Foreword: Equity, Diversity, and Inclusion—and Women’s Health xv
Preface: Not a 70-Kilogram Man xvii
Andrea E. Carter and Sarah Merriam
Menopause, which is defined as the point in time 12 months after a woman’s final menstrual period, is marked by a decrease in estrogen and accompanying symptoms including vasomotor and genitourinary symptoms. Hormone therapy is the most effective treatment of vasomotor symptoms and is first-line in women with moderate-to-severe vasomotor symptoms who are early in the menopausal transition and do not have a contraindication. Nonhormonal pharmacologic and nonpharmacologic treatments are also available for the treatment of menopause-related symptoms for women who prefer to avoid hormones or who have a contraindication to hormone therapy.
Osteoporosis is the most common bone disease in adults and confers significant morbidity and mortality in women. Universal screening is recommended for women above the age of 65 years; however, screening rates remain low. Bisphosphonates are the treatment of choice despite a decline in their use due to concerns about rare side effects. Treatment of osteoporosis dramatically decreases the likelihood of fragility fractures.
Polycystic Ovarian Syndrome 227
Sneha Shrivastava and Rosemarie L. Conigliaro
Polycystic ovarian syndrome (PCOS) is a complex, familial, polygenetic metabolic condition. The Rotterdam criteria are commonly used to diagnose PCOS. Lifestyle changes are the first-line treatment of PCOS. Treatment options for menstrual irregularities and hirsutism are based on the clinical goals and preferences of the patient. Along with treating the symptoms of PCOS, it is essential to screen and treat the comorbid conditions commonly associated with PCOS, including type 2 diabetes mellitus, obesity, nonalcoholic fatty liver disease, hyperlipidemia, obstructive sleep apnea, anxiety, depression, infertility, and vitamin D deficiency.
Abnormal Uterine Bleeding 235
Elena Lebduska, Deidra Beshear, and Brielle M. Spataro
Abnormal uterine bleeding is a common problem in premenopausal women and refers to uterine bleeding that is abnormal in frequency, duration, volume, and/or regularity. Etiologies can be classified using the PALM-COIEN system. Patients should receive a comprehensive history and physical with special attention to menstrual, sexual, and family history. Physical examination needs to include a pelvic examination with speculum and bimanual components. All patients need to have a pregnancy test and CBC with platelets. Treatments vary by etiology. Medical treatments include levonorgestrel intrauterine devices, oral contraceptive pills, and tranexamic acid. Surgical treatment options include endometrial ablation and hysterectomy.
Rachel A. Bonnema
This article outlines the basics of all contraceptive options available in the United States, providing providers necessary information to best provide equitable contraceptive care for women. Long-acting reversible contraception should be considered in all women as there are few contraindications to use. Levonorgestrel intrauterine devices have been found to be safe for use for longer periods of time, in some cases up to eight years. Combination hormone contraceptives remain popular and offer benefits beyond contraception; importantly newer formulations exist providing patients with more contraceptive options. Education regarding emergency contraception should be provided to all patients.
Cervical Cancer Screening 259
Katherine Gavinski and Deborah DiNardo
Cervical cancer screening is an essential component of preventative health care. Although rates of cervical cancer have decreased over the last 50 years, survival has not changed dramatically, and there are significant discrepancies in disease detection by race. Multiple national organizations contribute to the recommendations for cervical cancer screening timing, testing modalities, and management. This article aims to summarize the current understanding of cervical cancer pathogenesis, options for cervical cancer screening, and the shift in guidelines toward risk-based clinical management.
Breast Cancer: Risk Assessment, Screening, and Primary Prevention 271
Elena Michaels, Rebeca Ortiz Worthington, and Jennifer Rusiecki
This review provides an outline of a risk-based approach to breast cancer screening and prevention. All women should be assessed for breast cancer risk starting at age 18 with identification of modifiable and non-modifiable risk factors. Patients can then be stratified into average, moderate, and high-risk groups with personalized screening and prevention plans. Counseling on breast awareness and lifestyle changes is recommended for all women, regardless of risk category. High-risk individuals may benefit from additional screening modalities such as MRI and chemoprevention and should be managed closely by a multidisciplinary team.
Updates in Cardiovascular Disease Prevention, Diagnosis, and Treatment in Women 285
Sarah Jones, Melissa McNeil, and Agnes Koczo
Cardiovascular disease (CVD) is the leading cause of death for American women. CVD is preventable although risk reduction goals are not achieved for women compared with men. Considering a woman’s cardiometabolic profile for prevention counseling and prescribing may help. Coronary artery calcium scores provide additional risk assessment and reproductive and menopause histories identify risk enhancers. Diagnosis of CVD is often delayed, and treatment is less optimal for women compared with men. Differences in presentation and underlying CVD etiology (Including spontaneous coronary artery dissection and microvascular disease) may partially account for these disparities. Improvements in CVD imaging to better diagnose these etiologies may benefit women’s care.
Infectious Vaginitis, Cervicitis, and Pelvic Inflammatory Disease 299
Vaginal symptoms are one of the most common reasons women consult with physicians and can significantly impact quality of life. The differential diagnosis of vaginal discharge includes physiologic discharge, vaginitis, cervicitis, and pelvic inflammatory disease (PID). Vaginitis is inflammation of the vagina, most commonly caused by bacterial vaginosis (BV), vulvovaginal candidiasis, and trichomoniasis infections. Cervicitis is an inflammation of the cervix and typically caused by Chlamydia trachomatis and Neisseria gonorrhoeae. PID is infection of the female upper genital tract, involving the uterus, fallopian tubes, ovaries, and/or pelvic peritoneum and usually caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and bacterial vaginosis-associated pathogens. A pelvic exam should be performed for any woman presenting with vaginal discharge to confirm the diagnosis and rule out an upper tract infection. BV and vulvovaginal candidal infections only require treatment if symptomatic and do not require partner therapy, whereas treatment and partner therapy is recommended for sexually transmitted illnesses, such as trichomoniasis, chlamydia and gonorrhea. Vaginitis may be uncomfortable, but rarely leads to serious long-term consequence, but pelvic inflammatory disease can lead to serious long-term sequelae, including increased risk for ectopic pregnancy, infertility, and chronic pelvic pain.
Structural Gynecological Disease: Fibroids, Endometriosis, Ovarian Cysts 317
Amy H. Farkas, Hannah Abumusa, and Brianna Rossiter
Fibroids, endometriosis, and ovarian cysts are common conditions. Fibroids can be asymptomatic or present with heavy menstrual bleeding, pelvic pressure, and pain. Endometriosis is a common cause of cyclical pelvic pain. Ovarian cysts are generally diagnosed incidentally. Transvaginal ultrasound is the performed imaging modality for all structural gynecological disease. Symptomatic management is recommended for each condition. Fibroids can be managed medically or surgically depending on the patient’s symptoms and desire for future fertility. Nonsteroidal anti-inflammatory drugs are the first-line therapy for endometriosis followed by oral contraceptives and surgical management. Ovarian cysts can be managed expectantly.
Ovarian, Uterine, and Vulvovaginal Cancers: Screening, Treatment Overview, and Prognosis 329
Deborah Gomez Kwolek, Stefanie Gerstberger, Sarah Tait, and Jeanna M. Qiu
Ovarian, uterine, and vulvovaginal cancers affect approximately 96,000 women per year in the United States, resulting in approximately 29,000 deaths annually. Routine screening protocols do not detect these malignancies; thus, the recognition of risk factors and evaluation of worrisome symptoms are essential for early detection and improved prognoses. Treatment is managed by gynecologic oncologists, and often involves a combination of surgery, chemotherapy, and possible radiation treatments. Survivor care is managed by the primary-care clinician: expert attention to the mental, physical, and sexual health of each patient will ensure the best outcomes and quality of life.
Genitourinary Syndrome of Menopause 357
Shanice Cox, Ryan Nasseri, Rachel S. Rubin, and Yahir Santiago-Lastra
Introduced in 2014, genitourinary syndrome of menopause (GSM) describes a variety of unpleasant genital, sexual and urinary symptoms that can either be isolated or coexisting and are not related to other medical conditions. GSM is a chronic and progressive condition that requires early recognition and appropriate management to preserve urogenital health. Despite the importance of early detection and treatment, the condition is consistently underdiagnosed and undertreated. Herein, we emphasize how to diagnose GSM in postmenopausal, hypoestrogenic, and hypoandrogenic women and summarize evidence-based treatments focusing on prescription treatments and adjunctive therapies.
Affirming Care for Transgender Patients 371
Rebecca Green, Kristen L. Eckstrand, Morgan Faeder, Sarah Tilstra, and Eloho Ufomata
Gender identity is a deeply felt internal sense of self, which may correspond (cisgender) or not correspond (transgender) with the person’s assigned sex at birth. Transgender, nonbinary, and gender diverse people may choose to affirm their gender in any number of ways including medical gender affirmation. This is a primer on the medical care of transgender individuals which covers an introduction to understanding a common language, history of transgender medical care, creating a welcoming environment, hormone therapy, surgical therapies, fertility considerations, and cancer screening in transgender people.
Intimate Partner Violence 385
IPV is a widespread and destructive public health problem that impacts women across the world and the lifespan. IPV encompasses a wide range of negative behaviors towards a person’s romantic partner which include physical aggression, sexual violence, stalking, psychological torment, and coercive behaviors. Persons who experience IPV face a wide range of debilitating physical, mental health, and financial outcomes compared to those who have never experienced violence. Physicians play an important role in caring for patients who have experienced violence; knowledge of IPV’s impact, consequences, treatment, and patient preferences around IPV discussions can lead to improved patient satisfaction and outcomes.