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.