Chapter 2:OB/GYN's role in screening

Question 1

Where to go for info on vaccines

Answer 1

http://www.cdc.gov/vaccines

Question 2

How good is the HPV vaccine? Can pregnant women get this one?

Answer 2

• HPV vaccine: Nearly 100% effective at preventing the strains it covers. Do not give to pregnant mothers, but you can give to them while breastfeeding.

Question 3

Leading cause of cancer death in women and how we screen for it

Answer 3

• Lung Cancer: Leading cause of cancer death in women. We don’t screen for this.

Question 4

Most common cancer in women and how many women get it a year

Answer 4

• Breast cancer: Most common cancer, 2nd leading cause of death that is cancer related. 12.5% of women in lifetime.

Question 5

What can a woman do to help keep herself properly screened for breast cancer?

Answer 5

o Breast self-exams not recommended. Breast awareness is. Mammograms at 40 for average risk, clinical breast exam annually starting at 20-39 for above average risk and 1-3 years for average risk, after 40 it’s annual.

Question 6

In what circumstances do we screen someone under 21 for cervical cancer

Answer 6

Less than 21: No. Having sex? Don’t care. Risk factor? Don’t care.

Question 7

After 21, how do often do we screen for cervical cancer

Answer 7

o 21 – 29: Every 3 years with cytology

o 30 – 65: Every 3 years with cytology OR every 5 years with cytology and HPV testing with cotest

o 65+: No screening if negative history (three consecutive negative cytologies or 2 consecutive negative HPV tests in 10 years) AND no history of CIN 2+ within the last 20 years. Do not resume testing if deciding not to test, even if she has a new sexual partner.

Question 8

When do we do breast MRIs?

Answer 8

o MRI also recommended annually if women at high risk, defined as previous cancer, 20% lifetime risk based on a family history assessment or BRCA ½ mutation (or first degree relative with mutation).

Question 9

Gross. Colonoscopies. What can I do instead?

Answer 9

Other options if you’re squeamish
• Annual fecal occult blood testing or fecal immunochemical testing (Require 2-3 samples to be brought in, 1 not enough)
• Flexible sigmoidoscopy every 5 years (Misses right sided lesions which account for 65% of advanced colorectal cancers in women)
• Double-contract barium enema every 5 years
• Computed tomography colonography (virtual colonoscopy) every 5 years
• Stool DNA (no established interval)

Question 10

Do we screen women after a hysterectomy?

Answer 10

o S/P hysterectomy: No screening, even vaginally, as long as cervix was removed, unless history of CIN 2+. Do not resume screening, even if new sexual partner.

Question 11

How often do we screen CIN2/3 or adenocarcinoma?

Answer 11

o CIN2/3 or adenocarcinoma: No matter what age, continue screening 20 years beyond spontaneous regression or proper management

Question 12

HPV vaccine means don’t need to be screened right?

Answer 12

No. Doesn’t change a damn thing.

Question 13

How often do we do gynecological exams?

Answer 13

o Annual gynecologic examination recommended even if not screening during that visit

Question 14

3rd leading cause of cancer death in women and when do we start screening

Answer 14

Colorectal cancer.

o Screening begins at age 50 years for average risk

Question 15

When do fun old colonoscopies begin?

Answer 15

Colonoscopy every 10 years

Question 16

How do we screen for HIV?

Answer 16

o HIV: ELISA on blood sample or saliva/urine. Positive ELISA confirmed with Western Blot

Question 17

So HIV is super rare. What about the other three STDs we worry about in pregnancy particularly?

Answer 17

o	Chlamydia (400 cases per 100,000)
o	Gonorrhea (100 cases per 100,000)
o	Syphilis (8 cases per 100,000 in men, 1 case per 100,000 in women)

Question 18

Alright, so the most common chlamydia. When do we screen for it and how does it present?

Answer 18

 Trachomatis is the most commonly reported bacterial STD in the U.S.
 Often asymptomatic. If untreated can lead to chronic pelvic pain, infertility, and ectopic pregnancy
 Annual screening in sexually active females up to age 25. Starting at 26, continue screening if at high risk.

Question 19

How do we test for Chlamydia?

Answer 19

 NAATs of endocervical swab great for asymptomatic women, very sensitive/specific. Vaginal and urine samples are similarly effective

Question 20

What about screening and presentation for gonorrhea?

Answer 20

 Asymptomatic often, can present with cervicitis and vaginal discharge. Can progress to PID causing infertility, chronic pelvic pain, and ectopic pregnancy
 Annual screening in sexually active females up to age 25. Starting at 26, continue screening if at high risk.

Question 21

How do we test for gonorrhea?

Answer 21

 Swab cervical cultures or NAATs/nucleic acid hydridization tests with better sensitivity and comparable specificity.

Question 22

What causes syphillus and how does it present?

Answer 22

Caused by Treponema Pallidum

You’ll see the following, progressing as you don’t treat it:

 Painless chancre (ulcer with oozing clear fluid) to secondary and tertiary symptoms
• Second: Skin manifestations and lymphadenopathy
• Tertiary: Cardiac or ophthalmic manifestations, auditory abnormalities and gummatous lesions

Question 23

Screening and testing issues with Syphillus

Answer 23

 Early on, serological tests often negative
 Only screen if at “Increased risk”, pregnant (early on) and after delivery. If at high risk, due to the commonality of false negatives early on, repeat at beginning of third trimester

Question 24

For all STDs, we define “Increased risk” as:

Answer 24

o History of multiple sex partners
o Sexual partner with multiple sexual contacts
o Sexual contact with individuals with culture proven STDs
o History of repeated STDs
o Attendance at clinics for STDs

Question 25

How do we test for Syphilis?

Answer 25

 Screen with nontreponemal test (VDRL or RPR). Specificity reduced by conditions: pregnancy, collagen vascular disease, advanced cancer, tuberculosis, malaria, rickettsial disease. Confirm with treponemal tests like T pallidum particle agglutination

Question 26

How prevalent are bone issues?

Answer 26

o Osteoporosis: Affects 13-18% of American women over 50. Up to 50% of women have osteopenia (reduced density, BMD)

Question 27

How does BMD work and what does it tell us?

Answer 27

 BMD uses x-ray absorptionometry of hip or lumbar spine to assess fragility, and uses T score (standard deviation in young healthy individual) and a Z score (reference age, sex, and race of that patient). Huge difference in devices, so not a real screening test, but helpful

• Normal: T score greater than or equal to -1.
• Osteopenia: T score between -1 and -2.5
• Osteoporosis: T score less than -2.5

Question 28

What do we do if we get a BMD showing risk?

Answer 28

 If BMD indicates risk, do a FRAX (Fracture risk assessment tool) if age >40 to predict fracture in the next 10 years. Use this to decide on lifestyle or medical management.

Question 29

When do we recommend starting BMD? When would we do it earlier than this?

Answer 29

 Recommend BMD starting at 65 for postmenopausal women. Screen younger women when they have one of the following:
• Medical history of fragility fracture
• Body weight less than 127lbs
• Medical causes of bone loss (medications or disease)
• Parental medical history of bone disease
• Current smoker
• Alcoholism
• Rheumatoid Arthritis

Question 30

6 preventative measures for osteoporosis like conditions?

Answer 30

• 1,000 – 1,300 mg/day Ca
• 600 – 800 units of Vitamin D per day
• Regular weight bearing and muscle strengthening exercises to reduce falls and prevent fractures
• Smoking cessation
• Moderation of alcohol intake
• Fall prevention strategies

Question 31

When and how do we screen for regular ol diabetes?

Answer 31

Screen with fasting blood glucose starting at age 45 and every 3 years after

Earlier if: BMI>25, first degree relative with Diabetes, habitual physical inactivity, high risk race or ethnicity, having given birth to newborn > 9lbs, history of gestational diabetes, HTN, HDL 250, history of impaired glucose tolerance or fasting glucose, PCOS, vascular disease, and anything else associated with insulin resistance

Use HgbA1c

Question 32

When do we start screening for thyroid issues and how will hypothyroidism present in the elderly?

Answer 32

 Screen every 5 years with TSH starting at age 50 in women without risk factors. Earlier if Thyroid disease in family or autoimmune disease
 Hypothyroidism in older women can present as dementia

Question 33

How common is HTN? How do we define it?

Answer 33

o HTN – 30% of adults aged 20+ have HTN. 1/3 do not know they have it
 Defined as Sys > 140 or Dias > 90

Question 34

If HTN is so prevalent, when do we start screening

Answer 34

 Due to it being often symptomatic, annual screening 13+ regardless of BP level
 PreHTN (120-139/80-89) should be evaluated for comorbidities and screened more often

Question 35

How many people die of CHD? What’s the biggest indicator of risk?

Answer 35

 CHD causes 500,000 deaths per year in the U.S.
 Cholesterol linked to atherosclerosis, CVAs and CVD.
 1% reduction in serum cholesterol = 2% reduction in CHD rates

Question 36

When do we start screening for cholesterol

Answer 36

 1:5 Americans has Cholesterol > 240

 Screen every 5 years starting at 65, earlier with risk factors

Question 37

When do we consider someone obese and how do we treat it?

Answer 37

 Height/weight/BMI at every PHA. BMI > 30 have 2 fold increase rate in death
 Treat with behavioral modification and/or Bariatric surgery

Question 38

What sleep disorders do we see in pregnancy and how do we diagnose them?

Answer 38

 OSA and RLS (Restless leg) – Up to 10% of women have one or both
 Diagnose with overnight sleep study

Question 39

How do we treat sleep disorders and why do we even care?

Answer 39

 Treat with continuous positive pressure breathing for OSA and medication for RLS
 Can lead to IUGR in pregnancy, automobile accidents, and psychosocial dysfunction