What components and screenings should be included in a well woman examination?

Components of a Well-Woman Examination

A comprehensive well-woman examination should include targeted screening and assessment based on age, risk factors, and symptoms rather than routine pelvic examinations for all asymptomatic women. 1

Medical History Components

• Comprehensive health history:

  • Past medical and gynecologic history
  • Family history (as a risk assessment tool)
  • Medication review
  • Allergies
  • Reproductive life plan for women of childbearing age 2, 3

• Psychosocial assessment:

  • Screen for depression, anxiety, domestic violence, and major psychosocial stressors 4
  • Substance use assessment (tobacco, alcohol, drugs) using validated tools like CAGE or T-ACE questionnaires 4

Physical Examination Components

• Vital signs: Blood pressure, weight, height, BMI calculation

• General physical examination:

  • Thyroid examination
  • Heart examination
  • Breast examination (as part of a cancer-related checkup) 4
  • Skin examination for cancer-related changes 4

• Gynecologic examination:

  • External genitalia examination (assess for inflammation, pigmentation changes, lesions) 1
  • Pelvic examination should be performed only when clinically indicated, not routinely in asymptomatic women 4, 1
  • Cervical cancer screening according to age-appropriate guidelines (does not require bimanual examination) 1

Laboratory Testing

• Targeted laboratory testing based on age and risk factors:
  • Complete blood count when indicated
  • Urinalysis when indicated
  • Blood type and screen when indicated
  • Cervical cytology according to age-appropriate guidelines 4
  • STI screening (can be performed using urine samples or self-collected vaginal swabs without speculum examination) 1
  • Thyroid-stimulating hormone levels when indicated 4

Cancer Screening

• Cervical cancer: Starting at age 21, not at onset of sexual activity 1
• Breast cancer: Clinical breast examination as part of cancer-related checkup 4
• Colorectal cancer: Starting at age 50 per general population guidelines 4
• Endometrial cancer: Education about symptoms at menopause 4
• Lung cancer: Screening discussion for current/former smokers with appropriate history 4

Immunizations

• Age-appropriate vaccinations:
  • HPV, Tdap, and influenza vaccines as needed 4

Special Considerations

Bimanual Examination

The American College of Physicians strongly recommends against performing screening pelvic examinations in asymptomatic, nonpregnant adult women 4, 1. Bimanual examination should be performed only when specific clinical indications are present:

• Persistent vaginal discharge
• Lower abdominal or pelvic pain
• Abnormal vaginal bleeding
• Dysmenorrhea unresponsive to NSAIDs
• Amenorrhea
• Pregnancy evaluation
• Before IUD placement
• Symptoms of pelvic inflammatory disease
• Evaluation of suspected adnexal masses 1

Potential Harms of Routine Pelvic Examination

• Approximately 30% of women report pain, discomfort, fear, anxiety, or embarrassment during pelvic examinations 4, 1
• Can lead to false positives resulting in unnecessary surgery in approximately 1.5% of women screened 1
• No studies have demonstrated that routine bimanual examinations reduce mortality or morbidity from any condition in asymptomatic women 1, 5

Patient Comfort Techniques

• Explain procedure in detail before starting
• Allow patient to empty bladder
• Offer presence of a companion if preferred
• Ensure patient that nothing will be done without informing her first
• Use relaxation techniques before inserting speculum
• Allow patient to have control over the procedure 1

Preventive Counseling

• Reproductive health counseling:

  • Contraception options (no pelvic exam required before prescribing most hormonal contraceptives) 1
  • Preconception care when appropriate 4
  • STI prevention 4

• Health promotion counseling:

  • Nutrition assessment and counseling 4
  • Physical activity recommendations
  • Tobacco cessation
  • Alcohol and substance use counseling 4

Follow-Up Planning

• Schedule follow-up visits according to individual risk factors 4
• For women planning pregnancy, consider preconception care visits 4
• For women not planning pregnancy, continue well-woman examinations with updated reproductive life planning 2, 3

The well-woman examination provides an excellent opportunity for preventive care across a woman's lifespan, but components should be tailored based on age, risk factors, and current evidence-based guidelines rather than routine performance of all examination elements for every woman.