Case 1: 45-year-old female annual exam - Mrs.

Payne
Thomas Tafelski, D.O. University of Toledo

Mrs. Payne is a 45-year-old woman who has not had preventive health care in five years, presenting now for a
routine exam. History reveals signs that she is experiencing perimenopause, smokes one pack of cigarettes weekly,
and has had one abnormal Pap smear followed by a normal Pap smear since then. A complete physical exam is
performed with no remarkable findings, except that her BMI is 29 kg/m2, classifying her as overweight. Mrs. Payne
is counseled regarding nutrition and exercise to decrease her weight, osteoporosis prevention, and smoking
cessation. Preventative issues are also addressed when her immunizations are brought up to date with a Tdap shot,
a screening mammogram is scheduled, and fasting glucose and lipid profiles are ordered. Mrs. Paynes Pap smear
results show evidence of Atypical Squamous Cells of Undetermined Significance (ASC-US), which is explained at a
follow-up visit and repeat Pap is recommended in 12 months.
Final diagnosis: Women's health maintenance exam

Learning Objectives

1. Learn the principles of screening and the characteristics of a good screening
test.

2. Identify risk factors for breast and cervical cancer based on family history,
age, gender and exposure.

3. Learn how to perform a thorough breast exam.

4. Know current recommendations for mammography.

5. Learn the current recommendations for papanicolaou testing and the
different types of testing available.

6. Identify risk factors for osteoporosis and appropriate preventative measures.

7. Learn recommended immunizations for adults.

8. Learn counseling skills for behavior change.

Meeting Mrs. Payne
Familial Breast Cancer Risk
A patient has an increased risk of breast cancer if a first-degree relative has had breast cancer. (A first-degree
relative is a parent or a sibling.)
Health Maintenance
Question
Which of the following is/are correct regarding self breast examination?
Multiple Choice Answer:
A: O Most women regularly perform self-breast examination.
B: O The practice of regular breast self-examination by trained women reduces mortality.
C: X Breast self-examination actually increases the number of biopsies performed.
D: X Patients who choose to perform self-examination should be trained in appropriate technique and follow-up.
E: X Self breast exam allows motivated women to be in control of this aspect of their health care and allows for
patient autonomy and education.
Answer Comment
Evidence supporting the effectiveness of breast self-examination (BSE) and clinical breast exam (CBE) is
controversial. Recommendations about BSE and CBE varies among professional organizations.
Although breast self-examination (BSE) is often advocated as a noninvasive screening test, most women do not
regularly perform it (A). Patients who choose to perform self-examination should be trained in appropriate
technique and follow-up (D). BSE allows motivated women to be in control of this aspect of their health care
and allows for patient autonomy and education (E).
Research -
Evidence supporting the effectiveness of BSE and clinical breast exam (CBE) is controversial. It is not known
whether screening by CBE can reduce breast cancer mortality. Large, well-designed, randomized trials of adequate
duration have shown that the practice of regular breast self-examination (BSE) by trained women does not reduce
breast cancer-specific or all-cause mortality (B). A Cochrane review concluded that BSE has no beneficial effect and
actually increases the number of biopsies performed (C).

Clinical Guidelines -
The USPSTF does not recommend BSEs. However, the American Cancer Society (ACS) recommends that
women should know how their breasts normally feel and report any breast change promptly to their health
care providers. ACS suggests that breast self-exam (BSE) is an option for women starting in their 20s.

Similarly, the USPSTF concludes there is insufficient evidence to assess the additional benefits and harms
of CBE beyond screening mammography in women 40 years or older. While ACS recommends that
clinical breast exam (CBE) should be part of a periodic health exam, about every three years for women in
their 20s and 30s and every year for women 40 and over.

References:
Knutson D, Steiner E. Screening for breast cancer: current recommendations and future directions. Am Fam Physician. 2007 Jun 1;75(11):1660-
6.
Kosters JP, Gotzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database Syst Rev.
2003;(2):CD003373.
O'Malley MS, Fletcher SW. U.S. Preventive Services Task Force. Screening for breast cancer with breast self-examination. A critical review.
JAMA. 1987;257:2196-203.




Breast Exam
Performing a Breast Exam

A good breast exam consists of both visual inspection and palpation.
Visual inspection:
With patient sitting upright on the exam table, have her lower her gown to her waist so the breasts can be fully
visualized.
Look for symmetry in shape and assess skin changes, including any erythema, retractions, dimpling, or
nipple changes
Ask the patient to lift her hands overhead to accentuate any retraction or dimpling.
Palpation:
For the palpation portion of the exam, ask patient to lie back on the exam table and place her hands over her head,
thus flattening the breast tissue on the chest wall.
Carefully examine each breast using a vertical strip pattern.
When palpating, use the finger pads of the middle three fingers and varied pressure (light, medium, and
deep) as you complete your exam.
Finally, palpate both axillary and supraclavicular lymph nodes.

Pelvic Exam
Performing a Pelvic Exam
Preparation
First, elevate the head of the exam table to 30 to 45 degrees and assist the patient in
placing her heels in the stirrups, adjusting the angle and length as needed.
Carefully cover the patient's abdomen and legs down to her knees with a sheet.
Ask patient to slide down to the edge of the table and relax her knees outward just
beyond the angle of the stirrups.

External inspection and palpation
Look for any redness, swelling, lesions or masses.
Inspect the labia, the folds between them, and the clitoris, paying attention to any redness, swelling, lesions,
or discharge. Gently palpate the labia majora and minora.
Speculum exam
Use a warm and lubricated speculum for the examination. (There is some controversy about whether gel-
based lubricants distort cytologic assessment. For this reason, the speculum is lubricated with warm tap
water or a thin layer of gel lubricant, avoiding the tip of the speculum. You should know what is
recommended by the laboratory in your area.)
Inform the patient that you are about to begin the speculum exam.
Expose the introitus by spreading the labia from below using the index and middle fingers of the non-
dominant hand (peace sign).
Insert the speculum at a 45-degree angle, pointing slightly downward being careful to avoid contact with
the anterior structures.
Once past the introitus, rotate the speculum to a horizontal position and continue insertion until the handle
is almost flush with the perineum.
Open the "bills" of the speculum 2 or 3 cm using the thumb lever until the cervix can be visualized between
the bills.



Speculum Exam
Obtaining a Pap Test
The sample is obtained using an extended tip spatula and then a cytobrush.

First, the spatula is rotated several times to obtain a sample from the ectocervix.
Then the cytobrush is then inserted into the os and rotated 180 degrees.
Care is taken to make sure that the squamo-columnar junction (the area of the endocervix where there is rapid cell
division and where dysplastic cells originate) is adequately sampled.
The sample is then placed into a liquid medium.
Using the liquid-based system over the conventional Pap smear technology allows for later testing of the
sample for the presence of human papilloma virus (HPV) if the Pap comes back abnormal.

Currently two liquid-based systems are approved by the FDA. You should check with your lab to find out
which system is preferred



Bimanual Exam
Performing a Bimanual Exam
First, explain to your patient what you are going to do.

Next, apply lubricant (e.g., K-Y jelly) to the index and middle fingers of your non-dominant gloved hand and insert
them into the patient's vagina.
Palpate the cervix to ensure that it is non-tender and mobile.

Place your non-gloved hand on the abdomen just superior to the symphysis pubis, feeling for the uterus between
your two hands (see the picture). This gives you an idea of its size and position.
Then, moving your pelvic hand to each lateral fornix, try to capture each ovary between your abdominal and pelvic
hands. The ovaries are usually palpable in slender, relaxed women, but are difficult or impossible to feel in obese
women.
Some physicians perform a recto-vaginal exam for completeness, but in a patient whose uterus is easily palpated and
who has no rectal complaints, a rectal exam may not be indicated.

When you have left the room, Dr. Lee tells you that the New England Journal of Medicine has a good pelvic
examination tutorial video available to their on-line subscribers (Edelman A. Pelvic Examination. NEJM June 28,
2007; 356(26):e26).
Cervical Cancer Screening Guidelines

In 2012, the American College of Obstetrics and Gynecology (ACOG), the American Cancer Society (ACS),
American Society for Colposcopy and Cervical Pathology (ASCCP) and USPSTF came to a consensus on cervical
cancer screening.
The guidelines recommend that:
At 21 years of age -- cervical cancer screening should begin.
Between the ages of 21-29 years -- screening should be performed every three years.
Between the ages of 30-65 years -- screening can be done every three years with cytology alone, or every
five years if co-tested for HPV.

However, they stipulate that certain risk groups need to have more frequent screening. They include women with
compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or
have been exposed to diethylstilbestrol (DES) in utero (DES is a nonsteroidal estrogen that was given to pregnant
women to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and was
discontinued in 1971).
Women older than 65 years who have had adequate screening within the last ten years may choose to stop
cervical cancer screening. Adequate screening is three consecutive normal pap tests with cytology alone or two
normal pap tests if combined with HPV testing.
Women who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.
Question
Dr. Lee says, "Of course, these recommendations are based (in part) on the risk a patient will develop cervical
cancer. So, now I have a question for you: What do you think are the risk factors for developing cervical cancer?"
(Select all that apply.)
Multiple Choice Answer:
A: X Early onset of sexual intercourse.
B: X Multiple sexual partners.
C: X Cigarette smoking.
D: X Immunosuppressed patient.
Answer Comment
Virtually all cervical cancers are caused by infection with certain high-risk types of human papilloma virus (HPV).
HPV is transmitted via vaginal (or oral) intercourse. Transmission by nonpenetrative genital contact is rare.
Therefore, squamous cell carcinoma of the cervix is a disease of sexually active women. Factors such as age,
nutritional status, immune function, and possibly silent genetic polymorphisms modulate the incorporation of viral
DNA into host cells.
Sexual behaviors associated with an increased cervical cancer risk include:
Early onset of intercourse (A) and
A greater number of lifetime sexual partners (B).

Other risk factors include:
Diethylstilbestrol (DES) exposure in utero.
Cigarette smoking (C), which is strongly correlated with cervical dysplasia and cancer, independently
increasing the risk by up to fourfold.
Immunosuppression (D) also significantly increases the risk of developing cervical cancer.





Screening
Characteristics of a Good Screening Test
1. Accuracy (high sensitivity and specificity)
Sensitivity
Measures proportion of actual positives that are correctly identified as such (e.g., percentage of
sick people identified as having the condition).
The more sensitive the test the fewer false negative results.
Specificity
Measures the proportion of negatives that are correctly identified as such (e.g., percentage of
well people identified as not having the condition).
The more specific the test the fewer false positives.

2. Able to detect disease in an asymptomatic phase

3. Minimal associated risk
4. Reasonable cost
5. Acceptable to patients
Does the Pap smear meet these criteria?
The Pap smear fits into the definition of a good screening test because the test is relatively inexpensive, easy to
perform, and is acceptable to patients.
Cervical cancer has a long asymptomatic pre-invasive state (often a good decade or more), and there are effective
treatments for pre-invasive disease.
Although the Pap smear has a sensitivity of only between 30-80% and a specificity of 86-100%, cancer deaths from
cervical cancer decreased markedly in the U.S. after the Pap smear was introduced.

Question
Dr. Lee asks you what cancers (besides breast and cervical) Mrs. Payne should be screened for.
Multiple Choice Answer:
A: X Malignant melanoma
B: O Ovarian cancer
C: O Endometrial cancer
D: O Lung cancer

Answer Comment
On the occasion of a periodic health examination, the American Cancer Society recommends the cancer related
checkup should include examination of the skin.

The incidence of malignant melanoma (A) is rising faster than that of any other cancer in the U.S. Early detection
and treatment are critical and result in improved patient survival rates. In this situation, Dr. Lee follows the
American Cancer Society (ACS) guidelines. In her opinion, when a patient has already disrobed for her pelvic and
breast exam, you can use the opportunity to examine their skin. (The USPSTF, however, concludes that the current
evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a
primary care clinician.)
The USPSTF, the American College of Obstetricians and Gynecologists, the American College of Physicians, and
the Canadian Task Force on the Periodic Health Examination all recommend against routine screening for ovarian
cancer (B) in asymptomatic women.
Endometrial cancer screening (C) is not indicated at this time for Mrs. Payne. ACS recommends that at the time of
menopause all women should be informed about the risks and symptoms of endometrial cancer, and strongly
encouraged to report any unexpected bleeding or spotting to their doctors. According to ACS, there is insufficient
evidence to recommend screening for endometrial cancer in women with no identified risk factors. For women with,
or at high risk for, hereditary non-polyposis colon cancer (HNPCC), annual screening should be offered for
endometrial cancer, with endometrial biopsy beginning at age 35.
The USPSTF concluded that current evidence was insufficient to recommend for, or against, screening for lung
cancer (D) (I Statement). Note, however, USPSTF does recommend screening for lung cancer in patients 55-65
years old with 30-pack-history of smoking by low-dose CT scan. This does not apply to Mrs. Payne at this point as
she is only 45 years old.



Screening continued
Recommendations for Breast
Cancer Screening
Mammography
American Cancer Society
Yearly mammograms starting at age 40 and continuing for as long as a woman
is in good health

US Preventive Services Task
Force
Biennial screening mammography for women aged 50-74 years
(Grade B recommendation)
Decision to start regular, biennial screening mammography before the age of 50
years should be an individual one and take patient context into account,
including the patient's values regarding specific benefits and harms
(Grade C recommendation)


Most guidelines do not recommend routine mammography for women younger than 40 years unless they fall into a
high risk category such as women with a known BRCA mutation.


Breast Lump
Evaluating a Breast Lump
First take a good history from the patient, including:
Precise location of the lump
How it was first noticed (accidentally, by breast self-examination, clinical breast examination, or
mammogram)
How long it has been present
Presence of nipple discharge, and
Any change in size of the lump (especially ask whether the lump changes in size according to phase of the
menstrual cycle)

The next step is a thorough breast exam: Certain characteristics on physical exam increase the suspicion of
malignancy.
For example, the presence of a single, hard, immobile lesion of approximately 2 cm or larger with irregular
borders increases the likelihood of malignancy.
Diagnostic tests:
If it feels cystic, aspiration can be attempted and the fluid sent for cytology. Fine needle aspiration is a
procedure family physicians can do in the office.
If it feels solid, mammography is the next step.
Ultrasound can be helpful in distinguishing a solid mass from a cystic lesion.
Follow-up:
If the work-up suggests that the lesion is benign (which the vast majority are), close follow-up with regular breast
exams and mammography is indicated.

Nipple discharge
Evaluation of Nipple Discharge

Reasons for nipple discharge may be physiologic or pathologic:
Physiologic Pathologic
Pregnancy
Excessive breast
stimulation
Prolactinoma
Breast cancer
-Intraductal papilloma
-Mammary duct ectasia
-Paget's disease of the breast
-Ductal carcinoma in situ
Hormone imbalance
Injury or trauma to breast
Breast abscess
Use of medications use (e.g., antidepressants, antipsychotics, some
antihypertensives and opiates)

A comprehensive history and breast exam are necessary to evaluate the discharge.
For example, it is important to know if the discharge appears milky, purulent or bloody. Palpate nipples and
check for any discharge.

If a discharge is present, the patient needs further evaluation by imaging studies:
Mammogram
Ultrasound
Ductogram, and/or
Biopsy

Consider hormonal testing to exclude endocrinological reasons. If discharge is milky, check the prolactin level.
Review and discontinue any medications that may be the cause.

Mammogram
Mammography
Benefits
Mammography is a good screening test that can detect asymptomatic early stage disease, and there is good evidence
that mammography decreases breast cancer mortality.
Risks
As with any other screening test, there is a potential for false positive results (leading to unnecessary procedures) or
false negative results (giving patients a false sense of security). The sensitivity of mammography is between 60%
and 90%. Low sensitivity means more false negative results. False negative results are more common in younger
women since denser breast tissue makes it harder to find abnormalities on x-rays.
Mammography is a radiograph which involves some radiation exposure. However, modern mammography systems
use extremely low levels of radiation, usually about 0.1 to 0.2 rad per x-ray, which is minimal and provides
negligible risk.
Also, mammograms can be uncomfortable for patients.
Breast MRI
Not recommended for screening the general population of asymptomatic, average-risk women.
May be indicated in the surveillance of women with more than a 20% lifetime risk of breast cancer (for
example, individuals with genetic predisposition to breast cancer by either gene testing or family pedigree,
or individuals with a history of mantle radiation for Hodgkin's disease).
May be used as a diagnostic tool to identify more completely the extent of disease in patients with a recent
breast cancer diagnosis.
Contrast-enhanced breast MRI may be indicated in the evaluation of patients with breast augmentation in
whom mammography is difficult.

Breast Ultrasound
Not recommended for screening purposes. This tool is used for evaluation of suspected abnormalities.
Question
What are the risk factors for developing breast cancer in the general population? (Select all that apply).

Multiple Choice Answer:
A: X Family history of breast cancer in first degree relative
B: X Prolonged exposure to estrogen
C: X Genetic factors
D: X Age
E: X Obesity
F: X Excessive alcohol intake
Answer Comment
Understanding modifiable and non-modifiable factors that increase or decrease breast cancer risk allows
physicians to counsel women appropriately.
Non-modifiable factors associated with increased breast cancer risk include:
Family history of breast cancer in a first-degree relative (i.e., mother or sister) (A)
Prolonged exposure to estrogen (B), including menarche before age 12 or menopause after age 45
Genetic predisposition (C) (BRCA 1 or 2 mutation)
Advanced age (D) (The incidence of breast cancer is significantly greater in postmenopausal women, and
age is often the only known risk factor.)
Female sex
Increased breast density

Other hormonal risk factors associated with breast cancer include advanced age at first pregnancy, exposure to
diethylstilbestrol, and hormone therapy.
Environmental factors associated with increased risk for breast cancer include:
Therapeutic radiation and
Obesity (E)

Factors associated with decreased cancer rates include:
Pregnancy at an early age
Late menarche
Early menopause
High parity, and
Use of some medications, such as selective estrogen receptor modulators and, possibly, nonsteroidal anti-
inflammatory agents and aspirin.

No convincing evidence supports the use of dietary interventions for the prevention of breast cancer, with the
exception of limiting alcohol intake (F). And interestingly, most studies do not show that smoking increases the
risk of breast cancer.
So far, it appears that Mrs. Payne is at average risk of breast cancer since she is 45 years old and bordering on obese.
But, she does not have a first-degree relative with breast cancer, prolonged exposure to estrogen, excessive alcohol
intake, or known genetic factors.
Calculating the risk using the Gail criteria is helpful in individualizing recommendations for mammogram.

Osteoporosis
Menopause
Timing
On average, women reach menopause at 51. But, menopause can start earlier or later. A few women start menopause
as young as 40, and a very few as late as 60. Women who smoke tend to go through menopause a few years earlier
than nonsmokers. The timing of an individual's menopause cannot be predicted. Only after a woman has not
menstruated for 12 straight months can menopause be confirmed.
Perimenopause
The gradual transition to menopause is called perimenopause. The ovaries don't abruptly stop; they slow down.
During perimenopause it is still possible to get pregnant. The ovaries are still functional, and ovulation may occur,
although not necessarily on a monthly basis. Perimenopause can last from two to eight years.
Symptoms
Menopause affects each woman differently. Some women reach menopause with little to no trouble; others
experience severe symptoms that drastically hamper their lives. Menstrual irregularity is the hallmark of
perimenopause. Patients should be advised to call their provider if their menses come very close together, if the
bleeding is heavy, or if the bleeding lasts more than a week.

Other perimenopausal symptoms due to estrogen deficiency include:
Hot flashes: Hot flashes are brief feelings of heat that may make the face and neck flushed and cause temporary
red blotches to appear on the chest, back, and arms. Sweating and chills may follow. Hot flashes vary in intensity
and typically last between 30 seconds and ten minutes. Dressing in light layers, using a fan, getting regular exercise,
avoiding spicy foods and heat, and managing stress may help.

Vaginal dryness: This can make intercourse uncomfortable. A water-soluble lubricant may be
recommended. A woman's libido may also change.
Mood swings: Mood swings, especially depression, are common during perimenopause and menopause. Women
should let their provider know if they are experiencing this, so that resources and support may be found.
Menopause and Osteoporosis
Before menopause, estrogen offers some protection against heart disease and osteoporosis. This protection is lost
when estrogen levels ebb with menopause.
Calcium Intake
For bone health, it is recommended that premenopausal women need approximately 1000 mg of calcium daily
while postmenopausal women need 1500 mg of calcium daily.
Only a small amount of calcium is found in a normal diet if we exclude dairy products. To meet these needs, three or
four servings of dairy products are required. For instance, eight ounces of yogurt (228 gm) or milk (1 cup= 236 ml),
or 1.5 ounces of cheese can provide around 300 mg of calcium.
Most individuals do not ingest adequate amount of dairy products. How to meet these needs is controversial.
Calcium supplementation for osteoporotic fracture prevention has raised concerns that it may increase the risk of
atherosclerotic vascular disease as well as for kidney stones. However, it is unclear from the present data whether
intake of dietary calcium versus calcium supplementation increases cardiovascular risk or the risk for kidney stones.
A USPSTF 2012 draft recommendation statement concluded that current evidence is insufficient to assess the risks
and benefits of calcium and vitamin D supplementation for prevention of fractures in premenopausal and
noninstitutionalized postmenopausal women. Therefore the USPSTF is currently recommending against calcium
and vitamin D supplementation in healthy pre or post menopausal women.
At this time the most prudent recommendation would be to try to increase intake of dairy and try to include weight
bearing exercises such as walking into a daily routine.
Recommendations for Osteoporosis Screening
For women >65 years old, screening with dual energy x-ray absorptiometry (DEXA) is recommended.
For women <65 years old, the USPSTF recommends using the World Health Organization's Fracture Risk
Assessment Tool to risk-stratify. Screening with DEXA is recommended if the risk of fracture is greater
than or equal to that of a 65-year-old white woman without additional risk factors (9.3 percent over 10
years).
Question
Which of the following are other risk factors for osteoporosis?

Multiple Choice Answer:
A: X Early menopause
B: O BMI >30
C: X Sedentary lifestyle
D: O African American ethnicity
E: X History of previous fracture as an adult
Answer Comment
Risk factors for osteoporosis are mainly due to low estrogen states.
Low estrogen states may be caused by early menopause (A) (i.e., before age 45 years), prolonged premenopausal
amenorrhea, and low weight and body mass index.
Lack of physical activity (C) and inadequate calcium intake (which could be attributable to poor nutrition
or alcoholism) are also associated with osteoporosis.
Other risk factors include:
Family history of osteoporotic fracture
Personal history of previous fracture as an adult (E)
Dementia, and
Cigarette smoking

Obesity (BMI >30 (B)) is associated with a high estrogen level and can be protective against menopausal symptoms
and osteoporosis.
White race, not African American ethnicity (D), is a risk factor for osteoporosis.
References:
Dennerstein, L, Dudley, EC,Hopper, JL, et al. A prospective population-based study of menopausal symptoms. Obstet Gynecol 2000;96:351.
Sweet M, Sweet J, Jeremiah M, Galazka S. Diagnosis and Treatment of Osteoporosis. Am Fam Physician. 2009;79(3):193-200, 201-202.
WebMD. Slideshow: All about menopause and perimenopause. http://www.webmd.com/menopause/slideshow-menopause-overview Published
2005, Accessed June 7, 2010.
Gold EB, Bromberger J, Crawford S, et al. factors associated with age at natural menopause in a multiethnic sample of midlife women. Am J
epidemiol 2001; 153-865.
Physician's Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation. 2003.
Am Fam Physician. 2013 Jan 1;87(1):30-37.
http://www.familypracticenews.com/index.php?id=2633&cHash=071010&tx_ttnews[tt_news]=141107


Nutrition
Dr. Lee moves on to the next topic, "I'd like to talk next about your weight."
Body mass index (BMI)
BMI is an estimate of body fat. Individuals with elevated BMI are at greater risk of developing several diseases,
including:
High blood pressure
Coronary artery disease
Stroke
Osteoarthritis
Some cancers, and
Type 2 diabetes

Older age, a sedentary lifestyle, and smoking cigarettes increase the risk of developing these diseases even more.

Nutrition
Studies show that eating a healthy breakfast is very important. Also important is eating three vegetables a day.
The website Choose My Plate provides good information on healthy eating (e.g., eating 100% whole wheat bread,
brown rice, and whole grain pasta instead of white bread, rice, and pasta and confining high sugar, high fat foods
such as cakes, cookies, ice cream to only three servings a week).
Reducing portion size can also be very helpful.


Exercise
Physical Activity and Weight Loss

Increasing physical activity has benefits for both physical and mental health. Most experts recommend performing
20-30 minutes of moderate activity five to seven days a week. Some research suggests the need for > 30 minutes of
physical activity to aid with weight loss; however, any increase in physical activity will be beneficial.
Patients should be counseled to start slowly and gradually progress to a goal of moderate activity. More simply, he
or she should exercise at the maximal intensity at which he/she is still able to comfortably carry on a conversation.
Warm-up and cool-down periods consisting of five to ten minutes of less intense activity (e.g., slow walking,
stretching) should be included to decrease the risk of hypotension, musculoskeletal injuries, and cardiovascular
complications.

Smoking Cessation
Smoking Cessation Strategies
Setting a quit date
Using nicotine replacement
Joining a support group
Calling 1-800-QUIT-NOW
Choosing an activity to substitute for smoking (e.g., taking a walk or chewing sugarless gum when the urge
to smoke occurs)
Making a list of the reasons why it is important to quit smoking and keeping it handy to refer to
Keeping track of where, when, and why you smoke (helps identify smoking triggers to avoid)
Throwing away all tobacco and smoking paraphernalia (i.e., ashtrays, lighters, anything else associated
with the smoking habit)

Mrs. Payne declines assistance with medication to help her stop smoking.


Further Screening
Breast Cancer
Epidemiology
One in eight women will have breast cancer before they are 80 years old. The risk of developing breast cancer is
related to age.
Screening
The earlier breast cancer is detected, the higher the chances of successful treatment and a cure. Mammography can
help find cancer one or two years before breast cancer may be felt by breast self exam. Guidelines regarding breast
cancer screening differ, and for women between the ages of 40 to 50 with average risk, the decision should be
individualized. Mammograms are very safe.
Method: To obtain a mammogram (an x-ray image of the breasts), each one is separately pressed between two
plates. Breast compression allows the radiologic technologist to take an image of all the breast tissue. It also holds
the breast still and allows use of a lower dose of x-ray. It may be uncomfortable while the breast is being pressed
between the plates, but compression lasts only a few seconds. Patients may want to schedule their
mammogram for the time when their breasts are least likely to be tender (usually about a week after completing a
period).



Follow Up
The Bethesda System
Using this system of reporting, cervical cytology pathology results are given in three categories:
1. Specimen adequacy
In order to be "adequate," the Pap smear must contain over 5,000 squamous cells and have sufficient endocervical
cells. If they are present, it shows that you have sampled the transformation zone, and therefore the specimen is
'adequate.'
2. General categorization of results
Is there any evidence of intraepithelial lesion or malignancy?
3. Interpretation of results
Either the Pap is negative for intraepithelial lesion or malignancy, or there is evidence of epithelial abnormalities.
Epithelial abnormalities are further divided into four categories.
Atypical squamous cells (ASC): Some abnormal cells are seen. These cells may be caused by an infection
or irritation or may be precancerous.
Low-grade squamous intraepithelial lesion (LSIL). LSIL may progress to a high-grade lesion but most
regress.
High-grade squamous intraepithelial lesion (HSIL). This is considered a significant precancerous lesion.
Squamous cell carcinoma.

Immunization Against HPV
There are two vaccines that effectively protect women against the viruses that cause approximately 75% of cervical
cancers:

Gardasil Cervarix
HPV serotypes protected
against

6,11 (cause genital warts)
16 and 18 (cause most cervical cancers)

16 and 18 (cause most cervical
cancers)
31 and 45
Licensed for females ages 9-26 yrs females 10-25 yrs
Number of doses 3 3
Timing recommendation
before sexual debut or shortly
thereafter
before sexual debut or shortly
thereafter

Although both vaccines are relatively new, they appear to be safe and effective. The vaccines are recommended by
the Advisory Committee On Immunization Practices by the CDC.
The vaccines can be expensive, and patients should be advised to check with their individual insurance carrier about
coverage.