UPDATE IN WOMEN’S HEALTH 2009 September 11, 2009. Eileen C. West, MD Director, Internal Medicine Women’s Health Assoc. Professor of Internal Medicine, Obstetrics and Gynecology University of Oklahoma Health Sciences Center. OVERVIEW.
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UPDATE IN WOMEN’S HEALTH 2009September 11, 2009 Eileen C. West, MD Director, Internal Medicine Women’s Health Assoc. Professor of Internal Medicine, Obstetrics and Gynecology University of Oklahoma Health Sciences Center
OVERVIEW Review of literature from March, 2008 through February 2009 Journals, Cochrane, Medline search using medical subject heading “sex factors” Criteria Scientific rigor Potential to impact clinical practice
OVERVIEW • CV Risk Reduction • Menopause and Hormone Therapy • Osteoporosis • Breast Health • Cervical Cancer Screening Guidelines
CARDIOVASCULAR DISEASE IN WOMEN FOCUS ON RISK FACTOR REDUCTION
CV Risk Reduction • Yvonne is a 56 y/o woman worried about her potential risk of CVD. She requests a CRP level. Your response is: A. Sure B. Consider with lipids, glucose, TSH C. Other non-lab tests are more important
Background • Lowering LDL cholesterol with statins in women and men leads to less CHD & CVA –most effective in those high risk • Statins also lower high-sensitivity CRP levels • JUPITER Trial: In healthy women and men with LDL < 130 and hsCRP > 2 mg/L will treatment with rosuvastatin decrease CVD events?
JUPITERRosuvastatin Trial • Healthy women > 60 & men > 50 yrs • Entry: LDL < 130 and hsCRP > 2 mg/L • Participants were 38% female • Double-blind, placebo controlled multi-center trial in 26 countries • Primary Endpoint: Non-fatal MI or CVA, arterial revascularization, admission for unstable angina or confirmed CV death
JUPITER Results at 1.9 yrs: MI, CVA or CVD Death Primary Endpoint All Death
JUPITERPrimary Endpoints Subgroup Effects But more DM
From here to Jupiter • Research Question: How many NHANES ’99-’04 would qualify for statin therapy based on Jupiter? • Design: Reviewed NHANES data • Results: • Prior 58% statin indicated – use 24% • Additional 19% may become eligible • New pts female, older, obese, HTN, metabolic syndrome Spatz 2008
Impact for Practice • Treatment with statins benefit: High total cholesterol, LDL, low HDL, high-sensitivity CRP in addition to LDL • Under-treatment of lipids already occurs • DASH Diet also lowers hsCRP, weight & BP • OTHER KEY RF: - Weight - BMI - Abd girth - Blood pressure - Physical activity level - Glucose - Thyroid
Background • DM increases CVD risk in women • At time of DM diagnosis, lipids in women lower HDL than men • HTN treatment decreases CVD risk even more than glucose control • Hyperglycemia increases CVD risk
Framingham CVD Risk Impact of Weight in DM Over 30 yrs CVD Risk • Overall original cohort: CVD 39% women, 55% men • Overall offspring: CVD 27% women and 40% men. • CVD 54% in DM women with nl weight • CVD 70% in DM women overweight • CVD 79% in DM obese women Fox 2008
Framingham 30 yr CVD Risk % Fox 2008
Impact for Practice • DM increases CVD risk • Aggressive treatment of CV Risk Factors is indicated including statins, Renin-Angiotensin System drugs, and metformin • DM women who weigh less, have lower CVD rates
US Trends in Weight % Circ 2008: 118; 428
Obesity associated with higher mortality, morbidity and • DM • CHD • CHD Risk Factors: HTN, lipids, inflammatory markers, hypercoag • Stroke, DVT • Cancer: Breast, colon, endometrial, renal, esophageal • Pulm: Obstructive Sleep Apnea, hypoventilation, asthma Circ 2008: 118 (4): 428
Keeping the Weight Off • Iam Trying is completing a 6 month weight loss program where she has lost more than 15 lbs. What will help her maintain her lower weight the best? A. Self control B. Interactive computer system C. Monthly personal contact
Maintaining Weight Loss Phase 1 loss > 4 kg then: Circle = self-directed, Square = computer, Triangle = personal contact
BMI and abdominal girth correlate with complications RN Health Study abd fat assoc with all-cause mortality, CVD & cancer RF Modification in Obesity: Tobacco avoidance and increased activity Makes a difference Activity > 275 min/week associated with sustained weight loss at 2 yrs Obesity: Key Articles
Overwt and obesity increases MULTIPLE health risks Difficult to lose even 10% weight Even more difficult to sustain weight loss – more physical activity is key, focused brief counseling helps Obesity: Impact for Practice
Vasomotor Symptoms • Minnie Pause is a 53 year old woman who had her last menstrual period 18 months ago. She is still having hot flashes and awakens at least twice a night with them. She is considering taking estrogen but wants to know how much longer this will last. What do you tell her?
When will they go away? • Average duration is about 2 years and so they should be gone in about 6 months. • Average duration is about 4 years • They will never go away
Background • Treatment for menopausal symptoms is based on their transitory nature • Many clinical guidelines suggest that symptom duration is approximately 2 years • Many studies do not follow women more than 2 years • Risks and benefits of hormone therapy depend on duration of use • “Use lowest dose for shortest duration”
Clinical Questions • What is the natural progression of vasomotor symptoms during the menopause transition? • How long is it safe to use hormone therapy?
Duration of Vasomotor Symptoms • Politi MC et al. Revisiting the duration of vasomotor symptoms of menopause: a meta-analysis. JGIM 2008:23: 1507-13 • Objective: to estimate the natural progression of menopausal symptoms
Vasomotor Symptoms • Rigorous meta-analysis included 10 studies with over 35,000 participants • Clear definition of vasomotor symptoms • Assessed prevalence of symptoms and “bothersome symptoms”
Results • Percent of women with symptoms increased in the two years before the final menstrual period (FMP) , peaked one year after the FMP and did not return to premenopausal levels until 8 years after the FMP • 50% of women had symptoms during the 4 years after FMP • 10% of women had symptoms up to 12 years after FMP
Menopause: Impact for Practice • Menopausal symptoms last about 4 years • Risks and benefits of hormone therapy must be considered within the longer period of use
Key articles • New evidence based guidelines for the use of hormone therapy • Risk defined as “possibility or chance of harm” • Put level of risk in perspective • HT should not be used as an anti-depressant • No data to support any particular route of administration or dosing regimen • Use greater caution in women over 60 NAMS, Menopause, 2008
Key Articles • Menopausal complaints are associated with a less favorable cardiovascular risk profile • Gast, 2009 • Hormone therapy associated with an increased risk of GERD • Jacobson, 2008 • Hormone therapy associated with an increased risk of stroke regardless of time of initiation • Grodstein, 2008
Key Articles • Hormone therapy is associated with improvement in some quality of life measures in women with vasomotor symptoms and may improve sexual function and vitality - Hess, 2008; Welton, 2008 • Hypnosis and exercise may improve vasomotor symptoms - Elkins, 2008
OSTEOPOROSIS • Violet D. is a 69 year old woman who comes in for a health care maintenance exam. You order a bone mineral density test. She tells you she also wants a Vitamin D level checked. What do you do?
Vitamin D • Order a Vitamin D level • Don’t order a Vitamin D level because you are not sure to do with the results • Don’t order it but start her on a calcium/Vitamin D supplement
Background • Vitamin D deficiency is common in older adults, homebound individuals and women admitted with hip fracture • Association between Vitamin D level and fracture risk is inconsistent • Association could be influenced by renal function, muscle strength and estrogen receptors
Clinical Questions • What is the association between Vitamin D level and fracture? • When should Vitamin D levels be checked? • When and how should Vitamin D supplementation be given?
Vitamin D and Fracture Risk • Cauley JA et al. Serum 25(OH) vitamin D concentrations and risk for hip fractures. Ann Intern Med 2008:149: 242-250. • Aim: To determine whether serum 25 (OH) D concentration is associated with hip fracture in community dwelling older women
Methods • Nested case-control study within the Women’s Health Initiative Observational Study • 400 cases and 400 controls followed for a median of 7.1 years • Women had no prior history of hip fracture, were not on estrogen or other bone active therapies
Results: Hip Fracture Risk • P for trend 0.009 for unadjusted and 0.015 for adjusted models
HIP FRACTURE RISK • Association was linear • Dose response effect • No difference by age • Independent of geographic location
Impact for Practice • Low serum 25 (OH) vitamin D concentrations can help identify women at high risk for hip fracture • Perhaps we should consider Vitamin D level in decision making about anti-resorptive therapies
Background • Osteoporotic fractures are increasing as the population ages • Hip and vertebral fractures are associated with premature mortality
Clinical Questions • What is the mortality risk following an osteoporotic fracture? • Does degree of trauma matter? • Does subsequent fracture affect that risk?
Methods • Prospective cohort study from Dubbo Osteoporosis Epidemiology Study • Individuals who had a fracture between 1989 and 2007 • Age and sex specific standardized mortality ratios compared with general population for hip, vertebral, major and minor fractures