This chapter deals primarily with APGO Educational Topic Areas:
TOPIC 3 PAP SMEAR AND DNA PROBES/CUlTURE
TOPIC 7 PREVENTIVE CARE AND HEAlTH MAINTENANCE
Students should be able to counsel patients on important preventive medicine and health maintenance topics, such as immunization, diet, and exercise. They should be able to describe appropriate screening protocols for cancer, cardiovascular disease, and osteoporosis.
Clinical Case
A pleasant 57-year-old moderately obese, insulin-dependent diabetic, menopausal woman is seen for routine gynecologic care. She feels well generally but complains that she has constant perineal itching. Another physician has treated her for recurrent vulvovaginal candidiasis over the last 5 years, using topical antifungal and steroidal cream preparations. She is a 1-pack-per-day smoker who has unsuccessfully tried to quit multiple times in the past. On physical examination, you find hyphae on a KOH preparation from her vagina and also notice three areas of slight discoloration on both labia majora. You explain your concern about the relationship of continued vulvar pruritus and vulvar carcinoma and recommend a punch biopsy of one of the discolored areas of her labia. She consents, and two specimens are obtained. You also treat her with systemic and topical antifungal medications and suggest she see her internist to review her diabetic management. Again you discuss smoking cessation.
As the population ages, the health care needs of women will change, and thus the provision of primary and preventive care in the obstetric and gynecologic setting must evolve to meet these needs. The obstetrician–gynecologist is in a unique position to provide screening, preventive care, and counseling to women, which can have a positive impact on quality of life as well as morbidity and mortality.
PREVENTIVE CARE
Preventive care is both beneficial and cost-effective over time. Preventive medicine encompasses both primary and secondary prevention. In primary prevention, an attempt is made to eliminate or ameliorate risk factors for disease and, thus, prevent its occurrence or modify its severity. Primary prevention may include health education and behavioral interventions to promote a healthier lifestyle, including immunizations, fitness and nutrition, hygiene, smoking cessation, personal safety, and safe sex. Secondary prevention focuses on screening tests for diseases, which are performed when the patient is usually asymptomatic, allowing prompt intervention that reduces morbidity and mortality. Screening tests are performed as part of periodic health assessments (often called “annual examinations”) that afford an opportunity to evaluate and counsel patients based on their age and risk factors.
Primary preventive care concerning sexually transmitted diseases (STDs) is found in Chapters 28 and 29. Similar care to increase the quality of life of newborn and mother before, during, and after pregnancy is found in Chapter 6.
IMMUNIZATIONS
In the United States, vaccination programs that focus on infants and children have reduced the occurrence of many childhood diseases. However, many adolescents and adults are still affected by vaccine-preventable diseases, such as influenza, varicella, hepatitis A, hepatitis B, measles, rubella, and pneumococcal pneumonia. Each year, it is estimated that pneumococcal infection, influenza, and hepatitis B cause as many as 45,000 deaths in adults. Obstetrician–gynecologists and other clinicians who provide primary care to women have opportunities to counsel women on the need for immunizations and may administer them or refer the patient to a facility that does provide them.
The clinician should attempt to gather a complete immunization history from each patient, including risk factors, indicating the need for immunization. Previous vaccination records are particularly valuable if the patient is in doubt about her immunization history. In lieu of a clear history, the physician should assume that a patient has not been immunized and proceed accordingly. The recommended vaccinations for women are listed in Box 2.1. Because immunization recommendations do change, it is useful to know that the most current recommendations can be accessed at the Center for Disease Control’s (CDC) National Immunization Program Web page (www.cdc.gov/vaccines).
Prevention of cervical neoplasia and cancer with the use of the human papillomavirus (HPV) vaccine is discussed in detail in Chapter 47. The American College of Obstetricians and Gynecologists (College) recommends the initial vaccination for girls ages 11 to 12 years. Although obstetrician–gynecologists do not routinely care for girls in this age group, they are in a unique position to advocate for the use of the vaccine for females ages 13 to 26 years (the catch-up vaccination period). During a health care visit with a girl or a woman in the age range for vaccination, an assessment of the patient’s HPV vaccine status should be conducted and documented in the patient record. The HPV vaccine is most effective when given before any exposure to HPV infection, but sexually active women who were exposed to HPV prior to vaccination can receive and benefit from the vaccine. Women should be informed that HPV immunization has been shown to be nearly 100% effective in the prevention of diseases related to the virus genotypes covered by the particular vaccine. This may include cervical intraepithelial neoplasia (CIN) and condylomatous vulvar disease. HPV vaccination should not be given during pregnancy but may be given to breastfeeding mothers.
SECONDARY PREVENTION: PERIODIC ASSESSMENT AND SCREENING
Periodic assessments conducted at regular intervals (i.e., annually) are an integral part of preventive health care and include screening, evaluation, and counseling. Recommendations for periodic health assessments and screening vary by age group and are based on risk factors as well as epidemiologic information (see Appendix B). This care starts with a thorough medical history, physical examination, and appropriate laboratory testing. The history, physical examination, and results of laboratory tests help guide interventions and counseling and may reveal additional risks that require targeted screening or evaluation.
The recommendations presented in Appendix B have been selected from a variety of sources. These recommendations take into account factors such as the leading causes of morbidity and mortality in each age group as well as chronic health conditions that limit activity of adults (e.g., arthritis or other musculoskeletal disorders and circulatory disorders) that become more prevalent as women age.
Characteristics of Screening Tests
The principle behind routine screening is to detect the presence of disease in asymptomatic individuals without specific risk factors. Disease detection in this sojourn time interval allows maximum decrease in morbidity and mortality. The diseases screened for should be prevalent in the population and amenable to early intervention. Screening tests are currently available for a variety of cancers, metabolic disorders, and STDs. Examples of screening tests are the Pap test and mammography.
Not every disease can be detected by screening, and screening is not cost-effective or feasible for every disease. The concepts of sensitivity and specificity are used to describe the efficacy of screening tests in detecting a disorder. The sensitivity of a test is the proportion of affected individuals that test positive on the screening test. The specificity is the proportion of unaffected individuals that test negative on the screening test. An effective screening test should be both sensitive (it has a high detection rate) and specific (it has a low false-positive rate). Other criteria for effective screening tests pertain to the population being tested and the disease itself (Box 2.2).
Cancer Screening
The Pap smear (cervical cancer) and mammography (breast cancer) are the only recognized effective screening tests for gynecologic cancers. There is no screening test with the requisite sensitivity and specificity to detect ovarian cancer. Women should be educated about the unique early signs and symptoms of ovarian cancer that may aid in earlier diagnosis (see Chapter 50). Likewise, screening tests are not available for endometrial, vaginal, or vulvar cancers. A history of postmenopausal bleeding (endometrial cancer) or chronic and persistent vulvar itching (vulvar cancer) may be useful, but for these neoplasms, as well as for cervical cancer, a tissue biopsy is needed to identify either frank invasion or a precursor lesion.
Endometrial, vulvar, and vaginal biopsies are not screening tests.
BOX 2.2 Criteria for Screening Tests
Criteria for the Disease
• Asymptomatic period long enough to allow detection
• Prevalent enough to justify screening
• Treatable; treatment in an asymptomatic stage (preferably a superior treatment)
• Sufficient effect on quality and/or length of life
Criteria for the Test
• Sensitive
• Specific
• Safe
• Affordable
• Acceptable to patients
Criteria for the Population to Be Tested
• High disease prevalence
• Accessible
• Compliant with testing and treatment
Breast Cancer
Breast cancer is the most common cancer among women in the United States after skin cancer. It has a lifetime risk of 12.5%, and it is the second leading cause of cancer-related death in women. It is important that clinicians assess each patient’s breast cancer risk by taking a thorough history, because the recommendations for screening differ based on risk factors. A computer program called the Breast Cancer Risk Assessment Tool (http://www.cancer.gov/bcrisktool/) is available to estimate a patient’s risk of developing breast cancer (see Chapter 33).
For women at average risk, there are two major screening examinations for breast cancer: clinical breast examination and screening mammography. The College recommends:
• An annual clinical breast examination for all women ages 40 years and older and every 1 to 3 years for women ages 20 to 39 years (Women at high risk for breast cancer ages 20–39 years may be considered for annual clinical breast examination.)
• Screening mammography annually starting at age 40 years
The American Cancer Society recommends:
• Clinical breast examinations every 1 to 3 years for women between ages 20 and 39 years at average risk
• Annual clinical breast examination and screening mammography starting at age 40 years for women at average risk
Breast self-examination is not universally recommended; instead, breast self-awareness is to be encouraged and supported by physicians. Ultrasound and magnetic resonance imaging (MRI) have no current role in screening women at average risk but are used as adjunctive tests. These imaging modalities are used for the assessment of palpable masses. MRI is also recommended, in addition to yearly mammography, for women at very high risk (greater than 20% lifetime risk according to family history risk assessment or who have a first-degree relative with BRCA1 or BRCA2 gene mutation).
Cervical Cancer
Cervical intraepithelial neoplasia is the precursor lesion to cervical cancer. CIN may regress spontaneously, but, in some cases, CIN 2 and CIN 3 progress to cancer over time. Exfoliative cytology, specifically the Pap test (either slide or liquid based) with or without high-risk HPV identification, allows early diagnosis in most cases. The reduction in mortality from cervical cancer since the Pap test was introduced in the 1940s is testimony to the success of this screening program.
The following are recommendations for cervical cancer screening for women based on the U.S. Preventive Services Task Force as well as the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology. These guidelines apply to the general population but not to women at high risk (i.e., women with a history of cervical cancer or diethylstilbestrol exposure or women who are immunocompromised).
• Younger than 21 years: should not be screened regardless of age of sexual initiation or other risk factors.
• Ages 21 to 29 years: recommend screening every 3 years with cytology.
• Ages 30 to 65 years: recommend screening every 3 years with cytology or every 5 years with cytology and HPV testing (co-tests).
• Older than 65 years: recommend against screening in women with adequate negative prior screening (three consecutive negative cytology results or two consecutive negative co-tests in 10 years) and no history of CIN 2 or greater within the last 20 years. Screening should not be resumed for any reason, even with report of a new sex partner.
• After hysterectomy for benign conditions with removal of the cervix: recommend against screening for vaginal cancer without any history of CIN 2 or greater. Screening should not be resumed for any reason, even with report of a new sex partner.
• Women with a history of CIN 2, CIN 3, or adenocarcinoma in situ should continue screening for a total of 20 years after spontaneous regression or appropriate management of CIN 2, CIN 3, or adenocarcinoma in situ, even if it extends the screening past age 65 years.
• HPV vaccinated: should not change guidelines.
• Annual gynecologic examination is appropriate even if screening is not performed at each visit.
Colorectal Carcinoma
With nearly 75,000 new cases of colorectal cancer annually in women and over 25,000 deaths, colorectal cancer is the third leading cause of cancer death in women after lung cancer and breast cancer. Because early detection (preinvasive or early invasive stage) allows effective management for most patients, screening is appropriate and recommended.
Screening for colorectal cancer is recommended for all women at average risk, starting at age 50 years. The preferred method is colonoscopy performed every 10 years.
Other acceptable screening tests include:
• Annual fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT)
• Flexible sigmoidoscopy every 5 years
• Double-contrast barium enema every 5 years
• Computed tomography colonography (virtual colonoscopy) every 5 years
• Stool DNA, interval not established
Flexible sigmoidoscopy will miss right-sided lesions, which may account for up to 65% of advanced colorectal cancers in women. Both FOBT and FIT require two or three stool samples collected by the patient at home and returned for analysis. Screening by FOBT of a single stool sample from a rectal examination by the physician is not adequate for the detection of colorectal cancer and is not recommended. Different recommendations apply to women at increased risk and at high risk.
Sexually Transmitted Diseases
Appropriate STD screening in nonpregnant women depends on the age of the patient and the assessment of risk factors (Box 2.3). Because of the risk that STDs pose in pregnancy, pregnant women are routinely screened for syphilis, HIV, chlamydia, and gonorrhea (see Chapter 29).
Human Immunodeficiency Virus
The demographics of the HIV epidemic have changed over the last two decades. Prevalence has increased among adolescents, women, persons who reside outside metropolitan areas, and heterosexual men and women. Many are not aware that they are infected.
HIV testing is recommended for all women, and targeted testing is recommended for women with risk factors. Although women of reproductive age should be tested at least once in their lifetime, there is no consensus regarding repeat testing. Obstetrician–gynecologists should review their patient’s risk factors annually and assess the need for retesting. Repeat HIV testing should be offered at least annually to women who:
BOX 2.3 Risk Factors for Sexually Transmitted Diseases
• History of multiple sex partners
• Sexual partner with multiple sexual contacts
• Sexual contact with individuals with culture-proved STD
• History of repeated STDs
• Attendance at clinics for STDs
American College of Obstetricians and Gynecologists. Annual Women’s Health Care.http://www.acog.org/About_ACOG/ACOG_Departments/
Annual_Womens_Health_Care.
• Are injection drug users
• Have sex partners who are injection drug users or are HIV infected
• Exchange sex for drugs or money
• Have been diagnosed with another STD in the last year
• Have had more than one sex partner since their most recent HIV test
Obstetrician–gynecologists should also encourage women and their prospective sex partners to be tested prior to initiating a new sexual relationship. Periodic retesting could be considered even in the absence of risk factors, depending on clinical judgment and the patient’s wishes.
The most common screening test is the enzyme-linked immunosorbent assay (ELiSA), which is performed on a blood sample. There are also ELISA tests that use saliva or urine. A positive (reactive) ELISA must be confirmed by a supplemental test, such as the Western blot, to make a positive diagnosis.
Chlamydia Infection
Infection caused by Chlamydia trachomatis is the most commonly reported bacterial STD in the United States and is often asymptomatic. Over 1.3 million cases were reported to the CDC in 2010, a rate of 426 per 100,000, and it is estimated that another 1.7 million cases go undiagnosed. If untreated, chlamydia can cause significant long-term complications, including infertility, ectopic pregnancy, and chronic pelvic pain. Diagnosing chlamydia promptly is necessary to prevent these complications. The College recommends annual screening for chlamydia in sexually active women ages 25 years and younger. Asymptomatic women ages 26 years and older who are at high risk for infection should be routinely screened. Nucleic acid amplification tests (NAATs) of endocervical swab specimens can identify infection in asymptomatic women with high specificity and sensitivity. NAATs of vaginal swabs and urine samples have comparable sensitivity and specificity.
Gonorrhea Infection
Over 309,000 cases of gonorrhea were reported in 2010, a rate of 100.8 per 100,000. It is estimated that the same number went unreported. Infection can be symptomatic with cervicitis and vaginal discharge, or it may be asymptomatic. Gonorrhea may lead to pelvic inflammatory disease, which is associated with long-term morbidity due to chronic pelvic pain, ectopic pregnancy, and infertility.
The College recommends annual screening for gonorrhea in sexually active women ages 25 years and younger. Asymptomatic women ages 26 years and older who are at high risk for infection should be routinely screened.Screening can be done by cervical cultures or by newer techniques, such as NAATs and nucleic acid hybridization tests that have better sensitivity with comparable specificity (see Chapter 29).
Syphilis
Syphilis is not a common disease in the United States, but the rate has increased over the last few years. About 13,774 cases of primary and secondary syphilis were diagnosed in 2010, which translates to a rate of 7.9 cases per 100,000. Overall increases were seen primarily in men; in women, the rate is 1.1 cases per 100,000.
Syphilis is a systemic disease caused by the bacterium Treponema pallidum. If untreated, syphilis may progress from a primary infection characterized by a painless ulcer (chancre) to secondary and tertiary infections. Signs and symptoms of secondary infection include skin manifestations and lymphadenopathy; tertiary infection may cause cardiac or ophthalmic manifestations, auditory abnormalities, and gummatous lesions. Serologic tests may be negative in the early stages of infection.
The College recommends annual syphilis screening for women at increased risk (see Box 2.3). All pregnant women should be serologically screened as early as possible in pregnancy and again at delivery. Due to the possibility of a false-negative result in early stages of infection, patients who are considered at high risk or who are from areas of high prevalence should be retested at the beginning of the third trimester.
Screening is done with nontreponemal tests such as the Venereal Disease Research Laboratory test or rapid plasma reagin. These tests are followed by confirmatory treponemal tests such as T. pallidum particle agglutination. The specificity of the nontreponemal tests may be reduced in the presence of other conditions, such as pregnancy, collagen vascular disease, advanced cancer, tuberculosis, malaria, and rickettsial diseases.
Metabolic and Cardiovascular Disorders
Routine screening can also be applied to noninfectious and noncancerous diseases, such as metabolic disorders and cardiovascular disease. Women should be evaluated for lifestyle issues and risks based on a history and physical examination. In many cases, early identification of risk factors and appropriate interventions are key components of disease prevention.
Osteoporosis
osteoporosis affects approximately 13% to 18% of American women ages 50 years and older, and another 37% to 50% have osteopenia, or low bone mineral density (BMD). Osteoporosis-associated fracture, especially of the hip and spine, are leading causes of morbidity and mortality, increasing in proportion to age. Osteoporosis is a complication of menopause that is largely preventable with screening strategies, lifestyle modifications, and pharmacologic interventions.
BMD is an indirect measure of bone fragility. BMD is measured using dual-energy x-ray absorptiometry of the hip or the lumbar spine. The results are expressed in standard deviations compared with a reference population stratified by age, sex, and race. The T-score is expressed as the standard deviation from the mean peak BMD of a normal, young adult population; and the Z-score is expressed as the standard deviation from the mean BMD of a reference population of the same sex, race, and age as the patient. Z- and T-scores are used for hip and spine measurements. The World Health Organization (WHO) defines a normal BMD T-score as ≥−1. Osteopenia (low bone mass) is defined as a T-score between −1 and −2.5. Osteoporosis is defined as a T-score ≤−2.5. Because of variance in the measurements obtained by the different commercial devices and at different sites, T- and Z-scores cannot be used as true screening tests, but they are good predictors of the risk of fracture. When these scores indicate low bone mass, the fracture risk assessment tool (FRAX) can be used in women older than age 40 years to predict their risk of fracture in the next 10 years. Developed in collaboration with WHO, FRAX can be used to guide decisions about interventions including lifestyle changes and medical therapy to prevent or slow bone loss.
The College recommends BMD testing for all postmeno-pausal women starting at age 65 years. BMD testing should also be performed in younger postmenopausal women who have at least one risk factor for osteoporosis (Box 2.4). In addition, postmenopausal women who experience a fracture should have BMD testing to ascertain if they are osteoporotic; if so, treatment for osteoporosis is added to the therapy for the fracture. Certain diseases or medical conditions (e.g., Cushing disease, hyperparathyroidism, hypophosphatasia, inflammatory bowel disease, lymphoma, and leukemia) and certain drugs (e.g., phenobarbital, phenytoin, corticosteroids, lithium, and tamoxifen) are associated with bone loss. Women with these conditions or taking these drugs may need to be tested more frequently.
BOX 2.4 When to Screen for Bone Density Before Age 65 Years
Bone density should be screened in postmenopausal women younger than 65 years if any of the following risk factors are noted:
• Medical history of a fragility fracture
• Body weight less than 127 lb
• Medical causes of bone loss (medications or diseases)
• Parental medical history of hip fracture
• Current smoker
• Alcoholism
• Rheumatoid arthritis
American College of Obstetricians and Gynecologists. Osteoporosis, Practice Bulletin No. 129. Washington, DC: American College of Obstetricians and Gynecologists; September 2012.
Women should be counseled on the risks of osteoporosis and related fractures and the following preventive measures:
• Adequate calcium consumption (1,000–1,300 mg/day, depending on age) using dietary supplements if dietary sources are not adequate
• Adequate vitamin D consumption (600–800 international units daily, depending on age) and exposure to the natural sources of this nutrient
• Regular weight-bearing and muscle-strengthening exercises to reduce falls and prevent fractures
• Smoking cessation
• Moderation of alcohol intake
• Fall prevention strategies
Diabetes Mellitus
Diabetes mellitus is a group of disorders that share hyperglycemia as a common feature. Even when symptoms are not present, the disease can cause long-term complications. Ideally, it should be detected and treated in its early stages. A screening fasting blood glucose test is recommended for women beginning at age 45 years and every 3 years thereafter. Screening should begin at a younger age or more frequently in individuals with risk factors, which include being overweight (body mass index [BMI] ≥25), first-degree relative with diabetes mellitus, habitual physical inactivity, high-risk race or ethnicity, having given birth to a newborn weighing more than 9 lb, history of gestational diabetes, 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, and other clinical conditions associated with insulin resistance. In 2009, the American Diabetes Association endorsed the use of HgbA1c as the favored test for the diagnosis of diabetes.
Thyroid Disease
Thyroid disease is often asymptomatic and, if untreated, can lead to serious medical conditions including the appearance of dementia in older adults. Because hypothyroidism in older women can present as dementia, thyroid-stimulating hormone levels should be tested every 5 years starting at age 50 years in women without risk factors.
Earlier or more frequent screening should may be appropriate in women with a strong family history of thyroid disease or with an autoimmune disease (evidence of subclinical hypothyroidism may be related to unfavorable lipid profiles).
Hypertension
It is estimated that approximately 30% of adults ages 20 years and older have hypertension, which is defined as a systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg. Hypertension is one of the most important risk factors for heart disease and cerebrovascular accidents, two of the three leading causes for mortality among women. Hypertension is also a leading cause of mortality. About a third of those with hypertension do not know they have it. Because hypertension is often asymptomatic, the College recommends screening for hypertension annually for women and girls ages 13 years and older, regardless of blood pressure level.Prehypertension(120–139/80–90) should prompt a review for comorbid conditions and more frequent evaluation of blood pressure.
Lipid Disorders
Coronary heart disease (CHD) is a leading cause of death for both men and women in the United States and accounts for approximately 500,000 deaths each year. Abnormal cholesterol levels have been linked to atherosclerosis as well as cardiovascular and cerebrovascular disease. Physicians and patients alike should be reminded that a 1% reduction in serum cholesterol levels results in a 2% reduction in CHD rates. Lipid levels are monitored by measuring low-density lipoprotein, high-density lipoprotein, and triglycerides. Approximately one in five adult Americans has a high total cholesterol level (≥240 mg/dL).
Current guidelines recommend that women without risk factors have a lipid profile assessment every 5 years, beginning at age 65 years in women without risk factors. Earlier screening may be appropriate in women with risk factors. Risk factors for high cholesterol are a family history of familial hyperlipidemia, family history of premature (age younger than 50 years for men and younger than 60 years for women) cardiovascular disease, personal or family history of peripheral vascular disease, obesity, diabetes mellitus, and multiple CHD risk factors (e.g., tobacco use and hypertension).
Obesity
Obesity is associated with increased risk for heart disease, type 2 diabetes, hypertension, certain types of cancer (e.g., endometrial, colon, and breast), sleep apnea, osteoarthritis, gallbladder disease, and depression. Measurement of height and weight and the calculation of a BMI are recommended as part of the periodic assessment (Box 2.5). Obese people with a BMI of 30 or more have up to twofold increased risk of death. Behavioral therapy is the most common treatment, although bariatric surgery is an option to be considered in those who are morbidly obese and have proven refractory to treatment.
BOX 2.5 Body Mass Index
• BMI <18.5 = underweight
• BMI 18.5–24.9 = normal weight
• BMI 25–29.9 = overweight
• BMI 30–34.9 = obesity (Class I)
• BMI 35–39.9 = obesity (Class II)
• BMI ≥40 = extreme obesity
National Heart, Lung, and Blood Institute and North American Association for the Study of Obesity. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.Bethesda, MD: National Institutes of Health; 2000.
Sleep Disorders
The most common sleep disorders are obstructive sleep apnea (OSA) and restless legs syndrome (RLS). Both are surprisingly common, with reports showing that up to 10% of women have one or both disorders. The fatigue caused by the sleep disorder is associated with increased risk of injury (e.g., automobile accidents) and significant psychosocial dysfunction. OSA is suspected when a woman snores and also awakes each morning fatigued. It may be associated with obesity in approximately 50% of cases. RLS is suspected in women who awake each morning fatigued and/or with bed coverings awry, who fall asleep unexpectedly, and who are noticed to have leg movements while sleeping. Diagnosis for both OSA and RLS is made with an overnight sleep study. OSA is usually treatable by continuous positive pressure breathing. RLS is treatable in most cases with medication. Both OSA and RLS may have adverse effects in pregnancy including intrauterine growth restriction.
Clinical Follow-Up
The patient returns in 3 weeks and reports that her itching is somewhat improved and that her general physician had made a slight adjustment in her insulin regimen. She is concerned about the continued vulvar itching, however, given your previous discussion. You inform her that both vulvar biopsies revealed early vulvar malignancy. Because she is disheartened by this news, you reassure her that you are optimistic about a good outcome for this problem and had arranged an immediate consultation with a gynecologic oncologist. Subsequently, your consultant informs you that her very early noninvasive vulvar malignancy has been successfully treated, returning her to routine care in your practice and thanking you for the referral.
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