Download Women`s Disease Prevention

Women's Disease Prevention
Preconception counseling
Since women do not typically schedule a discussion with their physicians prior to
conception, it is important to try to counsel all women capable of becoming pregnant of a
few important preconception topics that will help lower the patient's risk of complications.
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All women capable of becoming pregnant should be on prenatal vitamins or assure
enough folic acid consumption (400 mcg/day) at least one month before conception
to reduce the risk of neural tube defects such as spina bifida.
Women with chronic diseases planning pregnancy should have their diseases be
well-controlled prior to conception. Discuss chronic diseases EARLY.
Potentially harmful chronic medications should be changed prior to conception.
Healthy lifestyle (especially weight) should be encouraged prior to conception.
Risk for potential genetic diseases should be obtained via good family history.
Assure varicella and rubella immunity (immunization contraindicated if already
pregnant!)
Alcohol misuse
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Definition of "misuse": >7 drinks per week or more than 3 drinks on one occasion
for women
Use AUDIT or CAGE to screen
A 15-minute counseling session can be helpful if positive screen.
Immunizations
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Tetanus every 10 years
Influenza every year
Pneumococcal at age 65 or earlier if chronic disease or institutionalized
Hepatitis B (for all young adults not immunized and high-risk middle-aged women)
Varicella if no history of infection
MMR: women born after 1956 should get primary series and booster if they didn't
get the second dose.
(Note: varicella and MMR contraindicated in pregnancy! Give when patient is
menstruating and ensure contraception afterwards.)
Pertussis booster if not already given
Gardasil series before sexual activity preferred, but should offer to all females up to
age 26.
Smoking
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USPSTF strongly recommends that clinicians screen all adults for tobacco use and
provide tobacco cessation interventions for those who use tobacco products. (A
recommendation)
Address tobacco use at each visit.
When ready, set date, give pharmacologic therapy, and follow-up.
Counseling alone effective 10% of the time; pharmacotherapy increases additional
5%-10%; when combined, one year quit rates 38%.
For more information on smoking cessation, including an updated clinical practice
guideline, please follow this link: http://www.surgeongeneral.gov/tobacco/.
Exercise
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30 minutes moderate intensity aerobic exercise on most if not all days of the week
should be encouraged.
Written prescriptions can be effective.
Seat belt use
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Recommended to be addressed in all adults by USPSTF
Depression
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Screening for depression is a B recommendation
Screening can be done by adding two questions to routine interviewing of all adults
patients: Over the past 2 weeks, have you felt down, depressed, or hopeless? Over
the past 2 weeks, have you felt little interest or pleasure in doing things?
If positive, then follow with written or oral depression screening.
Violence
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Lifetime prevalence of domestic violence between spouses 36-40%!
There is no typical profile for women who are abused.
Witnessing or experiencing violence as a child may be risk factors for becoming
abused.
Approach to screening:
In my practice, I am concerned about abuse prevention and personal safety, especially in
the family. Are you in a relationship where you are afraid for your personal safety, or
where someone is threatening you, hurting you, forcing you to have sex, or trying to control
your life?
As an adult, has anyone ever forced you to have sex when you did not want to?
When you were young, did anyone ever hurt or hit you or force you to have sex?
Aspirin
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Consider low dose aspirin in patients with moderate to high risk of cardiac events
(A recommendation).
Potential harms exist. For more information, go to the Women's Health Trials
Module and review the discussion of the Women's Health Study.
Weight (BMI)
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USPSTF recommends screening all adults for obesity and offering intensive
counseling and behavioral interventions to promote sustained weight loss for obese
adults (B recommendation)
Overweight: BMI>25
Obese: BMI>30
Intensive counseling: more than one person-to-person session per month for at least
the first 3 months of the intervention
Reduce saturated fat intake to less than 7% of total calories
60 minutes of daily exercise if trying to lose weight
Osteoporosis Screening
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Start at age 65 with a Bone Mineral Density test (usually DXA) in all women (per
USPSTF and NOF)
Start earlier if risk factors (history of fracture as an adult, history of fragility
fracture in first degree relative, low body weight <127 pounds, smoker, current or
previous use of oral corticosteroid therapy for >3 months)
Chlamydia
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USPSTF strongly recommends clinicians screen all sexually active women 25 and
younger, and other asymptomatic women at increased risk for infection
Lipids
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Adult Treatment Panel III (ATP III) of National Cholesterol Education Panel
(NCEP) recommends starting at age 20 with fasting lipid profile, primarily looking
at LDL cholesterol, and setting LDL goal based on cardiac risk factors and
Framingham risk stratification; if unremarkable, repeat every 5 years
USPSTF recommends screening men at 35 and women at 45 with a (non-fasting)
total cholesterol and HDL (start at 20 if CAD risk factors) and insufficient evidence
to recommend triglyceride screening.
Diabetes Type II
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American Diabetes Association recommends screening every 3 years starting at 45
with a fasting plasma glucose, earlier and more frequently in overweight and those
with diabetes risk factors.
USPSTF concluded that evidence insufficient to recommend for or against routinely
screening, but do recommend screening adults with hypertension or hyperlipidemia
and to be alert to symptoms of diabetes such as polydipsia and polyuria and to test if
present.
References:
The Guide to Clinical Preventive Services: Recommendations of the US Preventive Services
Task Force. AHRQ, 2006.
Bostock DJ, Auster S, Bradshaw RD, et al. Family Violence. Monograph, Edition No. 274,
Home Study Self-Assessment program. Leawood, Kan: American Academy of Family
Physicians, March 2002.
Choby BA. Midlife Care of Women. Monograph, Edition No. 278, Home Study SelfAssessment program. Leawood, Kan: American Academy of Family Physicians, July 2002.
Tyler CV Jr, Messinger-Rapport BJ. Well Older Adult. Monograph, Edition No. 280, Home
Study Self-Assessment program. Leawood, Kan: American Academy of Family Physicians,
September 2002.
Stephens MB, O’Connor FG, Deuster PA. Exercise and Nutrition. Monograph, Edition No.
283, AAFP Home Study. Leawood, Kan: American Academy of Family Physicians, December
2002.
Berg AO. Adult Prevention. FP Essentials, Edition No. 308, AAFP Home Study. Leawood,
Kan: American Academy of Family Physicians, January 2005.
Stendardo Stef, Berg Alfred, Kamerow Douglas. American Academy of Family Physicians:
Tertiary Prevention in Diabetes, CAD and Stroke: A Case-based Approach. 2003.
Guzman Susanna. American Academy of Family Physicians: Practical Advice for Family
Physicians to Help Overweight Patients. 2003.
Underbakke Gail, McBride Patrick. CME Bulletin: Metabolic Syndrome Part II: Addressing the
Metabolic Syndrome in Primary Care. Vol. 4. No. 2. Leawood, Kan. 2005.
AAFP Policy Action November 1996, Revision 5.7, April 2007. Order No. 968
Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC7). NIH Publication No. 03-5231. May 2003.
Mosca, L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease
prevention in women. Circulation. 2004;109:672-93.