Women's Disease Prevention

Preconception counseling

Since women do not typically schedule a discussion with their physicians prior to conception, it is important to try to counsel all women capable of becoming pregnant of a few important preconception topics that will help lower the patient's risk of complications.

  • All women capable of becoming pregnant should be on prenatal vitamins or assure enough folic acid consumption (400 mcg/day) at least one month before conception to reduce the risk of neural tube defects such as spina bifida.
  • Women with chronic diseases planning pregnancy should have their diseases be well-controlled prior to conception. Discuss chronic diseases EARLY.
  • Potentially harmful chronic medications should be changed prior to conception.
  • Healthy lifestyle (especially weight) should be encouraged prior to conception.
  • Risk for potential genetic diseases should be obtained via good family history.
  • Assure varicella and rubella immunity (immunization contraindicated if already pregnant!)

Alcohol misuse

  • Definition of "misuse": >7 drinks per week or more than 3 drinks on one occasion for women
  • Use AUDIT or CAGE to screen
  • A 15-minute counseling session can be helpful if positive screen.

Immunizations

  • Tetanus every 10 years
  • Influenza every year
  • Pneumococcal at age 65 or earlier if chronic disease or institutionalized
  • Hepatitis B (for all young adults not immunized and high-risk middle-aged women)
  • Varicella if no history of infection
  • MMR: women born after 1956 should get primary series and booster if they didn't get the second dose.
  • (Note: varicella and MMR contraindicated in pregnancy! Give when patient is menstruating and ensure contraception afterwards.)
  • Pertussis booster if not already given
  • Gardasil series before sexual activity preferred, but should offer to all females up to age 26.

Smoking

  • USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A recommendation)
  • Addresstobacco useat each visit.
  • When ready, set date, give pharmacologic therapy, and follow-up.
  • Counseling alone effective 10% of the time; pharmacotherapy increases additional 5%-10%; when combined, one year quit rates 38%.
  • For more information on smoking cessation, including an updated clinical practice guideline, please follow this link: .

Exercise

  • 30 minutes moderate intensity aerobic exercise on most if not all days of the week should be encouraged.
  • Written prescriptions can be effective.

Seat belt use

  • Recommended to be addressed in all adults by USPSTF

Depression

  • Screening for depression is a B recommendation
  • Screening can be done by adding two questionsto routine interviewing of all adults patients: Over the past 2 weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things?
  • If positive, then follow with written or oral depression screening.

Violence

  • Lifetime prevalence of domestic violence between spouses 36-40%!
  • There is no typical profile for women who are abused.
  • Witnessing or experiencing violence as a child may be risk factors for becoming abused.
  • Approach to screening:

In my practice, I am concerned about abuse prevention and personal safety, especially in the family. Are you in a relationship where you are afraid for your personal safety, or where someone is threatening you, hurting you, forcing you to have sex, or trying to control your life?
As an adult, has anyone ever forced you to have sex when you did not want to?
When you were young, did anyone ever hurt or hit you or force you to have sex?

Aspirin

  • Consider low dose aspirin in patients with moderate to high risk of cardiac events (A recommendation).
  • Potential harms exist. For more information, go to the Women's Health Trials Module and review the discussion of the Women's Health Study.

Weight (BMI)

  • USPSTF recommends screening all adults for obesity and offering intensive counseling and behavioral interventions to promote sustained weight loss for obese adults (B recommendation)
  • Overweight: BMI>25
  • Obese: BMI>30
  • Intensive counseling: more than one person-to-person session per month for at least the first 3 months of the intervention
  • Reduce saturated fat intake to less than 7% of total calories
  • 60 minutes of daily exercise if trying to lose weight

Osteoporosis Screening

  • Start at age 65 with a Bone Mineral Density test (usually DXA) in all women (per USPSTF and NOF)
  • Start earlier if risk factors (history of fracture as an adult, history of fragility fracture in first degree relative, low body weight <127 pounds, smoker, current or previous use of oral corticosteroid therapy for >3 months)

Chlamydia

  • USPSTF strongly recommends clinicians screen all sexually active women 25 and younger, and other asymptomatic women at increased risk for infection

Lipids

  • Adult Treatment Panel III (ATP III) of National Cholesterol Education Panel (NCEP) recommends starting at age 20 with fasting lipid profile, primarily looking at LDL cholesterol, and setting LDL goal based on cardiac risk factors and Framingham risk stratification; if unremarkable, repeat every 5 years
  • USPSTF recommends screening men at 35 and women at 45 with a (non-fasting) total cholesterol and HDL (start at 20 if CAD risk factors) and insufficient evidence to recommend triglyceride screening.

Diabetes Type II

  • American Diabetes Association recommends screening every 3 years starting at 45 with a fasting plasma glucose, earlier and more frequently in overweight and those with diabetes risk factors.
  • USPSTF concluded that evidence insufficient to recommend for or against routinely screening, but do recommend screening adults with hypertension or hyperlipidemia and to be alert to symptoms of diabetes such as polydipsia and polyuria and to test if present.

References:

The Guide to Clinical Preventive Services: Recommendations of the USPreventive Services Task Force. AHRQ, 2006.

Bostock DJ, Auster S, Bradshaw RD, et al. Family Violence. Monograph, EditionNo. 274, Home Study Self-Assessment program. Leawood, Kan: AmericanAcademy of Family Physicians, March 2002.

Choby BA. Midlife Care of Women. Monograph, Edition No. 278, Home StudySelf-Assessment program. Leawood, Kan: American Academy of Family Physicians, July 2002.

Tyler CV Jr, Messinger-Rapport BJ. Well Older Adult. Monograph, Edition No.280, Home Study Self-Assessment program. Leawood, Kan: AmericanAcademy of Family Physicians, September 2002.

Stephens MB, O’Connor FG, Deuster PA. Exercise and Nutrition. Monograph,Edition No. 283, AAFP Home Study. Leawood, Kan: American Academy ofFamily Physicians, December 2002.

Berg AO. Adult Prevention. FP Essentials, Edition No. 308, AAFP HomeStudy. Leawood, Kan: American Academy of Family Physicians, January 2005.

Stendardo Stef, Berg Alfred, Kamerow Douglas. AmericanAcademy of FamilyPhysicians: Tertiary Prevention in Diabetes, CAD and Stroke: A Case-basedApproach. 2003.

Guzman Susanna. AmericanAcademy of Family Physicians: Practical Advicefor Family Physicians to Help Overweight Patients. 2003.

Underbakke Gail, McBride Patrick. CME Bulletin: Metabolic Syndrome Part II: Addressing the Metabolic Syndrome in Primary Care. Vol. 4. No. 2. Leawood,Kan. 2005.

AAFP Policy Action November 1996, Revision 5.7, April 2007. Order No. 968

Seventh Report of the Joint National Committee of Prevention, Detection,Evaluation, and Treatment of High Blood Pressure (JNC7). NIH Publication No.03-5231. May 2003.

Mosca, L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004;109:672-93.