Disease Prevention in Women
Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
Disease prevention in women overview
Screening tests are a basic part of prevention medicine. All screening tests are commonly available through your general doctor. Some specialized tests may be available elsewhere. Take an active role and discuss screening tests with your doctor early in life. The following charts are beneficial (generally simple and safe) screening tests that can help detect diseases and conditions before they become harmful.
Osteoporosis
Osteoporosis is a condition with progressive loss of bone density leading to bone fractures. Estrogen is important in maintaining bone density. When estrogen levels drop after menopause, bone loss accelerates. Thus osteoporosis is most common among postmenopausal women.
Screening tests
Measurement of bone density using dual energy X-ray absorptiometry (DEXA) scan
DEXA bone density scanning can:
*detect osteoporosis before fractures occur
*predict the risk of future bone fractures
*Although still controversial, some doctors use bone density to monitor effects of osteoporosis treatments
Who to test and how often
The National Osteoporosis Foundation guidelines state that all postmenopausal women below age 65 who have risk factors for osteoporosis or medical conditions associated with osteoporosis and all women aged 65 and older should consider bone density testing.
High risk factors for osteoporosis include:
*early menopause or surgical absence of ovaries;
*family members with osteoporosis and related bone fractures;
*cigarette smoking and/or heavy alcohol use;
*over-active thyroid gland (hyperthyroidism), previous or current anorexia nervosa or bulimia;
*thin stature, light skin;
*Asian or Northern European descent;
*any condition associated with poor absorption of calcium or vitamin D;
*chronic use of oral corticosteroids (such as cortisone and prednisone [Deltasone, Liquid Prep]), excessive thyroid hormone replacement, and phenytoin (Dilantin) or other anti-seizure medications; and
*problems with missed menstrual periods.
Benefits of early detection
Osteoporosis produces no symptoms until a bone fracture occurs. Bone fracture in osteoporosis can occur with only a minor fall, blow, or even just a twist of the body that ordinarily would not cause an injury.
Prevention and treatment of osteoporosis can decrease the risk of bone fractures.
Prevention measures include:
*quitting smoking and curtailing alcohol intake;
*performing regular weight-bearing exercises, including walking, dancing, gardening and other physical activities, and (supervised) muscle strengthening exercises;
*getting adequate calcium and vitamin D intake;
*medications may be taken to prevent osteoporosis. The most effective medications for osteoporosis that are approved by the FDA are anti-resorptive agents, which prevent bone breakdown. Examples include Others include alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and zoledronate (Reclast); and
*while hormone therapy containing estrogen has been shown to prevent bone loss, increase bone density, and decrease the risk of fractures, HT has also been associated with health risks. Currently, HT is recommended for women for the treatment of menopausal symptoms only at the lowest effective dose for the short-term.
Breast cancer
Breast cancer is the most common cancer among women in the United States. Approximately one in nine women who live to age 65 will develop breast cancer, although many will not do so until after age 65.
Screening tests for breast cancer
*Breast self-examination/breast awareness:
*breast examination by a doctor, and
*mammography
Who to test and how often
Breast awareness
*In November, 2009, the U.S. Preventive Services Task Force recommended against teaching breast self-examination, stating a lack of benefit for a monthly self-exam. Groups such as the American Cancer Society agree with this conclusion and do not offer guidance on exactly how often a woman should check her breasts, but so state that a woman should be aware of any changes in her breasts.
*Breast examination by a doctor.
*Mammography: In their revised recommendations issued in November, 2009, the U.S. Preventive Services Task Force states that women age 40 to 49 do not require routine mammograms. They recommend biannual screening mammograms for women aged 49-74, and further state that: "The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms."
*However, The American Cancer Society (ACS) disagrees and recommends a baseline mammogram for all women by age 40 and annual mammograms for women 40 and older for as long as they are in good health.
*In women with "lumpy breasts" or breast symptoms, and also in women with a high risk of developing breast cancer, sometimes a baseline mammogram at 35 years of age is recommended. This recommendation is somewhat controversial, and there are other viewpoints.
High-risk factors include:
*previous breast cancer; and
*close relatives (mother, sister, or daughter) with breast cancer. The risk is especially higher if both the mother and sister have had breast cancers, if a relative developed her cancer before age 50, if the relative had breast cancer in both breasts, if there is both ovary and breast cancers in the family, or if a male family member has been diagnosed with breast cancer
Benefits of early detection
Early detection of breast cancer is important to every woman, regardless of risk factors, because the earlier a cancer is found, the smaller it is. Studies have clearly shown that the smaller the size of the breast cancer when detected, the better the chance of a surgical cure and long-term survival. Smaller breast cancers are also less likely to have already spread to lymph nodes and to other organs such as the lungs, liver, bones, and brain.
Mammograms can detect many small breast cancers long before they may be felt by breast examinations, and there is extensive evidence that early detection by mammograms has improved survival in women with this disease.
However, some 10% to15% of breast cancers is not detected by mammograms, but are detected by breast examinations. Therefore a normal mammogram does not completely exclude the possibility of breast cancer, and breast self-examinations and breast examinations by a doctor remain important.
Cancer of the cervix
Cancer of the cervix (the portion of the uterus that extends into the vaginal cavity) is the third most common gynecologic cancer. Cancer of the cervix is caused by infection with the human papillomavirus (HPV). Cervical cancer typically develops over the long term from abnormal precancerous (before-cancer) cells on the surface of the cervix. These abnormal cells transform into cervix cancer over a number of years. After turning cancerous, these cancer cells can invade or spread to other parts of the body.
Screening tests
Pap test also known as Pap smear.
A Pap test is a simple, quick office test in which a sample of cells from a woman's cervix is collected by aspiration or swabbing and spread (smeared) on a microscope slide. The cells are examined under a microscope in order to look for precancerous (before-cancer) or cancer cells.
Who to test and how often
Women should have Pap tests as part of a manual pelvic examination beginning at age 21. Because the risk of cervical cancer increases sharply in the first few years after sexual activity begins, some physicians begin screening women as soon as they become sexually active, but not before. High-risk factors for cancer of the cervix include:
*cigarette smoking;
*previous genital warts or other genital infection with the human papilloma virus (HPV);
*multiple sexual partners or a partner who has multiple sexual partners; and
*onset of sexual activity at a young age.
In 2009, the American College of Obstetricians and Gynecologists (ACOG) revised its recommendations regarding Pap screening. Instead of beginning at age 18 as previously recommended, the new recommendations advise beginning Pap smears at age 21. Further changes to the ACOG guidelines are:
*Women younger than 30 years of age should have a Pap test every 2 years.
*Women aged 30 years of age and older should have a Pap test every 2 years. After three normal Pap test results in a row, a woman in this age group may have Pap tests every 3 years if:
**she does not have a history of moderate or severe dysplasia;
**she is not infected with human immunodeficiency virus (HIV);
**her immune system is not weakened (for example, if she has had an organ transplant); and
**she was not exposed to diethylstilbestrol (DES) before birth.
It is rare to find pre-cancer or cancer of the cervix in women over age 65 who have repeatedly had normal Pap smears, so many doctors stop screening in women over age 65 who have had consistently normal Pap smears. Other doctors decrease the frequency of Pap screening under these circumstances.
Women who have had a hysterectomy (surgery to remove the uterus, including the cervix) no longer require a Pap test, but they should continue with manual pelvic and rectal examinations by their doctors as a part of their periodic medical evaluations for reasons other than cancer of the cervix.
Benefits of early detection
There has been a 70% decrease in the deaths from cancer of the cervix by regular use of the Pap test. Benefits of the Pap test include:
Pap tests can prevent cancer of the cervix by identifying and allowing treatment of abnormal cells before they become cancerous.
Pap tests can identify cancer of the cervix at an early curable stage, before cancer cells spread (metastasize) to other parts of the body.
Prevention
A vaccine (Gardasil) has received U.S. FDA approval for use in women between 9 and 26 years of age and confers immunity against HPV types 6, 11, 16, and 18. Initial trials with the vaccine have shown that the HPV-16/18 vaccine is safe and induces a high degree of protection against HPV-16/18 infection. Gardasil is given in three shots over six-months. The U.S. Centers for Disease Control and Prevention (CDC) recommends that girls 11-12 years of age receive the vaccine. It is also recommended for girls and women age 13 through 26 who have not yet been vaccinated or completed the vaccine series.
A newer vaccine (Cervarix) was approved by the FDA in October, 2009, for use in girls and young women ages 10-25 to help prevent cervical cancer. Cervarix targets two HPV strains, HPV 16 and HPV 18, A comparison of the two vaccines has not been carried out.
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