A 45-year-old G3P3 presents for her yearly examination. She last saw a doctor 7 years ago after she had her last child. She had three vaginal deliveries, the last of which was complicated by gestational diabetes and preeclampsia. She has not been sexually active in the past year. She once had an abnormal Pap smear for which she underwent cryotherapy. Her cycles are every 35 days and last for 7 days. She describes the flow as heavy for the first 2 days and occasionally passes blood clots the size of quarters. She reports no medical problems. Her family history is significant for coronary artery disease in her dad at the age of 65 years and a maternal aunt who developed ovarian cancer at the age of 67 years. She is normotensive, and her breast and pelvic examinations are normal.
Along with a Pap smear, mammogram, fasting glucose, and lipid profile, what other screening test is recommended for this patient?
Hemoglobin level assessment is warranted in women with excessive menstruation as described in her history. Mammography is indicated for her age. Measuring CA-125 levels has not been shown to be effective in population-based screening for ovarian cancer. 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. She is not diabetic or hypertensive and has no urinary symptoms so urinalysis is not indicated. Thyroid testing is reserved for symptoms, strong family history of thyroid disease or autoimmune disease.
A 30-year-woman presents to your office because she is afraid of developing ovarian cancer. Her 70-year-old grandmother recently died from ovarian cancer, and she is upset and tearful. You discuss with her the risk factors and prevention strategies for ovarian cancer.
Which of the following can decrease a woman’s risk of ovarian cancer?
Oral contraceptive use, multiparity, breastfeeding, and early menopause are all factors believed to decrease the risk of developing ovarian cancer because they reduce the number of years a woman spends ovulating. The use of combination oral contraceptives decreases the risk of developing ovarian cancer by about 40%. Nulliparity, increasing age, and fertility drugs all increase ovulatory cycles and therefore are risk factors for developing ovarian cancer. In the general population, the risk of developing ovarian cancer is about 1% to 1.5%. This risk increases to about 5% if a woman has one first-degree relative with ovarian cancer and to about 7% if she has two or more first-degree relatives with ovarian cancer.
A 42-year-old G4P3104 presents for her well-woman examination. She has had three vaginal deliveries and one cesarean delivery for breech presentation. She states her cycles are regular and reports no history of sexually transmitted infections. Currently she and her husband use condoms, but they dislike the hassle of a coital-dependent method. She is interested in a more effective contraception because they do not want any more children. She reports occasional migraine headaches, and had a serious allergic reaction to anesthesia as a child when she underwent a tonsillectomy. She drinks and smokes socially. She weighs 78 kg, and her blood pressure is 142/89 mm Hg. During her office visit, you counsel the patient at length regarding birth control methods.
Which of the following is the most appropriate contraceptive method for this patient?
An intrauterine device is a highly effective longterm method for which the patient has no contraindication. A bilateral tubal ligation would be another option; however, the patient had a serious allergic reaction to anesthesia as a child, and general anesthesia is required for female laparoscopic sterilization. The patient’s smoking and age contraindicate the use of combination oral contraceptives. Migraine headaches accompanied by neurologic symptoms such as loss of vision, paresthesias, and numbness are generally considered to be a contraindication to combination oral contraceptive use. Use of a diaphragm is a coital-dependent action and the patient relates that it is not something she desires.
A 55-year-old Caucasian G2P2 presents for her well-woman examination. She had two uneventful vaginal deliveries. Her last menstrual period was 2 years ago. She has occasional night sweats, but they are not bothersome. Her medical history is significant for hypothyroidism, which is well controlled on medication. She does not take any other medicines. She does not use tobacco, alcohol, or drugs. Her family history is significant for stroke, diabetes, and high blood pressure. On examination she is a pleasant female, stands 5 ft 6 in tall, and weighs 115 lbs. Her blood pressure is 130/72 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and temperature 37°C (98.4°F). Her breast, lung, cardiac, abdomen, and pelvic examinations are normal.
Which of the following aspects of her history would be an indication to order bone mineral density screening?
The patient meets criteria for screening based on her low body weight. Bone mineral density screening should be started at the age of 65 years in most women. Postmenopausal women with risk factors may require screening earlier if any of these risk factors are present: prior osteoporotic fracture, body weight less than 127 pounds, medications or diseases that cause bone loss, parental medical history of a hip fracture, current smoker, alcoholism, or rheumatoid arthritis.
A 32-year-old woman presents for her yearly examination. She has been smoking one pack of cigarettes a day for the past 12 years. She wants to stop, and you make some recommendations to her.
Which of the following is true regarding smoking cessation in women?
Cigarette smoking has been linked to many pathologic conditions, including coronary artery disease, obstructive pulmonary disease, and lung cancer. There are studies that demonstrate that smoking cessation is of benefit to pulmonary health regardless of how long one has smoked. Doctors should repeatedly counsel their patients to stop smoking, and follow-up visits to achieve these goals are effective. The “5 A’s” model is an evidence-based model that may be used successfully to address patient smoking. The 5 A’s are as follows: Ask (about tobacco use), Advise patients who smoke to quit, Assess the patient’s willingness to try to stop smoking, Assist in the attempt to quit for those who are willing, and Arrange follow up. In addition to counseling, all patients should be offered medication to improve quit success and reduce withdrawal symptoms. Medications include nicotine replacement therapy, prescription antidepressants such as bupropion, and varenicline, which blocks the pleasant effects of smoking from the brain.
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