Preventative care in gynecology

1. What every clinician should know

Periodic assessments provide an opportunity for physicians to screen, evaluate, and counsel women about preventive care. Age and risk factors should serve as a guide for offering appropriate screening tests or immunizations. Physicians can use this encounter to identify women at risk for high-risk conditions and to assist their patients to receive appropriate medical care.

Certain behaviors span all age groups and should be addressed at every visit. Exercise, healthy diet, safe sexual practices, and injury prevention should be evaluated and reinforced. Patients should be asked about tobacco use, alcohol consumption, drug abuse (either prescription or illegal drugs), and psychosocial interactions.

The focus of this chapter is on screening tests and interventions for the general population. Cervical cancer screening and sexually transmitted infection screening is discussed in other chapters. Recommendations for this chapter are based upon the American College of Obstetricians and Gynecologists' Committee Opinion "Primary and Preventive Care: Periodic Assessments."

Mammography

Women should receive clinical breast exams every 1-3 years beginning at age 19. The average risk woman should begin screening mammograms at age 40. She should receive a mammogram once every one to two years. Starting at age 50, women should receive mammograms annually. For average risk women, screening with MRI is not recommended.

The Gail Model can be used to estimate a woman's breast cancer risk. (www.cancer.gov/bcrisktool/). A lifetime breast cancer risk of below 15% is considered average risk. Women with a lifetime risk of above 25% are considered at highest risk and should be referred to a breast specialist to determine appropriate screening intervals. There are no specific guidelines for women at intermediate risk (between 15% and 25%) of breast cancer. Currently, recommendations for women at intermediate risk are the same as for women at average risk.

Bone density screening

The average risk woman should begin bone mineral density testing at age 65. In women with no risk factors for osteoporosis, bone mineral density testing should be repeated approximately every 3 to 5 years.

Bone mineral density testing may be performed on postmenopausal women younger than 65 years if they have one more of the following risk factors:

• family history of osteoporosis

• Caucasian

• dementia

• poor nutrition

• smoking

• low body mass index

• early menopause (younger than 45 years)

• prolonged premenopausal amenorrhea

• long-term low calcium intake

• alcoholism

• high risk for falls

All postmenopausal women with fractures should have bone mineral density testing. High risk women with ongoing factors which may increase bone loss should be screened no more frequently than every 2 years.

Various medical conditions or treatments may place women at greater risk for osteopopenia or osteoporosis and should be considered on a case by case basis. Women diagnosed with osteopenia or low bone mass should optimize their daily intake of calcium and vitamin D. Physicians should encourage these women to undertake regular weight bearing exercise, smoking cessation, and fall prevention strategies.

Pharmacologic treatment for osteopenia/osteoporosis is recommended for:

• Postmenopausal women with a fracture

• Postmenopausal women with no risk factors, but a T score of less than -2 (osteoporosis)

• Postmenopausal women with risk factors, and a T score of less than -1.5 (severe osteopenia)

Colon cancer screening

The average risk woman should begin colorectal cancer screening at age 50 and continue until age 75.

Acceptable screening tests include:

• Colonoscopy performed every 10 years

• Flexible sigmoidoscopy performed every 5 years

• Double contrast barium enema performed every 5 years

• Fecal occult blood test on 3 consecutive samples of stool performed yearly

Fecal occult blood testing performed on digital rectal examination during an office visit is insufficient for detection of colorectal cancer. Multiple advisory boards recommend that a single collection fecal occult blood testing should not be performed.

High risk patients include:

• Those with a history of colorectal cancer or adenomatous polyps in a first-degree relative younger than age 60

• Those with a family history of familial adenomatous polyposis or hereditary nonpolyposis colon cancer

• Those with a personal history of colorectal cancer or adenomatous polyps

• Patients with inflammatory bowel disease

• Those with chronic ulcerative colitis

• Patients with Crohn's disease

Screening for high risk patients should begin at age 40. If the risk factor is a first degree relative with cancer, screening should begin 10 years before the age of diagnosis of the family member.

Identifying chronic medical conditions in asymptomatic patients

Hypertension

High blood pressure is defined at a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher. Hypertension is diagnosed after 2 or more elevated readings obtained at 2 or more visits over a period of several weeks. Women with a systolic blood pressure below 120 mm Hg and a diastolic blood pressure below 80 mm Hg should be screened every 2 years. Women with a systolic blood pressure between 120-130 mm Hg and a diastolic blood pressure between 80-89 mm Hg should be screened every year.

Diabetes

For those of average risk, a fasting glucose test every 3 years after age 45 is recommended. For patients with any of the below risk factors, screen as long as risk factor persists. Alternate screening tests include the two hour glucose tolerance test and glycolated hemoglobin (A1c).

Patients at high risk to develop diabetes include:

• Overweight patients (BMI > 25)

• Those with a family history significant for diabetes

• Those of a high risk race or ethnicity (African-American, Latina, Native American, Pacific Islander)

• Patients with hypertension, dyslipidemia, or a history of vascular disease

Conditions among women which may predispose them to diabetes include history of gestational diabetes, giving birth to an infant weighing greater than 9 lbs, and polycystic ovarian syndrome.

High cholesterol

For those of average risk, it is recommended to have a lipid profile assessment every five years beginning at age 45. For those of high risk, a lipid profile assessment every five years is recommended beginning at age 20. The preferred screening test is total cholesterol and HDL on fasting or non-fasting samples.

Patients at increased risk for cardiovascular events who need earlier screening for cholesterol include patients with:

• Diabetes

• Obesity (BMI >30)

• Hypertension

• Tobacco use

• Previous personal history of CHD or non-coronary atherosclerosis

• Family history of cardiovascular disease before age 50 in males or before age 60 in females.

Thyroid disorders

Thyroid-stimulating hormone testing should be done every five years beginning at age 50 for those of average risk. Subtle signs of thyroid dysfunction in high risk populations should be evaluated.

High risk populations include:

• Elderly

• Post-partum women

• Women with Down syndrome

• Women with high levels of radiation exposure

• A strong family history of thyroid disease or history of autoimmune disease

These patients should be screened if indicated by symptoms.

Adult vaccinations

Many adults are at risk for vaccine preventable diseases. Since the obstetrician-gynecologist may be a woman's primary care physician, it is important to assess her vaccination status. Influenza is recommended for all healthy women annually and recommended for all pregnant and breastfeeding women. All women who have not previously received Tetanus, diphtheria, pertussis (Tdap) vaccine should receive it regardless of the timing of their last Td vaccination. All postpartum women should receive the Tdap vaccine postpartum. Women should receive Td boosters every 10 years.

Women who have no evidence of varicella immunity should receive the varicella vaccine. Varicella immunity may be documented by a known history of varicella or by laboratory testing. Women aged 9-26 years should receive the HPV vaccination series Zoster vaccination is recommended for all women 60 years or older regardless of history of shingles. All women over 65 years of age should receive the pneumococcus vaccine.

Adults with chronic medical conditions, workplace exposures, or a variety of lifestyle or behavioral factors may be eligible for vaccination at different ages than the recommendations above. Additionally, some women should receive the meningococcal, Hepatitis A, and Hepatitis B vaccine. Recommendations for these groups are available from the CDC.

2. What is the evidence for specific management and treatment recommendations?

"American College of Obstetricians and Gynecologists". Obstet Gynecol. vol. 117. 2011. pp. 1008-15.

"Recommendations for Adults. U.S". Preventative Services Task Force.. http://www.uspreventativeservicestaskforce.org/adultrec.htm.

"Immunizations for Women". The American College of Gynecologists and Obstetricians. http://www.immunizationforwomen.org.

"Adult Immunization Schedules. Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention.". http://www.cdc.gov/vaccines/recs/schedules.