6/4/18 9916thWCMPre-CongressWorkshop

RiskAssessmentandScreeninginthePerimenopause

Rod Baber

6/4/18 10016thWCMPre-CongressWorkshop

Perimenopause

Thephaseofawoman’slifewhichstartswithmenstrualirregularitiesandwhichconcludesoneyearafterthefinalmenstrualperiod.

• STRAWphase-2untilSTRAWphase+1a• Medianduration4-6yearsbutcanbe>10years• Ovariesarerunningoutoffollicles,Hormoneproductionirregular.• Womenmayexperience‘menopausal’symptoms.• Anovulatory cyclesarecommon• Mensesareirregular,oftenheavyandprolonged• Symptomsandabnormalbleedingoftenleadtomedicalconsultation.

6/4/18 10116thWCMPre-CongressWorkshop

Themidlifehealthcheck

Don’t• CheckFSH,LH,E2,TorPinawomanatthenormalageofmenopause• Bloodtestresultswillnotinfluencemanagementdecisions

Do• Takeagoodhistory;consideramenopausesymptomscorecard• Considerothercausesforsymptoms• Takeamenstrualhistory• Recordpersonalandfamilyhistoryofrelevantmedicalconditions.• Discussgeneralhealthandcontraception• Thisanexcellentopportunitytoreinforcekeypreventativehealthmessages

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Whatdoyouneedtoknow?Medical HistoryRelevant Gynecological facts•LMP and bleeding pattern•Hysterectomy /oophorectomy•Current use of Hormone therapy•Contraceptive needsMajor Medical illnesses•VTE / PE•Breast / endometrial cancer•Thyroid disease•Cardiovascular disease•Osteoporosis•Diabetes•Depression•Liver or Renal disease•Smoking / alcohol use•MedicationSignificant Family History•Cardiovascular•Osteoporosis / fracture•Cancer•DementiaSocial history

Examination•Height•Weight•Blood Pressure•Cardiovascular •Respiratory•Pelvic examination•Cervical smear•Breast check•Thyroid assessment

Investigations•FSH, LH – rarely needed anduseless in women onhormonal contraception

•Progest. / AMH – no value

Mid Life Assessment•Cervical Screening•Mammogram•Lipids•Fasting BSL•TSH•FBC / ferritin•Renal function•Liver function•Fecal occult blood test•Vitamin D•Bone density

APractitioner’stoolkit.JaneFMandDavisSRClim,acteric 2014;17:1-16

6/4/18 10316thWCMPre-CongressWorkshop

Perimenopause– keyissues:

• Diagnosis:- basedonhistory,bleedingpattern,exclusionofotherdiseasesManagementGoals:• Perimenopause Symptommanagement:- 20%willhaveseveresymptoms• Contraception:1-2yearsdependingonageatLMP.• Screeningfordiseasesofageing- Adviceonhealthylifestyleissues• Managementofabnormalbleeding

6/4/18 10416thWCMPre-CongressWorkshop

ScreeningforCervicalCancer

• CancerofCervixis>10xhigherincidenceinthedevelopingworld.• Hassheeverhadasmear?Ifsowhen?• Hassheeverhadanatypicalsmear• HasshereceivedHPVVaccination• SeeandTreat– Firstlinetreatmentinmanyhighburdensettings• VisualInspectionwithAceticAcid(VIA)/Lugols Iodine(VILI)• PapSmear• CervicalScreeningtest(HighRiskHPVDNAserotyping/Cytology)• GOAL:Cheapglobalvaccinationprogrammes

6/4/18 10516thWCMPre-CongressWorkshop

ScreeningforColorectalCancer

• CRCisthethirdmostcommoncancerinwesterncountries• Incidencerisesinmidlife• Historywillgivecluesaboutrisk:Sedentarylifestyle,smoking,alcoholconsumption,lowfibre diets,highlevelsofredandprocessedmeats

• Changeinbowelhabit• PRBleeding• FamilyHistory:Ifpositivethesewomenrequireclosermonitoring.• Prophylaxis:Lifestylemodification,lowdoseaspirin,altermicrobiome• Screening:immunochemicalfecaloccultbloodtesting(2years)sigmoidoscopy,colonoscopy,CTtests,fecalDNAtesting…

6/4/18 10616thWCMPre-CongressWorkshop

ScreeningforBreastCancer

• BreastCancerincidencerisesinperimenopausal years• Mortalityhassubstantiallyreducedinthepast20yearsbutwhetherduetoscreeningorbettertreatmentsremainsunclear.

• History: Hasshehadamammogramorbreastultrasound?When?• Hasshedetectedbreastlumps• Hasshehadbreastbiopsies• Isthereafamilyhistory• Discuss: BreastSelfexamination,ClinicalBreastexamination,Mammogram– particularlyifyouaregoingtoinitiatehormoneRx

• Screeningprogrammes ifavailable

6/4/18 10716thWCMPre-CongressWorkshop

ScreeningforOsteoporosis

• Osteoporosis andrelatedfracturesarecommoninwomenaftermidlife.• Fractures havesignificantmorbidity,mortality,costandreduceQOL.• Fractureriskcanbereducedbyidentifyingandtreatingriskfactors- LowBMI,smoking,glucocorticoiduse,Cushings,RhArthritis,malnutritionmalabsorption,sedentarylifestyle,diabetes,HyperPTH,LowVit D,HIV• FamilyHistoryisimportant• Onlinefractureriskcalculatorseg FRAXcanhelppredictrisk• RadiologicalInvestigations• ConventionalXRay,DEXA,QCT..

6/4/18 10816thWCMPre-CongressWorkshop

Fractureriskassessment

www.sheffield.ac.uk/FRAX

6/4/18 10916thWCMPre-CongressWorkshop

Theriskofheartdiseaseislinkedtoageatmenopause

AdaptedfromtheFraminghamStudy,DHEWNo74,1974

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Screeningformetabolicdisease

• History:PersonalandFamily• Examination:Fullphysical,BP,height,weight,BMI,eyes..• Bloodtests:BloodLipids,Sugars,Electrolytes,LFT,FBC,Iron,TSH• Urinanalysis• Advice:DietandlifestylemeasuresalonemayreduceCHDriskby10-15%- Exercise,normalizationofBMI,ceasesmoking,healthylifestyle• ManagementofhypertensionmayreduceCHDriskby20-25%

Lichtenstein A et al Circulation 2006;114:82-96Maruthur N et al Circulation 2009;119:2026-31Ridker P N Eng J Med 2005;352:1293-304Lobo R et al Climacteric 2014;17:540-556

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Gynecologicalmatters

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• Estrogencausesendometrialproliferation

• Progesteroneinducessecretorychangeinestrogenstimulatedendometrium

• Unopposedestrogen(eg withanovulation)causeshyperplasia,atypiacomplexatypia,cancer

HormonesandmenstrualBleeding

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Etiologyofabnormalbleeding

• Abnormalmenstrualpatternmaybeattributedtostructural andfunctional causes

• TheetiologyofDysfunctionalAUBispresumedtobehormonalimbalance,tendstobediagnosisbyexclusion

FIGOPALM- COEINClassification

Structural

•Polyp•Adenomyosis•Leiomyoma•Malignancy and hyperplasia

• Coagulopathy•Ovulatiory dysfunction•Endometrial•Iatrogenic•Notidentified

Functional

MunroMG,etal.Int JGynecol Obstet 2011;113(1):3-13