Screening Checklist

“An ounce of prevention is worth a pound of cure”, a quote by the famous Benjamin Franklin. This quote still holds true today, and it applies to all aspects of human life including medicine.  

The purpose of a screening test is to have very high sensitivity and cost effectiveness in detecting diseases. Which means that a screening test should be able to detect diseases at earlier stages when the cure is much more feasible. Screening helps you spot diseases before symptoms even ensue.

Some people can get scared of the idea of “knowing” that they may be at risk of a certain pathology, but trust me, the management is way less complicated the earlier the detection is.

So, let’s go through the most common screening recommendations for women.

 

Cervical cancer

Starting with one of the most preventable cancers worldwide. Cervical cancer is the most common gynecologic malignancy in the developing countries. But if we look at the developed countries that have adequate screening methods (most Western countries), cervical cancer becomes one of the least frequently encountered diseases in their population.

Pap smear detects any abnormal cells that can signify pre-cancerous lesions which can be managed with minor procedures to prevent their progression into cancer (a more detailed article about the significance of pap smear results will be published in the near future).

Also, HPV known as the Human Papilloma Virus, is the virus that is responsible for causing the big majority of cervical cancers. It is a type of sexually transmitted infection. There are different types of HPV, some cause genital/anal warts (for both females and males), and some are considered high risk and are thus associated with cervical, anal, vaginal, penile and vulvar cancers (cancers of the genital organs)

So, what is the screening recommendation for cervical cancer?

If you are sexually active and less than 21 years of age, cervical cancer screening is NOT recommended

Pap smear is recommended to be done in all sexually active women every 3 years between ages 21-30. This applied to women who have sex with women, and to women who are currently abstinent.
HPV testing as a primary modality for screening, is NOT recommended in this age group.

From ages 30-65, you can either do:

• Pap smear every 3 years (same as ages 21-30)
• Primary HPV testing every 5 years
• Co-testing (Pap smear + HPV test) every 5 years ·  

Your physician knows best what to do, so please follow with him/her about the preferred screening modality they use.

You can stop your cervical cancer screening at the age of 65 only if you satisfy the adequate prior screening criteria (check with your physician)

Screening in high risk women (HIV positive, women on immunosuppressive therapy …) is not discussed in this article.

Cervical cancer prevention by vaccination!

Good news! We have vaccines for the prevention of cervical cancer. Check with your physician about this important vaccine! This topic will be addressed in future posts.

 

Breast cancer

As for breast cancer, if you are young (20-40 years) with no personal or family history of breast cancers, it is recommended for you to see your gynecologist for an annual office based breast examination.

Also, you are encouraged to do a self-breast examination on a monthly basis (your physician can teach you how to self-assess for the presence of any suspicious breast lesions). Any suspicious lumps or masses should be followed with your physician.

What about mammography? When to start, and how often?

It defers between different medical societies; the US preventive Task Force recommends screening mammography to be started as of the age of 50 and to be repeated every 2 years. The American Cancer Society recommends it to be done annually starting the age of 45.

I personally follow the American College of Obstetricians and Gynecologists (followed by the AUBMC ObGyn department) and recommend mammography annually as of the age of 40, because specifically in Lebanon we are seeing breast cancers more often and at earlier age ranges compared to the Western countries.

Screening for breast cancer stops at the age of 75 or later depending on the functional status of the patient, her life expectancy and willingness to undergo treatment in case of any diagnosed breast pathology. So, it is recommended to continue screening for breast cancer after the age of 75 if the patient’s life expectancy is 10 years or longer.

To note that these screening guidelines only apply to low risk women! If you have a strong family history of breast or ovarian cancers, or a personal history of cancers please follow with your gynecologist for a more personalized screening strategy.

Colon cancer

Some women have the misconception that colon cancer is only seen in men, but this is incorrect, as both males are females are at an increased risk for colorectal cancer (Cancer of the large intestines and rectum). 

Consequently, it is recommended that women receive a colonoscopy screen every 10 years after the age of 50. Colonoscopy is the actual visualization of the insides of your large bowels via a camera. It is a relatively easy and fast procedure performed by Gastroenterologists, nonetheless you should know that it requires a head of time preparation by consuming strong laxatives to empty your intestines. Check with your physician for a detailed explanation of the procedure.

There are other screening methods for colon cancer that can be done every 5 years (sigmoidoscopy) and every 1 year (fecal occult blood tests) that I will not go through.

The idea is that women should not forget getting screened for colon cancer after the age of 50.

Again, this screening cutoff of 50 years only applies to low risk women, as women with personal or family histories of intestinal polyps or cancers should be screened at an earlier age, so in case you belong to a high risk population please check with your clinician for an adequate screening plan.

Body Mass Index

Yes, your height and weight are important screening methods that should be checked on a yearly basis, as obesity is a culprit in many metabolic diseases (hypercholesterolemia, thyroid disease, diabetes, hypertension, heart disease…).

Expect your height and weight to be checked routinely during your annual gynecologic visits.

 

Blood pressure

The older you get, the higher is the chance for you to have elevated blood pressure known as hypertension.

Hypertension is associated with heart, eyes and kidney diseases, in addition to a higher risk for strokes (brain blood vessels clotting).
An elevated blood pressure is defined as 130/80 mmHg or more (130 mmHg being the systolic blood pressure: when your heart beats, and 80 mmHg is defined as the diastolic blood pressure in between your heart beats). In case of any diagnosed elevated blood pressure disorder during your routine yearly gynecologic check, expect your physician to refer you to a blood pressure specialist for adequate management and initiation of anti-hypertensive medications (if needed).

Blood pressure screening for hypertension should start at the age of 21 (during the yearly gynecologic visits) and repeated every 1-2 years if within normal ranges

So, here again, expect to have your blood pressure measurement taken during your yearly gynecologic visits.  

 

Cholesterol

Elevated cholesterol level can cause your blood vessels to clog, and this in turn is associated with heart, brain and kidney diseases in addition to other organ damages.  

Fasting for 9-12 hours before your tests is a must.

Screening starts at the age of 45 and repeated every 3-5 years if normal

Your total cholesterol level should be less than 200 milligrams per decilitre (mg/dl)

In case of abnormal results, you will be referred to a specialist to initiate life style modifications and medications if needed.

 

Diabetes

Diabetes is one of the most common chronic medical conditions we see nowadays. It can cause heart or kidney disease, blindness, stoke and other serious conditions.

There are different screening modalities for diabetes. Screening starts at the age of 45 and repeated every 3 years if normal.

Your physician will choose the screening modality he\she is best accustomed to interpret. But briefly the recommended screening modalities can be summarized as follows:

Fasting blood sugar assessment (Fasting for 8 hours)

• Normal: <100 mg/dl
• Pre-diabetic (increased risk for developing diabetes): a level of 100-125 mg/dl.
• Diabetes: a level of 126 mg/dl or more.  

HbA1C (sugar stores)

• A level of 6.5% or more is diagnostic for diabetes 

Oral glucose tolerance test (you drink 75 grams of glucose in the laboratory and get your blood drawn afterwards)

• Level of 200 mg/dl or more is diagnostic for diabetes.   

The gist is that it is imperative to be screened for diabetes after the age of 45 regardless of the chosen screening method.

 

Bone strength

Brittle bones are one of the most common pathologies seen in post-menopausal women. After menopause, women start losing their bone mass, and thus become predisposed to easy fractures. Actually, one of the main symptoms for osteoporosis are bone fractures (arms, hip, spine) after minor trauma (falling from your standing height). Fortunately, you can screen for and prevent osteoporosis.

DEXA (Dual Energy X-ray Absorptiometry) scan is a bone scan that can measure bone strength and diagnose osteoporosis before breaks start. It can also help predict the risk of future fractures.

It is recommended after the age of 65, and to be repeated every 2-5 years.

Sooner screening is recommended in high risk women (check with your physician):

• Early menopause (defined as 12 consecutive months without period before the age of 40)
• Excessive alcohol consumption
• Current smoking  
• Previous history of fracture
• Chronic steroids therapy
• Rheumatoid arthritis (auto-immune joint inflammation)
• Low body weight 

 

Sexually transmitted infections (STI)

One of the most famous STIs is HIV (human immunodeficiency virus) which is the causative agent of AIDS (acquired immunodeficiency syndrome)

The Virus has no cure and no vaccine, hence early detection is key as earlier treatment with antiretroviral therapy will help your immune system in fighting the virus.

According to the US Preventive Task Force, all sexually active individuals aged 15-65 should be screened for HIV. 

Other sexually transmitted infections:

If you are sexually active at an age < 25, yearly screening for chlamydia and other STIs is recommended.

Yearly screening for STIs after the age of 25 is recommended in the high-risk population:

• If you have multiple sexual partners
• If you have a contact with an STI positive individual
• If you have an STI positive partner
• If you have a personal history of STI    

Thyroid

Your thyroid gland is the gland anterior to your neck. It secrets essential hormones responsible to regulate the metabolism of your body.

TSH (thyroid hormone test) should be done every 5 years after the age of 50.

In case of any abnormalities you will be managed accordingly by your primary health care provider/gynecologist, or by an endocrinologist

Skin

The skin is the largest “organ” in our body and thus it is essential to take good care of it as well. There are different types of skin cancers, the most dangerous is melanoma. The most important risk factor for skin cancers is sun overexposure.

You know yourself the most, so keep an eye on your moles and freckles and check for any changes in their sizes, shapes, colors or borders. BUT don’t obsess about them!

I advise you to seek a dermatologic opinion for any new abnormally looking mole. Moreover, during your annual examination with your general health care provider or gynecologist, an overall look at your skin is recommended.

According to the American Cancer Society, women should self-check their skin on a monthly basis at home, in addition to an annual skin examination by a specialist.

 

Eyes 

As per the Medical Eye Center “By keeping your eyes healthy, you keep your brain healthy – improving your overall quality of life! Good vision contributes to improved athletic ability, better driving skills, improved learning and comprehension and better quality of life”

The General eye examination recommendations are as follows:

• Once between ages 20-39
• Every 2-4 years at 40-64 years
• Every 1-2 years after the age of 65

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Teeth 

It is recommended for all men and women to have dental checks every 6 months regardless of age!

Always follow with your dentist and never postpone this biannual check-up, as earlier detection of any problem in your teeth/gum can save you time and money in its management.

 

Mental health 

It is true that physical health is of value, but you should never forget your mental health. All the high quality international recommendations advocate mental health screening on an annual basis.

Your physician should be qualified to check for any signs of depression, anxiety, or other mental health problems.

You should know that your physician would like to know about your mental well-being, so don’t be reserved to share. If you feel indirectly pressured by your physician not to talk about such matters in clinic, I encourage you again and again to pick another physician ready to hear about all your concerns.

Vaccines

Finally an important aspect of preventive medicine is immunization. Just like screening methods prevent you from reaching late disease stages unnoticed, vaccination also allows avoiding commonly escapable illnesses.

Annual influenza vaccine is recommended especially if you are 65 years or older

Pneumococcal vaccine (to protect you from lung disease) is recommended once after the age of 65

Tetanus-diphtheria booster vaccine is recommended every 10 years regardless of your age

Cervical Cancer Vaccination series! Follow with your gynecologist about the current recommendations and ASK for the vaccine! (more information in future posts)

Take good care of yourselves, and always stay up to date with your checklist for better health 

Karam