prevention Flashcards
top 5 causes of death in women
i. 1. Heart Disease
ii. 2. Cancer
iii. 3. Cerebrovascular events
iv. 4. COPD
v. 5. Pneumonia, Influenza
• Ages 15-34 years MCC of mortality
1. Accidents
2. Cancer (blood cancers)
3. Homicide/Suicide
• Ages 35-54 years MCC of mortality
1. Cancer (breast primarily)
2. Heart Disease (menopause >50)
3. Accidents
• Ages 55-74 years MCC of mortality
Cancer
2. Heart Disease
3. COPD
• Age 75 years and over
Heart Disease
2. Cancer (colon, GI, endometrial)
3. Cerebrovascular events
i. Cervical Cancer prevention
Pap smear, HPV vaccine
iv. Colorectal Cancer prevention screening .
→ Hemoccult testing, Colonoscopy starting at 50
1. Decrease risk by changing diet
anemia prevention screenin g
Hemoglobin, Hemoglobin electrophoresis
1. Very common in women of child bearing age
vi. Coronary Artery Disease prevention screening
→ lipid profile, BP screening, smoking cessation, ASA
- # 1 killer of women of all ages
- Counsel on diet and exercise, look at family hx
Thyroid disease prevention (more common in women)
screen with TSH (not in asymptomatic pts)
1. Especially in postpartum (thyroiditis)
Sexually Transmitted Infections screening
HPV vaccine, screening for chlamydia, gonorrhea
diabetes screening
→ FBS, Hgb A1c, diet/exercise
osteoporosis screening
bone density (DXA) scan, wt bearing exercise, Ca/vit D supplements after age 50
Well women exam hx (4 main areas)
menstual hx
OB
GYN
Sex and contraception
what 5 things should fall under menarche Hx
menarche, LMP, menopause, abnormal bleeding, symptoms
OB hx
GaPbcde, OB complications
G = pregnancies P = outcomes of pregnancies (b=term deliveries c=premature deliveries d=abortions e=living children)
GYN Hx
especially if they have irregular bleeding: PID disease, polyps, etc
gynecologic diseases surgeries STI history breast disease urinary complaints
every pregnant woman should be vaccinated with
TDAP including pertussis in the third trimester
helps to protect the baby so pregnant women need it even if they just got one
when do you normally get TDAP
every 10 yeaars
HPV vaccine
2 dose series given 6-12 months apart 11-12
not covered past 26 yrs of age and can cost 400 dollars
most common strains of HPV that cause cervical cancer
16 and 18
don’t give live vaccines to
babies under 6 months
- Pneumococcal are for
All adults age 65 and older should get vaccinated with PCV13 and PPSV23, 1 year apart
Adults at high risk should be vaccinated once with each vaccine
MMR vaccine
Everyone should have 2 doses by the age of 6 years
Required for school entrance
All women of childbearing age unable to show proof of Rubella immunity with titers
Live virus not indicated during pregnancy
for women getting ready to get pregnant should have MMR titers because
can get vaccinated for fetal protections if titers aren’t great
HEP B vaccine
IVDA, health care workers, current recipients of blood products, Hepatitis C, prostitutes
3 dose series, given at 0, 4 weeks and 8 weeks
Now required for school entrance in most areas
At postpartum visit if not immune
HEP A
not required
except in border areas of travlers
Varicella/Zoster vaccine
Recommended for anyone not previously exposed to chicken pox
2 doses given 4-8 weeks apart
Live virus not indicated during pregnancy
just don’t be around any patient with a rash if you can’t prove immunity with a tier
Zostavax available for adults >50 years of age, given routinely at age 60
PPD (TB skin testing)
Every 2 years for high-risk individuals
Should be considered in any patient with a cough lasting >4 weeks
Should be placed at the first prenatal visit
Cervarix
HPV vaccine types 16 & 18 only
Gardasil
HPV vaccine types 6, 11, 16, 18
Gardasil 9
HPV vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58
PCV13
= Pneumococcal Conjugate Vaccine (Prevnar
PPSV23
Pneumococcal Polysaccharide Vaccine (Pneumovax)
UA would be done as a well check for
pregnant women
PE for well women check should include
- Height, Weight, BMI; BP, pulse; LMP (should be part of your vitals)
- Urinalysis, UPT if indicated
- FBS or Hgb if indicated
- Laboratory tests: TSH, lipid profile, CBC, Chemistry panel as indicated
- Breast exam and lymph nodes
- Chest (CV and Respiratory)
- Pelvic exam, including exam of abdomen and lymph nodes
when would you do a rectovaginal exam
screening women over 50
or retroflexed uterus
6 topics for counseling in a well woman exam
- Diet and exercise
- STI prevention
- Contraception use, hormone therapy
- (Self breast exam) à 2016 guidelines don’t mention self breast exams
a. Now there are no recommendations for or against - Skin self exam (1qyr) and SPF use
- Smoking cessation, EtOH use
M&M in women
Remember that the #1 or #2 cause of M&M in women of any age group is cancer. We will focus here on Gynecologic cancers.
common and uncommon cancers in women
breast
cervical
endometrial- pretty common
ovarian will kill you but less than 2% of the population gets this
vuvlar:4th most common gynecologic cancer
vaginal
RF for vulvar neoplasim
smoking, vulvar dystrophy (eg, lichen sclerosus),
vulvar or cervical intraepithelial neoplasia
MCC: HPV infection (60%), immunodeficiency syndromes
a prior history of cervical cancer
and northern European ancestry
types of HPV that causes vulvar
HPV 16 and 33 are the predominant subtypes accounting for 55.5% of all HPV-related vulvar cancers
majority of vulvar cancers are
90% squamous cell carcinomas
Melanoma is the second most common type of vulvar cancer. Lesions typically arise de novo on the clitoris or labia minora, but can also develop within preexisting junctional or compound nevi
slow growing and superficial
kind of like squamous cell carcinoma of the skin
classification of vuvlar cancers
VIN-I, mild dysplasia
VIN-II, moderate dysplasia
VIN-III, severe dysplasia or carcinoma in situ
lesions do tend to be superficial and isolated
classifications of vulvar cancers that will progress
VIN-I and VIN-II are likely to progress to CIS or carcinoma
DDX of vulvar cancer
Epidermal inclusion cysts
lentigos- liver spots with age
disorders of Bartholin gland can cause hyperpigmentation
acrochordons-tree bark
hidradenomas
seborrheic keratosis
lichen sclerosus
other dermatoses
condyloma acuminate
Flesh colored lesions of vulvar
sebaceous glands, inclusion cysts, vestibular papillae, skin tags, cysts, and infections (warts, molluscum contagiosum)
vulvar malignancies are usually flesh colored can be white or red
White lesions
lichen sclerosus, lichen simplex chronicus, and vitiligo
MC sx is itching of neoplasm
maybe common sx of lichen too
Brown, black, or red vulvar lesions
Brown, black, or red vulvar lesions can be due to a wide variety of benign, infectious, inflammatory, and malignant conditions
Pustules, vesicles, and erosions of the vulva are usually
Pustules, vesicles, and erosions are usually related to infection or inflammation
Ulcers and fissures of the vulva can be caused by
Ulcers and fissures can be caused by infection, malignancy or systemic disease with vulvar involvement
Ulcers and fissures can be caused by
Vulvar pruritus is the most common symptom of vulvar cancer and a unifocal vulvar nodule, plaque, ulcer, or mass (fleshy, nodular, or warty) on the labia majora is the most common physical finding
when should you biopsy the vulva
Any suspicious lesion, chronic pruritis, lesion that does not resolve with standard treatment should be biopsied
may use colposcopy for better visualization if you have a mass on the inside
prognosis of vulvar cancers
5-year survival 70% - 90% for localized diseas
20% if deep pelvic nodes are involved but that take forever
paget disease of the vulva
- Extensive intraepithelial disease
- Not common (<1%)
- May be associated with carcinoma of the skin and pts with pagets disease of the skin anywhere else –>
Higher incidence of internal carcinoma, particularly of the colon and breast
tx of vulvular pagets
Treatment is wide local excision or simple vulvectomy and wide margins to prevent recurrence
Vulvar Melanoma
- Raised, irritated, pruritic, pigmented lesion
- 5% of all vulvar malignancies
- Wide local excision is required for diagnosis and staging
- Melanoma likes “hidy” places
- Rarest of all gynecologic cancers
Vaginal cancer
MCC with vaginal cancer
and what is the most common site
Most common c/o is vaginal bleeding
Posterior wall of the upper 1/3 of the vagina is most common site of the tumor**; red ulcerated or white hyperplastic lesions
most common type of vaginal cancer
and Tx
Colposcopy with directed biopsy for definitive diagnosis
Squamous cell carcinoma in 95% of cases
Treatment includes surgical excision; chemoradiation for invasive disease
prognosis of vaginal cancer
5-year survival is 50% - 80% with local disease
Most common gynecological cancer in US
Endometrial (Uterine) Cancer
most common type of endometrium cancer
Adenocarcinoma of the endometrium is the most common type of uterine cancer
more aggresive than squamous cell carcinoma
genetic syndrome associated with high risk of uterine cancer as well as other types of cancer
Lynch syndrome
average age of diagnosis for endometrial (uterine) cancer
Average age at diagnosis is 61 yrs, most women are early stage at diagnosis
usually presents with symptoms
RF for vaginal cancer
increased risks for HPV infection Early sexual activity High lifetime number of sexual partners Infection with HIV Smoking Long-term use of oral contraceptives (>5 years) Low socio-economic status
RF for endometrial cancer
Use of unopposed estrogen after menopause
Overweight women (high BMI)
Nulliparity
Tamoxifen therapy
protective factors for endometrial cancer
Childbearing, esp if last pg at older age
Combination oral contraceptives
Combination hormone replacement
screening tools for endometrial cancer
none
no real screening and a lot of women think that pap smears are screening for endometrial cancers bUT survival rates are really good
MC SX of endometrial cancer
Cardinal symptom is abnormal uterine bleeding but this is also the cardinal symptom of vaginal bleeding despite endometrial being more common you need to consider vaginal too
any pt over 40 with bleeding this needs to be on the ddx
when would you need further evaluation in women over 40 following a pap
Endometrial cells on Pap smear in women ≥40 years of age need further evaluation
if they finished their period over a week ago
best way to test for endometrial cancer ( in a pt over 40 with bleeding)
(GOLD STANDARD )
Endometrial sampling
Endometrial biopsy is gold standard for diagnosis
tissue is the issue and dx has to be histological
for women under 40 how would you test for endometrial cancer
Transvaginal US
you would do this before a biopsy in these younger populations
what would you see on transvaginal US in a pt with endometrial cancer
Thickened endometrium or endometrial stripe (>4-5mm) worrisome
20mm is the mean endometrial thickness for pts with cancer
anything over 5–> get biopsy
most OB practices will have ULS
Sonohysterography would be used to evaluate for endometrial cancer
Filling endometrial cavity with fluid to visualize focal lesions for biopsy
Sonography is not a valid alternative to endometrial sampling in premenopausal women. Evaluation for a nonendometrial source of bleeding, such as cervical, fallopian tube or ovarian cancer, should also be pursued.
Evaluation of the endometrium for malignant and premalignant disease indicated if
Abnormal uterine bleeding
Postmenopausal bleeding
Abnormal PAP with atypical cells favoring endometrial origin
D&C
refers to dilation, opening the cervical canal, and curettage, scraping the endometrium with a sharp instrument called a curette
recommendation for endometrial cancer
Total extrafascial hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) for staging
taking out the tubes and the ovaries
CT scan for mets to lymph
2nd most common GYN cancer in US
ovarian cancer
Lifetime risk 1.4%
Higher risk in hereditary cancer syndromes (BRCA)
ovarian cancer average age
v. Average age at diagnosis is 63 yrs
vi. 95% of ovarian cancers are epithelial cell origin
vii. BRCA mutations affect ovarian tissue as well
Risk Factors for ovarian cancers (4)
Age >60 years
Family history of ovarian or other gynecologic cancer
Hereditary cancer syndrome
Smoking
Protective Factors for ovarian cancer
Childbearing Combination oral contraceptives Breastfeeding Tubal ligation Hysterectomy
Screening Tools for ovarian cancer
what is the serum maker and is it specific
Pelvic exam can detect ovarian cancer = bad prognostic indicator
b/c Cancer usually advanced by the time it can be palpated
CA-125 serum marker –> not specific tumor marker (can be elevated in colon cancer as well) but useful in following the cancer
TVUS may be useful but a lot of pts don’t want a ULS
USPSTF recommends against routine screening (2012)
Tana says she would start with just genetic screening in a high risk pt
family hx of ovarian cancer does not cover TVUS
have you ever had irregular bleeding?
prognosis of ovarian cancer
5-year survival rate is 89% for localized disease
but most time it’s not found localized
36% for women with regional metastases
17% for women with distant metastases
average age of ovarian cancer
Most women aged 40-65 years at diagnosis
Serum CA-125 sensitivity for ovarian cancer
Serum CA-125 marker elevated in >80% of patients
CC sxs of ovarian cnacer
bloating
pelvic or abdominal pain
early satiety
ovaries drain to the retroperitoneal lymph nodes and you don’t feel this
ddx of adnexal mass
Ovarian malignancy (uncommon under 40)
Ovarian cyst–> soft and tender w/o other sxs
Ectopic pregnancy–>UPT
PID with TOA–> fever or vomiting
Pelvic kidney
GI etiology–> (L) diverticula, (R) appendicitis?
Crohn’s disease
Diverticulitis
GI neoplasm
central pelvic mass
Intrauterine pregnancy
Leiomyomata (fibroids)
Uterine malignancy
Bladder malignancy
Ovarian malignancy (if they get big and push everything over)
premenopausal ovarian mass
(post meno ULS and CT)
get an ULS
simple cyst less than 6cm and normal CA-125
–> observe
BC pills to regulate cycles
recheck ULS
in pts with solid or complex cyst over 6cm
–> surgical evaluation
what is FIGO
ternational Federation of Gynecology and Obstetrics
ternational Federation of Gynecology and Obstetrics
RF for vaginal cancers
increased risks for HPV infection Early sexual activity High lifetime number of sexual partners Infection with HIV Smoking Long-term use of oral contraceptives (>5 years) Low socio-economic status
what % of postmenopausal women with abnormal bleeding have endometrial cancer
5-20% postmenopausal women with abnormal uterine bleeding have endometrial cancer
when would sonography be used for irregular bleeding
Filling endometrial cavity with fluid to visualize focal lesions for biopsy
if you think that pt has a polyp or a fibroid based on the ULS findings you can repeat an ULS with this
Sonography is not a valid alternative to endometrial sampling in premenopausal women. Evaluation for a nonendometrial source of bleeding, such as cervical, fallopian tube or ovarian cancer, should also be pursued.
Hysteroscopy
is a procedure in which a telescope with a camera is used to evaluate or treat pathology of the endometrial cavity, tubal ostia, or endocervical canal.
During hysteroscopy, the uterus is distended with a gas or fluid medium. Most diagnostic and brief or minor operative procedures can be performed without anesthetic or with a local anesthetic. In women undergoing hysteroscopy under local anesthetic, we suggest a paracervical block over other methods of administering local anesthesia.
simple cyst less than 6cm and normal CA-125
–> observe 6-8 weeks
BC pills to regulate cycles
recheck ULS and see if it goes away
solid or comple over 6 cm or other worrisome signs workup
surgical evaluation
Leading cause of cancer death in women worldwide
breast cancer
Main cause of death in women 20-59 yo
Majority of breast cancers diagnosed by
Majority of breast cancers diagnosed by abnormal mammogram
RF breast cancer
Age >40 years and increases with age
Family h/o breast cancer (BRCA genes)
Menarche <12 yrs of age or >40 menstrual yrs
Oral contraceptive use >5 years
Nulliparity or first delivery >35 yrs of age
Obesity
Other types of cancer, including contralateral breast, uterus, ovary, salivary gland, colon
For women who are at average risk for breast cancer, most of the benefit of mammography results from
from biennial screening during ages 50 to 74 years
While screening mammography in women aged 40 to 49 years may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger. The balance of benefits and harms is likely to improve as women move from their early to late 40s.
Who benefits from early breast cancer screening
Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s.
