Gynecologists have an opportunity to evaluate their patients for leading causes of female morbidity and mortality and intervene accordingly. Thus, familiarity with various screening guidelines is essential. In 2014, recommendations by the American College of Obstetricians and Gynecologists (2014f) were updated. The USPSTF (2014) regularly revises its screening guidelines, which can be accessed at www.USPreventiveServicesTaskForce.org. These, along with other specialty-specific recommendations, offer valuable guidance for clinicians providing preventive care. Many of these topics are covered in other text chapters. Some remaining important subjects are present in the following sections.
The need for new or repeat administration of vaccines should be reviewed periodically. Some vaccines are recommended for all adults, whereas others are indicated because of patient comorbidities or occupational exposure risks. For most healthy adults who have completed the indicated childhood and adolescent immunization schedules, those that warrant consideration are listed in Table 1-2. This table summarizes recommended schedules, precautions, and contraindications for these adult vaccines. As of 2015, a link is provided to the full schedules at: http://www.cdc.gov/vaccines/schedules/.
TABLE 1-2Summary of Recommendations for Adult Immunization ||Download (.pdf) TABLE 1-2 Summary of Recommendations for Adult Immunization
|Vaccine and Route ||Reason to Vaccinate ||Vaccine Administration ||Contraindications and Precautionsa,b |
| Influenza || || || Precaution |
| Pneumococcal |
Give IM or SC
| || |
Age ≥65: PCV13, then PPSV23 after 6 months
Smoker aged 19–64: PPSV23 alone
Variant regimens for other indications d
| Hepatitis B |
| || || |
| Hepatitis A |
| || || |
| Td |
| || |
Primary series: Td given at 0, 1, and 7 months. If 19–64 yr, one of the three doses is Tdap
Td booster every 10 yr after primary series. If 19–64 yr, a one-time Tdap replaces one of the Td doses
At-risk wounds: booster Td dose if ≥5 yr since prior dose
Pregnancy: Tdap dose at 27–36 wk regardless of prior dosing
| Contraindication |
| Varicella |
| || || Contraindications |
| Zoster |
| || || Contraindications |
| Meningococcal |
| || || |
| MMR |
| || || Contraindications |
| HPV |
| || || Precaution |
In general, any vaccine may be coadministered with another type at the same visit. Notably, the influenza vaccine is available in several formulations. Vaccines for human papillomavirus infection prevention, Gardasil and Cervarix, are discussed additionally in Chapter 29.
In the United States, nearly 64,000 new cases of colorectal cancer are predicted, and this malignancy is the third leading cause of cancer death in women, behind lung and breast cancer (Siegel, 2015). Incidence and mortality rates from this cancer have declined during the past two decades, largely due to improved screening tools. However, adherence to colorectal cancer screening guidelines for women is usually less than 50 percent (Meissner, 2006).
Guidelines recommend screening average-risk patients for colorectal cancer beginning at age 50 with any of the methods shown in Table 1-3 (Smith, 2015). Screening is selected from either of two method categories. The first is capable of identifying both cancer and precancerous lesions. The second group of methods primarily detects only cancer and includes the fecal occult blood test, fecal immunochemical test, and stool DNA tests.
TABLE 1-3Screening Guidelines for the Early Detection of Colorectal Cancer and Adenomas for Average-risk Women Aged 50 years and Older ||Download (.pdf) TABLE 1-3 Screening Guidelines for the Early Detection of Colorectal Cancer and Adenomas for Average-risk Women Aged 50 years and Older
|Tests That Detect Adenomatous Polyps and Cancera |
| Test || Interval || Key Issues for Informed Decisions |
|Colonoscopy ||10 years ||Bowel prep required; conscious sedation provided |
|FSIG ||5 years ||Bowel prep required, sedation usually not provided |
Positive findings usually merit colonoscopy
|Barium enema (DCBE) ||5 years ||Bowel prep required; polyps ≥6 mm merit colonoscopy |
|Colonography (CTC) ||5 years ||Bowel prep required; polyps ≥6 mm merit colonoscopy |
|Tests That Primarily Detect Cancera |
| Test || Interval || Key Issues for Informed Decisions |
|gFOBT ||Annually ||Two to three stool samples collected at home are needed; a single stool sample gathered during office digital examination is not sufficient screening. Positive results merit colonoscopy |
|FIT ||Annually ||Positive results merit colonoscopy |
|Stool DNA (sDNA) ||3 years ||Positive results merit colonoscopy |
Of these, colonoscopy is often the preferred test for colorectal cancer screening. For the patient with average risk and normal findings, testing is repeated in 10 years. In the United States, flexible sigmoidoscopy is used less frequently. Its limitations include that only the distal 40 cm of colon are seen, and if lesions are found, then colonoscopy is still needed. A final suitable option—computed tomographic (CT) colonography—is not often covered by insurance plans.
Fecal occult blood testing (gFOBT) is an adequate annual screening method when two or three stool samples are self-collected by the patient, and the cards are returned for analysis. This method relies on a chemical oxidation reaction between the heme moiety of blood and alpha guaiaconic acid, a component of guaiac paper. Heme catalyzes the oxidation of alpha guaiaconic acid by hydrogen peroxide, the active component in the developer. This oxidation reaction yields a blue color (Sanford, 2009). Red meat, raw cauliflower, broccoli, members of the radish family, and melons have similar oxidizing ability and may yield false-positive results. Vitamin C may preemptively react with the reagents and lead to false-negative results. All of these are eliminated for 3 days before testing. Additionally, women should avoid nonsteroidal antiinflammatory drugs (NSAIDs) 7 days prior to testing to limit risks of gastric irritation and bleeding. These restrictions are cumbersome for some patients and lead to noncompliance with recommended testing.
Alternatively, the fecal immunochemical test (FIT) relies on an immune reaction to human hemoglobin. Similar to FOBT, the FIT test is performed for annual screening on two or three patient-collected stool samples and does not require pretesting dietary limitations. Advantages to FIT include greater specificity for human blood and thus fewer false-positive results from dietary meat and vegetables and fewer false-negative results due to vitamin C. As another option, screening may be completed with stool DNA (sDNA) testing. One FDA-approved test, Cologuard, screens stool for both DNA and hemoglobin biomarkers that are associated with colorectal cancer (Imperiale, 2014). Positive test results from any of these three warrant further evaluation by colonoscopy.
During patient evaluation of pelvic complaints such as pain, a gynecologist not uncommonly performs gFOBT testing on a single stool sample obtained during digital rectal examination. Although potentially helpful diagnostically, this single stool sample is not considered adequate colorectal cancer screening.
These guidelines are appropriate for those with average risk. High-risk factors include a personal history of colorectal cancer or adenomatous polyps, a first-degree relative with colon cancer or adenomas, chronic inflammatory bowel disease, known or suspected hereditary syndrome such as hereditary nonpolyposis colon cancer (Lynch syndrome) or familial adenomatous polyposis (Smith, 2015).
In the United States, this cancer is estimated to account for 13 percent of all new cancers diagnosed in women in 2015 (Siegel, 2015). It is now the leading cause of cancer-related death in both men and women. All smokers should be advised of tobacco-use risks and encouraged to stop. A list of potential aids is found on page 11.
Lung cancer screening focuses on those at high risk and referral is considered for individuals with general good health, aged 55 to 74, with at least a 30-pack-year history, and who actively smoke or quit within the past 15 years. One remembers that pack-year determination is calculated by multiplying the number of packs smoked per day by the number of years the person has smoked. By convention, one pack contains 20 cigarettes. For appropriate cases, low-dose helical CT scanning is the preferred test (Smith, 2015). Although a common diagnostic test, chest radiography is not recommended as a lung cancer screening tool.
The incidence of skin cancers (melanoma and non-melanomas) has increased in the United States during the past three decades. In 2015, melanoma is expected to account for 4 percent of all cancer deaths in women (Siegel, 2015). Skin cancer risks include prolonged sun exposure, family or personal history of skin cancer, fair skin, light hair or freckling, numerous moles, immunosuppression, and aging (American Cancer Society, 2013). The USPSTF notes insufficient evidence to recommend whole body screening by physician or patient for skin cancer in the general adult population (Wolff, 2009). It does advise clinicians to use the “ABCD” system—asymmetry, border irregularity, color, and diameter (>6 mm) to evaluate skin lesions of concern and refer appropriately.
Cigarette smoking is the single most preventable cause of death in the United States and has been linked with certain cancers, cardiovascular disease, chronic lung diseases, and stroke. Moreover, specific to women’s health, smoking is linked to diminished fertility, pregnancy complications, and postoperative complications. These are discussed in greater detail in their respective chapters.
Despite these known negative health outcomes, in 2003, only 64 percent of smokers who had routine examinations in the United States were advised by a physician to quit smoking (Torrijos, 2006). Guidelines from the U.S. Department of Health and Human Services encourage a brief behavioral patient intervention model found on page 12. Patients can also be referred to the National Cancer Institute’s smoking cessation website: www.smokefree.gov. This site provides free, evidence-based information and professional assistance to help the immediate and long-term needs of those trying to quit. Unless contraindicated, pharmacologic treatments to aid smoking cessation can be offered to all interested women and are listed in Table 1-4. Gynecologists who are proficient in the use of these therapies may prescribe. Referral is also appropriate (American College of Obstetricians and Gynecologists, 2014c).
TABLE 1-4Drugs Used for Smoking Cessation ||Download (.pdf) TABLE 1-4 Drugs Used for Smoking Cessation
|Agent ||Brand Name ||Initial Dosing ||Maintenance ||Drug Tapering ||Therapy Duration |
| Nicotine Replacement |
|Patch d ||Habitrol Nicoderm CQ ||If >10 CPD: a 21-mg patch is reapplied daily wk 1–6 |
If <10 CPD: 14-mg patch daily for wk 1–6
|14-mg patch is used wk 7–8— ||7-mg patch is used wk 9–10 |
7-mg patch is used wk 7–8
|8–12 wk |
|Gum d ||Nicorette |
4 mg (if ≥25 CPD)
|1 piece every |
1–2 hr for wk 1–6
(maximum 24 pieces/d)
|1 piece every 2–4 hr for wk 7–9 ||1 piece every 4–8 hr for wk 10–12 ||12 wk |
|Lozenge b ||Commit |
4 mg (if smokes <30 min after waking)
|1 piece every |
1–2 hr for wk 1–6
(maximum 20 pieces/d)
|1 piece every 2–4 hr for wk 7–9 ||1 piece every 4–8 hr forwk 10–12 ||12 wk |
|Inhaler d ||Nicotrol || ||6 (average use) to 16 cartridges puffed qd for 12 wk ||Use is then tapered ||12–24 wk |
|Nasal spray d ||Nicotrol || ||1 dose = 1 spray to each nostril per hr (maximum 5 doses/hr & 40/d) ||Use is then tapered starting wk 9 ||12–24 wk |
| Nicotine Agonists |
|Varenicline c ||Chantix ||0.5 mg PO qd for 3 d, then 0.5 mg PO bid for next 4 d ||Then 1 mg PO bid || ||12 wk |
| CNS Agents |
|Bupropion c ||Wellbutrin SR Zyban ||1–2 wk prior to cessation: 150 mg PO qd for 3 d ||Then 150 mg PO bid || ||7–12 wk; may use for 6 mo. |
|Nortriptyline a , d || ||25 mg PO qd with gradual increase ||75–100 mg PO qd || ||12 wk; may use for 6 mo. |
|Clonidine a , c ||Catapres ||0.1 mg PO bid, increase by 0.10 mg/d each wk as needed ||0.15–0.75 mg PO qd || ||3–10 wk |
| ||Catapres-TTS ||0.1-mg transdermal patch is changed weekly ||0.1- to 0.2-mg transdermal patch weekly || || |
Exercise has known benefits in preventing coronary artery disease, diabetes, osteoporosis, obesity, depression, insomnia, and breast and colon cancer (Brosse, 2002; Knowler, 2002; Lee, 2003; Vuori, 2001; Youngstedt, 2005). Many of these associations may result from the effects of exercise to lower blood pressure, decrease low-density lipoprotein cholesterol and triglyceride levels, increase high-density lipoprotein cholesterol levels, improve blood sugar control, and reduce weight (Braith, 2006; Pescatello, 2004; Sigal, 2004).
Despite these known benefits, based on U.S. government thresholds, only 45 percent of women in 2012 were considered sufficiently active (Blackwell, 2014). Recommendations from the U.S. Department of Health and Human Services (2008) include moderate-intensity activity such as walking, water aerobics, or yard work for at least 150 minutes each week or vigorous-intensity activities such as running, swimming laps, or aerobic dancing for 75 minutes each week. Activities can be performed in episodes of at least 10 minutes that are apportioned throughout the week. Additional health benefits are gained with physical activity beyond these amounts.
Although exercise programs have traditionally emphasized dynamic, aerobic lower-extremity exercise, research supports complementary resistance training to improve muscular strength and endurance, cardiovascular function, metabolism, coronary risk factors, weight management, and quality of life (Williams, 2007). Accordingly, government guidelines also encourage biweekly muscle-strengthening activities that involve all the major muscle groups. A fuller listing of general physical activities and their intensity description is found in the publication 2008 Physical Activity Guidelines for Americans at the CDC website: www.health.gov/paguidelines/guidelines.
To change any type of health-related behavior, counseling can be brief yet effective. One method is the five A’s system, which in this example is tailored for exercise (Fiore, 2008).
Ask: if she is physically active now
Advise: her about the benefits of regular physical activity
Assess: her willingness to change and decide if she is in a (1) precontemplation, (2) contemplation phase, (3) preparation, or (4) action phase. Her stage of readiness guides further discussion
Assist: her by recommending local exercise programs
Arrange: for follow-up evaluation to assess progress
For those with certain comorbidities, clearance by other health care providers may be indicated. For this, the Physical Activity Readiness Questionnaire helps identify women with risk factors who merit further evaluation and is available at: www.csep.ca/cmfiles/publications/parq/par-q.pdf.
Associated Risks and Diagnosis
In 2010, nearly 36 percent of women in the United States were obese, and almost twice that many were overweight (Flegal, 2012). Possible consequences of obesity include diabetes mellitus, metabolic syndrome, nonalcoholic fatty liver, cholelithiasis, hypertension, osteoarthritis, nonobstructive sleep apnea, and renal disease. Gynecologic issues related to obesity include abnormal menstruation, risks for endometrial neoplasia, and worsening polycystic ovary syndrome. Moreover, some hormonal contraceptives may have lower efficacy in obese women. Despite these considerable consequences, one study showed that fewer than half of physicians are comfortable discussing obesity (Schuster, 2008). Even if not trained as weight management specialists, clinicians ideally screen for obesity, provide initial obesity evaluation and management, and refer as needed.
Screening is accomplished with calculation of body mass index (BMI) or less commonly, waist circumference. BMI, although not a direct measure of body fat content, is valuable in assessing the risk for weight-related complications. The following calculations can be used: BMI = (Wt in lb/(Ht in inches × Ht in inches)) × 703 BMI = Wt in kg/(Ht in meters × Ht in meters)
More simply, an online calculator can be found at: www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html. For adolescents (and children), BMI is adjusted for age and gender and calculated as a percentile. A BMI calculator for adolescents can be found at http://apps.nccd.cdc.gov/dnpabmi/.calculator.aspx. Table 1-5 reflects the definitions for underweight, overweight, and obesity for adolescents and adults.
TABLE 1-5Definitions of Abnormal Weight for Adults and Adolescents Using Body Mass Index ||Download (.pdf) TABLE 1-5 Definitions of Abnormal Weight for Adults and Adolescents Using Body Mass Index
|Age Group ||Underweight ||Overweight ||Obese |
|Adult ||<18.5 ||25–29.9 ||≥30 |
|Adolescent ||<5th percentile for age ||Between 85th and 95th percentile for age ||>95th percentile for age |
Waist circumference positively correlates with abdominal fat content, which is a risk factor for poor health outcomes. Waist circumference is measured at the level of the iliac crests at the end of normal expiration. Values greater than 35 inches (88 cm) are considered elevated (National Heart, Lung, and Blood Institute, 2000).
No standard single or panel laboratory test is indicated for an obese woman. Evaluation for comorbidities is tailored to the patient, taking into consideration her family and social histories (Table 1-6). Blood pressure measurement, fasting lipid and glucose screening, and thyroid function testing can all be considered for the obese patient during initial evaluation.
TABLE 1-6Obesity Comorbid Risk Factors ||Download (.pdf) TABLE 1-6 Obesity Comorbid Risk Factors
|Coronary heart disease (CHD) |
Other atherosclerotic disease
Abnormal lipid levels
Family history of early CHD
Abnormal uterine bleeding
For a woman with elevated BMIs, a clinician should assess her readiness for change and thereby, provide appropriate guidance, support, or referral. In addition, questions regarding previous attempts at weight loss, social hurdles that impede diet and exercise change, and detrimental eating habits are discussed in a nonjudgmental manner.
Effective weight loss is best obtained with proper nutrition and consistent physical activity. Table 1-7 illustrates recommended guidelines to direct therapy for overweight or obese women. A detailed discussion of dietary weight loss extends beyond this chapter’s scope, but several clinician and patient aids can be found in The Practical Guide to Identification, Evaluation and Treatment of Overweight or Obesity in Adults, available at: www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf.
TABLE 1-7Treatment Recommendations According to BMI ||Download (.pdf) TABLE 1-7 Treatment Recommendations According to BMI
|Treatment ||BMI 25–26.9 ||BMI 27–29.9 ||BMI 30–34.9 ||BMI 35–39.9 ||BMI ≥40 |
|Diet, activity, behavioral therapy ||WCM ||WCM ||+ ||+ ||+ |
|Pharmacotherapy ||— ||WCM ||+ ||+ ||+ |
|Surgery ||— ||— ||— ||WCM ||+ |
In general, for the adult patient, a 10-percent weight loss within 6 months is realistic. According to the American Heart Association, suitable options are diets with 1200 to 1500 kcal/day or diets that incorporate a 500 or 750-kcal/d deficit (Jensen, 2014). No single diet plan is espoused as the gold standard for every patient, and the ideal regimen is one that can be adhered to.
In addition to diet and exercise, pharmacologic or surgical options may be implemented for selected obese patients. Four agents are FDA-approved for long-term obesity treatment. First, orlistat (Xenical) is a reversible inhibitor of gastric and pancreatic lipases and leads to a 30-percent blockage of dietary fat absorption (Henness, 2006). This drug is prescribed as 120-mg capsule taken orally three times daily with meals but is also available over-the-counter in 60-mg capsules (Allī), also taken three times daily. Associated malabsorption can lead to deficiencies of the fat-soluble vitamins A, D, E, and K, and all patients should receive a daily supplement enriched with these vitamins. Severe liver injury has been reported rarely, and new labeling reflects this risk (Food and Drug Administration, 2010).
Another medication, lorcaserin (Belviq) is a serotonin 2C receptor agonist used to suppress appetite (Fidler, 2011; Smith, 2010). One 10-mg tablet is taken orally twice daily. A third agent combines phentermine and topiramate (Qsymia)(Gadde, 2011). Doses begin at 3.75 mg/23 mg orally daily and are gradually titrated upward as needed to a maximum dose of 15 mg/92 mg daily. This drug has fetotoxicity potential and prescribing providers participate in a Qsymia Risk Evaluation and Mitigation Strategy program. Last, liraglutide (Saxenda) is a glucagon-like peptide-1 receptor agonist delivered by subcutaneous injection (Astrup, 2009). Dosing begins at 0.6 mg daily and is gradually escalated weekly to reach a 3-mg daily dose. Important potential risks include medullary thyroid carcinoma and pancreatitis. These last three agents are indicated for those with BMIs of 30 or greater, or 27 or greater if weight-associated comorbid risks exist.
As another adjunct, bariatric surgery may be selected for those with BMIs of 40 or greater, or with BMIs at or above 35 if other comorbid conditions are present (Jensen, 2014). Of available laparoscopic procedures, three are more commonly performed. Two are considered restrictive (limit intake), whereas bypass surgery promotes malabsorptive weight loss. First of these, gastric banding places an adjustable plastic ring around the stomach to limit food intake. Second, sleeve gastrectomy partitions off the lateral stomach by a staple line, and the remaining smaller stomach has a tubular, sleeve appearance. Last, the Roux-en-Y gastric bypass creates a small stomach pouch that is connected directly to the jejunum to bypass the duodenum. This reduces calorie and nutrient absorption. These surgeries lead to substantial weight loss in individuals with morbid obesity and have been linked with improvement in comorbid risk factors and decreased mortality rates (Hutter, 2011). With these, surgical complications are infrequent but can be serious and include gastrointestinal leaks at staple or suture lines, stomal obstruction or stenosis, thromboembolism, and bleeding (Jackson, 2012).
Following bariatric surgery, patients are advised to delay pregnancy for 12 to 24 months (American College of Obstetricians and Gynecologists, 2013). Rapid weight loss during this time poses theoretical risks for intrauterine fetal-growth restriction and nutritional deprivation. However, as weight is lost, fertility rates overall appear to be improved, and risks for pregnancy increase (Merhi, 2009). Thus, effective contraception is needed. Most contraceptive methods appear to be as effective in women with elevated BMIs compared with normal-weight controls. However, the contraceptive patch (OrthoEvra) is less effective in those weighing more than 90 kg (Zieman, 2002). Specific to those with malabsorptive bariatric surgery types, oral contraception efficacy may be lower due to poor absorption (Centers for Disease Control and Prevention, 2013). Last, due to its risk for associated weight gain, depot medroxyprogesterone acetate (Depo-Provera) may be an unpopular choice in women trying to lose weight.
In 2010, nearly 34 percent of the female population was affected by cardiovascular disease (CVD), and more than 400,000 women died from its complications (Go, 2014). Stratification of CVD predispositions can identify vulnerable patients for management or referral (Table 1-8). Ideal goals for exercise, glucose and lipid levels, blood pressure, and smoking cessation are discussed in other sections of this chapter. Specific dietary intake recommendations for women are listed in Table 1-9.
TABLE 1-8Classification of Cardiovascular Disease (CVD) in Women ||Download (.pdf) TABLE 1-8 Classification of Cardiovascular Disease (CVD) in Women
|≥1 assigns high-risk status ||Known CHD or CVD |
Peripheral arterial disease
End-stage renal disease
|≥1 assigns at-risk status ||Smoking |
SBP ≥120 or DBP ≥80 mm Hg, or treated hypertension
Total cholesterol ≥200 mg/dL, HDL <50 mg/dL, or treated dyslipidemia
Family history of premature CVD
Prior PIH or gestational DM
| Ideal, if all present ||Total cholesterol <200 mg/dL |
BP <120/<80 mm Hg
Fasting blood glucose <100 mg/dL
Body mass index <25
Abstinence from smoking
Healthy diet: see Table 1-9
TABLE 1-9Specific Dietary Intake Recommendations for Women ||Download (.pdf) TABLE 1-9 Specific Dietary Intake Recommendations for Women
|Food ||Serving |
|Fruits/vegetables ||≥4.5 cups/d |
|Fish ||2/wk |
|Fiber ||30 g/d |
|Whole grains ||3/d |
|Sugar ||≤5/wk |
|Nuts, legumes ||≥4/wk |
|Saturated fat ||<7%/total energy intake |
|Cholesterol ||<150 mg/d |
|Alcohol ||≤1/d |
|Sodium ||<1500 mg/d |
| trans-Fatty acids ||None |
Nearly 41 million American women are hypertensive. The risk of hypertension increases with age and is increased for black women compared with those of other races (Go, 2014). Chronic hypertension increases the risks for myocardial infarction, stroke, congestive heart failure, renal disease, and peripheral vascular disease. Moreover, chronic hypertension and its potential therapies may limit contraception choices for some women. Thus, gynecologists should be familiar with criteria used to diagnose hypertension. Although many may choose to refer their patients for treatment of hypertension, gynecologists should be aware of target goals and long-term risks associated with this disease.
For adult screening, the American Heart Association (2014) recommends blood pressure assessment starting at age 20 and evaluation repeated every 2 years if initially normal. For patients with elevated pressures, assessment is at least annually.
With screening, blood pressures are best taken with a woman seated in a chair with the tested arm resting on a table, at the level of the heart. Ideally, the patient has been able to rest quietly for a few minutes prior to measurement and to have refrained from tobacco and caffeine use immediately prior to testing. An appropriately sized cuff is selected, and the cuff bladder should encircle at least 80 percent of the arm. Hypertension is diagnosed if readings are elevated on at least two separate office visits over one or more weeks. Prehypertension is diagnosed if readings fall in the range 130–139/80–89 mm Hg. Notably, women with prehypertension are at significantly increased risk of developing hypertension later (Wang, 2004). Additionally, compared with normal blood pressure readings, prehypertension is associated with greater risks for CVD (Mainous, 2004).
If hypertension is diagnosed, further examination should exclude underlying causes of hypertension and resultant end-organ disease (Table 1-10). With the diagnosis of chronic hypertension, assessment then follows for both modifiable and nonmodifiable CVD risk factors. Thus, routine laboratory tests recommended before initiating therapy include an electrocardiogram, urinalysis, blood glucose, hematocrit, lipid profile, thyroid testing, and serum potassium and creatinine measurement. A more extensive search for identifiable causes is not generally indicated unless hypertension is not controlled with initial treatment (Chobanian, 2003).
TABLE 1-10Identifiable Causes of Hypertension ||Download (.pdf) TABLE 1-10 Identifiable Causes of Hypertension
|Chronic renal disease |
Chronic corticosteroid therapy and Cushing syndrome
Coarctation of the aorta
Drug-induced or drug-related
Nonsteroidal antiinflammatory drugs
Cocaine and amphetamines
Sympathomimetics (decongestants, anorectics)
Combination hormonal contraception
Cyclosporine and tacrolimus
Herbal medicines (ephedra, ma huang)
Thyroid or parathyroid disease
For treatment, lifestyle changes that mirror those for CVD are encouraged (see Table 1-9). However, if blood pressure is significantly elevated or resistant to lifestyle modification alone, then pharmacologic treatment may be needed to decrease long-term complications. Recommendations from the Eighth Joint National Committee (JNC 8) are shown in Table 1-11 (James, 2014).
TABLE 1-11Initial Drug Therapy for Adults with Hypertension ||Download (.pdf) TABLE 1-11 Initial Drug Therapy for Adults with Hypertension
|Health Status ||Goal BP ||Treatment |
|General ≥60 yr ||<150/90 || |
|General <60 yr ||<140/90 ||Nonblack: thiazide-type diuretic, ACEI, ARB, or CCB |
|Diabetes ||<140/90 ||Black: thiazide-type diuretic or CCB |
|Renal disease ||<140/90 ||ACEI or ARB |
This is the third leading cause of death in the United States, and in 2010, approximately 425,000 American women suffered a new or recurrent stroke (Go, 2014). Gender-specific risk factors for stroke in women include hypertension, atrial fibrillation, migraines with aura, and oral contraceptive use. Aspirin is recommended as prevention for stroke in normotensive women aged 65 years or older for whom the lowered risks for ischemic stroke and myocardial infarction outweigh the risks for gastrointestinal bleeding and hemorrhagic stroke (Bushnell, 2014). There is no consensus as to the optimal dose or frequency of aspirin for prevention. Options are 81 mg daily or 100 mg every other day.
Data support that low-density lipoprotein cholesterol (LDL) is the primary atherogenic agent. Although previously believed merely to collect passively within vessel walls, LDL is now felt to be a potent proinflammatory agent and creates the chronic inflammatory response characteristic of atherosclerosis. Logically, elevated levels of total and LDL cholesterol are associated with increased rates of coronary artery disease, ischemic stroke, and other atherosclerotic vascular complications (Horenstein, 2002; Law, 1994).
Preventively, the National Cholesterol Education Program Adult Treatment Panel-III (ATP-III) (2001) recommends that all adults 20 years and older be screened with a fasting serum lipoprotein profile once every 5 years. This profile includes measurement of total, LDL, and high-density lipoprotein (HDL) cholesterol levels and triglyceride concentrations. Table 1-12 lists interpretation of these levels. Notably, if other comorbid risks for coronary heart disease are present, then LDL goals are more stringent.
TABLE 1-12Interpretation of Cholesterol and Triglyceride Levels ||Download (.pdf) TABLE 1-12 Interpretation of Cholesterol and Triglyceride Levels
|Lipoprotein (mg/dL) ||Interpretation |
|Total cholesterol |
| <200 |
|LDL cholesterol |
| <100 |
|HDL cholesterol |
| <40 |
| <150 |
Lowering LDL levels has been associated with reduced rates of myocardial infarction and stroke (Goldstein, 2006; Sever, 2003). Initial management usually begins with lifestyle and dietary changes, discussed earlier for CVD, and outlined by the American Heart Association (Eckel, 2014). If these modifications are unsuccessful, this organization recommends lipid-lowering treatment consideration for: (1) those with known CVD, (2) those with LDL cholesterol levels at or above 190 mg/dL, (3) those aged 40 to 75 years with diabetes and LDL cholesterol levels of 70 mg/dL or more, and (4) those aged 40 to 75 years with LDL cholesterol levels of 70 mg/dL or higher and an estimated 10-year risk of a cardiovascular event that is at least 7.5 percent (Stone, 2014).
Triglycerides are delivered to tissues by very-low-density lipoprotein (VLDL), which is synthesized and secreted by the liver. This triglyceride-rich lipoprotein is taken up by adipose and muscle, where triglycerides are cleaved from VLDL. Ultimately, a VLDL remnant is created that is atherogenic. For this reason, triglyceride levels can be used as one marker for atherogenic lipoproteins, and high triglyceride levels have been linked to increases in CVD (Assmann, 1996; Austin, 1998). Its clinical importance is also underscored by its inclusion as one criterion for the metabolic syndrome.
Hypertriglyceridemia is diagnosed based on criteria found in Table 1-12. For most with mild or moderate triglyceride elevation, recommendations from American Heart Association emphasize diet changes and weight loss (Miller, 2011). Alternatively, for those with triglyceride levels of 500 mg/dL or greater, treatment goals focus primarily on triglyceride level lowering to prevent pancreatitis.
Diabetes is common, and approximately 13.4 million adult women in the United States are diabetic (Centers for Disease Control and Prevention, 2014). The long-term consequences of this endocrine disorder are serious and include coronary heart disease, stroke, peripheral vascular disease, periodontal disease, nephropathy, neuropathy, and retinopathy.
The USPSTF (2014b) recommends diabetes screening for asymptomatic adults with blood pressure of 135/80 mm Hg or greater. For normotensive adults, screening is individualized based on risks. However, the American Diabetes Association (2015) recommends that screening be considered at 3-year intervals beginning at age 45, particularly in those with BMIs of 25 or above. Moreover, testing is considered at a younger age or completed more often in those who are overweight and have one or more of the other risk factors shown in Table 1-13.
TABLE 1-13Adult Risk Factors for Diabetes Mellitus ||Download (.pdf) TABLE 1-13 Adult Risk Factors for Diabetes Mellitus
|Age ≥45 years |
Body mass index ≥25
Affected first-degree relative
Ethnicity: African-, Hispanic-, Native-, and Asian-Americans; Pacific Islanders
Prior prediabetes-range test values
Prior gestational diabetes mellitus or delivery of a baby weighing >9 lb
Hypertension: ≥140/90 mm Hg
HDL cholesterol ≤35 mg/dL and/or triglyceride level ≥250 mg/dL
Polycystic ovary syndrome
Conditions associated with insulin resistance
Existing cardiovascular disease
Diabetes and prediabetes may be diagnosed by various laboratory tests listed in Table 1-14. Laboratory measurement of plasma glucose concentration is performed on venous samples, and the aforementioned values are based on the use of such methods. Capillary blood glucose testing using a blood glucometer is an effective monitoring tool but is not currently recommended for diagnostic use.
TABLE 1-14American Diabetes Association Criteria ||Download (.pdf) TABLE 1-14 American Diabetes Association Criteria
|Diagnostic Criteria for Diabetes Mellitus |
Fasting plasma glucose ≥126 mg/dL. Fasting is no caloric intake for at least 8 hr
2-hr plasma glucose ≥200 mg/dL during an OGTT
Symptoms of diabetes plus random plasma glucose concentration ≥200 mg/dL. Classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss
| Criteria for Increased Diabetes Risk (prediabetes) |
|Fasting plasma glucose: 100–125 mg/dL |
2-hr plasma glucose during 75-g OGTT: 140–199 mg/dL
For those diagnosed with diabetes, referral to a specialist is usually indicated. Delayed onset and slower progression of many diabetic complications has been shown to follow control of elevated blood glucose levels (Cleary, 2006; Fioretto, 2006; Martin, 2006). Control can be achieved with diet modification alone or combined with oral hypoglycemic agents or injectable insulin. To lower diabetic morbidity, therapy goals for otherwise normal patients include hemoglobin A1c levels below 7 percent, preprandial glucose between 80 and 130 mg/dL, blood pressure readings below 120/80 mm Hg, low-density lipoprotein (LDL) levels below 100 mg/dL, HDL levels above 50 mg/dL, triglyceride levels below 150 mg/dL, weight loss, and smoking cessation (American Diabetes Association, 2015).
Patients with “prediabetes,” that is, impaired fasting glucose or impaired glucose tolerance, have an increased risk for developing diabetes. To avert or delay diabetes, management includes increased physical activity, weight loss, drugs such as metformin, nutritional counseling, and yearly diabetes screening. Metformin is considered especially for those with BMI above 35, age younger than 60 years, and prior gestational diabetes (American Diabetes Associations, 2015).
This syndrome is a clustering of major cardiovascular disease risk factors (Table 1-15). At present, a single unifying cause of the metabolic syndrome has not been identified, and it may be precipitated by multiple underlying risk factors. Of these, abdominal obesity and insulin resistance appear important (Grundy, 2005).
TABLE 1-15Diagnostic Criteria for Metabolic Syndrome in Women ||Download (.pdf) TABLE 1-15 Diagnostic Criteria for Metabolic Syndrome in Women
|Criteria ||Thresholds |
|Waist circumference ||≥88 cm (≥35 in) |
|Triglycerides ||≥150 mg/dL |
|HDL cholesterol ||<50 mg/dL |
|Blood pressure ||≥130/85 mm Hg |
|Fasting glucose ||≥110 mg/dL |
This syndrome is common, and in 2010, 22 percent of U.S. women met diagnostic criteria. Although genders appear equally affected, Mexican Americans show the highest prevalence, and incidence appears to increase in all ethnicities with age (Beltrán-Sánchez, 2014). The sequelae associated with metabolic syndrome are significant and include an increased risk of diabetes and mortality from coronary heart disease, CVD, and all causes (Lorenzo, 2003; Malik, 2004; Sattar, 2003). Among those with metabolic syndrome, risks are further increased, by cigarette smoking and elevated LDL cholesterol levels.
Goals of clinical management include reducing risks for clinical atherosclerotic disease and for diabetes. Accordingly, primary therapy for metabolic syndrome focuses on lifestyle modification, particularly weight reduction and increased exercise. During evaluation, each metabolic syndrome component is addressed and treated in accordance with current guidelines, as discussed in earlier sections.
The risk of thyroid disease increases with age, and dysfunction is more common in women. Accordingly, the American Thyroid Association recommends that adults, especially women, be screened for thyroid dysfunction by measurement of a serum thyroid-stimulating hormone (TSH) concentration. This begins at age 35 years and is repeated every 5 years thereafter (Garber, 2012). Moreover, individuals with clinical manifestations potentially attributable to thyroid dysfunction and those with risk factors for its development may require more frequent testing. People at higher risk for thyroid dysfunction include the elderly and those with prior neck radiation, thyroid surgery, autoimmune disease, affected first-degree relative, psychiatric disorders, or lithium use. In contrast, the U.S. Preventive Service Task Force (2004b) has found insufficient evidence to recommend for or against routine screening in asymptomatic women.
Women are now living longer, and the current life expectancy for women in the United States is 81 years (Arias, 2014). As a woman moves past menopause, many of her health care needs may not be gynecologic. However, a family may often contact a patient’s gynecologist first regarding a member’s lack of independent function or memory loss.
Of these, functional status is a patient’s ability to perform both basic and complex activities for independent living. Basic activities are grooming and toileting, whereas checkbook balancing, bill paying, and housekeeping tasks are more complex, instrumental activities of daily living (Katz, 1963; Lawton, 1969). Declines in functional status are linked to increased risks of hospitalization, institutionalization, and death (Walston, 2006). Identification of functional status loss may permit early intervention.
Second, loss of cognitive function may present as short- and long-term memory loss, difficulty with problem solving, or inattention to personal hygiene. Although not expert in recognition of cognitive problems, a gynecologist can perform initial screening and provide results that either reassure the patient and her family or prompt more formal evaluation by a geriatrician or neurologist.
For dementia, the Mini Mental Status Exam or, more recently, the Mini-Cog Test can screen for cognitive impairment in the primary care setting (Borson, 2000, 2006; Folstein, 1975). The Mini-Cog test requires approximately 3 minutes to administer and begins by giving the patient three items to remember early in the interview. Later in discussion, she is asked to recall those three items. For the clock-drawing test, a person is asked to draw a clock with the hands at a specific time, such as 8:30. A correct clock has numbers 1 through 12 labeled correctly in a clockwise fashion, with two arms (of any length) pointing at the correct numbers for the time requested. Any error or refusal to complete the clock is considered abnormal. An algorithm for scoring the Mini-Cog is shown in Figure 1-10. For a Mini-Cog Test result suggestive of dementia, referral to an internist, geriatrician, or neurologist, as available to the patient in that community, is indicated.
The Mini-Cog Test. CDT = clock-drawing test. (Modified with permission from Borson S, Scanlan J, Brush M, et al: The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000 Nov;15(11):1021–1027.)
Depression and Intimate Partner Violence
For women of all ages, these problems are pervasive and account for significant morbidity and mortality. Each is discussed in detail in Chapter 13 and should be routinely screened for at routine health visits. Simple questions such as “During the past 2 weeks, have you felt down, depressed, or hopeless?” and “Have you felt little interest or pleasure in doing things?” are often effective (Whooley, 1997). These two questions constitute the Personal Health Questionnaire-2 (PHQ2), a validated screening tool for depression (Kroenke, 2003). Any positive screening test should prompt further evaluation for depression as outlined in Chapter 13.
For intimate partner violence, American College of Obstetricians and Gynecologists (2012a) guidelines recommend that physicians routinely ask direct, specific questions regarding abuse. General introductory statements such as “Because abuse and violence are so common in women’s lives, I’ve begun to ask about it routinely” can help a health care provider introduce this subject for discussion.
Insomnia is common, and its definition includes: (1) difficulty initiating sleep, (2) trouble maintaining sleep, and (3) early waking. Insomnia may be primary or may be secondary to other conditions such as depression, time-zone travel, restless leg syndrome, stimulant use, and sleep apnea (National Institutes of Health, 2005). Accordingly, historical inventory investigates and treatment addresses these and other secondary causes.
Treatment of primary insomnia is typically cognitive-behavioral or pharmacologic. Cognitive therapy is aimed at changing patients’ beliefs and attitudes regarding sleep. Behavioral therapies are varied and include those that control sleep timing and duration; attempt to improve the bedroom environment; or focus on relaxation or biofeedback techniques (Morgenthaler, 2006; Silber, 2005). Medications may be used to aid sleep, and most agents are of the benzodiazepine family (Table 1-16).
TABLE 1-16Insomnia Medications Approved by the U.S. Food and Drug Administration ||Download (.pdf) TABLE 1-16 Insomnia Medications Approved by the U.S. Food and Drug Administration
Value lies in counseling women before conception so that each pregnancy is planned with the goal to achieve the best maternal and fetal outcomes. With this in mind, topics found in Table 1-17 are ideally addressed (American College of Obstetricians and Gynecologists, 2012b; Jack, 2008).
TABLE 1-17Preconceptional Counseling Topics ||Download (.pdf) TABLE 1-17 Preconceptional Counseling Topics
|Condition ||Recommendations for Preconceptional Counseling |
|Abnormal weight ||Calculate BMI yearly. |
BMI ≥25 kg/m2: Counsel on diet. Test for DM and metabolic syndrome if indicated
BMI ≤18.5 kg/m2: Assess for eating disorder
|Heart disease ||Counsel on cardiac risks during pregnancy. Optimize cardiac function, offer effective BCM during this time. Discuss warfarin, ACE inhibitor, and ARB teratogenicity, and if possible, switch to less dangerous agent when conception planned. Offer genetic counseling to those with congenital cardiac anomalies. Review infective endocarditis risks (Nishimura, 2014) |
|Hypertension ||Counsel on specific risks during pregnancy. Assess those with long-standing HTN for ventricular hypertrophy, retinopathy, and renal disease. Counsel women taking ACE inhibitors and ARBs on drug teratogenicity, on effective BCM during use, and on the need to switch agents prior to conception |
|Asthma ||Counsel on asthma risks during pregnancy. Optimize pulmonary function and offer effective BCM during this time. Treat women with pharmacological step therapy for chronic asthma based on ACOG-ACAAI (2000) recommendations |
|Thrombophilia ||Question for personal or family history of thrombotic events or recurrent poor pregnancy outcomes. If found, counsel and screen those contemplating pregnancy. Offer genetic counseling to those with known thrombophilia. Discuss warfarin teratogenicity, offer effective BCM during use, and switch to a less teratogenic agent, if possible, prior to conception |
|Renal disease ||Counsel on specific risks during pregnancy. Optimize blood pressure control and offer effective BCM during this time. Counsel women taking ACE inhibitors and ARBs on their teratogenicity, on effective BCM during use, and on the need to switch agents prior to conception |
|GI disease ||Inflammatory bowel disease: Counsel affected women on subfertility risks and risks of adverse pregnancy outcomes. Discuss teratogenicity of MTX and the other immunomodulators, about which less is known, e.g., mycophenolate mofetil. Offer effective BCM during their use and switch agents, if possible, prior to conception |
|Liver disease ||Hepatitis B: Vaccinate all high-risk women prior to conception (Table 1-2). Counsel chronic carriers on transmission prevention to partners and fetus |
Hepatitis C: Screen high-risk women. Counsel affected women on risks of disease and transmission. Refer for treatment, discuss ramifications of treatment during pregnancy, and offer effective BCM
|Hematologic disease ||Sickle-cell disease: Screen all black women. Counsel those with trait or disease. Test partner if desired |
Thalassemias: Screen women of Southeast Asian or Mediterranean ancestry
|Diabetes ||Advocate good glucose control, especially in periconceptional period to decrease known teratogenicity of overt diabetes. Evaluate for retinopathy, nephropathy, hypertension, etc. |
|Thyroid disease ||Screen those with thyroid disease symptoms. Ensure iodine-sufficient diet. Treat overt hyper- or hypothyroidism prior to conception. Counsel on risks to pregnancy outcome |
|CT disease ||RA: Counsel on flare risk after pregnancy. Discuss MTX and leflunomide teratogenicity. Offer effective BCM during their use and switch agents prior to conception. |
SLE: Counsel on risks during pregnancy. Optimize disease. Discuss mycophenolate mofetil and cyclophosphamide teratogenicity; offer effective BCM during their use. If possible, switch agents prior to conception
|Neurologic and psychiatric disorders ||Depression: Screen for symptoms. If affected, counsel on risks of treatment and of untreated illness and high risk of peripartum exacerbation |
Seizure disorder: Optimize seizure control using monotherapy if possible
|Skin disease ||Discuss isotretinoin and etretinate teratogenicity, offer effective BCM during their use, switch agents prior to conception |
|Cancer ||Counsel on fertility preservation options prior to cancer therapy and on decreased fertility following certain agents. Offer genetic counseling to those with mutation-linked cancers. Evaluate cardiac function in those given cardiotoxic agents, such as adriamycin. Obtain mammography for those given childhood chest radiotherapy. Discuss SERM teratogenicity, effective BCM during its use, and need to switch agents prior to conception. Review chemotherapy and discuss possible teratogenic effects if continued during pregnancy |
|Infectious disease ||Influenza: Vaccinate all women prior to flu season |
Malaria: Avoid travel to endemic areas; offer effective BCM or chemoprophylaxis for those planning pregnancy
Rubella: Assess immunity; vaccinate as needed and offer effective BCM during next 3 months
Tuberculosis: Screen high-risk women and treat
Tetanus: Update vaccination, as needed
Varicella: Assess immunity; vaccinate as needed and offer effective BCM during next 3 months
|STD || Gonorrhea, syphilis, chlamydial infection: Screen per Table 1-1 and treat as indicated |
HIV: Discuss initiation of treatment prior to conception to decrease perinatal transmission. Offer effective BCM to those not desiring conception
HPV: Provide screening per guidelines (Chap. 29). Vaccinate as indicated
HSV: Provide serological screening to asymptomatic women with affected partners. Counsel affected women on risks of perinatal transmission and of preventive measures during the third trimester and labor