WOMEN'S HEALTH
missed by mammography alone. The clinical breast exam provides
us with the opportunity to detect a palpable breast cancer that might
be missed by mammogram. We are also diligent in making sure the
patient has been referred for mammography if age appropriate. The
breast exam includes educating patients on breast self-awareness and
assessing their lifetime risk of breast cancer. This may also include
an opportunity to refer patients for genetic counseling and testing.
Speculum examination for cervical cancer screening begins
at age 21. Testing for STDs can be done on urine screening in
young women who do not need a speculum exam. Cervical cancer
screening can then be done every one to five
years based on whether or not co-testing with
HPV is performed. If a patient does have a
history of vulvar intraepithelial neoplasia,
history of cervical intraepithelial neoplasia,
is infected with HIV, has been exposed to
diethylstilbestrol in utero, or is immune
compromised, a yearly Pap smear may still
be performed. These indications also apply
for those patients that have had a hysterec-
tomy and may need a vaginal Pap smear. An
annual exam of the external genitalia should
always be performed. If a patient has had a
total hysterectomy and bilateral salpingo-oo-
phorectomy for benign indications, she may
not need an internal pelvic exam. Most ob-
stetricians/gynecologists do perform a rectal
exam on women after age 40. Anal cancer is
becoming more common in women, and in
my experience I diagnose one case yearly.
This is also an opportunity to perform a fecal
occult blood test and talk to the patient about
appropriate colon cancer screening.
"At the end of
the day, I hope
that I have
made a differ-
ence in the life
of at least one
patient that I
have seen that
day."
Some areas of special interest to the obstetrician gynecologist are
menopausal health and bone health. Many obstetricians/gynecol-
ogists evaluate for low bone density as the fastest rate of bone loss
occurs in the first five years after menopause. The bone density scan
is a very reproducible tool to evaluate fracture risk in women. In
women with low bone density, recommendations are usually made
to screen for hypercalciuria, hyperparathyroidism, hyperthyroidism,
celiac disease, vitamin deficiencies and multiple myeloma. Both the
primary care physician and the gynecologist play a role in advising
women on treatments for low bone density.
Menopause signals a new chapter in a woman’s life, which is often
accented by hot flashes, night sweats, insomnia, mood swings, sexual
dysfunction, changes in body shape and weight and other increases
in health problems. Nearly one-third of this country’s women are
16
LOUISVILLE MEDICINE
post-menopausal, and yet three-fourths of these women are often
not being treated for their menopausal symptoms. Hormone replace-
ment therapy was the primary treatment for menopausal symptoms
until the Women’s Health Initiative data was released in 2002. This
was a large study of almost 46,000 women ages 50-79 looking at
the effects of an oral combination of estrogen and progesterone vs
non-hormone users. In the women who were on oral estrogen and
progesterone, there was a statistically significant increase in heart
attack, stroke, blood clots and breast cancer. There was a decrease
in the risk of fragility fracture and the risk of colon cancer.
After the results of this study were re-
leased, there was a significant decrease in
the number of women who continued on
hormone replacement therapy or who started
hormone replacement therapy. It now ap-
pears that if the data is reevaluated according
to age, that the outcomes are not necessarily
true for women between the ages of 50-60.
Hormone replacement users in their 50s ac-
tually have a lower risk of all cause mortality
including cancer and heart disease. Women
ages 50-59 who have undergone hysterecto-
my with removal of ovaries and do not go
on estrogen therapy die earlier from car-
diovascular disease. All of the recent data
indicate that there is a critical window in
early menopause between 50-60 where it is
beneficial to use HRT for a brief period of
time. The data still indicate that breast can-
cer incidence does increase from long-term
use of combined progesterone and estrogen.
When vasomotor symptoms decline, discon-
tinuation of systemic hormone replacement should be considered
in that long-term use of these medications in women over 65 has
more risk.
It is also important to look at the route of administration of
estrogen therapy. It is clear that oral estrogens increase the risk
of venous thromboembolism and stroke two to five fold. This is
even greater if a patient has preexisting risk factors such as obesity,
increased age, cardiovascular disease, diabetes or any known throm-
bophilia. Conversely, low dose transdermal estrogen therapy (.05
mg patch or less) in the form of a patch or gel has not been shown
to increase thromboembolism. This is in contrast to oral estrogens
which increase the levels of prothrombotic substances due to the
first pass effect in the liver.
There is also no data proving that low dose vaginal estrogen for
the treatment of vaginal atrophy and dyspareunia has any increase