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Speaking of Women’s Health eNewsletter

Articles on health information, recipes, and advice from Cleveland Clinic experts.


Healthy Tips: Health Maintenance Recommendations

Cancer screening

Examination by a health care provider and mammogram every 1-2 years beginning at age 40 or by age 50 in lower risk women. (The Gail Model mathematical calculation helps to assess an individual woman’s risk for being diagnosed with breast cancer.)

Pap test (obtained during the pelvic exam) by age 21 and then every three years up to age 30 and if normal, then every five years after age 30 as long as you have had a normal Pap smear and a negative HPV DNA test. The HPV tests are done at the time of a Pap smear and should start at age 30. Pap tests are done more frequently in women with a history of multiple sexual partners, prior abnormal Pap tests, smokers, and those with HPV or HIV infection. (Pap smears may be discontinued age age 65-70 at physician/patient discretion if at low risk and previous tests were all normal.)

Unfortunately, there is no good screen for ovarian cancer (despite what you might read in lay magazines). Cleveland Clinic researchers are working hard to define a screening technique.

Colonoscopy every ten years or annual fecal occult blood test from age 50 with a flexible sigmoidoscopy every five years (or in combination with air contrast barium enema every five to ten years. For women at high risk (certain medical conditions and first degree relatives with colon cancer), different recommendations may apply. Women with a family history of colon cancer may want to be screened sooner. African American women may want to begin colon cancer screening at age 45.

Chest x-ray is not recommended as screen in persons without symptoms.

Periodic skin examinations and sun protection is advised.

Prevention of heart disease and osteoporosis in the menopausal woman

Heart disease and osteoporosis are two of the most serious health risks for women after the menopause. Diet, exercise and lifestyle choices like avoidance of tobacco and excessive alcohol, help modify these risks. Calcium and vitamin D3 are important. Hormone therapy does not seem to reduce the risk of heart disease in women who already have the disease and is not used solely to prevent heart disease. Hormone therapy is associated with an increased risk of blood clots, and there is an increased risk of gallbladder disease and stroke in older HT users, as well as a slight increased risk for breast cancer diagnosis after in women using long-term estrogen-progestin. HT reduces the risk of diabetes, colon cancer and reduces the risk of osteoporosis and bone breakage. Estrogen alone use in women who are post hysterectomy does not increase breast cancer risk.

Heart disease

Heart disease remains the most important cause of death in women. Risk factors of cardiovascular disease in women include: being overweight, a sedentary lifestyle, smoking, being over age 55, hypertension, diabetes, premature menopause and a family history of heart disease. High levels of cholesterol and triglycerides are associated with an increased risk of heart disease, although high levels of HDL-cholesterol (largely inherited) usually but not always may be protective. “us-CRP” (ultra-sensitive C-reactive protein) may further assess your risk for cardiovascular disease (although the test is not interpretable in women on oral hormone therapy).


Medicines proven to reduce cardiovascular disease risk in women with heart disease or at high risk for heart disease include: cholesterol lowering “statin” drugs, (atorvastatin {Lipitor}, simvastatin {Zocor}, pravastatin {Pravachol}, lovastatin {Mevacor}, rosuvastatin (Crestor)), ACE inhibitors for hypertension like (Altace {ramipril}); and diabetic control agents (Metformin/Glucophage).

A Mediterranean-type diet has also been shown to reduce the risk for heart disease. The FDA recommends considering substituting 25 grams of soy protein per day in place of animal protein to help lower cholesterol. Other food stuffs that may help lower cholesterol include: apple pectin, flax seed, oat bran, garlic and Benecol spread (in place of butter). Foods containing OMEGA-3 fatty acids (fish and/or almonds, walnuts, flax seed) should be consumed at least twice a week. Foods high in trans fatty acids (“partially hydrogenated vegetable oils”) should be completely avoided.


Osteoporosis of the advanced age type may be reduced by maintaining 1200 mg of calcium in divided doses and 1000 to 2000 IU of separate vitamin D3 daily from early adolescence. The postmenopausal trabecular bone type of osteoporosis is preventable with use of hormone therapy. Additional risk factors for osteoporosis besides low bone density include: a family history of osteoporosis, prednisone use, rheumatoid arthritis, smoking, the excessive intake of alcohol and being underweight for height. Vitamin D deficiency is a common condition and can lead to musculoskeletal aches and pain, a higher risk for diabetes and even some cancers.


Citracal (calcium citrate) is easily absorbed and does not require stomach acid for absorption (check you calcium supplement for USP grade rating as some calcium supplements are contaminated with lead and heavy metals). Calcium carbonate (like Tums) requires stomach acid for absorption. In addition to estrogen, risedronate (Actonel or weekly Atelvia), alendronate (Fosamax), raloxifene (Evista) and ibandronate (Boniva) may be used to manage osteoporosis. Forteo (injectable PTH) is an agent used to build bone and is given by injection daily for 2 years. Once yearly IV Reclast (Zoledronic acid) is available to treat postmenopausal osteoporosis and every other year for the prevention of postmenopausal osteoporosis. Denosumab (Prolia) is given by subcutaneous injection twice yearly for women at high risk for osteoporosis.

Bone Mineral Densitometry (BMD

Bone mineral densitometry is available to diagnose and monitor treatment for osteoporosis. Bone mineral density correlates with fracture (bone breakage) risk. It is imperative to return to the same DXA machine for serial study. Women should consider a bone density test within two years of menopause or at least by age 65.

Screening blood tests

A history of gestational diabetes and/or pre-eclampsia increases the risks of diabetes and hypertension. Fasting blood sugar testing is recommended every three years starting at age 45. Fasting lipid levels and TSH (thyroid) is considered every five years. Other blood and urine testing depends on your individual and family medical history.


Immunizations: Apart from usual childhood immunizations, the following are recommended:

  • Influenza vaccine. All adults should obtain the flu shot yearly in the fall months. Women who will be in their 2nd or 3rd trimester of pregnancy during flu season should receive the flu shot. (This vaccine is not a living virus and does not carry excess risk of illness). The nasal flu mist spray is available for persons ages 5 to 49.
  • Tetanus diphtheria (Td). A booster injection should be given every 10 years and at the very least, once at age 50. Tdap (Tetanus diphtheria with acellular pertussis) is also available which covers whooping cough.
  • Pneumococcal vaccine. This should be given between ages 50 and 65 and in patients at high risk at any age. A booster can be given in 5 years if the first vaccine was received prior to age 65.
  • Hepatitis B. This is a 3-shot immunization. (It is now given to all children and teenagers.)
  • Hepatitis A. This is a 2-shot immunization given to women traveling to third world countries with poor food handling conditions. (The second shot can be administered at 6 or 12 months.)
  • Varivax. (If no chicken pox as a child), this is a 2-shot immunization for non-pregnant adults.
  • Zostavax. (Shingles vaccine) is available for adults age 50 and older. (Check with your insurance, re: coverage).
  • Consider Menactra (meningitis vaccine) for college-bound dormitory-residing students.
  • Gardasil (HPV cervical cancer vaccine) is available in a series of 3 injections for girls and boys ages 9-26.
  • Prevnar (one time vaccination) for pneumococcal pneumonia.

Sexually transmitted infection (including HIV and hepatitis)

  • Abstinence is the only completely safe method.
  • Use of latex condoms (female and male type condoms). These reduce but do not eliminate the chances of infection. (Note: Mineral oil dissolves latex condoms as do some vaginal creams.)
  • Screening for Chlamydia and Gonorrhea is recommended in women under age 25 and those with risks for sexually transmitted disease.

Avoidance of unwanted pregnancy

Methods of contraception include: barrier methods (diaphragm), oral system birth control (pills, patches, monthly injections, rings and implants), intrauterine devices, tubal ligation (sterilization including hysteroscopic tubal ligation with Essure and Adiana) and spermicidal sponge including the Today contraceptive sponge. Barrier methods are the least effective, however, use of latex condoms also help to protect against sexually transmitted diseases. Hormonal contraceptives decrease the risk of ovarian and endometrial cancer and are also a good treatment for acne and menstrual irregularity. Birth control pills do NOT increase the risk of breast cancer.

“Emergency contraception” in the case of barrier method breakage include birth control pills as well as IUD insertion. Birth control pills may also be used as emergency contraception up to three days after unprotected intercourse. (A prepackaged emergency contraceptive kit is available called “Plan B” or “Preven”. Plan B is now available without a prescription to women age 17 and older. Another emergency contraceptive is ella.) Newer methods of birth control include: the Mirena intrauterine system, the NuvaRing/vaginal ring and Bayaz which treats PMDD. Ortho-Evra contraceptive patch (Ortho-Evra patch delivers 60% more estrogen and may be associated with an increased risk of blood clots over the risk with oral pills.) Long cycle oral contraceptives to reduce the number of periods are available.

Other health prevention and lifestyle factors

  • Exercise. Regular periods of exercise daily involving aerobic activities, such as brisk walking or cycling, is important to cardiovascular fitness. Exercise can be tailored to build strength and mobility. Weightbearing exercise helps to maintain bone density and muscle mass. Exercise reduces heart disease, diabetes and breast cancer risks. One hour of exercise daily is ideal.
  • Weight control. Prevention of obesity is far better and easier than treatment of obesity. Being overweight is associated with high blood pressure, diabetes, heart disease, arthritis, cancer and sleep apnea. The typical American diet is too high in calories and many women exercise too little. 10,000 steps per day is a minimum goal. Consider getting a pedometer.
  • Injury prevention. Wearing seat belts, bicycle helmets, etc. Avoid cell phone use and talking while driving, and do not text and drive.
  • Making home and workplace safe. Smoke and carbon monoxide detectors, firearm safety, improved lighting, rails on stairs and in the bath and removing obstacles and avoiding slippery surfaces to prevent falls are advised in creating a safe environment.
  • Smoking. Participation in a smoking cessation group, can be an aid to discontinuing tobacco. Medications include: nicotine patches, nicotine gum, Zyban and Chantix. The Cleveland Clinic campus is smoke-free.
  • Alcohol and other substance abuse. Avoidance is beneficial to a healthy lifestyle. Women should not ingest more than 5 alcoholic drinks per week.
  • Stress management. The Cleveland Clinic offers courses and a variety of approaches for stress management.
  • Vitamins. Folic acid supplements (0.4 mg) are necessary in young women to prevent birth defects and may be beneficial for the vascular system. In addition, vitamin D3 and B12 are recommended to many older women as absorption of these vitamins may be reduced with age. Women should NOT take beta carotene supplements. Excess vitamin A intake has been linked to birth defects and increased risk of hip fractures. A balanced diet of vegetables, fruits and whole grains is of most importance to providing good nutrition. Persons with diabetes should take a daily multivitamin with antioxidants and trace minerals as this has been shown to reduce the risk of infections.
  • Intimate partner violence. Women of all ages, ethnicity and socioeconomic backgrounds can be affected by domestic violence. The number for the Center for Prevention of Domestic Violence is 216-391-HELP. The National Hotline is 1-800-799-SAFE.

Advanced directives

  • Durable power of attorney for health care. This permits the naming of one principal and two reserve persons who can act for you in case you are incapacitated.
  • Living Will. This allows you to specify the type of treatment you desired in cases of serious illness or injury.

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