Periodic Woman Screening Sheet

1. Periodic Woman Screening Sheet By Periodic Woman Screening Committee January 2010

2. Page 1 Social and sexual History Occupation ------------ Education ------------- Exercise -------------------------------------------------Smoking No Yes -------- packs/ day Alcohol intake No Yes ---- drinks/ week Post-coital bleeding No Yes Marital status Single married Widow divorced Age at marriage/ First sexual contact ---------- History

3. Page 1 Menstrual History Age at first menarche: ------ Date of LMP:---------------- Duration: --------- regular irregular Menopause: No Yes Duration ----------- Use of HRT No Yes Duration ----------- History

4. Obstetric history: Para ------- Abortion -------- Age at first completed pregnancy --- Breast feeding No Yes Duration -------------- Contraception use Hormonal No Yes Duration ---------

5. Past medical history Date of last Clinical breast examination ------- Normal Abnormal Date of last mammography ---------------- Normal Abnormal No. of Breast biopsies (if done) --------- specify findings ----------------------- Date of last pap smear ----------------------- Normal Abnormal

6. History of breast cancer Yes No History of cervical cancer Yes No History of STI No Yes specify ----------------------------- Family History of first degree relatives with breast cancer No Yes No.-----

7. Physical Examination BP Height (m) Weight (Kg) BMI (Kg/) Neck NormalAbnormal Breast NormalAbnormal Axillary lymphadenopathy Normal Abnormal Abdomen Normal Abnormal Pelvic examination NormalAbnormal Speculum examination Normal Abnormal Other physical examination---------------------------- Comments -------------------------------------------------------------------------------------

8. Investigation requested/ results Pap smear Normal Abnormal HVS Normal Abnormal Mammography Normal Abnormal Others------------------------------------------------------------------------------------------------------------ Treatment ---------------------------------------------------------------------------------------------------------------------- Referral ------------------------------------------------------------------------------------------------------------------------------------------

9. Breast cancer screening guidelines summary Major components of breast screening program at primary health care: • Breast Self –Examination (BSE): to be performed once each month, beginning at age 20 and continue each month throughout a women's life time. • Clinical Breast Examination (CBE): do CBE for women from the age of 20, as a part of her routine check-up every three years, increasing to once a year from the age of 40 and above. • Mammography: To screen all women 40 years or above once every two years.

10. Cervical cancer screening guidelines • Frequency of cervical screening • Periodic women screening should be started three years after the onset of sexual activity or at 21 years of age whichever comes first. • Those women with high risk of cervical cancer should have Pap smear annually.   When to refer to SMC for colposcopy • 2 Consecutive incidence of ASC-U • ASC-H • HSIL • AGC-NOS • Endometrial cells in 40 years or above

11. Thank You