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CMDT 2013
42
Women’s Health Issues Megan McNamara, MD, MSc, & Judith Walsh, MD, MPH
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 evidencebased 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.
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PREVENTIVE HEALTH CARE
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. 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 A. Hypertension Hypertension is a risk factor for CHD and stroke in both men and women. 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).
B. 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 (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