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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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REFERENCES
Barr W, Smith A. Acute diarrhea in adults. Am Fam Physician. 2014;89(3):180-189.
Centers for Disease Control and Prevention. Travelers’ Health—2018 Yellow Book. http://wwwnc.cdc
.gov/travel/page/yellowbook-home. Accessed May 10, 2019.
McQuaid KR. Gastrointestinal disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds.
Current Medical Diagnosis & Treatment 2019 New York, NY: McGraw Hill; 2019: chap. 15.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449§ionid=194439115. Accessed
May 10, 2019.
Shane AK, Mody RK, Crump JA, Tarr PI, et al. 2017 Infectious Diseases Society of America clinical
practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis.
65(12):1963-1973. https://doi.org/10.1093/cid/cix959
Wilkins T, Sequoia J. Probiotics for gastrointestinal conditions: a summary of the evidence. Am Fam
Physician. 2017;96(3):170-178.
Yates J. Traveler’s diarrhea. Am Fam Physician. 2005;71:2095-2100, 2107-2108
CASE 11
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A 45-year-old woman presents to your office for an “annual physical
examination.” She reports that she is very healthy and has no specific complaints.
Her past medical history is significant for seasonal allergies and well-controlled,
mild, intermittent asthma. She is married and has two children via normal
spontaneous vaginal delivery without complication. She takes a multivitamin
daily and antihistamines (as needed) and a puff of an albuterol inhaler on
occasion. Her family history is significant for hypertension and type 2 diabetes
mellitus in her father, depression in her mother and sister, and breast cancer
diagnosed in her maternal grandmother at age 72. The patient is married
and monogamous, gets regular exercise, and does not smoke cigarettes, drink
alcohol, or use illicit drugs. On examination, her blood pressure is 129/79 mm Hg,
pulse is 74 beats/min and regular, height is 67 inches, weight is 152 pounds, body
mass index is 23.8 kg/m2, and abdominal waist circumference is 32 inches. Her
physical examination is unremarkable.
▶ What screening test(s) for cardiovascular disease should be recommended for
this patient?
▶ What screening test(s) for other chronic diseases should be recommended for
this patient?
▶ What screening test(s) for cancer should be recommended?
▶ What immunization(s) should be recommended?
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ANSWERS TO CASE 11:
Adult Female Health Maintenance
Summary: A 45-year-old woman presents with
Desire for an annual health maintenance examination (HME)
A history of seasonal allergies and mild, intermittent asthma
Medications include multivitamin daily and antihistamines (as needed) and occasionally,
an albuterol inhaler
Normal vital signs and healthy lifestyle
Family history significant for hypertension and type 2 diabetes mellitus in her father,
depression in her mother and sister, and breast cancer diagnosed in her maternal
grandmother at age 72
Recommended screening tests for cardiovascular disease: Blood pressure measurement (screening for hypertension); height, weight, body mass index, and abdominal waist circumference measurements (screening for obesity); nonfasting lipid
measurement (screening for hyperlipidemia).
Recommended screening tests for other chronic diseases: Fasting glucose or hemoglobin A1c (screening for diabetes mellitus); hepatitis C screening for adults ages
18–79; depression screening; intimate partner violence screening.
Recommended screening tests for cancer: Mammography per interval (screening for
breast cancer); Papanicolaou (Pap) smear, with or without high-risk human papilloma virus testing, per interval (screening for cervical cancer).
Recommended immunizations: Tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis vaccine (Tdap) if she has not had one after the age of 11
and then a tetanus-diphtheria (Td) or Tdap vaccine every 10 years; influenza
vaccine annually (per season); 23-valent pneumococcal polysaccharide vaccination
(PPSV-23) if she has not had it before because of her history of asthma; hepatitis A
and B vaccine series if indicated.
ANALYSIS
Objectives
1. List the elements of the evidence-based adult well female health maintenance
examination (HME). (EPA 1, 12)
2. Describe the recommended screening tests and immunizations for adult
women. (EPA 3, 12)
3. Counsel patients in ways to be healthier and improve health outcomes.
(EPA 10, 12)
Considerations
The patient described is a 45-year-old woman who presents for an annual HME.
In women aged 20 to 34 years, unintentional injuries are the leading cause of mortality.
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In women aged 35 to 54 years, cancer is the leading cause of mortality. In women
55 years of age and older, heart disease is the leading cause of mortality. Shared
decision-making is imperative when providing women with age-appropriate strategies for cardiovascular and chronic disease screening, cancer screening, and immunization updates.
Recommended adult immunizations are discussed in Case 1, tobacco use is discussed in Case 7, and screening and treatment for sexually transmitted infections
are discussed in Case 45. The interventions discussed in this chapter are primarily
based on recommendations of the United States Preventive Services Task Force
(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.
USPSTF RECOMMENDATION GRADES: Grades created by the USPSTF
after reviewing current evidence regarding screening tests; these consist of recommendations in five categories (A, B, C, D, I) based on the strength of evidence and
benefit of a screening test.
WOMEN’S HEALTH INITIATIVE: A research program sponsored by the
National Institutes of Health 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
Screening for Cardiovascular Disease
Many of the cardiovascular disease risk factors in women are the same as those in
men but are often underappreciated with relation to morbidity and mortality risks;
these risk factors include hypertension, high low-density lipoprotein cholesterol,
tobacco use, diabetes mellitus, and family history of cardiovascular disease. 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 hyper-
tension by the measurement of blood pressure (Grade A recommendation). The
USPSTF recommends screening all women aged 40-75 periodically for dyslipidemia. The American Heart Association and the American College of Obstetricians
and Gynecologists recommend routine lipid screening for all women.
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An area of cardiovascular disease risk unique to women is in postmenopausal
hormone replacement. Hormone replacement therapy is sometimes used for relief
of vasomotor symptoms (“hot flashes”). Studies such as 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 (Grade D), 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 over 40,000 deaths per year from breast cancer in the United States. Incidence increases with age; other risk factors include
having the first child after the age of 30, menarche before age 12 or menopause after
age 55, 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. The USPSTF
has determined that there is insufficient evidence to recommend CBE (Grade I)
and recommends against teaching BSE (Grade D). These recommendations suggest that BSE offers no significant mortality benefit and may lead to unnecessary
anxiety, biopsies, and false-positive test results. Clinicians are recommended to
encourage women to be familiar with how their breasts normally appear and feel
and to report any changes to their health care provider. The evidence regarding
CBE suggests that as the sole screening modality it may have good detection rates,
yet its benefits in conjunction with mammography are limited.
The USPSTF advises screening with mammography beginning at the age of
50 years, with a recommended interval of every 2 years (Grade B). For women
aged 40 to 49, biennial screening should be an individual decision and take into
account the patient’s values regarding the benefits and harms (Grade C). The
American Cancer Society, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists advocate offering patients annual
or biennial mammography starting at age 40 years and strongly encourage annual
mammography after the age of 50 years. 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.
Screening for Cervical Cancer
Mortality rates from cervical cancer have decreased dramatically in recent decades
as a direct result of routine cervical cancer screening via Pap smear (cytology). Risk
factors for cervical cancer include early onset of sexual intercourse, multiple sexual
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partners, human papilloma virus (HPV) infection with high-risk subtypes of HPV
(16, 18, 45, 56), and tobacco use.
Pap Smear. For any woman with a cervix, the USPSTF recommends that cervical cancer screening with Pap smear should begin at age 21 years regardless of
sexual activity and should be repeated at 3-year intervals. For women over the age
of 30 years desiring a longer interval between tests, cotesting for HPV can be used
in conjunction with or without cytology once every 5 years (Grade A). Since the
likelihood of a positive test result is higher with HPV cotesting (better sensitivity
at the cost of more false positives), women should be made aware of the possibility
of frequent and ongoing testing if they persistently test positive for HPV. Abnormal results should be followed per current guidelines.
Screening Intervals. 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 on providing the maxi-
mum benefit from treatment of precancerous lesions, while preventing overtreatment of HPV-related pathology 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 years (regardless of sexual activity) is
not recommended (Grade D).
Discontinuing Screening. For women who have had a hysterectomy for any reason
other than cervical cancer, screening should be discontinued (Grade D). Women
who have had a hysterectomy with retention of cervix (supracervical hysterectomy) should follow the recommendation for age-appropriate routine screening.
The USPSTF recommends cessation of cervical cancer screening at age 65 years
in women who have had three consecutive negative Pap results or two consecutive negative HPV results within the last 10 years (Grade D). An individualized
approach should be implemented in women who have previously been treated for
precancerous lesions or those who have never been tested before.
HPV Vaccination. HPV infection is the most significant cause of all cervical
cancers. A vaccine against high-risk HPV subtypes is available as a two-shot series
for children/adolescents who initiate the series between ages 9 and 14 and as a
three-injection series for those receiving the vaccination at age 15 or older. It is
indicated for use in both males and females aged 9 through 45. To date, there is no
recommendation to alter the Pap smear screening intervals for women who have
been vaccinated against HPV.
Screening for Osteoporosis
Osteoporosis is a condition of decreased bone mineral density associated with an
increased risk of fracture. One-half of all postmenopausal women will have an osteo-
porosis-related fracture in their lifetime. Common osteoporotic fractures include
hip and vertebral fractures, which are associated with higher risks of loss of independence, institutionalization, and mortality. 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.
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Bone Density Measurement. Screening for osteoporosis is performed by measurement of bone density in the greater trochanter and lumbar spine via dual-energy
x-ray absorptiometry (DEXA). 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. The USPSTF recommends screening
for osteoporosis via DEXA in women over the age of 65 years and considering
screening in women younger than 65 years with higher risk of osteoporosis-related
fractures (Grade B). There is no current recommendation on repeating screening if
the initial test is normal. See Case 58 for a discussion of medications used for the
prevention and treatment of osteoporosis.
Screening for Depression and Intimate Partner Violence
Depression screening is recommended if there are systems in place for ensuring
accurate diagnosis, treatment, and follow-up (Grade B). Because of the prevalence
of these disorders, screening and support are important.
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 are 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 partners, separated
or divorced status, and a history of childhood sexual/physical abuse. The USPSTF
recommends that providers should screen women between the ages of 14 and
46 years 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 (Grade B). There are many different screening tools available, including HITS
(Hurt, Insult, Threaten, Screen), HARK (Humiliation, Afraid, Rape, Kick), and
STaT (Slapped, Things, and Threaten) screens. Most of these are three- to fouritem 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 should be provided 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 (Adult Male Health Maintenance), Case 7 (Tobacco
Use and Cessation), Case 22 (Vaginitis and Other Vaginal Infections), and
Case 58 (Osteoporosis).
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COMPREHENSION QUESTIONS
11.1 A 21-year-old woman presents for her first Pap smear. She completed the
HPV vaccine series by 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. In 6 months, as the first Pap smear should be repeated within a year to
reduce a potential false-negative result
B. In 1 year, as she is higher risk of cervical cancer because of her age
C. In 3 years, as the Pap smear was normal
D. In 5 years, as she is at low risk because she received the HPV vaccine
11.2 A 32-year-old G2 P1 woman is pregnant at 12 weeks’ gestation. She is being
seen for her prenatal visit. As you examine her, you note some bruises on her
arms and neck area. She looks down at the floor and is tearful when you ask
about these bruises. She confides that her husband has been violent toward
her. Which of the following factors is associated with an increased risk of
intimate partner violence in this patient?
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-examinations have been shown to decrease mortality rates
B. Clinical breast examinations in conjunction with routine mammography
have been shown to improve mortality rates.
C. Most abnormalities found on routine mammography are not breast cancer.
D. Since 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 an annual examination. She has had a
supracervical hysterectomy and Pap smears with HPV cotesting every 5 years
since her 20s and all were normal. She read on the Internet that women who
have had a hysterectomy no longer require 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 hyster-
ectomy 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 in 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.”
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ANSWERS
11.1 C. Per the USPSTF, screening for cervical cancer should begin at age
21 years and be repeated at 3-year intervals. After age 30, patients can be
offered 5-year testing intervals (answer D) if they elect for HPV testing with
or without cytology. Six-month (answer A) and one-year (answer B) 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 partners, separated or divorced status, and a history of childhood sexual/physical abuse.
The other answer choices (answer B, older age; answer C, higher income; and
answer D, married status) are the opposite of risk factors.
11.3 C. Most abnormalities seen on mammography are not cancerous. They may,
however, require further imaging studies, testing, or biopsy. BSE (answer A)
has not been definitively shown to reduce cancer mortality. CBE (answer B)
may be of benefit but likely does not impact outcome if mammography is
available. The age to consider discontinuation of mammography screening
(answer D) 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,
with or without a uterus (answer A), should continue with screening for cervical
cancer as per screening recommendation for their age group. Cervical cancer
screening can be discontinued at age 65 years if the patient has had adequate
screening for the last 10 years, which is defined as three consecutive normal Pap
smears or two consecutive normal cotesting screens, with the most recent one
being in the last 5 years. A hysterectomy is not an indication for more frequent
testing (answer B). Pap smears are not indicated yearly (answer D).
CLINICAL PEARLS
» Cancer and cardiovascular disease pose the greatest mortality risk for
women in America.
» Risk factors for cardiovascular diseases in women need to be managed as
aggressively as they are in men.
» Human papilloma virus infection is the most significant cause of all cervi-
cal cancers. An HPV vaccine is available; however, vaccination status has
no bearing on cervical cancer screening recommendations.
» Women of childbearing age should be screened for intimate partner
violence.
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REFERENCES
American Cancer Society. Cancer Facts & Figures 2018. Atlanta, GA: American Cancer Society; 2018.
American College of Obstetricians and Gynecologists. Breast cancer risk assessment and screening in
average-risk women. Obstetrics and Gynecology; 2017;30(1):e1-e16.
Centers for Disease Control and Prevention. HPV Vaccine. Atlanta, GA: Centers for Disease Control
and Prevention; 2014.
Centers for Disease Control and Prevention. Leading causes of death. https://www.cdc.gov/nchs/
fastats/leading-causes-of-death.htm. Accessed April 30, 2020.
United States Preventive Services Task Force (USPSTF). BRCA Related Cancer: Risk Assessment,
Genetic Counseling, and Genetic Testing. August 20, 2019. https://www.uspreventiveservicestaskforce
.org/uspstf/recommendation/brca-related-cancer-risk-assessment-genetic-counseling-and-genetictesting. Accessed April 30, 2020.
United States Preventive Services Task Force (USPSTF). Recommendations for primary care
practice. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status
=P&searchterm=. Accessed April 30, 2020.
Women’s Health Initiative. https://www.nhlbi.nih.gov/science/womens-health-initiative-whi. Accessed
April 30, 2020.
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