Health Maintenance in Adult Female Case File

Health Maintenance in Adult Female Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 11

A 55-year-old Caucasian woman, new to your practice, presents for an "annual physical examination:' She reports that she is very healthy, generally feels well, and has no specific complaints. She has a history of having had a "total hysterectomy:' by which she means that her uterus, cervix, ovaries, and fallopian tubes

were removed. The surgery was performed because of fibroids. She has had a Pap smear every 3 years since the age of 21, all of which have been normal. She has had annual mammograms since the age of 50, 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, and does not smoke cigarettes or drink alcohol. She tries to avoid dairy products because of "lactose intolerance." She walks 30 minutes a day five times a week for exercise. Her physical examination is normal.

⯈ For this patient, how often should a Pap smear be performed?

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

⯈ According to the United States Preventive Services Task Force (USPSTF), what is the recommended interval for screening mammography?

ANSWER TO CASE 11:

Health Maintenance in Adult Female

Summary: A 55-year-old woman with a history of having had a total hysterectomy for a benign indication comes to your office for a routine health maintenance visit.

• Interval for cervical cancer screening: Based on her history of having a hysterectomy with removal of the cervix and no history of cancerous lesions, cervical cancer screening can be discontinued in this patient (USPSTF, Level B recommendation).
• Interventions to reduce her risk of developing osteoporosis: As a 55-year-old postmenopausal woman with no risk factors for fractures and dwelling outside of any institutions, USPSTF does not recommend supplementation outside of adequate dietary intake calcium and vitamin D daily (Level D recommendation). Regular weight-bearing and muscle-strengthening exercise, avoidance of tobacco smoke (active or passive), and excessive alcohol intake (>3 drinks/d) should be discussed as factors that increase risk of developing osteoporosis.
• USPSTF recommended interval for screening mammography in a 55-year-old woman: Biennial (every 2 years), between ages of 50 and 74 (Level B recommendation).

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 (CVD), breast cancer, cervical cancer, osteoporosis, and domestic violence. Other health maintenance measures, such as screening for colon cancer and routine adult immunizations, are discussed in Case 1 and tobacco use is discussed in Case 7. The interventions discussed in this chapter are primarily based on recommendations of the USPSTF; recommendations of other expert panels or advocacy organizations are included where appropriate.

Approach To:

Health Maintenance in Women

DEFINITIONS

BRCA: Abbreviation for genes associated with breast cancer and ovarian cancer. Mutations in the BRCA-1 or BRCA-2 genes can be associated with a three- to seven-fold increased risk for breast cancer, along with increased risks of ovarian, tubal, peritoneal, and possibly other types of cancer.

WOMEN'S HEALTH INITIATIVE: A National Institutes of Health (NIH)sponsored research program to address the most common causes of morbidity and mortality in postmenopausal women. This initiative included clinical trials of the effect of hormone therapy on the development of heart disease, fractures, and breast cancer.

CLINICAL APPROACH

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 low-density lipoprotein (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). However, because the 10-year risk for heart disease is low in women without risk factors as compared to their male counterparts of the same age, USPSTF recommendations on lipid screening differ between genders. Women more than age 45 with risk factors for heart disease, including diabetes, previous history of heart disease, family history of CVD, tobacco use, hypertension, and obesity, should be screened with a lipid panel (Level A recommendation). Furthermore, women between the ages of 20 and 44 who have risk factors as listed previously are also recommended to undergo a one-time screening for lipid disorders (Level B recommendation). Other professional organizations, such as the American Heart Association and the American College of Obstetricians and Gynecologists (ACOG) recommend routine lipid screening for all women. Abnormally elevated blood pressure or serum lipids should be managed appropriately.

An area of cardiovascular disease risk unique to women is in postmenopausal hormone replacement. Many women have taken hormone replacement therapy for relief of vasomotor symptoms ("hot flashes") 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 replacement 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 over 200,000 new cases and nearly 40,000 deaths per year from breast cancer in the United States each year. 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-1 or BRCA-2 gene.

The process of screening for breast cancer generally includes consideration of three modalities: the breast self-examination (BSE), the clinical breast examination (CBE) performed by a health-care professional, and mammography. Other modalities, including ultrasonography and magnetic resonance imaging (MRI), are available but currently they are not widely recommended for screening purposes, and are most beneficial as follow-up studies to screening mammograms when indicated. Upon review of the available trials, the USPSTF has determined that, at this time, there is insufficient evidence to recommend CBE (Level I recommendation) and recommend against teaching BSE (Level D recommendation). These trials suggest that in teaching of BSE to patients, there is no mortality benefit and, in fact, this modality may lead to unnecessary anxieties, biopsies, and tests. The evidence regarding CBE suggests that while as the sole screening modality it may have good detection rates, its benefits in conjunction with mammography are limited.

Mammography screening every 12 to 33 months has been shown to reduce mortality from breast cancer, with the most benefit at 24-month intervals. The benefits of routine mammographic screening increase with age, as the incidence of breast cancer is higher in older women. However, beyond the age of 75 years, continuation of screening should be individualized based on the overall health status and probability of death from other conditions prior to the expected benefits from detection of breast cancer.

Part of the discussion regarding mammography also includes the risk of falsepositive 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 50 for the general population, with a recommended interval of every 2 years (Level B recommendation). For women aged 40 to 49, biennial screening should be an individual decision and take into account patient's values regarding the benefits and harms (Level C recommendation). Recommendations are also available from other organizations, including the American Cancer Society (ACS), American Academy of Family Physicians, and ACOG, which advocate annual mammography after the age of 50. Their recommendations for women aged 40 to 49 vary, but generally advise screening every 1 to 2 years.

Screening for Cervical Cancer

Cervical cancer is the 10th leading cause of cancer death in women in the United States, with an incidence and mortality of over 12,000 and approximately 4000 cases, respectively, this year alone. Over the last several decades, however, this rate has decreased dramatically as a direct result of routine cervical cancer screening with Pap smear (cytology). 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.

As per the USPSTF, for any woman with a cervix, cervical cancer screening with Pap smear should begin at age 21 (regardless of sexual activity) and be repeated at 3-year intervals. For women more than age of 30 desiring a longer interval between tests, cotesting for HPV can be used in conjunction with cytology once every 5 years (Level A recommendation). However, because the likelihood of a positive test result is higher with HPV cotesting, women should be made aware of the possibility of frequent and ongoing testing if they persistently test positive for HPV. Both ACOG and ACS recommend beginning cervical cancer screening at age 21 with 3-year intervals without HPV cotesting, and in women above 30 years, 5-year intervals with cotesting.

HPV infection is the most significant cause of all cervical cancers. A vaccine against high-risk HPV subtypes is available as a three-series. It is indicated for use in females aged 11 through 26. To date, there is no recommendation to alter the Pap smear screening intervals for women who have been vaccinated against HPV.

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 therefore is based upon providing the maximum benefit from treatment of precancerous lesions, while preventing overtreatment of lesions that may have otherwise resolved spontaneously. Since the development of a cancerous lesion is a prolonged process, and at times treatment of cervical abnormalities is not without harm in terms of future childbearing potential, screening prior to age 21 (regardless of sexual activity) is not recommended (Level D recommendation).

Women who have had a hysterectomy constitute a group in whom special considerations regarding cervical cancer screening must be made. The recommendation for this group of women takes into account those who have undergone a supracervical hysterectomy with retention of the cervix versus those who have had their cervix removed, and the indication for this removal. As per USPSTF, in women who have had a hysterectomy with cervix removal for any reason other than cervical cancer, screening should be discontinued (Level D recommendation). A woman who had a hysterectomy for cancerous indications falls out of the general screening parameters discussed here. Women who have had a hysterectomy with retention of cervix should follow the recommendation for age-appropriate routine screening.

The USPSTF recommends stopping Pap smears at age 65 in women who have had three consecutive negative Pap results or two consecutive negative HPV results within the last 10 years (Level D recommendation). However, an individualized approach should be implemented in women who have previously been treated for precancerous lesions or those who have never been tested before. Both The ACS and ACOG recommend that screening may be stopped at the age of 65 if a woman has had adequate screening in the last 10 years, which is defined as three consecutive negative Pap smears or two consecutive negative cotests, with the most recent negative Pap smear within the last 5 years. This recommendation excludes women who have a history of cervical cancer.

Screening for Osteoporosis

Osteoporosis is a condition of decreased bone mineral density (BMD) associated with an increased risk of fracture. Half of all postmenopausal women will have an osteoporosis-related fracture in their lifetime. These include hip fractures, which are associated with higher risks of loss of independence, institutionalization, and death. The risk of osteoporosis is increased with advancing age, tobacco use, low body weight, poor nutrition, Caucasian or Asian ancestry, family history of osteoporosis, low calcium intake, and sedentary lifestyle.

Osteoporosis may also occur in men, although with a lower incidence than it does in women. Along with the risk factors noted above, the prolonged use of corticosteroids, presence of diseases that alter hormone levels (such as chronic kidney or lung disease), and undiagnosed low testosterone levels increase the risk of osteoporosis in men.

Screening for osteoporosis is done by measurement of bone density. Measurement of the hip bone density by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture. Measurement of bone density is compared to the bone density of young adults and the result is reported as standard deviation from the mean bone density of the young adult (T-score). Osteoporosis is present if the patient's T-score is at or below -2.5 (ie, measurement of the patient's bone density is more than 2.5 standard deviations below the young adult mean); osteopenia is present if the T-score is between -1.0 and -2.5. Other modalities, such as measurement of wrist or heel density, single-energy x-ray absorptiometry, and ultrasound are being evaluated and may have some short-term predictive value. The USPSTF recommends screening for osteoporosis via DXA in women over the age of 65 and considering screening in women younger than 65 with higher risk of osteoporosis-related fractures (Level B recommendation). There is no current recommendation on repeating screening if the initial test is normal. Although in theory repeated testing may improve the likelihood of predicting fracture risk, studies have not shown the benefit of repeated BMD measurements as opposed to a single BMD measurement.

The role of calcium and vitamin D intake in the prevention of osteoporosis is currently a controversial issue and one regarding which recommendations differ between organizations. The National Osteoporosis Foundation (NOF) believes in the role of supplementation in prevention of osteoporosis, recommending that women over the age of 51 consume 1200 mg of calcium daily, stressing the fact that there is no additional benefit of consuming calcium in excess of 1200 to 1500 mg/ d. They also recommend 800 to 1000 IU of vitamin D daily for women over the age of 50. If dietary intake is not sufficient, supplements may be used. Weight-bearing and muscle-strengthening exercise is also recommended both for its direct effects on increasing bone density and for its benefits in strength, agility, and balance, which may reduce the risk of falls, as is tobacco cessation and avoidance of excess alcohol intake. Although NOF still recommends vitamin D and calcium supplementation for primary prevention of osteoporosis, USPSTF maintains that trials have not been able to show the benefit of vitamin D and calcium supplementation in women who are not at risk for fractures and do not have osteoporosis. For this reason, and in light of an increased incidence of renal stones with calcium and vitamin D intake, USPSTF recommends against daily supplementation for primary prevention of fractures in postmenopausal women residing in the community (Level D recommendation). However, taking into account the burden imposed by fractures on the health-care system and on patient's quality of life, and the relatively low cost of supplementation, USPSTF still holds by its recommendation for daily vitamin D intake in women above the age of 65 who are at increased risk of falls (Level B recommendation).

When osteoporosis is diagnosed, patients should be treated with calcium, vitamin D, and exercise and strategies should be implemented to reduce the risk of falls. These strategies include evaluation and treatment, if needed, of vision and hearing deficits, management of medical disorders that can promote falls (movement disorders, neurologic disorders, etc), and periodic evaluation of medications taken that may affect balance or movement. Hip protectors may be beneficial in those at high risk for falls. See Case 58 for a discussion of medications used for the prevention and treatment of osteoporosis.

Screening for Domestic Violence

Estimates indicate that between 1 and 4 million women are sexually, physically, or emotionally abused by an intimate partner each year. Women are also much more likely to be abused by an intimate partner than men. Multiple factors are associated with intimate partner violence and include young age, low income status, pregnancy, mental illness, alcohol or substance use by victims or partner, separated or divorced status, and a history of childhood sexual/physical abuse. USPSTF recommends that physicians should screen women between the ages of 14 and 46 for evidence of physical, sexual, or psychological abuse by a current or former partner and to appropriately refer those with positive screens to interventional services (Level B recommendation). There are many different screening tools available to physicians, including HITS (Hurt, Insult, Threaten, Screen), HARK (Humiliation, Afraid, Rape, Kick), and STaT (Slapped, Threatened, and Throw). Most of these are three to four item questionnaires with very high sensitivity and specificity and are available in both English and Spanish. Documentation and treatment of injuries, counseling, and information regarding protective services are part of the evaluation when domestic violence is suspected. Reporting of domestic violence is mandatory in several states; be aware of the requirements of your state.

CASE CORRELATION

• See also Case 1 (Health Maintenance, Adult Male).

COMPREHENSION QUESTIONS

11.1 A 21-year-old woman presents for her first Pap smear. She received the full HPV vaccine series at age 19. Assuming that her examination and Pap smear results are normal, when would you recommend that she return for a followup Pap smear?

A. 6 months, as the first Pap smear should be followed up soon to reduce

the false-negative rate associated with this screening test

B. 1 year, as she is higher risk because of her age

C. 3 years, as the Pap smear was normal

D. 5 years, as she is at low risk because she received the HPV vaccine

11.2 Which of the following situations is associated with an increased risk of intimate partner violence?

A. Pregnancy

B. Older age

C. Higher income

D. Married status

11.3 Which of the following statements regarding breast cancer screening is true?

A. Breast self-examination (BSE) has been shown to decrease mortality rates from breast cancer.

B. Clinical breast examination (CBE) in conjunction with routine mammography is shown to improve mortality rates.

C. Most abnormalities found on routine mammography are not breast cancer.

D. Because breast cancer rates increase in older women, there is no upper age at which breast cancer screening may be discontinued.

11.4 A 48-year-old woman presents for a well-woman examination. She notes that she had a supracervical hysterectomy in the past. Your records reveal that she had her uterus removed, but the cervix and ovaries were left in place. You also note that she has had Pap smears with HPV cotesting every 5 years since her 20s and that all were normal. She read on the internet that women who have had a hysterectomy no longer need Pap smears. Which of the following would be your advice?

A. "You no longer need to get Pap smears since you have had a hysterectomy:'

B. "You should continue to have Pap smears every 3 years since your hysterectomy is an indication to shorten the interval for testing:'

C. "You should continue to have Pap smears with HPV cotesting every 5 years since your hysterectomy does not exclude you from routine screening recommendation for your age group:'

D. "You should continue with annual Pap smears until the age of 50. If they are all normal, you can stop having them at that time:'

ANSWERS

11.1 C. As per USPSTF, screening for cervical cancer should begin at age 21 and be repeated at 3-year intervals. Six months and 1-year intervals are inappropriate and not part of routine screening recommendations for women with normal Pap smears. The use of HPV vaccine is not an indication to alter cervical cancer screening recommendations at this time.

11.2 A. Intimate partner violence can occur in any relationship, but the risk is increased in certain situations, which include young age, low income status, pregnancy, mental illness, alcohol or substance use by victims or partner, separated or divorced status, and a history of childhood sexual/physical abuse.

11.3 C. Most abnormalities seen on mammography are not cancerous. They may, however, require further imaging studies, testing, or biopsy. Breast self-examination has not been definitively shown to reduce cancer mortality. Clinician breast examination may be of benefit but likely does not impact outcome if mammography is available. The age to consider discontinuation of mammography screening should be individualized, based on the woman's risk factors and overall health status.

11.4 C. Women who have had a hysterectomy with removal of the cervix for benign indications can discontinue Pap smear screening. Women who still have a cervix should continue with screening for cervical cancer as per screening recommendation for their age group. Cervical cancer screening can be discontinued at age 65, if she has had adequate screening for the last 10 years, which is defined as three consecutive normal Pap smears or two consecutive normal cotesting, with the most recent one being in the last 5 years.

CLINICAL PEARLS

⯈ Women of childbearing age should be screened for intimate partner violence.

⯈ The number one killer of women in America is cardiovascular disease. Risk factors for cardiovascular diseases in women need to be managed as aggressively as they are in men.

⯈ HPV infection is the most significant cause of all cervical cancers. HPV vaccine is available as a three-dose series for females aged 11 to 26; however, vaccination status has no bearing on cervical cancer screening recommendations.

REFERENCES

American Cancer Society. Cancer Facts & Figures. Atlanta, GA: American Cancer Society; 2014. 

American Congress of Obstetricians and Gynecologists. Screeningfor Cervical Cancer. Washington, DC: ACOG;2013. 

Centers for Disease Control and Prevention. HPV Vaccine. Atlanta, GA: CDC; 2014. 

National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2014. 

United States Preventive Services Task Force (USPSTF). Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility. Available at: http://www.uspreventiveservicestaskforce. org/ uspstf/uspsbrgen.htm. Accessed December 2014. 

United States Preventive Services Task Force (USPSTF). Osteoporosis screening. Available at: http:/ I www.uspreventiveservicestaskforce.org/ uspstf/uspsoste.htm. Accessed December 2014. 

United States Preventive Services Task Force (USPSTF). Screening for breast cancer. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Accessed December 2014. 

United States Preventive Services Task Force (USPSTF). Screening for cervical cancer. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm. Accessed December 2014. 

United States Preventive Services Task Force (USPSTF). Screening for family and intimate partner violence. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsfamv.htm. Accessed December 2014. 

Women's Health Initiative. Available at: http://www.nhlbi.nih.gov/whi/. Accessed December 2014.

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