Transcript Empower Yourself *Essential Health Information for Proactive Women

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Medical school - Nova Southeastern
University School of Osteopathic
Medicine in Fort Lauderdale, FL
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OB/GYN Residency – Mount Clemens
Regional Medical Center in Detroit, MI
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Employed at Premier OB/GYN, LLC
5323 4th Ave Circle East Bradenton, FL.
34208
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Married and mother of 2 young children
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No Disclosures
Mia Lin age 4 years and Nicholas Lin age 9 months
Nicholas Lin age 21 months and Mia Lin age 5
Method of cervical screening used to
detect potentially pre-cancerous and
cancerous processes in the cervix
 Involves collecting cells from the cervix
 Detecting abnormal cells early with a
pap smear is the first step in halting the
possible development of cervical
cancer.
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The incidence of cervical cancer in the U.S. has
decreased more than 50% in the past 30 years
because of screening.
In 1975, rate was 14.8 per 100,000. By 2011, it
decreased to 6.7 per 100,00.
Cervical cancer is much more common worldwide,
mainly in countries without screening programs, with
an estimated 527,624 new cases of disease and
265,672 resultant deaths each year.
When cervical cancer screening programs have
been introduced into communities, marked
reductions in cervical cancer incidence have
followed.
MOST CASES OF CERVICAL CANCER
OCCUR IN WOMEN WHO WERE EITHER
NEVER SCREENED OR WERE SCREENED
INADEQUATELY
 50% OF THE WOMEN IN WHOM CERVICAL
CANCER IS DIAGNOSED NEVER HAD
SCREENING
 ANOTHER 10% HAD NOT BEEN SCREENED
WITHIN THE 5 YEARS BEFORE DIAGNOSIS
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Double stranded DNA tumor virus
 45 – 55 nm icosohedral capsid
 More than 100 types
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Mucocutaneous
Verruca plantaris 1,2,4
Verruca vulgaris 2,4,29,38
Verruca plana 3,10,28
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Anogenital
Condyloma 6,11
Dysplasia and cancer 16,18,31,33,35,45,51,56
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It is estimated that 80% of men and women
will be exposed to the virus by the age of 50
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Median duration of any HPV infection – 8
months
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70% cleared in 1 year
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90% cleared in 2 years
1995 study Bosch et al., 932 cases of
cervical cancer from around the world
 Using PCR reactions, his group amplified
HPV DNA from the tumor and found that
93% of cervical carcinoma had HPV DNA
 1999 Walboomers et al. repeated Bosch’s
experiment using new PCR primers. Those
cancers that failed to test positive for HPV
DNA were retested with these new primers
and results showed that 99.7% of Bosch’s
original cases tested positive for HPV DNA.
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Viral DNA E6 and E7
are the main force in
stimulating cellular
proliferation
E6 inhibits p53. p53 is
a crucial cell protein
involved in apoptosis
(cell death).
E7 binds the
retinoblastoma (Rb)
protein. Once
bound, Rb releases
E2F transcription
factor which causes
cellular proliferation.
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Cervical cancer screening should begin
at age 21 years.
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Women younger than 21 years should
not be screened regardless of sexual
initiation.
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Women aged 21-29 years should be
tested with cervical cytology alone, and
should be performed every 3 years.
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For women aged 30-65 years, cotesting
with cytology and HPV testing every 5
years is preferred
Women aged 65 years and older – no
screening is necessary after adequate
negative prior screening results
 Women with history of CIN 2, CIN 3 or AIS
should continue screening for at least 20
years
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No screening is necessary
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Applies to women without a cervix
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Applies to women without a history of CIN 2,
CIN 3, AIS, or cancer for the past 20 years
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IF HYSTERECTOMY WAS DONE BECAUSE OF
ABNORMAL PAP – STILL NEED SCREENING!!!
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Women who have HIV – first year
diagnosed should have pap every 6
months, then it should be done annually
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Women who are immuncocompromised
(transplant patient) – Annual pap test
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Women who were exposed to DES in
utero – Annual pap test
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Breast imaging
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Clinical breast examination
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Patient self-screening
Obtains routine images of asymptomatic
women to detect cancer at a preclinical
stage
 Consists of 2 views of each breast
(craniocaudal and mediolateral
oblique)
 Breast compression is a necessary part of
the examination
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The smallest breast mass that can be palpated is about 1 cm,
but most do not notice it until about 2 cm.
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89% of tumors measuring 1cm or less are cured by primary
surgery
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By mathematical estimation a typical ductal
adenocarcinoma with a constant mean doubling time of 100
days would have been present for more than 11 years before
it grew to a generally palpable size of 2 cm.
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Mammography screening can identify a nonpalpable mass
measuring 1mm to 1cm during its preclinical phase, 3 years
before it becomes palpable
Established adjunct to mammogram
 Useful in evaluation inconclusive
mammogram findings, in evaluating
young patients and women with dense
breast tissue, in guiding tissue coreneedle biopsy and other biopsy
techniques, and in differentiating a cyst
from a solid mass.
 NOT RECOMMENDED AS A SCREENING
MODALITY
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Useful adjunct to mammography
 Cost, duration of examination, and
injection of IV contrast prohibit its use as
routine screening technique
 MRI screening is recommended for
women with a 20% or greater lifetime risk
of developing breast cancer
 BREAST MRI IS NOT RECOMMENDED FOR
SCREENING WOMEN AT AVERAGE RISK
OF DEVELOPING BREAST CANCER
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Color Doppler ultrasonography,
computer-aided detection, positron
emission tomography,
scintimammography, and digital breast
tomosynthesis have shown promise in
selected clinical situations as adjuncts to
mammography. However, these
techniques are not considered
alternatives to mammography.
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Performed by a healthcare professional
who is trained to recognize many
different types of abnormalities and
warning signs.
Evolution away from teaching self-breast
examination toward the concept of
breast self-awareness
 Breast self-awareness – a woman’s
awareness of the normal appearance
and feel of her breasts
 Approximately 50% of all cases of breast
cancer in women >50 and 70% of cases
of cancer <50 are detected by women
themselves
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A consensus of recommendations on this
issue does not exist
 Medical comorbidity and life
expectancy should be considered in a
breast cancer screening program for
women aged 75 years or older
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BRCA 1/BRCA 2 mutation –
-TWICE YEARLY CLINICAL BREAST EXAM
-ANNUAL MAMMOGRAM starting at least 10 years prior
to the earliest age cancer diagnosed, and no later
than age 25
- ANNUAL BREAST MRI
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Women who are estimated to have a
lifetime risk of breast cancer of 20% or
greater (based on risk models such as the
Gail model, Claus model, Tyrer Cuzick
model) –
- TWICE YEARLY CLINICAL BREAST EXAM
-ANNUAL MAMMOGRAM starting at least 10 years prior
to the earliest age cancer diagnosed, and no later
than age 25
- ANNUAL BREAST MRI
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Women who have had prior thoracic
radiation therapy (typically as treatment
for lymphoma) –
- CLINICAL BREAST EXAMS EVERY 6-12 MONTHS
- ANNUAL MAMMOGRAM starting at age 25
- ANNUAL BREAST MRI starting at age 25
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Women with personal history of high-risk
breast biopsy results, including atypical
hyperplasia and lobular carcinoma in
situ –
- CLINICAL BREAST EXAMS EVERY 6-12 MONTHS
- ANNUAL MAMMOGRAM starting at age 25
- ANNUAL BREAST MRI has been recommended for
women with history of lobular carcinoma in situ by
some organizations
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ANNUAL MAMMOGRAM
X-rays used in mammograms cannot go through
silicone or saline implants well enough to show the
tissue under them. So women with breast implants
have 4 extra pictures done (2 on each breast).
These extra pictures are called implant
displacement views in which the implant is pushed
back against the chest wall and the breast is
pulled forward over it.
Very rarely mammograms can rupture an implant
Approximately
one in three
people who
develop CRC
die of this
disease.
Stool-based tests:
Fecal occult blood test
 Immunochemical-based fecal occult
blood test (FIT)
 Cologuard (fecal DNA testing)
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Endoscopic and radiologic exams:
Flexible sigmoidoscopy
 Colonoscopy
 CT colonography
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Multi-Society Task Force guidelines (joint
guidelines from the American Cancer
Society, the United States Multi-Society
task force on Colorectal Cancer, and
the American College of Radiology)
 United States Preventive Task Force
 American College of Gastroenterology
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Offer screening beginning at age 50
years
 No single test is of unequivocal
superiority : Colonoscopy every 10 years
or Computed Tomographic
Colonography every 5 years or Flexible
Sigmoidoscopy every 5 years or Fecal
occult blood testing annually or Fecal
immunochemical-based testing annually
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Three screening options for adults 50-75
years old
1. Annual fecal occult blood testing
2. Flexible Sigmoidoscopy every 5 years
3. Colonoscopy every 10 years
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Colonoscopy – has the benefit of high
detection rate and lesions can often be
removed during the same procedure
Recommends colonoscopy as the
preferred screening/prevention test
 Recommends colonoscopy starts at age
45 for African Americans and age 50 for
the rest of the population
 The fecal immunochemical test is the
preferred screening/detection test for
those patients who absolutely refuse
colonoscopy
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Both the incidence of and mortality rates
from colorectal cancer have been
declining in the United states.
 Approximately 250,000 to 500,000
colorectal cancer cases may have been
prevented from 1987 to 2010, along with
a shift from late to early stage disease.
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Osteoporosis is a skeletal disorder
characterized by loss of bone mass,
deterioration of microarchitecture, and
a decline in bone quality – all of which
lead to increased risk of FRACTURE
Bone is a dynamic tissue
 Remodeling and repair of bone is
accomplished through resorption and
formation processes controlled by
osteoclasts (resorption) and osteoblasts
(formation).
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Osteoclasts breaking down old bone and osteoblasts building new bone
In the young adult years, net gain or loss
of bone mineral content is minimal
 In midlife, this bone turnover process
shifts to greater resorption than
formation, resulting in a net loss of bone
mineral content
 THE TIME OF MOST RAPID BONE LOSS IN
WOMEN COINCIDES WITH THE MARKED
DECLINE IN ESTROGEN LEVELS
ASSOCIATED WITH MENOPAUSE.
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Z-score – reference population is same
sex, age, race
 T-score – reference population is normal
young adult
 Osteopenia – T score -1 to -2.5 (standard
deviation below the mean)
 Osteoporosis – T score < - 2.5
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Of women older
than 80 years who
have had a hip
fracture, only 56%
could walk
independently after
1 year.
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Spinal compression fractures can permanently alter
the strength and shape of the spine. Most
compression fractures occur in the front of the
vertebra, which causes the front part of the bone to
collapse creating a wedge-shaped vertebra. The
back of the bone is unchanged because it's made of
harder bone. This creates the stooped posture called
kyphosis, or dowager's hump.
About two-thirds of spinal compression fractures are
never diagnosed because many patients and
families think the back pain is merely a sign of aging
and arthritis.
But if osteoporosis isn't treated, it can lead to future
fractures -- and possibly more severe compression
fractures.
The most widely recommended method
of diagnosing osteoporosis in the U.S. is
bone densitometry.
 DXA of the lumbar spine and hip is the
preferred method
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DXA screening should begin at age 65
years for women
 DXA screening can be used selectively
for women younger than 65 years if they
are postmenopausal and have other risk
factors for fracture
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Medical history of a fragility fracture
 Body weight less than 127lb
 Medical causes of bone loss
(medications or diseases)
 Parental medical history of hip fracture
or osteoporosis
 Current smoker
 Alcoholism
 Rheumatic and autoimmune diseases
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Ankylosing spondylitis, Lupus, Rheumatoid arthritis, Adrenal insufficiency, Cushing’s
syndrome, Diabetes mellitus, Hyperparathyroidism, Thyrotoxicosis, Celiac disease,
Gastric Bypass, GI surgery, Inflammatory bowel disease, Malabsorption, Pancreatic
disease, Primary biliary cirrhoisis, low calcium intake, high caffeine intake, alcohol (3 or
more drinks/day), Smoking, Vitamin D insufficiency, High salt intake, Inadequate
physical activity, Falling, Excess Vitamin A, Aluminum in antacids, Immobilization,
Thinness, Anticoagulants, Anticonvulsants, Aromatase inhibitors, Barbituates, Cancer
Chemotherapeutic drugs, cyclosporine A and tacrolimus, Depo- medroxyprogesterone,
Glucocorticoids, Gonadotropin releasing hormone agonists, Lithium, Cystic fibroisis, EhlersDanlos, Gaucher’s disease, Glycogen storage disease, Hemochromatosis, Homocystinuria,
Hypophosphatasia, Idiopathic hypercalciuria, Marfan syndrome, Menkes steely hair
syndrome, Osteogenesis imperfecta, parenal history of hip fracture, Porphyria, Riley-Day
syndrome, Androgen insensivity, Anorexia nervosa and bulemia, atheletic amenorrhea,
hyperprolactinemia, panhypopituitarism, Premature ovarian failure, Turner’s syndrome and
Klinefelter’s syndrome, Alcoholism, Amyloidosis, Chronic metabolic acidosis, Congestive
heart failure, Depression, Emphysema, End stage renal disease, Epilepsy, idiopathic
scoliosis, Multiple sclerosis, Muscular Dystrophy, Parenteral nutrition, Post-transplant bone
disease, Prior fracture as an adult, Sarcoidosis, Hemophilia, Leukemia and lymphomas,
Multiple myeloma, Sickle cell disease, Systemic mastocytosis, Thalassemia
Unfortunately there is no standard or
routine screening test for uterine cancer
or ovarian cancer.
 These cancers are usually diagnosed
based on evaluation of symptoms –
which is just another reason it is so
important to have a yearly female
wellness exam.
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Chelmow MD, David. “Cervical Cancer Screening and
Prevention.” ACOG Practice Bulletin Number 157, January
2016
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Griffin MD, Jennifer, Gemignani MD, Mary, Pearlman MD,
Mark. “Breast Cancer Screening.” AGOG Practice Bulletin
Number 122, August 2011
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Gass, MD, Margery. “Osteoporosis.” ACOG Practice Bulletn
Number 129, September 2012
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Doubeni MD, Chyke. “Screening for colorectal cancer:
Strategies in patients at average risk.” Uptodate. April 8, 2016.
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FETAL HEART RATE TRACING IS ALWAYS,
ALWAYS, ALWAYS on boards!!!!
Caused by fetal head compression
 Generally seen in active labor
 No associated with fetal hypoxia,
acidosis or low Apgar scores
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Results from fetal hypoxia
 Non-reassuring when persistent
 BUZZWORD – uteroplacental insufficiency
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Caused by umbilical cord compression
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Persistent mild umbilical cord
compression – may cause mild
respiratory acidosis from CO2 retention
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Prolonged, repetitive umbilical cord
compression – progressive fetal hypoxia
and metabolic acidosis