What are the clinical practice guidelines for a well woman exam?

From the Guidelines

Clinical practice guidelines for a well woman exam recommend annual visits for women aged 21 and older, with more frequent visits as needed based on individual risk factors. The exam typically includes a comprehensive health history, physical examination, vital signs measurement, and age-appropriate screenings. For women of reproductive age, this includes a pelvic examination, Pap smear (recommended every 3 years for ages 21-29 and every 5 years with HPV co-testing for ages 30-65) 1, breast examination, and STI screening as indicated. Preventive services should include blood pressure screening, BMI calculation, depression screening using tools like PHQ-2/PHQ-9, and immunization updates including HPV vaccination for eligible patients. Laboratory tests often include lipid screening every 5 years starting at age 45, diabetes screening for women with risk factors, and thyroid function tests when indicated. The visit should also address contraception needs, preconception counseling if desired, and lifestyle counseling regarding nutrition, exercise, smoking cessation, and alcohol use.

Some key points to consider:

• The American College of Physicians recommends against routine pelvic examination in asymptomatic, average-risk adult women 1.
• The American Cancer Society recommends annual mammography starting at age 40 and clinical breast examination every 3 years for women in their 20s and 30s, and annually for women 40 and older 1.
• Cervical cancer screening should begin approximately three years after a woman begins having vaginal intercourse but no later than 21 years of age, with screening every year with conventional Pap tests or every two years using liquid-based Pap tests 1.
• Women 70 years of age and older who have had three or more normal Pap tests and no abnormal Pap tests in the last 10 years and women who have had a total hysterectomy may choose to stop cervical cancer screening 1.

These comprehensive assessments allow for early detection of health issues and provide opportunities for preventive interventions, ultimately improving women's overall health outcomes through regular monitoring and timely interventions.

From the Research

Clinical Practice Guidelines for Well Woman Exam

The clinical practice guidelines for a well woman exam are as follows:

• The primary objective of a well woman exam is to clarify the indications for pelvic examination, including visual inspection, speculum examination, bimanual examination, single digit examination, and/or rectovaginal examination depending on the indication for examination 2.
• Pelvic examination may be performed for asymptomatic women as a screening tool for gynecologic cancer, infection, and asymptomatic pelvic inflammatory disease, but the evidence to support this practice is limited 3.
• Cervical cytology screening reduces both the incidence of, and mortality from, cervical cancer by detecting pre-invasive, treatable lesions, and should be performed in accordance with provincial/territorial guidelines 2.
• There is insufficient evidence to guide recommendations on screening pelvic examination for noncervical gynecologic malignancy or any benign gynecologic disease in healthy, asymptomatic women with average risk of malignancy 2, 3.
• Women with current or a history of cervical dysplasia, gynecologic malignancy, or in utero diethylstilbestrol exposure should be screened and managed according to guidelines specific to those gynecologic conditions 3.
• The decision to perform a pelvic examination should be a shared decision between the patient and her obstetrician-gynecologist or other gynecologic care provider, taking into account the potential benefits and harms of the examination 3.

Screening Intervals

• Screening intervals for cervical cancer screening have changed over the past half century, and current recommendations are to screen every 2-3 years in women 21-29, and every 3 years in women 30 and over, assuming no prior history of cervical dysplasia 4.
• Women who have undergone hysterectomy no longer need screening unless high-grade dysplasia was present 4.
• The frequency of pelvic examination in healthy asymptomatic women is not well established, and further study is needed to determine the optimal screening interval 4.

Special Populations

• Women who are immunosuppressed, including those with solid organ transplants, hematopoietic stem cell transplants, and certain autoimmune diseases, may be at increased risk of cervical neoplasia and cancer, and should be screened according to guidelines for HIV-infected women 5.
• Women with inflammatory bowel disease who are being treated with immunosuppressive drugs are at greater risk of cervical neoplasia and cancer than the general population, and should be screened according to guidelines for HIV-infected women 5.
• Women with systemic lupus erythematosus, whether on immunosuppressant therapy or not, and those with rheumatoid arthritis on immunosuppressant therapy, have a greater risk of cervical neoplasia and cancer than the general population, and should be screened according to guidelines for HIV-infected women 5.