Case

A 50-year old Caucasian female, new to your practice, presents for an "annual physical examination." She reports that she is generally very healthy, feels well and has no specific complaints. She has a history of having had a "partial hysterectomy," by which she means that her uterus and cervix were removed but her ovaries were left in place. The surgery was performed because of fibroids. She has had a pap smear every year since the age of 18. all of which have been normal. She has had annual mammograms since the age of 40. all of which have been normal. She has no other significant medical or surgical history. She takes a multivitamin pill daily but no other medications. Her family history is significant for breast cancer that was diagnosed in her maternal grandmother at the age of 72. The patient is married, monogamous, does not smoke cigarettes or drink alcohol. She tries to avoid dairy products because of "lactose intolerance." She walks 3 miles 4-times a week for exercise. Her physical examination is normal.

^ For this patient, how often should a Pap smear be performed for cervical cancer screening?

^ What could you recommend to reduce her risk of developing osteoporosis?

+ What is the recommended interval for screening mammography?

ANSWERS TO CASE 11: Health Maintenance in Adult Female

Summary: A 50-year old woman with a history of having had a hysterectomy for a benign indication comes to your office for a routine health maintenance visit.

^ Interval for cervical cancer screening in this patient: Based upon her history of having a hysterectomy for benign disease and her overall low risk status, cervical cancer screening can be discontinued in this patient

^ Interventions to reduce her risk of developing osteoporosis:

Supplementation with at least 1200 mg calcium and 400-800 IU vitamin D daily; regular weight-bearing exercise

♦ Recommended interval for screening mammography in 50-year old woman: Annual

Analysis

Objectives

1. Discuss age appropriate preventive health measures for adult women.

2. Review evidence in support of specific health maintenance measures.

Considerations

When evaluating patients for preventive health measures, there should not be a "one size fits all" approach to care. Some interventions are appropriate across age groups; some are age or risk factor specific and should be tailored accordingly. Interventions to consider include screening for cardiovascular disease, breast cancer, cervical cancer, osteoporosis and domestic violence. Other health maintenance measures, such as screening for colon cancer (Chapter 1), routine adult immunizations (Chapter 1 ) and tobacco use (Chapter 7) are discussed elsewhere. The interventions discussed in this chapter are primarily based upon recommendations of the United States Preventive Services Task Force (USPSTF); recommendations of other expert panels or advocacy organizations are included where appropriate.

Cardiovascular Disease in Women

Cardiovascular diseases are the number one killer of women in the United States. Many of the cardiovascular disease risk factors in women are the same as those in men: hypertension, high LDL-cholesterol. tobacco use, Diabetes Mellitus, family history of cardiovascular disease. As such, the USPSTF screening recommendations for cardiovascular disease for women are similar to those for men. All women aged 18 and older should be screened for hypertension by the measurement of blood pressure (Level A recommendation). Further, all women aged 45 and older should be screened for lipid disorders (Level A recommendation). Abnormally elevated blood pressure or serum lipids should be managed appropriately.

An area of cardiovascular disease risk unique to women is in post-menopausa! hormone replacement. Many women have taken hormone replacement therapy for relief of vasomotor symptoms ("hot Hashes") and reduction of risk of developing osteoporosis. Recent studies, most notably the Women's Health Initiative, have shown increased rates of adverse cardiovascular outcomes in women taking either estrogen alone or combined estrogen and progesterone. These risks include an increased risk of coronary heart disease, stroke and venous thromboembolic disease. For this reason, the use of hormone replacement therapy for the prevention of chronic conditions is not advised (Level D recommendation) and any use of hormone replacnt should be of the lowest effective dose for the shortest effective time period.

Screening for Breast Cancer

Breast cancer is second to lung cancer in number of cancer related deaths in women. There are approximately 190,000 new cases and over 40.000 deaths per year from breast cancer in the United States. The incidence increases with age: other risk factors include having the first child after the age of 30, a family history of breast cancer (particularly if in the mother or sister), personal history of breast cancer or atypical hyperplasia found on a previous breast biopsy, or a known carrier of the BRCA-I or BRCA-2 gene.

The process of screening for breast cancer generally includes consideration of three modalities: the breast self exam (BSE), the clinical breast exam (CBE) performed by a health care professional and mammography. Other modalities, including ultrasonography and magnetic resonance imaging, are available but currently are not widely recommended for screening purposes. Upon review of the available studies, the USPSTF has determined that, at this time, there is insufficient evidence to recommend either the CBE or SBE (Level I recommendation). Both SBE and CBE may be associated with increased risks of false positive results and subsequent need for biopsies while evidence is lacking that they reduce breast cancer mortality. Studies regarding both are ongoing.

Mammography screening every 12-33 months has been shown to reduce mortality from breast cancer. The benefits of routine mammographic screening increase with age, as the incidence of breast cancer is higher in older women. There is not an age cut off to stop screening, but a discussion about continuing screening can be considered in the older woman with significant co-morbid conditions that may limit her life expectancy. Part of the discussion regarding mammography also includes the risk of false positive or false negative (less common) results and need for additional interventions, such as breast biopsy. Most abnormalities found on mammography are not breast cancer but require further evaluation to make that determination. The USPSTF advises screening with mammography, beginning at the age of 40 for the general population. with a recommended interval of every 1-2 years (Level B recommendation). Recommendations are also available from other organizations, including the American Cancer Society. American Academy of Family Physicians and American College of Obstetrics and Gynecology, that advocate annual mammography after the age of 50. Their recommendations for women age 40-49 vary, but generally advise screening every 1-2 years.

Screening for Cervical Cancer

Cervical cancer is the tenth leading cause of cancer death in women in the United States, with 41 (X) deaths in 2002. The incidence of cervical cancer has fallen dramatically since the introduction of the Pap smear as part of routine screening. Risk factors for cervical cancer include early onset of sexual intercourse, multiple sexual partners, human papilloma virus (HPV) infection with high risk subtype of HPV (HPV viral types 16, 18,45,56) and tobacco use.

The optimal age to begin screening is unclear, but the USPSTF recommends starting at age 21 or within three years of the onset of sexual activity, whichever comes first (Level A recommendation). While there is limited utility in screening for cervical cancer in a person who has never been sexually active, many organizations will advocate an age based approach because of high rates of sexual activity by a certain ages and because health care providers may not always get accurate sexual histories.

Most cases of cervical cancer occur in women who either have not been screened in over 5 years or did not have follow up after an abnormal pap smear. The optimal screening interval between pap smears is not known. Based upon the available studies, the USPSTF has not found evidence that annual screening is better at reducing morbidity and mortality from cervical cancer than screening ever 3 years. The American Cancer Society recommends annual pap smears until age 30 and then spacing out the interval to every two to three years; other groups suggest spacing out the interval after three consecutive normal pap smears.

The purpose of a pap smear is to detect precancerous cervical changes or possible cases of cervical cancer early, in order to improve the odds of survival. Keeping this in mind, the USPSTF recommends against pap smears for women who have had a hysterectomy (including removal of the cervix) for benign indications (Level D recommendation). It is prudent to ask a woman who has had a hysterectomy why the surgery was performed and to confirm (either by reviewing the operative report or on exam) the absence of the cervix. A woman who had a hysterectomy for cancerous indications falls out of the general screening parameters discussed here.

The optimal age to stop screening is subject to debate. The USPSTF discusses discontinuing cervical cancer screening after the age of 65 both if no new risk factors have been identified (i.e., new partner) and there has been adequate recent screening. The incidence of cervical cancer falls with age; the false positive rate increases, thus potentially subjecting women to additional unnecessary procedures. The American Cancer Society recommends that screening may be stopped at the age of 70 if a woman has had three consecutive normal pap smears and no abnormal pap smears in the last 10 years.

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