Women's Health Challenges

Educational Objectives

The goal of this program is to improve management of cervical squamous intraepithelial neoplasia and other health challenges for women. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize screening in patients with cervical squamous cell carcinoma using the 2019 American Society of Colposcopy and Cervical Pathology guidelines.

2. Recommend appropriate treatment of abnormal uterine bleeding based on diagnosed causes.

Summary

Cervical Squamous Intraepithelial Neoplasia (CIN)

Overview: squamous cell cervical cancer is almost completely related to human papillomavirus (HPV) infection (ie, HPV 18, [specifically] HPV 16); high-risk HPV is a sexually transmitted infection; squamous cells susceptible to dysplastic and carcinogenic impacts of HPV infection; young, healthy people with active immune systems can rapidly eliminate the virus without residual viral effects, so there is a less aggressive response to early dysplasia; excisional procedures on cervix (eg, loop electrosurgical excision, cone biopsy) can contribute to preterm birth

2019 American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines: study conducted at a Northern California Kaiser hospital on >1.5 million patients over >10 yr; screening age requirements split into 21 to 24 yr of age group and ≥25 yr group; screening recommendations in otherwise healthy 21 to 24 yr of age group is cytology alone every 3 yr; with Atypical Squamous Cells of Undetermined Significance (ASCUS) perform a reflexive high-risk HPV test; with patients in the ≥25 yr group (usually to age 65), perform primary high-risk HPV screening; if negative, then perform another screen in 5 yr; an acceptable alternative to high-risk HPV testing is cotesting; simultaneous cytology and high-risk HPV testing should be performed; if negative, then repeat in 5 yr to 65 yr of age

Decision algorithm: patient’s 1-yr (immediate) and 5-yr CIN 3 risk (>4% and >0.55% are cutoffs, respectively) determines which measures to take; example 1 — patient with low-grade squamous intraepithelial lesion (LSIL) had immediate risk 2.1%, but 5-yr CIN3 risk of 3.8%, cervical cancer screening should be performed in 1 yr; example 2 — woman with a high-grade squamous intraepithelial lesion (HSIL) has a 1-yr CIN3 risk >4%, and requires a colposcopy

Screening immunosuppressed patients: new guidelines address, eg, human immunodeficiency virus (HIV) infection, long-term steroid use, other immunomodulators, transplant recipients; cervical cancer screening should start within 1 yr of sexual activity at any age; perform cytology annually for 3 consecutive yr; if normal, then adjust to every 3 yr to 65 yr of age

Screening patient with severe dysplasia or adenocarcinoma in-situ: continue cervical cancer screening for high-risk HPV, even after a hysterectomy, every 3 yr for 25 yr

Screening in patient vaccinated with HPV vaccine (Gardasil): measures taken are same with all vaccine types (eg, quadrivalent, bivalent); atypical glandular cells always warrant sampling of the endocervix and the endometrium in addition to a colposcopy

Screening in postmenopausal patients: if endometrial cells are postmenopausal on the result of Papanicolaou test, then endometrial sampling is required

Osteoporosis

Fracture risk assessment tool calculator: used to determine if individual at increased risk for osteoporosis requires dual-energy x-ray absorptiometry earlier than 65 yr of age

Risk factors: eg, alcoholism, smoking, low body mass index, Caucasian race, long-term corticosteroids, family history

Examples of DEXA scores: if 45-yr-old patient, weighing 70 kg, without history of fractures, smokes cigarettes, uses steroids, drinks alcohol, and has arthritis has 10-yr risk for a major osteoporotic fracture of >9.3%, DEXA required; 55-yr-old patient with 10-yr risk of 8.4% does not require DEXA; 60-yr-old, with 10-yr risk of 11% requires DEXA

Abnormal uterine bleeding (AUB): outdated terms (eg, metrorrhagia, menometrorrhagia) replaced by the term abnormal uterine bleeding; designation of heavy menstrual or intermenstrual bleeding and 1-letter identifier for cause also added per case; example — a patient with 20-wk-sized fibroid uterus, describes flooding periods lasting 7 to 8 days per mo, with cycles ≈28 days apart; the condition is described as AUB, HMBL, meaning abnormal uterine bleeding, heavy menstrual bleeding because of leiomyoma

Causes of AUB: PALM-COEIN mnemonic helpful; represents structural causes (polyp, adenomyosis, leiomyomas, and malignancy or hyperplasia) and nonstructural causes (coagulopathy or inherited bleeding disorder), ovulatory dysfunction [eg, polycystic ovarian syndrome, thyroid disorder], endometrial [eg, pelvic inflammatory disease], iatrogenic [eg, drugs], and not-yet-classified)

AUB work-up: a normal ovulatory pattern of bleeding lasts 3 to 7 days, occurs ≈28 days apart, no intermenstrual unpredictable bleeding (eg, interferes with daily activities, consists of orange-sized or larger clots); abnormal bleeding requires a urine pregnancy test, complete blood count, thyroid-stimulating hormone test, and hemoglobin A1c test; ultrasonography, and endometrial biopsy if warranted (eg, in women >45 yr of age to evaluate for hyperplasia or malignancy, women <45 yr of age with BMI 70); Papanicolaou test if not up to date

AUB therapy: dependent on diagnosed cause of bleeding; medical management — includes nonsteroidal anti-inflammatory drugs, hormonal contraceptives, and tranexamic acid (Lysteda; taken orally 3 times daily for 5 days); intermediate options — uterine artery embolization; endometrial ablation or hysteroscopic resection (of, eg, intracavitary polyp, fibroids); surgery — eg, myomectomy, hysterectomy

Contraception

Long-acting reversible contraceptives (LARC): eg, Kyleena, Liletta, Mirena; American College of Obstetricians and Gynecologists recommendations based on the CHOICE project, a prospective cohort study; found that by removing barriers (eg, cost), and provided counseling, most patients selected LARC method with good continuation at 1 and 2 yr; investigators did not observe increased high-risk sexual activity in young patients, and noted a decrease in pregnancy and abortion rates

Readings

Koeneman MM et al. Natural history of high‐grade cervical intraepithelial neoplasia: A review of prognostic biomarkers. Expert Rev Mol Diagn. 2015;15:527‐546; Marnach ML et al. Evaluation and management of abnormal uterine bleeding. Mayo Clin Proc. 2019;94:326‐335; doi:10.1016/j.mayocp.2018.12.012; Munro MG et al. FIGO classification system (PALM‐COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Obstet Gynecol. 2011;113:3‐13; doi:10.1016j.ijgo.2010.11.011; Perkins RB et al. 2019 ASCCP risk‐based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020;24:102‐131; doi:10.1097/lgt.0000000000000525; Secura GM et al. The contraceptive CHOICE project: reducing barriers to long‐acting reversible contraception. Am J Obstet Gynecol. 2010;203:115.e1‐115.e7; doi:10.1016/j.ajog.2010.04.017.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In her lecture, Dr. Crockett presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Crockett was recorded virtually at the Women’s Health Conference, held August 21, 2020, and presented by the Brody School of Medicine at East Carolina University and UNC Eshelman School of Pharmacy in association with Eastern Area Health Education Center. For more information on future CME activities from this sponsor, please visit Cme.ecu.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OB681202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.