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Preventing Common Health Risks in Women
US Pharm. 2005; 9:54-58 (September 2005)
by Jake Mossman, BSPh, RPh, President and Pharmacist-in-Charge
Taos Pharmacy and Total Health and Wellness Center, Taos, NM

Behavioral and lifestyle changes can help present heart disease, stroke, and cancer—the major causes of female mortality in the United States.

As incidence of heart disease, stroke, and lung disease continues to rise each year among American women, increased awareness of these diseases becomes necessary. Pharmacists can have an important role in raising awareness and encouraging healthy behaviors for the prevention, early detection, and monitoring of these significant causes of female death.

Hormone Replacement Therapy
The Women's Health Initiative (WHI) was a major 15-year research program that addressed cardiovascular disease, cancer, and osteoporosis—the most common causes of death, disability, and poor quality of life in postmenopausal women. Launched in 1991, the WHI consisted of a clinical trials and an observational study involving 161,808 generally healthy postmenopausal women. Clinical trials were designed to test the effects of postmenopausal hormone therapy, diet modification, and calcium and vitamin D supplements on the risk of heart disease, fractures, and breast and colorectal cancer (TABLE 1).

Based on the WHI findings on hormone replacement therapy (HRT), it is recommended that women follow the FDA's advice, which states that hormone therapy should not be taken to prevent heart disease. HRT products are approved for relief of moderate to severe hot flashes and symptoms of vulvar and vaginal atrophy. Although HRT is effective for the prevention of postmenopausal osteoporosis, it should be considered only in women who are at significant risk of osteoporosis who cannot take nonestrogen medications. The FDA recommends that HRT be used at the lowest doses for the shortest duration needed to achieve treatment goals. Postmenopausal women who use or are considering using HRT should discuss the possible benefits and risks with their physicians.³

Heart Disease and Stroke
Heart disease and stroke are the first- and third-leading causes of death for both men and women in the U.S.³ Over 927,000 Americans die of cardiovascular disease each year—at a rate of one death every 34 seconds.³ Although it is more common among people age 65 years or older, the number of sudden deaths from heart disease among people ages 15 to 34 has increased in recent years. Over one fourth of the American population (more than 70 million people) has a cardiovascular disease.³ Coronary heart disease (CHD) is a leading cause of premature, permanent disability in the U.S. workforce. Stroke alone accounts for disability among more than one million Americans. Over six million hospitalizations each year are due to cardiovascular disease.³

Two major, independent risk factors for cardiovascular disease are high blood pressure and high blood cholesterol levels. In 2000, nearly 30% of U.S. adults had high blood pressure and another 31% had prehypertension.⁴ In addition, more than 80% of people with an elevated high blood cholesterol level do not have it under control.⁴

A study by the American Heart Association reported that less than half (46%) of American women surveyed knew that heart disease was the leading cause of death in women.⁵ Women also tend not to consider heart disease a serious threat; only 13% of females regard heart disease as their greatest health risk. In addition, women often fail to associate major risk factors such as high blood pressure and high blood cholesterol levels with the risk of heart disease. Only 40% of all women and 27% of women between ages 25 and 34 years reported feeling well informed about heart disease. Increased awareness is an important first step to reducing the risk of heart disease in women.⁵

Stroke is the third-leading cause of death in American women and kills more than twice as many women as breast cancer.⁶ In the U.S., females account for more than three out of every five stroke-related deaths. Although stroke is most common in elderly individuals, more than 100,000 women under the age of 65 suffer a stroke each year.⁶ Women who are overweight, smoke, and have high blood pressure and high blood cholesterol levels are at higher risk for stroke. Other risk factors specific to women include migraine headaches preceded by vision loss, use of birth control pills, HRT use, autoimmune disease, and blood-clotting disorders.⁶

Preventing Heart Disease and Stroke
Pharmacists can contribute to the primary prevention of heart disease and stroke in women by promoting heart-healthy behaviors. For high blood pressure, these behaviors include increasing the level of aerobic physical activity, maintaining a healthy weight, limiting the consumption of alcohol to moderate levels, reducing salt and sodium intake, and following a reduced-fat diet high in fruits, vegetables, and low-fat dairy products. These measures can also lower blood cholesterol levels. Research has shown that a wide range of physical activity is beneficial to health and that all individuals can benefit from physical activity. Nonvigorous physical activity can also produce health benefits.⁷ Despite this, women are less likely to be physically active than men; more than 60% of women do not get the recommended 30 minutes per day of moderately intense exercise and more than 25% of women do not participate in any leisurely physical activity.⁸

Pharmacists can also prevent disease by monitoring patients' blood pressure. Taking blood pressure readings takes only a couple of minutes and allows the pharmacist an opportunity to describe the dangers of elevated blood pressure. Treatment goals should also be measured and shared with the primary care provider. Pharmacists should become familiar with the latest blood pressure guidelines recommended by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (TABLE 2).

Cholesterol-monitoring services have had a positive effect upon cholesterol management. The American Pharmacists Association Foundation's demonstration project, Project ImPACT: Hyperlipidemia, demonstrated that pharmacists who work with patients and physicians can provide an advanced level of care to successfully manage dyslipidemia.⁹ The project involved 26 community pharmacies in independent, chain-grocery, chain-professional, home/health infusion, clinic, and health maintenance organization/managed care settings in 12 states. In 397 patients, pharmacists were able to identify a 93.6% persistence rate and a 90.1% compliance rate with hyperlipidemia medication therapy. In addition, 62.5% of patients reached their therapeutic goals by the end of the 24-month program.⁹ These results were significant improvements over those in other studies.⁹ Combined with patient education, accurately monitoring patients' lipid levels resulted in significantly higher patient compliance with medication therapy and achievement of treatment goals. Pharmacists should consider participating in these practices to increase awareness and reduce the risk of heart disease in women.

Pharmacists should be familiar with the most recent lipid level recommendations by the National Cholesterol Education Program's Expert Panel on Detection, Evaluation, and Treatment of High Cholesterol in Adults (TABLE 3). Research indicates that elevated low-density lipoprotein (LDL) cholesterol is a major cause of CHD. In addition, recent clinical trials show that LDL-lowering therapy reduces risk for CHD.⁹ Elevated LDL cholesterol is a primary target of cholesterol-lowering therapy. As a result, the primary goals of therapy and the time frame for initiating treatment are stated in terms of LDL levels.

Cancer
Cancer is the second-leading cause of death in women in the U.S. As stated earlier, although lung cancer is the leading cause of cancer-related death in women and causes more than three times as many deaths, women fear breast cancer most. Breast cancer also takes a serious toll on the health of American women; an estimated two million women in the U.S. have either survived breast cancer or are currently living with the disease.¹⁰ Colorectal cancer is the third-leading cause of cancer-related death in women and accounts for about 2% of all deaths in American women.¹⁰

About 50% to 75% of cancer-related deaths in the U.S. are caused by behaviors such as smoking, physical inactivity, and poor dietary choices. Exposure to certain environmental chemicals is the second-highest risk factor for cancer. Secondhand smoke, radon in the home, and benzene in the air are all known to cause cancer. Smoking causes about 30% of all cancer-related deaths in the U.S. Approximately 23 million women and 30% of high school-age females were smokers in 2001, and about 80% of women started smoking before the age of 18.⁷ Since smoking and exposure to cigarette smoke are significant risk factors, avoiding tobacco use is an important step individuals can take to reduce their risk for cancer.¹¹

Breast cancer, the most frequently diagnosed nonskin malignancy in U.S. women, is the second-leading cause of cancer-related deaths. Breast cancer kills approximately 40,000 women each year and is women's greatest health fear, according to a recent poll conducted by the Society for Women's Health Research.¹¹ Factors associated with an increased incidence of breast cancer include HRT, exposure to ionizing radiation, obesity, alcohol use, and genetics. Studies have shown that combination HRT containing estrogen and progestin can result in a 24% increased incidence of invasive breast cancer.¹¹ Evidence of an association between estrogen-only therapy and breast cancer is mixed and inconclusive. Combination HRT should be avoided in women with a family history of breast cancer or in women with other associated risk factors. Exposure of the breast to ionizing radiation is associated with an increased risk of breast cancer, especially when the exposure occurs at a young age.¹¹

Factors associated with a decreased incidence of breast cancer include exercise, prophylactic bilateral mastectomy, and the use of selective estrogen receptor modulators. Tamoxifen can reduce the incidence of breast cancer in high-risk premenopausal and postmenopausal women.¹¹ However, tamoxifen treatment may increase the risk of endometrial cancer, thrombotic vascular events (e.g., pulmonary embolism, stroke, deep venous thrombosis), and cataracts.¹¹ There is fair evidence that raloxifene may reduce the risk of breast cancer.¹¹ Raloxifene appears to increase venous pulmonary embolism and deep venous thrombosis, but not endometrial cancer.

In women with an increased risk of breast cancer due to family history of the disease, bilateral prophylactic mastectomy can reduce the risk of breast cancer by as much as 90%.¹¹ Bilateral prophylactic mastectomy is an extreme measure with major physical and psychological effects. The procedure must be carefully considered on an individual basis in combination with risk assessment and counseling. Exercise may also decrease hormone levels and contribute to a decreased risk of breast cancer, especially in young women.¹⁰

Studies examining a link between diet and breast cancer have focused on dietary fat for several reasons. Pollutants and hormones that may trigger breast cancer are stored in animal fat. Body fat also triggers the production of estrogen, which may contribute to breast cancer. Fats and other high-calorie foods trigger the release of growth factors that may contribute to the risk of abnormal cell growth. Recently, large studies from Cambridge University (13,000 women) and Harvard University (100,000 women) found a significant link between animal (saturated) fat and increased risk for breast cancer. These two prospective studies suggest that the amount of animal fat consumed should be limited.¹²

Colorectal cancer is the third-leading cancer in both men and women in the U.S.¹² Colorectal cancer develops slowly over a number of years and usually begins as a noncancerous polyp that may become cancer. More than 95% of colon cancers are adenocarcinomas, which evolve from glandular tissue.¹² Risk factors for colorectal cancer include family and personal history of colorectal cancer, polyps, inflammatory bowel disease, age, sedentary lifestyle, weight, high-fat diets, smoking, and alcohol use. The American Cancer Society recommends a diet that includes five or more servings per day of fruits and vegetables, whole grains, and limited amounts of red meat, especially high fat and processed meats. Maintaining a healthy weight, adopting an active lifestyle, and limiting alcohol consumption are also recommended to prevent colorectal cancer.

Cancer Prevention
Since smoking contributes to an increased risk of cancer, pharmacists can improve women's health by providing smoking cessation products, information, and counseling. In New Mexico, pharmacists can become certified to provide smoking cessation counseling and prescribe smoking cessation medications. Smoking cessation programs can help reduce the number of women smokers. Other cancer-preventing behaviors include avoiding excess alcohol, eating five or more daily servings of fruits and vegetables, following a low-fat diet, participating in physical activity, maintaining a healthy weight, and avoiding excess exposure to sunlight. Pharmacists can also help increase awareness of the behavioral risk factors for cancer and provide specific dietary and exercise recommendations.

Regular screening mammography, followed by timely treatment when breast cancer is diagnosed, can help reduce the chances of dying from breast cancer. For women between ages 50 and 69 years, there is strong evidence that screening lowers the risk of breast cancer by 30%.¹⁰ For women in their 40s, screening can reduce the risk by about 17%. For women ages 70 and older, mammography may be helpful, although firm evidence is lacking.¹⁰

The American Cancer Society and the U.S. Preventive Services Task Force recommend colorectal cancer screening for men and women ages 50 and older. Individuals who are at higher risk may need more frequent screenings and should begin them at a younger age. It is recommended that people ages 50 and older at average risk for colorectal cancer should obtain one of the following options: a fecal occult blood test (FOBT) or a fecal immunochemical test (FIT) every year, flexible sigmoidoscopy every five years, FOBT or FIT with flexible sigmoidoscopy every five years, double contrast barium enema every five years, or colonoscopy every 10 years. For FOBT or FIT, a take-home multiple-sample test kit should be used. Colorectal cancer warning signs include rectal bleeding, blood in the stool or toilet after a bowel movement, a change in the shape of the stool, cramping pain in the lower abdomen, or a feeling of discomfort or an urge for a bowel movement when there is no need to have one.¹³

Pharmacists can educate women about risk factors and preventive measures for various cancers. Pharmacists should also encourage regular screenings and carry products necessary for various screening procedures. Over-the-counter product consultations offer an opportunity for pharmacists to identify patients who exhibit the signs and symptoms of a variety of cancers. These patients should be referred to their primary care practitioners for examination. Pharmacists can also educate patients about preventive measures such as medication therapy, healthy diet, and exercise to help reduce the risk of cancer.

Conclusion
There is a need to increase awareness in women about their risk of heart disease, stroke, and cancer. Pharmacists can play a key role in women's health by staying informed and passing on their information to their female patients. Studies and polls have shown that the majority of females cannot identify the leading causes of death for women in the U.S. Increasing awareness is a critical first step to reducing the risk of these serious diseases. Pharmacists should also educate women on the signs and symptoms of these diseases and provide screening services for some of these diseases. Routine disease screening may be supported through patient education and consultations regarding the tests themselves and required preparatory measures. Pharmacists can monitor the efficacy of medication therapy and the achievement of therapeutic goals. Disease prevention for women offers pharmacists a number of opportunities to expand their services and grow professionally.

REFERENCES
1. National Vital Statistics Report, Vol. 53, No. 5, Oct. 12, 2004.
2. International Communications Research of Media for the Society for Women's Health Research poll. June 22-29, 2005.
3. National Heart, Lung and Blood Institute. Women's Health Initiative, Questions and Answers About the WHI Postmenopausal Hormone Therapy Trials. April 2004.
4. National Center for Chronic Disease Prevention and Health Promotion. Preventing Heart Disease and Stroke Addressing the Nation's Leading Killers. 2005.
5. American Heart Association. AHA's Women's Survey Summary. 2005.
6. Stroke Connection Magazine. What women need to know about the hidden risk factors for stroke. November/December 2004.
7. National Centers for Chronic Disease Prevention and Health Promotion. Healthy People 2010. 2005.
8. National Heart, Lung and Blood Institute. The Heart Truth. 2002.
9. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in project ImPACT: hyperlipidemia. J Am Pharm Assoc. 2000;40:157-165.
10. National Cancer Institute. Women's Health Report, 2003-2004. March 2005.
11. National Cancer Institute. Cancer Progress Report - 2003 Update.
12. Cho E, et al. High levels of animal fat in diet might increase breast cancer risk. J National Cancer Institute. July 2003.
13. American Cancer Society. Colorectal Cancer Facts & Figures Special Edition. 2005. Atlanta: American Cancer Society; 2005.
14. National Heart, Lung, and Blood Institute. Women's Health Initiative. Findings from the WHI Postmenopausal Hormone Therapy Trials.
15. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Express Report.
16. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Adult Treatment Panel III.

US Pharm., Vol. No: 30:09 Posted: 9/15/2005

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