What is the typical level of service for a well woman exam (WWE)?

Level of Service for a Well Woman Exam

The typical level of service for a well woman exam (WWE) is a screening pelvic examination with a Medicare National Payment Amount value of $38.11 for the examination itself and $45.93 for collection of a Pap smear specimen (as of 2013), though many components of the traditional pelvic examination lack evidence supporting their routine use in asymptomatic women. 1

Components of the Well Woman Exam

• The traditional well woman exam includes inspection of external genitalia, speculum examination of the vagina and cervix, bimanual examination, and sometimes rectal or rectovaginal examination 1
• According to the American College of Obstetricians and Gynecologists (ACOG), the well woman visit should include a comprehensive history and preventive services counseling, though they acknowledge their recommendation for routine pelvic examinations is "based on expert opinion" rather than strong evidence 1
• Taking a comprehensive history (including detailed information on symptoms and past medical/gynecologic history) should inform whether certain physical examination components like breast or pelvic examination are indicated at that visit 2

Evidence on Pelvic Examination Components

• There is consensus that cervical cancer screening with Pap smears reduces mortality, but contemporary guidelines specify this should not be done more frequently than every 3 years or for women older than 65 years with prior negative examinations, women younger than 21 years, or women without a cervix 1
• Obtaining a specimen for cervical cytologic evaluation (Pap smear) does not require and is not an indication for bimanual examination 1
• No data support the use of pelvic examination in asymptomatic, average-risk women for conditions other than cervical cancer 1
• The positive predictive value of pelvic examination for detecting ovarian cancer was less than 4% in studies that reported this metric 1

Harms and Costs Associated with Pelvic Examinations

• About one-third of women report fear, embarrassment, anxiety, pain, or discomfort during or before pelvic examinations 1
• Women who reported pain or discomfort were less likely to return for another visit than those who did not 1
• Younger women are more likely than older women to experience pelvic examination-associated embarrassment and pain 1
• Fear of examination may lead women, especially teenagers, to delay or avoid obtaining oral contraceptives 1
• Pelvic examinations can lead to unnecessary surgery in approximately 1.5% of women screened, exposing them to risk for major surgical complications that may be as high as 15% 1
• The estimated total annual cost of preventive gynecologic examinations and associated laboratory and radiologic services in the United States is $2.6 billion 1

Current Practice Patterns

• In 2008,63.4 million pelvic examinations were performed in the United States 1
• Most primary care providers indicated they perform pelvic examinations "as part of a well-woman exam" 1
• In a clinical-vignette survey study of 521 obstetrician-gynecologists, more than 95% indicated they would perform bimanual examination in asymptomatic women even if they are not due for a Pap test 1
• Many providers perform pelvic examinations to obtain Pap tests for women in whom the test is not indicated, with 67% to 94% of respondents stating they would perform subsequent screening sooner than recommended by contemporary guidelines 1

Evolving Recommendations

• The Women's Preventive Services Initiative has developed a Well-Woman Chart summarizing current recommendations for preventive health services for women across the lifespan 3
• The well-woman visit remains an important opportunity for prevention, health education, screening, and early detection despite changing guidelines for specific components 4
• There is no evidence to support the use of the rectovaginal examination (RVE) in well-woman visits for asymptomatic women 5

Key Considerations for Providers

• The well-woman visit should focus on evidence-based preventive services rather than routine performance of all traditional examination components 2
• Family history should be used as a risk assessment tool and should be completed and updated regularly 2
• For reproductive-aged women, development and discussion of a reproductive life plan is a key component to ensure medical testing and treatments align with current and future plans 6
• Providers should be aware that the American Board of Internal Medicine Foundation's Choosing Wisely Campaign has highlighted the overuse of certain examination components 1