FMcases- 45 yo female well woman exam

Characteristics of a Good Screening Test?

1. Accuracy (high sensitivity and specificity) Sensitivity Measures proportion of actual positives that are correctly identified as such (e.g., percentage of sick people identified as having the condition). The more sensitive the test the fewer false negative results. Specificity Measures the proportion of negatives that are correctly identified as such (e.g., percentage of well people identified as not having the condition). The more specific the test the fewer false positives. 2. Able to detect disease in an asymptomatic phase 3. Minimal associated risk 4. Reasonable cost 5. Acceptable to patient 6. Have an available treatment for the disease

The Bethesda System for Reporting Cervical Cytology Using this system of reporting, cervical cytology pathology results are given in three categories:

1. Specimen adequacy In order to be 'adequate', the Pap smear must contain over 5,000 squamous cells and have sufficient endocervical cells. (Endocervical cells are columnar epithelial cells found just proximal to the squamo-columnar junction, the site of beginning dysplastic changes.) If they are present, it shows that you have sampled the transformation zone, and therefore the specimen is 'adequate'. 2. General categorization of results Is there any evidence of intraepithelial lesion or malignancy? 3. Interpretation of results Either the Pap is negative for intraepithelial lesion or malignancy, or there is evidence of epithelial abnormalities. Epithelial abnormalities are further divided into four categories. Atypical squamous cells (ASC): Some abnormal cells are seen. These cells may be caused by an infection or irritation or may be precancerous. Low-grade squamous intraepithelial lesion (LSIL). LSIL may progress to a high-grade lesion but most regress. High-grade squamous intraepithelial lesion (HSIL). This is considered a significant precancerous lesion. Squamous cell carcinoma.

Performing a breast exam?

A good breast exam consists of both visual inspection and palpation. Visual inspection: With patient sitting upright on the exam table, have her lower her gown to her waist so the breasts can be fully visualized. Look for symmetry in shape and assess skin changes, including any erythema, retractions, dimpling, or nipple changes Ask the patient to lift her hands overhead to accentuate any retraction or dimpling. Palpation: For the palpation portion of the exam, ask patient to lie back on the exam table and place her hands over her head, thus flattening the breast tissue on the chest wall. Carefully examine each breast using a vertical strip pattern. When palpating, use the finger pads of the middle three fingers and varied pressure (light, medium, and deep) as you complete your exam. Finally, palpate both axillary and supraclavicular lymph nodes.

Familial Breast Cancer Risk?

A patient has an increased risk of breast cancer if a first-degree relative has had breast cancer. (A first-degree relative is a parent or a sibling.)

Diabetes risk factors:

Age ≥ 45 years Overweight (body mass index ≥ 25 kg/m2) Family history diabetes mellitus in a first-degree relative Habitual physical inactivity Belonging to a high-risk ethnic or racial group (e.g., African-American, Hispanic, Native American, Asian-American, and Pacific Islanders) History of delivering a baby weighing > 4.1 kg (9 lb) or of gestational diabetes mellitus Hypertension (blood pressure ≥ 140/90 mmHg) Dyslipidemia defined as a serum high-density lipoprotein cholesterol concentration ≤35 mg/dL and/or a serum triglyceride concentration ≥250 mg/dL Previously identified impaired glucose tolerance or impaired fasting glucose Polycystic ovary syndrome History of vascular disease

Recommendations for Breast Cancer Screening Mammography American Cancer Society US Preventive Services Task Force

American Cancer Society Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be considered. Women age 45 to 54 should get mammograms every year. Women age 55 and older should switch to mammograms every 2 years, or have the choice to continue yearly screening US Preventive Services Task Force Biennial screening mammography for women aged 50-74 years (Grade B recommendation) 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 ( Grade C recommendation) Most guidelines do not recommend routine mammography for women younger than 40 years unless they fall into a high risk category such as women with a known BRCA mutation.

Lung Cancer Screening Recommendations

As of 2013, the USPSTF recommends annual screening with a low-dose CT scan to screen for lung cancer in patients aged 55-80 years old who have smoked for 30 pack years. To be considered, the patient should also be currently smoking or have quit within the prior 15 years.

Recommendations for Osteoporosis Prevention

Before menopause, estrogen offers some protection against heart disease and osteoporosis. This protection is lost when estrogen levels ebb with menopause. Calcium Intake For bone health, it is recommended that premenopausal women need approximately 1000 mg of calcium daily while postmenopausal women need 1200 mg of calcium daily. Only a small amount of calcium is found in a normal diet if we exclude dairy products. To meet these needs, three or four servings of dairy products are required. For instance, eight ounces of yogurt (228 gm) or milk (1 cup= 236 ml), or 1.5 ounces of cheese can provide around 300 mg of calcium. Most individuals do not ingest adequate amount of dairy products. How to meet these needs is controversial. Calcium supplementation for osteoporotic fracture prevention has raised concerns that it may increase the risk of atherosclerotic vascular disease as well as for kidney stones. However, it is unclear from the present data whether intake of dietary calcium versus calcium supplementation increases cardiovascular risk or the risk for kidney stones. A USPSTF 2013 recommendation statement concluded that current evidence is insufficient to assess the risks and benefits of calcium and vitamin D supplementation for prevention of fractures in premenopausal and noninstitutionalized postmenopausal women. Therefore the USPSTF is currently recommending against calcium and vitamin D supplementation in healthy pre or post menopausal women. At this time the most prudent recommendation would be to try to increase intake of dairy and try to include weight bearing exercises such as walking into a daily routine.

Breast Cancer Screening Studies- Mammography

Benefits Mammography is a good screening test that can detect asymptomatic early stage disease, and there is good evidence that mammography decreases breast cancer mortality. Risks As with any other screening test, there is a potential for false positive results (leading to unnecessary procedures) or false negative results (giving patients a false sense of security). The sensitivity of mammography is between 60% and 90%. Low sensitivity means more false negative results. False negative results are more common in younger women since denser breast tissue makes it harder to find abnormalities on x-rays. Mammography is a radiograph which involves some radiation exposure. However, modern mammography systems use extremely low levels of radiation, usually about 0.1 to 0.2 rad per x-ray, which is minimal and provides negligible risk. Also, mammograms can be uncomfortable for patients.

Body Mass Index (BMI)

Body mass index (BMI) is an estimate of body fat. Individuals with elevated BMI are at greater risk of developing several diseases, including: High blood pressure Coronary artery disease Stroke Osteoarthritis Some cancers, and Type 2 diabetes Older age, a sedentary lifestyle, and smoking cigarettes increase the risk of developing these diseases even more.

Breast Self-Exam and Clinical Breast Exam - Effectiveness & Recommendations?

Clinical Guidelines - The USPSTF does not recommend BSEs. Similarly, the USPSTF concludes there is insufficient evidence to assess the additional benefits and harms of CBE beyond screening mammography in women 40 years or older. While ACS recommends that clinical breast exam (CBE) should be part of a periodic health exam, about every three years for women in their 20s and 30s and every year for women 40 and over.

Breast Cancer Epidemiology & Screening Via Mammography

Epidemiology One in eight women will have breast cancer before they are 80 years old. The risk of developing breast cancer is related to age. Screening The earlier breast cancer is detected, the higher the chances of successful treatment and a cure. Mammography can help find cancer one or two years before breast cancer may be felt by breast self exam. Guidelines regarding breast cancer screening differ, and for women between the ages of 40 to 50 with average risk, the decision should be individualized. Mammograms are very safe. Method: To obtain a mammogram (an x-ray image of the breasts), each one is separately pressed between two plates. Breast compression allows the radiologic technologist to take an image of all the breast tissue. It also holds the breast still and allows use of a lower dose of x-ray. It may be uncomfortable while the breast is being pressed between the plates, but compression lasts only a few seconds. Patients may want to schedule their mammogram for the time when their breasts are least likely to be tender (usually about a week after completing a period).

Evaluating a Breast Lump

First take a good history from the patient, including: Precise location of the lump How it was first noticed (accidentally, by breast self-examination, clinical breast examination, or mammogram) How long it has been present Presence of nipple discharge, and Any change in size of the lump (especially ask whether the lump changes in size according to phase of the menstrual cycle) The next step is a thorough breast exam: Certain characteristics on physical exam increase the suspicion of malignancy. For example, the presence of a single, hard, immobile lesion of approximately 2 cm or larger with irregular borders increases the likelihood of malignancy. Diagnostic tests: If it feels cystic, aspiration can be attempted and the fluid sent for cytology. Fine needle aspiration is a procedure family physicians can do in the office. If it feels solid, mammography is the next step. Ultrasound can be helpful in distinguishing a solid mass from a cystic lesion. Follow-up: If the work-up suggests that the lesion is benign (which the vast majority are), close follow-up with regular breast exams and mammography is indicated.

Obtaining a Pap Test The sample is obtained using an extended tip spatula and then a cytobrush.

First, the spatula is rotated several times to obtain a sample from the ectocervix. Then the cytobrush is then inserted into the os and rotated 180 degrees. Care is taken to make sure that the squamo-columnar junction (the area of the endocervix where there is rapid cell division and where dysplastic cells originate) is adequately sampled. The sample is then placed into a liquid medium. Using the liquid-based system over the conventional Pap smear technology allows for later testing of the sample for the presence of human papilloma virus (HPV) if the Pap comes back abnormal. Currently two liquid-based systems are approved by the FDA. You should check with your lab to find out which system is preferred. Once the sample is obtained, let the patient know the speculum is about to be withdrawn. Then, withdraw the speculum slightly to clear the cervix, loosenss the speculum and allows the "bills" to fall together, and continue to withdraw while rotating the speculum to 45 degrees.

Recommendations for Osteoporosis Screening

For women > 65 years old, screening with dual energy x-ray absorptiometry (DEXA) is recommended. For women < 65 years old, the USPSTF recommends using the WHO's Fracture Risk Assessment Tool to risk-stratify. Screening with DEXA is recommended if the risk of fracture is greater than or equal to that of a 65-year-old white woman without additional risk factors (9.3 percent over 10 years).

Recommendations for Immunization Against HPV There are three vaccines that effectively protect women against the viruses that cause approximately 75% of cervical cancers:

Gardasil Cervarix Gardasil 9 quadravalent recombinant DNA vaccine (HPV4) bivalent vaccine (HPV2) HPV serotypes protected against 6,11 (cause genital warts) 16 and 18 (cause most cervical cancers) 16 and 18 (cause most cervical cancers) 31 and 45 6, 11 (anogenital), 16, 18 (most cervical cancer), 31, 33, 45, 52, 58 (~15% cervical cancer) Licensed for females & males ages 9-26 yrs females 9-25 yrs females & males ages 9-26 yrs Number of doses 3 3 3 Timing recommendation before sexual debut or shortly thereafter before sexual debut or shortly thereafter before sexual debut or shortly thereafter

Other perimenopausal symptoms due to estrogen deficiency include:

Hot flashes: Hot flashes are brief feelings of heat that may make the face and neck flushed and cause temporary red blotches to appear on the chest, back, and arms. Sweating and chills may follow. Hot flashes vary in intensity and typically last between 30 seconds and ten minutes. Dressing in light layers, using a fan, getting regular exercise, avoiding spicy foods and heat, and managing stress may help. Vaginal dryness: This can make intercourse uncomfortable. A water-soluble lubricant may be recommended. A woman's libido may also change. Mood swings: Mood swings, especially depression, are common during perimenopause and menopause. Women should let their provider know if they are experiencing this, so that resources and support may be found.

Cervical Cancer Screening Guidelines cont.

However, they stipulate that certain risk groups need to have more frequent screening. They include women with compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or have been exposed to diethylstilbestrol (DES) in utero (DES is a nonsteroidal estrogen that was given to pregnant women to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and was discontinued in 1971). Women older than 65 years who have had adequate screening within the last ten years may choose to stop cervical cancer screening. Adequate screening is three consecutive normal pap tests with cytology alone or two normal pap tests if combined with HPV testing. Women who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.

Cervical Cancer Screening Guidelines

In 2012, the American College of Obstetrics and Gynecology (ACOG), the American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP) and USPSTF came to a consensus on cervical cancer screening. The guidelines recommend that: At 21 years of age -- cervical cancer screening should begin. Between the ages of 21-29 years -- screening should be performed every three years. Between the ages of 30-65 years -- screening can be done every five years if co-tested for HPV (preferred) or ever three years with cytology alone (acceptable).

Two Methods of Obtaining Cytological Specimens?

In a conventional Pap smear, cells are obtained from the ectocervix by using an Ayers spatula and the endocervix by using a cytobrush. The specimen is then rolled (cytobrush) and smeared (spatula) onto a slide and then rapidly fixed to prevent air-drying. A single slide is used for both the ectocervical and endocervical samples. In the newer liquid-based systems, the sample is collected in a similar fashion, except an extended tipped plastic spatula is recommended along with the cytobrush. The sample is obtained using the broom-like device alone or both the extended tip spatula and then a cytobrush. The samples are then quickly placed into an alcohol based preservative solution. There are currently two liquid based systems approved by the FDA; the ThinPrep system and the Sure Path system. Both liquid based systems appear to be as good as, or better than, conventional technology in diagnosing intraepithelial lesions and for obtaining adequate specimens. The liquid-based technology has the advantage of being able to co-test for HPV.

Risk Factors for Breast Cancer Understanding modifiable and non-modifiable factors that increase or decrease breast cancer risk allows physicians to counsel women appropriately.

Non-modifiable risk factors include: Family history of breast cancer in a first-degree relative (i.e., mother or sister), Prolonged exposure to estrogen, including menarche before age 12 or menopause after age 45, Genetic predisposition (BRCA 1 or 2 mutation), Advanced age (The incidence of breast cancer is significantly greater in postmenopausal women, and age is often the only known risk factor.), Female sex, Increased breast density Other hormonal risk factors include: Advanced age at first pregnancy, Exposure to diethylstilbestrol, Hormone therapy Environmental factors include: Therapeutic radiation, Obesity Factors associated with decreased breast cancer rates include: Pregnancy at an early age, Late menarche, Early menopause, High parity, Use of some medications, such as selective estrogen receptor modulators and, possibly, nonsteroidal anti-inflammatory agents and aspirin. No convincing evidence supports the use of dietary interventions for the prevention of breast cancer, with the exception of limiting alcohol intake. And interestingly, most studies do not show that smoking increases the risk of breast cancer.

Breast Cancer Screening Studies- Breast US

Not recommended for screening purposes. This tool is used for evaluation of suspected abnormalities.

Breast Cancer Screening Studies- Breast MRI

Not recommended for screening the general population of asymptomatic, average-risk women. May be indicated in the surveillance of women with more than a 20% lifetime risk of breast cancer (for example, individuals with genetic predisposition to breast cancer by either gene testing or family pedigree, or individuals with a history of mantle radiation for Hodgkin's disease). May be used as a diagnostic tool to identify more completely the extent of disease in patients with a recent breast cancer diagnosis. Contrast-enhanced breast MRI may be indicated in the evaluation of patients with breast augmentation in whom mammography is difficult.

Shared Decision-Making in the Setting of Conflicting Guidelines

Part of a physician's job is to help patients make informed decisions that incorporate their personal and family history/risk factors and personal health beliefs. Physicians need to be aware of the different guidelines. It is important to present the pros and cons of different recommendations and guide patients in a shared decision-making process. In situations where there are differences in recommendations, it is important to get the patient's input.

Physical Activity and Weight Loss

Physical activity has been shown to benefit a variety of common disease including obesity, diabetes, hypertension, and depression. For adults to achieve "substantial health benefits", the 2015-2020 Dietary Guidelines recommend getting 150 minutes of moderate-intensity exercise, 75 minutes of vigorous intensity exercise, or a combination of both per week. For more 'extensive' benefits, double that amount is recommended. At least 2 days a week, strengthening exercises involving all muscle groups should be incorporated into exercise. Lifestyle modifications (e.g., taking the stairs instead of the elevator or walking short distances instead of driving) seem to be easier to adhere to than more structured activities such as going to a fitness class. Encouraging patients to participate in physical activities they enjoy may help to increase exercise. Having an exercise partner or including family is another way to stay motivated and increase physical activity.

Evaluation of Nipple Discharge Reasons for nipple discharge may be physiologic or pathologic:

Physiologic Pathologic Pregnancy Prolactinoma Excessive breast stimulation Breast Cancer -Intraductal papilloma -Mammary duct ectasia -Paget's disease of the breast -Ductal carcinoma in situ Hormone imbalance Injury or trauma to breast Breast abscess Use of medications use (e.g., antidepressants, antipsychotics, some antihypertensives and opiates) A comprehensive history and breast exam are necessary to evaluate the discharge. For example, it is important to know if the discharge appears milky, purulent or bloody. Palpate nipples and check for any discharge. If a discharge is present, the patient needs further evaluation by imaging studies: Mammogram Ultrasound Ductogram, and/or Biopsy Consider hormonal testing to exclude endocrinological reasons. If discharge is milky, check the prolactin level. Review and discontinue any medications that may be the cause.

Stages of Change

Pre-contemplation Stage patients do not even consider changing. For example, smokers who are "in denial" may not see that the advice applies to them personally or patients with high cholesterol levels may feel "immune" to the health problems that strike others. Contemplation Stage patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain. During this stage, patients assess barriers (e.g., time, expense, hassle, fear, "I know I need to, doc, but ...") as well as the benefits of change. Preparation Stage patients prepare to make a specific change. They may experiment with small changes as their determination to change increases. For example, sampling low-fat foods may be an experimentation with or a move toward greater dietary modification. Action Stage At this point patients take definite action to change. Maintenance Stage This is the stage of continued commitment to sustaining new behavior. Physician should plan for follow up support and also discuss coping with relapse. Relapse Resumption of old behavior. Trigger for relapse should be evaluated. Motivation and barriers need to be reassessed and stronger coping strategies developed.

Performing a Pelvic Exam

Preparation First, elevate the head of the exam table to 30 to 45 degrees and assist the patient in placing her heels in the stirrups, adjusting the angle and length as needed. Carefully cover the patient's abdomen and legs down to her knees with a sheet. Ask patient to slide down to the edge of the table and relax her knees outward just beyond the angle of the stirrups. External inspection and palpation Look for any redness, swelling, lesions or masses. Inspect the labia, the folds between them, and the clitoris, paying attention to any redness, swelling, lesions, or discharge. Gently palpate the labia majora and minora.

Osteoporosis Risk Factors

Risk factors for osteoporosis are mainly due to low estrogen states. Low estrogen states may be caused by early menopause (i.e., before age 45 years), prolonged premenopausal amenorrhea, and low weight and body mass index. Lack of physical activity and inadequate calcium intake (which could be attributable to poor nutrition or alcoholism) are also associated with osteoporosis. Other risk factors include: Family history of osteoporotic fracture Personal history of previous fracture as an adult Dementia Cigarette smoking White race Obesity (BMI >30) is associated with a high estrogen level and can be protective against menopausal symptoms and osteoporosis.

Performing a Bimanual Exam

Screening for ovarian cancer with a bimanual exam is not recommended, however this is the technique you would use should you need to do the exam for a symptomatic patient. First, explain to your patient what you are going to do. Next, apply lubricant (e.g., K-Y jelly) to the index and middle fingers of your non-dominant gloved hand and insert them into the patient's vagina. Palpate the cervix to ensure that it is non-tender and mobile. Place your non-gloved hand on the abdomen just superior to the symphysis pubis, feeling for the uterus between your two hands (see the picture). This gives you an idea of its size and position. Then, moving your pelvic hand to each lateral fornix, try to capture each ovary between your abdominal and pelvic hands. The ovaries are usually palpable in slender, relaxed women, but are difficult or impossible to feel in obese women.

Diabetes Screening

Screening recommendations for diabetes vary between the American diabetic Association (ADA) and United States Preventive Services Task Force (USPSTF). The two organizations differ between whether to screen the entire population or certain "high risk" groups. The ADA recommends testing for diabetes in all adults with BMI equal or greater than 25 kg/m2 and one or more additional risk factors (see below). In individuals without risk factors, testing should begin at age 45 years. The United States Preventive Services Task Force concluded that there was insufficient evidence to recommend for or against screening for diabetes in asymptomatic adults. This conclusion was based primarily on the lack of evidence that earlier detection of diabetes improves long-term outcomes. However, the task force found that there was moderate evidence for and recommended screening in adults with hypertension (blood pressure >135/80 mmHg) as part of an integrated approach to reduce cardiovascular risk. The USPSTF clinical practice guideline for screening for type 2 diabetes mellitus in adults, as well as other USPSTF guidelines, can be accessed through the website for the Agency for Healthcare Research and Quality

Screening and Dx of DM II

Screening tests for type 2 diabetes include measurement of fasting plasma glucose (FPG), two-hour plasma glucose during an oral glucose tolerance test (2-h OGTT), or glycosylated hemoglobin (HBA1C). The ADA has recently revised their guidelines and included the use of HBA1C as a diagnostic test. ADA recommended a cut point for HBA1C level of 6.5 % or greater to diagnose diabetes. The diagnosis should be confirmed with a repeat A1C. HBA1C within range of 5.7% -6.4 % has been included as a category of increased risk for future diabetes. A diagnosis of diabetes is made if HBA1C is greater than or equal to 6.5%, or two fasting plasma glucose values over 125 mg/dl, two-hour plasma glucose values over 200 mg/dL during an oral glucose tolerance test, or a random glucose greater than or equal to 200 mg/dL with symptoms of diabetes.

Smoking Cessation Strategies

Setting a quit date Using nicotine replacement Joining a support group Calling 1-800-QUIT-NOW Choosing an activity to substitute for smoking (e.g., taking a walk or chewing sugarless gum when the urge to smoke occurs) Making a list of the reasons why it is important to quit smoking and keeping it handy to refer to Keeping track of where, when, and why you smoke (helps identify smoking triggers to avoid) Throwing away all tobacco and smoking paraphernalia (i.e., ashtrays, lighters, anything else associated with the smoking habit) Medication

Hormone Therapy

Some women take hormone therapy (HT) to relieve menopausal symptoms. HT may also protect against osteoporosis. Estrogen and progestin are the two hormone supplements most often used in HT. Taking estrogen without progestin to balance the hormonal cycle may cause over-stimulation of the endometrial tissue. This may lead to uncontrolled tissue growth called hyperplasia, which may lead to endometrial cancer. Progestin counteracts this risk. Therefore, women who have intact uterus are usually prescribed estrogen and progestin together. Estrogen has been found to be most effective at treating vasomotor symptoms such as hot flashes and is FDA approved for this use. Estrogen therapy may be administered through oral, transdermal, or vaginal routes. HT also has risks. It can increase the risk of breast cancer, heart disease, blood clots and stroke.

Performing a Pelvic Exam cont.

Speculum exam Use a warm and lubricated speculum for the examination. (There is some controversy about whether gel-based lubricants distort cytologic assessment. For this reason, the speculum is lubricated with warm tap water or a thin layer of gel lubricant, avoiding the tip of the speculum. You should know what is recommended by the laboratory in your area.) Inform the patient that you are about to begin the speculum exam. Expose the introitus by spreading the labia from below using the index and middle fingers of the non-dominant hand (peace sign). Insert the speculum at a 45-degree angle, pointing slightly downward being careful to avoid contact with the anterior structures. Once past the introitus, rotate the speculum to a horizontal position and continue insertion until the handle is almost flush with the perineum. Open the "bills" of the speculum 2 or 3 cm using the thumb lever until the cervix can be visualized between the bills.

Immunization: Tdap

Tetanus, diptheria, and acellular pertussis (Tdap) should replace a single dose of Td for adults age 19 through 64 years who have not received a dose of Tdap previously.

Pap Test Exemplifies the Characteristics of a Good Screening Test

The Pap test fits into the definition of a good screening test because the test is relatively inexpensive, easy to perform, and is acceptable to patients. Cervical cancer has a long asymptomatic pre-invasive state (often a good decade or more), and there are effective treatments for pre-invasive disease. Although the Pap test has a sensitivity of only between 30-80% and a specificity of 86-100%, cancer deaths from cervical cancer decreased markedly in the U.S. after the Pap test was introduced.

Interpretation of Pap Test Results

The Pap test generally shows one of the following: normal results low grade squamous epithelial cells (LSIL) high grade squamous epithelial cells (HSIL) atypical glandular cells of undetermined significance (AGUS), or atypical squamous cells of undetermined significance (ASC-US). ASC-US is considered an inconclusive pap test result that requires follow-up testing to determine appropriate patient management. An ASC-US Pap test result is often triaged by HPV testing when using liquid-based cytology. "Reflex HPV testing" is easily performed as a follow-up test by utilizing residual cells from the liquid-based Pap test vial to test for the presence or absence of high-risk HPV.

Ovarian Cancer Screening Recommendations

The USPSTF, the American College of Obstetricians and Gynecologists, and the American College of Physicians all recommend against routine screening for ovarian cancer in asymptomatic women.

Body Mass Index Classification System for Adults?

The WHO has formulated an index for defining obesity. body mass index (BMI), is based on the patient's height in meters and weight in kilograms: BMI = weight in kilograms / (height in meters)2. This classification works for all patients except those at the extremes of height or muscle mass, where body proportions affect the calculation. The International Obesity Task Force has further stratified obese patients into three different classes (see table below). Classification of Overweight and Obesity in Adults Classification BMI (kg per m2) Risk of comorbidities Underweight < 18.5 Low Normal range 18.5 to 24.9 Average Overweight 25.0 to 29.9 Mildly increased Obese > 30.0 Class I 30.0 to 34.9 Moderate Class II 35.0 to 39.9 Severe Class III > 40.0 Very Severe Class III overweight is also commonly referred to as morbid obesity. Waist circumference is also important to consider. In adults with a BMI of 25 to 34.9 kg/m2, a waist circumference greater than 102 cm (40 in) for men and 88cm (35 in) for women, is associated with a greater risk of hypertension, type 2 diabetes, and dyslipidemia and CHD.

Osteoporosis vs. Osteopenia

The World Health Organization (WHO) defines osteoporosis as a spinal or hip bone mineral density (BMD) of 2.5 standard deviations or more below the mean for healthy, young women (T-score of −2.5 or below) as measured by dual energy x-ray absorptiometry (DEXA). Osteopenia is defined as a spinal or hip BMD between 1 and 2.5 standard deviations below the mean (T-score between -1 and -2.5).

Dietary Guidelines

There is varying information on the significance of breakfast for adults regarding weight loss. However, some studies show a decreased risk of type 2 diabetes in those who eat breakfast. Of course, what you eat for breakfast is important. The current recommendation is to eat a serving of whole-grain carbohydrate, a fruit, and either a dairy or lean protein.

Menopause

Timing On average, women reach menopause at 51. But, menopause can start earlier or later. A few women start menopause as young as 40, and a very few as late as 60. Women who smoke tend to go through menopause a few years earlier than nonsmokers. The timing of an individual's menopause cannot be predicted. Only after a woman has not menstruated for 12 straight months can menopause be confirmed. Perimenopause The gradual transition to menopause is called perimenopause. The ovaries don't abruptly stop; they slow down. During perimenopause it is still possible to get pregnant. The ovaries are still functional, and ovulation may occur, although not necessarily on a monthly basis. Perimenopause can last from two to eight years. Symptoms Menopause affects each woman differently. Some women reach menopause with little to no trouble; others experience severe symptoms that drastically hamper their lives. Menstrual irregularity is the hallmark of perimenopause. Patients should be advised to call their provider if their menses come very close together, if the bleeding is heavy, or if the bleeding lasts more than a week.

Cervical Cancer Risk Factors

Virtually all cervical cancers are caused by infection with certain high-risk types of human papilloma virus (HPV). HPV is transmitted via vaginal (or oral) intercourse. Transmission by nonpenetrative genital contact is rare. Therefore, squamous cell carcinoma of the cervix is a disease of sexually active women. Factors such as age, nutritional status, immune function, and possibly silent genetic polymorphisms modulate the incorporation of viral DNA into host cells. Sexual behaviors associated with an increased cervical cancer risk include: Early onset of intercourse A greater number of lifetime sexual partners Other risk factors include: Diethylstilbestrol (DES) exposure in utero. Cigarette smoking, which is strongly correlated with cervical dysplasia and cancer, independently increasing the risk by up to fourfold. Immunosuppression also significantly increases the risk of developing cervical cancer.

Skin Cancer Screening Recommendations

While skin cancer is the most common type of cancer, the USPSTF is currently reviewing guidelines regarding screening. Presently, the draft statement states that current evidence is insufficient to assess if there is more harm or benefit to visual skin cancer screening in adults. The USPSTF is also currently evaluating if there is any benefit in providing behavioral counseling for skin cancer prevention.