July 2002, Volume 2, Issue 2
Special Points of Interest (click topic)
AAAHC Accreditation
Enrolling Clinical Research Studies
Medical Fact
WHP Position on Women's Health Initiative Study Halt
Latest Publications
Medical Terminology
Unwanted Facial Hair and Hirsutism
Protecting Against Skin Cancer
Did You Know?
Prevention of Gynecologic Cancers
Mammographic Density Changes
Kathleen Snyder, C.A.N.P., Joins WHP Staff
__________________________
Suzanne Trupin, MD, FACOG
2125 South Neil Street, Champaign, IL 61820
PHONE (217)356-3736
FAX (217) 356-5849
www.womenshealthpractice.com
WHP Achieves National Accreditation
Women's Health Practice (WHP) has been accredited for three years by the Accreditation Association for Ambulatory Health Care, Inc. Status as an accredited organization means WHP has passed a series of rigorous and nationally recognized standards for provision of quality health care. We are pleased and proud to have our efforts recognized with this accreditation and feel our patients are the ultimate beneficients from our participation in the accreditation program.
Enrolling Clinical Research Studies
WHP is currently enrolling patients for research studies in the following areas:
• OVERACTIVE BLADDER
Do you sometimes feel like it's a race to the bathroom? If you have been diagnosed with overactive bladder, you may qualify to participate in a clinical research study evaluating responses to a single dose of an FDA approved medication. To qualify you must be a woman between 18-70 years of age, have been diagnosed with overactive bladder for at least three months, have a sense of urgency associated with voiding and urinary incontinence.
• CONTRACEPTIVE PATCH
To evaluate the safety and efficacy of a new contraceptive patch, applied weekly, compared to a daily oral contraceptive pill. You may qualify if you are between the ages of 18-39 years of age, have not taken birth control pills in the last month, have regular periods, and are a generally healthy woman.
• MENOPAUSE/HORMONE REPLACEMENT THERAPY
Confused about hormone replacement therapy? Are you a postmenopausal woman with an intact uterus, and between the ages of 40-75? You may qualify for a study evaluating an investigational medication that may relieve menopausal symptoms including hot flashes, insomnia, and mood swings.
• STRESS URINARY INCONTINENCE
To assess the safety and optimal dosage of an investigational drug compared to placebo in women with symptoms of stress urinary incontinence (SUI). If coughing, sneezing, exercising, or other movements cause you to leak urine, you may have stress urinary incontinence- the most common form of incontinence in women.
• OSTEOPOROSIS
Investigational drug for osteoporosis in postmenopausal women ages 50-80. Eligible participants must not have used hormone replacement therapy or a drug to treat osteoporosis in the last six months and not have had a period in the last two years. This study is approxi- mately 36 months with 11 visits.
• LOW LIBIDO
To evaluate the safety and efficacy of a new testosterone patch compared to placebo in postmenopausal women with low libido. You may qualify if you are between the ages of 20-70 years, are postmenopausal and have experienced low sex drive since menopause, have been in a stable, monogamous relationship for at least one year, and are generally a healthy woman.
• BACTERIAL VAGINOSIS INFECTION
Do you think you might have a vaginal infection? If you've found symptoms (like abnormal discharge and odor) within the past 72 hours, are not pregnant, and 18 years or older, you may qualify for a research study.
• SEVERE PREMENSTRUAL SYNDROME
To evaluate the safety and efficacy of an approved medication in the treatment of Premenstrual Dysphoric Disorder-a severe form of PMS. You may qualify if you are between the ages of 18- 40 years, have not taken birth control pills in the last three months, have regular periods, and are a generally healthy woman.
Informational (walk-in) meetings regarding clinical research studies are held Monday, Tuesday, and Thursday at 5:00 PM at Women's Health Practice. If interested in any of these studies, please contact Louise Adam, Clinical Research Coordinator, at 217-356-3736. Study participants receive study-related clinical exams, laboratory testing, and study medications at no cost, and are compensated for their time and travel.
Stress urinary incontinence (SUI) after vaginal birth affects:
• One in five women, even if no problems immediately following delivery, five years later.
• Ninety-two percent still experience SUI five years post-delivery if symptoms immediately after delivery.
WHP Position on Women's Health Initiative Study Halt
Maintaining health through menopause is a complex and individual process. Women in menopause are at risk for many disorders, which include vasomotor symptoms (hot flashes) with accompanying sleep, mood and cognition disorders, osteopenia and osteoporosis (varying degrees of bone loss), urogenital diseases including incontinence, pelvic floor dysfunction, diminished sexuality, macular degeneration of the eye, decreased muscle changes, reproductive cancers, and cardiovascular disease (CVD). We believe women should have individual assessment and a yearly course of treatment that addresses these concerns. For many women, at the time of menopause, a selected regimen of hormone replacement therapy will be an important and beneficial treatment. As we age our physical needs change, and for several years we have been telling women that at some point in their life the best course of treatment may no longer include traditional estrogen and progesterone combinations. Yearly re-evaluation of benefits and risks has been, and continues to be, our recommended strategy for your care.
Cardiovascular disease is the leading cause of both illness and death in American women. There are many known risk factors for cardiovascular disease some of which include modifiable life style changes. These modifiable life style changes have been and continue to be the most important way we have of controlling heart disease in women.
A woman's risk of CVD elevates dramatically as she passes through menopause. All the best information suggests this is directly linked to the simultaneous dramatic drop of natural estrogen. Basic scientific research has shown that estrogen has both powerful and beneficial effects on the cardiovascular system. Some studies have shown that various forms of estrogen and combination estrogen therapy can provide cardiovascular benefits to women as they age.
Recent research has shown that not all hormone therapy is alike, not all patients will be able to realize cardiovascular benefit from the therapy. We want to remind patients that cardiovascular protection has never been, and is not currently an approved use of estrogen or combination estrogen and progesterone therapy.
For our patients: If you are currently on hormone replacement therapy you are likely receiving this therapy for benefits other than the presumptive heart benefits. We do believe that future information on this subject will clarify which patients may actually accrue some cardiovascular benefits, and which patients may be at risk. Each patient should have a yearly reassessment of her menopausal management. The diseases menopausal women face can indeed be treated by therapies other than traditional hormones. Most women will not stay on their estrogen therapy permanently. Some HRT patients can benefit by switching to a SERM (a so-called "designer estrogen"), for bone loss we support bisphosphonates, and for cholesterol reduction we suggested approved lipid-lowering medications. We support continued, well-designed, carefully monitored research in menopausal health.
Dr. Suzanne Trupin is quoted in the following publications:
"Sexual Health Sanity Check", Glamour, July 2002, pages 88-95.
"What's Up Down There", Parents Magazine, July 2002, pages 91-94.
MASTALGIA (breast pain)
May be cyclic or non-cyclic.
70% of women experience mastalgia.
Occurs primarily in ages 30-50.
Cyclic responds somewhat to treatment; noncyclic is much harder to treat, but resolves without treatment half the time.
Treatment
• Low-fat, high carbohydrate diet
• No real evidence for evening primrose oil, progesterone, or diuretics
• Possible medications
• Danazol(weak male hormone)
• Bromocryptine (given to dry up milk)
• Tamoxifen (anti-estrogen SERM)
What To Do
1) Breast self examination
2) Firm and well-fitting bra
3) Weight reduction
4) Tylenol
5) Lower dietary fat
6) Moderate caffeine intake
7) If unresolved in 6-8 weeks, get a check-up
VULVOYDYNIA (vulvar pain)
Usually is diffuse over the vular area, unrelenting burning.
Can extend to the thighs and buttocks, and occasionally be associated with urethral and rectal pain.
No known cause.
Women with pudendal nerve damage, however, have symptoms that are similar.
DYSMENORRHEA (menstrual pain)
Physicians used to call menstrual pain "spasmotic" or "congestive", neither term has any modern validity or use.
Primary – the first 6-12 months of menstrual cycles. Should start with menstrual bleeding and last 8-72 hours.
Secondary – due to other causes (endometriosis or ovarian cysts).
More common in smokers and those experiencing second hand smoke.
What To Do
• Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen)-start one day before the period is expected
• Exercise
• Hydrate
• Decrease smoking and reduce secondary smoke exposure
• Heating pad
• Oral contraceptives (most effective if used continuously, not cyclically, so you have fewer menstrual periods).
• Japanese cure, Toki-Shakuyaku-san (a 6 herb mixture including anglica and peony root), also not confirmed as beneficial
Unwanted Facial Hair (UFH) and Hirsutism
Unwanted facial hair (UFH) affects up to 41 million women in the U.S., is known to worsen with age, and is defined as the presence of hair that is coarser, longer, and more profuse than is normal for a woman's ethnicity or age.
Hirsutism may be hormonal, nonhormonal, or idiopathic. Clinical diagnosis is most associated with androgen excess, with hair seen on the face, chin, chest, abdomen, and inner thigh, and is often a presenting manifestation of polycystic ovarian syndrome. It is frequently underreported, affecting 2% to 8% of women aged 18-45.
Evaluation of UFH and hirsutism include family history (mother, grandmother, and sisters), menstrual history, determine if ovulation is/is not occurring, and, laboratory evaluation in select patients.
The most commonly used diagnostic method for hirsutism in women is the Ferriman-Gallwey Hirsutism Rating Scale. The score is determined by visual inspection and quantification of excessive hair growth on 12 body areas (upper lip, sideburn area, chin, lower jaw and upper neck, upper back, lower back, upper arm, thighs, chest, upper abdomen, lower abdomen, and perineum). Hair growth is rated using a scale of 0 (no terminal hair) to 4 (maximal growth) for a total score of 48. A score of 8 or greater indicates the presence of androgen excess. It is also important to evaluate current drugs for masculine side effects, which might produce hair growth.
UFH management may include cosmetic methods (bleaching, shaving, depilatories), or a mechnical method that affects the hair follicle (plucking, waxing, sugaring, electrolysis, or laser phototherapy). Off label pharmaceutical therapies, such as spironolactone, flutamid, finasteride, and oral contraceptives, are an option. Another medical management option is elfornithine HCI cream.
Unwanted facial hair and hirsutism can cause detriments to self image, psychological well being, and reduced quality of life. If you are experiencing UFH or hirsutism, seek consultation. At WHP, we offer consultation, evaluation, and management options for these diagnoses.
Adapted from Symposium Highlights-Unwanted Facial Hair: New Strategies for Optimal Management, 2001 Annual Cinical Meeting of ACOG.
Protecting Against Skin Cancer
This is the time of year when most people remember to think about skin cancer. Although the sun's rays can be damaging all year, summer outdoor activities and more exposedskin make awareness especially signifciant this time of year. The most important strategies for reducing your risk of getting skin cancer are preventative; namely, minimizing your exposure to the sun.
• Limit time in the sun between 10 A.M. and 4 P.M., when the sun is strongest.
• Wear a hat with a wide brim, and closely woven clothing. If light can get through the fabric, UV rays can get through, too.
• Always wear sunscreen, even if you have dark skin. Although the risk is lower for black or dark skin, it is still possible to get skin cancer.
• Stay away from artificial tanning devices (exposure to the radiation of a tanning booth may be more risky than exposure to the sun).
The second important factor in skin cancer prevention is early detection. Be aware of being at greater risk because of factors like having light skin, family or personal history of melanoma, many moles or freckles, severe childhood sunburn, or have had a lot of sun exposure over many years. If detected early enough, nearly all types of skin cancer can be completely cured. Have a doctor inspect any suspicious growth or changes in moles, and have a skin examination once a year.
• The sun's harmful ultraviolet (UV) radiation can penetrate many types of clothes.
• It can also go through automobile and residental windows.
• It can damage your eyes, contributing to cataracts, macular degeneration, and eyelid cancers.
• When you're on snow or ice, your face and eyes are at almost twice the risk of UV damage because of reflected glare.
Prevention of Gynecologic Cancers
Medicine's focus on primary prevention strategies, beyond detection and treatment, has far-reaching implications on a woman's ablity to make choices and avoid certain risk factors for cancer. This can be especially true for gynecologic cancers. Research in ovarian, endometrial (uterine), cervical, vaginal, and vulvar cancer prevention has resulted in some helpful guidelines.
Cervical cancer may arise in some women as the result of a sexually transmitted factor. It follows that prevention strategies would include monogamy, avoidance of intercourse in adolescent years, and use of barrier contraceptives (condom use plus spermicide).
Smoking and deficiencies in the diet of vitamins A, C, and folic acid have also been implicated in cervical cancer development. Endometrial (uterine) cancer strikes the lining of the uterus. Prevention measures include use of oral contraceptives, a weight maintenance program, and judicious use of hormone replacement therapy in menopause.
Ovarian cancer prevention is enhanced through oral contraceptive use and breastfeeding, and tubal sterilization may be helpful. Oral contraceptive protection lasts 15 years. DepoProvera, Norplant, and possibly Mirena IUS contraceptive methods may also protect against ovarian cancer.
In all cases, a regular pelvic examination and Pap smear are essential in the prevention and early detection of gynecologic cancers. As a prevention method, Pap smears can detect a cervical precancerous problem, which can help to determine intervention methods to prevent the cancer. From the early warning indicated in the Pap test, physicians and healthcare providers can counsel on altering behaviors that may contribute to the risk of cancer.
Mammographic Density Changes
CHANGES IN MAMMOGRAPHIC DENSITY IN THREE INDIVIDUAL WOMEN ACCORDING TO TREATMENT: Mammograms were obtained before and after six months of therapy. The woman receiving Ex/NETA had an apparent increase in breast density, whereas no change was recorded in the women on tibolone and placebo treatment.
Lundstrom et al. Effects of tibolone and continuous combined hormone replacement therapy on mammographic breast density. Am J Obstet Gynecol 186(4):717-722, April 2002.
Kathleen Snyder, C.A.N.P., Joins WHP Staff
Women's Health Practice welcomes Kathleen Snyder, C.A.N.P., to our staff. Kathleen is an Adult Nurse Practitioner certified by the American Nurses Credentialing Center. She trained at and obtained her Master of Science in Nursing and Adult Nurse Practitioner at the University of Akron, Akron Ohio, and Bachelor of Science in Nursing at the University of Illinois, Urbana-Champaign, Illinois. Her special interests in women's health include disease prevention and wellness with early screening. Kathleen will focus on clinical research studies/trials at WHP, in addition to clinical nursing.
