A 66-year-old woman comes in or a routine physical examination. Her menopause occurred at age 51 years, and she is currently taking an estrogen pill along
with a progestin pill each day. The past medical history is unremarkable. Her amily history includes one maternal cousin with ovarian cancer. On examination, she
is ound to have a blood pressure o 120/70 mm Hg, a heart rate o 70 beats per
minute, and a temperature o 98°F (36.6°C). She weighs 140 lb and is 5 eet 4 in tall.
The thyroid is normal to palpation. Examination o her breasts reveals no masses
or discharge. The abdominal, cardiac, and lung evaluations are within normal limits. The pelvic examination shows a normal, multiparous cervix, a normal-sized
uterus, and no adnexal masses. She had undergone mammography 3 months
previously.
» What is your next step?
» What would be the most common cause o mortality or this patient?
CASE 29
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ANSWERS TO CASE 29:
Health Maintenance, Age 66 Years
Summary: A 66-year-old woman comes for health maintenance. A mammogram
has been performed 3 months previously.
Next step:Each of the following should be performed: Calculate the body mass
index, send stool for occult blood, colonoscopy, pneumococcal vaccine, influenza vaccine, tetanus and diphtheria vaccines (if not performed within the past
10 years), herpes zoster vaccine, lipid profile, fasting blood glucose, thyroid
function tests, bone mineral density screening, and urinalysis.
Most common cause of mortality: Cardiovascular disease.
ANALYSIS
Objectives
1. Understand which health maintenance studies should be performed for a
66-year-old woman.
2. Know the most common cause of mortality for a woman in this age group.
3. Understand that preventive maintenance consists of cancer screening, immunizations, and screening for common diseases.
Considerations
The approach to health maintenance includes three parts: (1) cancer screening,
(2) immunizations, and (3) addressing common diseases for the particular patient
group. For a 66-year-old woman, this includes annual mammography for breast
cancer screening, colon cancer screening (annual stool test for occult blood and
either intermittent colonoscopy or air contrast barium enema), tetanus, and diphtheria booster every 10 years, the pneumococcal vaccine, annual influenza immunization, and herpes zoster vaccine. She should undergo a lipid profile every 5 years
up to the age of 75 years, thyroid function testing every 5 years, and fasting blood
glucose levels every 3 years. Because urosepsis is common in geriatric patients, a
urinalysis is also usually performed. Osteoporosis screening is indicated for women
of age 65 and over. Finally, the most common cause of mortality in a woman in this
age group is cardiovascular disease.
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APPROACH TO:
Health Maintenance in Older Women
DEFINITIONS
SCREENING TEST: A study used to identify asymptomatic disease in the hope
that early detection will lead to an improved outcome. An optimal screening test
has high sensitivity and specificity, is inexpensive, and is easy to perform.
PRIMARY PREVENTION: Identifying and modifying risk factors in people who
have never had the disease of concern.
SECONDARY PREVENTION: Actions taken to reduce morbidity or mortality
once a disease has been diagnosed.
COST EFFECTIVENESS: A comparison of resources expended (dollars) in an
intervention versus the benefit, which may be measured in life years or qualityadjusted life years.
CLINICAL APPROACH
In each age group, particular screening tests are recommended (Table 29– 1).
Rationale
When the patient does not have any apparent disease or complaint, the goal of
medical intervention is disease prevention. One method of targeting diseases is
by using the patient’s age. For example, the most common cause of death for a
16-year-old person is a motor vehicle accident; hence, the teenage patient would
be well served by the physician encouraging him or her to wear seat belts and to
avoid alcohol intoxication when driving. In contrast, a 56-year-old woman will
most likely die of cardiovascular disease, so the physician should focus on exercise,
weight loss, and screening for hyperlipidemia. In a woman beyond 65 years of age,
if prior Pap smears have been normal, cervical cancer screening is not cost-effective.
Patients who have had a total hysterectomy (removal of uterine corpus and cervix)
do not require vaginal cytology (Pap smears) as long as the patient had no history
of cervical dysplasia. (See Table 29– 2 for cervical cytology screening guidelines).
Tobacco Cessation
The most important modifiable factor contributing to mortality is tobacco use.
Thus, it is crucial that every patient be identified as to whether they are a smoker.
Each patient who is a smoker should be approached on whether they are willing to
stop, and if so, then one of the major effective interventions (bupropion, nicotine
gum, nicotine inhaler, nicotine nasal spray, or nicotine patch) can be offered. Those
unwilling to quit should be given a brief intervention based on the 5 R’s:
Relevance—indicate why quitting is personally relevant.
Risks—help patient to identify negative consequences of smoking.
www.myuptodate.comTable 29–1 • SCREENING BASED ON AGE
13-18 Yr 19-39 Yr 40-64 Yr 65+ Yr
Cancer
screening
• Pap smear: starting at age 21,
q 3 yrs
Age 30, then either pap alone
q3yrs or co-testing (pre erable)
q 5 yrs
• Pap smear co-test q 5 yrs
(pre erable) or pap alone q 3 yrs,
• Stool for occult blood, age 50,
annual
• Colonoscopy, age 50, q 10 yrs
• Mammographya
• Pap smears not needed if hx negative
• Stool for occult blood, annual
• Colonoscopy q 10 yrs
• Mammographya
Immunizations • Tetanus + diphtheria
booster once between
ages 11-18 yrs
• Hepatitis A
• Hepatitis B
• Human papillomavirus,
ages 9-26
• Meningococcus booster,
age 16
• Influenza, annual
• Tetanus + diphtheria q 10 yrs
(substitute TdaP once)
• Human papillomavirus,
ages 9-26
• Meningococcusb, ages 19-21
• Influenza, annual
• Tetanus + diphtheria q 10 yrs
• Influenza, age 50, annual
• Herpes zoster, age 60
• Tetanus + diphtheria q 10 yrs
• Pneumococcal 23 valent vaccine
• Influenza, annual
• Herpes zoster
Other diseases • Gonorrhea + Chlamydia,
annual, i sexually active
• Gonorrhea + Chlamydia,
annual, up to age 25
• HIV, annual
• Lipid profile q 5 y at age 45
• Fasting blood glucose q 3 y at
age 45
• TSH q 5 y at age 50
• HIV, annual
• Lipid profile q 5 y
• Fasting blood glucose q 3 y
• Bone mineral density study at 65
(earlier with risk actors)
• TSH q 5 y
• Urinalysis
Most common
causes of
mortality
• Motor vehicle accidents
• Cancer
• Suicide
• Cancer
• Accidents
• Cardiovascular disease
• Cancer
• Cardiovascular disease
• Accidents
• Cardiovascular disease
• Cancer
• Cerebrovascular disease
aSome experts recommend mammography beginning at age 40 yr whereas others question its ef cacy in decreasing mortality.
bAdminister Meningococcus vaccine to students, ages 19-21, who are in rst year of college or who live in residence halls.
(Data rom ACOG Committee Opinion No. 534, 2012. Washington, DC: American College o Obstetricians and Gynecologists; 2012 [Reaf rmed 2014].)
www.myuptodate.comSECTION II: CASES 293
Rewards—ask the patient to identify benefits of stopping tobacco use.
Roadblocks—identify barriers to quitting.
Repetition—motivational intervention should be repeated.
Screening in HIV-Positive Women
H IV-positive women have specific screening. There is a greater prevalence of
abnormal pap smears and increased risk of progression to high grade disease or
cancer, especially with a lower CD4 count. Pap smears twice in the first year after
diagnosis or entry into care, and if normal, then annually; there does not seem to be
a role for human papillomavirus (H PV) testing in this population. There is no data
for when to discontinue (ie, perhaps continue cytology even after hysterectomy or
after age 65). Although lung cancers occur more often in H IV-infected individuals, there is likely no utility for chest x-ray or sputum screening. There is a higher
incidence of anal cancers in these individuals, and some experts recommend anal
cytology, although there is no consensus. They should receive the usual immunizations except varicella zoster which is usually withheld. They should also receive the
pneumococcal 13-valent vaccine, and if the vaccine is given when the CD4 count is
below 200 cells/ mm3, it should be repeated.
Controversies
Recently, several clinical trials have refuted the clinical utility of the internal pelvic
examination (bimanual examination) for low-risk and asymptomatic women. The
American College of Physicians issued guidelines in 2014 recommending against
performing screening speculum/ bimanual pelvic examination in asymptomatic,
nonpregnant adult women. There is poor sensitivity of the bimanual examination
to detecting adnexal masses. The American College of Obstetricians and Gynecologists recommends annual pelvic examinations and advises that the physician
should discuss the complete (internal speculum and/ or bimanual) examination
with the patient. Women with symptoms such as vaginal discharge, pelvic pain,
urinary incontinence, or pelvic pressure should have a complete examination.
Table 29–2 • SUMMARY OF CERVICAL CYTOLOGY SCREENING
• <21 years: No screening recommended
• 21-29 years: Cytology (Pap smear) alone every 3 years
• 30-65 years (two options): Cytology with HPV cotesting every 5 years (preferred) or cytology
alone every 3 years (acceptable)
• 65+ years: No screening recommended if adequate prior screening has been negative and high
risk is not present
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COMPREHENSION QUESTIONS
29.1 A 59-year-old woman is being seen for a health maintenance appointment.
She has not seen a doctor for over 10 years. She had undergone a total hysterectomy for uterine fibroids 12 years ago. The patient takes supplemental calcium. The physician orders a fasting glucose level, lipid panel, mammogram,
colonoscopy, and a Pap smear of the vaginal cuff. Which of the following
statements is most accurate regarding the screening for this patient?
A. The Pap smear of the vaginal cuff is unnecessary.
B. In general, colon cancer screening should be initiated at age 50 but this
patient has very sporadic care, therefore colonoscopy is reasonable.
C. Because the patient takes supplemental calcium, a DEXA scan is not
needed.
D. Pneumococcal vaccination should be recommended.
29.2 A 63-year-old woman has had annual health maintenance appointments and
has followed all the recommendations offered by her physician. The physician counsels her about varicella zoster vaccine. Which of the following is the
most accurate statement about this vaccine?
A. This vaccine is recommended for patients who are aged 50 and older.
B. This vaccine is not recommended if a patient has already developed
shingles.
C. This vaccine is a live-attenuated immunization.
D. This vaccine has some cross-reactivity with herpes simplex virus and
offers some protection against H SV.
29.3 An 18-year-old adolescent female is being seen for a health maintenance
appointment. She has not had a Pap smear previously. She currently takes oral
contraceptive pills. She began sexual intercourse 1 year previously. Which of
the following statements is most accurate regarding health maintenance for
this individual?
A. A Pap smear should not be performed in this patient at this time.
B. The H PV vaccine should be administered only if she has a history of
genital warts.
C. The most common cause of mortality for this patient would be suicide.
D. Hepatitis C vaccination should be offered to this patient.
www.myuptodate.comSECTION II: CASES 295
29.4 A 39-year-old G1P1 woman who is H IV positive is being seen for a well
woman examination. The CD4 count is 600 cells/ mm3. She had a mammogram and cervical cytology 1 year ago which were both negative. Which of the
following is most appropriate at this time?
A. Chest x-ray
B. Colonoscopy
C. Mammography
D. Cervical cytology
E. Pelvic ultrasound for ovarian cancer screening
ANSWERS
29.1 A. Cervical cytology of the vaginal cuff is unnecessary when the hysterectomy was for benign indications (not cervical dysplasia or cervical cancer)
and when there is no history of abnormal Pap smears. Colon cancer screening
is generally started at age 50. DEXA scan for osteoporosis screening should
be considered in any postmenopausal woman at risk, such as having an osteoporosis-related fracture, a family history, or being thin and Caucasian. Pneumococcal vaccine is generally given at age 65.
29.2 C. The varicella zoster vaccine is a live-attenuated vaccine, recommended for
individuals aged 60 and above, and has been shown to greatly reduce the incidence of herpes zoster (shingles), and the severity and likelihood of postherpetic neuralgia. It has no efficacy in preventing H SV.
29.3 A. Cervical cytology should be deferred until age 21. Adolescents frequently
clear the H PV infection and allow an abnormal Pap smear to return to
normal. Smoking inhibits the ability to clear H PV. The delayed screening
prevents unnecessary and costly diagnostic procedures. The H PV vaccine
should be recommended to all females between the ages of 9 and 26 regardless of exposure. The most common cause of mortality for adolescent females
is motor vehicle accidents. The hepatitis C vaccine is undergoing testing for
safety and efficacy and is not currently available.
29.4 D. Annual cervical cytology is indicated for H IV-infected women, and usually without H PV cotesting, since the prevalence is so high that there is little
differentiation on triaging based on the result. There is no definite end date
(age) to cervical cancer screening in these patients. Mammography and colon
cancer screening is the same as H IV-negative patients.
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CLINICAL PEARLS
» The basic approach to health maintenance is three old: (1) cancer
screening, (2) age-appropriate immunizations, and (3) screening or
common diseases.
» The most common cause o mortality in a woman younger than 20 years
is motor vehicle accidents.
» The most common cause o mortality o a woman older than 39 years is
cardiovascular disease.
» Major conditions in women aged 65 years and older include osteoporosis,
heart disease, breast cancer, and depression.
» Cervical cytology screening does not appear to be cost-e ective in
women older than age 65 when prior Pap smears have been normal.
» Tobacco use is the single most important modi iable risk actor contributing
to mortality.
REFERENCE
American College of Obstetricians and Gynecologists. Low bone mass (osteopenia) and fracture risk.
ACOG Committee Opinion 407. Washington, DC; 2008.
American College of Obstetricians and Gynecologists. Well-women visit. ACOG Committee Opinion
534. Washington, DC; 2012. (Reaffirmed 2014.)
American College of Obstetricians and Gynecologists. Primary and preventive care: periodic assessments. ACOG Committee Opinion 483. Washington, DC; 2011.
Centers for Disease Control. Immunization schedule for adults, 2015. www.cdc.gov/ vaccines/ recs/
schedules/ adult-schedule.htm#everyone. Accessed 25.08.2015.
Centers for Disease Control. Immunization schedule for persons 7 through 18 yrs, 2015. www.cdc.gov/
vaccines/ recs/ schedules/ downloads/ child/ 7-18 yrs-schedule-pr.pdf. Accessed 25.08.2015.
Qaseem A, H umphrey LL, H arris R, et al. Screening pelvic examination in adult women: a clinica
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