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.
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.
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 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 (NCEP) recommends screening all individuals
aged 20 and over. Before screening a woman for hyperlipidemia, an
important consideration is whether or not treatment recommendations
will change based on the results. Since therapeutic lifestyle changes
are recommended for all women, the question is at what point should
medication treatment be considered.
There is clear evidence that medication treatment of hyperlipidemia reduces CHD events in women who already have CHD, but when lipid-lowering medications are used in women who do not already have CHD, the evidence of benefit is less clear (see also Chapter 28: Lipid Disorders). Decisions about when to initiate medication treatment should include an assessment of an individual’s absolute risk of CHD in the next 10 years. Medication treatment should be targeted toward women with CHD and high-risk women who are most likely to benefit. The NCEP recommends different thresholds at which to initiate medication therapy based on individual CHD risk. For example, for a woman with known CHD, lipid-lowering medication is initiated at an LDL cholesterol of > 130 mg/dL, whereas for a woman with 0–1 risk factor, medication therapy is not initiated until the LDL cholesterol measures > 190 mg/dL.
Diabetes is a CHD risk factor in both men and women. Studies
have reached conflicting conclusions about the effect of tight control
of diabetes on CHD outcomes in both men and women, although lipid
lowering is clearly associated with a reduction in CHD events in
diabetic women. All women should focus on primary prevention of
diabetes with avoidance of obesity and maintenance of regular exercise. Women with diabetes also should focus on treatment of hypertension given the impact on CHD events (see Chapter 27: Diabetes Mellitus & Hypoglycemia).
Obesity has been established as an independent risk factor for
CHD in women. It is not known whether or not weight loss will decrease
CHD risk. Since most obese women who lose weight gain it back, the
overall goal should be ongoing avoidance of weight gain above normal
weight (see Chapters 1: Disease Prevention & Health Promotion and 29: Nutritional Disorders).
Biomarkers and Clinical Tests
The use of high-sensitivity C-reactive protein (hsCRP) has increased
in recent years. CRP is an inflammatory biomarker that has been
shown to predict cardiovascular events. However, there is currently
no evidence that screening for hsCRP improves cardiac outcomes.
It has been suggested that measuring hsCRP may be useful in women
for whom it would change treatment outcomes, but there is currently
no evidence to support this. The USPSTF has published guidelines
outlining the use of nontraditional risk factors in the evaluation
of CHD. The risk factors included in the recommendation were hsCRP,
ankle-brachial index, leukocyte count, fasting blood glucose, periodontal
disease, carotid intima media thickness, coronary artery calcification
score, electron beam CT, homocysteine, and lipoprotein (a). The
USPSTF concluded that there is insufficient evidence to balance
the benefits and harms of screening asymptomatic men and women with
no history of CHD to predict CHD events and did not recommend routine