Gynecology_Novak

Gynecology_Novak. Colorectal cancer screening† Colorectal cancer or adenomatous polyps in first-degree relative younger than age 60 years or in two or more first-degree relatives of any ages; family history of familial adenomatous polyposis or hereditary non-polyposis colon cancer; history of colorectal cancer, adenomatous polyps, inﬂammatory bowel disease, chronic ulcerative colitis, or Crohn’s disease Diphtheria and reduced tetanus Adults who have or who anticipate having close contact with an infant aged less than 12 toxoids and acellular pertussis months and health care providers. When possible, women should receive Tdap before vaccine‡ becoming pregnant.


Gynecology_Novak

Gynecology_Novak. Fasting glucose testing§ Overweight (BMI greater than or equal to 25); first-degree relative with diabetes mellitus; habitual physical inactivity; high-risk race or ethnicity (eg, African American, Latina, Native American, Asian American, Pacific Islander); have given birth to a newborn weighing more than 9 lb or have a history of gestational diabetes mellitus; hypertension; high-density lipoprotein cholesterol level less than 35 mg/dL; triglyceride level greater than 250 mg/dL; history of impaired glucose tolerance or impaired fasting glucose; polycystic ovary syndrome; history of vascular disease; other clinical conditions associated with insulin resistance Fluoride supplementation Live in area with inadequate water ﬂuoridation (less than 0.7 ppm)


Gynecology_Novak

Gynecology_Novak. Fluoride supplementation Live in area with inadequate water ﬂuoridation (less than 0.7 ppm) Genetic testing/counseling Considering pregnancy and: patient, partner, or family member with history of genetic disorder or birth defect; exposure to teratogens; or African, Cajun, Caucasian, European, Eastern European (Ashkenazi) Jewish, French Canadian, Mediterranean, or Southeast Asian ancestry Hemoglobin level assessment Caribbean, Latin American, Asian, Mediterranean, or African ancestry; history of excessive menstrual ﬂow HAV vaccination Chronic liver disease, clotting factor disorders, illegal drug user, individuals who work with HAV-infected nonhuman primates or with HAV in a research laboratory setting, individuals traveling to or working in countries that have high or intermediate endemicity of hepatitis A


Gynecology_Novak

Gynecology_Novak. HBV vaccination Hemodialysis patients; patients who receive clotting factor concentrates; health care workers and public safety workers who have exposure to blood in the workplace; individuals in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions; injecting drug users; individuals with more than one sexual partner in the previous 6 months; individuals with a recently acquired STD; all clients in STD clinics; household contacts and sexual partners of individuals with chronic HBV infection; clients and staff of institutions for the developmentally disabled; international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months; inmates of correctional facilities


Gynecology_Novak

Gynecology_Novak. HCV testing History of injecting illegal drugs, recipients of clotting factor concentrates before 1987, chronic (long-term) hemodialysis, persistently abnormal alanine aminotransferase levels, recipients of blood from donors who later tested positive for HCV infection, recipients of blood or blood-component transfusion or organ transplant before July 1992, occupational percutaneous or mucosal exposure to HCV-positive blood


Gynecology_Novak

Gynecology_Novak. HIV testing More than one sexual partner since most recent HIV test or a sexual partner with more than one sexual partner since most recent HIV test, have received a diagnosis of another STD in the past year, drug use by injection, history of prostitution, past or present sexual partner who is HIV positive or injects drugs, long-term residence or birth in an area with high prevalence of HIV infection, history of transfusion from 1978 to 1985, invasive cervical cancer, sexually active adolescent younger than age 19 years, adolescent entering detention facilities. Recommend to women seeking preconception evaluation. Table 8.5 (Continued ) Table 8.5 (Continued ) Thyroid-stimulating hormone Strong family history of thyroid disease; autoimmune disease (evidence of subclinical testing hypothyroidism may be related to unfavorable lipid profiles)


Gynecology_Novak

Gynecology_Novak. Thyroid-stimulating hormone Strong family history of thyroid disease; autoimmune disease (evidence of subclinical testing hypothyroidism may be related to unfavorable lipid profiles) Tuberculosis skin testing HIV infection; close contact with individuals known or suspected to have tuberculosis; medical risk factors known to increase risk of disease if infected; born in country with high tuberculosis prevalence; medically underserved; low income; alcoholism; intravenous drug use; resident of long-term care facility (eg, correctional institutions, mental institutions, nursing homes and facilities); health professional working in high-risk health care facilities; recent tuberculin skin test converter (individuals with baseline testing results who have an increase of 10 mm or more in the size of the tuberculin skin test reaction within a 2-year period); radiographic evidence of prior healed tuberculosis


Gynecology_Novak

Gynecology_Novak. Varicella vaccination Adults and adolescents aged 13 years or older; all adolescents and adults without evidence of immunity; students in all grade levels, and persons attending college or other postsecondary educational institutions; susceptible persons who have close contact with persons at high risk for serious complications, including health care workers; household contacts of immunocompromised individuals; teachers; daycare workers; residents and staff of institutional settings, colleges, prisons, or military installations; adolescents and adults living in households with children; international travelers; nonpregnant women of childbearing age


Gynecology_Novak

Gynecology_Novak. Abbreviations: BMI, body mass index; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; MMR, measles–mumps–rubella; STD, sexually transmitted disease; Tdap, diptheria and reduced tetanus toxoids and acellular pertussis vaccine. ∗For a more detailed discussion of bone mineral density screening, see Osteoporosis, ACOG Practice Bulletin No. 50. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;103:203–16.


Gynecology_Novak

Gynecology_Novak. †For a more detailed discussion of colorectal cancer screening, see Levin B, Lieberman DA, McFarland B, Smith RA, Brooks D, Andrews KS, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Mutti-Society Task Force on Colorectal Cancer, and the American College of Radiology. American Cancer Society Colorectal Cancer Advisory Group; US Multi-Society Task Force; American College of Radiology Colon Cancer Committee. CA Cancer J Clin 2008;58:130–60.


Gynecology_Novak

Gynecology_Novak. ‡For more information, see Broder KR, Cortese MM, Iskander JK, Kretsinger K, Slade BA, Brown KH, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-3):1–34.; Kretsinger K, Broder KR, Cortese MM, Joyce MP, Ortega-Sanchez I, Lee GM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. Centers for Disease Control and Prevention; Advisory Committee on Immunization Practices; Healthcare Infection Control Practices


Gynecology_Novak

Gynecology_Novak. Committee (HICPAC), for use of Tdap among health-care personnel. Centers for Disease Control and Prevention; Advisory Committee on Immunization Practices; Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2006;55(RR-17):1–37. §For more information, see Postpartum screening for abnormal glucose tolerance in women who had gestational diabetes mellitus. ACOG Committee Opinion No. 435. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:1419–21. From American College of Obstetricians and Gynecologists, Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 452. Obstet Gynecol 2009;144:1444–1451.


Gynecology_Novak

Gynecology_Novak. not permit “even moderated certainty” about the net benefit of the preventive service. The role of judgment in the domains of the potential preventable burden of suffering from the condition, the potential harm of the intervention, the cost, the context of current practice, and the potential role of other domains are recognized by the task force, with the conclusion that “decision making under conditions of uncertainty is a recurring issue in medicine” (20).


Gynecology_Novak

Gynecology_Novak. International efforts to categorize the effectiveness of treatments include the Cochrane Library, which produces and disseminates high-quality systematic reviews of health care interventions. These reviews and abstracts are published monthly and are available online and on DVDs by subscription (21). The Cochrane Library provides searchable databases online and through institutional purchase of licenses. Evidence-based guidelines are published in journals available in print and online by discipline (i.e., medicine, mental health, and nursing). Another source of evidence-based information is Clinical Evidence, a subscription service published by the British Medical Journal in print, via PDA, and online (22). This service describes its content as driven by important clinical questions rather than by the availability of research evidence. The advantages of Web-based sites are the ease of updating and the availability of evidence to clinicians in clinical practice sites throughout the


Gynecology_Novak

Gynecology_Novak. than by the availability of research evidence. The advantages of Web-based sites are the ease of updating and the availability of evidence to clinicians in clinical practice sites throughout the world. Other Web sites that provide tools and information about evidence-based health care include the Oxford Centre for


Gynecology_Novak

Gynecology_Novak. Table 8.6 U.S. Preventive Services Task Force Ratings The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reﬂecting the strength of evidence and magnitude of net benefit (benefits minus harms). After May 2007, updated definitions of the grades it assigns to recommendations are noted below with “suggestions for practice” with each grade (50). Evidence-Based Medicine, the Database of Abstracts of Reviews of Effects (DARE), and the American College of Physicians (ACP) Journal Club (23–25).


Gynecology_Novak

Gynecology_Novak. Around the same time that clinicians were evaluating the primary health care needs of adults, clinicians who practice adolescent medicine (with backgrounds in pediatrics, internal medicine, family medicine, gynecology, nursing, psychology, nutrition, and other professions) recognized that the guidelines for adult and pediatric health services did not always fit the needs and health risks of adolescence. Neither the ACOG Guidelines for Primary Preventive Care nor the USPSTF recommendations is sufficiently comprehensive or focused on this age group, although both documents include many important aspects of adolescent health care (10,13). The American Medical Association, with the assistance of a national scientific advisory board, developed the Guidelines for Adolescent Preventive Services (GAPS) in response to this perceived need for recommendations for delivering comprehensive adolescent preventive services (13,14,26).


Gynecology_Novak

Gynecology_Novak. Obstetricians-gynecologists typically see adolescents in crisis to provide care for unintended pregnancies or STDs, including pelvic inﬂammatory disease. The urgency for preventing these crises is evident. The GAPS report extends the framework of services provided to adolescents. The impetus for developing GAPS was the belief that a fundamental change in the delivery of adolescent health services was necessary. This concept is strongly supported by the Society for Adolescent Medicine, the American Academy of Pediatrics, and the American Academy of Family Physicians (27). Gynecologists could easily provide most, if not all, of the recommended services. The American College of Obstetricians and Gynecologists developed a “Tool Kit” on primary and preventive health care for female adolescents in recognition of the needs of this population, and recommended that the “first visit to the obstetrician-gynecologist for health guidance, screening, and the provision of preventive health care


Gynecology_Novak

Gynecology_Novak. in recognition of the needs of this population, and recommended that the “first visit to the obstetrician-gynecologist for health guidance, screening, and the provision of preventive health care services should take place between the ages of 13 years and 15 years” (28,29). Subsequent annual visits are recommended by ACOG to provide preventive guidance and services including contraception and STD treatment as required. The guidelines and recommendations for adolescent health care address the delivery of health care, focus on the use of health guidance to promote the health and well-being of adolescents and their families, promote the use of screening to identify conditions that occur relatively frequently in adolescents and cause significant suffering either during adolescence or later in life, and provide guidelines for immunizations for the primary prevention of specific infectious diseases. Considerable barriers exist to adolescents’ accessing these services, including barriers


Gynecology_Novak

Gynecology_Novak. in life, and provide guidelines for immunizations for the primary prevention of specific infectious diseases. Considerable barriers exist to adolescents’ accessing these services, including barriers inherent in the US health care system and legal barriers (30).


Gynecology_Novak

Gynecology_Novak. The recommendations for adolescent preventive services stem from the conclusion that the current health threats to adolescents are predominantly behavioral rather than biomedical, that more of today’s adolescents are involved in behaviors with the potential for serious health consequences, that adolescents are involved in health-risk behaviors at younger ages than previous generations, that many adolescents engage in multiple health-risk behaviors, and that most adolescents engage in at least some type of behavior that threatens their health and well-being (26). Gynecologists are in a good position to detect high-risk behaviors and to determine whether multiple risk-taking behaviors exist; for example, the early initiation of sexual activity and unsafe sexual practices are associated with substance use (30,31). Adolescents who are sexually active are much more likely than are adolescents who are not sexually active to have used alcohol (6.3 times greater risk), to have used drugs


Gynecology_Novak

Gynecology_Novak. with substance use (30,31). Adolescents who are sexually active are much more likely than are adolescents who are not sexually active to have used alcohol (6.3 times greater risk), to have used drugs other than marijuana (four times greater risk), and to have been a passenger in a motor vehicle with a driver who was using drugs (nearly 10 times greater risk) (32). Thus, by being aware of comorbidities, gynecologists can screen for these behaviors and potentially intervene before serious harmful health consequences occur. In recognition of the role that obstetricians-gynecologists could play in providing preventive services for adolescents, ACOG issued guidelines that suggest an initial visit (not necessarily including gynecologic examination) to the obstetrician-gynecologist for health guidance, screening, and the provision of preventive health care service between the ages of 13 and 15 years and subsequent annual preventive health care visits (29).


Gynecology_Novak

Gynecology_Novak. During periodic assessments, patients should be counseled about preventive care based on their age and risk factors. Obesity, smoking, and alcohol abuse are associated with preventable problems that can have major long-term impacts on health. Patients should be counseled about smoking cessation and moderation in alcohol use and directed to appropriate community resources as necessary. Positive health behaviors, such as eating a healthy diet and engaging in regular exercise, should be reinforced. Adjustments may be necessary based on the presence of risk factors and the woman’s current lifestyle and condition. Efforts should focus on weight control, cardiovascular fitness, and reduction of risk factors associated with cardiovascular disease and diabetes (1).


Gynecology_Novak

Gynecology_Novak. Nutrition Patients should be given general nutritional information and referred to other professionals if they have special needs (1). Assessment of the patient’s body mass index (BMI; weight [in kilograms] divided by height [in meters] squared [kilograms per square meter]) will give valuable information about the patient’s nutritional status. Tables and methods to calculate BMI are available in print and electronic resources. Patients who are 20% above or below the normal range require evaluation and counseling and should be assessed for systemic disease or an eating disorder. Of adult women in the United States, 64% are overweight (BMI 25.0–29.9) or obese (BMI ≥30) 36% are obese (33,34). Overweight and obesity substantially increase the risk of morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and cancers of the endometrium, breast, and colon (35). ACOG has emphasized the role of the


Gynecology_Novak

Gynecology_Novak. type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and cancers of the endometrium, breast, and colon (35). ACOG has emphasized the role of the obstetrician-gynecologist in the assessment and management of obesity (36).


Gynecology_Novak

Gynecology_Novak. Central obesity—measured as waist-to-hip ratio—is an independent risk factor for disease. Women with a waist circumference greater than 35 inches are at higher risk of diabetes, dyslipidemia, hypertension, and cardiovascular disease (37). Metabolic syndrome is a complication of obesity that, while somewhat variably defined, includes a clustering of atherogenic dyslipidemia, elevated blood pressure, elevated plasma glucose, and abdominal obesity and confers an increased risk for cardiovascular disease and diabetes (38). One-third to one-half of premenopausal women with polycystic ovarian syndrome (PCOS) meet the criteria for metabolic syndrome (39).


Gynecology_Novak

Gynecology_Novak. Figure 8.1 MyPlate Icon. This is a new communications initiative based on 2010 Dietary Guidelines for Americans, replacing the Food Pyramid. It is designed to remind Americans to eat healthfully, and illustrates the five food groups using a familiar the familiar mealtime visual of a place setting. (From the United States Department of Agriculture, http://www. ChoseMyPlate.gov) Key nutritional recommendations were issued by the Dietary Guidelines Advisory Committee to the U.S. Department of Agriculture (40). These recommendations are included in the MyPlate 2010 Guidelines, which has an emphasis on fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products (Fig. 8.1) (41). The guidelines include recommendations to balance food and physical activity and stay within daily calorie requirements.


Gynecology_Novak

Gynecology_Novak. Fiber content of the diet is being studied for its potential role in the prevention of several disorders, particularly colon cancer. It is recommended that the average diet for women contain 25 g of fiber per day (40). Whole-grain foods, and vegetables, citrus fruits, and some legumes, are high in fiber and are emphasized in the guidelines for healthy foods. Adequate calcium intake is important in the prevention of osteoporosis. A postmenopausal woman should ingest 1,500 mg per day. Adolescents require 1,300 mg per day. Because it may be difficult to ingest an adequate amount of calcium daily in an average diet, supplements may be required.


Gynecology_Novak

Gynecology_Novak. The U.S. Public Health Service has recommended that women of reproductive age who are capable of becoming pregnant take supplemental folic acid (0.4 mg daily) to help prevent neural tube defects in their infants. Surveys indicate that in 2007, 40% of women of childbearing age consumed a supplement, a percentage that is only half of the Healthy people 2010 objective of 80% (42). Women who are contemplating pregnancy should be counseled about the risk of fetal neural tube defects and the role of folic acid supplementation prior to conception in their prevention (43).


Gynecology_Novak

Gynecology_Novak. Alcohol Alcoholic beverages should be limited to one drink per day for women (40). A simple device called the T-ACE questionnaire (Tolerance; been Annoyed by criticism of drinking; felt need to Cut down; need for Eye-opener) can be used to elicit information about alcohol use and identify problem drinkers (44). Women should be questioned in a nonjudgmental fashion about their alcohol use and directed to counseling services as required.


Gynecology_Novak

Gynecology_Novak. Exercise Exercise can help control or prevent hypertension, diabetes mellitus, hypercholesterolemia, and cardiovascular disease and helps to promote overall good health, psychological wellbeing, and a healthy body weight. Moderate exercise along with calcium supplementation can help retard bone loss in postmenopausal women. During early menopause, weight-bearing exercise alone is not sufficient to prevent bone loss, although it will slow the rate of bone loss (45). Exercise helps promote weight loss, strength and fitness, and stress reduction. Federal exercise guidelines from the U.S. Department of Health and Human Services note that “regular physical activity reduces the risk of many adverse health outcomes; some physical activity is better than none; for most health outcomes, additional benefits occur as the amount of physical activity increases through higher intensity, greater frequency, and/or longer duration; most health benefits occur with at least 150 minutes (2 hours and 30


Gynecology_Novak

Gynecology_Novak. benefits occur as the amount of physical activity increases through higher intensity, greater frequency, and/or longer duration; most health benefits occur with at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity physical activity, such as brisk walking. Additional benefits occur with more physical activity; both aerobic (endurance) and muscle-strengthening (resistance) physical activity are beneficial; health benefits occur for children and adolescents, young and middle-aged adults, older adults, and those in every studied racial and ethnic group; the health benefits of physical activity occur for people with disabilities; and the benefits of physical activity far outweigh the possibility of adverse outcomes” (46). To sustain weight loss in adulthood, 60 to 90 minutes of daily moderate-intensity physical activity are recommended. Cardiovascular conditioning, stretching exercises for ﬂexibility, resistance exercises, or calisthenics for muscle strength and


Gynecology_Novak

Gynecology_Novak. minutes of daily moderate-intensity physical activity are recommended. Cardiovascular conditioning, stretching exercises for ﬂexibility, resistance exercises, or calisthenics for muscle strength and endurance are recommended for most people. Most healthy adults do not need to see a physician before starting a moderate-intensity exercise program, although those with chronic diseases and women over 50 who plan a vigorous program have been advised to do so (40). Women should be counseled about safety guidelines for exercise. Factors that should be considered in establishing an exercise program include medical limitations, such as obesity or arthritis, and careful selection of activities that promote health and enhance compliance (1).


Gynecology_Novak

Gynecology_Novak. Cardiovascular fitness can be evaluated by measurement of heart rate during exercise. As conditioning improves, the heart rate stabilizes at a fixed level. The heart rate at which conditioning will develop is called the target heart rate (1). The traditional formula for calculating the target heart rate is 220 minus the patient’s age times 0.75. A 2010 study examined the definition of a normal heart rate response to exercise stress testing in women and noted that the traditional male-based calculation of target heart rate may not be appropriate for women (47). The new formula for target heart rate, based on this research, is 206 minus the patient’s age times 0.88.


Gynecology_Novak

Gynecology_Novak. Smoking Cessation Smoking is a major cause of preventable illness, and every opportunity should be taken to encourage patients who smoke to quit. Patient education about the benefits of smoking cessation, clear advice to quit smoking, and physician support improve smoking cessation rates, although 95% of smokers who successfully quit do so on their own. Self-help materials are available from the National Cancer Institute, and community-based support groups and local chapters of the American Cancer Society and the American Lung Association. The combination of counseling and medication (nicotine and nonnicotine options) is more effective than either used alone, and Clinical Practice Guidelines on treating tobacco use and dependence from the U.S. Department of Health and Human Services provide recommendations (48).


Gynecology_Novak

Gynecology_Novak. U.S. Department of Health and Human Services provide recommendations (48). The “5 As”—Ask, Advise, Assess, Assist, and Arrange—are designed to be used with smokers who are willing to quit (49). The Assist component typically includes first-line pharmacotherapy with bupropion or nicotine replacement in the form of gum, inhaler, nasal spray, or patch. In addition, ongoing visits for counseling and support are essential and may include practical counseling and assistance with problem-solving skills and social support during and after treatment. Relapse prevention is important, with congratulations for any successes and encouragement to remain abstinent. Patients who use tobacco but are unwilling to quit at the time of the visit should be treated with the “5 Rs” motivational intervention: Relevance, Risks, Rewards, Roadblocks, and Repetition (48). 1.


Gynecology_Novak

Gynecology_Novak. 1. ACOG Editorial Committee for Guidelines for Women’s Health Care. Guidelines for women’s health care: a resource manual. 3rd ed. Washington, DC: ACOG, 2007:573. 2. Coleman VH, Laube DW, Hale RW, et al. Obstetrician-gynecologists and primary care: training during obstetrics-gynecology residency and current practice patterns. Acad Med 2007;82:602– 607. 3. Taylor D, Levi A, Simmonds K. Reframing unintended pregnancy prevention: a public health model. Contraception 2010;81:363– 366. 4. Donaldson M, Yordy N, Vanselow N, eds. Defining primary care: an interim report. Institute of Medicine. Washington, DC: National Academy Press, 1994. 5. Franks P, Clancy CM, Nutting PA. Defining primary care. Empirical analysis of the National Ambulatory Medical Care Survey. Med Care 1997;35:655–668. 6. American College of Obstetricians and Gynecologists. ACOG Legislative Priorities. ACOG, 2011. Available at http://www.acog.org/ departments/dept web.cfm?recno = 44 7.


Gynecology_Novak

Gynecology_Novak. 6. American College of Obstetricians and Gynecologists. ACOG Legislative Priorities. ACOG, 2011. Available at http://www.acog.org/ departments/dept web.cfm?recno = 44 7. ACOG Committee. ACOG Committee Opinion No. 423: motivational interviewing: a tool for behavioral change. Obstet Gynecol 2009; 113:243–246. 8. Hing E, Burt CW. Characteristics of office-based physicians and ther practices: United States, 2003–04. Hyattsville, MD: National Center for Health Statistics, 2007. 9. Henderson JT, Weisman CS. Women’s patterns of provider use across the lifespan and satisfaction with primary care coordination and comprehensiveness. Med Care 2005;43:826–833. 10. ACOG Committee. ACOG Committee Opinion No. 452: Primary and preventive care: periodic assessments. Obstet Gynecol 2009;114: 1444–1451. 11.


Gynecology_Novak

Gynecology_Novak. 10. ACOG Committee. ACOG Committee Opinion No. 452: Primary and preventive care: periodic assessments. Obstet Gynecol 2009;114: 1444–1451. 11. American College of Obstetricians and Gynecologists. Primary and preventive health care for female adolescents. In: Health care for adolescents. Washington, DC: American College of Obstetricians and Gynecologists, 2003:1–24. 12. American Academy of Family Physicians. Summary of recommendations for clinical preventive services. 2010. Available online from: http://www.aafp.org/online/etc/medialib/aafp org/documents/clinical/ CPS/rcps08–2005.Par.0001.File.tmp/February2011CPS03142011.pdf. 13. U.S. Preventive Services Task Force. Recommendations for adults. 2010. Available online at: http://www.ahrq.gov/clinic/uspstfix.htm 14. American Medical Association. Guidelines for adolescent preventive services (GAPS). Chicago, IL: American Medical Association, 1997:8. 15.


Gynecology_Novak

Gynecology_Novak. American Medical Association. Guidelines for adolescent preventive services (GAPS). Chicago, IL: American Medical Association, 1997:8. 15. Agency for Healthcare Research and Quality. National guideline clearinghouse. 2010. Available online at: htp://www.guideline. gov. 16. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report 2008;8: 1–29. 17. Brett KM, Burt CW. Utilization of ambulatory medical care by women: United States, 1997–98. Atlanta: U.S. Centers for Disease Control, 2001:1–17. 18. Scholle SH, Chang J, Harman J, et al. Characteristics of patients seen and services provided in primary care visits in obstetrics/ gynecology: data from NAMCS and NHAMCS. Am J Obstet Gynecol 2004;190:1119–1127. 19. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55[RR14]: 1–17. 20.


Gynecology_Novak

Gynecology_Novak. 19. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55[RR14]: 1–17. 20. Petitti DB, Teutsch SM, Barton MB, et al. Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med 2009;150:199–205. 21. The Cochrane Collaboration. The Cochrane Library. 2010. Avail able online at: http://www.thecochranelibrary.com 22. British Medical Journal. Clinical evidence. 2010. Available online at: http://www.clinicalevidence.bmj.com 23. University of Oxford. Oxford Centre for Evidence Based Medicine. 2010. [Aim to develop, teach and promote evidence-based health care and provide support and resources ot doctors and health care profes sionals to help maintain the highest standards of medicine]. Available online at: http://www.cebm.net/ 24.


Gynecology_Novak

Gynecology_Novak. Centre for Reviews and Dissemination. Database of abstracts of reviews of effects (DARE). 2010. [Contains 15,000 abstracts of systematic reviews including over 6000 quality assessed reviews and details of all Cochrane reviews and protocols. The database focuses on the effects of interventions used in health and social care.] Available online at: http://www.crd.york.ac.uk/crdweb/Home.aspx?DB=DARE 25. American College of Physicians. ACP Journal Club. 2010. [Qualityassessed, clinically rated original studies and reviews from over 130 clinical journals.] Available online at: http://www.acpjc.org/ 26. Elster AB, Kuznets NJ. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore: Williams & Wilkins, 1994:1–191. 27. Rosen DS, Elster A, Hedberg V, et al. Clinical preventive services for adolescents: Position paper of the society for adolescent medicine. J Adolesc Health 1997;21:203–214. 28.


Gynecology_Novak

Gynecology_Novak. 27. Rosen DS, Elster A, Hedberg V, et al. Clinical preventive services for adolescents: Position paper of the society for adolescent medicine. J Adolesc Health 1997;21:203–214. 28. American College of Obstetricians and Gynecologists. Tool kit for teen care. Washington, DC: ACOG, 2010. 29. ACOG Committee on Adolescent Health Care. The initial reproductive health visit. Committee Opinion. Washington, DC: ACOG, 2010. 30. English A, Ford CA, Santelli JS. Clinical preventive services for adolescents: position paper of the Society for Adolescent Medicine. AmJ Law Med 2009;35:351–364. 31. Zabin LS, Hardy JB, Smith EA, et al. Substance use and its relation to sexual activity among inner-city adolescents. J Adolesc Health Care 1986;7:320–331. 32. Orr DP, Beiter M, Ingersoll G. Premature sexual activity as an indicator of psychosocial risk. Pediatrics 1991;87:141–147. 33.


Gynecology_Novak

Gynecology_Novak. 32. Orr DP, Beiter M, Ingersoll G. Premature sexual activity as an indicator of psychosocial risk. Pediatrics 1991;87:141–147. 33. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010;303:235– 241. 34. Centers for Disease Control and Prevention. Vital signs: state-specific obesity prevalence among adults—United States, 2009. MMWR Morb Mortal Wkly Rep 2010;59:951–955. 35. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003;289: 76–79. 36. ACOG Committee. ACOG Committee Opinion No. 319, October 2005. The role of obstetrician-gynecologist in the assessment and management of obesity. Obstet Gynecol 2005;106:895–899. 37.


Gynecology_Novak

Gynecology_Novak. 36. ACOG Committee. ACOG Committee Opinion No. 319, October 2005. The role of obstetrician-gynecologist in the assessment and management of obesity. Obstet Gynecol 2005;106:895–899. 37. National Heart, Lung, and Blood Institute Obesity Education Initiative. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. Obesity Education Initiative 2000. Available online at: http://www.nhlbi.nih.gov/guidelines/ obesity/practgde.htm 38. Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;120:1640–1645. 39.


Gynecology_Novak

Gynecology_Novak. 39. Essah PA, Wickham EP, Nestler JE. The metabolic syndrome in polycystic ovary syndrome. Clin Obstet Gynecol 2007;50:205–225. 40. U.S. Department of Agriculture. Dietary guidelines for Americans. 2005. Available online at: http://www.health.gov/dietaryguidelines 41. U.S. Department of Agriculture. My pyramid. 2005. Available online at: http://www.mypyramid.gov 42. Centers for Disease Control and Prevention. Use of supplements containing folic acid among women of childbearing age—United States, 2007. MMWR Morb Mortal Wkly Rep 2008;57:5–8. 43. ACOG Committee. ACOG Committee Opinion No. 313: the importance of preconception care in the continuum of women’s health care. Obstet Gynecol 2005;106:665–666. 44. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol 1989;160:865. 45.


Gynecology_Novak

Gynecology_Novak. 44. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol 1989;160:865. 45. American College of Obstetricians and Gynecologists. Osteoporosis. Washington, DC: American College of Obstetricians and Gynecologists, 2004. 46. U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services, 2008:76. 47. Gulati M, Shaw LJ, Thisted RA, et al. Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project. Circulation 2010;122:130–137. 48. Fiore MC, Ja´en CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. In: Clinical practice guideline. Washington, DC: U.S. Department of Health and Human Services, 2008. Available online at: http://www.surgeongeneral.gov/tobacco/treating tobacco use08.pdf.


Gynecology_Novak

Gynecology_Novak. Available online at: http://www.surgeongeneral.gov/tobacco/treating tobacco use08.pdf. 49. Agency for Healthcare Research and Quality. Five major steps to intervention (the “5A’s”). Available online at: http://www.ahrq.gov/ 50. U.S. Preventive Services Task Force. U.S. preventive services task force grade definitions and levels of certainty regarding net benefit. 2008. Available online at: http://www.uspreventiveservicestaskforce. org/uspstf/grades.htm Sharon T. Phelan Thomas E. Nolan Empiric therapy for women with pneumonia should be based on the specific patient profiles and the severity of their pneumonia. All patients with possible community-acquired pneumonia should have a chest radiograph to establish the diagnosis and the presence of complications.


Gynecology_Novak

Gynecology_Novak. Most patients with hypertension will require two or more antihypertensive medications to achieve optimal blood pressure control less than 140/90 or less than 130/80 mm Hg for patients with diabetes or kidney disease, respectively. There is an increased use of cholesterol-lowering drugs, including the “statins,” a class of drugs that lower cholesterol by blocking a liver enzyme necessary to produce cholesterol, and they are very effective in reducing the risk of heart attacks and deaths. Type 2 diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people with diabetes may be undiagnosed: individuals at risk should be screened and a comprehensive plan of care initiated for those diagnosed with diabetes.


Gynecology_Novak

Gynecology_Novak. The sensitive thyroid-stimulating hormone (TSH) assay is the single best screening test for hyperthyroidism and hypothyroidism: in clinical hypothyroidism, the standard treatment is levothyroxine replacement, which must be tailored to the individual patient. As health care providers for women, gynecologists are responsible for providing care that extends beyond diseases of the reproductive organs to include much of the general medical care of their patients. Broadening the spectrum of care requires adjustments in practice, with less emphasis placed on the surgical aspects of the specialty. Early diagnosis and treatment of medical illnesses can have a major impact on a woman’s health. Although timely referral is important for complex and advanced diseases, many conditions can be recognized and treated initially by gynecologists.


Gynecology_Novak

Gynecology_Novak. Respiratory problems are the most common reasons patients seek care from a physician, so gynecologists should be aware of their pathophysiology. Cardiovascular disease has a significant impact on overall morbidity and is the main cause of death in women. Cardiovascular disease is associated with cigarette smoking, hypertension, hypercholesterolemia, and diabetes mellitus. These conditions are responsive to screening, behavior modification, and control to lower risk factors. Thyroid disease is a major cause of morbidity for women. Because of the interaction of hormones and the overall effect on the endocrine system, thyroid disease can be of special significance in women. The gynecologist should provide screening and initial therapy for these conditions and assess the need for referral.


Gynecology_Novak

Gynecology_Novak. Infections of the respiratory system can range from the common cold to life-threatening illness. Those with risk factors should be counseled about preventive measures. Vaccines against ﬂu and pneumonia should be offered as indicated. Sinusitis A problem frequently encountered in women is self-diagnosed “sinus problems.” Many medical problems—headaches, dental pain, postnasal drainage, halitosis, and dyspepsia—may be related to sinus conditions. The sinuses are not an isolated organ, and diseases of the sinuses are often related to conditions that affect other portions of the respiratory system (i.e., the nose, bronchial tree, and lungs). The entire respiratory system can be infected by one particular virus or pathogen (the sinobronchial or sinopulmonary syndrome); however, the most prominent symptoms are usually produced in one anatomic area. Therefore, during the evaluation of symptoms attributable to sinusitis, the presence of other infections should be investigated.


Gynecology_Novak

Gynecology_Novak. Multiple infectious and chemical agents or reactions to nervous, physical, emotional, or hormonal stimuli may cause an inﬂammatory response in the respiratory system (1). Systemic diseases such as connective tissue syndromes and malnutrition may contribute to chronic sinusitis. Environmental factors in the workplace and geographic conditions (e.g., cold and damp weather) may aggravate or accelerate the development of sinusitis. Factors contributing to the development of sinus disease include atmospheric pollutants, allergy, tobacco smoke, skeletal deformities, dental conditions, barotrauma from scuba diving or airline travel, and neoplasms.


Gynecology_Novak

Gynecology_Novak. Most acute infections (lasting less than 4 weeks) begin with a viral agent in the nose or nasopharynx that causes inﬂammation, blocking the draining ostia (1). The location of the symptoms varies by anatomic site of infection—maxillary sinus over the cheeks, ethmoid sinus across the nose, frontal sinus in the supraorbital area, and sphenoid sinus to the vertex of the head—and typically last 7 to 10 days, clearing with nothing more than a decongestant. Viral agents impede the sweeping motion of ciliary function in the sinus and, in combination with edema from inﬂammation, may occasionally lead to superinfection with bacteria. The most common bacterial agents infecting sinuses are Streptococcus pneumoniae and Haemophilus inﬂuenzae. Gram-negative organisms are usually limited to compromised hosts in intensive care units. Although less than 2% of acute sinusitis cases transition from viral to bacterial infections requiring antibiotics, more than 85% of patients receive antibiotic


Gynecology_Novak

Gynecology_Novak. hosts in intensive care units. Although less than 2% of acute sinusitis cases transition from viral to bacterial infections requiring antibiotics, more than 85% of patients receive antibiotic prescriptions. Chronic sinusitis (lasting more than 12 weeks) develops from either inadequate drainage or compromised local defense mechanisms. The ﬂora usually is polymicrobial, consisting of aerobic and anaerobic organisms.


Gynecology_Novak

Gynecology_Novak. Sinus ailments frequently occur in middle-age individuals. Acute infection is usually located in the maxillary and frontal sinuses. Classically, infection in the maxillary sinus results from obstruction of the ostia found in the medial wall of the nose. Fever, malaise, a vague headache, and pain in the maxillary teeth are early symptoms. Reports of “fullness” in the face or exploding pressure behind the eyes often are elicited as well as increasing pain with bending over. Pressure and percussion over the malar areas can cause severe pain. Purulent exudates in the middle meatus of the nose or in the nasopharynx often are present. Five clinical findings are most useful in diagnosis: (i) maxillary toothache, (ii) poor response to nasal decongestants, (iii) abnormal transillumination, (iv) colored visible purulent nasal secretions, and (v) a history of colored nasal discharge. When four or more features are present, the likelihood of sinusitis is high, and when none is present, sinusitis


Gynecology_Novak

Gynecology_Novak. visible purulent nasal secretions, and (v) a history of colored nasal discharge. When four or more features are present, the likelihood of sinusitis is high, and when none is present, sinusitis is highly unlikely (2). Initial episodes of sinusitis do not require imaging studies; however, when persistent infections occur, studies and referral are indicated. Computed tomography of the sinuses demonstrated that 90% of patients with colds have radiological evidence of sinus disease that usually will resolve in 2 to 3 weeks. Radiographic changes do not reliably identify sinusitis secondary to bacteria. After sinus needle aspiration, about 60% of patients with abnormal radiographic images have positive cultures (3). Unless culture samples are obtained by direct needle drainage, they are contaminated by oropharyngeal ﬂora and are thus of no value. For this reason, therapy usually is empiric.


Gynecology_Novak

Gynecology_Novak. Systemic decongestants containing pseudoephedrine are useful in shrinking the obstructive ostia and promoting sinus drainage and ventilation. Topical decongestants should be used for no longer than 3 days because prolonged use may lead to rebound vasodilation and worsening of symptoms. Mucolytics like guaifenesin may help thin sinus secretions and promote drainage. Antihistamines should be avoided in acute sinusitis because of their drying effects, which can lead to thickened secretions and poor drainage of the sinuses. Analgesics are recommended for pain relief. Therapies to relieve symptoms include facial hot packs and analgesics. Topical nasal steroids may accelerate the recovery in patients with viral sinusitis and those with a history of chronic rhinitis or recurrent sinusitis who seek treatment of acute rhinosinusitis (4,5). Improvement should be apparent within 48 hours of treatment, but 10 days may be necessary for complete resolution of symptoms. When improvement is not


Gynecology_Novak

Gynecology_Novak. seek treatment of acute rhinosinusitis (4,5). Improvement should be apparent within 48 hours of treatment, but 10 days may be necessary for complete resolution of symptoms. When improvement is not rapid, resistance should be presumed, and other classes of antibiotics should be given (6). In persistent cases, referral to an otolaryngologist for sinus irrigation may be necessary (7).


Gynecology_Novak

Gynecology_Novak. Broad antibiotic coverage of common aerobes and anaerobes is necessary but should be limited to patients with acute pain, especially unilateral maxillary tooth, facial, or sinus pain, and purulent discharge, particularly if the symptoms initially improved and then worsen. This cluster of symptoms is more suggestive of bacterial rather than viral acute sinusitis. It should be noted that the majority of acute bacterial sinusitis cases resolve in 7 to 10 days without antibiotics, similarly to the viral form. For acute bacterial sinus infections, amoxicillin (500 mg three times a day) or trimethoprim/sulfamethoxazole (1 tablet twice a day) remains the treatment of choice. Amoxicillin is inexpensive, penetrates the sinus tissues well, and can be changed to another antibiotic if symptoms have not improved in 48 to 72 hours. If these give only a minimal or no response after 7 days, consider broader spectrum antibiotics. If beta-lactam resistance is likely, amoxicillin/clavulanic acid (875 mg


Gynecology_Novak

Gynecology_Novak. improved in 48 to 72 hours. If these give only a minimal or no response after 7 days, consider broader spectrum antibiotics. If beta-lactam resistance is likely, amoxicillin/clavulanic acid (875 mg twice daily) or azithromycin (5-day course once a day) may be used. Other second-line drugs include cefuroxime (250 mg twice daily), ciproﬂoxacin (500 mg twice daily), clarithromycin (500 mg twice daily), levoﬂoxacin (500 mg once a day), and loracarbef (400 mg twice daily). The usual treatment course is 10 to 14 days, and patients should be informed that relapses might occur if the full course of treatment is not completed.


Gynecology_Novak

Gynecology_Novak. Chronic sinusitis may result from repeated infections with inadequate drainage. The interval between infections becomes increasingly shorter until there are no remissions. Presenting symptoms are recurrent pain in the malar area or chronic postnasal drip. In the preantibiotic era, chronic sinusitis was the result of repeated acute sinusitis with incomplete resolution, whereas allergy is currently a more common cause. Injury of surface ciliated epithelium results in impaired removal of mucus. A vicious cycle ensues of incomplete resolution of infection, followed by reinfection, and ending with the emergence of opportunistic organisms. Allergies have become an important factor in chronic sinusitis. The swelling and edema of the mucosa in conjunction with hypersecretion of mucus leads to ductal obstruction and infection. Chronic sinusitis is associated with chronic cough and laryngitis with intermittent acute infections. Treatment is directed at the underlying etiology: either allergy


Gynecology_Novak

Gynecology_Novak. obstruction and infection. Chronic sinusitis is associated with chronic cough and laryngitis with intermittent acute infections. Treatment is directed at the underlying etiology: either allergy control or aggressive management of infections. Resistant cases require computed tomography and endoscopic surgery for polyp removal. Nasoantral window formation is a radical surgery that is occasionally necessary.


Gynecology_Novak

Gynecology_Novak. No clinical criteria can reliably identify those patients who might benefit from treatment with antibiotics. It is reasonable to treat women with presumed bacterial sinusitis if they have high fever, systemic toxicity, immune deficiency, or possible orbital or intracranial involvement (6). Although very rare, untreated sinus infections may have dire consequences, such as orbital cellulitis, leading to orbital abscess, subperiosteal abscess formation of the facial bones, cavernous sinus thrombosis, and acute meningitis. Brain and dural abscesses are rare; when they occur, it usually is the result of direct spread from a sinus. A patient complaining of abnormal vision such as diplopia, changes in mental status, and periorbital edema should prompt a referral to emergency room for evaluation of intracranial or orbital extension. Computed tomography scanning is the most accurate diagnostic tool. The use of aggressive surgical approaches with broad-spectrum antibiotics is necessary for


Gynecology_Novak

Gynecology_Novak. of intracranial or orbital extension. Computed tomography scanning is the most accurate diagnostic tool. The use of aggressive surgical approaches with broad-spectrum antibiotics is necessary for adequate drainage.


Gynecology_Novak

Gynecology_Novak. Otitis Media Otitis media remains primarily a disease of children, but may affect adults, often secondary to a concurrent viral infection of the upper respiratory tract. Diagnosis in most cases reveals ﬂuid behind the tympanic membrane. Treatment is directed to symptoms and involves the use of antihistamines and decongestants, despite few data to support their use. Acute otitis media is usually a bacterial infection; Streptococcus pneumoniae and Hemophilus inﬂuenza are the most common pathogens. Symptoms include acute purulent otorrhea, fever, hearing loss, and leukocytosis. Physical examination of the ear reveals a red, bulging, or perforated membrane. Indicated treatment is broad-spectrum antibiotics such as amoxicillin/clavulanic acid, cefuroxime axetil, and trimethoprim-sulfamethoxazole.


Gynecology_Novak

Gynecology_Novak. Bronchitis Acute bronchitis is an inﬂammatory condition of the tracheobronchial tree. Most often it is viral in origin and occurs in winter. Common cold viruses (rhinovirus and coronavirus), adenovirus, inﬂuenza virus, and Mycoplasma pneumoniae (a nonviral pathogen) are the most common pathogens involved. Bacterial infections occur less commonly and may be secondary pathogens. Cough, hoarseness, and fever are the usual presenting symptoms. In the initial 3 to 4 days, the symptoms of rhinitis and sore throat are prominent; coughing may last as long as 3 weeks. The prolonged nature of these infections promotes the use of antibiotics to “clear up the infection” (8). Sputum production commonly occurs and may be prolonged in cigarette smokers. Most serious bacterial infections occur in cigarette smokers, who have damage to the lining of the upper respiratory tree and changes in the host ﬂora.


Gynecology_Novak

Gynecology_Novak. Physical examination discloses a variety of upper airway sounds, usually coarse rhonchi. Rales are usually not present on auscultation, and signs of consolidation and alveolar involvement are absent. During auscultation of the chest, signs of pneumonia such as fine rales, decreased breath sounds, and euphonia (“E to A changes”) should be sought. If the results of the physical examination are uncertain or the patient’s condition appears to be in respiratory distress chest radiography should be performed to detect the presence of parenchymal disease. Paradoxically, as the initial acute syndrome subsides, sputum production may become more purulent. Sputum cultures are of limited value because of the polymicrobial nature of infections. In the absence of complications, treatment is directed to relief of symptoms. The use of antibiotics is reserved for patients in whom chest radiography findings are consistent with pneumonia. Cough is usually the most aggravating symptom and may be treated


Gynecology_Novak

Gynecology_Novak. relief of symptoms. The use of antibiotics is reserved for patients in whom chest radiography findings are consistent with pneumonia. Cough is usually the most aggravating symptom and may be treated with antitussive preparations containing either dextromethorphan or codeine. The efficacy of any expectorant is not proved.


Gynecology_Novak

Gynecology_Novak. Chronic bronchitis is defined as a productive cough from excessive secretions for at least 3 months in a year for 2 consecutive years. Prevalence is estimated to be between 10% and 25% of the adult population who are smokers. Previously the incidence was lower in women than men, but as the prevalence of cigarette smoking in women increased, so too has the incidence of bronchitis in women. Chronic bronchitis is classified as a form of chronic obstructive pulmonary disease (COPD; e.g., “blue bloaters”). Other causes include chronic infections and environmental pathogens found in dust. The cardinal manifestation of disease is an incessant cough, usually in the morning, with expectoration of sputum. Because of frequent exacerbations, the hospitalizations involved and the complexity of medical management, these patients should be referred to an internist.


Gynecology_Novak

Gynecology_Novak. Pneumonia Pneumonia is defined as inﬂammation of the distal lung that includes terminal airways, alveolar spaces, and the interstitium. Pneumonia may have multiple causes, including viral and bacterial infections or aspiration. Aspiration pneumonia is usually the result of depressed awareness commonly associated with the use of drugs and alcohol or anesthesia. Viral pneumonias are caused by multiple infectious agents, including inﬂuenza A or B, parainﬂuenza virus, or respiratory syncytial virus. Most viral syndromes are spread by aerosolization associated with coughing, sneezing, and even conversation. Incubation is short, requiring only 1 to 3 days before the acute onset of fever, chills, headache, fatigue, and myalgias. Symptom intensity is directly related to intensity of the host febrile reaction. Pneumonia develops in only 1% of patients who have a viral syndrome, but mortality rates may reach 30% in immunocompromised individuals and the elderly. An additional risk is the


Gynecology_Novak

Gynecology_Novak. febrile reaction. Pneumonia develops in only 1% of patients who have a viral syndrome, but mortality rates may reach 30% in immunocompromised individuals and the elderly. An additional risk is the development of secondary bacterial pneumonias after the initial viral insult. These infections are more common in elderly patients and may explain the high fatality in this group (8). Staphylococcal pneumonias, which often arise from a previous viral infection, are extremely lethal regardless of patient age. The best treatment for viral pneumonia is prevention by immunization. Treatment is supportive and consists mostly of administration of antipyretics and ﬂuids.


Gynecology_Novak

Gynecology_Novak. Bacterial pneumonia is classified as either community acquired or nosocomial, and in many cases the classification determines prognosis and antibiotic therapy. Risk factors that contribute to mortality are chronic cardiopulmonary diseases, alcoholism, diabetes, renal failure, malignancy, and malnutrition. Prognostic features associated with poor outcome include greater than two lobe involvement, respiratory rate greater than 30 breaths per minute on presentation, severe hypoxemia (<60 mm Hg on room air), hypoalbuminemia, and septicemia. Pneumonia is a common cause of adult respiratory distress syndrome (ARDS), with a mortality rate between 50% and 70% (9,10).


Gynecology_Novak

Gynecology_Novak. Signs and symptoms of pneumonia vary depending on the infecting organism and the patient’s immune status. In typical pneumonias, the usual presentation is a patient with high fever, rigors, productive cough, chills, and pleuritic chest pain. Chest radiography often will show infiltrates (11). The following agents, listed in decreasing order, cause two-thirds of all bacterial pneumonias: Streptococcus pneumoniae, Haemophilus inﬂuenza, Klebsiella pneumoniae, gram-negative organisms, and anaerobic bacteria. Atypical pneumonias are more insidious in onset than typical pneumonias. Patients have moderate fever without the characteristic rigors and chills. Additional symptoms include a nonproductive cough, headache, myalgias, and mild leukocytosis. Chest radiography reveals bronchopneumonia with a diffuse interstitial pattern; characteristically, the patient does not appear to be as ill as the x-ray suggests. Common causes of atypical pneumonia include viruses, Mycoplasma pneumoniae,


Gynecology_Novak

Gynecology_Novak. with a diffuse interstitial pattern; characteristically, the patient does not appear to be as ill as the x-ray suggests. Common causes of atypical pneumonia include viruses, Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia pneumoniae (also called the TWAR agent), and other rare agents.


Gynecology_Novak

Gynecology_Novak. A strong index of suspicion is required for diagnosis, especially in elderly and immunocompromised individuals, who have altered response mechanisms. This is true with “typical agents.” Subtle clues in the elderly include changes in mentation, confusion, and exacerbation of other illnesses. The febrile response may be entirely absent, and the results of the physical examination are not predictive of pneumonia. In high-risk groups, an increased respiratory rate of greater than 25 breaths per minute remains the most reliable sign of infection. Mortality in these high-risk groups of patients is strongly correlated with the ability of the host to mount normal defenses to the symptoms of fever, chills, and tachycardia. All women suspected of having pneumonia should undergo chest radiography to establish the diagnosis and to detect alternate diagnoses such as congestive heart failure and tumors.


Gynecology_Novak

Gynecology_Novak. The chest radiograph can detect complications like pleural effusions and multilobar disease. Laboratory studies helpful in identifying community-acquired pneumonia are sputum Gram stain, sputum culture, and two sets of blood culture. An “adequate sputum” sample (defined as more than 25 neutrophils with less than 10 epithelial cells per low-powered field on microscopic examination) may be difficult to obtain. Respiratory therapists are an excellent resource for inducing sputum. Hospitalized patients undergo assessment of blood–gas exchange by either oximetry or arterial blood–gas analysis. Diagnosis of Legionella pneumoniae requires a different laboratory technique: measuring urinary antigen levels. Mycoplasma pneumoniae should be suspected when cold agglutinin findings are positive in the presence of the appropriate clinical symptoms.


Gynecology_Novak

Gynecology_Novak. The American Thoracic Society updated their original guidelines in 2001 (10). These clinical recommendations use an evidence-based approach for the diagnosis and management of community-acquired pneumonia. Therapy should be directed at the responsible or most likely pathogen, but in many cases of pneumonia, the exact cause cannot be determined, and empiric therapy should be initiated. The American Thoracic Society recommends empiric therapy based on four groups of specific patient profiles, the presence of modifying factors, and pneumonia severity (Table 9.1). Group I. Outpatients with no cardiopulmonary disease (congestive heart failure or COPD) and no modifying factors. These patients are in the lowest-risk group and are usually infected by pathogens such as Chlamydia pneumoniae, Mycoplasma pneumoniae, or Streptococcus pneumoniae. Patients should be treated with an advanced generation macrolide such as azithromycin, clarithromycin, or doxycycline.


Gynecology_Novak

Gynecology_Novak. Group II. Outpatients with cardiopulmonary disease or modifying factors. Patients in this group usually have some comorbidities and are older than 50 years of age. Aerobic gram-negative bacilli, mixed infections with atypical pathogens, and drug-resistant S. pneumoniae (DRSP) should be considered in this patient population. Drug recommendations include monotherapy with an antipneumococcal ﬂuoroquinolone, such as gatiﬂoxacin or levoﬂoxacin; a combination of a macrolide (or doxycycline) with a betalactam such as cefpodoxime, cefuroxime, or amoxicillin-clavulanate; or parenteral ceftriaxone followed by cefpodoxime. Table 9.1 Modifying Factors that Increase the Risk of Infection with Specific Pathogens Beta-lactam therapy within the past 3 months Immune-suppressive illness (including therapy with corticosteroids) Exposure to a child in a day-care center Corticosteroid therapy (>10 mg of prednisone per day) Broad-spectrum antibiotic therapy for >7 days in the past month


Gynecology_Novak

Gynecology_Novak. Exposure to a child in a day-care center Corticosteroid therapy (>10 mg of prednisone per day) Broad-spectrum antibiotic therapy for >7 days in the past month Adapted from American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Am J Respir Crit Care Med 2001;163:1730–1754. Group III. Inpatients who are not in the intensive care unit and have cardiopulmonary or modifying factors. Drugs for these patients include intravenous ﬂuoroquinolone monotherapy or a combination of an intravenous beta-lactam agent plus either intravenous or oral administration of an advanced macrolide or doxycycline. For the small group of inpatients who do not have cardiopulmonary diseases or modifying factors, intravenous azithromycin alone can be used. Alternatives include doxycycline plus a beta-lactam agent (if macrolide allergy or intolerance is present) or monotherapy with an antipneumococcal ﬂuoroquinolone.


Gynecology_Novak

Gynecology_Novak. Group IV. Inpatients in the intensive care unit. These patients usually have the most severe pneumonia, and all antibiotics are given intravenously. Immediate consultation with an internist, hospitalist, or infectious disease specialist is recommended. Oxygen therapy and hydration should be initiated in addition to antibiotic therapy. Most patients will have an adequate clinical response within 3 days of treatment. Oral antibiotics may be given when patients meet the following criteria: ability to eat and drink, improvement in cough and dyspnea, afebrile (<100◦F) on two occasions 8 hours apart, and a decreasing white blood cell count. If other clinical features are favorable, patients may be switched to oral antibiotics even if febrile. They may be discharged on the same day that oral antibiotics are started if other medical and social factors are favorable.


Gynecology_Novak

Gynecology_Novak. Vaccination The pneumococcal vaccine should be given to people at high risk for pneumonia, which includes adults 65 years or older and people with special health problems, such as heart or lung disease, alcoholism, kidney failure, diabetes, HIV infection, or certain types of cancer. Repeat vaccination is recommended 5 years after the first dose is given. The vaccine is active against 23 types of pneumococcal strains, and most individuals develop protection within 2 to 3 weeks of inoculations. The inﬂuenza vaccine should be given every fall to high-risk groups: individuals 50 years of age or older; anyone with serious long-term health problems such as heart disease, lung disease, kidney disease, diabetes, and weak immune systems as with HIV and AIDS; Table 9.2 Major Risk Factors for Coronary Artery Disease Family history of cardiovascular disease (men <55 y; women <65 y)


Gynecology_Novak

Gynecology_Novak. Table 9.2 Major Risk Factors for Coronary Artery Disease Family history of cardiovascular disease (men <55 y; women <65 y) Adapted from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560–2572.


Gynecology_Novak

Gynecology_Novak. individuals on long-term steroids or receiving cancer treatment; women who are pregnant during the ﬂu season (November through April); and anyone coming in close contact with people at risk of serious inﬂuenza like physicians, nurses, and family members. Vaccination is best given from October to mid-November. Antiviral agents should not be used as a substitute for vaccination but may be a useful adjunct. The four agents approved for use in the United States are amantadine, rimantadine, zanamivir, and oseltamivir. These drugs should be given within 2 days of the onset of symptoms to shorten the duration of uncomplicated illness caused by inﬂuenza (11–13).


Gynecology_Novak

Gynecology_Novak. The risk factors for coronary artery disease are presented in Table 9.2. Central to treating cardiovascular disease is the control of contributing diseases and risk factors through lifestyle modifications (Table 9.3). Aerobic exercise protects against cardiovascular disease (14). Additional aspects of prevention of myocardial disease, renal disease, and stroke include control of hypertension, identification and control of diabetes and obesity, and control of dietary fats, especially cholesterol, in susceptible individuals (Fig. 9.1). The presence or absence of target organ damage shown in Table 9.4 also determines the risk of coronary artery disease in hypertensive patients.


Gynecology_Novak

Gynecology_Novak. Hypertension The relationship between hypertension and cardiovascular events such as stroke, coronary artery disease, congestive heart disease, and renal disease is well known. More than 50 million people in the United States have hypertension. It is found in 15% of the population between the ages of 18 and 74 years; the incidence increases with age and varies with race. The contribution of hypertension to overall cardiovascular morbidity and mortality in women was Table 9.3 Lifestyle Adjustments to Manage Hypertension Weight reduction to maintain a body mass index of 18.5–24.9 Limit alcohol use to 2 drinks per day for men (24 oz beer, 10 oz of wine, 3 oz of 80-proof whiskey) and no more than 1 drink per day in women and lighter-weight persons Regular aerobic exercise (at least 30 minutes per day of brisk walking most days of the week) Decrease salt intake to less than 2.4 g of sodium or6gof sodium chloride per day


Gynecology_Novak

Gynecology_Novak. Regular aerobic exercise (at least 30 minutes per day of brisk walking most days of the week) Decrease salt intake to less than 2.4 g of sodium or6gof sodium chloride per day Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat Adapted from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560–2572. Figure 9.1 Disease and risk factors contributing to cardiovascular disease.


Gynecology_Novak

Gynecology_Novak. Figure 9.1 Disease and risk factors contributing to cardiovascular disease. thought to be less important than that in men, but this may reﬂect the relative absence of research in women (15). After age 50, women have a higher incidence of hypertension than men; this may be a confounding variable related to the overall mortality of men at an earlier age (16). More than 60% of those individuals older than age 60 years can be classified as hypertensive (17). Recognition and treatment of hypertension may decrease the development of renal and cardiac disease.


Gynecology_Novak

Gynecology_Novak. Epidemiology The incidence of hypertension is twice as high in African Americans than in whites. Geographic variations exist: the southeastern United States has a higher prevalence of hypertension and stroke, regardless of race (16). One multi-institutional study confirmed an increased incidence of hypertension in African Americans, and that the incidence is increased in individuals with lower levels of education (17). Preventive measures can be most effective in those at highest risk, such as in African American women and individuals from the lowest socioeconomic level (17). The inﬂuence of genetic predisposition is poorly understood. Studies of women are limited to those that determine side effects of medication and the impact of certain medications on long-term lipid status (13).


Gynecology_Novak

Gynecology_Novak. Classically, hypertension is defined as blood pressure levels higher than 140/90 when measured on two separate occasions. Medication may be indicated only for individuals at high risk. Individuals at low risk, such as white women with no other risk factors, may benefit from lifestyle modification alone. Life insurance risk tables indicate that when blood pressure is controlled to lower than 140/90, normal survival occurs over a 10-to 20-year follow-up, regardless of gender. Current recommendations are based on sustained blood pressures higher than 140/90 (18). Table 9.4 Target Organ Damage Adapted from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560–2572. Table 9.5 Laboratory Tests and Procedures Recommended in the Evaluation of Uncomplicated Hypertensiona


Gynecology_Novak

Gynecology_Novak. Table 9.5 Laboratory Tests and Procedures Recommended in the Evaluation of Uncomplicated Hypertensiona Lipid profile that includes HDL, LDL, and triglycerides after a 9-to 12-hour fast HDL, high-density lipoprotein; LDL, low-density lipoprotein. aIf any of the above are abnormal, consultation or referral to an internist is indicated. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560–2572.


Gynecology_Novak

Gynecology_Novak. More than 95% of individuals with hypertension have primary or essential hypertension (cause unknown), whereas fewer than 5% have secondary hypertension resulting from another disorder. Key factors to be determined in the history and physical examination include presence of prior elevated readings, previous use of antihypertensive agents, a family history of cardiovascular death before age 55, and excessive intake of alcohol or sodium. Lifestyle modification is considered important in the therapy of hypertension; thus, a detailed history of diet and physical activity should be obtained (14). Baseline laboratory evaluations to rule out reversible causes of hypertension (secondary hypertension) are listed in Table 9.5. Diagnosis and management are based on the classification of blood pressure readings, as presented in Table 9.6.


Gynecology_Novak

Gynecology_Novak. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) released their seventh report in 2003. The purpose was to provide an evidence-based approach to the prevention and management of hypertension. Following are key points of this report: Systolic blood pressure in those older than 50 years is a more important cardiovascular risk factor than diastolic blood pressure. Beginning at 115/75 mm Hg, the risk of cardiovascular disease doubles for each increment of 20/10 mm Hg. Individuals who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension. Patients with prehypertension (systolic blood pressure 120–139 mm Hg or diastolic blood pressure 80–89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and cardiovascular disease.


Gynecology_Novak

Gynecology_Novak. For uncomplicated hypertension, thiazide diuretic should be used in most cases for medical treatment, either alone or combined with drugs from other classes. Table 9.6 Blood Pressure (BP) Classification (Adults 18 Years and Older) Modified from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560–2572. Table 9.7 Drug Choices for Hypertension with Compelling Indications ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; MI, myocardial infarction. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560–2572.


Gynecology_Novak

Gynecology_Novak. Other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers) should be used in the presence of specific high-risk conditions (Table 9.7). Two or more antihypertensive medications are required to achieve optimal blood pressure levels (<140/90 mm Hg or <130/80 mm Hg, respectively) for patients with diabetes or chronic kidney disease. For patients whose blood pressure is more than 20 mm Hg above the systolic blood pressure goal or more than 10 mm Hg above the diastolic blood pressure goal, initiation of therapy using two agents, one of which will be a thiazide diuretic, should be considered.


Gynecology_Novak

Gynecology_Novak. Regardless of therapy or care, hypertension will be controlled only if patients are motivated to maintain their treatment plan. If blood pressure control is not easily achieved, if the systolic blood pressure is higher than 180 mm Hg, or if the diastolic reading is higher than 110 mm Hg, referral to an internist is recommended. Referral is indicated if secondary hypertension is suspected or evidence of end-organ damage (renal insufficiency or congestive heart failure) is present. Measurement of Blood Pressure


Gynecology_Novak

Gynecology_Novak. Measurement of Blood Pressure An essential variable in evaluation of hypertension is how measurements are obtained and the need to standardize measurements (19). “White coat” or office hypertension (i.e., elevated just by seeing a physician) may occur in up to 30% of patients. For patients who have repeated normal measures outside of the office, it is reasonable to use ambulatory or home monitoring devices. Given the variation of accuracy and patient interpretation, it is advisable for the patient to bring their blood pressure unit into the office to calibrate it against the office-based measurements. In most patients, office readings are sufficient to adequately diagnose and monitor hypertension and eliminate problems of reliability with commercial devices and patient interpretation skills.


Gynecology_Novak

Gynecology_Novak. Blood pressure protocols for measurement should be standardized. The patient should be allowed to rest for 5 minutes in a seated position and the right arm used for measurements (for unknown reasons, the right arm has higher readings). The cuff should be applied 2 cm above the bend of the elbow and the arm positioned parallel to the ﬂoor. The cuff should be inﬂated to 30 mm Hg above the disappearance of the brachial pulse, or 220 mm Hg. The cuff should be deﬂated slowly at a rate no more than 2 mm Hg per second.


Gynecology_Novak

Gynecology_Novak. The cuff size is important, and most cuffs are marked with “normal limits” for the relative size they can accommodate. The most common clinical problem encountered is small cuffs used with obese patients, resulting in “cuff hypertension.” Phase IV Korotkoff sounds are described as the point when pulsations are mufﬂed, whereas phase V is complete disappearance. Most experts in hypertension advocate the use of phase V Korotkoff sounds, but phase IV sounds may be used in special circumstances, with the reason documented.


Gynecology_Novak

Gynecology_Novak. The use of automated devices may help eliminate discrepancies in measurements. Regardless of the method or device used, two measurements should be obtained with less than a 10 mm Hg disparity to be judged adequate. When repeated measures are performed, there should be a 2-minute rest period between readings. Blood pressure has a diurnal pattern, so determinations preferably should be done at the same time. Ambulatory monitoring is not cost-effective in all patients, but may be used to evaluate resistance to therapy, to assess “white coat” hypertension, and to determine whether syncopal episodes are related to hypotension or episodic hypertension (20).


Gynecology_Novak

Gynecology_Novak. Therapy Nonpharmacologic interventions or lifestyle modifications should be attempted before initiation of medication unless the systolic blood pressure exceeds 139 mm Hg or the diastolic blood pressure exceeds 89 mm Hg. Drug therapy should be initiated for systolic blood pressure greater than 130 mm Hg or diastolic blood pressure greater than 80 mm Hg in those with diabetes or chronic renal failure. An important element in lifestyle modifications is to modify all contributors to cardiovascular disease. In obese patients, weight loss, especially in individuals with truncal and abdominal obesity, can play a significant role in the prevention of atherosclerosis (14,21). A loss of just 10 pounds was reported to lower blood pressure (22). Inquiries into dietary practices should be made to eliminate excess salt in the diet, specifically certain food groups that are high in sodium, such as canned goods, snack food, pork products, and soy sauce (23). Cholesterol and fat intake in the diet


Gynecology_Novak

Gynecology_Novak. excess salt in the diet, specifically certain food groups that are high in sodium, such as canned goods, snack food, pork products, and soy sauce (23). Cholesterol and fat intake in the diet should be limited. Dietary interventions that use calcium, magnesium, and potassium supplementation did not make a clinically significant reduction in pressure (24). An exercise program, weight loss, and moderating alcohol intake (to no more than two alcoholic beverages per day) contribute to overall cardiovascular health. Aerobic exercise alone may prevent hypertension in 20% to 50% of normotensive individuals (14).


Gynecology_Novak

Gynecology_Novak. The goal of therapy is for the patient to lower blood pressure into the “normal range”: a systolic reading less than or equal to 120 mm Hg and a diastolic reading less than or equal to 80 mm Hg. If lifestyle modifications are not sufficient to control blood pressure, then pharmacologic intervention is indicated (Fig. 9.2). Hypertension without compelling indications Hypertension with compelling indications (See Table 9.7) • If not at goal BP, optimize dosages or add additional drugs until goal is achieved. • Consider consultation with hypertension specialist. Stage I hypertension Stage II hypertensionSystolic BP 140–159 mm Hg or Diastolic BP 90–99 mm Hg • Thiazide-type diuretics for most • May consider ACE inhibitor, ARB, beta-blocker, CCB, or combination Systolic BP ≥160 mm Hg or Diastolic BP ≥100 mm Hg • Two-drug combination for most (usually thiazide-type diuretic and ACE inhibitor, ARB, beta-blocker, or CCB)


Gynecology_Novak

Gynecology_Novak. Figure 9.2 Algorithm for the drug choices for hypertensive patients unresponsive to lifestyle changes. Goal blood pressure (BP) is <140/90 mm Hg, or <130/80 mm Hg for those with diabetes or chronic kidney disease, respectively. ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CCB, calcium channel blocker. (Modified from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560– 2572, with permission.)


Gynecology_Novak

Gynecology_Novak. The most commonly used medication for initial blood pressure reduction is a thiazide diuretic. The mechanism of action is to reduce plasma and extracellular ﬂuid volume. This lowering of volume is thought to decrease peripheral resistance. Cardiac output initially decreases and then normalizes (25). The important long-term effect is a slight decrease in extracellular ﬂuid volume. The maximum therapeutic dose of thiazides should be lowered to 25 mg, rather than the commonly used 50 mg. The benefit of higher doses is eliminated by the corresponding increase in side effects. Potassium-sparing diuretics (spironolactone, triamterene, or amiloride) are available in fixed doses and should be prescribed to prevent the development of hypokalemia. Potassium supplementation is less effective than the use of potassium-sparing agents. Thiazide diuretics are best used in patients with creatinine levels less than 2.5 g/L. Loop diuretics (furosemide) work better than thiazide diuretics at lower


Gynecology_Novak

Gynecology_Novak. the use of potassium-sparing agents. Thiazide diuretics are best used in patients with creatinine levels less than 2.5 g/L. Loop diuretics (furosemide) work better than thiazide diuretics at lower glomerular filtration rates and higher serum creatinine levels. Control of hypertension with concurrent renal insufficiency is difficult and is probably best handled by an internist or nephrologist. Thiazides and loop diuretics should not be used concurrently because profound diuresis may occur and lead to renal impairment. Concurrent use of nonsteroidal anti-inﬂammatory drugs (NSAIDs) limits the effectiveness of this class of drugs. Other side effects that further limit the usefulness of thiazide diuretics include hyperuricemia, which may contribute to acute gout attacks, glucose intolerance, and hyperlipidemias (26). The metabolic side effects of these drugs limit their popularity.


Gynecology_Novak

Gynecology_Novak. Beta-blockers were used extensively for years as antihypertensive agents. The mechanism of action is decreasing cardiac output and plasma renin activity, with some increase in total peripheral resistance. As a class, they are an excellent source of first-line therapy, especially for migraine sufferers. The original formulation, propranolol, is highly lipid soluble and contributed to bothersome side effects such as depression, sleep disturbances (nightmares in the elderly), and constipation in higher doses. Propranolol has a relative lack of beta selectivity, which promotes other undesirable phenomena. Formulations such as atenolol are water soluble, are beta1 selective, and have fewer side effects than propranolol. At higher doses, beta2 effects emerge. There is no evidence to support speculation that beta1 selective agents may be safe for use in individuals who have asthma. An advantage of water-soluble agents is a longer half-life. Reduced dosing schedules improve compliance. Side


Gynecology_Novak

Gynecology_Novak. that beta1 selective agents may be safe for use in individuals who have asthma. An advantage of water-soluble agents is a longer half-life. Reduced dosing schedules improve compliance. Side effects of beta-blockers include an increase in triglyceride levels and a decrease in high-density lipoprotein (HDL) cholesterol and blunting of adrenergic release in response to hypoglycemia. NSAIDs may decrease the effectiveness of beta-blockers. Contraindications to beta-blockers are asthma, sick sinus syndrome, or bradyarrhythmia. Beta-blockers are often used for the treatment of angina and after myocardial infarctions. However, if these drugs are acutely withdrawn, a rebound phenomenon of ischemia may occur, leading to acute myocardial infarction. Despite these potential problems, beta-blockers continue to be useful in counteracting reﬂex tachycardia, which often occurs with the use of smooth muscle relaxing drugs.


Gynecology_Novak

Gynecology_Novak. Use of alpha1-adrenergic drugs became popular in men because of their minimal effects on potency and unique relationship to lipids. They may contribute to stress urinary incontinence in women because of altered urethral tone. As single agents, they decrease total cholesterol and low-density lipoprotein (LDL) cholesterol while increasing HDL cholesterol, in contrast to the metabolic effects of beta-blocking agents. Their mode of action is to promote vascular relaxation by blocking postganglionic norepinephrine vasoconstriction in the peripheral vascular smooth muscle. Prazosin and doxazosin are two preparations available in this class. A serious side effect of these drugs, which is commonly described in the elderly patients, is called the “first-dose effect.” In susceptible individuals, severe orthostasis was reported when therapy was initiated but subsided after several days. When alpha1-adrenergic drugs are used in combination with diuretics, hypotension may be further exacerbated.


Gynecology_Novak

Gynecology_Novak. orthostasis was reported when therapy was initiated but subsided after several days. When alpha1-adrenergic drugs are used in combination with diuretics, hypotension may be further exacerbated. Therapy should begin with small doses taken at bedtime followed by incremental increases. Other side effects that may limit the usefulness of these agents in some patients include tachycardia, weakness, dizziness, and mild ﬂuid retention.


Gynecology_Novak

Gynecology_Novak. The angiotensin-converting enzyme (ACE) inhibitors are first-line drugs in the treatment of hypertension. Their rapid rise in popularity results from the introduction of new formulations, which allow dosing once or twice a day with a good therapeutic response. There are relatively few side effects; chronic cough is the most worrisome and is a common reason of discontinuing the use of this group of drugs. Other side effects are occasional first-dose hypotension and blood dyscrasias. Occasionally, patients will suffer from rashes, loss of taste, fatigue, or headaches. Other agents should be considered for patients at risk for pregnancy (a strict contraindication). ACE inhibitors can be used in combination with other agents, including diuretics, calcium channel antagonists, and beta-blocking agents. In contrast to beta-blocking agents, these medications can be used in patients with asthma, depression, and peripheral vascular disease. For unknown reasons, they are less effective in


Gynecology_Novak

Gynecology_Novak. agents. In contrast to beta-blocking agents, these medications can be used in patients with asthma, depression, and peripheral vascular disease. For unknown reasons, they are less effective in African Americans unless a diuretic is used concomitantly. Use with diuretics increases the effectiveness of both drugs, but hypovolemia may result. If renal failure is present, hyperkalemia may result from potassium supplementation and altered tubular metabolism. Any NSAID, including aspirin, may decrease the antihypertensive effectiveness. Use of NSAIDs, volume depletion, and renal artery stenosis may precipitate acute renal failure when administration of an ACE inhibitor is initiated. Creatinine levels should be measured at the start of therapy and 1 week after initiation of any ACE inhibitor. An increase of up to 35% of the baseline creatinine value is acceptable, and treatment should be continued unless hyperkalemia develops.


Gynecology_Novak

Gynecology_Novak. The angiotensin-receptor blockers such as losartan and valsartan interfere with the binding of angiotensin II to AT1 receptors. As with ACE inhibitors, they are effective in lowering blood pressure without causing the side effect of coughing. Angiotensin-receptor blockers have favorable effects on the progression of kidney disease in individuals who have diabetes, and on those without diabetes and congestive heart failure.


Gynecology_Novak

Gynecology_Novak. Calcium-channel blockers represent a major therapeutic breakthrough for patients with coronary artery disease. They are effective in patients with hypertension and peripheral vascular disease. The mechanism of action is to block calcium movement across smooth muscle, therefore promoting vessel wall relaxation. Calcium channel blockers are useful in treating concurrent hypertension and ischemic heart disease as an alternative to beta-blockers, if needed. Additionally, these drugs are particularly effective in the elderly and African Americans. Side effects noted include headache, dizziness, constipation, gastroesophageal reﬂux, and peripheral edema. The addition of long-acting calcium-channel blockers made these preparations more amenable for use in hypertension. A relative contraindication for use of these drugs is the presence of congestive heart failure or conduction disturbances.


Gynecology_Novak

Gynecology_Novak. Hydralazine is a potent vasodilator used for years in obstetrics for severe hypertension associated with preeclampsia and eclampsia. The mechanism of action is direct relaxation of vascular smooth muscle, primarily arterial. Major side effects include headaches, tachycardia, and ﬂuid (sodium) retention that may result in paradoxical hypertension. Several combinations are used to counter the side effects and enhance antihypertensive effects. Diuretics may be added to reverse ﬂuid retention caused by excess sodium. When used in combination with beta-blockers, tachycardia and headaches may be controlled without compromising the objective of lowering blood pressure. Drug-induced lupus was widely stated as a potential side effect but is rare with normal therapeutic doses of 25 to 50 mg three times daily. Minoxidil is another extremely potent drug in this class but is of limited use to the gynecologist because of its side effects in women (beard growth). Because of minoxidil’s potency, only


Gynecology_Novak

Gynecology_Novak. daily. Minoxidil is another extremely potent drug in this class but is of limited use to the gynecologist because of its side effects in women (beard growth). Because of minoxidil’s potency, only experienced practitioners should use it.


Gynecology_Novak

Gynecology_Novak. Central-acting agents (methyldopa and clonidine) have long been used in obstetrics. The mechanism of action is to inhibit the sympathetics in the central nervous system, resulting in peripheral vascular relaxation. Side effects, including taste disorders, dry mouth, drowsiness, and the need for frequent dosing (except for the transdermal form of clonidine), limited the popularity of this group of drugs. Sudden withdrawal of clonidine may precipitate a hypertensive crisis and induce angina. Clonidine withdrawal syndrome is more likely to occur with concomitant use of beta-blockers. Compliance is always a major issue, and side-effect profiles contribute significantly to patient nonadherence. With the introduction of new classes of drugs with improved efficacy and reduced side effects, use of medications in this class is expected to decline.


Gynecology_Novak

Gynecology_Novak. Monitoring Therapy Blood pressure readings should be monitored frequently by a nurse, the patient, or in the office at 1-to 2-week intervals. If the patient has other diseases (i.e., cardiovascular, renal), therapy should be initiated earlier and directed to the target organ. If lifestyle modification alone is successful, close monitoring is necessary at 3-to 6-month intervals. When lifestyle modification is unsuccessful, a blood pressure medication should be started to decrease target organ disease. When beginning therapy, concurrent medical conditions treatable with a common agent should be sought. Gender is not an important consideration in choosing an antihypertensive agent. Concurrent diseases and race are important for patients who: Have migraine headaches, for which beta-blockers or calcium channel agonists may be the best choice Are African American and are likely to respond better to a combination of diuretics and calcium channel blockers


Gynecology_Novak

Gynecology_Novak. Are African American and are likely to respond better to a combination of diuretics and calcium channel blockers Have diabetes, chronic kidney disease, and heart failure, for which ACE inhibitors should be used Have had myocardial infarctions and should receive beta-blockers because they reduce the risk for sudden death and recurrent myocardial infarctions. A summary of the compelling indications for individual drug classes is listed in Table 9.7.


Gynecology_Novak

Gynecology_Novak. Once antihypertensive medications are initiated, monitoring should be instituted at approximately monthly intervals to determine blood pressures and to assess side effects. Patients with stage II hypertension or with complicated comorbid illnesses may need more frequent monitoring. The serum creatinine and potassium levels should be monitored 1 to 2 times per year. When blood pressure goals are reached, patients may be seen in the office at 3-to 6-month intervals. Patients capable of home blood pressure monitoring should be encouraged to measure blood pressure at the same time twice weekly (20). If intolerable side effects develop, a different class of medications should be used and the patient’s progress monitored. Patients whose blood pressure is difficult to control with two agents should be considered for referral. Causes of resistance to therapy include diseases missed during the initial evaluation, unrecognized early end-stage disease, and poor compliance. Patients with evidence


Gynecology_Novak

Gynecology_Novak. be considered for referral. Causes of resistance to therapy include diseases missed during the initial evaluation, unrecognized early end-stage disease, and poor compliance. Patients with evidence of target organ disease should be considered for referral to the appropriate specialist for more intensive diagnostic workup and therapy.


Gynecology_Novak

Gynecology_Novak. Cholesterol The dietary inﬂuence of cholesterol on atherosclerosis and its relationship to hypertension and cardiovascular events (myocardial infarction and stroke) is widely debated in the scientific and lay communities. The controversy centers on the effect of dietary cholesterol in assessing risk and prevention of cardiovascular disease (26,27). Many assume that all cholesterol and fat in the diet have negative health consequences (28). Cholesterol metabolism is complex, and some of our knowledge is extrapolated from animal models. The role of cholesterol testing (who, when, and at what age) is hotly debated among health care professionals, and the test itself is fraught with multiple variables that affect results. Understanding the metabolism of cholesterol will help identify and treat patients at risk of complications from hypercholesterolemia.


Gynecology_Novak

Gynecology_Novak. Terms and Definitions Cholesterol is usually found in an esterized form with various proteins and glycerides that characterize the stage of metabolism. The following components are important lipid particles in cholesterol metabolism: Chylomicrons This large lipoprotein particle consists of dietary triglycerides and cholesterol. Chylomicrons are secreted in the intestinal lumen, absorbed in the lymph, and passed into general circulation. In adipose tissue and skeletal muscle, they adhere to binding sites on the capillary wall and are metabolized for energy production. Lipoprotein Particle Lipoprotein particles are separated into five classes based on physical characteristics. The various cholesterol metabolites are separated by density. As lipoprotein particles are metabolized and lipids are removed for energy production, they become more dense.


Gynecology_Novak

Gynecology_Novak. Figure 9.3 Metabolic pathways of lipid metabolism. Apo, apoprotein; LP, lipoprotein; FFA, free fatty acid; IDL, intermediate-density lipoprotein; LDL, low-density lipoprotein; VLDL, verylow-density lipoprotein; HDL, high-density lipoprotein; LCAT, lecithin cholesterol acyltransferase. Attached apoproteins are modified as cholesterol moves from the so-called exogenous pathway (dietary) to the endogenous pathway (postabsorption and metabolization by the liver). Following are the subdivisions of the lipoprotein classes (Fig. 9.3). Chylomicrons and remnants are composed of major lipids and apoproteins of the A, B-48, C and E classes. These are large particles made up of dietary cholesterol molecules that are absorbed with triglycerides. Very low-density lipoproteins (VLDL) are transient remnants found after initial liver metabolism and compose only 10% to 15% of cholesterol particles. They consist of endogenously synthesized triglycerides.