Preventive Health For Women

Author: Dr Jennifer Frank University of Wisconsin 2009-12-15

Preventive Health For Women: Find out what the "annual exam" is really all about. Do you really need an annual "physical" at the doctor's office? Well, that is a matter of some debate, but there are some preventive health measures - things to keep you healthy and detect problems early - that you do need, especially if you are 50 years or older. Read below to find out what is essential and what is not.

How to talk to your doctor

Author : Dr Jennifer Frank University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin

2009-08-18

How to Talk to Your Doctor Getting : the most out of a short-but-sweet office visit

We all, unfortunately, have to go to the doctor now and then. Usually, the doctor is rushed and can use a lot of big words and say things really quickly. It is easy to forget all your questions, mix-up what he or she said, or leave the visit without feeling like you got what you needed. Read below for a 10 point how-to approach to your next doctor's visit.

Image : CDC

Getting Ready for the Visit

The first step is to figure out why you are going to the doctor.  Is it for an annual "check-up", to get a diagnosis, for a medication, or to figure out why something isn't going right?  Maybe you were referred to a specialist or maybe you are just trying to establish care with a new doctor.  Whatever the reason, don't walk into that office unprepared!

What to Bring With You to the Doctor's Office

1. All of your medications in the bottles.  Include over-the-counter medications that you take weekly (or more often).  
2. Old medical records from previous doctors, including things like previous mammograms or EKGs.
3. A list of what you want to accomplish at the visit.
4. A list of any questions or concerns you have.
5. Your immunization record.
6. A friend, spouse, or family member if you anticipate that the visit will bring up complex or difficult issues.  Someone else being present can help remind you to ask all the questions you wanted to ask and can help you remember what the doctor said when you get home.
7. A good book or your iPod - in case the doctor keeps you waiting!

10 Steps to Making the Most Out of Your Doctor's Visit

1. Identify your Agenda

    There is nothing doctors dread more than to hear "Oh, by the way..." from a patient as their hand is on the doorknob at the end of the visit.  As you can imagine, when the visit is over and the doctor is already thinking about the next patient, it is not the best time to bring up a serious concern. 
    Most of the time, the doctor has an idea of what he or she wants to accomplish during the office visit based on the "reason for visit" noted at the time you make your appointment.  So, if you have more you want to discuss, make sure that everyone from the receptionist to the nurse to the doctor knows what is on your agenda. 

2.  Make a List

    Write down the top 3 things you want to discuss plus any others (if there is extra time).  Make sure to think about the things you want to discuss before you get to the exam room.  This way you will have all the information you need at the time of  your visit.  Maybe you have a question about something you read in the paper - bring the article along.  If you want to know something specific about your medication - bring the bottle along.  You get the idea.  It is kind of like going grocery shopping.  If you don't write down everything you need,  you will inevitably forget the milk or eggs.

3.  Ask for the Time you Need

    Expecting too much from the limited amount of time allotted for your office visit is another way to sabotage a successful doctor's appointment.  In general, a 15 minute visit is about enough time to address one or at the most two concerns.  Make sure to let the receptionist know everything you want to discuss at the visit.  This way, enough time can be scheduled to make sure you get a chance to get to everything on your list.

4.  Be Honest

    Let's be honest...some of the things you talk about in the doctor's office are downright embarrassing.  Sexual dysfunction, hemorrhoids, vaginal discharge, a rash "down there" are all things that can be hard to discuss with your doctor.  However, and let me be very clear here, there is nothing we haven't heard as doctors.  And I do mean, nothing.  So, feel free to spill all the gory details about whatever it is that is concerning you.  It is the best and fastest way to get better.

5.  Be Patient

    It is understandable that after you have suffered with some type of ailment for weeks, months, or even years, you want an answer today.  Usually it will take some time for the doctor to make a diagnosis (maybe after getting a lab, xray, or other test) and to formulate a treatment plan.  In fact, you may want to be wary of any doctor who jumps to a diagnosis and treatment before giving your adequate time to share your history, do a careful exam, and get other needed information.  It is also important to give the treatment (whether that is physical therapy or a medication) time to work. 

6.  Be Nice to the Office Staff

    I am amazed sometimes to find out that a patient who was perfectly nice to me was yelling at my receptionist just minutes before.  Most of the time, the people who are working in your doctor's office actually like people and want to help you.  They understand that nobody is at their best when they are sick, but the receptionist, nurse, lab people, and administrative staff do want to be treated just like you do - politely.   In my clinic, I have a very low tolerance for any patient yelling at or cussing at my staff.  So, if you can't be nice, you may be looking for a different doctor.

7.  Make Sure You Understand

    It is hard to remember what the doctor said even 15 minutes after you have left the office.  A lot of doctors are great at explaining things and writing them down for patients, but a lot of doctors go too quickly through complex information.  This really struck me when I had eye surgery.  Even though I am a doctor and should know all this stuff (yeah right!), I was given 4 different eye drops to use and couldn't remember which one was just to use "as needed" and which one I was supposed to take every day.  If you need to remember more than one thing, it is usually best to write everything down.  Ask Me 3 is one approach to making sure patients understand what is going on at a doctor's visit.  It recommends that patients ask (and write down the answers to) 3 questions:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

8.  Tell the Doctor about Barriers

    This is a super-important, often over-looked part of the visit.  If you can't read or can't read well (this is actually very common), let your doctor know.  You may do better by watching a video or getting one-on-one nursing teaching than by reading a pamphlet.  If you can't afford your medication, let your doctor know.  What is the point to getting a prescription you can't fill?  If you are not willing to engage in lifestyle change (losing weight, quitting smoking, etc), let your doctor know.  That way he/she can come up with Plan B to get your chronic diseases under better control.

9.  Follow Up as Directed

    If your doctor asks you to come back in 3 months to get that little spot on your arm checked, make sure to do it.  If you are not any better after one month on the medication the doctor started, follow up.  This is the only way to make sure that you get the care you need, that things don't get worse, and that if the first remedy doesn't work, you move quickly to the next.

10.  Be the Coach

    You are in charge of your health care team.  Make sure that you act as the coach.  Get input from and advice from your doctor, but take an active role in managing your health care.  This incorporates steps 1-9 listed above.  Do not be a passive bench-warmer as your health care is decided for you. 
    

Additional Resources

Include links to other related knols or resource pages.

• Patient Communication
• Talking With Your Doctor
• Shared Decision Making

Preventive health for women

Author : Dr Jennifer Frank University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin

2009-12-15

Preventive Health For Women : Find out what the "annual exam" is really all about.

Do you really need an annual "physical" at the doctor's office? Well, that is a matter of some debate, but there are some preventive health measures - things to keep you healthy and detect problems early - that you do need, especially if you are 50 years or older. Read below to find out what is essential and what is not.

Preventive Health Defined

Preventive health is widely defined, but basically refers to those things you do to keep yourself healthy.  This includes everything from getting your blood pressure checked to taking enough calcium.  Common areas of preventive health include: 

• Laboratory Studies:  These are tests that look for diseases (like diabetes or high cholesterol), infections (like Human Immunodeficiency Virus (HIV) or chlamydia), or screen for cancer (like stool cards checking for blood that can indicate colon cancer).
• Radiologic Studies:  These include xrays, ultrasounds, mammograms, and CAT scans that are done to screen (usually) for cancer, osteoporosis, or vascular disease. 
  
• Other diagnostic studies:  This may include an EKG looking for heart disease.
• Questions the doctor asks you about your personal and family history, symptoms you may be having, and lifestyle habits (like smoking, exercising, and calcium intake)
• Physical examination looking for signs of disease
• Immunizations to prevent you from getting diseases like influenza or pneumonia
• Counseling about ways to be healthier

How to figure out what you need

With all the testing listed above, it can be difficult to figure out what you need to have done, how often, and at what age.  While your primary care doctor can generally advise you what is needed and what is not, what follows is a quick guide to what is currently recommended.*

*One thing that makes all of this even more confusing is that different medical societies make different recommendations.  The recommendations I am outlining reflect what is recommended by the US Preventive Services Task Force, a national government organization that makes recommendations about preventive health care services.

Focus on Women

In this knol, I am focusing on what is recommended for women.  Please see my future knol for men's recommendations.

Immunizations

Immunizations for almost all women (18 and older)

• Tetanus is needed every 10 years.  There is a new vaccination called Tdap (Adacel is the brand name) that includes a booster immunization against pertussis.  Pertussis is whooping cough, which is annoying but not dangerous for adults.  However, it can be dangerous for unimmunized infants and children.  Since immunity fades after your childhood vaccine series, it is possible for adults to pass on whooping cough to children.  So, the Centers for Disease Control (CDC) recommends that all adolescents and adults (ages 11 - 64) receive a pertussis booster.  You can wait until you are due for your next tetanus booster, or just go ahead and get it now if it has been at least 2 years since your last tetanus booster.  It is particularly important to get the pertussis booster if you have contact with children under 1 year of age or work in a health care setting.

• Influenza vaccine is administered each fall.  It is recommended for all adults who are 50 years and older and younger adults who have certain chronic diseases (like asthma, diabetes, heart disease, kidney disease, cancer, or a problem with their immune system).  The influenza shot is given to people 50 years and older (as well as children and younger adults for whom the vaccine is recommended).  For adults younger than 50, an alternative is an influenza vaccine administered as a nasal spray.  You should check with your doctor or check out www.cdc.gov to find out whether you need the shot or can get the nasal spray. 
• Zostavax is administered once after the age of 60 to prevent shingles.  The URL for the CDC's recommendation is here: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm
• Pneumovax is given to adults 65 years of age and older once to prevent a common form of pneumonia.  It is also given to younger adults with chronic health problems or smokers (and should be repeated after age 65 in these people).

Immunizations for some women

• Human Papilloma Virus (brand name Gardasil) is recommended for women 26 years old and younger.  It is a 3 part vaccination that you receive once in your lifetime to prevent an infection with Human Papilloma Virus (HPV) - the virus that causes cervical cancer.  This vaccine protects against 4 of the most common types of HPV.

Immunizations to consider:

• Hepatitis A is a 2 part vaccination that you receive once in your lifetime to prevent a form of hepatitis that is transmitted usually by something you eat or drink that was touched by someone who has Hepatitis A.  It is now recommended for all kids and is a good idea for adults as well, particularly if you live in a high-risk area or have a high-risk condition (certain chronic diseases or lifestyle risks).
• Hepatitis B is a 3 part vaccination that you receive once in your lifetime to prevent a form of hepatitis that is transmitted by blood or sexual activity.  This is also now recommended for all kids and is a good idea for adults as well, particularly if you work in a health care setting, have risky sexual behaviors or are exposed to bodily fluids.
• Catch up vaccinations:  If you have never received MMR (measles, mumps, and rubella) or meningococcal vaccination or if you have not had either the varicella vaccination or chicken pox, you need to get "catch up" vaccinations.

Laboratory studies

The screening labs you need depend on your own personal health history, your family health history and your age.  Screening labs are different from diagnostic labs.  If you have a sore throat and go to the doctor to be seen, you may have a throat culture done.  The throat culture is done to diagnose strep throat.  A screening test is done to find out if you have a disease before you start having symptoms.  A good example would be a fasting blood sugar to see if you have diabetes, even if you don't have any symptoms of diabetes.

• Diabetes testing is done by checking your blood sugar to see if it is too high.  There are a few different ways to do this:
• Fasting blood sugar is checked after you've had nothing to eat or drink for 8-12 hours.  If the blood sugar is 126 or higher, you may have diabetes.  In order to be diagnosed with diabetes, you need to have a reading of 126 or higher on 2 separate occasions when you are in your usual state of health.
• 2 hour oral glucose tolerance test combines a fasting blood sugar (above) with another blood sugar check 2 hours after you have taken a very sugary drink.  If your 2 hour sugar level is 200 or higher, you have diabetes.
• Random blood sugar is checked randomly - whether or not you have eaten.  If the sugar level is 200 or higher (and you have symptoms of diabetes like urinating a lot), you have diabetes
• Cholesterol is measured either randomly (without fasting) or after having nothing to eat or drink for 12 hours.  A cholesterol panel has several separate measurements.  I will describe the 4 that are looked at most closely below:
• Total Cholesterol level is just that - the total cholesterol number.  It is good to be 200 or lower.
• Triglycerides measure the "fat" in your blood.  It is good to be 150 or lower.
• HDL stands for high-density lipoprotein and is the "good" or Healthy cholesterol.  The higher the better.  Men should have levels of 40 or higher.  Women should have levels of 50 or higher.
• LDL stands for low-density lipoprotein and is the "bad" or Lethal cholesterol.  Your goal level changes based on your risk of heart disease.  People who have had a heart attack should have levels less than 70, whereas healthy young adults may be okay with levels 160 or higher.
• Thyroid function is checked with a test called the TSH which stands for thyroid stimulating hormone. 
  
• Occult blood in the stool is checked by testing stool samples you submit to the lab.  This is a screening test for colon cancer.
• Vitamin D Levels - Vitamin D deficiency is gaining increased attention.  While not often done, it is probably a good idea to have your Vitamin D levels checked (test is called 25 (OH) D level) if you are older (more than 65 years old), have dark skin, any problems with not absorbing nutrients from your gut, or do not get outside very often.

Cancer Screening

Cancer screening is done to look for a cancer that is treatable in people at risk for a cancer but who do not have symptoms.  We purposely do not screen for some types of cancer (pancreatic, brain, lung) because screening, on the whole, does not produce a benefit.  Cancer screening can include blood tests, pap tests, ultrasound, and physical exams.

Cancer screening for almost all women

• Pap smear testing looks at cells from the cervix (bottom part of your uterus) to see if there are cancerous or pre-cancerous cells.  Pap smears should be done in all women at age 21 or within 3 years of starting vaginal intercourse, whichever comes first.  A new recommendation from the American College of Obstetricians and Gynecologists (November 2009) recommends that women should start testing at 21, regardless of when they first have intercourse.  Testing is done annually until age 30 and then may be spaced out to every 2-3 years in low risk women.  Pap smear testing can stop at age 65-70 in normal-risk women or if you have had a hysterectomy for reasons other than cancer.
• Skin cancer screening - the benefit of examining your skin all over on a regular basis is debatable.  But it is not too difficult to look at your skin from time to time to see if any moles are growing, bleeding, or changing colors.
• Breast cancer screening is done in several different ways.  While self-breast exams are often recommended, how helpful they are in finding cancer early is unclear.  While women can find their own breast cancer lumps, they are much more likely to find non-cancerous lumps that lead to psychological stress, imaging, and possibly surgery.  The younger you are, the lower your risk, so the lower the benefit from self-breast exams.

Cancer screening for women at certain ages

• Breast cancer screening with a mammogram is recommended starting at age 40.  Usually it is repeated every year, although some experts advise that it can be done every other year, particularly between 40 and 50.  There is no specific age when mammograms are stopped - it depends on the general health of the woman.  A recent recommendation by the USPSTF (a government organization that issues recommendations on preventive health measures) recently (November 2009) recommended that women between the ages of 40 and 50 discuss the pros/cons of mammography with their physicians as the risk of false positives (an abnormal mammogram when you don't have cancer) may cause psychological harm and lead to unneccesary surgery without significantly reducing your chances of dying from breast cancer.
• Colorectal cancer screening is recommended for average risk women starting at age 50.  It can be done in a variety of ways - colonoscopy, flexible sigmoidoscopy, stool test for blood, virtual colonoscopy, barium enema.  Recent recommendations promote colonoscopy as the "best" test to start with for most patients.  This is for several reasons:  colonoscopy allows direct visualization of the colon and the doctor can take a sample of anything abnormal that is seen, colonoscopy can pick up pre-cancerous lesions that can be removed before they even become cancer, the other tests, if abnormal, require colonoscopy for further evaluation. 
  

Cancer screening for women at increased risk

• Breast cancer screening in women at increased risk may include MRI or ultrasound testing.  If you have a family history of breast cancer, ask your doctor if you are at increased risk and what testing he or she would recommend.
• Ovarian cancer screening is generally not recommended, although may be done in women at increased risk.  There are pros and cons of testing, which generally includes a pelvic ultrasound and a blood test called CA125 (which can be high in ovarian cancer as well as other conditions). 
  
• Uterine (endometrial) cancer screening is done with an endometrial biopsy in which a sample of cells from the uterine lining is examined for precancerous or cancerous changes.  It is only recommended in women who are at increased risk because of their family history.

Other types of testing

• Bone density testing for osteoporosis is recommended for women starting at age 65, or younger if they have an increased risk of osteoporosis. 
  
• Ankle-brachial index is screening for blood vessel (vascular) disease and is recommended in women at high risk for vascular disease.
• Coronary calcium score is a newer test that goes by other names (cardiac CT, EBCT).  It is a CT scan of your heart that measures the amount of calcium deposited in the heart blood vessels.  It can help your doctor to find out if your risk for heart disease is higher or lower than what would be predicted based on your cholesterol results, personal history, and family history.  

Coronary CT Scan

• Ultrasensitive CRP is a blood test that measures something called CRP or C-Reactive Protein.  This protein is a marker of inflammation.  It will be high if you have an infection or some type of inflammatory condition like rheumatoid arthritis.  It also can be high in people who have increased inflammation for other reasons.  People with high ultrasensitive CRP values are at higher risk of having heart disease.
• Abdominal ultrasound is done to screen for a dilated blood vessel in your abdomen called a "triple A" or "AAA" which stands for Abdominal Aortic Aneurysm.  Currently, it is recommended for men ages 65-75 who have ever smoked.
  

Counseling Topics

Your doctor may talk to you about ways to be healthier or stay healthy.  These include:

• Stop smoking.
• Get enough calcium and vitamin D.  For women who have not gone through menopause and are not at increased risk for osteoporosis, it is recommended that you get 1000 mg of calcium each day.  For women who have gone through menopause, you should get 1200-1500 mg of calcium each day.  A serving of yogurt, cheese or milk has about 250-300 mg of calcium.  If you don't get enough calcium in your diet, you should add a calcium supplement.  Since your body cannot absorb a lot of calcium at once, you shouldn't take more than about 600 mg of calcium at a time.  Vitamin D is an important part of bone health.  You should be getting about 800-1000 units per day, depending on how much sunlight exposure you get.
• Eat healthy.  This includes avoiding lots of high-fat, high-salt, high-cholesterol, or sugary foods.  Some good rules of thumb:
• Eat lots of fresh fruits and veggies (aim for at least 5 servings each day)
• Eat brown grains - whole wheat rice, breads, whole grains
• Eat lean proteins - nuts, fish, chicken, beans
• Exercise is really, truly good for you.  Get some exercise everyday.  The best initial approach is to just increase your activity by:
• Parking your car in the farther spot from the store (not a lot of competition for these spots)
• Use your feet instead of the remote control
• Stairs instead of the elevator
• Wear your seatbelt and bike/motorcycle helmet

Conclusion

    Part of staying healthy is preventing disease or finding it early.  One way to do this is to see your primary care doctor on a regular (usually every 1-2 years) basis.  The annual physical is nothing to be afraid of!

A Cool Tool:

If you would like to plan your next preventive health visit with your doctor, there is a great new tool available from the USPSTF and Agency for Healthcare Research and Quality.  The Electronic Preventive Services Selector will identify the preventive services you need based on your age, gender, and health habits.

Preventive health for men

Author : Dr Jennifer Frank University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin

2009-12-15

Preventive Health for Men : Find out what the "annual exam" is really all about.

Do you really need an annual "physical" at the doctor's office? Well, that is a matter of some debate, but there are some preventive health measures - things to keep you healthy and detect problems early - that you do need, especially if you are 50 years or older. Read below to find out what is essential and what is not.

Preventive Health Defined

Preventive health is widely defined, but basically refers to those things you do to keep yourself healthy.  This includes everything from getting your blood pressure checked to taking enough calcium.  Common areas of preventive health include: 

• Laboratory Studies:  These are tests that look for diseases (like diabetes or high cholesterol), infections (like Human Immunodeficiency Virus (HIV) or chlamydia), or screen for cancer (like stool cards checking for blood that can indicate colon cancer).
• Radiologic Studies:  These include xrays, ultrasounds, mammograms, and CAT scans that are done to screen (usually) for cancer, osteoporosis, or vascular disease. 
• Other diagnostic studies:  This may include an EKG looking for heart disease.
• Questions the doctor asks you about your personal and family history, symptoms you may be having, and lifestyle habits (like smoking, exercising, and calcium intake)
• Physical examination looking for signs of disease
• Immunizations to prevent you from getting diseases like influenza or pneumonia
• Counseling about ways to be healthier

How to figure out what you need

With all the testing listed above, it can be difficult to figure out what you need to have done, how often, and at what age.  While your primary care doctor can generally advise you what is needed and what is not, what follows is a quick guide to what is currently recommended.*

*One thing that makes all of this even more confusing is that different medical societies make different recommendations.  The recommendations I am outlining reflect what is recommended by the US Preventive Services Task Force, a national government organization that makes recommendations about preventive health care services.

Focus on Men

Men and women have many similar preventive health needs, but do have difference risks for things like cardiovascular disease or cancer.  Therefore, this knol focuses on what is currently recommended for men.

Immunizations

Immunizations for almost all men (18 and older)

• Tetanus is needed every 10 years.  There is a new vaccination called Tdap (Adacel is the brand name) that includes a booster immunization against pertussis.  Pertussis is whooping cough, which is annoying but generally not dangerous for adults.  However, it can be dangerous for unimmunized infants and children.  Since immunity fades after your childhood vaccine series, it is possible for adults to pass on whooping cough to children.  So, the Centers for Disease Control (CDC) recommends that all adolescents and adults (ages 11 - 64) receive a pertussis booster.  You can wait until you are due for your next tetanus booster, or just go ahead and get it now if it has been at least 2 years since your last tetanus booster.  It is particularly important to get the pertussis booster if you have contact with children under 1 year of age or work in a health care setting.

• Influenza vaccine is administered each fall.  It is recommended for all adults who are 50 years and older and younger adults who have certain chronic diseases (like asthma, diabetes, heart disease, kidney disease, cancer, or a problem with their immune system).  The influenza shot is given to people 50 years and older (as well as children and younger adults for whom the vaccine is recommended).  For adults younger than 50, an alternative is an influenza vaccine administered as a nasal spray.  You should check with your doctor or check out www.cdc.gov to find out whether you need the shot or can get the nasal spray. 
• Pneumovax is given to adults 65 years of age and older once to prevent a common form of pneumonia.  It is also given to younger adults with chronic health problems or smokers (and should be repeated after age 65 in these people).

Immunizations for some men

• Herpes Zoster (brand name Zostavax) is recommended for adults 60 years and older who have a history of chicken pox to prevent shingles (whether or not you have already had shingles).  This is a one time vaccine.

Immunizations to consider:

• Hepatitis A is a 2 part vaccination that you receive once in your lifetime to prevent a form of hepatitis that is transmitted usually by something you eat or drink that was touched by someone who has Hepatitis A.  It is now recommended for all kids and is a good idea for adults as well, particularly if you live in a high-risk area or have a high-risk condition (certain chronic diseases or lifestyle risks).
• Hepatitis B is a 3 part vaccination that you receive once in your lifetime to prevent a form of hepatitis that is transmitted by blood or sexual activity.  This is also now recommended for all kids and is a good idea for adults as well, particularly if you work in a health care setting, have risky sexual behaviors or are exposed to bodily fluids.
• Catch up vaccinations:  If you have never received MMR (measles, mumps, and rubella) or meningococcal vaccination or if you have not had either the varicella vaccination or chicken pox, you need to get "catch up" vaccinations.

Laboratory studies

The screening labs you need depend on your own personal health history, your family health history and your age.  Screening labs are different from diagnostic labs.  If you have a sore throat and go to the doctor to be seen, you may have a throat culture done.  The throat culture is done to diagnose strep throat.  A screening test is done to find out if you have a disease before you start having symptoms.  A good example would be a fasting blood sugar to see if you have diabetes, even if you don't have any symptoms of diabetes.

• Diabetes testing is done by checking your blood sugar to see if it is too high.  There are a few different ways to do this:
• Fasting blood sugar is checked after you've had nothing to eat or drink for 8-12 hours.  If the blood sugar is 126 or higher, you may have diabetes.  In order to be diagnosed with diabetes, you need to have a reading of 126 or higher on 2 separate occasions when you are in your usual state of health.
• 2 hour oral glucose tolerance test combines a fasting blood sugar (above) with another blood sugar check 2 hours after you have taken a very sugary drink.  If your 2 hour sugar level is 200 or higher, you have diabetes.
• A "random" blood sugar is checked whenever - without relation to when you last ate or drank.  If the sugar level is 200 or higher (and you have symptoms of diabetes like urinating a lot), you have diabetes
• Cholesterol is measured either randomly (without fasting) or after having nothing to eat or drink for 12 hours.  A cholesterol panel has several separate measurements.  I will describe the 4 that are looked at most closely below:
• Total Cholesterol level is just that - the total cholesterol number.  It is good to be 200 or lower.
• Triglycerides measure the "fat" in your blood.  It is good to be 150 or lower.
• HDL stands for high-density lipoprotein and is the "good" or Healthy cholesterol.  The higher the better.  Men should have levels of 40 or higher. 
• LDL stands for low-density lipoprotein and is the "bad" or Lethal cholesterol.  Your goal level changes based on your risk of heart disease.  People who have had a heart attack should have levels less than 70, whereas healthy young adults may be okay with levels 160 or higher.
• Thyroid function is checked with a test called the TSH which stands for thyroid stimulating hormone. 
• Occult blood in the stool is checked by testing stool samples you submit to the lab.  This is a screening test for colon cancer.
• Vitamin D Levels - Vitamin D deficiency is gaining increased attention.  While not often done, it is probably a good idea to have your Vitamin D levels checked (test is called 25 (OH) D level) if you are older (more than 65 years old), have dark skin, any problems with not absorbing nutrients from your gut, or do not get outside very often.

Cancer Screening

Cancer screening is done to look for a cancer that is treatable in people at risk for a cancer but who do not have symptoms.  We purposely do not screen for some types of cancer (pancreatic, brain, lung) because screening, on the whole, does not produce a benefit.  Cancer screening can include blood tests, pap tests, ultrasound, and physical exams.

Cancer screening for almost all men

• Skin cancer screening - the benefit of examining your skin all over on a regular basis is debatable.  But it is not too difficult to look at your skin from time to time to see if any moles are growing, bleeding, or changing colors.

Cancer screening for men at certain ages

• Colorectal cancer screening is recommended for average risk men starting at age 50.  It can be done in a variety of ways - colonoscopy, flexible sigmoidoscopy, stool test for blood, virtual colonoscopy, barium enema.  Recent recommendations promote colonoscopy as the "best" test to start with for most patients.  This is for several reasons:  colonoscopy allows direct visualization of the colon and the doctor can take a sample of anything abnormal that is seen, colonoscopy can pick up pre-cancerous lesions that can be removed before they even become cancer, the other tests, if abnormal, require colonoscopy for further evaluation.  
• Prostate cancer screening is recommended for men who choose to have it at about age 50.  It may start at age 40-45 if you are African-American or have a family history of prostate cancer.  There is a lot of debate and research about prostate cancer screening right now.  This is why:
• Prostate cancer is very slow growing, so even if you have it, it is not likely to kill you.
• Prostate cancer is very common, especially as you get older.  An old adage from medical school is that about 80% of men will have some degree of prostate cancer by age 80.  So, if almost all men get it if they live long enough, and you are not likely to die from it, is it worth looking for? 
• The treatment for prostate cancer can leave you with a lot of problems.  Most commonly, complications can include incontinence and impotence.  However, men can also be left with irritative voiding symptoms (pain or discomfort or even difficulty when you urinate).  So, if prostate cancer is common and unlikely to kill you, maybe the treatment is worse than the cure.
• We don't know who is most likely to benefit from early detection or treatment.  A lot of research is going on right now to figure out which men are most likely to benefit from finding and treating prostate cancer early.  But, at this point, we're just not sure who is most likely to benefit. 
• If you do decide to get prostate cancer, the best way to have it done is with a combination of a digital rectal exam (the doctor inserts a gloved finger into your rectum and gently feels your prostate gland for any lumps or nodules) plus a prostate specific antigen (PSA) test (a simple blood test).  If you have a prostate gland, your prostate will make some of the prostate specific antigen.  If your prostate is growing from cancer, the PSA level may be high.  The difficulty with both of these tests is:
• For the digital rectal exam, the doctor can only feel a part of the prostate gland.  So, the part the doctor can feel may feel normal but there could be a cancer growing in a different part.
• For the PSA test, the test can be high from other conditions (like benign prostatic hypertrophy (BPH) which is age-related enlargement of the prostate gland) or may be normal even if you have cancer. 

Other types of testing

• Bone density testing for osteoporosis is recommended for men if they have an increased risk of osteoporosis. 
• Ankle-brachial index is screening for blood vessel (vascular) disease and is recommended in men at high risk for vascular disease.
• Coronary calcium score is a newer test that goes by other names (cardiac CT, EBCT).  It is a CT scan of your heart that measures the amount of calcium deposited in the heart blood vessels.  It can help your doctor to find out if your risk for heart disease is higher or lower than what would be predicted based on your cholesterol results, personal history, and family history.  

Coronary CT Scan

• Ultrasensitive CRP is a blood test that measures something called CRP or C-Reactive Protein.  This protein is a marker of inflammation.  It will be high if you have an infection or some type of inflammatory condition like rheumatoid arthritis.  It also can be high in people who have increased inflammation for other reasons.  People with high ultrasensitive CRP values are at higher risk of having heart disease.
• Abdominal ultrasound is done to screen for a dilated blood vessel in your abdomen called a "triple A" or "AAA" which stands for Abdominal Aortic Aneurysm.  Currently, it is recommended for men ages 65-75 who have ever smoked.

Counseling Topics

Your doctor may talk to you about ways to be healthier or stay healthy.  These include:

• Stop smoking
• Get enough calcium and vitamin D. 
  Men should get between 1000-1200 mg of calcium each day.  A serving of yogurt, cheese or milk has about 250-300 mg of calcium.  If you don't get enough calcium in your diet, you should add a calcium supplement.  Since your body cannot absorb a lot of calcium at once, you shouldn't take more than about 600 mg of calcium at a time.  Vitamin D is an important part of bone health.  You should be getting about 800-1000 units per day, depending on how much sunlight exposure you get.
• Eat healthy. 
  This includes avoiding lots of high-fat, high-salt, high-cholesterol, or sugary foods.  Some good rules of thumb:
• Eat lots of fresh fruits and veggies (aim for at least 5 servings each day)
• Eat brown grains - whole wheat rice, breads, whole grains
• Eat lean proteins - nuts, fish, chicken, beans
• Exercise is really, truly good for you.  Get some exercise everyday.  The best initial approach is to just increase your activity by:
• Parking your car in the farther spot from the store (not a lot of competition for these spots)
• Use your feet instead of the remote control
• Stairs instead of the elevator
• Wear your seatbelt and bike/motorcycle helmet

Conclusion

    Part of staying healthy is preventing disease or finding it early.  One way to do this is to see your primary care doctor on a regular (usually every 1-2 years) basis.  The annual physical is nothing to be afraid of!

A Cool Tool:

If you would like to plan your next preventive health visit with your doctor, there is a great new tool available from the USPSTF and Agency for Healthcare Research and Quality.  The Electronic Preventive Services Selector will identify the preventive services you need based on your age, gender, and health habits.

Links:
The US Preventive Services Task Force Recommendations

Osteoporosis in Men

Coronary Calcium Score

Preventive Health in Men

Post-partum fitness

Author : Dr Jennifer Frank University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin

2010-03-15

Postpartum Fitness : Working off the baby weight

Weight gain is an inevitable part of pregnancy. Getting rid of the extra weight (especially if you gained more than the recommended 25-35 lbs) can be difficult. The demands of taking care of a new baby, increased caloric needs if you are breastfeeding, and the overwhelming fatigue new mothers experience all can make weight loss efforts difficult. There are a lot of resources available that can help you in your goal to lose weight and regain your fitness.

Get moving

This is the very best thing you can do to feel healthier and lose the baby weight.  This is also daunting to most new moms.  First of all, you are probably exhausted from the pregnancy, delivery, and demands of your new little person. You also may have let your exercise routine lapse during your pregnancy.  Getting motivated to exercise is challenging under the best of circumstances and these are not the best of circumstances.    Here are some ways to get started:

1.  Go for a walk. 

    This is a gimme one but is relatively easy to do and as a bonus, you can bring baby with you.  Your gym or local YMCA may even have stroller based exercise classes.  Walking is great for burning calories (faster walking = more calories burned), helps to "reset" your pelvic muscles and bones, and provides an opportunity to clear your head, listen to music, or talk with a friend. 

2.  Take advantage of the internet. 

    You must have internet access if you are reading this.  Go surfing for exercises that you enjoy doing.  One of my favorite sites is Yoga Journal's website which has free 20 minute videos that allow you to practice yoga in the privacy of your own home.  Prevention magazine also has free workouts as do many other websites. 

3. Check out the library (and check out from the library). 

    I get easily bored with exercise DVDs.  After doing them for a couple of times, I am ready to move on.  So, it could get quite pricey if I tried to maintain my own home fitness DVD library.  I explore DVDs on websites like Amazon and read the reviews.  I then request those titles from my local library.  Voila!  I have a chance to test-drive the DVD first and figure out if it's worth the money to own it.  You could also start your own lending library among your friends and exchange exercise DVDs.

4.  Jumping rope isn't just for grade school. 

    I got this idea from my husband who is in excellent shape.  Jumping rope for 20 minutes (or, honestly, even 2 minutes) is a great cardiovascular workout.  A jump rope is light, portable and can be done practically anywhere.

5.  Dance, dance, dance.

    Okay, my particular favorite dance tunes are I like to move it move it from the movie Madagascar and Hannah Montana/Miley Cyrus' You get the best of both worlds.  This may be because kids' songs are all that are played in our house.  Whatever gets your groove on, turn it up, grab that little one and get movin'.

Photo by Andy Newson

6.  Video games can be the key to your fitness routine. 

    Most everyone has heard of the Nintendo Wii and this video game system can get you moving.  (You can also just move the controller around so the system thinks you're moving, but this is not as effective at getting you back in shape).  My current favorite is EA Active

which has a 30 day workout program to start with as well as a wide variety of different exercise routines.  Wii Fit is also a good introductory, not too difficult game to try.

7.  Take a class. 

    Exercise classes can be a great way to get some adult time and to encourage you to workout.  It is easier to cancel an exercise appointment with yourself than with a class.  There are even postpartum classes that will allow you to meet other moms.

These are some initial ideas to get you started. I would encourage other readers to comment on what has worked well for them.

Other tips can be found at About.com postpartum fitness tips.

Vasectomy complications

Author : Dr Jennifer Frank Family University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin

2010-04-28

Complications of a Vasectomy : Vasectomy is usually safe and effective but has potential complications.

Just like any other surgical procedure, you may experience complications. You can expect to experience minor discomfort for a few days after you have the vasectomy. Other potential complications include bleeding, infection or inflammation, pain, and failure. If you follow the advice you are given for post-operative recovery, you will lower your risk of having a complication.

Hematoma formation

                A hematoma is a collection of blood that forms in your scrotum.  This is the most common complication and causes pain.  Your risk of having a hematoma develop is low overall.  You can further reduce your risk by choosing to have a vasectomy done by an experienced physician (who does at least 2 to 4 vasectomies per month).  Also, your risk of hematoma formation is lower if you have a no-scalpel vasectomy.

Sperm granuloma

                A sperm granuloma is inflammation at the end of the vas deferens (the tube that is cut during a vasectomy).  The sperm that leak out of the end of the tube cause cells in your body to form a type of scar called a granuloma.  This may feel like hard beads in your scrotum but usually causes no other problems but you may experience pain at the site of the granuloma.

Infection

                Like the risk for a hematoma, risk of infection is lower if your surgeon performs a no-scalpel vasectomy.  Infection after a vasectomy is uncommon and is usually localized to the structures in the scrotum.  If you experience infection, symptoms would include, pain, redness, fever, or foul-smelling drainage from your incision site.  A short course of antibiotics will usually take care of the infection.

Pain

                You can expect to experience pain or discomfort for days to weeks following the vasectomy.  A very small number of men experience long term pain.  It is not well understood why this occurs, but there are a number of theories including that your scrotal structures may get congested which leads to pain.  If you experience pain after your vasectomy, your doctor may prescribe anti-inflammatory medications, rest, antibiotics, or pain medications.  Rarely, surgery may be needed if the pain is severe and doesn’t respond to more conservative treatment.

Failure

                Having a vasectomy is a very effective way to achieve sterility.  However, just like any contraceptive method, it can fail.  You may have failure initially (the vasectomy doesn’t result in sterility) or may develop failure later (the vasectomy is initially successful but later fails).  The combination of cautery (burning the ends of the vas deferens) and fascial interposition (separating the ends of the vas deferens with a piece of your tissue (called fascia) offers the lowest risk of failure.    

Resources:

Vasectomy: What you should know

What are the complications and know risks of vasectomy?
What are the complications and known risks of vasectomy?

References:

• "Urologic Clinics of North America"; Risks and Complications of Vasectomy;Christopher Adams and Moshe Wald;August 2009.
• "American Family Physician";Vasectomy: An Update; Paul Dassow and John Bennett;December 2006.
• "Journal of Andrology"; Testicular Pain Following Vasectomy: A Review of Postvasectomy Pain Syndrome; Cory Christiansen and Jay Sandlow, 2003.

Ovarian cancer symptoms

Author : Dr Jennifer Frank Family University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin  2010-04-28

Ovarian Cancer Symptoms : Digestive symptoms may occur early in ovarian cancer

Women are often diagnosed with ovarian cancer when it is late stage and more difficult to treat, partly because the earliest symptoms are vague and commonly experienced by otherwise healthy women. In the August 2005 journal “Cancer”, Dr. Lloyd Smith and colleagues reported that women with ovarian cancer experienced symptoms like abdominal pain and swelling before they were diagnosed more often than women with breast cancer or women who were cancer free.

Abdominal pain

While, abdominal pain is something that almost everyone will experience at some time, it can occasionally be the first symptom of ovarian cancer. In a study conducted between 2000 and 2007, reported in “British Medical Journal”, Dr. William Hamilton and colleagues reported that over half of women diagnosed with ovarian cancer had abdominal pain in the months before their diagnosis.

Abdominal distention or bloating

Abdominal distention (swelling of your abdomen) is often caused by something relatively minor like over-eating.  Rarely, it can be an early sign of something more sinister like ovarian cancer. In the Hamilton study, about one-third of women with ovarian cancer reported having abdominal distention before they were diagnosed. If you have both abdominal distention and loss of appetite, the risk of this being caused by ovarian cancer is higher. 

Diarrhea

The most common cause of diarrhea is a viral infection which is usually mild and resolves quickly. However, just like the symptoms listed above, diarrhea can rarely be an early symptom of ovarian cancer.

Weight loss

Most women wouldn’t mind losing a little weight. However, when it occurs unintentionally (not because you are dieting or exercising more), it is concerning for things like cancer. Almost any type of cancer, including ovarian cancer, is sometimes a cause of unintentional weight loss. 

Other symptoms

Other digestive symptoms you can experience with ovarian cancer include difficulty eating, feeling full quickly, constipation, and loss of appetite. Like the symptoms listed above, these are rarely caused by ovarian cancer and are experienced at times by many women. You should become concerned if they persist for months, get worse, or occur with other digestive symptoms. If you are 70 years of age or older, you are already at higher risk for ovarian cancer, so new digestive symptoms should be reported to your doctor.

Resources:

American Cancer Society - Ovarian Cancer Symptoms May Begin Before Diagnosis

American Cancer Society - Early Ovarian Cancer Symptoms

American Cancer Society - Specific Symptoms of Ovarian Cancer

References:

• "British Medical Journal"; Ovarian Cancer; William Hamilton and Usha Menon; January 2010
• "British Medical Journal", Risk of Ovarian Cancer in Women with Symptoms in Primary Care: Population Based Case-Control Study; William Hamilton, Tim J Peters, Clare Bankhead, Deborah Sharp; 200.
• "Cancer"; Ovarian Cancer: Can We Make the Clinical Diagnosis Earlier?; Lloyd Smith, Cyllene Morris, Shagufta Yasmeen, Arti Parikh-Patel, Rosemary Cress, Patrick Romano;2005

Contraception: IUDs

Author : Dr Jennifer Frank University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin

2010-03-12

INTRAUTERINE DEVICES: IUDs

Background Info
   If you are in your 30's or older you probably have heard about the Dalkon Shield used in the 1970s.  It was an intrauterine device (IUD) - something that stays inside the uterus to prevent a pregnancy.  Unfortunately it caused a lot of harm - infections and even a few deaths - and made IUDs an unpopular form of birth control.  I learned from yahoo.com that IUDs were actually first invented in 1909.  Those early models are not in use today, but there are two available IUDs in the U.S.  One is a copper IUD - it looks like a small T and fits easily inside the woman's uterus.  Another is the levonorgestrel (a fancy name for a hormone called progesterone) impregnated IUD called Mirena.  It also looks like a T and fits easily inside the uterus.How IUDs work
    IUDs prevent pregnancy by preventing the sperm and egg from meeting.  Copper IUDs release copper ions (or very small particles) that harm sperm, making it difficult for the sperm to get far enough to fertilize an egg.  Levonorgestrel IUDs (LNG-IUD) release a small amount of hormone (progesterone) that makes cervical fluid thick (so sperm can't get through) and makes the uterus an unfriendly place for both sperm and fertilized eggs.  Approximately one out of every four women will also stop ovulating (not release an egg) and may not have periods at all.

    IUDs can also make the environment (fallopian tube and uterus) inhospitable (not very friendly) to a fertilized egg.  Some people think this is like an abortion because it prevents a fertilized egg from implanting.  Some people do not consider this an abortion-like effect. Whatever your view is, it is important to know that this is a possible effect of the IUD, although not the main way that it works.Where everything is located

Copper IUDs versus hormonal IUDs (LNG-IUD)
The Copper IUD generally does not make your menstrual flow lighter or less frequent but can stay in place for up to 10 years.  The LNG-IUD often make women's periods lighter and less frequent, but only can stay in place for up to 5 years.  They are equally effective in preventing pregnancy - about 99% effective.

So, who can get an IUD? 
Well, there is a lot of misleading information out there.  Basically, you may be a good candidate for an IUD if:

-You've had a baby or you've never had a baby
-You have a normal shaped uterus
-You are not at risk for sexually transmitted infections - this usually means that you are with one sexual partner long-term
-You are not in the middle of an evaluation for abnormal uterine bleeding or an abnormal pap smear
-You smoke or you don't smoke
-You don't have a current or recent pelvic infection
-You can check for the IUD strings (you feel comfortable putting your fingers in your vagina to check the strings on a regular basis - usually about once per month)
-You are breastfeeding (or bottle feeding)
    Why get an IUD? 
We are really lucky to live in a time when there are lots of options for birth control.  There are pluses and minuses to all forms of birth control.  IUDs have some advantages:
1.  They are fairly maintenance-free.  Once it is in place, you usually don't have to do anything other than check to make sure the strings are in place monthly. 
2.  You don't have to prepare anything in advance of intercourse (like inserting a diaphragm or spermicide or putting on a condom).  HOWEVER, YOU SHOULD ALSO USE A CONDOM IF THERE IS ANY CHANCE OF BEING EXPOSED TO A SEXUALLY TRANSMITTED INFECTION.
3.  It is effective - 99% or higher.
4.  A LNG-IUD (the one with the hormone in it) can make your periods lighter and/or less frequent.
5.  There are minimal side effects - we'll talk about some of the potential bad parts of an IUD later.
6.  It lasts a long time - 5 to 10 years.So, if it is so great, why doesn't everyone have one? 
    This is a great question.  Part of the reason is because not everyone is a good candidate for an IUD.  If you have risky sexual behavior - any sexual activity that puts you at risk for a pelvic infection, an IUD is probably not a good choice.  Another reason is that the whole idea of something being put inside you can be kind of scary.  Some women just don't like the idea of something staying inside your uterus or having to check the IUD strings.  And finally, lots of women have heard negative things about the IUD - either the history of the Dalkon Shield or things friends have experienced.  How do I get an IUD?
    IUDs are placed by physicians or other health care providers experienced in IUD placement.  You can either make an appointment with your primary care doctor, visit a gynecologist, or go to a Planned Parenthood Clinic (call first to make sure they do IUD placement).  You may have to have one visit to talk about the IUD and find out if it is a good choice and a second appointment to actually get it placed.

 What happens during the IUD placement?  What can I expect? 
    You will go to the doctor's office like you do for a regular appointment.  You may be asked to take some ibuprofen (Motrin or Advil) before your appointment so that you don't experience as much cramping when the IUD is placed.  You will probably be asked to have a pregnancy test since the IUD is not inserted if you are already pregnant.  In the exam room, you will be asked to undress from the waist down, just like a pap smear appointment.  The doctor may do a pelvic exam to find out how your uterus is angled so that he or she can insert the IUD more easily. 

    Next, you are asked to lay down and put your feet into stirrups (just like for a pelvic exam).  A speculum is inserted into your vagina so that the doctor can see your cervix (this is the opening to your uterus).  The doctor will clean the cervix with a special soap called betadine - this is to make sure that you don't get an infection when the IUD is put in.  Next, the doctor will sound your uterus.  This means that he or she will place a very thin metal or plastic rod inside your cervix into the uterus.  This allows the doctor to find out how large your uterus is (usually will be 6-8 centimeters deep).  Next, the doctor will prepare the IUD and get it ready for insertion. The doctor will place a marker at the same depth as your uterus was measured.  This makes sure that the IUD is put in far enough.

Sometimes the cervix can be floppy or move around a lot.  If this happens, the doctor may need to use something called a tenaculum.  This is an instrument that holds the cervix in place (by grasping it) so that the IUD can be put in.  Next, the IUD is inserted.  You may feel some cramping (like menstrual cramps) when the IUD is put in.  After the IUD is placed, the doctor will cut the IUD strings to about 2 centimeters long.  This will be long enough so that you can still feel the strings, but not so long as to bother you or your sexual partner.

You may have some mild cramping or bleeding after the IUD is placed.  It is pretty common to have irregular vaginal bleeding right away and also to have some irregular bleeding for a few months after the IUD is put in.  This should go away.

What could go wrong? 
    Generally, IUDs are very safe.  Occasionally, a woman may experience more bleeding than normal. This is more common with a Copper IUD.  Since something is being inserted into your body, it is possible to get an infection.  The risk of infection is highest right after the IUD is placed and for about 20 days afterwards.  Like all birth control measures, IUDs can fail and you can get pregnant.  IUDs are very effective (99%) but no method (except abstinence) is 100% effective.  The IUD can fall out or move further inside your uterus.  Finally, very rarely an IUD can go through the wall of the uterus (uterine perforation).  This is very serious and usually requires surgery to take out the IUD and sew up the wall of the uterus.  While this is rare, it may be more likely to happen if you have any history of problems with your uterus or if you recently (within the past 3 months) had a baby and are breastfeeding.  It is generally safe to have an IUD after you have had a baby, even if you are breastfeeding.

CALL YOUR DOCTOR RIGHT AWAY IF YOU EXPERIENCE:
-Heavy bleeding
-Severe cramping or abdominal pain
-Strings are no longer there
-Yucky smelling vagina discharge or fever
-Positive pregnancy test

What will sex be like after the IUD? 
    IUDs should not affect your sex life (except to make you less worried about getting pregnant).  Sometimes the male partner can feel the string with deep penetration, but this often goes away as the strings get "stuck" in the cervical mucus and become more difficult to feel.  Also, your doctor can cut the strings shorter if this is a problem.

    In summary, IUDs are a good birth control option for a lot of women.  If you think that an IUD could be a good choice for you, talk to your doctor about it.