Session 1 Assignment: Discuss HRT (what medications are available, indications, and associated risks), Hemoglobin A1c (prediabetes vs diabetes levels and HgbA1c levels and age), and Sister Mary Joseph Nodules.

HRT

• Not used as much anymore as in the past
• Considerations:
  • Age
  • Severity of symptoms
  • Years post-menopause
  • NO LONGER indicated for prevention of chronic diseases like coronary heart disease, osteoporosis, cognitive function, or prevention of dementia
• Contraindicated in women with a history of breast cancer, coronary heart disease, previous venous thromboembolic event or stroke, active liver disease, unexplained vaginal bleeding, high-risk endometrial cancer, or TIA
• 2 types:
  • Unopposed estrogen
    • For women with hysterectomy
  • Estrogen-progestin therapy
    • For women with intact uterus
    • To prevent estrogen-associated endometrial hyperplasia
  • Goals:
    • Relieve menopausal symptoms
  • Formulations
    • Systemic
      • For women being treated for menopausal symptoms like hot flashes and others
      • Avoid oral in women with hypertriglyceridemia, active gallbladder diseases, or known thrombocytopenia
      • Transdermal preferred in women with history of migraines with aura
    • Topical vaginal
      • For women being treated for vaginal atrophy only
    • Meds:
      • All types of estrogen are effective
        • 17-beta estradiol (1 mg/day PO or 0.05 mg/day transdermal)
          • If younger women with bilateral oophorectomy start at double dose and taper down after 2-3 years
          • Preferred because it is bioidentical (structurally identical) to the natural estrogen produced in the body
        • Conjugated equine estrogen (0.625 mg/day oral)
        • Low-estrogen oral contraceptive is an option for perimenopausal women who seek symptom relief and also contraception
          • Ethinyl estradiol
        • Progestin for women with intact uterus
          • 1^st line is oral natural micronized progesterone (start at 200 mg/day for 12 days/month to mimic the normal luteal phase or 100 mg/day in a continuous regimen
          • Medroxyprogesterone acetate (2.5 mg/day)
            • Aka Provera
          • If they can’t tolerate the cyclical or continuous oral progesterone therapy:
            • Vaginal use of micronized progesterone
            • Levonogestrel-releasing IUD (Mirena)
              • Not currently approved for this use in the US, but if perimenopausal women had this in place already their doctor might suggest leaving it in until they finish the transition to menopause
            • Conjugated estrogen/bazedoxifene (Selective estrogen receptor modulator [SERM])
              • Bazedoxifene prevents endometrial hyperplasia so progestin is not necessary
            • Side effects of estrogen:
              • Breast soreness
              • Vaginal bleeding in almost all women receiving cyclic estrogen-progestin therapy
              • Increased risk of breast and ovarian cancer
              • Increased risk of blood blots
              • Endometrial hyperplasia or carcinoma
            • Side effects for progesterone:
              • Mood symptoms
              • Bloating

HgbA1c

• Typically, we want the HgbA1c to be below 5.7%
• Prediabetes:
  • 7 – 6.4%
• Diabetes:
  • 5% or above
  • Higher number = lower blood sugar control
• HgbA1c levels positively associated with age in nondiabetic populations without diabetes, but this is pretty nonspecific
  • Typically over the age of 65 with more than 10 years life expectancy the targer A1c is 7 – 7.5% and with less than 10 years life expectancy 7.5 – 8%
  • Efficacy of this screening decreases with age

Sister Mary Joseph Nodule

• Palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen
• Can be painful to palpation
• Mostly present in GI malignancies
  • Gastric
  • Colonic
  • Pancreatic
    • Often 1^st sign
    • Usually indicative of cancer in the tail and body
  • Gynecological malignancies account for 25% of SMJ nodes
    • Primarily ovarian and uterine
  • Rarely from appendiceal cancer and pseudomyxoma peritonei
    • Pseudomyxoma peritonei:
      • Condition caused by cancerous cells that produce abundant mucin or gelatinous ascites
      • Causes fibrosis of tissues and impedes digestion or organ function
      • If left untreated, the tumors and mucin will fill the abdominal cavity and compress the organs

Session 2: Discuss the differential diagnosis for excessive vomiting during pregnancy

In addition to hyperemesis gravidarum:

Session 3 Assignment: Find an article relevant to OB/GYN and submit it with an article summary

Adjuvant Human Papillomavirus Vaccine to Reduce Recurrent Cervical Dysplasia in Unvaccinated Women: A Systematic Review and Meta-Analysis

Lickter, K., Krause, D., Xu, J., Tsai, S. H. L., Hage, C., Weston, E., Eke, A., & Levinson, K. (2020). Adjuvant Human Papillomavirus vaccine to reduce recurrent cervical dysplasia in unvaccinated women: A systematic review and meta-analysis. Obstetrics & Gynecology; 135 (5), 1070 – 1083.

https://journals.lww.com/greenjournal/Fulltext/2020/05000/Adjuvant_Human_Papillomavirus_Vaccine_to_Reduce.12.aspx

Summary

This article is a systematic review and meta-analysis that aims to determine whether administering the HPV vaccination in unvaccinated women decreases the incidence of recurrence of cervical intraepithelial neoplasia (CIN) 2 or greater specifically linked to HPV strains 16 and 18 6-48 months following surgical excision (LEEP, conization, and cryosurgery therapy). The researchers compiled nearly 6,000 articles published within the last 20 years and selected 6 that fit their inclusion criteria.

A total of 2,984 women were included in the study. Studies that included women with invasive disease, immunodeficiency, autoimmune conditions, women taking systemic corticosteroids other than inhaled or less than 10mg of prednisone or an equivalent, pregnant women or less than 3 months postpartum, and breastfeeding women were excluded from this systematic review and meta-analysis.

They found that adjuvant administration of the HPV vaccination with surgical treatment for CIN 2 or greater was associated with a significantly decreased risk of recurrence 6-48 months after excision (p = .0001, RR 95% CI 0.36 [0.23 – 0.55]). Secondarily, they also found that there was a decreased risk of CIN 1 with adjuvant administration of the HPV vaccination. One hypothesis of why this is so is because the vaccination may potentially provide cross protection for other strains of HPV to which the patient has not been exposed or even other strains not necessarily covered by the vaccination itself. Another hypothesis for the efficacy of the vaccination is that the surgery may cause a change in the microenvironment akin to that of an unexposed patient, so the prophylactic effect might be similar to that experienced by unexposed patients receiving the vaccination.

One strength of this study is how recently it has been published; this allowed the researchers to survey the newest studies and most up-to-date information to come to their conclusion. Additionally, all the articles they included in their systematic review were of high quality and allowed them to include a large number of participants, making the power of the study quite high.

One limitation of this study was that the six studies had unequal numbers of participants, so those with a greater number of participants could have skewed the data. Additionally, not all six studies included were randomized, which might have led to some reporting or observational bias. Moreover, the point at which the women included in the study were vaccinated was not standardized among all 6 studies included, so this would need to be further investigated.