CHAPTER 1: Well Woman Care

Serving as both specialist and primary care provider, a gynecologist has an opportunity to diagnose and treat a wide variety of diseases. Once problems are identified, clinicians, in consultation with the patient, determine how best to manage chronic medical issues based on their experience, practice patterns, and professional interests. Although some conditions may require referral, gynecologists play an essential role in patient screening, in emphasizing ideal health behaviors, and in facilitating appropriate consultation for care beyond their scope of practice.

Various organizations provide preventive care recommendations and update these regularly. Commonly accessed guidelines are those from the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control and Prevention (CDC), U.S. Preventive Services Task Force (USPSTF), and American Cancer Society.

During a comprehensive well-woman visit, patients are first queried regarding new or ongoing illness. To assist with evaluation, complete medical, social, and surgical histories are obtained and include obstetric and gynecologic events. Gynecologic topics usually cover current and prior contraceptives; results from prior sexually transmitted disease (STD) testing, cervical cancer screening, or other gynecologic tests; sexual history, described in Chapter 3; and menstrual history, outlined in Chapter 8. Obstetric questions chronicle circumstances around deliveries, losses, or complications. Current medication lists include both prescription and over-the-counter drugs and herbal agents. Also, prior surgeries, their indications, and complications are sought. A social history covers smoking and drug or alcohol abuse. Screening for intimate partner violence or depression can be completed, as outlined on page 18 and more fully in Chapter 13. Discussion might also assess the patient’s support system and any cultural or spiritual beliefs that might affect her general health care. A family history helps identify women at risk for familial or multifactorial disease such as diabetes or heart disease. In families with prominent breast, ovarian, or colon cancer, genetic evaluation may be indicated, and criteria are outlined in Chapters 33 and 35. Moreover, a significant family clustering of thromboembolic events may warrant testing, as describe in Chapter 39, especially prior to surgery or hormone initiation. Last, a review of systems, whether performed by the clinician or office staff, may add clarity to new patient problems.

For adults, following historical inventory, a complete physical examination is completed. Many women present to their gynecologist with complaints specific to the breast or pelvis. Accordingly, these are often areas of increased focus, and their evaluation is described next.

Breast Examination

Clinical Evidence

Self breast examination (SBE) is an examination performed by the patient herself to detect abnormalities. However, studies have shown that SBE increases diagnostic testing rates for ultimately benign breast disease and is ineffective in lowering breast cancer mortality rates (Kösters, 2008; Thomas, 2002). Accordingly, several organizations have removed SBE from their recommended screening practices (National Cancer Institute, 2015; Smith, 2015; U.S. Preventive Services Task Force, 2009). That said, the American College of Obstetricians and Gynecologists (2014b) and the American Cancer Society (2014) recommend breast self-awareness as another method of patient self-screening. Self-awareness focuses on breast appearance and architecture and may include SBE. Women are encouraged to report any perceived breast changes for further evaluation.

In contrast, clinical breast examination (CBE) is completed by a clinical health-care professional and may identify a small portion of breast malignancies not detected with mammography. Additionally, CBE may identify cancer in young women, who are not typical candidates for mammography (McDonald, 2004). One method includes visual inspection combined with axillary and breast palpation, which is outlined in the following section.

The American College of Obstetricians and Gynecologists (2014b) recommends that women receive a CBE every 1 to 3 years between ages 20 and 39. At age 40, CBE is completed annually. That said, the USPSTF (2009) and the American Cancer Society report insufficient evidence to recommend routine CBE (Oeffinger, 2015).

Breast Examination

Initially during CBE, the breasts are viewed as a woman sits on the table’s edge with hands placed at her hips and with pectoralis muscles flexed (Fig. 1-1). Alone, this position enhances asymmetry. Additional arm positions, such as placing arms above the head, do not add vital information. Breast skin is inspected for breast erythema; retraction; scaling, especially over the nipple; and edema, which is termed peau d’orange change. The breast and axilla are also observed for contour symmetry.

Following inspection, axillary, supraclavicular, and infraclavicular lymph nodes are palpated most easily with a woman seated and her arm supported by the examiner (Fig. 1-2). The axilla is bounded by the pectoralis major muscle ventrally and the latissimus dorsi muscle dorsally. Lymph nodes are detected as the examiner’s hand glides from high to low in the axilla and momentarily compresses nodes against the lateral chest wall. In a thin patient, one or more normal, mobile lymph nodes less than 1 cm in diameter may commonly be appreciated. The first lymph node to become involved with breast cancer metastasis (the sentinel node) is nearly always located just behind the midportion of the pectoralis major muscle belly.

After inspection, breast palpation is completed with a woman supine and with one hand above her head to stretch breast tissue across the chest wall (Fig. 1-3). Examination includes breast tissue bounded by the clavicle, sternal border, inframammary crease, and midaxillary line. Breast palpation within this pentagonal area is approached in a linear fashion. Technique uses the finger pads in a continuous rolling, gliding circular motion (Fig. 1-4). At each palpation point, tissues is assessed both superficially and deeply (Fig. 1-5). During CBE, intentional attempts at nipple discharge expression are not required unless a spontaneous discharge has been described by the patient.

If abnormal breast findings are noted, they are described by their location in the right or left breast, clock position, distance from the areola, and size. Evaluation and treatment of breast and nipple diseases are described more fully in Chapter 12.

During examination, patients are educated that new axillary or breast masses, noncyclic breast pain, spontaneous nipple discharge, new nipple inversion, and breast skin changes such as dimpling, scaling, ulceration, edema, or erythema should prompt evaluation. This constitutes breast self-awareness. Patients who desire to perform SBE are counseled on its benefits, limitations, and potential harms and instructed to complete SBE the week after menses.

Pelvic Examination

This examination is typically performed with a patient supine, legs in dorsal lithotomy position, and feet resting in stirrups. The head of the bed is elevated 30 degrees to relax abdominal wall muscles for bimanual examination. A woman is assured that she may stop or pause the examination at any time. Moreover, each part of the evaluation is announced or described before its performance.

Inguinal Lymph Nodes and Perineal Inspection

Pelvic cancers and infections may drain to the inguinal lymph nodes, and these are palpated during examination. Following this, a methodical inspection of the perineum extends from the mons ventrally, to the genitocrural folds laterally, and to the anus. Notably, infections and neoplasms that involve the vulva can also involve perianal skin. Some clinicians additionally palpate for Bartholin and paraurethral gland pathology. However, in most cases, patient symptoms and asymmetry in these areas will dictate the need for this specific evaluation.

Speculum Examination

Both metal and plastic specula are available for this examination, each in various sizes to accommodate vaginal length and laxity. The plastic speculum may be equipped with a small light that provides illumination, whereas metal specula require an external light source. Preference between these two types is provider dependent. The vagina and cervix are typically viewed after placement of either a Graves or Pederson speculum (Fig. 1-6). Prior to insertion, a speculum may be warmed with running water or by warming lights built into some examination tables. Additionally, lubrication may add comfort to insertion. Griffith and colleagues (2005) found that gel lubricants did not increase unsatisfactory Pap smear cytology rates or decrease Chlamydia trachomatis detection rates compared with water lubrication. If gel lubrication is used, a dime-sized aliquot is applied sparingly to the outer surface of the speculum blades.

Immediately before insertion, the labia minora are gently separated, and the urethra is identified. Because of urethral sensitivity, the speculum is inserted well below the meatus. Alternatively, prior to speculum placement, an index finger may be placed in the vagina, and pressure placed posteriorly against the bulbospongiosus muscle. A woman is then encouraged to relax this posterior wall to improve comfort with speculum insertion. This practice may prove especially helpful for women undergoing their first examination and for those with infrequent coitus, dyspareunia, or heightened anxiety.

With speculum insertion, the vagina commonly contracts, and a woman may note pressure or discomfort. A pause at this point typically is followed by vaginal muscle relaxation. As the speculum bill is completely inserted, it is angled approximately 30 degrees downward to reach the cervix. Commonly, the uterus is anteverted, and the ectocervix lies against the posterior vaginal wall (Fig. 1-7).

As the speculum is opened, the ectocervix can be identified. Vaginal walls and cervix are inspected for masses, ulceration, or unusual discharge. As outlined in Chapter 29, cervical cancer screening is often completed, and additional swabs for culture or microscopic evaluation can also be collected. Screening for Neisseria gonorrhoeae and Chlamydia trachomatis and other STDs is listed in Table 1-1.

Bimanual Examination

Most often, the bimanual examination is performed after the speculum evaluation. Some clinicians prefer to complete the bimanual portion first to better identify cervical location prior to speculum insertion. Either process is appropriate. Uterine and adnexal size, mobility, and tenderness can be assessed during bimanual examination. For women with prior hysterectomy and adnexectomy, bimanual examination is still valuable and can be used to exclude other pelvic pathology.

During this examination, a gloved index and middle finger are inserted together into the vagina until the cervix is reached. For cases of latex allergy, nonlatex gloves are available. To ease insertion, a water-based lubricant can be initially applied to these gloved fingers. Once the cervix is reached, uterine orientation can be quickly assessed by sweeping the index finger inward along the ventral surface of the cervix. In those with an anteverted position, the uterine isthmus is noted to sweep upward, whereas in those with a retroverted position, a soft bladder is palpated. However, in those with a retroverted uterus, if a finger is swept along the cervix’s dorsal aspect, the isthmus is felt to sweep downward. With a retroverted uterus, this same finger is continued posteriorly to the fundus and then side-to-side to assess uterine size and tenderness.

To determine the size of an anteverted uterus, fingers are placed beneath the cervix, and upward pressure tilts the fundus toward the anterior abdominal wall. A clinician’s opposite hand is placed against the abdominal wall to locate the upward fundal pressure (Fig. 1-8).

To assess adnexa, the clinician uses two vaginal fingers to lift the adnexa from the cul-de-sac or from Waldeyer fossa toward the anterior abdominal wall. The adnexa is trapped between these vaginal fingers and the clinician’s other hand, which is exerting downward pressure against the lower abdomen. For those with a normal-sized uterus, this abdominal hand is typically best placed just above the inguinal ligament.

Rectovaginal Examination

The decision to perform rectovaginal evaluation varies among providers. Some prefer to complete this evaluation on all adults, whereas others elect to perform rectovaginal examination for those with specific indications. These may include pelvic pain, an identified pelvic mass, rectal symptoms, or risks for colon cancer.

Gloves are changed between bimanual and rectovaginal examinations to avoid contamination of the rectum with potential vaginal pathogens. Similarly, if fecal occult blood testing is to be done at this time, the glove is changed after bimanual examination to minimize false-positive results. Initially, an index finger is placed into the vagina and a middle finger into the rectum (Fig. 1-9). These fingers are swept against one another in a scissoring fashion to assess the rectovaginal septum for scarring or peritoneal studding. The index finger is removed, and the middle finger completes a circular sweep of the rectal vault to exclude masses. If immediate fecal occult blood testing is indicated, it may be performed with a sample from this portion of the examination. As noted later, this single fecal occult blood testing does not constitute adequate colorectal cancer screening.

Examination Interval

Periodic health evaluation and screening can prevent or detect numerous medical conditions. Moreover, periodic visits also foster a patient-physician partnership to help guide a woman through adolescence, reproductive years, and past menopause.

An initial reproductive health visit is recommended between ages 13 and 15 years (American College of Obstetricians and Gynecologists, 2014e). This visit initiates a discussion between an adolescent and health-care provider on issues of general reproductive health, puberty, menstruation, contraception, and STD protection. Although not mandated, a pelvic examination may be necessary if gynecologic symptoms are described. Adolescents may prefer to include parents in their gynecologic health care. However, as discussed in Chapter 14, adolescents may seek care for STDs, substance abuse, contraception, or pregnancy without parental permission (American College of Obstetricians and Gynecologists, 2014a).

For women older than 21 years, the American College of Obstetricians and Gynecologists (2014f) recommends annual well woman visits, during which physical and pelvic examinations are completed. Pelvic evaluation contains those components listed on page 4, namely, inspection and speculum, bimanual, and rectal examinations. However, evidence neither supports nor refutes the value of annual pelvic evaluation in asymptomatic women. Thus, exclusion of this portion is a shared decision following patient-provider discussion. Women with gynecologic complaints are encouraged to permit this examination.

One topic in this conversation is cervical cancer screening. For many women, the appropriate screening interval may not be annually, and specific screening methods and schedules are discussed in Chapter 29. Second, in the past, endocervical swabs for gonorrhea and chlamydia infection screening during speculum examination were preferred. Now, such screening can be completed with similar accuracy using nucleic acid amplification testing of urine, vaginal, or endocervical samples.

Other professional organizations have also published statements regarding preventive care visits. The Institute of Medicine (2011) recommends at least one annual well woman visit to obtain preventive services, including preconception and prenatal care. However, investigators from the American College of Physicians (ACP) reviewed pelvic examination benefits and harms in asymptomatic adult women (Qaseem, 2014). These authors describe scarce data to determine the ideal interval for routine pelvic examination. Accordingly, the ACP recommends against screening pelvic examination for asymptomatic, nonpregnant adult women. Thus, again, with each annual visit, a discussion of benefits and risks and an agreement to examination is prudent.

Gynecologists have an opportunity to evaluate their patients for leading causes of female morbidity and mortality and intervene accordingly. Thus, familiarity with various screening guidelines is essential. In 2014, recommendations by the American College of Obstetricians and Gynecologists (2014f) were updated. The USPSTF (2014) regularly revises its screening guidelines, which can be accessed at www.USPreventiveServicesTaskForce.org. These, along with other specialty-specific recommendations, offer valuable guidance for clinicians providing preventive care. Many of these topics are covered in other text chapters. Some remaining important subjects are present in the following sections.

Immunization

The need for new or repeat administration of vaccines should be reviewed periodically. Some vaccines are recommended for all adults, whereas others are indicated because of patient comorbidities or occupational exposure risks. For most healthy adults who have completed the indicated childhood and adolescent immunization schedules, those that warrant consideration are listed in Table 1-2. This table summarizes recommended schedules, precautions, and contraindications for these adult vaccines. As of 2015, a link is provided to the full schedules at: http://www.cdc.gov/vaccines/schedules/.

In general, any vaccine may be coadministered with another type at the same visit. Notably, the influenza vaccine is available in several formulations. Vaccines for human papillomavirus infection prevention, Gardasil and Cervarix, are discussed additionally in Chapter 29.

Cancer Screening

Colon Cancer

In the United States, nearly 64,000 new cases of colorectal cancer are predicted, and this malignancy is the third leading cause of cancer death in women, behind lung and breast cancer (Siegel, 2015). Incidence and mortality rates from this cancer have declined during the past two decades, largely due to improved screening tools. However, adherence to colorectal cancer screening guidelines for women is usually less than 50 percent (Meissner, 2006).

Guidelines recommend screening average-risk patients for colorectal cancer beginning at age 50 with any of the methods shown in Table 1-3 (Smith, 2015). Screening is selected from either of two method categories. The first is capable of identifying both cancer and precancerous lesions. The second group of methods primarily detects only cancer and includes the fecal occult blood test, fecal immunochemical test, and stool DNA tests.

Of these, colonoscopy is often the preferred test for colorectal cancer screening. For the patient with average risk and normal findings, testing is repeated in 10 years. In the United States, flexible sigmoidoscopy is used less frequently. Its limitations include that only the distal 40 cm of colon are seen, and if lesions are found, then colonoscopy is still needed. A final suitable option—computed tomographic (CT) colonography—is not often covered by insurance plans.

Fecal occult blood testing (gFOBT) is an adequate annual screening method when two or three stool samples are self-collected by the patient, and the cards are returned for analysis. This method relies on a chemical oxidation reaction between the heme moiety of blood and alpha guaiaconic acid, a component of guaiac paper. Heme catalyzes the oxidation of alpha guaiaconic acid by hydrogen peroxide, the active component in the developer. This oxidation reaction yields a blue color (Sanford, 2009). Red meat, raw cauliflower, broccoli, members of the radish family, and melons have similar oxidizing ability and may yield false-positive results. Vitamin C may preemptively react with the reagents and lead to false-negative results. All of these are eliminated for 3 days before testing. Additionally, women should avoid nonsteroidal antiinflammatory drugs (NSAIDs) 7 days prior to testing to limit risks of gastric irritation and bleeding. These restrictions are cumbersome for some patients and lead to noncompliance with recommended testing.

Alternatively, the fecal immunochemical test (FIT) relies on an immune reaction to human hemoglobin. Similar to FOBT, the FIT test is performed for annual screening on two or three patient-collected stool samples and does not require pretesting dietary limitations. Advantages to FIT include greater specificity for human blood and thus fewer false-positive results from dietary meat and vegetables and fewer false-negative results due to vitamin C. As another option, screening may be completed with stool DNA (sDNA) testing. One FDA-approved test, Cologuard, screens stool for both DNA and hemoglobin biomarkers that are associated with colorectal cancer (Imperiale, 2014). Positive test results from any of these three warrant further evaluation by colonoscopy.

During patient evaluation of pelvic complaints such as pain, a gynecologist not uncommonly performs gFOBT testing on a single stool sample obtained during digital rectal examination. Although potentially helpful diagnostically, this single stool sample is not considered adequate colorectal cancer screening.

These guidelines are appropriate for those with average risk. High-risk factors include a personal history of colorectal cancer or adenomatous polyps, a first-degree relative with colon cancer or adenomas, chronic inflammatory bowel disease, known or suspected hereditary syndrome such as hereditary nonpolyposis colon cancer (Lynch syndrome) or familial adenomatous poly­posis (Smith, 2015).

Lung Cancer

In the United States, this cancer is estimated to account for 13 percent of all new cancers diagnosed in women in 2015 (Siegel, 2015). It is now the leading cause of cancer-related death in both men and women. All smokers should be advised of tobacco-use risks and encouraged to stop. A list of potential aids is found on page 11.

Lung cancer screening focuses on those at high risk and referral is considered for individuals with general good health, aged 55 to 74, with at least a 30-pack-year history, and who actively smoke or quit within the past 15 years. One remembers that pack-year determination is calculated by multiplying the number of packs smoked per day by the number of years the person has smoked. By convention, one pack contains 20 cigarettes. For appropriate cases, low-dose helical CT scanning is the preferred test (Smith, 2015). Although a common diagnostic test, chest radiography is not recommended as a lung cancer screening tool.

Skin Cancer

The incidence of skin cancers (melanoma and non-melanomas) has increased in the United States during the past three decades. In 2015, melanoma is expected to account for 4 percent of all cancer deaths in women (Siegel, 2015). Skin cancer risks include prolonged sun exposure, family or personal history of skin cancer, fair skin, light hair or freckling, numerous moles, immunosuppression, and aging (American Cancer Society, 2013). The USPSTF notes insufficient evidence to recommend whole body screening by physician or patient for skin cancer in the general adult population (Wolff, 2009). It does advise clinicians to use the “ABCD” system—asymmetry, border irregularity, color, and diameter (>6 mm) to evaluate skin lesions of concern and refer appropriately.

Lifestyle Changes

Smoking

Cigarette smoking is the single most preventable cause of death in the United States and has been linked with certain cancers, cardiovascular disease, chronic lung diseases, and stroke. Moreover, specific to women’s health, smoking is linked to diminished fertility, pregnancy complications, and postoperative complications. These are discussed in greater detail in their respective chapters.

Despite these known negative health outcomes, in 2003, only 64 percent of smokers who had routine examinations in the United States were advised by a physician to quit smoking (Torrijos, 2006). Guidelines from the U.S. Department of Health and Human Services encourage a brief behavioral patient intervention model found on page 12. Patients can also be referred to the National Cancer Institute’s smoking cessation website: www.smokefree.gov. This site provides free, evidence-based information and professional assistance to help the immediate and long-term needs of those trying to quit. Unless contraindicated, pharmacologic treatments to aid smoking cessation can be offered to all interested women and are listed in Table 1-4. Gynecologists who are proficient in the use of these therapies may prescribe. Referral is also appropriate (American College of Obstetricians and Gynecologists, 2014c).

Exercise

Exercise has known benefits in preventing coronary artery disease, diabetes, osteoporosis, obesity, depression, insomnia, and breast and colon cancer (Brosse, 2002; Knowler, 2002; Lee, 2003; Vuori, 2001; Youngstedt, 2005). Many of these associations may result from the effects of exercise to lower blood pressure, decrease low-density lipoprotein cholesterol and triglyceride levels, increase high-density lipoprotein cholesterol levels, improve blood sugar control, and reduce weight (Braith, 2006; Pescatello, 2004; Sigal, 2004).

Despite these known benefits, based on U.S. government thresholds, only 45 percent of women in 2012 were considered sufficiently active (Blackwell, 2014). Recommendations from the U.S. Department of Health and Human Services (2008) include moderate-intensity activity such as walking, water aerobics, or yard work for at least 150 minutes each week or vigorous-intensity activities such as running, swimming laps, or aerobic dancing for 75 minutes each week. Activities can be performed in episodes of at least 10 minutes that are apportioned throughout the week. Additional health benefits are gained with physical activity beyond these amounts.

Although exercise programs have traditionally emphasized dynamic, aerobic lower-extremity exercise, research supports complementary resistance training to improve muscular strength and endurance, cardiovascular function, metabolism, coronary risk factors, weight management, and quality of life (Williams, 2007). Accordingly, government guidelines also encourage biweekly muscle-strengthening activities that involve all the major muscle groups. A fuller listing of general physical activities and their intensity description is found in the publication 2008 Physical Activity Guidelines for Americans at the CDC website: www.health.gov/paguidelines/guidelines.

To change any type of health-related behavior, counseling can be brief yet effective. One method is the five A’s system, which in this example is tailored for exercise (Fiore, 2008).

• Ask: if she is physically active now

• Advise: her about the benefits of regular physical activity

• Assess: her willingness to change and decide if she is in a (1) precontemplation, (2) contemplation phase, (3) preparation, or (4) action phase. Her stage of readiness guides further discussion

• Assist: her by recommending local exercise programs

• Arrange: for follow-up evaluation to assess progress

For those with certain comorbidities, clearance by other health care providers may be indicated. For this, the Physical Activity Readiness Questionnaire helps identify women with risk factors who merit further evaluation and is available at: www.csep.ca/cmfiles/publications/parq/par-q.pdf.

Obesity

Associated Risks and Diagnosis

In 2010, nearly 36 percent of women in the United States were obese, and almost twice that many were overweight (Flegal, 2012). Possible consequences of obesity include diabetes mellitus, metabolic syndrome, nonalcoholic fatty liver, cholelithiasis, hypertension, osteoarthritis, nonobstructive sleep apnea, and renal disease. Gynecologic issues related to obesity include abnormal menstruation, risks for endometrial neoplasia, and worsening polycystic ovary syndrome. Moreover, some hormonal contraceptives may have lower efficacy in obese women. Despite these considerable consequences, one study showed that fewer than half of physicians are comfortable discussing obesity (Schuster, 2008). Even if not trained as weight management specialists, clinicians ideally screen for obesity, provide initial obesity evaluation and management, and refer as needed.

Screening is accomplished with calculation of body mass index (BMI) or less commonly, waist circumference. BMI, although not a direct measure of body fat content, is valuable in assessing the risk for weight-related complications. The following calculations can be used: BMI = (Wt in lb/(Ht in inches × Ht in inches)) × 703 BMI = Wt in kg/(Ht in meters × Ht in meters)

More simply, an online calculator can be found at: www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html. For adolescents (and children), BMI is adjusted for age and gender and calculated as a percentile. A BMI calculator for adolescents can be found at http://apps.nccd.cdc.gov/dnpabmi/.calculator.aspx. Table 1-5 reflects the definitions for underweight, overweight, and obesity for adolescents and adults.

Waist circumference positively correlates with abdominal fat content, which is a risk factor for poor health outcomes. Waist circumference is measured at the level of the iliac crests at the end of normal expiration. Values greater than 35 inches (88 cm) are considered elevated (National Heart, Lung, and Blood Institute, 2000).

No standard single or panel laboratory test is indicated for an obese woman. Evaluation for comorbidities is tailored to the patient, taking into consideration her family and social histories (Table 1-6). Blood pressure measurement, fasting lipid and glucose screening, and thyroid function testing can all be considered for the obese patient during initial evaluation.

For a woman with elevated BMIs, a clinician should assess her readiness for change and thereby, provide appropriate guidance, support, or referral. In addition, questions regarding previous attempts at weight loss, social hurdles that impede diet and exercise change, and detrimental eating habits are discussed in a nonjudgmental manner.

Treatment

Effective weight loss is best obtained with proper nutrition and consistent physical activity. Table 1-7 illustrates recommended guidelines to direct therapy for overweight or obese women. A detailed discussion of dietary weight loss extends beyond this chapter’s scope, but several clinician and patient aids can be found in The Practical Guide to Identification, Evaluation and Treatment of Overweight or Obesity in Adults, available at: www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf.

In general, for the adult patient, a 10-percent weight loss within 6 months is realistic. According to the American Heart Association, suitable options are diets with 1200 to 1500 kcal/day or diets that incorporate a 500 or 750-kcal/d deficit (Jensen, 2014). No single diet plan is espoused as the gold standard for every patient, and the ideal regimen is one that can be adhered to.

In addition to diet and exercise, pharmacologic or surgical options may be implemented for selected obese patients. Four agents are FDA-approved for long-term obesity treatment. First, orlistat (Xenical) is a reversible inhibitor of gastric and pancreatic lipases and leads to a 30-percent blockage of dietary fat absorption (Henness, 2006). This drug is prescribed as 120-mg capsule taken orally three times daily with meals but is also available over-the-counter in 60-mg capsules (Allī), also taken three times daily. Associated malabsorption can lead to deficiencies of the fat-soluble vitamins A, D, E, and K, and all patients should receive a daily supplement enriched with these vitamins. Severe liver injury has been reported rarely, and new labeling reflects this risk (Food and Drug Administration, 2010).

Another medication, lorcaserin (Belviq) is a serotonin 2C receptor agonist used to suppress appetite (Fidler, 2011; Smith, 2010). One 10-mg tablet is taken orally twice daily. A third agent combines phentermine and topiramate (Qsymia)(Gadde, 2011). Doses begin at 3.75 mg/23 mg orally daily and are gradually titrated upward as needed to a maximum dose of 15 mg/92 mg daily. This drug has fetotoxicity potential and prescribing providers participate in a Qsymia Risk Evaluation and Mitigation Strategy program. Last, liraglutide (Saxenda) is a glucagon-like peptide-1 receptor agonist delivered by subcutaneous injection (Astrup, 2009). Dosing begins at 0.6 mg daily and is gradually escalated weekly to reach a 3-mg daily dose. Important potential risks include medullary thyroid carcinoma and pancreatitis. These last three agents are indicated for those with BMIs of 30 or greater, or 27 or greater if weight-associated comorbid risks exist.

As another adjunct, bariatric surgery may be selected for those with BMIs of 40 or greater, or with BMIs at or above 35 if other comorbid conditions are present (Jensen, 2014). Of available laparoscopic procedures, three are more commonly performed. Two are considered restrictive (limit intake), whereas bypass surgery promotes malabsorptive weight loss. First of these, gastric banding places an adjustable plastic ring around the stomach to limit food intake. Second, sleeve gastrectomy partitions off the lateral stomach by a staple line, and the remaining smaller stomach has a tubular, sleeve appearance. Last, the Roux-en-Y gastric bypass creates a small stomach pouch that is connected directly to the jejunum to bypass the duodenum. This reduces calorie and nutrient absorption. These surgeries lead to substantial weight loss in individuals with morbid obesity and have been linked with improvement in comorbid risk factors and decreased mortality rates (Hutter, 2011). With these, surgical complications are infrequent but can be serious and include gastrointestinal leaks at staple or suture lines, stomal obstruction or stenosis, thromboembolism, and bleeding (Jackson, 2012).

Following bariatric surgery, patients are advised to delay pregnancy for 12 to 24 months (American College of Obstetricians and Gynecologists, 2013). Rapid weight loss during this time poses theoretical risks for intrauterine fetal-growth restriction and nutritional deprivation. However, as weight is lost, fertility rates overall appear to be improved, and risks for pregnancy increase (Merhi, 2009). Thus, effective contraception is needed. Most contraceptive methods appear to be as effective in women with elevated BMIs compared with normal-weight controls. However, the contraceptive patch (OrthoEvra) is less effective in those weighing more than 90 kg (Zieman, 2002). Specific to those with malabsorptive bariatric surgery types, oral contraception efficacy may be lower due to poor absorption (Centers for Disease Control and Prevention, 2013). Last, due to its risk for associated weight gain, depot medroxyprogesterone acetate (Depo-Provera) may be an unpopular choice in women trying to lose weight.

Cardiovascular Disease

In 2010, nearly 34 percent of the female population was affected by cardiovascular disease (CVD), and more than 400,000 women died from its complications (Go, 2014). Stratification of CVD predispositions can identify vulnerable patients for management or referral (Table 1-8). Ideal goals for exercise, glucose and lipid levels, blood pressure, and smoking cessation are discussed in other sections of this chapter. Specific dietary intake recommendations for women are listed in Table 1-9.

Chronic Hypertension

Nearly 41 million American women are hypertensive. The risk of hypertension increases with age and is increased for black women compared with those of other races (Go, 2014). Chronic hypertension increases the risks for myocardial infarction, stroke, congestive heart failure, renal disease, and peripheral vascular disease. Moreover, chronic hypertension and its potential therapies may limit contraception choices for some women. Thus, gynecologists should be familiar with criteria used to diagnose hypertension. Although many may choose to refer their patients for treatment of hypertension, gynecologists should be aware of target goals and long-term risks associated with this disease.

For adult screening, the American Heart Association (2014) recommends blood pressure assessment starting at age 20 and evaluation repeated every 2 years if initially normal. For patients with elevated pressures, assessment is at least annually.

With screening, blood pressures are best taken with a woman seated in a chair with the tested arm resting on a table, at the level of the heart. Ideally, the patient has been able to rest quietly for a few minutes prior to measurement and to have refrained from tobacco and caffeine use immediately prior to testing. An appropriately sized cuff is selected, and the cuff bladder should encircle at least 80 percent of the arm. Hypertension is diagnosed if readings are elevated on at least two separate office visits over one or more weeks. Prehypertension is diagnosed if readings fall in the range 130–139/80–89 mm Hg. Notably, women with prehypertension are at significantly increased risk of developing hypertension later (Wang, 2004). Additionally, compared with normal blood pressure readings, prehypertension is associated with greater risks for CVD (Mainous, 2004).

If hypertension is diagnosed, further examination should exclude underlying causes of hypertension and resultant end-organ disease (Table 1-10). With the diagnosis of chronic hypertension, assessment then follows for both modifiable and nonmodifiable CVD risk factors. Thus, routine laboratory tests recommended before initiating therapy include an electrocardiogram, urinalysis, blood glucose, hematocrit, lipid profile, thyroid testing, and serum potassium and creatinine measurement. A more extensive search for identifiable causes is not generally indicated unless hypertension is not controlled with initial treatment (Chobanian, 2003).

For treatment, lifestyle changes that mirror those for CVD are encouraged (see Table 1-9). However, if blood pressure is significantly elevated or resistant to lifestyle modification alone, then pharmacologic treatment may be needed to decrease long-term complications. Recommendations from the Eighth Joint National Committee (JNC 8) are shown in Table 1-11 (James, 2014).

Stroke

This is the third leading cause of death in the United States, and in 2010, approximately 425,000 American women suffered a new or recurrent stroke (Go, 2014). Gender-specific risk factors for stroke in women include hypertension, atrial fibrillation, migraines with aura, and oral contraceptive use. Aspirin is recommended as prevention for stroke in normotensive women aged 65 years or older for whom the lowered risks for ischemic stroke and myocardial infarction outweigh the risks for gastrointestinal bleeding and hemorrhagic stroke (Bushnell, 2014). There is no consensus as to the optimal dose or frequency of aspirin for prevention. Options are 81 mg daily or 100 mg every other day.

Dyslipidemia

Hypercholesterolemia

Data support that low-density lipoprotein cholesterol (LDL) is the primary atherogenic agent. Although previously believed merely to collect passively within vessel walls, LDL is now felt to be a potent proinflammatory agent and creates the chronic inflammatory response characteristic of atherosclerosis. Logically, elevated levels of total and LDL cholesterol are associated with increased rates of coronary artery disease, ischemic stroke, and other atherosclerotic vascular complications (Horenstein, 2002; Law, 1994).

Preventively, the National Cholesterol Education Program Adult Treatment Panel-III (ATP-III) (2001) recommends that all adults 20 years and older be screened with a fasting serum lipoprotein profile once every 5 years. This profile includes measurement of total, LDL, and high-density lipoprotein (HDL) cholesterol levels and triglyceride concentrations. Table 1-12 lists interpretation of these levels. Notably, if other comorbid risks for coronary heart disease are present, then LDL goals are more stringent.

Lowering LDL levels has been associated with reduced rates of myocardial infarction and stroke (Goldstein, 2006; Sever, 2003). Initial management usually begins with lifestyle and dietary changes, discussed earlier for CVD, and outlined by the American Heart Association (Eckel, 2014). If these modifications are unsuccessful, this organization recommends lipid-lowering treatment consideration for: (1) those with known CVD, (2) those with LDL cholesterol levels at or above 190 mg/dL, (3) those aged 40 to 75 years with diabetes and LDL cholesterol levels of 70 mg/dL or more, and (4) those aged 40 to 75 years with LDL cholesterol levels of 70 mg/dL or higher and an estimated 10-year risk of a cardiovascular event that is at least 7.5 percent (Stone, 2014).

Hypertriglyceridemia

Triglycerides are delivered to tissues by very-low-density lipoprotein (VLDL), which is synthesized and secreted by the liver. This triglyceride-rich lipoprotein is taken up by adipose and muscle, where triglycerides are cleaved from VLDL. Ultimately, a VLDL remnant is created that is atherogenic. For this reason, triglyceride levels can be used as one marker for atherogenic lipoproteins, and high triglyceride levels have been linked to increases in CVD (Assmann, 1996; Austin, 1998). Its clinical importance is also underscored by its inclusion as one criterion for the metabolic syndrome.

Hypertriglyceridemia is diagnosed based on criteria found in Table 1-12. For most with mild or moderate triglyceride elevation, recommendations from American Heart Association emphasize diet changes and weight loss (Miller, 2011). Alternatively, for those with triglyceride levels of 500 mg/dL or greater, treatment goals focus primarily on triglyceride level lowering to prevent pancreatitis.

Diabetes Mellitus

Diabetes is common, and approximately 13.4 million adult women in the United States are diabetic (Centers for Disease Control and Prevention, 2014). The long-term consequences of this endocrine disorder are serious and include coronary heart disease, stroke, peripheral vascular disease, periodontal disease, nephropathy, neuropathy, and retinopathy.

The USPSTF (2014b) recommends diabetes screening for asymptomatic adults with blood pressure of 135/80 mm Hg or greater. For normotensive adults, screening is individualized based on risks. However, the American Diabetes Association (2015) recommends that screening be considered at 3-year intervals beginning at age 45, particularly in those with BMIs of 25 or above. Moreover, testing is considered at a younger age or completed more often in those who are overweight and have one or more of the other risk factors shown in Table 1-13.

Diabetes and prediabetes may be diagnosed by various laboratory tests listed in Table 1-14. Laboratory measurement of plasma glucose concentration is performed on venous samples, and the aforementioned values are based on the use of such methods. Capillary blood glucose testing using a blood glucometer is an effective monitoring tool but is not currently recommended for diagnostic use.

For those diagnosed with diabetes, referral to a specialist is usually indicated. Delayed onset and slower progression of many diabetic complications has been shown to follow control of elevated blood glucose levels (Cleary, 2006; Fioretto, 2006; Martin, 2006). Control can be achieved with diet modification alone or combined with oral hypoglycemic agents or injectable insulin. To lower diabetic morbidity, therapy goals for otherwise normal patients include hemoglobin A_1c levels below 7 percent, preprandial glucose between 80 and 130 mg/dL, blood pressure readings below 120/80 mm Hg, low-density lipoprotein (LDL) levels below 100 mg/dL, HDL levels above 50 mg/dL, triglyceride levels below 150 mg/dL, weight loss, and smoking cessation (American Diabetes Association, 2015).

Patients with “prediabetes,” that is, impaired fasting glucose or impaired glucose tolerance, have an increased risk for developing diabetes. To avert or delay diabetes, management includes increased physical activity, weight loss, drugs such as metformin, nutritional counseling, and yearly diabetes screening. Metformin is considered especially for those with BMI above 35, age younger than 60 years, and prior gestational diabetes (American Diabetes Associations, 2015).

Metabolic Syndrome

This syndrome is a clustering of major cardiovascular disease risk factors (Table 1-15). At present, a single unifying cause of the metabolic syndrome has not been identified, and it may be precipitated by multiple underlying risk factors. Of these, abdominal obesity and insulin resistance appear important (Grundy, 2005).

This syndrome is common, and in 2010, 22 percent of U.S. women met diagnostic criteria. Although genders appear equally affected, Mexican Americans show the highest prevalence, and incidence appears to increase in all ethnicities with age (Beltrán-Sánchez, 2014). The sequelae associated with metabolic syndrome are significant and include an increased risk of diabetes and mortality from coronary heart disease, CVD, and all causes (Lorenzo, 2003; Malik, 2004; Sattar, 2003). Among those with metabolic syndrome, risks are further increased, by cigarette smoking and elevated LDL cholesterol levels.

Goals of clinical management include reducing risks for clinical atherosclerotic disease and for diabetes. Accordingly, primary therapy for metabolic syndrome focuses on lifestyle modification, particularly weight reduction and increased exercise. During evaluation, each metabolic syndrome component is addressed and treated in accordance with current guidelines, as discussed in earlier sections.

Thyroid Disease

The risk of thyroid disease increases with age, and dysfunction is more common in women. Accordingly, the American Thyroid Association recommends that adults, especially women, be screened for thyroid dysfunction by measurement of a serum thyroid-stimulating hormone (TSH) concentration. This begins at age 35 years and is repeated every 5 years thereafter (Garber, 2012). Moreover, individuals with clinical manifestations potentially attributable to thyroid dysfunction and those with risk factors for its development may require more frequent testing. People at higher risk for thyroid dysfunction include the elderly and those with prior neck radiation, thyroid surgery, autoimmune disease, affected first-degree relative, psychiatric disorders, or lithium use. In contrast, the U.S. Preventive Service Task Force (2004b) has found insufficient evidence to recommend for or against routine screening in asymptomatic women.

Geriatric Screening

Women are now living longer, and the current life expectancy for women in the United States is 81 years (Arias, 2014). As a woman moves past menopause, many of her health care needs may not be gynecologic. However, a family may often contact a patient’s gynecologist first regarding a member’s lack of independent function or memory loss.

Of these, functional status is a patient’s ability to perform both basic and complex activities for independent living. Basic activities are grooming and toileting, whereas checkbook balancing, bill paying, and housekeeping tasks are more complex, instrumental activities of daily living (Katz, 1963; Lawton, 1969). Declines in functional status are linked to increased risks of hospitalization, institutionalization, and death (Walston, 2006). Identification of functional status loss may permit early intervention.

Second, loss of cognitive function may present as short- and long-term memory loss, difficulty with problem solving, or inattention to personal hygiene. Although not expert in recognition of cognitive problems, a gynecologist can perform initial screening and provide results that either reassure the patient and her family or prompt more formal evaluation by a geriatrician or neurologist.

For dementia, the Mini Mental Status Exam or, more recently, the Mini-Cog Test can screen for cognitive impairment in the primary care setting (Borson, 2000, 2006; Folstein, 1975). The Mini-Cog test requires approximately 3 minutes to administer and begins by giving the patient three items to remember early in the interview. Later in discussion, she is asked to recall those three items. For the clock-drawing test, a person is asked to draw a clock with the hands at a specific time, such as 8:30. A correct clock has numbers 1 through 12 labeled correctly in a clockwise fashion, with two arms (of any length) pointing at the correct numbers for the time requested. Any error or refusal to complete the clock is considered abnormal. An algorithm for scoring the Mini-Cog is shown in Figure 1-10. For a Mini-Cog Test result suggestive of dementia, referral to an internist, geriatrician, or neurologist, as available to the patient in that community, is indicated.

Mental Health

Depression and Intimate Partner Violence

For women of all ages, these problems are pervasive and account for significant morbidity and mortality. Each is discussed in detail in Chapter 13 and should be routinely screened for at routine health visits. Simple questions such as “During the past 2 weeks, have you felt down, depressed, or hopeless?” and “Have you felt little interest or pleasure in doing things?” are often effective (Whooley, 1997). These two questions constitute the Personal Health Questionnaire-2 (PHQ2), a validated screening tool for depression (Kroenke, 2003). Any positive screening test should prompt further evaluation for depression as outlined in Chapter 13.

For intimate partner violence, American College of Obstetricians and Gynecologists (2012a) guidelines recommend that physicians routinely ask direct, specific questions regarding abuse. General introductory statements such as “Because abuse and violence are so common in women’s lives, I’ve begun to ask about it routinely” can help a health care provider introduce this subject for discussion.

Insomnia

Insomnia is common, and its definition includes: (1) difficulty initiating sleep, (2) trouble maintaining sleep, and (3) early waking. Insomnia may be primary or may be secondary to other conditions such as depression, time-zone travel, restless leg syndrome, stimulant use, and sleep apnea (National Institutes of Health, 2005). Accordingly, historical inventory investigates and treatment addresses these and other secondary causes.

Treatment of primary insomnia is typically cognitive-behavioral or pharmacologic. Cognitive therapy is aimed at changing patients’ beliefs and attitudes regarding sleep. Behavioral therapies are varied and include those that control sleep timing and duration; attempt to improve the bedroom environment; or focus on relaxation or biofeedback techniques (Morgenthaler, 2006; Silber, 2005). Medications may be used to aid sleep, and most agents are of the benzodiazepine family (Table 1-16).

Preconceptional Counseling

Value lies in counseling women before conception so that each pregnancy is planned with the goal to achieve the best maternal and fetal outcomes. With this in mind, topics found in Table 1-17 are ideally addressed (American College of Obstetricians and Gynecologists, 2012b; Jack, 2008).