Primary Care in Obstetrics and Gynecology
Ronald L. Young and Maureen C. Lucas
Table Of Contents
Ronald L. Young, MD
Maureen C. Lucas, BA
The future of office gynecology and the routine management of our patients is as likely to be determined by economic, social, and political pressures as by medical considerations. Many of the rules governing our practices, therefore, are generated from outside of our profession and, consequently, are outside of our immediate control. Nevertheless, we are obligated to keep pace with advances in technology as well as changes in practice guidelines to give the very best care to our patients.
The primary concerns are to continue to increase the quality of care delivered to our patients and to expand the base of that care to include those not already benefiting from it. A practical approach to affordable health care must first be achieved so that a more ideal approach may be realized. To better participate in the shaping of our medical future, we must offer a health care plan that is both logical and workable; that is, it must be acceptable to those who deliver and those who receive medical care as well as to those who pay the bills.
The model for the overall problem has been the routine care of menopausal patients. Although true statistics are not yet available, in the United States, not more than half of eligible patients receive either estrogen replacement therapy or combined hormone replacement therapy in their menopausal years. Of the women who do begin replacement therapy, about half drop out before the elapse of any meaningful amount of time. Although the reasons for these compliance problems go far beyond economic considerations, routine costs do affect care, treatment, and participation decisions in the elderly and cannot be ignored. Increasing the numbers of patients receiving adequate health care will remain difficult as long as the cost of that care is too high.
The argument that money spent now is less money spent later is well taken but apt to fall on deaf ears. A past example of this is routine bone densitometry studies.1 At $100 to $300 per study, multiplied by the projected 50 million menopausal women expected in the United States by the first decade of the 21st century, the annual bill becomes a staggering $6 billion or more. Those put off by the magnitude of such a number need only be reminded that the costs for treating osteoporotic fractures will be in excess of $10 billion per year in the same time frame.2 Nevertheless, it has never been easy to extract the dollars for prophylactic measures in this country; preventative medicine gets a great deal of lip service but struggles for real support.
The following discussion therefore is calculated to take rational approaches to good general coverage for patients at all stages of their lives, but with an eye to holding costs to an acceptable level. Future battles are likely to be fought over the question of quality screening of a few patients versus mass screening. Therefore, routine screening tests for the asymptomatic patient must be examined in light of cost-effectiveness as well as the type of data that may be generated. We must face the question of whether such data actually lead to prevention of or delay in the onset of morbidity as well as affecting the outcome of a disease process.
No physician is in a better position to deal with these problems than the obstetrician-gynecologist, who represents the major source of medical care and advice for female patients for the greater part of their reproductive years. The acceptability of the Papanicolaou (Pap) smear as a routine yearly screening procedure represents an excellent starting point from which to build. The argument over the necessity of yearly Pap tests in younger women loses significance in light of the fact that the annual visit to the gynecologist represents the only medical care enjoyed by significant numbers of women over the greater portion of their lives.3
The role of the obstetrician-gynecologist in the care of the newborn female infant primarily is limited to postpartum supportive and resuscitative routines, which are not within the scope of this chapter. Primary care of the newborn also should include a thorough examination of the external genitalia at the time of delivery. It is extremely important to note any apparent irregularities and report them to the pediatrician so that appropriate care and additional evaluation may proceed without delay. This small effort may avoid additional anguish to parents whose infant may have a congenital intersexual disorder. This is especially true in cases in which there is an eventual reversal of gender assignment. The examination should include careful observation of the pubic, perineal, and anal areas. An attempt to palpate internal structures is not, however, routinely indicated.4
Mandatory Laboratory Testing.
Any mandatory laboratory testing generally is in the hands of the neonatologist.
Treatment of children remains primarily in the hands of the pediatrician. Occasionally, the gynecologist is called on to see the infant or very young patient. This may be triggered by some concern of a parent and almost certainly is mandated if there is notice of light spotting or a disturbing discharge or of developmental or anatomic irregularities such as labial fusion. Monilial vulvovaginitis, in this as in any age group, commonly is associated with diabetes or antibiotic use.4
The gynecologic examination of the child is one of the most difficult procedures for the inexperienced physician to master. It is important to learn examination techniques or to obtain the help of a pediatric or adolescent gynecologist. Although this is not a boarded subspecialty, growing numbers of physicians are taking the time and extra training to become more expert at the difficult examination techniques involved in the care and handling of patients this young. Standard adolescent gynecologic textbooks are informative, especially concerning proper instrumentation for vaginoscopy and the removal of foreign bodies.
Mandatory Laboratory Testing.
There are no routine gynecologic tests in this age group. Screening is mandatory for sexually transmitted diseases (STDs) in cases with a high degree of suspicion. Be aware of rules regulating the reporting of positive findings (e.g., Sections 97.132, 97.134, and 97.135, Article 95, Title 25, Texas Administrative Code).
As the girl grows, it is important to take note of sexual and physical development. The gynecologist should show concern and occasionally inquire if physical development appears to be progressing normally in the daughters of patients. To this end, the gynecologist should be familiar with the schedule and patterns of development, including the expected appearance as well as the subsequent stages of thelarche, pubarche, and adrenarche, so that answers may be forthcoming when unexpected questions arise.
Parents are concerned about reports of increasing sexual experience in younger children, and the gynecologist should offer advice and counseling on sexual matters as well as on STDs. If the rare meeting with the younger patient does occur, the gynecologist may participate in education about pending puberty and the associated bodily changes the girl can expect. Literature may be given to parents to assist in this matter.
Mandatory Laboratory Testing.
No gynecologic tests are routine in this age group. Screening for STDs is mandatory in cases with a high degree of suspicion.
Puberty may be the first occasion for contact between the gynecologist and the young patient. As with prepuberty, concerns about physical development usually trigger this contact. It also is at this time that the pediatrician may begin to defer to the gynecologist and that a familiarity with developmental norms is extremely important.
An area of controversy may arise over the initiation of an evaluation for primary amenorrhea. The traditional approach has been to defer such testing until 16 or 17 years of age provided that height and secondary sexual development appear to be within expected norms. Loss to medical follow-up, however, can result in an attainment of exaggerated height in patients with Swyer's syndrome or similar gonadal dysgenesis. It is therefore important to advise the patient and her parents about the potential negative aspects of excessive delay of evaluation and to follow those patients whose menarche is significantly delayed.
In cases in which dysfunctional uterine bleeding dominates the postpubertal time period, a conservative if watchful approach is recommended with an eye to avoidance of costly and nonproductive laboratory testing as well as unnecessary surgery for functional ovarian cysts. Blood counts are beneficial in cases in which heavy bleeding characterizes the menstrual pattern. Uterine curettage is to be avoided when possible. Conversely, the gynecologist should be prepared to counsel and intervene in the case of the patient with severe primary dysmenorrhea, a condition that, if not handled correctly, could lead to consequential emotional and functional problems.
Because sexual activity is of increasing concern in this age group, it is imperative that gynecologists be proactive as health care providers for these young patients and their frequently anxious parents. A balance should be struck between concerns for contraception and concerns for the dangers of acquiring STDs brought about by sexual intimacy. The gynecologist must not neglect the possibility that providing contraception may actually increase the degree of sexual freedom perceived by the young patient. This is an extremely difficult area with no easy answers and often is demanding of time and resources.
Mandatory Laboratory Testing.
No gynecologic tests are routine in this age group. Karyotyping is indicated in cases of delayed puberty. Screening for STDs is important. A pregnancy test should not be delayed if there is genuine concern about a possible pregnancy. Cholesterol screening in the young adolescent has not proved to be of much value.5
If the young woman has negotiated her pubertal years without any difficulties, the question of the eventual timing of her first gynecologic examination now gains in importance. This examination should be mandated by any problem that clearly falls within the gynecologic discipline, and the gynecologist should be more aggressive in taking over as primary caregiver for any such problems. Possible problems include all types of menstrual disorders, persistent pelvic pain, and any lingering questions of physical and anatomic development, such as those dealing with the hymen, external genitalia, or the breasts. The adolescent patient should be advised to practice routine self-examination of the breasts early in her teenage years. Proper methods of this examination should be taught and literature provided.
If the first period has not begun by 16 or 17 years of age, evaluation for primary amenorrhea should commence. Because buccal smears are not in routine use, karyotyping is mandatory. Anxiety on the part of the parents may pressure the physician to intervene at an earlier age, but this should be avoided if possible. Absence of secondary sexual characteristics by age 14 should expedite concerns and intervention.
In the absence of particular problems, the first examination should at least coincide with the onset of sexual activity or the first request for contraceptives or contraceptive advice. Failing these events, the young woman should be advised to undergo her first pelvic examination and Pap test at about 18 years of age.6 The gynecologist should stress the importance of this decision if the patient is leaving to continue her education elsewhere but intends to obtain her basic gynecologic care at home. Establishing baseline findings may help in dealing with new problems as they arise.
Once pelvic and breast examinations and Pap tests are begun, yearly checkups are advisable as a minimum of care. Rubella vaccine should be administered before the patient's first gestation. Despite recent investigations that have implied increased risks of breast cancer and premalignant as well as malignant changes in the cervix in younger women taking oral contraceptives, there is no apparent reason to recommend more frequent follow-ups in women 20 to 30 years old.7,8,9,10 No recommendations for changes in drug labeling or prescribing practice have been made.6
Routine screening for STDs is another controversial area. More than 1 million cases of pelvic inflammatory disease are reported annually, and the costs for treatment and sequelae are expected to rise from around $4.2 billion in 1990 to $10 billion by the year 2000.11 If practice prevalence for chlamydial infection reaches 7%, it is thought to be costeffective to screen high-risk patients, such as those under 24 years of age, those with new or frequent sexual partners, and those not using barrier contraceptives.12 When screening is indicated, it should include testing for gonorrhea, syphilis, herpes, and human immunodeficiency virus.
Beginning the use of oral contraceptives inevitably raises concerns about their effect on lipids and cardiovascular disease. A great deal of research effort has gone into establishing the metabolic effects of estrogens and progestins.13 The relative safety of the newer agents and formulations has been well established and should be reinforced with the patient.14,15
Mandatory Laboratory Testing.
As sexual activity increases, special attention should be given to screening for STDs. A pregnancy test is indicated if there is any suspicion of pregnancy. Once initiated, Pap tests should be continued annually. Obligatory safety screening for an oral contraceptive prescription should include weight and blood pressure as well as obtaining a smoking history and history of vascular disease, hyperlipidemias, diabetes, and cardiac and liver disease. As a rule, cholesterol screening in the young patient is not cost-effective, even in families at high risk for cardiovascular disease.5
Baseline values for a complete blood count (CBC) are indicated, as well as for fasting blood glucose levels, particularly if there is a family history of diabetes or the patient is obesity. These latter two tests may be repeated periodically thereafter.
A yearly physical examination including breast and pelvic examinations and Pap smear is recommended for the female patient throughout the rest of her life. The rationale for a yearly Pap test has been debated both in this country and abroad, with financial factors often playing a role in foregoing annual testing. We believe that an annual visit including breast and pelvic examination should remain routine. During the reproductive years, a woman may see no physician other than her gynecologist for long periods of time; therefore, avoidance of a once-yearly examination cannot be justified. Because the Pap test is the linchpin consideration, we feel that advising against annual cytologic screening would result in loss of considerable numbers of patients to regular health care maintenance. Conversely, we do not believe that more frequent than annual physician visits are necessary. As discussed previously, some studies have shown that oral contraceptive use in younger women may be associated with increased risks of breast and cervical cancers.7,8,9,10 As yet, however, no study has justified more frequent examinations as an effective countermeasure. To justify the argument for continued yearly examinations, it is important to update the interval medical history and to test and record weight and blood pressure. It always is wise to take the time to counsel the patient about smoking and alcohol abuse as well as bad eating and exercise habits. Risk factors for heart disease, some of which can be lowered, have been clearly identified.16 Lowering serum cholesterol levels may lead to a decrease in the incidence of coronary heart disease.17 Ancillary personnel may be of great help in office counseling routines.
The first mammogram usually falls within the reproductive age group, and the current recommendation is for a baseline examination at about 35 years of age followed by yearly examinations after 40 years of age. Alternatively, these may be recommended every 1 to 2 years after 40 years of age, with yearly examinations commencing after 50 years of age. A positive family history may mandate a more conservative protocol. Usually, however, we begin annual mammograms after 50 years of age.
As women age, the frequency of all neoplastic diseases increases. In 1997, there were an estimated 596,600 new cases of cancer (excluding basal and squamous cell skin cancers and in situ carcinomas, except bladder) and 265,900 cancer-related deaths in American women.18 The goals of screening are to reduce morbidity and mortality, but reduction of risk factors, when possible, also is important. Smoking is associated with 79% of all cases of lung cancer in women.19
The controversies regarding yearly Pap smears have already been mentioned. There were an estimated 65,000 new cases of carcinoma in situ of the cervix in 1995, and 4800 women are expected to die of cervical cancer in 1997.18,20 The 5-year survival rate of women with carcinoma in situ is virtually 100%.19 Most studies conclude that screening every 3 to 5 years affords adequate protection, whereas annual or biannual Pap tests improve detection effectiveness by only 5%.21,22 Frequent screening, then, represents a net cost to society.22 The current recommendation of the American Cancer Society is for an annual Pap test and pelvic examination for all women who are sexually active or at least 18 years of age. After three consecutive negative Pap smears, frequency of repeat cytologic screening is at the discretion of the physician.19
Mandatory Laboratory Testing.
Yearly Pap tests and stool testing for occult blood are indicated. Cholesterol level should be taken every 5 years. CBC and blood chemistry profile are not recommended as cost-effective routine screening tests for asymptomatic patients in this age group.23 Routine urinalysis also is of questionable benefit.24 Annual urine dipstick tests that can detect glucose and leukocytes may be of value after 40 years of age.24 The first mammogram should be performed at 35 years of age. Follow-up mammograms should be given yearly or biannually after 40 years of age. STD screening is dependent on the patient's lifestyle.
The chief health concerns of women who are approaching menopause are not significantly different from those of the preceding 20 to 30 years. The climacteric, however, often involves insidious changes that may be confusing and frightening as well as discomforting to the patient. It is thus a period in a woman's life that makes increasing demands of time and takes sympathetic understanding on the part of the physician. The consequential nature of her infirmities, as well as the increase in cancer risks as she gets older, makes the perimenopausal patient especially demanding of the gynecologist's time. If her concerns are met with patience and a genuine involvement, then the trust won during this time serves the doctor-patient relationship well in those subsequent menopausal years that constitute an even greater challenge.
Careful counseling regarding the inevitability of loss of ovarian function, as well as plan for routine care during the last half of her expected lifespan, is mandatory at this time. This also is a time when patients often select themselves into specific groups according to how they are able to deal with middle and old age as well as how much time and money they are willing to spend on their health care. In this regard, certain patients may try the physician's resolve by demanding tests that may not yield worthwhile information or demanding that a valuable test be repeated at greater-than-recommended intervals. There is no question that tailor-made medical care becomes much more of a reality in this period than at almost any other time in a woman's life.
Cancer screening does become much more important at this time and the addition of the digital rectal examination at about 40 years of age and testing for the presence of blood in the stools underscores this concern. The perimenopause also is the time to initiate counseling on the issues of osteoporosis, heart disease, and hormone replacement therapy. This can be done in a more unfocused and generalized manner than in the menopausal years and may result in a trusting relationship that will reward both physician and patient later. Employment of ancillary personnel for these tasks may conserve time and establish a broader base of support in the mind of the patient.
During the perimenopause, however, another significant change in the relationship between gynecologist and patient must inevitably take place; this involves the readiness on the part of the physician to surrender more and more areas of the patient's medical concerns to specialists in other fields. The reluctance to change the primary caregiver that characterizes the evolution of the female from a pediatric to a gynecology patient must not be repeated now when she may need to be placed in the hands of the internist or gerontologist. Simple screening for blood chemistries, thyroid function, or glucose metabolism may continue in the gynecologist's office, but abnormalities should be dealt with immediately and with whatever outside help is needed. Some of these problems may be mitigated through the evolution of gynecologists into more primary care types, with concurrent broadening of the scope of their practices.
Mandatory Laboratory Testing.
An annual Pap test, a mammogram annually or every 2 years, and lipid screening every 3 to 5 years are indicated. Stool sample for occult blood should be taken at each visit. It is generally agreed that mass screening of perimenopausal women with bone densitometries is unjustified. Thus, a baseline bone densitometry examination before the onset of menopause may be mandated only in specific cases. Thyroidstimulating hormone baseline levels should be obtained sometime in the mid-forties.
The ideal menopausal patient is one who has been prepared for the changes secondary to loss of ovarian function by proper counseling and appropriate perimenopausal care. Such women enter menopause with a maximum of trust and confidence in the future. The patient must be made to understand that she is not merely “going through” the menopause, but rather, once having entered it, will be menopausal and in need of routine gynecologic follow-up for the rest of her life.
Dealing with patients in this age category is complicated by endless debate within the medical community, not only over proper modes of care but also over the necessity for universal care. Because this debate is avidly reported in the media, it is not unusual for patients to be confused about the risks compared with the benefits of hormone therapy and to have this confusion evolve into fears and reservations about therapy. It also is not unusual for physicians, increasingly burdened by these insecurities in their patients, to acquiesce readily when patients voluntarily withdraw from further therapy. Sadly, a much less than ideal percentage of American women, estimated at never more than 50%, enter into menopausal hormone replacement regimens, and half of these drop out before any meaningful amount of time.
It is not within the scope of this chapter to enter into the debate about whether all patients who lack contraindications should be started on hormone replacement. Growing concerns about the daunting nature of the task—the fiscal challenges as well as the traditional battles over compliance—have led many clinicians to conclude that universal therapy is not a proper goal and that it is preferable to identify those patients at highest risk for the more serious consequences of menopause and target them for therapy. This argument probably will not resolve until additional information on the long-term value of hormone replacement in areas other than lipid metabolism and osteoporosis is established. It is expected that large ongoing studies, such as the Women's Health Initiative and HERS, may provide this data (Women's Health Initiative: National Institute of Health Women's Health Initiative, NIH-WH-93-30-W; HERS: Heart and Estrogen/Progestin Replacement Study, Wyeth-Ayerst Protocol No. 713B-401-U.S. IND No. 21,696).
Although there are some differences between the follow-up of patients taking hormones and those not doing so, it is important to understand that a rational and routine protocol for following all menopausal patients must be established and maintained. Yearly visits are a necessity, and an increasing awareness of general medical problems is mandated. Counseling on diet and exercise programs should increase, and mammograms become an annual routine examination. Goals of care at this point are to promote and prolong optimal physical and mental function. To this end, a thorough update on interval medical history as well as increases in counseling time is mandatory. As the patient ages, special attention should be paid to exercise programs and injury prevention. If the time or facilities are not available in the gynecologist's office, patients may be referred to menopausal or geriatric programs that offer education, activities, and support.
Other areas of controversy for the gynecologist in the time of menopause may include differences about what tests should be included in routine follow-up. Before initiation of hormone replacement therapy, we do not recommend an office baseline endometrial biopsy, nor do we carry out interval biopsies on a routine basis. Instead, these interventions should be reserved for clear indications of suspicious bleeding. An arbitrary age at which the Pap test should be discontinued also has been debated. Twenty-four percent of new cases and 40% of deaths from cervical cancer occur in women older than 64 years of age.25 One study showed that three fourths of women older than 65 years of age had been screened inadequately and one fourth not at all.26 These authors recommend continued screening of the elderly until more data are at hand. Medicare now pays for Pap tests done at 3-year intervals.27
Routine bone densitometry has been recommended increasingly in recent years. The costs of such a test may be prohibitive, even though it can be argued that the expenditures are rewarded with savings in fracture prevention. It must also be remembered that judgment purely on the basis of risk factors has poor predictive value for future fractures.28 A great deal of broad-based study is necessary before universal radiographic bone screening can be recommended.
Additional investigation also is called for in the area of heart and vascular disease in women. The idea that cardiovascular problems are somehow only male problems is exposed as a myth when one understands that heart disease kills more women than men annually and is by far the overall leading cause of mortality in women. A great deal of research is being done on the effects of estrogen replacement alone or estrogen and progestin therapy on cardiovascular diseases in the menopausal population. That estrogen appears to have beneficial effects on the heart has already been shown.29
Reserve also must be maintained in the face of calls for routine pelvic ultrasonography, particularly the newer color Doppler studies, to screen for ovarian cancers. This may have limited value in conjunction with physical findings on pelvic examination and elevated levels of serum tumor markers. In the absence of more supportive data, such studies still must be considered less than cost-effective.
Finally, in this age group, women worry more about neoplastic diseases. Lung cancer has exceeded breast cancer as the leading cause of death in women, with 66,000 deaths estimated in 1997.18 The overall 5-year survival rate for lung cancer is 13%, and no screening method adequately reduces mortality.19,30,31,32 Breast cancer incidence peaks after menopause, when 90% of cases occur.33 One in eight women contract breast cancer, and about half of these women have no identifiable risk factors beyond being female and aging.34 Survival still depends on the stage of the disease at the time of diagnosis. Mammography is the only reliable screening technique and may result in decreased mortality.33 The costs of mammography, however, can be a deterrent for large segments of the population. The case for self-examination of the breasts is strongly promulgated in the United States, although the Canadian Task Force on Periodic Health Examination has questioned self-examination when its overall effects on survival are weighted against the anxiety caused by false-positive findings in healthy women.35,36
Colon cancer incidence rates are declining in women; mortality has fallen 29% for women during the past 30 years.19 In 1997, there were an estimated 48,600 new cases of colon cancer among women and 24,000 deaths.18 The age-adjusted incidence per 100,000 for 1985 to 1989 was 42.3 for women, and 90% of cases occur in patients older than 50 years of age.37 The American Cancer Society recommends digital rectal examinations annually beginning at 40 years of age and testing stool for occult blood at 50 years of age.19 Given the relative inexpensiveness of a digital rectal examination, it can be recommended yearly beginning at 40 years of age; a digital rectal examination test kit may be purchased over the counter and is easily administered by the patient herself. Proctosigmoidoscopy is recommended beginning at about 50 years of age and every 3 to 5 years thereafter.
In 1997, it is estimated that there were 26,800 new cases of ovarian cancer and 14,200 deaths from this disease.18 Ovarian cancer is a frightening entity for which early detection would have enormous beneficial consequences. The 5-year survival rate for adequately treated stage I disease is greater than 90%, whereas the rate for stage III is 15% to 20% and for stage IV, less than 5%.38 A test with 80% sensitivity would reduce mortality by 50%, leading to 5000 more 5-year survivors annually.39 Unfortunately, no such test is available at this time.40 Serum CA-125 levels are elevated in 80% of ovarian cancer patients, with the levels dependent on the stage of the disease.41 Lower levels may have good negative predictive value.42 The combined use of transvaginal ultrasonography and CA-125 for ovarian cancer detection is limited by their relatively poor sensitivity and specificity. The addition of color Doppler imaging has not yet been established to improve overall efficacy of the ultrasound screening.38 To date, these tests are best considered adjuncts to the pelvic examination and clinical impression in the suspicion of ovarian cancer. Table 1 shows the epidemiologic features of some important cancers in women.
* New overall incidence rates for in situ and invasive carcinoma of the cervix were not available at the time of publication. Cervical carcinoma is now more common than invasive cancer. The incidence of invasive cancer has decreased steadily over the years.19
† Includes all other genital cancers.
Mandatory Laboratory Testing.
A Pap test, examination for occult blood in stools, and a mammogram should be given annually. Thyroid function screening (for thyroid-stimulating hormone levels) may be repeated in the mid-50s and done biannually after 60 years of age.43 Cholesterol levels should be taken at 3- to 5-year intervals after 50 years of age, and a CBC should be done at 5-year intervals. Bone densitometry studies may be recommended at periodic intervals, especially if the efficacy of therapy needs closer scrutiny. Ovarian tumor markers, such as CA-125, may be measured annually, particularly in instances of cancer in primary relatives. These are of some value in conjunction with physical and ultrasonagraphic findings. In general, patients tend to see their internist, gerontologist, or family physician with increased regularity as they get older, and provision must be taken to coordinate care and avoid repetition of tests. The internist may be prone to order many of the above-mentioned tests annually, which is more frequently than is recommended. Table 2 presents a synopsis of scheduled care of female patients.
*Basic examination includes a thorough history update, weight, blood pressure, pelvic examination,and breast and abdominal examinations.
TSH, Thyroid stimulating hormone.
Generating a protocol for providing routine health care throughout the life cycle of the female patient is an important consideration because obstetrician-gynecologists probably provide the most care and counseling for women during the greater part of their adult lives. We are constrained not only by the problems engendered in developing a consensus within the medical community but also by forces outside of our immediate control, such as financial, social, and political factors that may attend and influence our decisions. All of these considerations will undoubtedly provide serious challenges in the coming years. Nevertheless, a significant portion of our experience will remain within the traditional framework of the physician-patient relationship that has characterized the practice of medicine in the United States. Therefore, the decisions we make in our practices will continue to have a significant bearing on every level of health care, from the status of the solitary patient to the overall costs to society for the care of all patients. Considering this, we must practice with an eye on the practical as well as on the ideal. Mindful of some of the harm generated by the “feminine forever” philosophy that impacted the area of menopausal estrogen replacement in the past, it is important that we do not oversell the value of some of the routine screening that we recommend. Ultimately, all patients succumb to one disease or another. No amount of densitometry screening can eliminate osteoporotic fractures, and no amount of mammography screening cuts into the incidence of breast cancer. A mutually trusting and honest relationship between patient and physician should ease the journey toward our goal of providing the most beneficial care, in the most feasible manner, to the greatest number of people.
17. Lipid Research Clinics Program: The lipid research clinics coronary primary prevention trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 251:364, 1984
28. Kleerekoper M, Peterson E, Nelson D et al: Identification of women at risk for developing postmenopausal osteoporosis with vertebral fractures: Role of history and single photon absorptiometry. Bone Miner 7: 171, 1989
34. Harris J, Morrow M, Norton L: Malignant tumors of the breast. In DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Oncology, ed 5, pp 1557–1562. Philadelphia, Lippincott-Raven, 1997
37. Cohen AM, Minsky BD, Schilsky RL: Cancer of the colon. In DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Oncology, 5th ed, pp 1144–1153. Philadelphia, Lippincott-Raven, 1997
38. Ozols RF, Schwartz PE, Eifel PJ: Ovarian cancer, fallopian tube carcinoma, and peritoneal carcinoma. In DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Oncology, 5th ed, pp 1502–1511. Philadelphia, Lippincott-Raven, 1997