ILC)
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Inflammatory Breast Cancer (IBC)*
Prognostic Factors
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Tumor Markers
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Estrogen
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Progesterone
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Her2/neu
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Ki67
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Grade
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Oncotype
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Genetic test
Breast Cancer Staging
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Tumor Node Metastasis (TNM)
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c = clinical
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p = pathologic
Breast Cancer Staging: T
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TX: Primary tumor cannot be assessed
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Tis: DCIS
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T0: No evidence of primary tumor
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T1: Tumor < 20 mm in greatest dimension
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T2: Tumor >20 mm but <50 mm in greatest dimension
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T3: Tumor >50 mm in greatest dimension
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T4: Tumor of any size with direct extension to the chest wall and/or to
the skin
Breast Cancer Staging: N
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NX: Regional lymph nodes cannot be assessed (ex. Previously removed)
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N0: No regional lymph node metastases
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N1: Metastases to moveable ipsilateral level I, II axillary node(s)
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N2: Metastases in ipsilateral level I, II axillary lymph nodes that are
clinically fixed or matted; or in clinically detected apparent ipsilateral
internal mammary nodes in absence of clinically evident axillary lymph
node metastases
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N3: Metastases in ipsilateral infraclavicular (level III) node(s) with or
without level I, II axillary node involvement; or in clinically detected
ipsilateral internal mammary nodes with clinically evident level I, II
axillary lymph node metastases; or metastases in ipsilateral
supraclavicular node(s) with or without axillary or internal mammary
node involvement
Breast cancer staging: M
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Mx: Not assessed
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M0: No clinical or radiographic evidence of distant metastases
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M1: Distant detectable metastases as determined by classic clinical
and radiographic means and/or histologically proven larger than
0.2 mm
Breast Cancer Staging
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Most common sites of metastasis are lymph nodes, bone, liver, and
lung
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Indicated in patients with positive lymph nodes or >T3
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Bone Scan
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CT Abdomen/Pelvis
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Chest Xray
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+/- PET/CT
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+/- Brain MRI
Types of Treatment
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Surgical Oncology
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Segmental/Partial Mastectomy (Lumpectomy/Breast conservation
therapy)
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Total Mastectomy
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Modified Radical Mastectomy
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Sentinel Node Biopsy
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Axillary Node Dissection
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Radiation Oncology
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Medical Oncology
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Chemotherapy
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Endocrine therapy (Hormone therapy)
Radiation Therapy
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Whole breast radiation
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Daily for 4-6 weeks
Partial breast radiation (APBI)
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Daily for 5 days
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Targeted therapy
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Side effects: skin discoloration, fatigue, breast shrinkage, increased
risk of lymphedema
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Contraindications: collagen vascular disorders
Chemotherapy Indications
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Positive lymph nodes
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Her2/neu+
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Triple negative
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Large tumor size, shrink prior to surgery
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Oncotype
Chemotherapy
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Taxol
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Adriamycin/ (AC)
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Weekly x 12 cycles
Every 3 weeks x 4 cycles
Herceptin
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Every 3 weeks x 1 year
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Most Common Side Effects: Hair loss, fatigue, nausea, diarrhea,
neuropathy
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Possible contraindication: heart disease
Hormone Therapy
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Tamoxifen
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Premenopausal
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5-10 years
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Side effects: risk of DVT, RARE endometrial cancer, menopause
Arimidex
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Postmenopausal
Treatment Timeline
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Surgery
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Upfront
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1 month before or after chemo
Chemotherapy
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6 months
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1 month before or after surgery
Radiation
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Final treatment 5 days or 4-6 weeks
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1 month after surgery or chemo
Plastic Surgery
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Local tissue rearrangement
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Tissue expander
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Contraindications: DM, smoking, possibly heart disease
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Implant
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Autologous
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Nipple reconstruction
Gynecology
Gs and Ps
Leiomyoma
Fibroids
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Benign Smooth Muscle tumor - Often multiple
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NOT Sarcoma (don’t confuse leiomyosarcoma 1/1000)
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Most common benign tumors
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More common in African Americans
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Middle to late reproductive years
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Heavy menstruation/urinary frequency
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Often cited for reason for Hysterectomy
Treatment
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NSAIDs
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? Levonorgestrel IUD
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Refer to GYN for other hormonal rx
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Uterine artery embolization/ligation
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RFA
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Myomectomy
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Hysterectomy
Uterine Prolapse
Uterine prolapse
Aging
 Loss of support structures
 Obesity
 Traumatic /multiple vaginal births
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Painful/Loss of function
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Kegel exercises
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+/- Biofeedback/PT
HRT
 Pessaries
 Surgery
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Uterine Prolapse
Grading of prolapse
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1st degree: To the ischial spine
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2nd degree: To the introitus
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3rd degree: Just beyond the introitus
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4th degree: Complete uterine and vaginal inversion involving
bladder and bowel
Cystocele
Cysts
Ovarian Cysts
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Common
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Majority of women have at some point
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Can be severe
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Pelvic pain most common symptom
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Diagnose with pelvic ultrasound * Fluid filled
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Due to hormonal fluxes – treatments surround this
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Surgery can be performed - typically laproscopic
Types
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Follicular –
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Corpus Luteum cysts –
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heterogenous – hair, teeth, etc.
Cystadenomas
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after egg released Up to 4 in. usually last only a few weeks
Dermoid –
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failure to release egg 1-2 in. last 2-3 mo.
On outside of ovary – can be large and cloudy
PCOS
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Multiple cysts mature sacs but no release
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Hirsuitism
Other Cysts
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Plugging of gland
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PE diagnostic
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Can be painful or
Or painless
Watchful waiting
Compresses
Screen for STI
Drain
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Marsupialization vs.
balloon
Menopause
Vaginitis
Most common types
•
•
•
•
Bacterial vaginosis
Yeast infections
Trichomoniasis
Vaginal atrophy
Vulvovagintis
Vaginitis
Trichomoniasis
Vaginalis
Cause
pH (norm is 3.8-4.2)
Discharge
characteristics
KOH (whiff test)
T. vaginalisflagellated
protozoan
>4.5
Malodorous,
yellow-green,
copious, frothy
+/-
Bacterial
Vaginosis (BV)
Inbalance of
vaginal florareplaced by
Gardenerella
vaginalis
>4.5
Malodorous, thin,
gray or white,
sticky
+; “fishy odor”
Vaginal
Candidiasis
90% Candida
albicans
<4.5
White, “cottage
cheese”
Absent (odorless)
Other diagnostic
factors
Motile flagellelated Clue Cells
on wet prep
WBCs
Pseudohyphae
with buds
(spaghetti and
meatballs)
Other S/S
Vulvar irritation
Worse after sex,
pruritis
Pruritis, burning,
dysuria,
dyspareunia
Tx
Flagyl 2g po x 1
Flagyl 500 mg po
bid x 7d, clinda
Fluconazole (oral
or topical)
Comments
STD- 7.4 million/yr
Common in PG
Inc risk PID
PG, DM, steroids,
OCP, Abx, immuno
2010 WebMD
Contraceptive Methods
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http://www.womenshealth.va.gov/WOMENSHEALTH/outreachmater
ials/GeneralHealthandWellness/maternity.asp
Human
Papillomavirus
(HPV)
HPV

DNA virus AKA venereal or anogenital warts
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Most common STD in US – 20 million*
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“HPV is so common that most sexually active adults become infected at
some point in their lives” – CDC
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HPV occurs in 50-80% of sexually active women by the age of 50
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~100 recognized human papillomaviruses; 30+ can infect the genital
area
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Most patients (90%) will clear virus on their own but persistence of
ongocenic types can lead to cervical cancer

99% of cervical cancers contain at least 1 high-risk (oncogenic) type
of papillomavirus
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70% cervical cancers are HPV 16 and 18
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HPV types 6 & 11 (condyloma acuminata)
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
Most typical form

Rarely associated with invasive SCC
HPV types 16, 18, 31, 33, & 45 + 8 more
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Associated with SCC
HPV Treatment
1° goal – removal
 Chemical treatments
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Patient-applied:

Podofilox 0.5% gel/solution

Imiquimod 5% cream
Provider-applied:

Podophyllin resin 15-25% - standard treatment

Trichloroacetic acid (TCA)
Ablative treatment



Cryotherapy
Laser treatment
Excisional
HPV Complications
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Women
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Cervical dysplasia – 1,000,000 cases / yr
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Cervical Cancer – 12,357 cases / yr
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Vulvar, Vaginal and Anal Carcinoma
Men- “the carriers”
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Penile Cancer – 1,570 cases / yr
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Anal Cancer
Both men and women
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Condyloma acuminata
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Studies link HPV with some H&N cancers
HPV: Prevention

June 2006 – Gardasil approved by the FDA for HPV serotypes 6,
11, 16, & 18
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Recommended by the CDC in females 9-26 y/o
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Gardasil now recommended in males 9-26 y/o
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These 4 types of HPV cause 70% of Cervical Ca and 90% genital
warts
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Administered in 3 doses at 0, 2, & 6 months
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Only ¼ of adolescent girls in 2007 vaccinated
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New vaccination released Feb. 2015 – Gardasil 9