It’s time to re-tool the annual exam: Here’s how

Although quality evidence is lacking on the benefit of counseling about weight reduction and exercise, my experience is that providing a message to patients consistently about a healthy lifestyle is more effective than almost any other medical intervention. To have an impact on cardiovascular health, however, it is imperative that we have basic knowledge about nutrition and exercise physiology—which were not taught in medical school.

It is, clearly, not useful to simply tell a patient to lose weight. Evidence does support sustained weight loss when a person participates in an organized program, such as Weight Watchers. Even moderate weight loss is associated with a reduction in the risk of hypertension, an improvement in lipid levels, and a substantial reduction in the risk of breast cancer.

I find that this last statistic—namely, that lifetime physical activity and maintenance of normal body weight is associated with a 20% to 40% reduction in the risk of breast cancer compared with the risk in women who do not exercise or who gain 10 kg or more above their high school weight—is a huge motivator. Why? It’s well-known that women are more concerned about breast cancer than about cardiovascular disease—even though statistics demonstrate that heart disease is the leading cause of death among women.

Diabetes. Women who have a history of gestational diabetes also have a markedly increased risk of type II diabetes within 5 years of the pregnancy. Clearly, these women, as well as those who are obese, have a strong family history of diabetes, or have abnormal lipid levels, should be screened with a random glucose measurement. Women who suffer chronic monilial infection should also be assessed for diabetes.

Colorectal cancer. The second leading cause of cancer death and the fourth most common cancer in the United States carries the same risk for women as it does for men. Polyps and cancers are more likely to present on the right (ascending) side of the colon in women, however, making screening with flexible sigmoidoscopy potentially less useful.

Sixty-five percent of the US population has not been adequately screened for colorectal cancer. This is regrettable, because good-quality data support an association between screening and a reduction in mortality—even simple screening with annual fecal occult blood testing. Ideally, colon cancer testing in people of average risk should begin at 50 years with either

• colonoscopy every 10 years
  
• flexible sigmoidoscopy every 5 years with or without annual fecal occult blood testing
  
• dual-contrast barium enema every 5 years
  
• fecal occult blood testing annually or
  
• perhaps, virtual colonoscopy or stool-based DNA testing for patients who decline traditional evaluation.
  

Osteoporosis. For most women, screening for osteoporosis should begin at 65 years with a test of bone mineral density. Younger women who have a significant risk factor (weight, less than 127 pounds; hyperthyroidism; steroid use; a strong family history) might benefit from screening at an earlier age. All women who take more than 7.5 mg of prednisone daily or who have sustained a nontraumatic fracture should be treated to prevent osteoporosis regardless of findings on a dual energy x-ray absortiometry (DEXA) scan.

(Note: It is vital for you to provide osteoporosis screening to Medicare patients because this is 1 of only 2 office-based performance measures in the voluntary Medicare pay-for-performance list for 2007 that are applicable to gynecology practice; the other is screening for incontinence.)

Depression. We know that depression is more common, and tends to present with more physical complaints, in women than in men. Any patient who has vague somatic symptoms, chronic pain, fatigue, decreased libido, and sleep disturbances, or such “hormonal” complaints as premenstrual syndrome and hot flashes, should be screened for depression.

I have found that the Beck Depression Inventory is easy and quick to administer if indicated. This screening instrument can be downloaded from several Web sites (search the terms Beck/Depression/Inventory). For patients who screen positive, provide a resource sheet that includes a listing of specialist referrals and local depression hotline numbers.

TABLE 2

The pillars of an annual primary screening program

Plus 3 at your discretion

The USPSTF has listed 3 optional areas for annual assessment: thyroid disease, bladder health, and domestic violence.