Disease and Disorders Common in Midlife Women

Question 1

arthritis

Answer 1

-joint-based pain; swelling and restricting movement
-common w increasing age & women
-meno effects incidence & severity
-need good H&P, see sxs pattern

Question 2

rheumatoid arthritis

Answer 2

-multiple joints; symmetrical
-progressive; variable with activity
-early morning stiffness >30min
-joint swelling, tenderness, +MCP swelling

Question 3

osteoarthritis

Answer 3

-single/multiple; a/symmetrical
-episodic/progressive; with activity
-NO early morning stiffness
-joint swelling, maybe tender, occasional MCP swelling

Question 4

gout/pseudogout

Answer 4

-single or few; no symmetry
-episodic, some flare up with activity
-early morning stiffness with flare-ups
-joint swelling, redness, tenderness; occasional MCP swelling

Question 5

OA

Answer 5

-60% risk in obese women
-progressive loss of cartilage ->joint fail
-knees, hips, hands
-onset around meno

Question 6

OA tx

Answer 6

-wt control/exercise
-devices that offload movement in joints
-tylenol & topical NSAIDs first line
-surgery

Question 7

RA

Answer 7

-inflammatory arthritis
-peak onset 35-55yo women; 3x more
-perimeno & postmeno –> rheum specialist
-no issues with hormone therapy

Question 8

RA tx

Answer 8

-methotrexate, hydroxychloroquine, sulfasalazine
-modern biologics, TNF antagonists - abatacept, humira, etc
-goal is remission

Question 9

seronegative spondyloarthritis

Answer 9

-inflamm back pain, restricted spine
-sensitivity at SI joints; prolonged stiffness w inactivity
-a/w iritis, IBS, tendinopathies, peripheral enthesitis
-MRI & XR changes
-tx NSAID and PT, some biologics

Question 10

psoriatic arthritis

Answer 10

-peripheral arthritis
-responds to TNF antagonists
-ab testing usually negative

Question 11

crystal arthropathies

Answer 11

-gout –> monosodium urate crystals
-pseudogout –> calcium pyrophosphate crystals

Question 12

depression - predictive factors

Answer 12

-hx of depression, premens syndrome, postpartum depression
-menopause transition
-hx of abuse/trauma

Question 13

windows of vulnerability

Answer 13

some (not all) women are particularly sensitive to change in the hormone milieu, esp in those experienced premenstrually, during the postpartum period, or during meno transition
-change in sex hormones & metabolism; lifestyle, behaviories, sexuality, QOL

Question 14

depression expression

Answer 14

-CV risk factors - wt, smoking, etc
-Metabolic risk factors
-Severity of VMS
-sleep changes
-ethnicity
-lifestyle
-stressful life

Question 15

risk of depressive sxs

Answer 15

-25-30% risk in premeno
-45-70% risk in perimeno
-SWAN - hispanic women
-3 studies show increased risk in meno transition
-no hx of depression, greater risk if having significant VMS or life events

Question 16

anxiety in midlife

Answer 16

-lower QOL regardless of VMS and sleep change
-surge of anxiety late in perimeno vs premeno
-hot flashes <–> anxiety
-PTSD, OCD, panic

Question 17

anxiety sxs

Answer 17

-irritability
-nervousness
-feeling fearful for no reason

Question 18

estrogen on depression

Answer 18

-estrogen causes modulatory effect via neurotransmitter pathways & neural receptors; monoaminergic systems - serotonin & noradrenaline
-ER throughout brain; prefrontal cortex, hippocampus for mood/cognition
-improves tryptophan levels
-can have benefits in prevention during meno transition

Question 19

antidepressants

Answer 19

-SSRI/SNRI
-beneficial in tx when combined w ET
-good efficacy & tolerability

Question 20

thyroid disease

Answer 20

-common in women; increase w age
-regulates metabolism
-sxs of hyper/hypo can be confused w meno
-screening recs vary
-circulating iodine + amino acid tyrosine = T3 or T4
-efx on liver, muscle, heart, bone, & CNS

Question 21

hypothyroidism

Answer 21

-low production of thyroid hormone
-Hashimoto thyroiditis (x7 times in women at midlife)
-fatigue, lethargy, cold intolerance, wt gain, constipation, dry skin, heavier/longer menses
-TSH testing gold standard; plus free T4 & antithyroperoxidase ab (+Hashimoto)
-tx levothyorxine; 1.6mcg/kg wt based

Question 22

monitoring hypothyroidism

Answer 22

-monitor every 6-12mo
-dose change w TSH level in 6-8wk
-med taken early to enhance absorption
-oral estrogen = increase in thyroid-binding globulin (TBG) = lowers FT4

Question 23

subclinical hypothyroidism

Answer 23

-high TSH, normal FT4
-increased prevalence with age
-tx is individualized depending on sxs if any

Question 24

hyperthyroidism

Answer 24

-prevalence 0.5%
-anxiety, palpitations, lighter/less frequent menses, heat intolerance; mimics meno sxs
-Graves, toxic multinodular goiter, solitary hyperfunctioning (toxic) adenoma
-dx with TSH; if low, check FT4. if normal, check TT3

Question 25

thyroid nodule

Answer 25

-discrete lesion w/in thyroid
-high prev in women & elderly; 5% palpable
-further eval if seen on US or felt on PE

Question 26

thyroid cancer

Answer 26

-dx’d more in women
-incidence 40-50yo
->90% differentiated thyroid ca are papillary or follicular
-tx management w endo
-no screening in asymptomatic adults per USPSTF

Question 27

gallbladder disease

Answer 27

-2x in women than in men
-most asymptomatic
-RFs: sex, increased parity, age, hormone use, obesity, rapid weight loss
-highest incidence in 1) American Indians & 2) Mexican Americans

Question 28

Gallbladder & Hormone Therapy

Answer 28

-exogenous estrogen alone or in combined hormone contraceptives risk developing cholesterol gallstones by increasing hepatic secretion of biliary cholesterol
-incr risk cholelithiasis, -cystitis, -cystectomy
-oral is worse than transdermal
-admin HT w caution in women w hx of chole-

Question 29

STIs

Answer 29

-incr risks (including HIV) with vaginal atrophy
-older women need more info than younger; still at risk if sex active
-HIV & hep C in certain populations; no routine screening for sexually active postmeno women, based on sex hx
-consider expedited partner tx per state recs

Question 30

STIs

Answer 30

-chlamydia trachomatis
-neisseria gonorrhoeae
-genital herpes (HSV)
-human papillomavirus (HPV)
-hepatitis B
-hepatitis C
- HIV
-syphilis
-vaginal trichomoniasis

Question 31

STI routine screening

Answer 31

-screening for defined populations of asymptomatic women based on age, pregnancy status, or geographic factors, irrespective of personal behaviors or risk factors

Question 32

STI targeted screening

Answer 32

-women who have an increased risk of infection based on personal sexual behaviors (more than 1 sexual partner in the past year; new partner in the past 90 days
-factors identified locally, including prevalence of infection in the community, are important

Question 33

STI contact testing

Answer 33

-woman’s sexual partner is suspected or known to have chlamydia, gonorrhea, syphilis, HIV, or hep B or C

Question 34

STI coinfection testing

Answer 34

-performed after a woman is dx’d w one STI to find coincident infection with other pathogens
-women dx’d w chlamydia, gonorrhea, syphilis, HIV, or primary herpes should be screened for other pathogens
-not necessary for women dx’d w recurrent genital warts or recurrent genital herpes
-bacterial vaginosis and vaginal candidiasis are not sexually transmitted and are not a reason to perform this test

Question 35

STI diagnostic testing

Answer 35

-should be performed for any woman who, because of s/sxs of infection, is suspected of having an STI

Question 36

chlamydia

Answer 36

-mostly women <25yo
-sxs include purulent cervical or vaginal discharge, dysuria, deep dyspareunia, AUB
-dx’d w nucleic acid amplification tests; urine testing is okay (picks up 10% less)
-test of cure not necessary; rescreen in 3 mo

Question 37

chlamydia tx

Answer 37

-single dose azithromycin 1g PO
-doxycycline 100mg BID x7 days PO

Question 38

gonorrhea

Answer 38

-found in cervix, anus, urethra, pharynx, eyes
-sxs include pain/burning w urination, vaginal discharge, postcoital, intermenstrual, or postmeno bleeding
-dx w nucleic acid amplification tests w vaginal sample
-quinolones no longer rec for tx d/t resistance

Question 39

gonorrhea tx

Answer 39

-ceftriaxone 250mg IM + azithromycin 1g PO
-single dose cefixime 400mg PO + azithromycin 1g PO

Question 40

genital herpes

Answer 40

-HSV 1 and HSV 2 transmitted by skin-to-skin genital contact; can be caused by asymptomatic shedding
-sxs include prodromal burning, itching, & skin hypersensitivity, followed by vesicles or pustules on the vulva, perineum, or rectum, that break and leave tender ulcers
-initial infection can take 2-3wks to heal with primary herpes and 7-10days with recurrent herpes
-dx with a type-specific herpes culture or a polymerase chain reaction test from active lesion
-routine serologic testing not recommended

Question 41

genital herpes tx

Answer 41

-not for cure: antiviral medication during earliest phase of an outbreak can shorten duration, including acyclovir, famciclovir, valacyclovir for
-7-10days (initial outbreak)
-1-5days (recurrence)

Question 42

human papillomavirus

Answer 42

-causes almost all cervical ca as well as ca of the vagina, vulva, penis, anus, rectum, & oropharynx
-genotype 16/18 are high risk for cervical a
-genotype 6 & 11 can cause genital warts and low-grade cervical lesions
-by age 50yo, at least 80% of US women will have acquired genital HPV infection and most clear it on their own
-9 valent vaccine (Gardasil 9) should e given to girls and women age 9-26yo; which has been expanded through 45yo

Question 43

hepatitis B

Answer 43

-concentrated in blood, semen, vaginal secretions, and wound exudates, and is transmitted primarily by percutaneous exposure to blood and sexual contact
-10% of adults develop chronic hepatitis (risk for cirrhosis and liver ca)
-national strategy for control is through vaccination
-screen high-risk persons: HIV positive, injection, drug users, household contacts, or sex partners of positive persons, men who have sex w men, immigrants from geographic regions w prevalence of 2% or more
-immunize adults w DM and chronic liver disease

Question 44

hepatitis C

Answer 44

-passed mainly by blood contact (sharing IV drug equipment)
-most become chronic, incurring risk of cirrhosis and liver ca
-asymptomatic, so anyone born between 1945 and 1965 should be screened
-if positive, should be under brief etoh screen and intervention and referral to appropriate services (hepatology)

Question 45

HIV

Answer 45

-16% of people infected w HIV don’t know they are infected, so adults between 15-65yo should be screened at least once regardless of risk factors
-targeted annual screening: past or present injection drug users, sex partners of HIV-infected persons, men who have sex w men, more than one sex partner
-testing is done with 4th gen HIV ag-abcombo testing or 3rd gen ab immunoassay
-guidance recommends antiretroviral therapy for all HIV-infected patients to reduce the risk of disease progression and transmission; best done by HIV experienced specialist (ID)

Question 46

syphilis

Answer 46

-caused by treponema pallidum & is considered the “great imitator” bc many of its s/sxs are indistinguishable from those of other diseases
-includes: PRIMARY stage (single, painless chancre for 3-6wks); SECONDARY stage (multiple chancres, skin rashes, mucous membrane lesions); LATENT stage (untreated can cause death)
-test w rapid plasma regain & confirm by treponemal serum ab test (risk of false positives)
-tx: single injection of benzathine penicillin

Question 47

vaginal trichomoniasis

Answer 47

-most curable STI; seen in all ages
-caused by trichomonas vaginalis and can involve vagina, endocervix, urethra; 5% may be asymptomatic colonization
-sxs include yellow-green or gray vaginal discharge, vulvovaginal irritation & itching, strong unpleasant odor, discomfort w intercourse or urination
-dx: saline suspension, POCT, nucleic acid testing
-tx: metronidazole or tinidazole single oral dose, tx partners

Question 48

bacterial vaginosis

Answer 48

-not an STI
-imbalance in vaginal bacterial flora in which normal lactobacilli are replaced by Gardnerella vaginalis and other anaerobic bacteria
-sxs include thin, white, or gray vaginal discharge w a high pH and strong fishy odor
-dx: 4 Amsel’s criteria = a thin homogenous white vaginal discharge, clue cells accounting for at least 20% of vag epithelial cells on microscopy, pH higher than 4.5, and positive “whiff” test (w KOH or amine test), or POCT probe
-tx: metronidazole or clindamycin vag cream, alternative regimens include oral tinidazole and or oral clindamycin