Disease Prevention in Women

Screening tests are a basic part of preventative medicine. All screening tests are commonly available through your primary care physician. Some specialized tests may be available only through specialists. Take an active role and discuss screening tests with your doctor early in life. The following examinations represent beneficial (generally simple and safe) screening tests that can help detect diseases and conditions before they become well-established and harmful.

Osteoporosis is a condition characterized by progressive loss of bone density leading to bone fractures. Estrogen is important in maintaining bone density. When estrogen levels drop after menopause, bone loss accelerates. Thus, osteoporosis is more common among postmenopausal women.

Screening tests

Measurement of bone density using dual energy X-ray absorptiometry (DEXA) scan

DEXA bone density scanning can:

• detect osteoporosis before fractures occur
• predict the risk of future bone fractures
• be used to monitor the efficacy of treatment regimens to combat osteoporosis.

Who to test and how often

The National Osteoporosis Foundation guidelines state that all postmenopausal women below age 65 who have risk factors for osteoporosis or medical conditions associated with osteoporosis and all women aged 65 and older should consider bone density testing.

High risk factors for osteoporosis include:

• early spontaneous menopause or surgical menopause secondary to removal of the ovaries;
• family members with osteoporosis and related bone fractures;
• cigarette smoking and/or heavy alcohol abuse;
• over-active thyroid gland (hyperthyroidism); 
• previous or current anorexia nervosa or bulimia;
• thin body habitus; 
• light skin;
• Asian or Northern European descent;
• conditions associated with poor absorption of calcium or vitamin D;
• chronic use of oral corticosteroids (such ascortisone and prednisone [Deltasone, Liquid Prep]), excessive thyroid hormone replacement, and phenytoin (Dilantin) or other anti-seizure medications; and 
• problems with missed menstrual periods.

Benefits of early detection

Osteoporosis produces no symptoms until a bone fracture occurs. Bone fracture secondary to osteoporosis can occur with only a minor fall, blow, or even just a twist of the body that normally would not cause an injury.

Prevention and treatment of osteoporosis can decrease the risk of bone fractures.

Preventative measures include:

• quitting smoking;
• curtailing alcohol intake;
• performing regular weight-bearing exercises, including walking, dancing, gardening, and other physical activities;
• supervised muscle strengthening exercises;
• getting adequate calcium and vitamin D intake;
• using medications to prevent osteoporosis. The most effective medications for osteoporosis prevention that are approved by the FDA are anti-resorptive agents, which prevent bone breakdown. Examples include alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and zoledronate (Reclast); and

While hormone therapy containing estrogen has been shown to prevent bone loss, increase bone density, and decrease the risk of fractures, HT has also been associated with health risks. Currently, hormone therapy is recommended for women for the treatment of menopausal symptoms. The lowest effective dosage of hormone therapy should be used, and it should only be continued until symptoms have resolved.

Breast cancer is the most common cancer among women in the United States. Approximately one in nine women who live to age 65 will develop breast cancer, although many will not do so until after age 65.

Screening tests for breast cancer

The most important screening methods to detect breast cancer include:

• breast examination by a trained professional, and
• mammography

Who to test and how often

Breast awareness

• In November 2009, the U.S. Preventive Services Task Force recommended against teaching breast self-examination, citing a lack of benefit for a monthly self-examination. Groups such as the American Cancer Society agree with this conclusion and do not offer guidance on exactly how often a woman should check her breasts, but do state that a woman should be aware of any changes in her breasts.
• Breast examination by a professional trained in breast examination.
• Mammography: In their revised recommendations issued in November 2009, the U.S. Preventive Services Task Force states that women age 40 to 49 do not require routine mammograms. They recommend biannual screening mammograms for women aged 49-74, and further state that: "The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms."
• However, The American Cancer Society (ACS) disagrees and recommends a baseline mammogram for all women by age 40 and annual mammograms for women 40 and older for as long as they are in good health.
• In women with "lumpy breasts" or breast symptoms, and also in women with a high risk of developing breast cancer, a baseline mammogram at 35 years of age is sometimes recommended. This recommendation is somewhat controversial, and there are other viewpoints.

High-risk factors for breast cancer include:

• a history of breast cancer;
• first-degree relatives (mother, sister, or daughter) with breast cancer. The risk is especially higher if both the mother and sister have had breast cancers, if a relative developed her cancer before age 50, if the relative had breast cancer in both breasts, if there is both ovarian and breast cancers in the family, or if a male family member has been diagnosed with breast cancer

Benefits of early detection

Early detection of breast cancer is important to every woman, regardless of risk factors, because the earlier a cancer is found, the smaller it is likely to be. Studies have clearly shown that the smaller the size of the breast cancer when detected, the better the chance of a surgical cure and long-term survival. Smaller breast cancers are also less likely to have already spread to lymph nodes and to other organs such as the lungs, liver, bones, and brain.

Mammograms can detect many small breast cancers long before they may be felt during breast examinations. There is extensive evidence that early detection by mammography has improved survival in women with this disease.

Some 10% to 15% of breast cancers are not detected through mammograms but are detected by breast examinations. Therefore a normal mammogram does not completely exclude the possibility of breast cancer, and breast self-examinations and breast examinations by a doctor remain important.

About one-sixth of all Americans have high blood pressure, and the incidence of this disease increases with age. Consequently, the proportion among adults is higher, and it is even higher among seniors. African-Americans are more likely than others to have high blood pressure.

High blood pressure can cause arterial disease (atherosclerosis) that can lead to heart attack, congestive heart failure, stroke, and kidney failure.

Screening tests

Blood pressure measurements

• High-normal blood pressure is 130-139/85-89.
• Stage 1 hypertension is 140-159/90-99.
• Stages 2 and 3 blood pressure are >160 / >100.

Who to test and how often

• How often blood pressure should be checked depends on how severely elevated the blood pressure is. It also depends on the presence of other risk factors for heart attack and stroke.
• Adults with most recent normal blood pressure of systolic < 130 and diastolic < 85 should be checked at least every other year.

Benefits of early detection

High blood pressure can cause diseases without any early warning symptoms.

There is good evidence that treatment of high blood pressure can reduce the risk of heart disease, stroke, and kidney failure.

Actually, there is good evidence that adults with all degrees of high blood pressure can benefit from the lowering of blood pressure. It is important to discuss weight management, exercise, and stress management with your doctor.

Cancer of the cervix (the portion of the uterus that extends downward into the vagina) is the third leading cause of gynecologic cancer.  

It is almost always caused by a sexually transmitted organism human papillomavirus (HPV). Cervical cancer typically develops over the long term from abnormal precancerous (before-cancer) cells on the surface of the cervix. Once cancer develops, the cells may spread (i.e. metastasize) to other organs.

Screening tests

Pap test also known as Pap smear.

A Pap test is a simple, quick office test in which a sample of cells from a woman's cervix is collected by swabbing the surface of the cervix and spreading the cells on a microscope slide or placed in a special solution. The cells are examined under a microscope in order to look for precancerous (before-cancer) or cancer cells.

Who to test and how often

Women should have Pap tests as part of an annual pelvic examination beginning at age 21 or three years following the onset of sexual activity. The risk of cervical cancer increases sharply during the first few years following the initiation of sexual activity. Some physicians begin screening women as soon as they become sexually active, but not before. High-risk factors for cervical cancer of the cervix include:

• cigarette smoking;
• a history of genital warts or other genital infection with the human papilloma virus (HPV);
• multiple sexual partners or a partner who has multiple sexual partners;
• the onset of sexual activity at a young age.

In 2009, the American College of Obstetricians and Gynecologists (ACOG) revised its recommendations regarding Pap testing. Instead of beginning at age 18 as previously recommended, the new recommendations advise beginning Pap smears at age 21. Further changes to the ACOG guidelines are:

• women younger than 30 years of age should have a Pap test every 2 years.
• women aged 30 years of age and older should have a Pap test every 2 years. After three normal Pap test results in a row, a woman in this age group may have Pap tests every 3 years if:
  • she does not have a history of moderate or severe dysplasia;
  • she is not infected with human immunodeficiency virus (HIV);
  • her immune system is not weakened (for example, if she has had an organ transplant);
  • she was not exposed to diethylstilbestrol (DES) before birth.

As it is rare to find a pre-cancerous or cancerous lesion of the cervix in women over the age of 65 who have repeatedly had normal Pap smears, many doctors decrease the frequency of Pap screening under these circumstances.

Women who have had a hysterectomy (surgery to remove the uterus, including the cervix) do not need Paps unless they have had a cancerous or pre-cancerous lesion of the genital tract. However, they should continue to have manual pelvic and rectal examinations by their doctors as a part of their periodic medical evaluations for reasons other than cancer of the cervix.

Benefits of early detection

There has been a 70% decrease in the death rate from cervical cancer, in large part because of judicious use of the Pap test. Benefits of the Pap test include:

1. early identification and treatment of abnormal cells before they become cancerous.
2. identification of cervical cancer at an early stage, thereby allowing optimum treatment before the cancer has metastasized.

Prevention

A vaccine (Gardasil) has received U.S. FDA approval for use in young women between 9 and 26 years of age. Early vaccination will consistently protect against HPV types 6, 11, 16, and 18 unless the patient has already been infected by one of these viral types. HPV types 16 and 18 are known to be the two viral types most frequently associated with pre-cancerous and cancerous lesions of the cervix. Initial trials with the vaccine have shown that the HPV-16/18 vaccine is safe and induces a high degree of protection against HPV-16/18 infection. Gardasil is given in three injections over a six-month interval. The U.S. Centers for Disease Control and Prevention (CDC) recommends that girls 11-12 years of age receive the vaccine. It is also recommended for girls and women age 13 through 26 who have not yet been vaccinated or completed the vaccine series.

A newer vaccine (Cervarix) was approved by the FDA in October, 2009, for use in girls and young women ages 10-25 to help prevent cervical cancer. Cervarix targets two HPV strains, HPV 16 and HPV 18. A well-controlled study comparing Gardisil and Cervarix has yet to be conducted.

HIV is the virus that causes AIDS (Acquired immune deficiency syndrome). While modern anti-HIV medications have significantly improved long-term survival and quality of life of HIV infected individuals, there is still no cure or vaccine. HIV infection is still eventually lethal in everyone who is infected. Therefore, preventing the spread of HIV is the most important step in preventing illness and death due to HIV infection.

Screening tests

• Screening blood test for antibodies to HIV is called an ELISA test. Confirmatory test for antibodies to HIV is called a Western blot.
• HIV infected individuals can remain free of symptoms for many years. 
• Patients will know if they are infected ONLY if a blood test for HIV is done.
• HIV testing can be performed by a physician or at a testing center.

Who should be tested

The following individuals should be routinely offered HIV testing:

• pregnant women;
• individuals with occupational exposure to HIV (health care workers and researchers working with HIV);
• individuals with high-risk sexual behavior (multiple sexual partners, unprotected intercourse),
• drug users who practice needle-sharing;
• anyone requesting HIV testing; and
• individuals with active tuberculosis, unexplained fevers, low white blood cell counts, or who have been diagnosed with a sexually transmitted infection.

Most infected individuals will develop a positive HIV blood test within three months of being exposed to HIV. If the HIV test at three months is negative and there are risk factors for infection, the test should be repeated in another three months.

Benefits of early detection

Theoretically, early treatment with anti-HIV medications may help the body's immune system fight the virus. So far, early treatment cannot cure or eradicate the virus. Therefore, early detection is most important to prevent viral spread.

The HIV virus may be present in the blood, genital fluid, and other body secretions of virtually all infected individuals, regardless of whether or not they have symptoms. The HIV virus is spread from one person to another when these secretions come in contact with the vagina, anal area, mouth, eyes, or a break in the skin, such as from a cut, bruise, sore, or puncture by a needle. Sexual transmission of HIV has been described from men to men, men to women, women to men, and women to women through vaginal, anal, and oral sex.

Prevention of spread of HIV

• Abstinence from sex until both partners are certain that they are not infected (for example both partners test negative for HIV antibody after the last potential exposure) is paramount in preventing the spread of HIV. While most newly infected individuals test positive by two months after infection, up to 5% are still negative after six months with routine testing. If abstinence is not possible, use latex barriers such as a condom.  A dental dam (i.e. a piece of latex that prevents vaginal secretions from coming in direct contact with the mouth) can also be employed.
• For pregnant women infected with HIV, proper prenatal counseling, treatment with anti-HIV drugs after the first trimester, proper handling of the delivery process, and short-term treatment of the newborn child can substantially reduce HIV infection in the newborn.
• Avoid sharing of needles, razor blades, and toothbrushes.
• Health care workers who experience a needle stick or exposure of the eyes, mouth, or injured skin to fluids from an infected person should take anti-HIV medication in order to reduce the risk of developing a clinical infection.

Elevated LDL cholesterol or low HDL cholesterol increases the risk of developing atherosclerosis ("hardening of the arteries"). Atherosclerosis can begin to develop in adolescence and progress without any symptoms for many years. It can lead to heart attack and stroke later in life.

Hyperlipidemia is a common and treatable cause of atherosclerosis. Atherosclerosis is the most common cause of death in both men and women in developed countries. The goal is to diagnose and retard or reverse atherosclerosis while it is still in a silent early state

Screening tests

Blood lipid panel that includes:

• total cholesterol;
• LDL ("bad") cholesterol;
• HDL ("good") cholesterol; and
• triglycerides

Who to test and how often

• LDL is the part of the cholesterol panel that is most significant when deciding patient treatment, as well as determining how often lipid panels are checked.
• All adults over 20 should have a lipid panel every five years. The panel should be repeated more frequently in high-risk situations.

Benefits of early detection

There is good evidence that lowering elevated LDL cholesterol and increasing low HDL is beneficial in heart attack prevention and, in some cases, stroke prevention in subjects with or without known atherosclerosis.

Treatment of elevated LDL cholesterol is multi-dimensional. Patients should discuss their total caloric intake, total fat, saturated fat, and cholesterol intake as well as weight management and regular exercise with their doctor. Cholesterol-lowering medications represent an important part of treatment for many people with elevated blood lipid levels.

Diabetes mellitus is a condition characterized by elevated blood sugar levels ("hyperglycemia") due to impaired utilization of insulin, decreased production of insulin, or both.

Diabetes is the seventh leading cause of death in the United States. An estimated 18% of all Americans over 65 have diabetes. Over ten million Americans have been diagnosed with diabetes; and at least half as many more are thought to have undiagnosed diabetes. Many more people have a condition that precedes diabetes, referred to as prediabetes, characterized by sluggish metabolism of sugar (glucose) to a lesser degree than is present in those with diabetes.

Diabetes is the leading cause of new cases of blindness in adults aged 20-74 years, the leading cause of chronic kidney disease, and the leading cause of lower extremity amputations not related to injury. Individuals with diabetes are 2-4 times more likely to have a heart attack or stroke than are those without diabetes.

Screening tests

Tests for diabetes mellitus include:

• fasting blood sugar (blood sugar test after at least eight hours without calories), normal level less than 100 mg/dl;
• pre-diabetes is characterized by a fasting blood sugar level of 100-125 mg/dl;
• diabetes is diagnosed by a fasting glucose level greater than 126 mg/dl; and
• two-hour postprandial blood sugar (blood sugar test drawn two hours after a meal), A normal postprandial level less than 140mg/dl.

Who to test and how often

Healthy subjects over 45 years of age should have fasting blood glucose level checked every three years. Adults at a higher than normal risk of developing diabetes mellitus should be checked on a more frequent basis.

Risk factors for diabetes include:

• excessive weight;
• a first-degree blood relative with adult-onset diabetes;
• certain ethnic groups such as African-Americans, Hispanics, certain Native American, and Asians Groups;
• delivery of a baby weighing more than 9 lbs or a history of diabetes during pregnancy ("gestational diabetes");
• impaired glucose tolerance, currently or previously; and
• low HDL cholesterol (35 mg/dl or less) or elevated triglyceride level (over 250 mg/dl).

There is good evidence in diabetic patients that curtailing total caloric intake (especially intake of processed starches, sugar and sweets), regular exercise, and the loss of excess weight can help prevent the development of diabetes mellitus. Weight control will usually lead to improved metabolism of glucose, often to levels in those without impaired glucose tolerance.

There is good evidence that in diabetic patients with diabetes, pharmacological blood sugar controls, diet, weight loss, and regular exercise can slow the development of diabetic complications.

There is also strong evidence that even those with impaired glucose tolerance can significantly improve their otherwise increased risk for atherosclerotic disease (including heart attacks and stroke) with appropriate changes in diet, physical activity, and weight.

Colorectal cancer is the second most common cause of death from cancer overall and ranks third in both women (after lung and breast cancer) and men (after lung and prostate cancer).

Scientists believe that majority of the colon cancers develop from colonic polyps (precancerous growths on the inner surface of the colon). These tumors may become malignant, with the cells invading locally or spreading (metastasizing) to other parts of the body.

Colon cancer is preventable by removing colon polyps before they evolve into a cancer. Colon cancer is curable if removed before spread occurs.

Screening tests

• Stool occult blood test: Stool occult blood test is a chemical test to detect trace amounts of blood in the stool. It is inexpensive and easily performed, though not always accurate. Some cancers are not detected by this test, and many positive tests are caused by other problems besides cancer.
• Flexible sigmoidoscopy: Flexible sigmoidoscopy is a relatively quick and easy office procedure which allows direct visualization and biopsy of suspicious lesions from the distal portion of the colon. The procedure is uncomfortable, and it is less accurate than a full colonoscopy.
• Colonoscopy: Colonoscopy allows visualization of the entire colon and is the most complete and thorough test. It requires intravenous sedation, is much more expensive, and is not covered by some insurance plans as a screening procedure. Although screening colonoscopies may have a slightly higher risk of complications than flexible sigmoidoscopies, both screening tests are very safe when performed by trained professionals.

Who to test and how often

All healthy subjects should have stool occult blood tests and flexible sigmoidoscopy at age 50, followed by stool occult blood annually and flexible sigmoidoscopy every five years.

Alternatively, instead of flexible sigmoidoscopy, all healthy subjects can undergo screening colonoscopy at age 50 and then every 10 years if tests remain normal and there is no prior history of polyps or cancer.

Higher risk patients (individuals with a family history of colonic polyps or cancer, long-standing ulcerative colitis, or a prior personal history of colon polyps or cancer) require colonoscopy earlier and more frequently.

Benefits of early detection

Stool occult blood testing, flexible sigmoidoscopy, and colonoscopy have been documented to reduce colon cancer mortality by:

1. preventing colon cancer by identifying and removing polyps before they become cancerous.
2. increasing cancer cure rate by identifying early cancer at a treatable stage before the cancer has spread (metastasized).

Screening tests

• Initial  screening for bladder cancer  is carried out by determining if there is blood in the urine (hematuria). This may be done using a dipstick that is placed in the urine. If positive, the urine should be examined under the microscope.
• Alternatively, the urine may be visualized microscopically without the dipstick being used.
• Bladder cancer can cause gross hematuria (a large amount of blood in the urine), or microscopic hematuria (the blood can only be seen with the aid of a microscope).
• Bladder cancer is only one of many causes of hematuria.

(Note that bladder cancer is only one of many causes of blood in the urine.)

Who to test and how often

All people who are current or former cigarette smokers or who have a history of occupational exposure to certain chemicals such as those used in the dye, leather, tire, and rubber industries should have a urine examination for blood periodically after the age of 60 years.

Benefits of early detection

Early bladder cancer may produce no symptoms and no gross blood in the urine. However, the blood is almost always visible microscopically.

Treatment can be effective if the cancer is detected early, and survival is strongly associated with the stage of disease at the time of initiation of treatment.

Cessation of cigarette smoking is always advisable.

Glaucoma is a condition with abnormally elevated intra-ocular pressures (pressure within the eyeball).

Screening tests

• Measurement of intra-ocular pressure should be a standard component of a comprehensive eye examination.
• Note that a checkup for vision does not always measure intra-ocular pressure.
• Intra-ocular pressure should be measured by eye care specialists.

Who to test and how often

The American Academy of Ophthalmology's recommended intervals for eye exams, including glaucoma screening, are:

• Have an eye examination every three to five years. Others should have an eye exam at least once during this period.
• Age 20-29: Individuals of African descent or a family history of glaucoma should have two screenings during this period.
• Age 30-39: Individuals of African descent or with a family history of glaucoma. 
• Age 40-64: Every two to four years.
• Age 65 or older: Every one to two years.

Although there is no formal screening recommendation for healthy subjects with normal risk, everyone over 60 years of age should have periodic intra-ocular pressure measurements periodically, perhaps yearly.

Benefits of early detection

Glaucoma can cause extensive damage of the retina, as well as irreversible loss of vision without warning symptoms and before the individual becomes aware of a loss of vision.

There is good evidence that treatment of elevated eye pressure from glaucoma can prevent blindness.

Melanoma is the most serious form of skin cancer.

Who to test and how often

The American Cancer Society recommends a skin check every three years between the ages of 20 and 40, and a skin check annually over age 40.

Adults with higher than normal risk for melanoma should be particularly vigilant if they have:

• a family history of melanoma;
• are middle-aged adults with frequent sun exposure;
• a history of serious or frequent sunburn. Childhood sunburn is particularly risky;
• more than 50 moles; and
• fair skin.

See a doctor if the mole has the following characteristics:

• a diameter more than 6mm;
• asymmetric, meaning an uneven shape;
• an irregular border; and
• a variable color pattern, usually blue or black.

Benefits of early detection

Skin cancer is the most common cancer. Even though the benefit of skin cancer screening is uncertain (so far, research has not shown that death from skin cancer can be decreased following the institution of a regular screening program is instituted), early treatment of skin cancer can be effective. Melanomas may be detected at an earlier stage with regular skin exams. Thinner melanomas are more successfully treated than are thick ones that have grown downward into the deeper portions of the skin.

Previous contributing author and editor: Daniel L. Gornel, MD, MPH and Dennis Lee, MD