PrEP for Women

Truvada for pre-exposure prophylaxis (PrEP) to prevent HIV transmission has been available to at-risk patients since it was approved by the FDA in 2012.  Despite this, it has found limited use among non-MSM (men who have sex with men) for HIV prevention. Truvada (emtricitabine/tenofovir disoproxil) is a pill that can be taken once a day that, when used consistently, can reduce the risk of acquiring HIV by more than 90%¹.  Truvada is generally well tolerated and is covered by most private insurance and Medicaid.  The CDC currently recommends PrEP for women with a known HIV+ sexual partner, a recent bacterial STI, multiple sexual partners, inconsistent or no condom use, women living in high prevalence areas, or women who are commercial sex workers¹.  The only criteria for starting PrEP are a negative HIV test and no signs/symptoms of acute HIV, normal renal function, and a documented hepatitis B status. 

 

Despite these generally broad recommendations for PrEP, few women are currently using it.  The use of PrEP has seen massive growth in the MSM community; however, the uptake of PrEP among women has been slow.  In data released by Gilead, the pharmaceutical company that produces Truvada, only 2,491 women were using PrEP in 2015 (approximately 20% of all patients using PrEP), which remained relatively stable from 2012 through 2015².  Yet, the CDC estimated in 2015 that 0.6% of women aged 18-59, or 468,000 women, had indications for using PrEP³.  Additionally, of those women initiating PrEP, significantly fewer African American women have used PrEP as compared with White women, despite being at greater risk of acquiring HIV².  According to data from the CDC, African American women are the group of women most at risk of acquiring HIV⁴.  4,189 African American women were estimated to be newly diagnosed with HIV in 2016 as compared with 1,032 White women and 1,025 Hispanic women⁴.  This absence of PrEP use is likely due to patients and physicians underestimating patients' HIV risk as well as a lack of knowledge regarding the use of PrEP in heterosexual females.  Those aware of PrEP often think of it as something that is purely for the MSM population and do not think of women that live in communities with high HIV prevalence.  Discussing the initiation of appropriate heterosexual females on PrEP is something that should be prioritized by primary care physicians as a means of further preventing HIV transmission, particularly in communities with high HIV prevalence. 

1. Centers for Disease Control and Prevention. Pre-exposure prophylaxis (PrEP) for HIV prevention. 2014. Available at: https://www.cdc.gov/hiv/pdf/PrEP_fact_sheet_final.pdf (accessed Dec 2017)
2. Bush, S. Magnuson D, Rawlings MK, et al. Racial characteristics of FTC/TDF for pre-exposure prophylaxis (PrEP) users in the US.  ASM Microbe 2016, 16-20 June 2016, Boston, MA.  
3. Smith DK, Van Handel M, Wolitski RJ et al. Vital signs issue details: estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV Acquisition – United States, 2015. MMWR Morb Mortal Wkly Rep. 2015; 64: 1291–1295.
4. Centers for Disease Control and Prevention. Basic Statistics.  Available at: https://www.cdc.gov/hiv/basics/statistics.html (accessed Dec 2017).

Alyssa Mezochow

DUCOM 2018

Validation of rights to preventive care and responsible primary preventive care for LGBTQ patients

LGBTQ persons tend not to seek care as often for services, such as pap smears and mammograms. Their reproductive organs may not serve their gender identity and therefore are neglected in terms of medical seeking behaviors.  One meta-analysis supported the fact that “health and utilization of healthcare services among LGBTQ individuals are adversely affected by marginalization; and

approximately 30% of LGBTQ adults do not seek healthcare services or lack a regular healthcare provider compared to 10% of age-matched heterosexuals.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4609168/

Many transgendered patients, however, do seek primary care services.  These services are protected by the Affordable Care Act which states: “An individual’s sex assigned at birth or gender identity also cannot limit them from a recommended preventive service that is medically appropriate for that individual; for example, a transgender man who has breast tissue or an intact cervix and meets other requirements for mammography or cervical cancer screening must receive those services without cost sharing regardless of sex at birth.” 

https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/

 

Paps for Chaps

The current laws that provide pap smears and mammograms for transgender males are being threatened by publicly announced attitudes held by the highest seat of federal power this year.

One physician shared the frustration she experienced while navigating transgender healthcare for her patients on the heels of these public announcements this summer on the AAFP blog:

http://www.aafp.org/news/blogs/freshperspectives/entry/20170803fp-transgendercare.html

This problem could be avoided if legally, and in the electronic health care records, people can be identified by their biological reproductive organ status in compliment to their gender status. Some EHRs have transitioned to this holistic approach but insurance companies and the government have not yet adopted this strategy to better serve the health of its constituents.  Medical provider and healthcare societies such as the AAFP, AMA, APA, ACOG and many more  have supported the equality of rights for transgendered individuals which is a promising step in the right direction.

http://www.lambdalegal.org/sites/default/files/publications/downloads/ll_trans_professional_statements.rtf_.pdf

 

Educating the Medical Workforce

Further efforts have been made by the Association of American Medical Colleges (AAMC) to create a database to educate medical providers on how to create and maintain trusted physician patient relationships so as to appreciate the diversity of medical needs and risks within the interplay of gender identity, biological sex and sexual orientation that comprise individuals.  Particularly important to medical education is assessing how well providers are motivated to acquire knowledge and retain the skills to provide competent care for LGBTQ patients.

https://www.aamc.org/initiatives/diversity/431388/videos.html

https://www.aamc.org/initiatives/diversity/450606/clinicalvignettes.html

 

One resource for medical education tools in assessing Trainee Competence in LGBT Patient Care is the MedEdPortal.org, a peer-reviewed, open-access journal that promotes educational scholarship and dissemination of teaching and assessment resources in the health professions.

Learning modules created and sponsored by the Fenway Institute for the National LBGT Health Education center can be found here for interested students and providers.

https://www.lgbthealtheducation.org/topic/transgender-health/

Practice guidelines for endocrine treatment of LGBT individuals have just been updated this year by the Endocrine Society. This step is significant in providing structure for interdisciplinary collaboration, evaluating patient outcomes, and further highlighting the validity and appropriateness of medical treatments for this patient population.

https://jamanetwork.com/journals/jama/fullarticle/2654242?resultClick=1

My hope for my graduate medical training and for the students entering medical school is that institutions will embrace awareness of the need for climate change around LGBT health and implement a curriculum to suit these needs. We must be the outspoken advocates for protection of patients’ rights to care.

Lindsey Lee  DUCOM 2018

 

Establishing a History of Trauma and Patient Advocacy in Light of #MeToo Viral Campaign

As emerging doctors in the early 21^st century we will set the tone for helping our patients reconnect with the world after a jarring interface with assault/ harassment that is out of proportion with their emotional and psychological perspective on life. This is not just a fad but a stake of civil unrest that had an earlier voice this year with the worldwide Women’s March. 

The following articles in reaction to the recent #metoo campaign provide personal stories and insights from survivors and their doctors. http://www.aafp.org/news/blogs/freshperspectives/entry/20171019fp-metoo.html

For people affected by gender based harassment, violence and abuse of power, these experiences are real and violating though they did may not amount to physical sexual misconduct by the aggressing party. In my own experience as a medical student, a patient without regard for the professional setting of the hospital placed me in a very uncomfortable situation. He knew that my role was to assess his symptoms, and after I asked him if he was ready to discuss this with me he proceeded to masturbate in his hospital bed. I wasn’t sure if I should believe what I saw and asked if he needed to use the restroom before our interview. He said no while never stopping his activity. At that point I told him I would not be conducting the interview until he stopped and was ready to act appropriately, and walked out of the room. I felt frozen and unable to stop the sexually harassing behavior when it was not acknowledged by the aggressor and felt that I had somehow failed. After that encounter, every patient room in the hospital felt too small and hostile for a few weeks. This encounter broke the trust I had with professional settings and rules of common social decency.  

As physicians and providers of healthcare, we should provide validation of stories from all vulnerable populations, showing them that their trauma is real and relatable so as not to further isolate the person.  We can do this by normalizing the spectrum of reactions and acknowledging that reactions may manifest in other ways such as mental health issues, physical stress, social isolation, inability to care for family members, or inability to function efficiently and at a high level at work. The provider, as the listener, should not insinuate that the abuse of power and harassment was unrelatable or unbelievable.  These experiences are the social determinants of health, and we need to meet the patient where they are in their struggle of revealing their truth.

The CDC provides many resources on violence prevention and the consequences that victims may experience as a result. Interestingly, some studies have shown long term repercussions of these events such as decreased likelihood to marry, which could be speculated to stem from a distrust of intimate partners, shame and guilt, and fear of future trauma.

https://www.cdc.gov/violenceprevention/sexualviolence/consequences.html

 

Physicians can also pick up on new health risk behaviors that may clue them in to inquiring about past abuse or violent events. When screening and counseling patients Trauma Informed Care in Behavioral Health Services suggests the use of the SLE screening or the STaT intimate partner violence screening tool and offers the following:

Advice to Counselors: Screening and Assessing Clients

• Ask all clients about any possible history of trauma; use a checklist to increase proper identification of such a history (see the online Adverse Childhood Experiences Study Score Calculator [http://acestudy.org/ace_score] for specific questions about adverse childhood experiences).
• Use only validated instruments for screening and assessment.
• Early in treatment, screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma.
• When clients screen positive, also screen for suicidal thoughts and behaviors (see TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment; Center for Substance Abuse Treatment [CSAT], 2009a).
• Do not delay screening; do not wait for a period of abstinence or stabilization of symptoms.
• Be aware that some clients will not make the connection between trauma in their histories and their current patterns of behavior (e.g., alcohol and drug use and/or avoidant behavior).
• Do not require clients to describe emotionally overwhelming traumatic events in detail.
• Focus assessment on how trauma symptoms affect clients’ current functioning.
• Consider using paper-and-pencil instruments for screening and assessment as well as self-report measures when appropriate; they are less threatening for some clients than a clinical interview.
• Talk about how you will use the findings to plan the client’s treatment, and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or moving directly into the active phase of treatment. It is helpful to explore the strategies clients have used in the past that have worked to relieve strong emotions (Fallot & Harris, 2001).
• At the end of the session, make sure the client is grounded and safe before leaving the interview room (Litz, Miller, Ruef, & McTeague, 2002). Readiness to leave can be assessed by checking on the degree to which the client is conscious of the current environment, what the client’s plan is for maintaining personal safety, and what the client’s plans are for the rest of the day.

Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 4, Screening and Assessment. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207188/

https://www.ncbi.nlm.nih.gov/books/NBK207188/

Further, Trauma Informed Care in Behavioral Health Services suggests that screening for histories of trauma is a primary prevention in the development of behavioral health disorders and health risk behaviors. It is our duty as physicians to address physical and psychosocial determinants of health at every interaction with patients. After all, we may only interact with a patient once over the course of their lives and cannot assume their last interaction with a physician is an accurate depiction of the person presenting to us.

As a medical student, I have learned several valuable lessons on the wards, possibly the most important of which is to never assume the previous record is complete or correct.  People have ever changing histories and truths that we must explore before simplifying an interaction to a diagnosis and treatment plan.

Lindsey Lee

DUCOM 2018

 

Osteoporosis--Earlier prevention, the better

Of the 10 million Americans who suffer from osteoporosis, 80% of them are women! Osteoporosis is a serious condition wherein bone mass is lost or not created at all, causing one's bones to become more porous or look like a honeycomb under a microscope. This causes bones to break easily from falls or minor injuries depending on the severity. Osteoporosis affects all bones, and in cases of the vertebrae, patients may even lose height because of a hunched stature. 


Unfortunately, this condition affects post menopausal women more because they have thinner, weaker bones than men. Additionally, estrogen, which is a key hormone that protects bones in women to decreases significantly in post-menopausal women, thereby also contributing to osteoporosis.
Current treatments for osteoporosis include short term hormone replacement therapy, specific medication to reduce fracture and slow bone breakdown, and bone strengthening exercises.
However, the good news is, methods of prevention earlier in one's life can greatly decrease the risks of osteoporosis. Prevention can be from actions as little as exercising regularly to build muscle and bone weight from an earlier age. Additionally, ensuring adequate dietary calcium or taking calcium supplements plus vitamin D starting in young adulthood can help build bones and greatly reduce fractures from osteoporosis. 


Osteoporosis is a severe condition that can lead to extremely painful consequences that are long lasting.  But with simple preventive steps starting today, you can start working on becoming a healthier and stronger version of yourself for the future!


Meghana Pisupati
IHS 2017

The #MeToo Campaign

Recently, on social media platforms, women and men have stood in solidarity with one another over this empowering--and unfortunate issue. The status goes,"If all the women who have been sexually harassed or assaulted wrote, 'Me too' as a status, we might give people a sense of the magnitude of the problem." As I was scrolling through my own social media feed, I was alarmed by the number of strong women who were impacted by horrible circumstances. When an issue as enormous as this is silently happening, where every 98 seconds, one American is sexually assaulted, awareness is NOT enough and we must all take a stand together.

http://www.vawlearningnetwork.ca/learning-network-resources/learning-network-infographics
Understanding and preventing rape culture is essential in this fight against sexual assault. 

There are approximately 371,500 victims of rape and sexual assault every year in America, and unfortunately, most of them are younger women, and transgender students.^{1, 2} Moreover, the long term effects on victims include PTSD, suicidal thoughts, and drug use.³ The fact that so many women and men have come forth in solidarity with this campaign speaks in volumes about our inability to address it thus far. 
While prevention remains the primary method of combating these staggering numbers, it will take generational change to learn the immense value of consent and respecting one another. Women should not be forced to dress certain ways, or constantly look over their shoulder during a late night walk, or be wary when not with a group of people. There should be legitimate repercussions for assailants' actions, which is not seen now, when only 6 out of 1,000 predators ends up in jail. 
We shouldn't be silenced for something that happened outside our control, and voicing our support for one another is where we should start. By taking a stand today, we can prevent the same from happening tomorrow. 

1. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2010-2014 (2015).
2. David Cantor, Bonnie Fisher, Susan Chibnall, Reanna Townsend, et. al. Association of American Universities (AAU), Report on the AAU Campus Climate Survey on Sexual Assault and Sexual Misconduct (September 21, 2015). ("Victim services agency” is defined in this study as a “public or privately funded organization that provides victims with support and services to aid their recovery, offer protection, guide them through the criminal justice process, and assist with obtaining restitution.” RAINN presents this data for educational purposes only, and strongly recommends using the citations to review any and all sources for more information and detail.)
3. DG Kilpatrick, CN Edumuds, AK Seymour. Rape in America: A Report to the Nation. Arlington, VA: National Victim Center and Medical University of South Carolina (1992).

Meghana Pisupati

IHS 2018 

Showing Migraines Who's Boss

At least one in four women suffer from migraines, a staggering number with a not so flattering history. Women who suffered from migraines in the past were considered incapable of coping with stress or suffering from hysteria. Luckily, this ignorant perception was quickly shattered once individuals realized that migraines were debilitating headaches with causes outside of "women being women." Although the exact specifics are still unknown, factors like genetics and environment are known to play a definite role. Also, changes in the brainstem, trigeminal pathway, hormonal influences with hormones like estrogen and serotonin have all been associated with migraine development.
The good news is that instead of curling up in your bedroom, void of any light, there are things you can do every day to prevent or at least reduce the extent of your next migraine! The first is by watching your diet; there are certain foods that may trigger migraines, including aged cheese, salty foods, excessive sweetness, wine, and caffeine. Stress, bright light, changes in sleep cycle and environment can also be triggers. So what can you do, you ask?  Eating these trigger foods in moderation is ideal in conjunction with a high ketone diet. A ketogenic diet is a low carbohydrate diet that helps reduce migraines by blocking high concentrations of glutamate, which is found in migraines and epilepsy. Moreover, the healthy fats found in this diet may also lower cholesterol, hitting two birds with one stone.
Regular exercise also can help to prevent migraines, especially aerobic ones like walking, swimming, and cycling. Ultimately, leading a healthy lifestyle with a regular schedule can greatly help to ameliorate migraines. Here's to beating migraines one day at a time!


Meghana Pisupati
IHS 2018

Cancer Screening in Transgender Individuals

Last year, one of our 4^th year Pathway students (Kelly Guttman) created a very informative presentation on Cancer Screening Health Disparities Among Transgender Patients – a topic worth revisiting here.  Many transgender individuals have had negative experiences with the healthcare system, often due to discrimination and lack of provider knowledge.  Many healthcare providers don’t know how to screen transgender patients for potential cancers so they are often overlooked.                                                                                                                                                                                   Bottom line:  If they have the “part” (e.g. breast, cervix, prostate), check it!

CERVICAL CANCER

Approximately 80% of transgender men [female-to-male (FTM) patients] have a uterus and cervix and therefore need screening.  Unfortunately, being transgender has been associated with 37% lower odds of being up-to-date with recommended cervical cancer screening.  Inadequate Paps have been over 8 times higher among transgender men, likely due to a combination of factors including histological changes induced by testosterone and patient/provider discomfort. 

BREAST CANCER

Approximately half of transgender men have surgery to remove their breasts while 80% of transgender women [male-to-female (MTF) patients] use estrogens to help grow the size of their breasts.  MTF patients taking exogenous estrogen and androgen antagonists develop breast tissue histologically identical to that of a cis-gender female.  Although studies have failed to show that MTF patients taking exogenous estrogen have an increased risk of breast cancer, there have been cases so individuals still need to be screened.  In addition, for transgender men who have undergone mastectomies, providers need to be aware that not all breast tissue may be removed, especially in a nipple-sparing procedure.

PROSTATE CANCER

Transgender women should be given all the same information provided to cis-males and be allowed to make an informed decision regarding screening.  Although guidelines for prostate cancer screening have changed and prostate-specific antigen (PSA) is no longer routinely recommended, it’s important to note that in the setting of prolonged estrogen exposure, as is the case with many transgender women patients, the PSA may be falsely low and therefore especially unreliable as a screening tool.  Rectal or transvaginal (if a neovagina has been created) exam of the prostate is recommended. 

 

SUMMARY

The American College of Obstetricians and Gynecologists recommends the following:

For FTM Patients - age appropriate screening for breast and cervical cancer unless complete mastectomy or hysterectomy has been performed.  Patients on androgen therapy who have not had a hysterectomy may be at increased risk for endometrial and ovarian cancer and should have a bimanual pelvic exam as recommended.

For FTM Patients - age appropriate screening for breast and prostate cancer

                                                     What you can do for a transgender patient

                                                             Create a welcoming environment.

                                 Be knowledgeable, non-judgmental and don’t make assumptions.

                Have an open discussion with patients about their cancer screening needs and schedule.

                                                                                                                   Judith Wolf, MD  Associate Director, WHEP