Key Components of a Well Female Exam Treatment and Plan
The well female exam should include age-appropriate screenings, with cervical cancer screening for women aged 21-65 years with cervical cytology (Pap smear) every 3 years, or for women aged 30-65 years, screening with a combination of cytology and HPV testing every 5 years. 1
Recommended Screenings by Age
For All Women
- History and Physical Examination
- Comprehensive medical history including family history
- Reproductive life plan discussion
- Vital signs including height, weight, BMI, and blood pressure
- Screening for depression, anxiety, domestic violence, and substance use
Ages 13-20
- External genital examination only when clinically indicated
- HPV vaccination according to schedule
- STI screening based on risk factors (can be performed with urine samples or self-collected vaginal swabs)
- No routine internal pelvic examination or Pap testing recommended
Ages 21-29
- Cervical cytology (Pap smear) every 3 years 1
- No HPV co-testing in this age group
- STI screening based on risk factors
- Clinical breast examination is optional (USPSTF has insufficient evidence for recommendation) 1
Ages 30-39
- Cervical cytology every 3 years OR
- Combination of cytology and HPV testing every 5 years 1
- Clinical breast examination optional (ACOG recommends annually, but USPSTF cites insufficient evidence) 1
- STI screening based on risk factors
Ages 40-49
- Cervical cytology every 3 years OR
- Combination of cytology and HPV testing every 5 years 1
- Mammography screening (USPSTF recommends individualized decisions for women <50 years) 1
- Clinical breast examination optional
Ages 50-65
- Cervical cytology every 3 years OR
- Combination of cytology and HPV testing every 5 years 1
- Biennial mammography (USPSTF Grade B recommendation) 1
- Colorectal cancer screening beginning at age 50
- Bone density screening based on risk factors
Ages >65
- Discontinue cervical cancer screening after adequate prior screening with no history of high-grade precancerous lesions
- Continued mammography until age 74 (USPSTF recommendation) 1
- Continued colorectal cancer screening until age 75
Key Components of the Physical Examination
Pelvic Examination
The USPSTF concludes that there is insufficient evidence to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, non-pregnant adult women (I statement) 1. However, this statement does not apply to specific disorders for which the USPSTF already recommends screening (cervical cancer, gonorrhea, and chlamydia).
The pelvic examination should be performed when clinically indicated rather than as routine screening 2. Components may include:
- External genital examination
- Speculum examination (when indicated)
- Bimanual palpation (when indicated)
- Rectovaginal examination (when indicated)
Breast Examination
Clinical breast examination has the potential to detect palpable breast cancer but has insufficient evidence to assess the balance of benefits and harms 1. If performed, it should follow a systematic approach:
- Visual inspection of the breasts
- Palpation of breast tissue in a systematic pattern
- Proper positioning to spread breast tissue evenly over the chest wall
Laboratory Testing
- Cervical cytology (Pap smear) according to age-appropriate guidelines 1
- STI screening (gonorrhea and chlamydia) for sexually active women ≤24 years and older women at increased risk 1
- HIV screening at least once for all women aged 13-64 years, with repeat screening based on risk
- Lipid screening based on age and risk factors
- Diabetes screening based on risk factors
- Thyroid screening when clinically indicated
Counseling and Prevention
- Contraception counseling and provision based on reproductive life plan 1
- STI prevention counseling
- Cancer prevention strategies including smoking cessation
- Immunizations including HPV vaccine for eligible women
- Nutrition and physical activity counseling
- Substance use screening and counseling
Common Pitfalls and Caveats
Overscreening: Performing cervical cancer screening more frequently than recommended or in women <21 years is not beneficial and may lead to unnecessary procedures 1.
Routine pelvic examinations: Performing routine pelvic examinations in asymptomatic women has not been shown to reduce morbidity or mortality and may lead to unnecessary procedures 2. Approximately 1.5% of women screened experience false-positive findings leading to unnecessary surgery 1.
Patient anxiety: About one-third of women report fear, embarrassment, anxiety, pain, or discomfort during pelvic examinations 1, 2. Use trauma-informed approaches, especially for women with history of sexual violence.
Inadequate screening: Despite recommendations, many women do not receive appropriate cervical cancer screening. Strategies should focus on reaching underserved populations 3.
Misunderstanding the components: Many providers perform pelvic examinations when not indicated or as part of prescribing contraception, which is not necessary 1.
The well female exam should be tailored to the individual woman's age, risk factors, and health needs while avoiding unnecessary procedures that do not improve health outcomes. The focus should be on evidence-based screening that reduces morbidity and mortality while minimizing potential harms.