PREPARE FOR 50 YEAR OLD CHECK UP: FEMALE

Dear patient:

This packet contains important information that you need to know about your upcoming visit to your primary care doctor. Your “annual visit” is a time for you and your doctor to look at your health since your last visit.  It is also a time to see if you are at risk for any health problems and to decide what steps you need to take to stay healthy. This packet will help you prepare for your annual visit#.

WHAT TO EXPECT AT YOUR ANNUAL VISIT:
                               

• A review of your health history to see if anything has changed since your last visit
• A complete physical examination
• A talk about behaviors that can affect your health, such as diet, exercise, alcohol use, and smoking
• An update of your shots
• A talk about tests you may need to screen for some cancers

1) YOUR HEALTH HISTORY

Changes in Your Health:  It is important for your doctor to know about any changes in your health since your last visit. Do not think that a change in your health is just part of “getting older.” A change in your health could be a sign of a problem that can be easily treated.

Before your visit, write down any new symptoms that you have been having.  Include when the problem occurs and what makes it better or worse. If you have more than one new health problem, you may need to schedule a separate visit with your doctor for a complete evaluation.

Medicine:  Your doctor will want to review your medicines with you.  It is helpful if you come ready to do this.  Look at the list of your medicines that is included in this packet.

• Cross off the ones you no longer take.
• Add any new ones that are not on the list. This should include any over-the-counter medicines (like aspirin, allergy medicine, or pain medicine), vitamins, supplements, and any herbal medicines.
• Make sure the dose on the list matches what you actually take. If it is different, write down the dose you take.   
• Ask your doctor to give you an updated list of your medicines before you leave your visit

Family History:  Your doctor will ask if there have been new health problems in your family. It is important that you find out what health problems affect your parents, grandparents, brothers, sisters, aunts, uncles and children. Your risk for some health conditions, like diabetes, breast cancer, colon cancer, glaucoma, and depression, may be related to your family history. Your doctor may suggest that you have certain tests based on this information.

2) COMPLETE PHYSICAL EXAM

A physical exam helps to see if you are at risk for certain health problems. The goal is to find problems at an early stage so they can be taken care of. Your physical exam will include:

• Blood pressure
• Weight
• Skin exam
• Show your doctor any new or changed moles. Moles that have grown in size, or have changed shape or color may need to be looked at more carefully.
• Breast exam
• You should tell your doctor about any breast discomfort or any lumps that you have found. If you are not sure how to perform a monthly breast exam yourself, you should ask your doctor.
• Pelvic and rectal exam
• This examination may or may not be performed depending on the date of your last examination (see section on cervical cancer screening below)
• Your doctor might also check your heart, abdomen, blood flow, and joints. 

3) YOUR HEALTH HABITS

Some things you do may increase or decrease your risk for certain diseases. For example, smoking increases your risk for lung and mouth cancer, heart disease, and stroke. On the other hand, regular physical activity can decrease your risk for heart problems and diabetes.

If there are lifestyle factors that could be improved, you and your doctor can discuss possible changes. You should think about the following questions:

• Am I ready to change this behavior?
• What is preventing me from changing this behavior?
• If I have tried to change before, what did I learn from that experience?

Your doctor can give you some ideas about how to get started with changing a behavior. In addition, your doctor has written information about:

• Quitting smoking                      
• Decreasing alcohol intake  
• Starting an exercise program
• Eating healthy              
• Losing weight                                     

4) UPDATE ON YOUR SHOTS

Your annual visit is a good time to see if you need any vaccinations. Many adults think that vaccinations are only for kids. This is not true!

• Tetanus is a serious illness, also called “lockjaw” that can be caused when the tetanus bacteria gets into a wound. Although the disease is very rare, there are still almost 50 cases a year in the United States. People over 60 are at highest risk for dying from the disease. 

A tetanus vaccine is recommended every ten years.

• Influenza, or “the flu,” is a virus that can cause serious complications. In a typical year, about 10 out of 100 people get the flu. People who are over 65 years, have lung problems like asthma or emphysema, have diabetes, or have heart problems like congestive heart failure are at higher risk of a serious complication from the flu. About 36,000 people die each year from complications of the flu.

If you have lung problems, heart problems, or diabetes, you should get a flu shot every year. If you live with a person with any of these problems, it is a good idea for you to get a flu shot.

• Pneumonia is a serious infection of the lungs caused by the pneumococcal bacteria. About 5 out of 100 people who get pneumonia will die. A vaccination is available to prevent infections due to this bacteria.

In general, people over 65 and those with the same medical problems that make flu shots a good idea should be vaccinated. This vaccination usually only has to be given once. But, if you are vaccinated when you are younger because of a chronic medical problem, you should get a booster shot once more at age 65 (or after 5 years, whichever comes later).

If you have lung problems, heart problems, or diabetes, you should get a pneumonia vaccine.

• Hepatitis B is a virus that is spread by contact with blood or through sexual activity. Adults at high risk of hepatitis B infection should get a full set of vaccinations.  This involves 3 shots over 6 months.

People at risk for hepatitis B include:

• sexually active heterosexual adults with more than 1 sex partner in the past 6 months or with a history of a sexually transmitted disease
• men who have sex with men
• people who inject illegal drugs
• health care workers and people who work with the developmentally disabled
• household and sexual contacts of persons with chronic hepatitis B infection

If you are at risk for hepatitis B infection, you should get vaccinated.

5) CANCER SCREENING 

Cancer is the number 2 cause of death in the United States (heart disease is number 1). For women, the most common causes of cancer death are:

1. Lung cancer
2. Breast cancer
3. Colorectal cancer

The number of deaths due to cervical cancer has decreased significantly over the past 40 years. Cervical cancer screening is the reason for this decrease and can prevent most occurrences of the disease.  

The biggest risk factor for lung cancer is smoking. The best way to prevent dying from lung cancer is to quit smoking! Currently, there are no proven tests to detect early lung cancer and prevent death from lung cancer. However, the use of x-ray tests known as CT scans is being studied. These tests are not recommended until more information is available. If you want to learn more about lung cancer screening, ask your doctor for written information.

Breast cancer is the most common type of cancer in women (besides skin cancer), and the number 2 cause of cancer death in women (lung cancer is number 1). About 40,000 women die of breast cancer each year. However, many women who are diagnosed with breast cancer are successfully treated.
About 75 out of 100 diagnosed cases of breast cancer are in women aged 50 or older. Breast cancer is easier to treat if it is found early. The best way to detect breast cancer early is to do the following:

• Have a mammogram every year
• Have your doctor check your breasts at your annual physical examination.
• Check your breasts for new lumps or changes every month.

Although most women start to have mammograms at age 40, mammograms appear to be more accurate after menopause and can detect smaller cancers than a breast examination. If you have not had a mammogram before, you should ask your doctor for information about how the test is performed.
There is debate among medical experts about the value of doing self-exams. On one hand, women who do self-exams can detect lumps earlier. However, self-exams can also cause false alarms and increase anxiety. If you are familiar with your “normal” exam, you are more likely to recognize a change.

Colorectal cancer is cancer of the large intestine. Almost 6 out of 100 Americans will get this cancer at some point in their lives.
Colorectal cancer starts as a small growth, or polyp, in the intestine. These polyps will cause no symptoms. Luckily, there is good evidence that finding colorectal cancer early and treating it lowers the risk of dying from this cancer. Doctors screen for colorectal cancer by looking at the inside of your colon with a tiny camera that is inserted into your rectum. 
More information about colorectal cancer and screening tests used to find it is on page 6.

The risk of death from cervical cancer has decreased greatly since Pap smears were introduced 40 years ago. However, about 3,700 women still die from this preventable disease each year. Pap smears involve taking a sample with a small brush from your cervix (the narrow end of the uterus). The Pap smear can detect changes in the cervix early, and the abnormal tissue can be removed without major surgery.

Risk factors for cervical cancer include smoking and a family history of cervical cancer. The most important risk factor is infection with the human papillomavirus (HPV). There are many types of this virus. Some types of HPV cause warts on the skin or genital area, but other types can cause changes in the cervix. When changes are seen on your Pap smear, your doctor can test if HPV infection is present to see if further treatment is needed.

Not all women need to have the Pap test completed every year. If your Pap test was normal for three years in a row, the test can be repeated every 2 to 3 years. In addition, a woman who has had a total hysterectomy (removal of the uterus and cervix) does not need regular Pap smears (as long as the surgery was not for cancer).

If you are planning to have a Pap smear at your annual check-up, you should schedule your visit when you are not having your monthly period. In addition, you should avoid using vaginal creams, birth control foams, and tampons for two days before the test.

WHAT YOU NEED TO KNOW ABOUT COLORECTAL CANCER SCREENING

• Colorectal cancer is one of the most commonly diagnosed cancers in the United States.
• 2 to 3 out of 100 women will die from colorectal cancer.
• The death rate has been going down for the past 15 years. One reason is that there are fewer cases. Another reason is that more cancer is being found earlier when it is easier to treat.
• The risk of developing colorectal cancer goes up with age. More than 90 out of 100 cases occur in people over 50.
• Most people who have colorectal cancer do not have a family history of this cancer. However, if a parent or sibling has had colorectal cancer, you are at higher risk for developing it and you may need more screening than other people.
• Other risk factors include lack of regular physical activity, poor diet (low fruit and vegetable intake, and a low-fiber and high-fat diet), obesity, heavy use of alcohol, and tobacco use.

There are several tests to detect and remove colorectal polyps and cancer. Your doctor suggests one of the following plans:

A sigmoidoscopy every 5 years and a stool blood test every year

During a sigmoidoscopy, a doctor places a flexible, lighted tube with a camera on it into the rectum to look at the inside of the rectum and the about half of the colon. Sigmoidoscopy does not require staying in the hospital, or getting anesthesia. Most people find the test uncomfortable, but not painful. The test usually takes less than 15 minutes. You will usually get the results right away.
Since sigmoidoscopy can miss polyps or cancers in the rest of the large intestine, a stool blood test should be done every year. For this test, you use a home kit to collect samples of stool. You mail the samples to your primary care doctor’s office where it will be checked for hidden traces of blood.
If either of these tests is not normal, your doctor will recommend that you have a colonoscopy. You can also do the colonoscopy as a screening test right from the start.

• A colonoscopy every ten years

A colonoscopy is a longer version of the sigmoidoscopy that lets the doctor see the entire colon. You will get intravenous medication to help you relax. You will be sleepy but not unconscious. You may feel some cramping, but most of the time there is little or no discomfort. The test takes about 30 minutes. Because of the medicine you get during the test, you will need a family member or friend to take you home.

Most experts feel that the colonoscopy is the more complete test and that this is the preferred method. However, the colonoscopy involves a more extensive preparation (the preparation involves a gallon of laxative the day before the test versus about 16 ounces of laxative for the sigmoidoscopy) and it involves intravenous sedation. Also, your insurance may not cover all the screening tests. If you are paying for the tests yourself, the sigmoidoscopy is less expensive.

WHAT YOU NEED TO KNOW ABOUT MENOPAUSE

Menopause is a normal event that happens to every woman. It is not a medical illness. Even though people often call it “the change,” menopause is not a single event. Instead, it is a series of changes that can occur at any time between the ages of 41 and 59. The average age of menopause is about 50.

Menopause begins naturally as a result of expected changes in your reproductive system. As your egg supply ages, your body begins to ovulate less. This causes estrogen and progesterone levels to vary. Eventually, these hormone levels decline enough that the menstrual cycle stops completely.  Menopause is defined as the time after you’ve had no menstrual period for one year.

Hot flashes are often the most bothersome symptom of menopause. A hot flash is a warm sensation in your upper body and face. Your skin can become red, and you may break into a sweat at the end of the episode. Hot flashes can start a few years before your periods change, and can last several years after periods stop. Most women have them for two years or less.

Some suggestions to help with hot flashes include:

• Decrease caffeine and alcohol intake.
• Wear loose clothing. Dress in layers to remove clothing at the start of the hot flash.
• Have a cold drink or use a cold washcloth when a hot flash begins.
• Keep the room temperature cool.

There are several medications to treat hot flashes, including estrogen replacement therapy (see below). You may wish to discuss treatment options with your doctor.

Estrogen is very important to the tissues around your vagina and urinary tract. As estrogen levels decline, these tissues become thinner and drier. Vaginal dryness can make sexual activity uncomfortable, and urinary changes may include increased frequency or difficulty controlling urination. Water-based lubricants and estrogen creams can help with vaginal dryness.

Estrogen replacement therapy is the most effective way to treat menopausal symptoms. However, recent studies have shown that use of estrogen can increase the risk of breast cancer, stroke, and blood clots. Although estrogen was once thought to protect against heart attacks and Alzheimer’s disease, recent studies have shown that this is not true.

Despite the concerns with long-term use, short-term estrogen replacement may be right for women with severe menopausal symptoms. If you decide to try short-term estrogen therapy, your doctor will prescribe the lowest effective dose. Your doctor can also tell you about non-hormone medications that might help.

If you have questions about menopause and want to learn about ways to treat your symptoms, you may be interested in attending “Menopause and Your Health,” a small group program developed for our patients.  Programs are offered monthly.  Contact Mary Ellen Heike, RN at 617 724 8044 or by e-mail at mheike@partners.org for more details.

WHAT YOU NEED TO KNOW ABOUT OSTEOPOROSIS

Osteoporosis is the term used to describe bones that are too thin. Thin bones increase the risk of fractures, especially in the back and hip. Women are at increased risk for osteoporosis, and the risk increases after menopause.

Other risk factors for osteoporosis include smoking, excessive alcohol intake, a family history of hip fracture, low body weight, and use of certain medications, such as seizure medications or corticosteroids (prednisone).

The following steps can help prevent osteoporosis:

• Eat enough calcium and vitamin D:  In general, women need to have at least three servings of dairy products a day (this equals 1000 mg of calcium). Dairy products include milk, cheese, yogurt, and ice cream. Some foods, like orange juice and cereal, have calcium added to them. After menopause, the calcium intake should be 1500 mg a day. For most women, a multivitamin needs to be taken to reach this goal.

• Exercise on a regular basis:  Exercise should include both weight-bearing exercise (like walking, playing sports, or dancing) and resistance exercise (like lifting weights). If you do not currently exercise, you should start slowly. Your doctor can discuss what exercise program is right for you.

• Maintain a healthy lifestyle:  Quitting smoking can reduce your future risk of osteoporosis. Alcohol intake should be limited to 7 drinks per week.

A bone density test can detect osteoporosis by measuring the thickness of your bones. This test is like a regular bone x-ray, and involves no needles or injections.

For women of average risk of osteoporosis, bone density testing is not recommended until age 65. For women with one or more risk factors, the test should be completed earlier.

WHERE TO FIND MORE HEALTH INFORMATION

Information about estrogen replacement therapy, osteoporosis, and any of the other topics in this packet is available at the Blum Patient and Family Learning Center at Massachusetts General Hospital. The staff at the Blum Center can help you find the health information you are looking for.

In addition to written information, the Blum Center has videos about many health topics.  These videos are designed to help you make better, more informed decisions about some health care and screening options available to you.  The videos are produced by the Foundation for Informed Medical Decision Making.      You can request a copy of a video when you visit or call the Blum Center.

The Blum Center is located on the first floor of the White Building.  You can also access the Blum Center online at http://www.massgeneral.org/pflc/ or by phone at 617-724-PFLC (7352).

Please remember to complete the form enclosed in this packet. This will assist your doctor in focusing on your most important concerns and health issues.