Chapter 2:OB/GYN's role in screening Flashcards
Where to go for info on vaccines
http://www.cdc.gov/vaccines
How good is the HPV vaccine? Can pregnant women get this one?
- 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.
Leading cause of cancer death in women and how we screen for it
- Lung Cancer: Leading cause of cancer death in women. We don’t screen for this.
Most common cancer in women and how many women get it a year
- Breast cancer: Most common cancer, 2nd leading cause of death that is cancer related. 12.5% of women in lifetime.
What can a woman do to help keep herself properly screened for breast cancer?
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.
In what circumstances do we screen someone under 21 for cervical cancer
Less than 21: No. Having sex? Don’t care. Risk factor? Don’t care.
After 21, how do often do we screen for cervical cancer
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.
When do we do breast MRIs?
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).
Gross. Colonoscopies. What can I do instead?
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)
Do we screen women after a hysterectomy?
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.
How often do we screen CIN2/3 or adenocarcinoma?
o CIN2/3 or adenocarcinoma: No matter what age, continue screening 20 years beyond spontaneous regression or proper management
HPV vaccine means don’t need to be screened right?
No. Doesn’t change a damn thing.
How often do we do gynecological exams?
o Annual gynecologic examination recommended even if not screening during that visit
3rd leading cause of cancer death in women and when do we start screening
Colorectal cancer.
o Screening begins at age 50 years for average risk
When do fun old colonoscopies begin?
Colonoscopy every 10 years
How do we screen for HIV?
o HIV: ELISA on blood sample or saliva/urine. Positive ELISA confirmed with Western Blot
So HIV is super rare. What about the other three STDs we worry about in pregnancy particularly?
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)
Alright, so the most common chlamydia. When do we screen for it and how does it present?
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.
How do we test for Chlamydia?
NAATs of endocervical swab great for asymptomatic women, very sensitive/specific. Vaginal and urine samples are similarly effective
What about screening and presentation for gonorrhea?
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.
How do we test for gonorrhea?
Swab cervical cultures or NAATs/nucleic acid hydridization tests with better sensitivity and comparable specificity.
What causes syphillus and how does it present?
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
Screening and testing issues with Syphillus
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
For all STDs, we define “Increased risk” as:
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
How do we test for Syphilis?
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
How prevalent are bone issues?
o Osteoporosis: Affects 13-18% of American women over 50. Up to 50% of women have osteopenia (reduced density, BMD)
How does BMD work and what does it tell us?
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
What do we do if we get a BMD showing risk?
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.
When do we recommend starting BMD? When would we do it earlier than this?
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
6 preventative measures for osteoporosis like conditions?
- 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
When and how do we screen for regular ol diabetes?
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
When do we start screening for thyroid issues and how will hypothyroidism present in the elderly?
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
How common is HTN? How do we define it?
o HTN – 30% of adults aged 20+ have HTN. 1/3 do not know they have it
Defined as Sys > 140 or Dias > 90
If HTN is so prevalent, when do we start screening
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
How many people die of CHD? What’s the biggest indicator of risk?
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
When do we start screening for cholesterol
1:5 Americans has Cholesterol > 240
Screen every 5 years starting at 65, earlier with risk factors
When do we consider someone obese and how do we treat it?
Height/weight/BMI at every PHA. BMI > 30 have 2 fold increase rate in death
Treat with behavioral modification and/or Bariatric surgery
What sleep disorders do we see in pregnancy and how do we diagnose them?
OSA and RLS (Restless leg) – Up to 10% of women have one or both
Diagnose with overnight sleep study
How do we treat sleep disorders and why do we even care?
Treat with continuous positive pressure breathing for OSA and medication for RLS
Can lead to IUGR in pregnancy, automobile accidents, and psychosocial dysfunction
