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	James L. Holly, M.D.

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Your Life Your Health - Preventive Health Screening for Women: What to have When

Norma Duncan,MSN, APRN-BC, FP

April 17, 2003

Your Life Your Health - The Examiner

Do you only visit the doctor when you're sick? I hope not. Preventive health screenings can save your life. The Pap smear, mammogram, bone density, colonoscopy, lipid profiles, blood pressure measurement and blood sugar measurement are the screenings you can expect to take place when you come for a "well visit". At SETMA, we really hate surprises. We want our patients to come in at specific times for specific screenings. We base our choices and timing on national standards of care and "best practices" defined by experts in their fields. We want to find "bad stuff" early and control it, or get rid of it. In this way, we minimize surprises.

The best compliment you can receive from your health care provider is that you are really boring. This means we find nothing to treat at the present. Having said this, you'll most likely find your provider poking around your family history to predict what "might" happen. That way, we help you intervene to prevent a heart attack in your 40's or diabetes in your 50's. We don't want you to end up in the nursing home with a fractured hip, or a stroke like most of your great aunts. It's incredibly important to have an accurate snapshot of your family history. So take your time filling out those forms or answering questions regarding the parents, grandparents and brothers and sisters.

You will also be asked to fill out a form or answer questions regarding your present health. For instance, when I am examining a woman in her 50's, I will ask specific questions about her health as I move from head to toe. These questions shape my plan of care for the coming years. At the end of a physical, I give a woman my recommendations for lifestyle changes and health screening which will help her retain her health and/or regain her health, so much as is possible. Of course, I also prescribe medications for her hypertension and diabetes, or for her allergies. The presence of these illnesses may tip the scales to additional specific screenings.

The first screening most women can relate to is a pap smear. Why? We do them to detect cervical cancer. Cervical cancer is a preventable cancer. Modern pap smears detect changes well before anything serious happens. Cervical cancer is caused by certain strains of the human papilloma virus. The woman comes into contact with these forms of the virus when she becomes sexually active. The initial Pap smear usually takes place when the woman becomes sexually active. Yearly pap smears are the norm for most women who have a cervix.

I am commonly asked by women who have had a hysterectomy why they should come in for a physical that includes a pap smear. My initial response, especially to an older woman, is that I am looking for lots of other things as I examine them. If they have ovaries remaining, I will assess them. I am looking for bladder and rectal problems. I am checking the effectiveness of their hormone replacement, if they are on hormones. I am looking at their skin in a place they can not readily examine. They are asked to remove all their clothing during this exam. This facilitates a good and thorough exam of the skin on the rest of their body. Melanoma can occur anywhere but it is statistically more likely to occur on the legs of a woman. This is easily checked during this exam. It is unlikely to occur in a physical that does not demand complete disrobing.

The US Preventive Services Task Force III is reviewing recommendations for cervical cancer screenings for older women and women with hysterectomies. They have not issued new guidelines.

Mammograms save women's lives. Are they perfect? No, they are not. Are they best thing we have that is approved for screening? Yes, they are. New knowledge emerges daily. We'll have better tools in the future. Our young daughters and their daughters will have much more sophisticated screenings. Breast cancer may become a preventable cancer like cervical and colon cancer.

When should you have your first mammogram? If you don't have a mother, or sister who has had breast cancer, most doctors will recommend that you begin at age 40. The older you get the more important it is to have yearly mammograms. Breast cancer rates increase with age. If your mother or sister developed breast cancer, many health care providers will begin screening with mammograms ten years before the cancer was first found in your mother or sister.

If you palpate something abnormal in your breasts have it checked out by your provider. Many women say they have a hard time knowing whether something is abnormal in their breasts. My response is to get to know your breasts by monthly self examinations. In women with menstrual cycles, the examination should occur a few days after the cycle. In women who don't have menses, the exam should occur at a regular time every month. If something feels different, bring it to the attention of your health care provider.

Bone density should be a hot topic in high school health classes. Why? It's a time when we can intervene early and prevent bone deterioration by the loss of calcium. Our young women should be encouraged to maintain a healthy body weight. A woman who is too thin risks osteoporosis later. If your daughters won't drink milk, or eat much dairy products, you may want to provide calcium supplements. As you would imagine, bad habits like smoking (a deadly habit), excessive caffeine, or alcohol intake will increase your risk of osteoporosis. A sedentary lifestyle puts you at additional risk, also. These are modifiable risks. So, modify yourself if you fit into these categories.

We have 1.3 millions bone fractures every year in the United States that can be attributed to osteoporosis. Fracturing your hip or having several fractured vertebrae can put you off your feet. This can make you dependent on others, or place you in a nursing home. This is not a desirable circumstance for most of the older women I care for everyday and are the ones they fear the most.

When should we begin screening? If we follow government guidelines, barring unusual risk factors, you would receive your first bone density at age 65. That is too late for many women. If I have a concerned peri-menopausal woman (a woman about to start menopause), or a postmenopausal woman, who has older relatives with osteoporosis and who is willing to begin treatment based on the results of the bone density, I will screen her. If a plain x-ray suggests osteoporosis, I will begin treatment and screen her to stage her osteoporosis. This is really an unfortunate finding for it means that she has already lost 30% to 50% of her bone mass. On occasion, a dentist sends us a patient because they have identified bone loss on their exams.

There are also special populations that need mentioning.

Some young women have their ovaries and uterus removed at a young age by medical necessity. They will be on hormone replacement therapy but they will need to be screened earlier to monitor for bone loss. If the woman reaches menopause before 45 she should be screened.

I have many wheelchair bound patients who are young adults. Their lack of weight bearing puts them at risk for osteoporosis. A woman who has been on steroid therapy for a certain amount of time will need early bone density screening because this enhances bone loss.

Women who are on certain drugs for seizures should be screened earlier. Young women who have been on Depo-Provera injections for birth control for long period of time may be at risk.

Finally, if you have had a fracture as an adult you should have a bone density screening.

The best tool on the market is the Dual-energy x-ray absorptiometry (DXA) scan. Typically it looks at bone density at the hip and vertebrae of the spine. This is a painless test that takes a short amount of time. Treatment is based on established guidelines. Most clinicians will only begin treatment based on the DXA scan because they consider it the gold standard for reliable results.

The Pap smear, mammogram, and bone density are some of the tools we use to prevent and treat disease and promote health in our women. I like to look at each patient and project where they will be on the health spectrum in 20, 30, or 40 years from now. I try to treat them so that aging will be a healthy, slower process. I want them to remain independent and satisfied with their quality of life: remembering all the while that it is their life and their health.

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