Fam med case 17
What is the recommendation for ovarian cancer screening via CA-125?
CA-125 is not indicated as a screening tool for ovarian cancer by the USPSTF. This is supported by evidence that although it may detect ovarian cancer at an earlier stage, it does not lower mortality rates. In addition, the prevalence of ovarian cancer is low, giving the test a low positive predictive value, which makes this a poor screening tool.
What usefulness does calcitonin have in the treatment of osteoporosis?
Calcitonin has been shown to reduce vertebral fractures, but not hip or other fractures. For most women, more effective treatments are available.
What is the recommendation based on age for colon cancer?
Colon cancer screening is recommended for everyone over the age of 50 continuing until the age of 75
What is the risk associated with combined estrogen and progesterone?
Combined estrogen and progestogen use beyond three years increases the risk of breast cancer.
Which of the following are treatment options for osteoporosis? Select all that apply. A. Prednisone B. Alendronate (Fosamax) C. Parathyroid Hormone (Forteo) D. Raloxiphen E. Calcitonin
> B, C, D, E have been selected by the expert.
On a bone density scan, what T-score indicates osteoporosis?
A DEXA scan is a bone densitometry study that usually looks at the lumbar spine and hip density to determine if someone has osteoporosis. This is done based on a T-score. A T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia. Osteopenia is not a clinical diagnosis and just indicates the degree of bone decline since peak bone mass. It is usually not an indication for treatment aside from lifestyle. A T-score of less than -2.5 indicates osteoporosis. Based on the patient's risk for fracture and their T-score, we can then make recommendations for treatment of osteoporosis. NOTE**a T-score of -1.0 indicates a bone density that is one standard deviation below the BMD of a young healthy person. This statistic is then used to classify the BMD of an individual into normal (0 to -1), osteopenia (-1 to -2.5) and osteoporosis (below -2.5).
What is the gold standard for the evaluation of postmenopausal bleeding or abnormal bleeding?
A histologic evaluation of the endometrium after dilation and curettage (D&C) is the traditional gold standard for the evaluation of postmenopausal bleeding and for abnormal bleeding in younger women at high risk for endometrial cancer. Office-based sampling using the Pipelle device is now widely used for this purpose and has sensitivity for detecting endometrial cancer in postmenopausal women as high as 99%. An endometrial biopsy will obtain a tissue sample that will be sent to Pathology to look for evidence of endometrial hyperplasia or endometrial cancer.
Which of the following are recommended screening exams for women in their fifties without any specific symptoms or risk factors? Select all that apply. A. Mammogram B. Pap smear C. DEXA scan D. Colon cancer screening E. CA-125
Answer: A, B, D NOTE**Osteoporosis (C) Since Mrs. Parker is younger than 65, if she is of average risk, screening is not recommended for her at this time (see further discussion later in this case). CA-125 level (E) CA-125 is not indicated as a screening tool for ovarian cancer by the USPSTF
Which of the following are benefits of menopausal HT? Select all that apply. A. Decrease in vasomotor symptoms. B. Decreased incidence of stroke. C. Improvement in atrophic vaginitis symptoms. D. Decreased risk of breast cancer. E. Prevention of osteoporosis.
Answer: A, C, E
What strategies can be used to prevent osteoporosis? Select all that apply. A. Smoking cessation B. Calcium intake of 1200 mg per day C. Weight bearing exercise D. Adequate intake of Vitamin D
Answer: All of the above. Smoking increases risk of osteoporosis
Which of the following treatments are clearly safe and probably effective for the management of hot flashes according to the best available evidence? Select all that apply. A. Mind and body practices such as yoga, tai chi, qi gong, and acupuncture B. Phytoestrogens such as soy and red clover C. Botanicals such as black cohosh, don quai, and kava D. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) E. Bioidentical Hormone Replacement therapy and DHEA F. Prescription medications such as clonidine and gabapentin
Answer: D and F D. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) F. Prescription medications such as clonidine and gabapentin
What are the three main parts of a physical exam to focus on in a woman with abnormal vaginal bleeding post-menopause?
Answer: Pelvic, Neck, and Skin; Pelvic Exam: Look for vulvar or vaginal lesions, signs of trauma, and cervical polyps or dysplasia. On bimanual examination, assess the size and mobility of her uterus, as a firm, fixed uterus would be concerning for uterine cancer. Neck Exam: Thyroid exam to look for goiter or nodules, as thyroid disease is one of several systemic diseases that can cause dysfunctional uterine bleeding. Skin Exam: Look for evidence of bleeding disorders, like bruises. Also, jaundice on skin exam and hepatomegaly on abdominal exam might signify an underlying acquired coagulopathy via liver disease.
Which of the following are in your differential for vaginal bleeding in a woman 3 years post-menopause? A. Cervical polyp B. Endometrial hyperplasia C. Hormone-producing ovarian tumors D. Normal bleeding with hormone replacement and no further work up warranted E. Endometrial cancer F. Proliferative endometrium
Answer: all but D A) Cervical polylps, most common; E) Endometrial cancer, must be considered; NOTE**Normal bleeding with hormone replacement (D) is incorrect because this patient has been on daily HRT for more than 12 months. Bleeding in the first 12 months of HRT can be normal, however bleeding after 12 months of therapy always requires further evaluation.
Which of the following would be appropriate to the evaluation of postmenopausal bleeding? Select all that apply. A. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels B. Transvaginal ultrasound C. Endometrial biopsy D. Complete blood count E. Thyroid-stimulating hormone (TSH) level
B. Transvaginal ultrasound C. Endometrial biopsy D. Complete blood count E. Thyroid-stimulating hormone (TSH) level
What are 2 key risks of hormone replacement therapy for menopause and what is the current recommendation?
Beginning HT after age 60 increases the risk of coronary artery disease. HT increases the risk of stroke at least for the first one to two years of use. HT for menopausal symptoms should use the lowest effective doses for the shortest possible times.
What are risk factors for osteoporosis?
Corticosteroid use Family history of osteoporosis, especially if a first-degree relative has fractured a hip. Previous fragility fracture defined as a low-impact fracture Smoking Heavy alcohol use Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density. Obesity (B) does not put patients at risk for osteoporosis, but neither is obesity protective against osteoporosis. Caucasian race - At any given age, African-American women on average have higher bone mineral density (BMD) than white women. The USPSTF, while acknowledging that the data for non-white women is less compelling than for whites, recommends screening all women at age 65 or earlier if they have equivalent risk.
What is the main diagnosis that must be considered in a postmenopausal woman presenting with bleeding?
Endometrial cancer is fourth most common cancer in women, and the main diagnosis that must be considered in a woman presenting with postmenopausal bleeding. Also must be considered in women over the age of 35 with symptoms suggestive of anovulatory bleeding (spotting, menorrhagia, metrorrhagia). Ninety percent of patients with endometrial cancer have abnormal vaginal bleeding.
What is the technique used to perform an endometrial biopsy?
First, have the patient get into the lithotomy position and insert a speculum. Use betadine solution to cleanse the cervix. Then, use a tenaculum (forceps with a sharp hook at the end of each jaw used for grasping tissues in surgery) to grasp the cervix on the the superior / anterior portion. Next, insert the pipelle into the os and obtain specimens from at least four different areas of the uterus. Withdraw the pipelle and place the samples into the formalin. Remove the tenaculum and speculum. The specimen is sent in formalin to the lab.
What are key symptoms of menopause?
Hot flashes or vasomotor symptoms are the most common symptoms of menopause, and are present in up to 80% of menopausal patients. Many women will also experience symptoms of atrophic vaginitis, which can lead to vaginal dryness and dyspareunia (pain during intercourse) and urinary symptoms. Since menopause can be associated with a variety of additional problems including sexual dysfunction, sleep disturbance, mood disturbance, and concentration difficulties, it can significantly affect a woman's daily functioning and quality of life.
When would prednisone be used in the treatment of osteoporosis?
It wouldn't. Prednisone and other corticosteroids actually increase the risk of osteoporosis when used long term.
What is a generally accepted recommended dose of calcium and vitamin D for women over 50yo?
Most women over 50 should consume an average of 1200 mg of calcium and 800 to 1,000 IU of vitamin D daily.
What are the National Center for Complementary and Integrative Health (NCCIH) (the Federal Government's lead agency for scientific research on the diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine) recommendations for alternative treatments to medications for hot flashes?
NCCIH identified some weak evidence to support the use of hypnotherapy and mindfulness for the management of menopausal symptoms, but outlines specific concerns and recommends against the use of compounded hormones marketed as Bioidentical Hormone Replacement therapy and against the use of DHEA. Furthermore, natural medicines, such as phytoestrogens and botanicals, have not been shown to be clearly safe and effective according to usual standards for prescription medications.
what is the def of menopause?
National guidelines define menopause as 12 months without a cycle.
What is the screening recommendation for osteoporosis?
Osteoporosis screening is recommended by the USPSTF for all women at, or over the age of 65, and in younger women who have equivalent fracture risks to the average white woman at age 65.
What are bisphosphonates and what are some examples?
Osteoporosis treatment. Biphosphonates are potent inhibitors of bone resorption and reduce bone turnover, resulting in increase in bone mineral density. Biphosphonates have been shown to decrease the risk of vertebral and non-vertebral fractures. Alendronate (Fosamax) and risedronate (Actonel) are available in generic form, making them more affordable. Ibandronate (Boniva) is only available in trade name and the cost may be prohibitive to some patients. Zoledronic acid, an intravenous preparation, is given annually and can be used in patients who do not tolerate the oral bisphosphonates.
What is Forteo?
Parathyroid hormone (Forteo) is an anabolic drug and is approved by the FDA for those with osteoporosis at high risk for fracture. It is given subcutaneously and has been shown to decrease fracture risk by 50% to 65%. It does not have demonstrated efficacy and safety beyond two years and is quite costly.
When is progesterone replacement indicated in addition to estrogen?
Patients with an intact uterus must also be treated with progesterone to decrease the risk of endometrial cancer related to unopposed estrogen.
What are some key consequences of osteoporosis?
Patients with osteoporosis can suffer a fracture following even minimal trauma. These fractures are most commonly of the vertebrae, the hip, distal radius and proximal humerus. The lifetime risk of fracture for a 50-year-old woman exceed her risk of developing endometrial or breast cancer. Fractures secondary to osteoporosis place an enormous burden on the elderly personally, medically, and economically. Patients with hip fractures have an average one-year mortality rate of 20 to 25 percent. Hip fractures are associated with significant loss of independence, with 15 to 25 percent of previously independent patients require nursing home placement for at least one year, and less than 30 percent of patients regain their prefracture level of function.
When is raloxiphen used to help reduce osteoporosis risk?
Raloxiphen is a selective estrogen receptor modulator (SERM) which is used if bisphosphonates are not tolerated, but only work to prevent vertebral fractures.
What are the key risks you're considering when thinking about placing a woman on hormone replacement therapy?
Risk factors to consider include: age family and personal history of heart disease, stroke, breast cancer, blood clots, or osteoporosis medications
What is a main concern with endometrial hyperplasia?
Simple hyperplasia progresses to cancer in less than 5% of patients; atypical complex hyperplasia is a premalignant lesion that has a 25% probability of progressing to cancer. Therefore, careful monitoring and treatment is important with this disorder.
What are the 2 screening methods used for colon cancer and when is each used?
Stool-based tests: Usually performed annually. Guaic-based fecal occult blood tests (gFOBT) are a bit less convenient than fecal immunochemical tests (FIT) as they require collecting three samples, whereas FIT only require one sample. Studies have found FIT testing more sensitive than gFOBT testing for colorectal cancer and adenomas. Any positive stool-based screen must be evaluated with a more definitive test, usually a colonoscopy. Colonoscopy: Allows for a biopsy. Is often utilized especially if the patient has a family history of colon cancer, a change in bowel habits, or any reported rectal bleeding.
What are key symptoms of atrophic vaginitis?
Symptoms: Vaginal dryness, dyspareunia, urinary symptoms and vaginal pruritis.; Urinary symptoms: Recurrent urinary tract infections, urinary frequency, and dysuria. Local estrogen may help women with urge incontinence and recurrent urinary tract infections. We're not sure if estrogen helps with overactive bladder, and there is conflicting evidence about its effect on stress incontinence. Vaginal pruritis: Local symptoms are usually best treated with topical estrogen in the form of either a vaginal cream or an estrogen ring, which is an estrogen impregnated ring inserted into the vagina. Physical exam findings:Smoother vaginal mucosa and cervix, related to postmenopausal changes from decreased estrogen levels.
How does postmenopausal bleeding influence your interpretation of someone's risk for ovarian cancer?
postmenopausal bleeding is one of several symptoms associated with a higher risk for ovarian cancer (6.6 fold increased risk).
What is the best diagnostic option for women with postmenopausal bleeding and low risk of endometrial cancer?
TVUS may be the most cost-effective initial test in women at low risk for endometrial cancer who have abnormal uterine bleeding. It will tell us the thickness of the endometrium. If the endometrium is less than 4 mm (some sources say < 5 mm) on ultrasound, it is reassuring and more workup may not be necessary unless the bleeding continues. Besides endometrial thickening, transvaginal ultrasonography may reveal leiomyoma (fibroids) or focal uterine masses, and may also reveal ovarian pathology. Although this imaging modality may miss endometrial polyps and submucosal fibroids, it is highly sensitive for the detection of endometrial cancer (96%) and endometrial abnormality (92%).
A 53-year-old woman with a past medical history of diet-controlled hypertension presents to the office with a two-month history of worsening hot flashes. Her menstrual cycles are regular, occurring every 30-32 days, but they have gradually lessened in duration, now lasting 4-5 days instead of the previous 6-7 days. Vital signs and physical exam are normal. Which one of the following herbal treatments is most likely to improve the patient's symptoms? A. Black cohosh B. Ginkgo biloba C. Ginseng D. Echinacea E. Fenugreek
The correct answer is A. Soy, black cohosh, flaxseed, and St. John's Wart are alternative remedies that have been found to be at least possibly effective for treatment of hot flashes. Ginkgo biloba is used as an alternative remedy for depression/anxiety, erectile dysfunction, and vertigo. Ginseng is used as an energy supplement. Echinacea is used as an herbal remedy for upper respiratory infections. Fenugreek is an herb used by mothers to increase milk production for breastfeeding.
A 52 year-old female with no past medical history presents to your office with amenorrhea. The patient states that her menstrual cycles previously occurred approximately every 28-34 days. However, she has not had a menstrual cycle for the last 10 months. She also endorses insomnia and intermittent dysuria. She denies any headaches, abdominal pain, constipation or diarrhea, changes in hair distribution, or easy bruising. She has lost 15 pounds since her last visit eight months ago, which she attributes to improving her diet and beginning regular exercise. Which one of the following tests can be used to confirm your diagnosis? A. Thyroid Stimulating Hormone (TSH) and Free T4 B. Luteinizing Hormone (LH) and Follicular Stimulating Hormone (FSH) C. Prothrombin Time (PT) and International Normalized Ratio (INR) D. Morning Cortisol and Prolactin E. Testosterone and Dehydroepiandrosterone sulfate (DHEA-S)
The correct answer is B. Elevated FSH and LH levels can be used to confirm menopause. During menopause, ovarian granulosa cells produce less inhibin, thereby affecting the negative feedback loop of FSH and LH secretion from the pituitary gland. TSH and free T4 are used in testing thyroid function. One might be concerned about thyroid function if there was unexplained weight loss along with other positive symptoms in the ROS, but those are not present in this case. PT and INR are used to test bleeding time and can be an indicator of liver function, while morning cortisol tests adrenal function - and neither are of concern in this patient. Prolactin is produced by the pituitary but is not affected during menopause.
An otherwise healthy 57 year-old G2P2 female presents to your office with vaginal bleeding that began one week ago. She began her menses at age 13 and had regular menstrual cycles until the age of 49. She denies any tobacco or alcohol use. Further review of systems is negative. You perform a physical exam, including a vaginal exam, pap smear, and bimanual exam. Which of the following is the most appropriate next step? A. Reassurance B. Trial of oral contraceptives C. Transvaginal ultrasound D. Endometrial ablation E. Referral for hysterectomy
The correct answer is C. Any postmenopausal bleeding needs to be investigated; reassurance alone is inappropriate in this case. A transvaginal ultrasound is the most cost-effective initial test in women with abnormal uterine bleeding at low-risk for endometrial cancer. It is highly sensitive (96%) for the detection of endometrial cancer. Endometrial biopsy is considered the gold standard for evaluation of post-menopausal bleeding and is up to 99% sensitive. Oral contraceptives, endometrial ablation, and hysterectomy are treatment modalities that would not be appropriate until an actual diagnosis is made.
What are some symptoms/signs of ovarian cancer?
postmenopausal bleeding, pelvic or abdominal pain, increase in abdominal size or bloating, and difficulty eating or feeling full.
A 56-year-old woman with a past medical history significant for hypothyroidism and recurrent urinary tract infections presents to a local health fair to discuss dyspareunia and hot flashes that began approximately one year ago. Her last menstrual cycle was 14 months ago, and her family history is significant for breast cancer in her sister, diagnosed at the age of 47. She has become increasingly bothered by the frequency of her hot flashes and has stopped attending social events with her friends due to these symptoms. Which one of the following is true regarding the risks and benefits of hormone-replacement therapy (HRT)? A. Use of combined estrogen and progesterone therapy decreases the risk of breast cancer. B. Use of unopposed estrogen in patients with an intact uterus decreases the risk of endometrial cancer. C. Use of hormone therapy for less than five years will not affect a patients risk of coronary artery disease. D. Use of hormone therapy decreases the risk of osteoporotic fractures.d. Use of hormone therapy decreases the risk of osteoporotic fractures. E. Both systemic and topical estrogens are equally effective for the treatment of vasomotor symptoms. Submit
The correct answer is D. Use of combined estrogen and progesterone beyond three years increases the risk of breast cancer. Use of unopposed systemic estrogen in women with an intact uterus increases endometrial cancer risk. Beginning HRT after age 60 increases the risk of coronary artery disease. Systemic estrogen is most effective for treatment of vasomotor symptoms. HRT has been shown to decrease the risk of osteoporotic fractures.
A 61 year-old G4P4 female presents to a local emergency room with vaginal bleeding. The bleeding began two days ago and is described as spotting. She began her menses at age 16 and had regular menstrual cycles until the age of 59. She endorses smoking ½ pack per day for the last 23 years and drinks 1-2 glasses of wine with dinner every evening. She denies any abdominal pain or dysuria. She is 5'7" and weighs 112 lbs. You perform a physical exam, including a vaginal exam, pap smear, and bimanual exam. Which one of the following characteristics of this particular patient increases her risk of endometrial cancer? A. Smoking B. Multiparity C. Body habitus D. Age of menarche E. Age of menopause Submit
The correct answer is E. Any characteristic that increases exposure to unopposed estrogen increases the risk of endometrial cancer. This includes Tamoxifen therapy, obesity, anovulatory cycles no prior history of pregnancy, early menarche (before age 12), and late menopause (after age 52). Smoking decreases estrogen exposure, thereby decreasing risk. Oral contraceptives increase progestin levels, thus providing protection against endometrial cancer.
What is the recommendation for PAP smears?
The recommendations from the American Society for Colposcopy and Cervical Pathology call for Pap smear screening to start at age 21 and continue every three years until age 30. Preferred screening from age 30-65 is with HPV testing in addition to the cytology test (Pap) every five years. Screening this age group (30-65) with cytology alone every three years is an acceptable alternative.
The results of a transvaginal ultrasound in a patient with postmenopausal bleeding read as follows: "Uterus of normal size, endometrial stripe of 6mm, no lesions identified. Ovaries of normal size and morphology for age." What does this indicate and what is the next diagnostic step?
The ultrasound does not suggest any obvious genital tract pathology, but the endometrial thickness is > 4 mm. A thickness of 4 mm or less is reassuring that the patient does NOT have endometrial cancer. Since that is the diagnosis we need to exclude, we will require the endometrial biopsy. The likely etiology of the bleeding lies within the endometrium and is either proliferative endometrium, endometrial hyperplasia, or endometrial cancer. The results of the biopsy will guide treatment.
What are the recommendations for yoga, tai chi, qi gong, and acupuncture in hot flash treatment?
There is inconsistent evidence to support their effectiveness.
Why is the thyroid important to check when evaluating post-menopausal or abnormal bleeding?
Thyroid disorders may cause abnormal uterine bleeding and are associated with an increased risk for endometrial cancer. We assess thyroid function via the thyroid-stimulating hormone (TSH). This is an inexpensive test.
What are the US Preventive Service Task force and American College of Obstetricians and Gynecologists/American Cancer Society recommendations for mammography?
U.S. Preventive Service Task Force (USPSTF) Recommends biennal screening mammography for women aged 50-74 and that starting screening mammography prior to 50 years of age should be a decision that is individualized for each patient. (They found insufficient evidence to assess the benefits and harms for women over age 75.) The American College of Obstetricians and Gynecologists and the American Cancer Society Recommend annual screening mammography for women beginning at age 40.
What is a risk associated with unopposed estrogen?
Use of unopposed systemic estrogen in women with a uterus increases endometrial cancer risk.
What are key risk factors for endometrial cancer?
unopposed estrogen therapy tamoxifen (Nolvadex) - Often used in women with breast cancer and has an estrogenic effect on the female genital tract. obesity anovulatory cycles estrogen-secreting neoplasms early menarche (before age 12) late menopause (after age 52) menstrual cycle irregularities nulliparity Also: hypertension, diabetes, and breast or colon cancer, age
