Health Maintenance for Women L. Jill Moore, MD, CCD

US Women’s Health Stats Approximately 155 million women (all ages) 17% of women age >18 currently smoke 36% of women age >20 are obese 33% of women age >20 have hypertension 68% of women age >40 had a mammogram in the past 2 years 75% of women age >18 had Pap smear in past 3 years

Leading Causes of Death Heart Disease Cancer Stroke

10 Leading Causes of Death, 2007 US Women 1Diseases of the Heart306, % 2Malignant Neoplasms270, % 3Cerebrovascular Diseases (stroke)81,8416.7% 4Chronic Lower Respiratory Diseases (COPD)66,6895.5% 5Alzheimer’s Disease52,8324.3% 6Accidents/Unintentional Injuries43,8793.6% 7Diabetes Mellitus35,9042.9% 8Influenza and Pneumonia28,6462.3% 9Kidney Disease/Kidney Failure23,8322.0% 10Septicemia18,9891.6%

How Do I Stay Healthy?

Staying Healthy Proper Diet Appropriate Exercise Good Sleep Habits Manage Stress Immunizations Screening Exams Spiritual Health

DISCLAIMER Screening and immunization recommendations may vary depending on the source (CDC, WHO, NIH, AMA, American Cancer Society, your insurance carrier, or local church group bible study) Specific disease states or conditions may warrant earlier or more frequent testing than discussed here today

IMMUNIZATIONS

Immunizations Yearly influenza vaccine – all ages (yes, everyone) HPV vaccine – age 9 up to age 26 Meningococcal vaccine – for college students and military recruits Tetanus-diphtheria-pertussis booster every 10 years – all ages Pneumococcal vaccine – once at age 65, sooner if risk factors such as asthma, COPD, diabetes Herpes Zoster (Shingles) vaccine – once > age 60

SCREENING EXAMS

Blood Pressure Will be checked at annual wellness visit Average blood pressure 120/80, need to treat if >140/90 on 2 different days

Height and Weight Will be checked at annual wellness visit Calculation of BMI Recommendations can be given regarding appropriate weight for height

Cholesterol Test Total cholesterol goal < 200 Triglycerides goal < 150 HDL (good cholesterol) >50 LDL (bad cholesterol) <130 – If diabetic then < 100 – If history of stroke or heart attack, then < 70 Frequency of testing to be determined by provider based on risk factors

Glucose Test/Diabetes Screening Elevated blood sugar is often asymptomatic Check at least every 3 years starting in 40’s More frequent and earlier testing would be appropriate for those at higher risk such as those with family history, overweight status, or specific symptoms

Thyroid Function Test Proper thyroid function is critical for most body systems Malfunctioning thyroid may not initially cause symptoms Based on overall health and risk factors, doctor can determine frequency of screening

Pap Test Cervical Cancer Screening

Pap Test 20’s – start age 21, every 2 years 30’s – every 3 years 40’s – every 3 years 50’s – every 3 years 60’s – discuss with doctor about when to stop 70’s – may not be necessary, but optional Pelvic exam every year beginning at age 21

STD Testing Annual chlamydia test until age 25 if sexually active, repeat if new or multiple partners (all ages); the same specimen collected may also test for gonorrhea. Both partners should be tested for HIV, syphilis, hepatitis. (all ages) Always request additional testing for any suspicious symptoms.

Mammogram

Digital Mammogram vs. Traditional X-ray Mammogram

Digital Mammogram vs. MRI

Mammogram Frequency Starting age 40 Every 1-2 years, discuss with your physician regarding individual risk factors May need to start sooner depending on family history Still need annual breast manual exam by healthcare provider, between 10-15% of breast lumps are not visible on standard mammogram

Clinical Breast Exam 20’s and 30’s at least every 3 years 40’s and over, every year

Breast Self-Exam Previous recommendation was monthly self- exam after proper instruction Research no longer supports this recommendation, but be sure to share concerns with your doctor

Risk Factors for Breast Cancer Family History of Breast or Ovarian Cancer Genetics and Ethnicity, Blacks or Ashkenazi Jewish are higher risk Cigarette Smoking Obesity Excess Alcohol Use, 2 servings per day Advanced Age Early Onset of Menses < age 12 BPA exposure/plastics ? Excess Soy, plant estrogens ? Estrogen HRT +/- Progesterone, WHI study revisited

BRACAnalysis Test A test for hereditary breast and ovarian cancer syndrome The test does not tell you if you have cancer currently, but detects genetic mutations in BRCA 1 and BRCA 2 genes. Insurance coverage for this blood test makes it affordable for most.

Who Should Consider BRACAnalysis testing?

Patients with any of the following in their personal or family history may be candidates for BRACAnalysis® testing: Breast cancer diagnosed < age 50 Ovarian cancer at any age Two primary breast cancers Male breast cancer Triple negative breast cancer Pancreas cancer with additional HBOC cancer Ashkenazi Jew descent with additional HBOC cancer A previously identified BRCA gene mutation in the family

Abnormal BRCA gene increases risk of Breast and Ovarian Cancer

Risks can be Reduced with Proven Medical Management

Medical Management Options Increased Surveillance for Breast Cancer in Mutation Carriers Monthly breast self-exams starting at age Annual or semiannual clinical breast exams starting at age Yearly mammography starting at age 25 12, Yearly magnetic resonance imaging (MRI) starting at age 25 or individualized based on earliest case in the family 12, Increased Surveillance for Ovarian Cancer in Mutation Carriers Annual or semiannual transvaginal ultrasound 12, Annual of semiannual blood test for CA125 beginning at age 25 12,13CA Annual pelvic exams Risk Reducing Medications for Mutation Carriers Tamoxifen use has been associated with a reduction of 53% in the risk of a second primary breast cancer in contralateral cancers Oral contraceptives, when taken for 6 or more years, have been associated with a reduction of up to 60% in the risk of ovarian cancer Prophylactic Surgery in Mutation Carriers Prophylactic mastectomy reduces breast cancer risk by at least 90% Prophylactic oophorectomy reduces ovarian cancer risk by up to 96% and breast cancer risk by up to 68% 18, *Any discussion of medical management options is for general informational purposes only and does not constitute a recommendation. While genetic testing and medical society guidelines provide important and useful information, medical management decisions should be made based on consultation between each patient and his or her healthcare provider.

DXA Scan Osteoporosis Screening Vertebral Fracture Analysis

DXA Scan Generally start at age 50 or at onset of menopause, whichever is first It measures calcium content of bones of lower spine and hip (and sometimes wrist) Diagnosis of osteoporosis is not made by finger or heel scan Higher calcium content usually means increased bone strength Frequency of testing depends on results and other risk factors

Vertebral Fracture Analysis Special “from the side” X-ray of the spine from upper shoulders to pelvis Degree of compression of individual vertebrae can be measured This test is recommended for women over age 65, especially with low bone density, significant loss of height (3/4 inch), or other concerning risks

Vertebral Fracture Analysis

Fragility Fractures Any broken bone from standing height (excluding fingers/toes/face/nose) or any low trauma fracture Any fragility fracture = diagnosis of osteoporosis and it should be treated as such even if the DXA result is normal Common sites of fragility fractures : hip, spine, wrist Approximately 25% of patients who have a fragility fracture of the hip will die within 1 year Only 25% of those with hip fracture will ever regain previous level of function

Colorectal Cancer Screening

Begins at age 50 Colonoscopy every 10 years until late 70’s Alternative study – Flexible Sigmoidoscopy every 5 years with annual fecal blood test Annual fecal blood test alone

References Centers for Disease Control and Prevention Magee-Women’s Hospital of UPMC Discover Magazine U.S. Department of Health and Human Services, Office of Women’s Health National Cancer Institute at the National Institutes of Health