A 21-year-old G0 presents to your office for a routine annual gynecologic examination. She reports that she has previously been sexually active, but currently is not dating anyone. She has had three sexual partners in the past, and says she diligently used condoms. She is a senior in college and is doing well academically and has many friends. She lives at home with her parents and a younger sibling. She reports her 80-year-old grandmother was recently diagnosed with breast cancer. She has no other family history of cancer. She says she is healthy and has no history of medical problems or surgeries. She smokes tobacco and drinks beer occasionally, but denies any illicit drug use. Her menses started at the age of 13 years, and are regular and light without dysmenorrhea. Her blood pressure is 90/60 mm Hg. Her height is 5 ft 6 in and she weighs 130 lb.
Based on this patient’s history, what would be the most likely cause of death if she were to die at the age of 21 years?
The leading causes of death in women between the ages of 20 and 24 years, in order of decreasing frequency, are as follows: injuries/accidents, suicide, malignancy, homicide, heart disease, pregnancy complications, birth defects, influenza and pneumonia, stroke, septicemia, and diabetes.
A 17-year-old G1P1 presents to your office for her yearly well-woman examination. She had an uncomplicated vaginal delivery the previous year. She has been sexually active for the past 4 years and has had four different sexual partners, but has been monogamous in the previous year with the same partner. Her menses occurs every 28 days and lasts for 4 days. She denies any intermenstrual spotting, postcoital bleeding, or vaginal discharge. She reports no tobacco, alcohol, or illicit drug use.
Which of the following are appropriate screening tests for this patient?
Routine screening for sexually transmitted disease is not warranted for all women; however, all sexually active women younger than 25 years of age should be routinely screened for gonorrhea and chlamydia, and older women with risk factors such as new or multiple partners, sex work, or concurrent STD should also be screened. There is no routine screening recommended for hepatitis B virus or herpes simplex virus. Hepatitis C screening should occur in those with risk factors such as intravenous drug use, dialysis, partner with hepatitis C, multiple partners, and received blood products prior to 1990. Syphilis screening should also occur in those with risk factors such as sex work, confinement in an adult correction facility or men having sex with men. Screening for cervical cancer should begin at the age of 21 years.
A 15-year-old woman presents to your office for her routine physical examination while she is on summer break from school. She denies any medical problems or prior surgeries. She had chicken pox at the age of 4 years. Her menses started at the age of 12 years and are regular. She has recently become sexually active with her 16-year-old boyfriend. She states that they use condoms for contraception. Her physical examination is normal.
Which of the following vaccines is appropriate to administer to this patient?
It would be appropriate for this patient to receive a human papilloma vaccination, since it is recommended for all previously unvaccinated women aged 9 to 26 years. She is not a candidate for the varicella vaccine since she has had chicken pox. The hepatitis A vaccine is indicated for international travelers, illegal drug users, and health care workers. The pneumococcal vaccine is indicated in immunocompromised persons, those with chronic illnesses, and individuals older than 65 years. Meningococcal vaccination is recommended for college freshmen living in dorms, asplenia, or travel or residence in countries where meningococcal disease is endemic.
A 26-year-old woman presents to your office for her well-woman examination. She reports no medical problems or prior surgeries. She states that her cycles are monthly. She is sexually active and uses oral contraceptive pills for birth control. Her physical examination is normal. She reports that her 43-year-old paternal aunt was recently diagnosed with breast cancer and is undergoing treatment. She reports that her paternal grandmother died from ovarian cancer at the age of 75 years. She wants genetic testing (BRCA) for breast and ovarian cancer.
Which of the following statements regarding genetic testing for breast and ovarian cancer is true?
Germline mutations in BRCA1 and BRCA2 account for the vast majority of families with hereditary breast and ovarian cancer syndrome. Approximately 10% of cases of ovarian cancer and 3% to 5% of cases of breast cancer are due to germline mutations in BRCA1 and BRCA2. In the general population, it is estimated that approximately 1 in 300 to 1 in 800 individuals carry a mutation in BRCA1 or BRCA2. For a woman with a BRCA1 mutation, the risk of ovarian cancer is 39% to 46%. For a woman with a BRCA2 mutation, the risk of ovarian cancer is 12% to 20%. The estimated lifetime risk of breast cancer with a BRCA1 or BRCA2 mutation is 65% to 74%. Evaluating a patient’s risk for hereditary breast and ovarian cancer syndrome should be a routine part of obstetric and gynecologic practice. When evaluating a family history, it is important to remember that breast cancer and ovarian cancer predisposing genes can be transmitted through the father as well as the mother. If possible, genetic testing should begin with a person in the family who has ovarian cancer or early onset breast cancer (affected individual). For obstetrician–gynecologists, certain clinical criteria have been developed to assist in determining which patients would benefit from a genetic risk assessment. The first group of criteria includes those patients with greater than an approximate 20% to 25% chance of having an inherited predisposition to breast cancer and ovarian cancer and for whom genetic risk assessment is recommended. The second group of criteria includes those patients with greater than an approximate 5% to 10% chance of having an inherited predisposition to breast and ovarian cancer and for whom genetic risk assessment may be helpful. Although, in most cases, an inherited predisposition to ovarian cancer is caused by mutations in BRCA1 or BRCA2, current technology does not allow identification of all mutations that must exist in these genes.
A 21-year-old woman presents to your office for well-women examination and screening for sexually transmitted infections. Her menses started at the age of 13 years and are regular. She is currently sexually active with her 20-year-old boyfriend and has had three sexual partners in her lifetime. She uses Depo-Provera and condoms for contraception. She has a history of asthma, for which she uses an inhaler as needed. She reports no prior surgeries. Her family history is significant for hypertension, high cholesterol and heart disease in her father, aged 48. She weighs 125 lb and is normotensive.
Besides screening for cervical cancer and sexually transmitted infections, what other routine screening should be done for her at this visit?
The National Cholesterol Education Program recommends that all adults 20 years and older have a serum lipoprotein profile every 5 years. Lipid profiles are also recommended if there is a family history of premature cardiovascular disease (age younger than 50 in men and 60 in women). Even though use of Depo-Provera is associated with decreased bone mineral density there is no indication for bone mineral density screening for women using it. Testing for diabetes is indicated for individuals with BMI greater than 25, family history of diabetes, polycystic ovarian syndrome, hypertension, prior history of gestational diabetes. Thyroid testing is reserved for symptoms, strong family history of thyroid disease or autoimmune disease. Urinalysis is indicated for symptoms of infection or yearly screening in diabetics and periodically in women older than 65 years.
Click to expand