What are the best practices for gynecological care in women 50 and older?

Best Practices for Gynecological Care in Women 50 and Older

For women aged 50 and older, gynecological care should include cervical cancer screening until age 65 with cytology every 3 years or co-testing (cytology plus HPV testing) every 5 years, annual breast cancer screening with mammography, and discontinuation of routine pelvic examinations unless medically indicated by symptoms or history.

Cervical Cancer Screening

Recommendations for Average-Risk Women

• Ages 50-65:
  • Preferred approach: Co-testing with HPV and cytology every 5 years 1
  • Acceptable alternative: Cytology alone every 3 years 1
  • Annual screening is NOT recommended for any age group 1

When to Stop Screening

• At age 65: Discontinue screening if:
  • Woman has had 3 consecutive negative cytology results or 2 consecutive negative co-test results within the previous 10 years 1
  • Most recent test was performed within the last 5 years 1

Special Considerations

• After hysterectomy:

  • No cervical screening needed if cervix was removed for benign reasons 1
  • Continue screening if history of CIN2/3 or cervical cancer until three consecutive negative tests 1
  • Women with subtotal hysterectomy (cervix intact) should continue screening per guidelines 1

• High-risk women should continue annual screening regardless of age:

  • History of cervical cancer
  • In-utero DES exposure
  • Immunocompromised status (HIV, organ transplant, long-term steroid use) 1

Breast Cancer Screening

• Annual mammography beginning at age 40 and continuing without an upper age limit as long as the woman is in good health 1
• Clinical breast examination (CBE) should be performed annually 1
• Breast self-examination (BSE) is optional but women should be informed about benefits and limitations 1

Colorectal Cancer Screening

For women aged 50 and older, one of the following options:

• Annual fecal occult blood test (FOBT) or fecal immunochemical test (FIT) 1
• Flexible sigmoidoscopy every 5 years 1
• Colonoscopy every 10 years 1
• CT colonography every 5 years 1

Pelvic Examination

• The USPSTF found insufficient evidence to recommend for or against routine pelvic examinations in asymptomatic women 1
• ACOG recommends pelvic examinations be performed when indicated by medical history or symptoms, not as a routine screening procedure 2
• The decision to perform a pelvic examination should be shared between patient and provider 2

Bone Health

• Bone density testing should be considered for:
  • All women aged 65 and older
  • Postmenopausal women younger than 65 with risk factors for osteoporosis 1

Endometrial Cancer Screening

• No routine screening recommended for average-risk women
• At menopause, women should be informed about risks and symptoms of endometrial cancer and encouraged to report any unexpected bleeding or spotting 1

Common Pitfalls to Avoid

1. Over-screening: Annual cervical cytology is no longer recommended for any age group and may lead to unnecessary procedures 1

2. Under-screening: Some providers discontinue screening too early or fail to screen women who have never been screened 3

3. Inappropriate discontinuation: Continuing to screen women after age 65 who meet criteria for discontinuation, or stopping screening in women who don't meet criteria 1

4. Post-hysterectomy confusion: Failing to determine if the cervix was removed or if the hysterectomy was performed for benign reasons before discontinuing screening 1

5. Neglecting gynecologic assessment: Even when cervical screening is discontinued, gynecologic symptom assessment should remain part of annual health examinations 3

By following these evidence-based guidelines, providers can deliver high-quality gynecological care to women over 50 while avoiding unnecessary procedures and optimizing cancer detection.