Anticoagulation

Anticoagulation inpatients with atrial fibrillation will definitely reduce the risk of primary stroke by 48-72 i Warfarin was significantly more effective than aspirin as prevention for both primary and second strokes. Guidelines suggest warfarin use in patients of any age with atrial fibrillation and any of the risk factors for stroke listed in Table 13.3. Anticoagulation for patients in normal sinus rhythm is not indicated and even increases the risk of hemorrhagic stroke.

Clinical breast examination

Whether health professional-performed CBE is an adequate, sufficient, or effective tool for screening by itself is disputed. The efficacy of CBE is dependent on the amount of time the provider spends. Its sensitivity has been estimated at 54 , with a specificity of 94 .8 In women aged 50-59 years, one large RCT found that CBE alone was as effective as mammography, although mammography was more sensitive in detecting small cancers.9 Other studies found that CBE diagnosed a percentage of breast...

Lung cancer prevention and screening

Lung cancer is the most common cancer in men. In women, it is the third most common cancer, but the most common cancer cause of death. It is estimated to have caused more than 65 700 deaths in women in the USA in 2002.2 In the UK, lung cancer accounts for one out of 6.5 deaths from cancer - more than 30 000 in 1996.6,16 Because women have recently been smoking cigarettes in greater numbers, quitting in smaller numbers, and smoking for 30 years or more, the incidence of lung cancer in women may...

Difficulttotreat hypertension

Hypertension may be difficult to control because the blood pressure levels have been measured inaccurately, because the disease has progressed with time, because it is caused by another disease or medication, and or because the medication used is suboptimal. The patient may be taking too much sodium and or inadequate diuretics. Certain medications or diets may interfere with blood pressure medicines (Table 13.1) 2. One in ten individuals uses non-steroidal anti-inflammatory drugs (NSAIDs), and...

Beneficial effects of alcohol consumption

Before the age of 60, breast cancer is a more important cause of death than heart disease. Later on, the risk of heart disease exceeds that of breast cancer, so the benefits of moderate drinking are more apparent. The consumption of at least one drink a day by mid-life and elderly women is associated with a 20 reduction in the risk of cardiovascular disease compared with non-drinkers.38 Like men, women appear to experience a U-shaped relationship between alcohol consumption and coronary artery...

Environmental factors

Stress is considered to be a major component in the initiation and continuation of drug use as well as relapse. Smokers often state that they smoke more when stressed, partly because cigarette smoking is anxiolytic. Stress frequently provokes smoking relapse. Emotional trauma and impaired social circumstances are also vulnerability factors for problem drinking in women. Women are more likely than men to self-medicate with alcohol they often attribute the start of their problem drinking to a...

Aspirin for primary prevention

Aspirin has a role in preventing CHD in women. A study of more than 87 000 women showed that those who took a low dose of aspirin regularly were less likely to have a first MI than women who took no aspirin.35 However, regular aspirin ingestion is associated with side effects such as gastrointestinal bleeding and hemorrhagic stroke. The risk benefit ratio for aspirin to decrease the incidence of CHD is favorable if the woman's risk of CHD is greater than 1.5 per year. 36,37 The risk of CHD can...

Evaluation

First, a precise definition of bowel pattern is necessary, including number of stools, color, associated blood or mucus, consistency, and whether the stool is fatty, foul-smelling, and floats in the toilet. A history of travel, ownership of pets, chronic or frequent use of antibiotics, the duration of the diarrhea, its Table 21.2 Common causes of chronic diarrhea Irritable bowel syndrome Inflammatory bowel disease Endocrine causes Diabetic diarrhea Hyperthyroidism Chronic infectious diarrhea...

Diabetes complications

The complications of diabetes develop over manyyears and include microvas-cular disease (neuropathy, retinopathy, nephropathy) and macrovascular disease (myocardial infarction, stroke, peripheral vascular disease). Given the chronicity of diabetes, the increasing evidence that improving glycemic control in type 1 diabetes31 and type 2 diabetes32 can decrease microvascular complications and ameliorate macrovascular complications has been encouraging. Prevention and management of diabetes...

Inflammatory bowel disease

Individuals with inflammatory bowel disease, particularly those with ulcerative colitis, have an increased risk of colon cancer and need more frequent and ongoing follow-up. Cancer in this setting develops from dysplastic mucosa rather than polyps and, thus, evaluation by colonoscopy is more difficult. In addition, random biopsies every 10 cm and biopsies of suspicious areas are suggested throughout the colon during colonoscopy, although the efficacy of this screening is uncertain.14 Risk of...

Phytoestrogens

Studies of phytoestrogens, naturally occurring substances found in most plants, have yielded conflicting results. Phytoestrogens are classified as phenolic estrogens, contrasted with steroidal estrogens, such as estradiol, which are manufactured by human ovaries. They are weaker than steroidal estrogens, with a potency of 1 20 000 to 1 50 that of estradiol. They mimic many estrogen effects in the body. Isoflavones are the most estrogenically potent of the five most common types of...

History and pelvic examination

Retrospectively, symptoms have been reported by 78 of patients with early tumor diagnosis, including abdominal pelvic pain (35 ), bloating (32 ), and vaginal bleeding (19 ).26 Clinicians providing primary care to women will recognize that abdominal and pelvic complaints are common. Diagnostic investigations in the setting of the above symptoms may be more properly considered case-finding than screening, and the yield of an ovarian cancer diagnosis may be low compared with other diagnoses. The...

Clinical presentation

The presentation of depression in a middle-aged woman may be complex and or difficult to recognize. A high index of suspicion is required. Women often are reluctant to view themselves as depressed, do not directly complain of a depressed mood, or are hesitant to discuss emotional concerns. Depression may also be masked by physical or vegetative features that are more prominent than mood symptoms. Depressed women commonly present with non-specific complaints of tiredness, low energy, malaise,...

Hormonal fluctuations

Women have more erratic fluctuations in their hormonal status compared with men. Estrogens and progesterone rise to high levels during pregnancy, only to drop abruptly postpartum as prolactin levels elevate. Perimenopause is now recognized as a unique physiological entity, with dropping levels of estrogen and an even greater loss of progesterone as ovulationbecomes inconsistent. The perimenopausal state can last years before menopause. Based on the results of small studies, the perimenopausal...

Regular physical activity

Moderate levels of physical activity have significant effects on a woman's health. Burning approximately 150 kilocalories per day or 1000 kilocalories per week leads to a reduction in the risk of coronary heart disease by 50 and of hypertension, diabetes, and colon cancer by 30 .2 After adjusting for covariates such as age, smoking, alcohol use, history of hypertension, and history of high cholesterol, women who are regularly physically active are 50 less likely to develop type II diabetes...

Nutritional prevention

Bone mineralization depends on adequate nutritional status in childhood and adolescence. Therefore, measures to prevent osteoporosis should begin with improving the nutritional status of adolescents to increase bone mineralization, including increasing milk intake.6 Because other nutrients Table 14.1 Risk factors for osteoporosis Excessive alcohol use Long-term use of certain drugs Postmenopausal status Low body weight Impaired calcium absorption besides calcium are essential for bone health,...

Screening and early detection The Pap smear

The Pap test is one of the better tests for detecting precursors of cancer. If followed by evaluation and treatment, it significantly reduces the mortality from cervical cancer. The purpose of the Pap test is to detect and treat cervical intraepithelial neoplasia (CIN) and, thus, prevent invasive cancer. Of those women treated for CIN, the likelihood of cure and survival is nearly 100 . Most women who develop cervical cancer have never had a Pap test, or have not had one in the past ten years....

Intrauterine devices

Intrauterine devices (IUDs) continue to be used, although their exact mechanism of action remains unclear. Constructed of plastic, metal, or combinations, IUDs offer long-term contraception at a relatively low cost. Furthermore, devices require a single procedure for insertion, may be inserted by properly trained non-physicians, and allow for restored fertility soon after removal. No compelling evidence exists to suggest that infertility rates are significantly higher than in non-IUD wearers...

Relational aging

The many roles women fulfill in the family and culture may transition over the mid-life years. There is no distinct orderly sequence for this series of transitions, because they are dependent upon the individual woman's life circumstances. Shifting demographics in modern Western culture have altered norms for ages of partnering, marriage, childbearing or choosing not to have children, and entering or leaving the workplace. As a woman enters the mid-life years, she may progress in orderly...

Symptoms and signs

The history and physical examination are important in screening for secondary forms of osteoporosis and directing the evaluation, although they are neither sensitive enough nor sufficient for diagnosing primary osteoporosis. A medical history provides valuable clues to the presence of chronic conditions, behaviors, physical fitness, and or the use of long-term medications that could influence bone density. Patients already affected by complications of osteoporosis may complain of upper or...

Summary

Although decline in sexual activity is reported for aging women, in general women are no less interested in sexual activity as they age, but they and their sexual partners are affected more often by chronic illness and changes in physiology. Sexual difficulties remain common for mid-life and older women, including increase in difficulty for single women to find consistent partners in their age group. Clinicians are encouraged to raise the topic of sexual health and to assist mid-life women as...

Alcoholics Anonymous Women for Sobriety and 12step facilitation therapy

Alcoholics Anonymous (AA) is a worldwide spiritual program that addresses people from all social strata. Group members share their experiences in a confidential environment and provide each other with help and support in order to maintain sobriety. AA and similar self-help groups follow 12 steps that alcoholics should work through during recovery. There are women-only AA groups. Twelve-step facilitation (TSF) is a formal treatment approach incorporating AA and similar 12-step programs.46 Women...

Immediate treatment detoxification the control of alcohol withdrawal syndrome

In heavy, chronic drinkers, withdrawal symptoms begin 6-48 hours after the last drink, peak within 24-48 hours, and gradually resolve within five to seven days. The severity of withdrawal symptoms increases with each withdrawal episode. Severe withdrawal (grand mal convulsions, delirium tremens) occurs in 2-5 of heavy-drinking chronic alcoholics. With treatment, mortality is about 1 , death usuallybeing caused by cardiovascular collapse or concurrent infection. Benzodiazepines are used widely...

Prevention of coronary heart disease in women

Ulstad, M.D., M.P.H., M.P.A., F.A.C.C. Case 1 a 62-year-old woman comes to you as a new patient. She has no complaints but needs preventive care. She smokes one pack of cigarettes per day and is on no medications. She does no regular physical exercise and has a desk job. She has no chronic medical problems. Her blood pressure is 150 90 mmHg, and she has a body mass index (BMI) of 38 kg m2 and a waist-to-hip ratio of 1.2. There are no other physical exam abnormalities. You order...

Dietary factors

Dietary factors have been postulated as a means of risk reduction in multiple common malignancies. One Chinese case-control study found a significantly reduced odds ratio for ovarian cancer in women who drank green tea, which was dependent on frequency and duration.43 A US case-control study of women in Hawaii and Los Angeles found a significant reduction in the odds ratio for ovarian cancer in women with the highest quartile of dietary calcium intake compared with the lowest quartile, with a...

Longterm relationships

Lack of spontaneity, routine, and attention to matters other then sexual relationships can add particular challenges to long-term relationships. The earlier erotic nature of the newness of the relationship becomes replaced by a predictable and less prioritorized sexual exchange. Responsibilities of paying bills, concerns about health, and caringfor children, grandchildren, or agingparents can take priority over the time the couple has to spend with each other. Quality of life, satisfaction with...

Lifestyle changes and nonpharmacological therapy

The primary treatment of hypertension definitely starts with lifestyle changes, especially in individuals with borderline hypertension. Diet and weight reduction, if needed, are the primary treatments. A low-fat, low-salt diet is important. Weight loss of 10-20 may obviate or reduce the need for pharmacological therapy. Patients who lose weight may be able to stop medication. A weight loss of 10 kg may reduced a woman's risk of hypertension by 26 . Alternatively, an increase in weight of 1 kg...

Addressing glucocorticoidinduced osteoporosis

Glucocorticoids are used widely in the treatment of many chronic diseases, particularly asthma, chronic lung disease, and inflammatory and rheumato-logic disorders, and in people who have undergone organ transplantation. The risk that oral steroid therapy poses to BMD, among other side effects, has been known for some time. As a result, clinicians have eagerly substituted inhaled steroids in an endeavor to partially protect the patient from unwanted negative steroid effects. Recent evaluations...

Physical and laboratory assessment

Physical examination and laboratory investigations serve primarily to identify comorbid conditions that could have precipitated the episode of MDD and or are likely to complicate its management. Investigations are targeted to the needs of the individual patient. They may include complete blood count, thyroid studies, assessment of electrolyte (sodium, potassium, calcium) and glucose levels, and evaluation of hepatic and renal function. Menopausal status maybe confirmed by increased levels of...

Anxiety

The anxiety disorders are characterized by maladaptive, abnormal response to perceived threats or stressors, with resulting mood, cognitive, or physical symptoms (Table 7.6).37 They are the most common psychiatric disorders, with a lifetime prevalence of nearly 25 in the USA.38 Women are twice as likely as men to develop panic disorder, simple phobia, post-traumatic stress disorder, and generalized anxiety disorder, and are at increased risk for obsessive-compulsive disorder and social...

Comorbidity with other psychiatric disorders

Alcoholism is complicated by the fact that, particularly in women, it is often accompanied by other psychiatric disorders therefore, a holistic approach is required for treatment. Comorbid conditions include tobacco use, drug abuse, major depression, anxiety disorders, bulimia nervosa, and antisocial personality disorder (ASPD).4 Alcohol problems predict the subsequent use of tran-quilizing drugs in older women.5 Severe alcoholism, impulsivity, and suicidal tendencies also tend to coexist but...

Evaluation of abnormal Pap test

Assuming an adequate specimen, normal or negative Pap test results can be followed as in Table 17.1. Controversies and variation in consensus of the evaluation of other readings occur. Atypical cells of undetermine sequence (ASCUS) may be the reading that causes much of the difficulty. One wants to neither overinvestigate with invasive procedures nor miss a cervical cancer before cure is possible. Use of HPV testing, often done routinely by the laboratory if ASCUS is detected, may determine a...

Definitions

Diabetes mellitus refers to a group of common metabolic disorders characterized by hyperglycemia. Diabetes may be type 1 (juvenile-onset or insulin-dependent diabetes mellitus - IDDM), type 2 (adult-onset or non-insulin-dependent diabetes mellitus - NIDDM), or gestational (during pregnancy). In type 1 diabetes, hyperglycemia is caused by an absolute deficiency of insulin secretion. In type 2 diabetes, hyperglycemia is caused by a combination of insulin resistance and inadequate compensatory...

Diagnosis

An individual with stroke presents with the sudden onset of a focal neurological deficit. Clinical history and physical examination cannot distinguish a thrombotic from a hemorrhagic stroke, although the symptoms of a thrombotic stroke may resolve within an hour while those of a hemorrhagic stroke seldom do. Radiological examination is imperative. A computed tomography (CT) scan done within two weeks should distinguish between the types of stroke. Magnetic resonance imaging (MRI) may show a...

Diabetes prevention program

Type 2 diabetes is a preventable disease for both men and women if obesity and physical inactivity can be modified with lifestyle changes. The Diabetes Prevention Program (DPP) research group conducted a large, randomized, controlled trial to compare directly the effects of lifestyle modification and medical therapy with metformin in the prevention of diabetes.12 In this study, more than 3200 US adults at high risk for the development of type 2 diabetes were randomized to standard lifestyle...

Pap smears

Although the major reason for periodic Papanicolaou (Pap) smear screening is the detection of cervical dysplasia and squamous cervical carcinoma, endometrial pathology may be detected by cytologic examination on routine Pap smears. Benign endometrial cells are detected in Pap smears more frequently in women on HRT than in women who are not on HRT, and abnormal endometrial histology is less frequent in follow-up of women on HRT than in women with endometrial cells who are not on HRT.30...

Hormonal changes at menopause

Estrogen levels in postmenopausal women are one-tenth of those in premenopausal women. Postmenopausal estrogens are produced by the adrenal glands and fat cells rather than the ovary, the primary source of premenopausal estrogen. Estrone, produced by fat, replaces estradiol as the main source of estrogen. HT approximately doubles the estrogen level of a postmenopausal woman. After menopause, progesterone is essentially absent. Another hormone that declines around the time of menopause is...

Technique

Non-selective endometrial biopsy (EMB) or sampling is learned easily and can be performed safely and conveniently in ambulatory settings. It is useful to keep several biopsy instruments in the office setting, since different patients may require different methods for obtaining a good sampling of tissue. The procedure carries an extremely low incidence of complications, the most important being uterine perforation. Since bacteremia is possible with the procedure, patients needing bacterial...

Eating disorders

Eating disorders are associated most commonly with younger women -teenagers and young adults. Anorexia nervosa rarely persists into later life, but without successful treatment it may be fatal. When anorexia does last into mid life, serious health consequences can arise due to prolonged malnutrition. These include heart failure, liver damage, and hypokalemia-induced arrhythmias. In contrast, bulimia and binge eating can persist for years and may be associated with obesity. Purging is less...

Alternative therapies

Alternative therapies, such as yoga and t'ai chi, have also demonstrated positive improvements in health.36-38 Yoga involves various standing, seated, and supine postures and breathing and relaxation techniques designed to enhance functioning of the various physiological systems by supporting a natural posture. T'ai chi incorporates slow body movements, called forms, that concentrate on balance and body-weight transfers. Young and old men and women have performed yoga and t'ai chi for centuries...

Dietary factors that may decrease risk

An association exists between consumption of fruits and vegetables and decreased incidence of lung, oral, esophageal, gastric, and colon cancer.5 One should eat five or more servings of fruits and vegetables per day. Food sources are superior to Table 3.3 Foods not found to be associated with an increased risk of cancer Foods contaminated by pesticides and herbicides supplements. Tomatoes in particular (with a small amount of added fat) are thought to aid in cancer prevention. Arandomized...

Difficulties with orgasm

Difficulties with orgasm are related most often to lack of understanding of what sort of sexual stimulation is required, difficulty communicating this need to one's partner, or lack of the partner's initiative to provide this stimulation. Additionally, medications, most notably psychotropic agents, can prolong arousal, making orgasm very difficult to attain. Androgen deficiency is believed to contribute to the higher threshold required for orgasm and the lower intensity for orgasm.14 Exploring...

Implications for work with midlife women

The medical orientation of training has been to approach life stages that are marked by biological events, such as birth and menopause, as pathological Table 4.1 Psychosocial factors to explore when caring for mid-life women Assess life stage as opposed to chronological age Identify care-giving roles and their meanings Appreciate the multiple spheres of work (home, job, community, etc.) and how each one brings rewards and stressors Review self-care behaviors (exercise, diet, social supports,...

Genetic counseling and testing

Genetic testing results in useful information about a mutation if the testing is performed with an affected individual in the family. Once the presence of a mutation is established, genetic testing maybe offered to the rest of the family to determine whether other individuals carry the mutation. Several considerations that may make counseling or testing unacceptable to a woman include a fear of stigmatization or discrimination by insurance companies (health or life),52 lack of health insurance...

Calcium and vitamin D

Calcium supplementation produces small beneficial effects on bone mass throughout postmenopausal life and may reduce fracture rates by more than the change in BMD would predict -possibly as much as 50 .27 Postmenopausal women receiving supplemental calcium over a three-year period in a placebo-controlled, randomized clinical trial had stable total body calcium and bone density in the lumbar spine, femoral neck, and trochanter compared with the placebo group.28 Vitamin D increases calcium...

Balancing intake and output

Perhaps the most important characteristic of a healthy diet is balance - a balance of food types and a balance of intake and output. To maintain a stable weight, one must burn off as much as one has taken in. Therefore, a healthy diet is always connected closely with healthy levels of activity (see Chapter 2 for details on exercise). Two models that are useful regarding the proper balance of food types are the Food Pyramid and the New American Plate. The Food Pyramid, developed by the US...

Prevention of diabetes

In April 2002, the ADA published a position statement on the prevention or delay of type 2 diabetes.9 This statement reviews the evidence for the benefits of prevention, which people to screen, and how to implement prevention programs. Screening should occur during the regular office visit with either FPG or two-hour OGTT. If impaired glucose tolerance (IGT, defined as glucose > l40 mg dl but < 200mg dL on OGTT) or impaired fasting glucose (IFG, defined as FPG level of > ll0 mg dl but <...

Dietary factors that may increase risk

Alcohol has been associated with cancer of the mouth, pharynx, larynx, breast, esophagus, cervix, and liver. Women should limit intake of alcohol to no more than one drink per day (360 ml beer, 150 ml wine, 30 ml 100-proof spirits). Women who are at high risk for breast cancer may consider not drinking any alcohol. The combination of alcohol and tobacco use increases risk far more than either one alone. Obesity is associated with increased risk of colon, breast, and endometrial cancers....

Screening

The US Preventive Services Task Force (USPSTF) has made an A recommendation that all individuals over age 50 years should be screened for colon cancer. There is a variety of methods of screening, most of which are equally effective, but they carry different risks and benefits. Fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and a combination of these three methods are all considered valid screening methods (Table 20.2). However, Table 20.1 Lifetime risk of colon cancer Two...

Conclusion

Detecting and treating alcohol problems in mid-life women can be both challenging and complex because of the secrecy, the layers of comorbidity, and the frequent undercurrent of (often suppressed) past adverse life events, particularly childhood sexual abuse. Nevertheless, family physicians are in a good position to diagnose and treat problem drinking because most adults visit their primary care physician at least once every two years and women in particular usually consult their physicians...

Treatment of problem drinking the use of brief intervention in family practice

The family physician can play a key role in recognizing problem drinking and can often intervene successfully, particularly in the early stages. Several formal screening instruments for problem drinking alcoholism are available.2 Brief intervention is a short-term, counseling strategy based on motivational enhancement therapy that concentrates on changing patient behavior and increasing patient compliance with therapy. It is designed for health professionals who are not specialists in...

Herbal preparations black cohosh

The German Commission E Monographs report that black cohosh has estrogen-like actions, suppresses LH, binds to estrogen receptors, and lacks contraindications to its use. Side effects include gastric discomfort, sweating, weight gain, and headache. A six-month trial funded by the manufacturer of one black cohosh product reported that women benefited from a 70 reduction in symptoms such as hot flushes, mood swings, night sweats, and insomnia. Higher doses did not improve symptoms.70 Overdose can...

Irritable bowel syndrome

IBS is an ill-defined syndrome consisting of abdominal pain, bloating, cramping and a change of bowel habits - constipation or diarrhea, or both - without any other diagnosed gastrointestinal condition and without evidence of other organic or anatomic disease.9 It accounts for 12 of visits to primary-care physicians and 28 of visits to gastroenterologists, accounting for 30 million individuals in the USA.10,11 It has been considered a diagnosis of exclusion. Criteria for diagnosis of IBS have...

Diagnostic criteria

Diagnostic criteria and classification schemes for diabetes have been proposed and published by the ADA and the WHO.5'6 In January 2002, the ADA published revised criteria for the diagnosis of diabetes, which state that diabetes can be diagnosed by any one of three criteria (Table 15.3). In the absence of unequivocal hyperglycemia with metabolic decompensation, the criteria should be confirmed by repeat testing on a different day. The OGTT is not recommended for routine clinical use, but it...

Spermicidal devices

These devices come in various preparations, including jellies, suppositories, creams, and foams. They provide a direct killing effect on sperm while also forming a physical barrier between the vagina and the cervix. The effectiveness of a properly applied, non-defective condom with a properly applied spermicidal device has a failure rate of virtually zero. Though not optimally effective as a prevention strategy for sexually transmitted disease (STDs), evidence suggests that spermicidal...

Other herbs and botanicals

Studies have not demonstrated efficacy for evening primrose oil, ginseng, red clover (alone), chasteberry, or dong quai compared with placebo.73,74 Dong quai may act as a photosensitizing agent. It may contain warfarin-like compounds, resulting in a potential for many drug and herbal interactions. St John's wort may be useful in women with mild to moderate mood disorder, but not for menopausal symptoms themselves. It is potentially photosensitizing and can interact with selective serotonin...

Developmental issues for the midlife woman

Women in the USA are presented with two predominantly negative scripts of the mid-life experience. One script is of a medicalized focus on menopause as a time of transition from a healthy, estrogen-rich time of life to the stage of inevitable health decline, with an attendant increased risk of heart disease and osteoporosis. The other readily available scenarios are social descriptions of an empty nest, abandonment for the woman, or that of a useless, used-up fertility has-been.1 Both of these...

Endurance training

Case Sarah is a 42-year-old bank teller with no cardiac risk factors and who was found to have a fasting total cholesterol level of 299 mg dl with a low-density lipoprotein (LDL) cholesterol level of 179 mg dl at a recent screening. After three months of vigorous change of diet to a low-fat diet, she returns for a fasting lipid profile. Total cholesterol has only decreased to 245 mg dl, with an LDL of 145 mg dl. She asks what else she can do without starting on pharmocotherapy. You suggest...

Risks of hormone therapy

Any discussion of HT risks must include the baseline risks of women not using HT or ET (Figure 10.2). Table 10.4 outlines the probability that a menopausal woman will develop chronic disease Another useful perspective maybe gained by comparing these risks with risks from some common everyday activities (Table 10.5). One out of 100 women who use HT for one year will experience a net additional adverse outcome compared with non-users. Safer preventive strategies for most chronic conditions are...

Pharmacotherapy

Avariety of classes of laxatives can help induce more normal bowel movements. If an immediate effect is not needed and a long-term treatment is required, then bulk laxatives, which are a form of non-starch polysaccharides, are useful.2 These include wheat, plant-seed mucilage, and methylcellulose. Ispaghula, plant-seed mucilage, and psyllium are available in a variety of formulations that are swallowed with water. They ferment in the colon and can quadruple fecal bulk. More immediate therapy or...

Genetic factors

Inheritable vulnerability factors for addiction can be classified broadly into three categories. First, having certain heritable personality traits may predispose an individual to seek out and consume large quantities of alcohol (self-medication) and, therefore, increase their chances ofbecoming addicted. Neuroticism and anxious temperament have been associated with alcoholism in women but not men.10,11 Neuroticism is also associated strongly with the development of nicotine withdrawal in...

Selective estrogen receptor modulators

Raloxifene, the first of a new class of drugs, termed selective estrogen receptor modulators (SERMs), has estrogen agonist effects on bone and antagonist effects on breast and endometrium. It blocks estrogen in a similar manner to tamoxifen, while also binding and stimulating other tissue receptors to act like estrogen. Raloxifene inhibits trabecular and vertebral bone loss in a manner similar, but not identical, to estrogen - i.e. by blocking the activity of cytokines that stimulate bone...

Chronic lung disease

S.L. is 58 years old and a smoker since she was 13. She just cut back from two packs a day to one. She's experiencing more frequent acute exacerbations of her chronic bronchitis, and her recovery seems to take longer each time. She is worried that she seems to be losing more and more weight with each bout of bronchitis. She's read that fish oil is supposed to be good for your lungs, and wonders if there's anything she can do with her diet to help. Table 3.5 Ways to improve diet of patients with...

Exercise prescription for healthy populations

The type of exercise performed depends on the desired goal. If a woman wants to build muscular strength, then resistance training is appropriate. Endurance training (walking, running, cycling, swimming) is required if a woman wants to improve her cardiovascular health and endurance. Yoga and t'ai chi are therapeutic alternatives to the rigors of strength and endurance training that can reduce stress, increase strength and flexibility, and improve cardiovascular parameters. A certified yoga or...

Rhythm methods

Also known as periodic abstinence or natural family planning, this method is based on the knowledge of the relatively small window of fertility during the menstrual cycle. The premise is simple - timed coitus to minimize the likelihood of a released ovum and sperm meeting in the oviduct. The period of fertility extends for two to three days following ovulation. Women must attempt to predict ovulation accurately. Generally, the three established methods in increasing reliability and cost are the...

Sustained treatment prevention of relapse

There is considerable evidence that long-lasting neurobiological changes in the brains of alcoholics contribute to the persistence of craving. At any stage during recovery, relapse can be triggered by internal factors (craving for alcohol, depression, and anxiety) or external factors (environmental triggers, social pressures, life events, taking drugs, and narcotics). Depression is associated with relapse in women but not in men. For both sexes the severity of alcoholism is a predictor of...

Cancer prevention

16 Breast cancer screening and prevention 275 Jo Ann Rosenfeld 17 Cervical cancer prevention, screening, and early 18 Endometrial cancer prevention, screening, and 19 Ovarian cancer prevention, screening, and early 20 Colon, lung, and skin cancer screening and prevention 327 Jo Ann Rosenfeld 21 Common gastrointestinal and urinary problems 335 Jo Ann Rosenfeld

Phobias

Phobias are characterized by unreasonable or excessive fear of social situations (social anxiety disorder) or of specific objects or situations (specific phobia). Phobic patients strenuously attempt to avoid the trigger object or situation, and experience extreme anxiety if exposure cannot be avoided. Although sufferers relatively rarely seekmedical advice, social anxiety is the most common anxiety disorder and the third most common psychiatric disorder in the USA (exceeded only by depression...

Treatment

The treatment options that a family physician may discuss with a patient will depend on the severity of the alcohol problem, the presence of comorbid medical and psychosocial problems, the patient's motivation to change, and the patient's gender. The genders differ in the causes and consequences of alcoholism and in comorbidity, communication styles, levels of self-esteem, interpersonal relationships, and societal roles. Mixed-gender treatment groups are usually composed primarily of men and...

Etiology

Low fiber intake and poor diet can cause constipation. Medications also can lead to constipation (Table 21.1). Constipation is associated with many metabolic and endocrine disorders, including hypocalcemia, renal failure, hy-pothyroidism, hyperparathyroidism, and diabetes.1 Neurological disorders can impede normal GI movement multiple sclerosis, strokes, and spinal cord injury can cause constipation. Malfunction or anatomical abnormalities, including colitis, cancer, diverticular disease, and...

Weight concerns Overweight and obesity

Case M.B. is a 51-year-old female who presents asking for advice on how to lose weight. She is 160 cm tall and weighs 85 kg (body mass index, (BMI) 33). Table 3.4 Conditions in which weight loss is specifically recommended To lower blood pressure in overweight and obese persons with high blood pressure To improve plasma lipid levels in overweight and obese persons with dislipidemia To lower blood glucose levels in overweight and obese persons with type 2 diabetes She has been overweight all her...

Posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops weeks to months after a specific or repeated life-threatening stressor or traumatic event. The patient has persistent re-experiencing of the event (intrusive recollections, flashbacks), persistent avoidance of reminders of the event, feelings of detachment, and symptoms of increased arousal (exaggerated startle response, hypervigilance, poor concentration). Women are more likely than men to develop PTSD following a...

Mood disorder due to a medical condition

For this diagnosis, the mood disorder must be integral to the medical condition, perhaps even sharing the pathophysiology. Depressive symptoms can be part of many medical conditions that are common in middle-aged women (Table 7.4) and sometimes are the presenting symptoms of a condition. Up to one-third of cancer survivors and their family members suffer from depression,34 and at least half of patients with epilepsy or Parkinson's disease have depression.35 Management consists primarily of...

Signs and symptoms

In mid life, type 2 diabetes is the most common type of diabetes. The diagnosis of type 2 diabetes is based on symptoms of hyperglycemia and the measurement of elevated blood-glucose readings. The classic symptoms of significant hyperglycemia include polyuria, polydipsia, weight loss, polyphagia, and blurred vision. Hyperglycemia may also cause fatigue, vaginitis, or other non-specific symptoms, which maybe attributed to menopause. If the onset of hyperglycemia is gradual, then there may not be...

Takehome points

Physiologic changes of menopause can worsen glycemic control. Use of HRT in menopausal women with diabetes remains controversial. Women with diabetes are at increased risk for cardiovascular disease, which is the leading cause of death in menopausal women with diabetes. Osteoporosis and depression need to be addressed in the menopausal woman with diabetes. A diabetes management plan should include education, self-blood glucose monitoring, diet, and exercise, as well as medications and insulin...

Statins

Statins yield a significant decrease in mortality, recurrent MI, recurrent episodes of unstable angina, stroke, the need for revascularization, and hospitalization in patients with established atherosclerosis.43-45 Statins reduce inflammation and stabilize vulnerable plaques and have been shown to benefit patients with total cholesterol and LDL cholesterol in low, normal, and high The Medical Research Council (MRC) British Heart Foundation (BHF) Heart Protection Study examined statin use in 20...

Hormones

Estrogens certainly improve hot flushes.64 Doses as low as 20 mg transdermal estrogen have been demonstrated to reduce the severity of symptoms. HT should be used only if menopausal symptoms are troublesome, alternatives are not acceptable or effective, and the woman is informed fully of the risks. If a woman has no personal history of an estrogen-dependent cancer, coronary artery disease, clotting disorder (such as factor V Leiden or protein C or S deficiency), or thromboembolic event (such as...

Anne Walling

Case I am turning into a big fat lump that just lies around eating, sleeping and feeling sorry for myself all the time This sudden outburst during a visit for a routine pap smear is completely out of character for Marie, a 44-year-old divorced schoolteacher who is usually smartly groomed, articulate, and vivacious. Tactful questioning reveals about a four-week history of excessive sleeping and feelings of fatigue, low stamina, and worthlessness. She has been snacking excessively and has gained...

In vitro fertilization

The first live birth resulting from in vitro fertilization (IVF) occurred in the late 1970s.15 The resulting wave of scientific discovery has led to countless successes and new techniques. Consequently, the improved techniques have ushered in an era of debate regarding scientific intervention into the physiology, biochemistry, and genetics of conception. Table 11.6 Drugs that may affect fertility adversely Antibiotics - tetracycline, nitrofurantoin Indications for IVF include severe tubal...

Type 1 diabetes and menopause

The relationship between type 1 diabetes and menopause is even more complex, as menopause in patients with type 1 diabetes may occur at a younger age.24' Genetic factors, including haplotypes found in association with the DR4 haplotype (more common in type 1 diabetes), may increase the risk of early menopause two-fold. The long-term effects of premature menopause, in addition to a shorter time for childbearing, include a higher risk of cardiovascular disease, abnormal lipid profile, and...

Margaret Gradison MD

Case S.J. is a 47-year-old woman who presents with abnormal uterine bleeding. She had regular periods until two years ago, at which time her periods became unpredictable. Her current menses started three weeks ago she says it alternates between needing to change pads hourly to requiring only a daily panty liner. Ms J. is obese and smokes a pack of cigarettes a day. Her only medication is thyroid supplements. Her obstetrical history is gravida three para two spontaneous abortion one (G3P2 AB 1)....

Kathy Andolsek

Case a 51-year-old healthy woman presents to the office. She has two children, 24 and 21 years of age, both delivered by cesarean section for fetal distress. Following the second delivery, she had a bilateral tubal ligation for contraception. She has had no other medical conditions. She reports that her menses have changed over the past year, becoming shorter and lighter. She occasionally skips a period altogether. She reports hot flushes, palpitations, and some sleep disruption. She believes...

Genetic risk factors

Family history for specific malignancies is the most important risk factor. If one first-degree relative has been diagnosed with ovarian cancer, then a woman's lifetime risk of ovarian cancer increases to 3.5-7 . With two first-degree relatives, lifetime risk increases to 7-15 .1,2 The relative risk of developing ovarian cancer is increased if family members developed this cancer at a younger Familial ovarian cancer appears in three types (1) familial history of ovarian cancer only, (2)...

Sexual pain syndromes

Pain during sexual activity can vary from pain with initiation of intercourse to deep dyspareunia (Table 5.8). Sexual pain syndromes are associated with a history of abuse. Clinicians should screen for this history and provide suggestions for individual and couple therapy to support the woman as she tries to reconcile her past. Vestibulitis, a painful condition of the vaginal introitus, can be reproduced on examination by light touching of the introital area, particularly between 3 and 6...

Treatment of alcohol dependence and abuse

A formal diagnosis of alcoholism can have enormous personal implications for a patient. Therefore, assessment should be detailed.2 Alcohol abuse and dependence have a variable course characterized by periods of remission and relapse. There are three components to alcoholism (i) physiological dependence (symptoms of withdrawal), (ii) psychological dependence (alcohol used as self-medication), and (iii) habit (the incorporation of drinking into the framework of daily living). Alcohol dependence...

When and how often

The frequency, initiation, and cessation of regular Pap tests are controversial. The 2003 American Cancer Society (ACS) guidelines are shown in Table 17.1.10 Further modifications of these guidelines may include a test for human papilloma virus (HPV), which may delineate those women who need closer follow-up and evaluation. A study of more than 2000 women found that those with normal Pap tests but with positive detection of abnormal HPV were more likely to have subsequent abnormal Pap tests...

Screening of asymptomatic individuals

Since hyperglycemia can be asymptomatic, those individuals at increased risk for diabetes should be screened at regular intervals. Individuals at increased risk for type 2 diabetes include those with increasing age, obesity, and lack of physical activity. Obesity is a major contributing factor to insulin resistance and diminished beta-cell reserve capacity in type 2 diabetes even those patients who are not overweight by standard criteria may have an increased percentage of body fat and or an...

Aging children

The empty nest syndrome is a period of transition that is well described and with several hundred websites devoted to the idea.39,40 However, there is little scientific evidence to support the notion that such a syndrome exists. Although traditionally defined as feelings of sadness, grief, depression, and loss as children prepare to accomplish their own developmental task of leaving home, most women accomplish this transition with little long-term negative effect. Feelings of loss, fear for the...

Types of estrogenprogestin therapy and estrogenalone therapy

There is a variety of available products and routes of administration for both estrogen and progestin. Most of the studies have been done on only some of these products. The WHI study, for instance, used conjugated estrogen and medroxyprogesterone (MPA). There are many different chemical kinds of estrogen and progestin as well as a variety of possible routes for administration (Table 10.9). It is not known whether different estrogen and progestin preparations carry the same risk as conjugated...

Relational theory

Arelational theory of women's development, described by several authors,28-30 provides an excellent anchor from which to understand the challenges that may face the mid-life woman as she ages. This theory holds that a woman's development must be understood in the context of attachment, relationship, and mutuality. Autonomy is achieved through connection to others, rather than through separation or detachment. Those forces that serve to foster continued connectedness, even in the face of loss,...

Breast cancer

Breast cancer survivors are at increased risk for endometrial carcinoma. This maybe related in part to coexistent risk factors of obesity and higher circulating estrogen levels. Additionally, women who have been treated with tamoxifen for prevention of breast cancer recurrence experience an increased risk of endometrial hyperplasia and carcinoma related directly to the duration of tamoxifen therapy, with risk peaking for women taking tamoxifen as adjuvant therapy at two to five years of therapy...

Introduction

Breast cancer has the highest incidence and the third highest death rate for cancer in women in the USA. More than 200 000 women annually develop breast cancer in the USA.1 The incidence of breast cancer increased between 1973 and 1998 by 40 , perhaps caused by an increase in early-stage breast cancer detection.2 A woman in the USA has approximately a one in eight risk of developing breast cancer in her lifetime. The incidence of breast cancer increases with age, making screening more important...

Medical consequences of longterm alcoholism Harmful effects

The principal harmful effects of heavy drinking include liver pathology (hepaptitis, hepatoma, cirrhosis), neurological complications, and cancers of the mouth, larynx, oesophagus, and breast. Medical sequelae are likely to start to present in middle age in those alcoholics and smokers who started drinking and smoking in their youth. Women achieve higher blood alcohol concentrations than men after the consumption of equivalent doses per body weight. The most likely explanation for this is that...

Mary Anne Enoch Md Mrcgp

Case Mrs A., a middle-aged, smartly dressed woman who prided herself on her homemaker skills, came to see her family practitioner, Dr B., complaining of tiredness, depressed mood, anxiety, disturbed sleep, and weight gain. Dr B. knew that her husband, a well-known local politician, had recently left her for a younger woman, so he tactfully avoided that subject, asking instead after her grown children who lived out of state. After questioning Mrs A. about her symptoms, Dr B. concluded that she...

Pharmacological therapy

Pharmacological therapy is initiated in individuals in whom lifestyle changes are not accomplished or are inadequate to control hypertension and in those individuals who have sustained blood pressure readings greater than 160 mmHg systolic and or 100 mmHg diastolic.9 In individuals with diabetes or who have evidence of end-stage target organ damage, treatment should be started if blood pressure is higher than 140 90 mmHg.3 Recent studies have found that the most important factor is getting the...

Phillippa Miranda and Diana McNeill

Case a 51-year-old woman who has had type 2 diabetes for five years is managed with metformin, diet, and exercise. She notes worsening hyperglycemia, but attention to diet and exercise does not seem to improve glycemic control as it has in the past. She mentions to her physician that she has missed her last two menstrual periods and that she seems to be a bit more edgy. She wonders whether there is a correlation between her worsening diabetes control and her menstrual changes.

Management of sexual concerns Decreased sexual desire

Sexual desire is that which causes one to be receptive to or initiate sexual activity. For women, the quality of the relationship and the emotional and physical satisfaction she receives from that relationship appear to be critical elements. Desire requires androgens such as testosterone and DHEAs, neurotransmitters, and the sensory system. Starting in the twenties, there is a progressive decline of physiologically available androgens for both men and women, which can contribute to decreased...

Psychosocial issues

A qualitative study of 11 women during mid life, exploring their sense of confusion, found that most notable were their comments about negative societal views of aging and lack of health-related information on physical and physiological changes of midlife.10 The most relevant factors influencing a woman's quality of life during the menopausal transition are her previous emotional and physical health, her social situation, her experience of stressful life events (particularly bereavements and...

Indications of upper tract disease and need for hospitalization

Although dysuria, polyuria, and nocturia are primarily symptoms of lower tract disease, they can also occur with upper tract infection or pyelonephritis. CVA or flank tenderness can occur in both, but fever, chills, nausea, and vomiting are more likely to occur in pyelonephritis. In women with pyelonephritis, the white blood cell (WBC) count is likely to be elevated. WBC casts are diagnostic for pyelonephritis but are rarely seen. There is no test that determines or detects upper tract versus...

Skin cancer

There are approximately 23 500 cases of melanoma in women yearly in the USA, making it the sixth most common cancer in women, with more than one million cases of basal-cell and squamous-cell cancers identified yearly. Melanoma is ten times more likely in Caucasians than African-Americans. Excessive exposure to radiation, excessive tanning and burning, and fair complexion are risk factors. Occupational exposures to coal tar, arsenic, radium, pitch, and creosote also increase the risk of skin...