Approach to Women’s Health

Cardiovascular Disease

Cardiovascular disease ( Chapter 40 ) is the overall leading cause of death in women. However, because cardiovascular-related death occurs most often in women older than age 65 years, its impact is often under-recognized or underestimated. Race and ethnicity play a large role in the risk for cardiovascular disease; Black women have much higher incidence and mortality rates than any other racial or ethnic group, and Latinas and Asian women also have higher rates than White populations.

The incidence rate of cardiovascular disease in women lags 10 years behind that of men from ages 40 through 70 years; that is, a 65-year-old woman has a similar risk to a 55-year-old man. There is no abrupt increase in the risk of cardiovascular disease at menopause in women, thereby suggesting that menopausal changes in estrogen or progesterone do not account for this sex difference. Randomized clinical trials have confirmed that combined estrogen/progestin hormone therapy in women does not prevent cardiovascular disease and is not indicated for cardiovascular disease prevention, but conjugated estrogen alone may reduce the risk of heart disease over the following 18 years when begun in women ages 50 to 59 years. Estrogen monotherapy or combined estrogen/progestin therapy has complex systemic effects, and the net rates of adverse outcomes when used for chronic disease prevention may vary according to an individual woman’s risk factor profile. For example, data suggest an overall benefit when estrogen therapy is started between the ages of 50 to 59 years but not if started later. Therefore, an individualized risk stratification approach is advocated in menopausal women who are otherwise potential candidates for hormone therapy because of other indications (see Chapter 222 ). Supplementation of calcium and vitamin D, which can improve bone health in women ( Chapter 225 ), is not indicated to prevent cardiovascular disease. Other risk factors for cardiovascular disease in women are the same as those in men: elevated lipid levels ( Chapter 190 ), lack of physical activity, obesity ( Chapter 201 ), smoking ( Chapter 363 ), hypertension ( Chapter 64 ), and diabetes ( Chapter 210 ). Women with diabetes have the same risk for cardiovascular disease as men of the same age with diabetes.

However, there are notable disparities in the burden of coronary heart disease among some groups of women, especially women who are disadvantaged because of race, ethnicity, income level, and educational attainment. Cigarette smoking continues to be an important behavioral risk factor for cardiovascular disease, especially in younger women, Native American women, and women with low incomes and low educational attainment. The incidence of many known risk factors, including obesity, hypertension, and hypercholesterolemia, is greater in Black women than in White women. Furthermore, data suggest that women are less likely to receive risk factor reduction therapy, a reflection of an inertia caused by clinicians’ misperceptions of their risk for heart disease.

The presentation of coronary artery disease in women differs from that in men. Although chest pain is the most common presentation in women, atypical and noncardiac pain is a more frequent presentation in women than in men, and fewer women have typical chest tightness or pressure as their presenting complaint. For this and other reasons, women often face delays in seeking and receiving emergency care for an acute coronary syndrome ( Chapter 57 ) or acute myocardial infarction ( Chapter 58 ), thereby increasing their risk for death and recurrent myocardial infarction.

Medical management is similar for men and women with acute coronary syndromes ( Chapter 57 ) and acute myocardial infarction ( Chapter 58 ). Women with ST-segment-elevation myocardial infarction or any high-risk women with non–ST-segment-elevation myocardial infarction obtain the same benefits from either percutaneous cardiac interventions of coronary bypass graft surgery ( Chapter 59 ) as do men, after controlling for other comorbid conditions, but women commonly have lower rates of revascularization. Recent randomized clinical trials indicate similar benefits of new therapies for heart failure for women and men, including sodium-glucose cotransporter-2 inhibitors, defibrillator use, and transitions of care support.

U.S. guidelines for the management of lipid disorders ( Chapter 190 ) are based on 10-year risk of cardiovascular disease as well as absolute lipid levels. Although these guidelines are not gender specific, they attempt to avoid overtreatment of younger women at very low risk while avoiding undertreatment of women with the lower low-density lipoprotein (LDL) cholesterol level but much higher overall risks of cardiovascular disease. High-intensity statin therapy is recommended as secondary prevention for women who have clinical atherosclerotic disease, as well as for primary prevention for women who have a 20% or greater risk of atherosclerotic cardiovascular disease, an LDL cholesterol level higher than 190 mg/dL, or diabetes and a 7.5% or greater 10-year risk of atherosclerotic cardiovascular disease ( Chapter 190 ). A moderate-intensity statin is recommended for lower risk women with diabetes or with a 5 to 20% 10-year risk of atherosclerotic cardiovascular disease. Women lag behind men in use of medical therapy for lipid disorders, perhaps in part because of higher reported rates of adverse effects, especially from statins; however, most patients who report such symptoms can successfully use statins after a blinded trial (see Chapter 190 ).

Type 2 Diabetes

The rates of type 2 diabetes ( Chapter 210 ) continue to rise, with a greater risk in women who are overweight, obese, or physically inactive. Rates are higher in many racial and ethnic groups including Black, Asian, Native American, and Latina women than among White women. Lifestyle changes (primarily diet and exercise) can reduce the incidence of type 2 diabetes. No randomized clinical trials have shown that screening for diabetes is beneficial, but current U.S. guidelines recommend screening overweight or obese adults with a high A _1C level as part of their cardiovascular risk assessment beginning at age 35 and continuing to age 70 years. For women who develop gestational diabetes ( Chapter 221 ), the risk of developing type 2 diabetes later in life increases five-fold, so screening with hemoglobin A _1C levels at 6 to 12 weeks postpartum and every 3 years thereafter is recommended.

The incidence of diabetes is rising in women at younger ages, with significant perinatal and maternal health implications. Ongoing discussion of fertility control and family planning is critical in diabetic women with childbearing potential. Tight glycemic control before conception and through the first trimester is critical to reduce the risk for birth anomalies, and it is important later in pregnancy to reduce the risk for adverse fetal events, including macrosomia (large for gestational age) and preterm birth ( Chapter 221 ). Ideally, women planning a pregnancy should switch from oral agents to insulin, with home glucose monitoring for tight control ( Table 219-2 ). Risks of maternal complications from diabetes including vascular disease, retinopathy, hypertension, preeclampsia, renal disease, and neuropathy are general related to glycemic control before and during pregnancy and usually not specifically due to pregnancy itself.

Cancer

Cancer is the leading cause of death in women ages 40 through 65 years, and it is the leading cause of years of life lost in women younger than age 65 years. Breast cancer ( Chapter 183 ) is the most common type of cancer and the second leading cause of cancer death in women. Studies indicate that many women significantly overestimate their personal risk for the disease. The lack of understanding of the cause of most breast cancers and the limitations of the imaging modalities used as screening tests have hampered efforts at breast cancer control. Data suggesting overdiagnosis of breast cancer, especially in women ages 40 to 50 years, has prompted an appreciation for the implications of screening mammography and the virtue of shared decision making, especially in this age group. After decades of an increasing incidence of breast cancer in the United States, incidence rates have fallen in the past decade. The cause of this decline is not understood; reduced use of postmenopausal hormone therapy and recent declines in screening rates have been implicated. In women who are known carriers of the BRCA1 and BRCA2 mutations, estimates now can be made for age-specific risks of breast, ovarian, and contralateral breast cancer (see Chapter 183 ).

Lung cancer ( Chapter 177 ) is now the leading cause of cancer death in women, and rates continue to rise, commensurate with the timeline for increasing rates of smoking in women. Most lung cancers are smoking related, although women are more likely than men to have lung cancers that are not tobacco related. Based on the results of randomized trials, guidelines recommend low-dose chest tomographic screening of women as well as men who have a greater than a 20 pack-year smoking history, who are current smokers, or who quit within the previous 15 years. Nevertheless, smoking cessation ( Chapter 363 ) continues to be the most effective strategy to prevent lung cancer and should be the focus of primary prevention.

Colorectal cancer ( Chapter 179 ) has a similar incidence in both women and men. Screening is recommended beginning at age 45 years and continuing to age 75 years for both women and men using colonoscopy every 10 years, sigmoidoscopy every 5 years, annual stool testing with a fecal immunochemical test or every 1 to 3 years with a DNA fecal immunochemical test. Rates of screening in women are similar to men, but neither reach Healthy People 2030 goals for this effective preventive screening.

Ovarian cancer ( Chapter 184 ) is relatively rare, with about 21,000 cases in the United States, and its annual and incidence has declined in recent decades. However, mortality is high owing to its presentation at late stages in most cases. Lower abdominal or pelvic pain, urinary symptoms, and changes in bowel habits are nonspecific and common in many women, thereby limiting the ability to detect this cancer at an early stage. A screening pelvic examination is not useful in asymptomatic women, and no effective screening test has been shown to reduce mortality from ovarian cancer. As a result, screening of the general population is not recommended.

The greatest advance in cancer prevention is the development of vaccines against the most carcinogenic subtypes of human papillomavirus (HPV) associated with cervical cancer ( Chapters 184 and 344 ) and anal cancer. Although concern of tacit approval of sexual activity among young adolescents has been cited by parents as a reason to delaying vaccination, evidence does not demonstrate this concern to be founded, and vaccination is recommended for girls at ages 11 to 12 years ( Chapter 15 ). Pap test screening can be delayed until age 21 years. Cervical cancer screening is generally recommended with cervical cytology about every 3 years in women age 21 to 29 years and then either every 3 years with cytology alone or every 5 years with HPV testing in women ages 30 to 65 years. Pap tests are not recommended for women after hysterectomy for nonmalignant indications or for women older than 65 years with adequate recent screening and no high-risk factors.