A 23-year-old woman with a 5-pack-year history of cigarette use wonders if she is a candidate for the quadrivalent HPV vaccine. She has been sexually active for 5 years with three partners. Her recent first pap smear was normal, but her examination revealed two nontender vaginal lesions which resemble flesh-colored cauliflower. You first educate her that quitting smoking will help her immune system fight the strain of HPV that she already has acquired.
What advice should you give her?
Human papillomavirus (especially subtypes 16, 18, 33, and 45) has an established relationship to genital warts and cervical cancer. The current multivalent vaccines are highly effective in establishing immunity to the subtypes included in the vaccine, even if one or more of the subtypes is already acquired. It is yet to be proven how much cross-reactive protection exists to subtypes not included in the vaccine. The vaccine is not effective in treatment of any disease (ie, vaginal warts) caused from prior infection. Because over 40 sexually transmitted HPV subtypes exist and the vaccine includes the types responsible for about 70% of cervical cancer, there is still a risk of cervical dysplasia caused from other subtypes not covered in the vaccine. Therefore, continued pap screening is needed. This patient’s likelihood of clearing her current HPV infection increases with tobacco cessation.
A 45-year-old woman presents to your office to establish care. She has been watching television programs hosted by doctors recommending various screening tests, and she wishes to have “everything done.” She has a history of gastroesophageal reflux and seasonal allergies, and no family history of diabetes or cancer. Her best friend was recently diagnosed with ovarian cancer, so she would like to be tested for that.
Which of the following recommendations (based on the United States Preventive Services Task Force) would be appropriate?
(www.uspreventiveserevicestaskforce.org/recommendations.htm; Fife pp 316-317.) The USPSTF recommends screening for alcohol use disorder in all adults. Maximum recommended consumption is one or less standard drink per day for adult women, and two or fewer standard drinks per day for adult men. On average, women have higher blood alcohol levels than men after ingestion of the same amount of alcohol. Evidence also supports that women have accelerated development of fatty liver, hypertension, malnutrition, and GI hemorrhage with excessive alcohol use. A meta-analysis of studies examining the association between all-cause mortality and average alcohol consumption found that men averaging at least four drinks per day and women averaging two or more drinks per day experienced increased mortality relative to nondrinkers. Bone density screening by DXA is recommended for all women over 65 years of age or for women whose fracture risk is equivalent to that of a 65-year-old woman. Risks for low bone mass include early menopause, long-term use of systemic prednisone or other bone-toxic medications, cigarette smoking, rheumatoid arthritis, and family history of osteoporosis. The newest recommendations for screening frequency for cervical cancer for a woman age 30 and older are every 2 to 3 years due to the improved sensitivity of the ThinPap technology. CA-125 and pelvic sonogram are not recommended for screening of ovarian cancer because of their low sensitivity. Mammogram screening is recommended every-other-year for a normal-risk woman beginning at age 50.
A 60-year-old white woman presents for an office visit. Her mother recently broke her hip, and the patient is concerned about her own risk for osteoporosis. She weighs 165 lb and is 5 ft 6 in tall. She has a 50-pack-year history of tobacco use. Medications include a multivitamin and levothyroxine 50 µg/d. Her exercise regimen includes mowing the lawn and taking care of the garden. She took hormone replacement therapy for 6 years after menopause, which occurred at age 49.
Which recommendation for osteoporosis screening is most appropriate for this patient?
Accepted indications for bone mineral density testing include estrogen-deficient women at clinical risk of osteoporosis and all women over age 65. This patient’s risk factors include estrogen deficiency, low calcium intake, family history, and previous tobacco use; therefore peripheral bone densitometry, such as a heel quantitative ultrasound, would not be sufficient. The heel ultrasound, which does predict fracture risk in women over 65, is less accurate than DXA and is useful for population-wide screening programs, not individual treatment recommendations. A nuclear medicine bone scan has no role in the diagnosis of osteoporosis. Quantitative CT allows for adequate prediction of vertebral fractures, but is not considered standard of care at this time, and exposes the patient to greater radiation than DXA.
A 21-year-old woman presents for her annual examination. She enjoys drinking to excess on the weekends with her friends and smokes cigarettes to “keep her weight down.” She avoids dairy products because they cause bloating and diarrhea. Her medications include birth control pills and OTC antihistamine. She runs 3 miles per day at least 5 days per week. She is 5 ft 2 in and 105 lb. In addition to counseling her on using a barrier method for avoidance of sexually transmitted diseases,
what other advice should you give?
Peak bone mass is achieved around age 30, and is largely determined by genetics, nutrition, endocrine health, and physical activity. Cigarettes are a known toxin to bone metabolism. This patient’s weight bearing exercise should be continued, not replaced by nonweight bearing activities such as swimming or water aerobics. This patient should be advised to ingest, preferably through calcium-rich foods, the USDA recommended 1000 mg of calcium and 600 international units of vitamin D per day. Binge drinking increases her risk of sexual assault, fatal automobile accident, and alcohol poisoning. Other, less risky methods of weight maintenance should be recommended.
An orthopedic surgeon asks you to help him manage an 82-year-old woman who just received a hip replacement as a result of a hip fracture. The patient was watering her flowers when she tripped on the water hose and heard her hip crack as she fell to the ground. She has a history of hypothyroidism, mild CVA, and hypertension. Her mother had lost about 5 inches of height in her older years. She believes that she has lost “a few inches” in comparison to her husband. On review of systems, she admits to chronic diarrhea. Her only home medication is metoprolol. On physical examination, her blood pressure is 158/90; pulse 88 and regular; the hip is tender to palpation. Labs show normal calcium, renal function, and alkaline phosphatase. TSH, celiac panel, and 25-OH vitamin D level are also normal.
Which of the following medications would be most effective in preventing another fracture?
This patient has a diagnosis of osteoporosis based on the occurrence of the hip fracture, regardless of her T-score. Bisphosphonate therapy is proven to reduce the high risk of subsequent hip and vertebral fractures. Raloxifene is less appropriate for this patient with her history of a CVA, as it has been associated with increased incidence of thromboembolic events and stroke. The effect of nasal calcitonin on fracture risk is unknown. Estrogen therapy is approved by the FDA for the prevention of osteoporosis, but not for treatment. Estrogens and raloxifene are equally thrombogenic. Hydrochlorothiazide decreases urine calcium loss and helps maintain bone density. Epidemiologic data suggest decreased first fracture risk with long-term use, but it is not proven to decrease risk of subsequent fractures.
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