It should be clear by now that prevention means not only solving problems, but also not creating new ones. It also extremely important that we not let health problems we are already aware of advance to become bigger problems. One of the most important things you can do to insure your own wellness and well-being is to have periodic health screening examinations.
Whether your insurance company will like it or not, whether you have insurance or pay cash, knowing what you must to do and doing it may make the difference between a sound healthy life or a life of illness, pain and suffering. In this section, we will present information you need to know. We will, however, leave the decision making up to you to make sure that it gets done. Over the years we heard the same story over and over again, "I hate doctors!" "I hate going to doctors!" "I hate being examined. I hate having to take off my clothes and be touched and pummeled."
All of this may be true, but you're not having periodic checkups could be translated into the following, "I hate growing old gracefully, I would rather die early of some incurable disease which was found too late to help you." Why allow yourself to be compromised this way when you can find and reverse problems early before you have to suffer and your family has to do without you. Why should you have to suffer just because you "dislike" doctors or "hate" examinations? Why should you and your family suffer and lose for a little inconvenience or some brief discomfort?
Too more fully understand the screening process we should first take a look at the incidence of the most common problems that will face the perimenopausal, menopausal and post-menopausal women.
Heart Attack and Stroke
While most women are fearful of cancer, the risk of heart attack is really the most common problem they face. Cancer is a distant second and stroke is just below cancer as the main disease risks women face.
More often than not, heart disease can be picked up early. It can also be reversed more easily when found early. Simple tests like taking your blood pressure, checking your pulse and listening to your heart may be all that is necessary to make a diagnosis. Blood testing or an electrocardiogram may ultimately be necessary to confirm the diagnosis.
Having your blood pressure, pulse and listening to your heart should be performed every time you have a preventive health checkup. They should be checked routinely every six months if there are no problems and sooner if there are problems such as shortness of breath, chest pain, pain into the left arm, upper back, neck or jaw.
Cancer
While there are many Illnesses that affect people possibly nothing is more fearful or devastating then cancer. If we first look at the incidence of all cancers diagnosed among women of all ages (See Diagram-1) we will see that the cancers of the reproductive system especially the breasts appear to be the most common. Next are cancers of the colon and rectum. Third, is a diffuse group of all other cancers.
Cancer of the Breasts
The single largest risk for women, representing more than 22%-28% of all cancers found in women, is cancer of the breasts. Cancer of the breast has been described as a disease of aging and almost half of the cases occur in women 65 years of age or older. Approximately 16% are diagnoses in women in the 40-49 age group, while 29% occur in women 50-64 years of age. It has been estimated that a woman who reaches 85 years of age has at least a one in eight chance of developing breast cancer during her life.
Breast cancer is much more common in women than men, and the highest rates of breast cancer exist in North America and northern Europe. In American women, the annual incidence of breast cancer increases rapidly with age, from approximately 20 per 100,000 at age 30 to 180 per 100,000 at age 50. The risk for women with a family history of premenopausally diagnosed breast cancer in a relative is about two to three times that of the average woman of the same age in the general population.
The rate of cancer of the breast appears to be increasing slowly as women live longer, just a few years ago her chances of developing breast cancer were only one in nine. At age 50 the risk of a woman getting breast cancer is one in four.
Women with previous breast cancer are at increased risk, as are women with a history of benign breast disease. Other factors with some clinical or statistical association with breast cancer include first pregnancy after age 30, menarche before age 12, menopause after age 50, obesity, high socioeconomic status, and a history of ovarian or endometrial cancer.
The three screening tests usually considered for breast cancer are: clinical examination of the breast, x-ray mammography, and breast self-examination (BSE).
There is no question that self-breast examinations, physician breast examinations and the newer techniques for mammography can make a difference in early detection. When breast cancer is detected early enough, it is virtually 100% curable with nondestructive surgical techniques such as lumpectomy where only a small area of tissue, a little larger than a biopsy, is taken. If it is found later, rather than earlier, then the mortality rate increases, the types of surgical treatments become more destructive and invasive, and radiation and chemotherapy may also be necessary.
The Well Woman Examination
Examining Your Own Breasts:
Learn to perform self-breast examinations and do them regularly. If you are still menstruating, do your exam on the first day of your regular period. If your periods are irregular or you are having no menstrual periods do the examinations on the first day of every month by the calendar.
If there is a family history of breast cancer special attention should be paid to your breasts including regular self-examination, physician examination and routine mammography. Table-1 can be used as a guideline for determining what and when screening should be done.
Table-1
These guidelines suggest that if you have no immediate family history of cancer of the breast and you are less than 40 years of age you should have physician breast examination at least every year to three years. At or about 50 years of age this should be performed on a yearly basis. Having practiced OB-Gyn for many years it has always been my feeling that every woman should have a breast examination every six months. While this may seem excessive in light of the above recommendations consider what it would mean to not find a tumor early enough and what trouble this would be. If moneys are a problem then sticking to the above schedule would be minimal criteria. Remember: Most women find their own cancers at the time of self-breast examinations. Never rely on your physician to find what you can find months or even years earlier.
We should be clear that cancer of the breast is not the only problem menopausal women must consider in relation to the breasts. The greatest majority of "lumps" that women or their doctors find on examination are caused by Fibrocystic Changes in the breasts. The overwhelming percentage of all lumps found, some 96%, will be benign tumors. Because of the fear of cancer many women will experience emotional pain, anguish and discomfort until the "lump" are clearly found to be harmless. This is a shame but, we have never found a way of preventing it except through early evaluation to rule out malignancy.
To determine if these lumps are cancer or not, you may have to suffer through either mammography or breast biopsy, or both. While the majority of the time the diagnosis of breast cancer can be made through mammography, on some occasions a biopsy must be done. Of the biopsies performed less than 30% of the time the tissue samples will suggest that there is some malignant potential even though it is still read as benign. In recent years needle biopsies have become more and more acceptable and are slowly replacing open breast biopsies. At this point almost 90% of all palpable lumps can be accessed by needle biopsy.
While pain and nipple discharge (white or greenish fluids) are often scary, they generally have little significance related to cancer and more like represent a noncancerous process that needs to be dealt with through non-surgical means. A bloody discharge (bright or dark red blood or a brownish discharge) should always be suspect and brought to the attention of your physician immediately.
Breast Implants:
Somewhere between one and two million women have breast implants. More than 80% of these were performed for cosmetic reasons. Many questions have been raised on what influence this will have on the transition of these women into the menopausal era. To date there is no clear cut evidence of risk of malignancy associated with either silicone or the implants themselves.
Many women have told us that they are fearful of checking their own breast or that they are fearful of going to the doctor to have these examinations done. They are afraid that they or their doctor will find a cancer. The problem here is that the examinations do not cause cancer, so if a cancer is found it is already present. If it is already present aren't you better off finding it early before it is so advanced that major surgery or chemotherapy is essential. If you don't find it early, the problem is that when you finally do find it, it may be too late. Remember, these examinations don't cause cancer, they merely find it if it is already present.
Cervical Cancer:
The rate of cervical cancer is lowest of all genital cancers. It is the sixth most common cancer in women. Of the three endometrial, ovarian and cervical cancers, it occurs earlier and it is easiest to diagnose. The Pap smear is the primary diagnostic tool. There may be no symptoms or spotting or discharge may be the only indication that there is a problem. We ill discuss screening when we talk about the Pap smear in a later section.
Endometrial Cancer:
Endometrial Cancer is the fourth most common cancer in women. It occurs most frequently in women over 50 years of age. Spotting and irregular bleeding are the main symptoms. Diagnosis is best made by endometrial biopsy or by Dilatation and Curettage (D&C).
Ovarian Cancer
Ovarian cancer is the fifth most common cancer in women. Its frequency is about the same as bladder and kidney cancer combined. It is difficult to diagnose and must be considered every time a pelvic mass is found. Of the three female genital cancers it is most likely only to be found on routine pelvic exam. It generally has no external symptoms until it is too late.
Lung Cancer
While not a genital cancer it is important because it occurs as the third most common cancer in women. Lung examination and periodic chest x-ray are important screening tools. Women who smoke, have family history of lung cancer or who are around considerable second hand smoke should have yearly checkups including a lung examination and chest x-ray.
Skin Cancer
While the incidence is only slightly lower than endometrial cancer making the eighth most common cancer in women, it should not be forgotten. The two most important screening techniques are self-examination and physician examination and when necessary a skin biopsy.
Any skin lesions that are growing rapidly, changing color, send out growths for it or breaking down or bleeding should be evaluated. Because most women cannot see their back or the back of their neck, it is important for the woman's partner, if she has one, to assist in check and evaluating her back side. Any lesion that looks suspicious that wasn't there before or is changed should then be evaluated by a dermatologist. Examination by a General practitioner or OB-Gyn can be a first step to obtain a referral, if it is needed. However, best results are obtained by seeing a Dermatologist in early diagnosis and treatment.
The Pelvic Examination
No woman likes to have a pelvic examination. Many women even hate it as we suggested earlier. However, this is really no reason to avoid it. We have always believed that the so-called Yearly PAP Smear is really just a way to get women into the office for a preventive check up examination. Once in the office there are a number of things that can happen:
- A careful Breast Examination can be done.
- The Pelvic Examination can also be done.
- Your heart can be listened to.
- Your blood pressure can be checked.
- A Skin Examination can be done to check for skin cancer.
- A Rectal Examination with a test for occult blood can be done to look for colon and rectal cancer.
- Any new complaints can be checked out or appropriate referrals made.
- Blood tests can be taken for anemia, diabetes, liver disease or cancer.
This type of examination would constitute a good examination for women who are entering the menopausal era (perimenopause), who are already within the menopause period or are in the post-menopausal era. It would be looking for the main causes of mortality and illness in the women of this age group. Before prescription of Estrogen Replacement Therapy (ERT) or Hormonal Replacement Therapy (HRT) this type of examination would essentially along with counseling about their risks and benefits. Once the woman is using ERT or HRT or Oral Contraceptives (OC's) routine examinations and diagnostic laboratory testing is a necessity to make sure that she develops no complications or problems.
At this point take a second and look back at Diagram-1. Please notice that in this type of complete examination the breasts, which are external to the body, the skin which is external to the body can be examined with little or no discomfort. The pelvic exam allows your physician to check for cancer of the vulva, vagina, cervix, uterus, tube and ovaries. The pelvic area is easily accessible and the examination is relatively easy to perform. When the pelvic examination is performed with a rectal, the pelvic organs can be evaluated better, and the physician can check for rectal cancer at the same time.
Just doing this type of brief examination represent screening for literally 59.3% of all of the cancers that you might risk. Add listening to your lungs and looking in your throat and taking some simple blood tests and we reach 80-90%.
The Pap Smear:
The pap smear is primarily used to look for cancer of the cervix is a relatively inefficient test. There is roughly a 30% false negative rate associated with any single smear. This means that one-third of the time your pap smears are inaccurate. If done only once a year this might mean that a cancer of the cervix could be missed and it would be more than two years of no treatment before it was found again, that is, assuming it was picked up on the next testing. If pap smears are done every six months, the rate of failure decreases significantly. When the rest of the examinations we listed above, or at least examinations of the breasts, pelvis and rectum are done, you greatly increase your chance of an early diagnosis of cancer, should it exist.
When there is a family history of uterine or ovarian cancer a pelvic examination and pap smears should definitely be performed every six months.
We realize that many physicians may disagree with our personal recommendations. We have always felt that prevention means preventing and not wishing that you had prevented it. Since all cancers respond best to early diagnosis and treatment, the only other issue is physician availability, and cost. For many physicians every six month routine examinations are boring, for insurance companies they are expensive but for some individual they will be life saving.
The Woman Using HRT, ERT or OC's
Women over 40 years of age using OC's should, in our estimation, have examinations every six months. This should include most of what we outlined above. Your individual physician may think that you need an examination only once a year. We have already made our feeling clear, the rest is up to you and your physician.
Checking for Heart Disease
Here again this depends upon prior history and risk. If you are on HRT, ERT or OC's, every six months. If you are not, and are otherwise well, then blood tests for cholesterol, LDL and HDL fractions, lipoprotein(a) and triglycerides should be performed at least on a yearly basis. If your blood pressure is elevated or chemistries are abnormal your doctor will tell you how often he or she wants to see you.
While we have spent the greatest amount of time discussing the risks of cancer statistics suggest that the menopausal woman is more likely to die of heart disease, then any other cause.
Remember: prevention through diet and exercise, frequent blood pressure checks, occasional electrocardiogram and frequent examinations by your physician is the best medicine.
Diabetes
Once again if no family history, or other high risk problems such as obesity, poor diet or symptoms once a year is sufficient. If there are high risk attributes then your physician will tell you how often to come in for testing.
Sexually Transmitted Diseases
Women who are sexually active with multiple partners should have routine examinations and specific diagnostic testing when indicated. AIDS, syphilis, herpes, papilloma virus and even gonorrhea are not age related. These conditions can cause harmful effect, especially if not diagnosed early and treated correctly.
Protecting Against Unwanted Pregnancy
A fact, which is little known by most women, is that perimenopausal women have the highest rate of unwanted pregnancy. It is almost equal to the rate for 16 to 19 year old women. Unwanted pregnancy is a major health problem for perimenopausal women. It requires that they chose between continuing an unwanted pregnancy and suffer risks of maternal-child birth or that they opt to have an abortion. Neither is a "good" option for the woman who does not want to be pregnant. We clearly recommend that if you are not using a reliable method of contraception that you find a physician who will educate you and prescribe the safest and best method for you. To not take chances you might lose.
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