Chapter 42

The field of women’s health encompasses more than the reproductive health issues commonly addressed by obstetricians and gynecologists; it evaluates diseases and conditions only seen or experienced in women or experienced by women in ways different than men, as well as the evidence-based prevention and treatment of risk factors and diseases in women. Hence, all primary care providers, including internists and family physicians, should be well versed in women’s health issues. While this chapter refers to other disease-based chapters in the textbook, it also emphasizes the understanding of issues from the particular perspective of women.

Prevention of disease can be primary (preventing disease before it happens as well as identifying and modifying risk factors), secondary (identifying early disease), or tertiary (treating complications of the disease or limiting the impact of established disease). Important areas for primary prevention include encouraging women to exercise regularly to reduce the risk of coronary heart disease (CHD) and breast cancer as well as counseling women to discontinue smoking to reduce the risk of cardiac and lung diseases. Cancer screening in women focuses on secondary prevention, so that disease is detected early when prompt treatment improves outcome.

### Cardiovascular Disease Prevention

Although cardiovascular disease is the leading cause of death in women, they are often more concerned about developing breast cancer (see below) than about developing heart disease. While some heart disease risk factors such as age and family history are not modifiable, as with men, other risk factors such as hypertension, hyperlipidemia, smoking, obesity, and diabetes are potentially modifiable (see also Chapter 1: Disease Prevention & Health Promotion). The Framingham risk calculator (http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof) can be used to estimate a woman’s 10-year risk of CHD based on her age, smoking status, blood pressure, and cholesterol levels.

#### Modifiable Risk Factors

##### Hypertension

Hypertension is a risk factor for CHD and stroke in both men and women (see Chapter 1: Disease Prevention & Health Promotion). Approximately 70–80% of women over age 70 have hypertension. A woman with high blood pressure is at lower risk for CHD than a similar aged man. For many young and otherwise healthy women, drug treatment can be deferred, since their absolute risk of CHD in the next 10 years is likely to be low. When pharmacotherapy is started, the choice of medication is similar to those used in men (see Chapter 11: Systemic Hypertension).

##### Hyperlipidemia

Hyperlipidemia is a CHD risk factor in both men and women, but low levels of high-density lipoprotein (HDL) is more predictive of CHD risk in women. Elevated cholesterol is defined as a total cholesterol > 240 mg/dL (> 7.2 mmol/L) or low-density lipoprotein (LDL) cholesterol > 160 mg/dL (> 4.8 mmol/L). Borderline cholesterol is defined as a total cholesterol between 200 mg/dL and 240 mg/dL (6 mmol/L and 7.2 mmol/L) or an LDL cholesterol of 130–159 mg/dL (3.9–4.77 mmol/L). Ideal cholesterol is defined as a total cholesterol < 200 mg/dL (< 6 mmol/L) or an LDL < 130 mg/dL (< 3.9 mmol/L) and an HDL cholesterol > 50 mg/dL (> 1.5 mmol/L).

The US Preventive Services Task Force (USPSTF) recommends screening all women aged 45 and older for hyperlipidemia, whereas the National Cholesterol Education Program ...

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