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Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier


Many of the conditions that cause the greatest morbidity and mortality in women can be prevented or delayed by the early recognition and treatment of risk factors and the identification of individuals who might benefit the most from early intervention. The U.S. Preventive Services Task Force (USPSTF) publishes primary preventive guidelines that can assist clinicians in providing care to women. The recommendations are conservative and represent the minimum level of preventive services that should be offered.

On the basis of recommendation from the USPSTF, all women should have periodic blood pressure evaluation, height and weight measurements, and screening for obesity and depression. Cervical cancer screening with Pap smears is recommended in sexually active women. Although guidelines about when to start or to stop Pap smear screening and the optimal screening interval in low-risk women differ among policymaking organizations, the USPSTF recommends initiation of screening 3 years after sexual activity begins or at the age of 21 years, whichever occurs first, and screening of low-risk women at least every 3 years after two or three annual normal Pap smears. Routine screening is not recommended in low-risk women after the age of 65 years if they have had adequate recent screening or in women who have had a total hysterectomy for benign reasons. Newer screening methods using liquid-based cytology offer advantages over conventional Pap smears, such as the option of reflex HPV testing, but are more expensive. Until more information is available from trials assessing the role of HPV testing in cervical cancer screening, the USPSTF’s position is that the evidence is insufficient at this time to recommend the use of this new technology over the routine Pap smear. Prophylactic vaccines shown in clinical trials to be highly effective against HPV infection are now available for widespread immunization; guidelines for their use are being developed. [10] [11] Sexually active women younger than 25 years should be screened routinely for chlamydia; screening for chlamydia, gonorrhea, syphilis, and HIV infection should be done in any woman with risk factors for these diseases.

Breast cancer screening with mammography, with or without clinical breast examination, is recommended every 1 to 2 years starting at the age of 40 years, although women aged 50 to 65 years and those at increased risk for breast cancer benefit the most. Clinicians should discuss the risks and benefits of breast cancer chemoprophylaxis in high-risk women. Routine screening for ovarian cancer is not recommended.

Cholesterol screening is recommended every 5 years in women starting at the age of 45 years; those with hypertension or hyperlipidemia should be screened further for diabetes. As in men, colorectal screening is recommended beginning at the age of 50 years. Routine screening for osteoporosis in women is recommended starting at the age of 65 years; however, many younger women have conditions that put them at increased risk for osteoporotic fractures. In these women, screening is recommended starting at the age of 60 years. Periodic vision and hearing screening is recommended in both women and men after the age of 65 years.

On the basis of findings from studies that were conducted primarily in men, the USPSTF currently recommends that clinicians discuss the use of aspirin for the primary prevention of coronary heart disease with postmenopausal women and younger women with risk factors for coronary heart disease. However, results from the first randomized trial that assessed the risks and benefits of aspirin as chemoprevention for coronary heart disease in women found a beneficial effect only in women aged 65 years or older.[12] In younger women, aspirin reduced the risk of thromboembolic stroke but had little effect on coronary heart disease, findings opposite to those described in men. Similar to its use in men, the use of aspirin in older women was associated with an increased risk of hemorrhagic stroke and major gastrointestinal hemorrhage. Until more information is available about aspirin’s effects in women, discussions about its use should be individualized for each patient.

The USPSTF recommends counseling women of childbearing age about folic acid supplementation to reduce the risk of neural tube defects and women of all ages about adequate calcium and vitamin D intake. All women should be counseled about tobacco and other substance use, strategies to decrease the transmission of sexually transmitted diseases, effective methods of contraception, healthy diet and increased physical activity, and injury prevention, with a focus in older individuals on falls and the potential dangers of multiple medication use.

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