Cynthia s Primary Care Primer on Gyn: Paps, HPV, Birth Control and STDs

Cynthia’s Primary Care Primer on Gyn: Paps, HPV, Birth Control and STDs Cynthia Morris DO, FACOOG, FACOS Medical Director Fayette County Memorial Hosp...
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Cynthia’s Primary Care Primer on Gyn: Paps, HPV, Birth Control and STDs Cynthia Morris DO, FACOOG, FACOS Medical Director Fayette County Memorial Hospital Women’s Wellness Center

The goals of this presentation are…. 1. Understand and be able to implement current American Society of Cytologists and Cytopathologists (ASCCP) guidelines for cervical cancer screening  2. Understand patient selection as well as risks and benefits of the human papilloma virus (HPV) vaccine  3. Understand current Center for Disease Control (CDC) guidelines for chlamydia screening 

Background

Percent* of Women Who Said Topic Was Discussed During First Visit With New Gynecological or Obstetrical Doctor/Health Care Professional Breast Self Exam

4%

69%

Pap Smear

60%

12%

Birth Control

33%

20%

Mammograms

34%

7%

Sexual History and/or Current… Alcohol Use

1%

24%

HIV/AIDS STDs other than HIV/AIDS

3%

36% 2%

19% 12% 0%

HCP asked Pt. asked

3% 20%

40%

60%

80%

may not total to 100% because of rounding or respondents answering “Don’t know” to the question “Who initiated this conversation?” 3 Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997 *Percentages

Pap Smears…. Use liquid based preparation for best results Know the ASCCP guidelines for screening Understand when HPV testing with pap is appropriate Know when colposcopy is needed

Pap test utilization

NOTE: Pap tests (Pap smears) may be used for screening or diagnostic purposes; the purpose cannot be determined from NHIS. SOURCE: CDC/NCHS, Health, United States, 2015, Figure 10 and Table 71. Data from the National Health Interview Survey (NHIS).

When to pap…. 

  

Starting at age 21 (no pap in women under the age of 21). Pap smear recommended every 3 years. HPV testing as routine is NOT recommended but if ASC-US (atypical squamous cells of undetermined significance) then reflex HPV testing recommended. (acceptable ages 21-24, recommended ages 25-29) Ages 30-65 pap and HPV testing together recommended every 5 years After age 65 no screening is recommended After hysterectomy no screening is recommended

Exceptions for pap screening 

If the patient has had the HPV vaccine……. Follow the same screening guidelines for their age group.



If the patient has their cervix after hysterectomy (supracervical hysterectomy)….Follow the guidelines for their age



If the patient had a hysterectomy for cervical cancer or severe dysplasia (cervical intraepithelial neoplasia CIN 2/3) continue pap smears of the vaginal cuff and vagina for 20 years after the procedure (even beyond age 65)



After age 65 if patient has had CIN 2/3 then the screening continues for 20 years

Managing abnormal pap smears 

Unsatisfactory cytology….repeat pap in 2-4 months



Normal pap but no endocervical cells on pap…follow routine screening guidelines



Normal pap but HPV positive –repeat pap and HPV in 1 year OR do HPV DNA typing …..checking for HPV types 16 or 18……if negative for HPV 16 or HPV 18, repeat pap and HPV in 1 year but if positive the colposcopy is recommended.



If ASCUS, HPV testing is preferred BUT could also repeat pap and HPV in 1 year. If ASCUS and HPV negative, repeat pap and HPV in 3 years. IF HPV positive, then needs colposcopy



In ages 21-24 with ASCUS or LSIL (low grade squamous intraepithelial lesion), repeat pap in 12 months.



ASC-H or ASCUS-H…this means that the pathologist cannot rule out a high grade lesion and this patient needs colposcopy

There is an app for that….. 

ASCCP has an app with screening guidelines and management protocols



It is $9.99



ASCCP graphics cannot be used without written permission



If you do a lot of pap smears, you should download the app

Human Papilloma Virus (HPV) 

Over 100 types of HPV 

80 cutaneous types 



Common foot and hand warts

40 mucosal types 



Low risk types 

6,11



Low grade pap changes



Genital warts



Laryngeal papillomatosis

High grade types 

16/18 most aggressive types



Cervical cancer



Oral cancer



Anal cancer



Abnormal pap smears

HPV 

Responsible for 17,000 female cancers in the US



Responsible for 9,000 male cancers in the US



27,000 new cancers in the US yearly



1 new case of cancer caused by HPV every 20 minutes



79 million people in the US currently infected



14 million new cases in the US every year



Cervical cancer worldwide  500,000

new cases with 275,000 deaths yearly (2008 statistics)



Cervical cancer US  11,000

new cases with 4,000 deaths yearly (2011 statistics)

Cervical cancer 37%

of cases in US are diagnosed in ages 20-44 13% ages 20-34 24% ages 35-44

HPV Vaccine 

Gardasil 9  Gardasil

(quadravalent vaccine) is no longer available

 Protects

against 6,11,16 and 18

 Additionally  Long

protects against 31,33,45,52 and 58

lasting-no evidence of waning protection

 HPV

16/18 cause 51 % of cervical cancers

 HPV

31,33,45,52 and 58 cause 15% of cervical cancers

 Protects

against 99% of genital warts

 Protects

against oral cancer

HPV burden in the US 

2.25 million cases of female genital HPV



$7 billion in healthcare costs for female genital HPV alone  1.4

million cases of LGSIL/CIN 1

 500,000

cases of genital warts

 330,000

cases of HGSIL, CIN 2/3

 11,000  4,000

cases of cervical cancer

cervical cancer deaths

Poor HPV vaccination rates 

71% of youth in Australia are vaccinated



60% of youth in United Kingdom



33% of youth in United States  87.6%

get Tdap

 79.3%

get MCV

 60%

females get first dose

Only  41.7%

39.7% complete the series

males get first dose

Only

21.6% complete the series

HPV vaccine side effects 

No risk of venous thrombotic episodes



No associated risk of autoimmune disease



Of 7.6% of total side effects that were reported as serious,  The

majority were

 HEADACHE  NAUSEA  VOMITING  FEVER 

The main side effects are fainting and arm soreness

Birth control

Let’s

talk about sex……..

Teen sex by the numbers…. 

By the end of high school, 65% (if not higher) of students have had sex



Of those teens sexually active, 1 in 5 will have four or more sexual partners



Teens are more likely to  Have

multiple partners

 Have

unprotected sex

 Use

drugs and alcohol

 Have

high risk behavior under the influence

Access to Contraception 

Access to contraception is protected by law in Ohio  Minors

can be seen for contraception and they do not need parental permission  You

should counsel minors about this and about billing to insurance that may show reason for the visit.

 Confidentiality  Same

protected by law

is true for evaluation and treatment of STDs

Teenage childbearing

SOURCE: CDC/NCHS, Health, United States, 2015, Figure 4 and Table 3. Data from the National Vital Statistics System (NVSS).

Birth control 

LARC  Long

acting contraception

Nexplanon

implant

Intrauterine Skyla

Mirena Paragard

device

Use of emergency contraception

Emergency Contraception 

Over the counter options 

Plan B One Step 

1.5mg levonorgestrel tablet. 





Take one pill orally one time. 

Take within 72 hours of sex



May have some benefit up to 5 days

Next Choice 

0.75mg levonorgestrel tablets (two tablets in package)



Also available as generic



Take one pill as soon as possible and then take second pill 12 hours later



OR Take both pills at the same time

Prescription option 

Ella 

30 mg of ulipristal 

Take one pill one time 

Take within 5 days of having sex

Emergency Contraception 

Copper IUD 

Paragard 

Can be inserted within 5 days of unprotected sex for emergency contraception

Sexually Transmitted Diseases (STDs) by the numbers 

In 2013 there were 56,482 cases of syphilis, 1,401,906 cases of chlamydia and 33,004 cases of gonorrhea reported



1 in 20 women ages 14-24 will be positive for chlamydia



1 in 5 men and women will have herpes by adulthood



Men ages 20-24 have the highest new rate of gonorrhea



In ages 15-24, 25% are sexually active and they have half of all newly diagnosed STDs.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Sexually Transmitted Disease Prevention

Background

Where Do People Go for STD Treatment? 

Population-based estimates from National Health and Social Life Survey Private provider

59%

Other clinic

15%

Emergency room

STD clinic

10%

9%

Family planning clinic

7%

Source: Brackbill et al. Where do people go for treatment of sexually transmitted diseases? 46 Family Planning Perspectives. 31(1):10-5, 1999

Chlamydia — Rates of Reported Cases by Sex, United States, 1994–2014

NOTE: As of January 2000, all 50 states and the District of Columbia have regulations that require the reporting of chlamydia cases. 2014-Fig 1. SR, Pg 8

Chlamydia — Percentage of Reported Cases by Sex and Selected Reporting Sources, United States, 2014

* HMO = health maintenance organization; HD = health department. NOTE: Other includes: Drug Treatment, Tuberculosis Clinic, Correctional Facility, Laboratory, Blood Bank, Labor and Delivery, Prenatal Care, National Job Training Program, School-based Clinic, Mental Health Provider, Other Hospital, Indian Health Service, Military, and HIV Counseling and Testing Site.

2013-Fig 8. SR, Pg 11

Chlamydia — Rates of Reported Cases by Age and Sex, United States, 2014

2014-Fig 5. SR, Pg 10

Chlamydia—Percentage of Reported Cases by Sex and Selected Reporting Sources, United States, 2012

*HMO=health maintenance organization; HD=health department

NOTE: Of all cases, 11.4% had a missing or unknown reporting source. Among cases with a known reporting source, the categories presented represent 69.8% of cases; 30.2% were reported from sources other than those shown.

2012-Fig 8. SR, Pg 12

CDC guidelines for treatment chlamydia Azithromycin

1 gram orally as a

single dose OR Doxycycline 100mg orally twice a day for 7 days

Gonorrhea — Rates of Reported Cases by Year, United States, 1941–2014

2014-Fig 12. SR, Pg 19

Gonorrhea — Rates of Reported Cases by Sex, United States, 1994–2014

2014-Fig 13. SR, Pg 19

CDC guidelines for treatment of gonorrhea  Ceftriaxone

250mg IM in a single dose PLUS azithromycin 1 gram orally in a single dose  If ceftriaxone is not available then cefixime 400mg orally in a single dose PLUS azithromycin 1 gram orally in a single dose

Primary and Secondary Syphilis — Reported Cases by Sex and Sexual Behavior, 27 Areas*, 2007–2014

*27

states reported sex of partner data for 70% of reported cases of primary and secondary syphilis for each year during 2007–2014. †

MSM = men who have sex with men; MSW = men who have sex with women only.

2014-Fig 32. SR, Pg 33

Primary and Secondary Syphilis — Rates of Reported Cases by Sex and Male-to-Female Rate Ratios, United States, 1990–2014

2014-Fig 33. SR, Pg 34

Trichomoniasis and Other Vaginal Infections Among Women—Initial Visits to Physicians’ Offices, United States, 1966–2013

NOTE:

The relative standard errors for trichomoniasis estimates range from 16% to 21% and for other vaginitis estimates range from 8% to 13%. SOURCE:

National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services™, IMS Health Report, 1966–2013. The 2014 data were not obtained in time to include them in this report.

2014-Fig 55 SR Pg 49

CDC guidelines for treatment of trichomoniasis  Metronidazole

2 grams orally in a single dose

OR  Tinidazole

2 grams orally in a single dose

OR  Metronidazole

days

500mg orally twice a day for 7

Genital Herpes—Initial Visits to Physicians’ Offices, United States, 1966–2013

NOTE:

The relative standard errors for genital herpes estimates of more than 100,000 range from 19% to 23%.

SOURCE:

National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services™. IMS Health Report, 1966– 2013. The 2014 data were not obtained in time to include them in this report. 2014-Fig 53. SR Pg 48

Genital Warts—Initial Visits to Physicians’ Offices, United States, 1966–2013

NOTE:

The relative standard errors for genital warts estimates of more than 100,000 range from 18% to 23%.

SOURCE:

National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services™. IMS Health Report, 1966– 2013. The 2014 data were not obtained in time to include them in this report. 2014-Fig 50. SR Pg 46

EPT 

Expedited Partner Therapy



Ohio State Law 4731.93  Prescribe

or furnish treatment for partners of patients diagnosed with chlamydia, gonorrhea or trichomonas



Ohio State Law 4729.282  Prescription

does not need to contain the name of the person being treated



Retest patient in 3 months



Abstain from sex for 7 days after treatment of patient and partners