What should be included in a woman's annual gynecological (gyn) visit?

Annual Gynecological Visit Components

The annual gynecological visit should focus on comprehensive health maintenance including screening, counseling, and preventive services, but routine pelvic examination is not indicated for asymptomatic women without specific risk factors or symptoms. 1, 2

Essential Components for All Women

History and Risk Assessment

• Comprehensive medical history including chronic conditions, medications, allergies, family history, and menstrual history (age at menarche, cycle regularity, menstrual problems) 3, 4
• Reproductive planning discussion at every visit, including contraceptive needs, pregnancy intentions, and birth spacing counseling 3
• Psychosocial screening for depression, anxiety, intimate partner violence (physical, sexual, emotional abuse), and major life stressors 3, 4
• Social and behavioral assessment including tobacco, alcohol, and drug use screening 3, 4

Physical Measurements

• Height, weight, BMI calculation, and blood pressure measurement 4

Screening and Laboratory Testing

Cervical Cancer Screening:

• Do not screen women under age 21 regardless of sexual activity or risk factors 3, 4
• Ages 21-29: Cervical cytology every 2-3 years (conventional or liquid-based Pap test) 3
• Ages 30-65: Either cytology alone every 3 years OR co-testing (cytology plus HPV DNA testing) every 3 years 3
• After age 65: Discontinue screening if three consecutive normal tests in past 10 years 3
• Post-hysterectomy: Discontinue screening unless history of CIN II/III or cervical cancer 3

STI Screening:

• Screen based on sexual activity and risk factors using urine samples or self-collected vaginal swabs—pelvic examination is not required for asymptomatic women 4, 5, 6
• Test for chlamydia, gonorrhea, and other STIs as indicated by risk assessment 3, 4

Preventive Counseling and Education

• Contraception counseling for all women of reproductive age, including emergency contraception options, regardless of reported sexual activity 3, 4
• Folic acid supplementation (400 mcg daily) for all women of reproductive age; higher doses for those at high risk of neural tube defects 3, 4
• Immunization review and updates according to current recommendations 3, 4
• Lifestyle counseling on nutrition, physical activity, sleep, tobacco cessation, and substance use avoidance 3, 4
• Weight counseling for women with BMI ≥30 or <18.5 kg/m² regarding fertility and pregnancy risks 3

When Pelvic Examination IS Indicated

Symptomatic Women (Strong Indication)

Perform appropriate pelvic examination components for women with:

• Vulvar complaints, vaginal discharge, or pelvic pain 5
• Abnormal premenopausal or postmenopausal bleeding 5
• Dyspareunia, pelvic organ prolapse symptoms, or urinary incontinence 5
• New unexplained gastrointestinal symptoms (abdominal pain, bloating, early satiety) 5
• Infertility evaluation 5
• Symptomatic STI concerns (visual inspection, speculum, and bimanual examination required to rule out pelvic inflammatory disease) 5

High-Risk Asymptomatic Women

More frequent pelvic examinations may be warranted for:

• History of cervical cancer or CIN II/III (annual screening for at least 20 years post-treatment) 3, 5
• HIV infection (every 6 months first year, then annually) 3
• In utero diethylstilbestrol exposure 3, 5
• Genetic diagnosis increasing gynecologic malignancy risk 5
• Women over age 70: Consider periodic vulvar inspection for vulvar disease even after cervical screening ends 5

When Pelvic Examination is NOT Required

Asymptomatic Average-Risk Women

• No evidence supports routine pelvic examination (visual, speculum, or bimanual) for screening ovarian cancer, bacterial vaginosis, or other conditions in asymptomatic women 1, 2, 6
• Bimanual examination has positive predictive value <4% for ovarian cancer detection 1
• No pelvic examination needed before prescribing hormonal contraception in healthy, asymptomatic women 5, 6

Important Caveats About Pelvic Examination

Potential Harms:

• Approximately one-third of women experience fear, embarrassment, anxiety, pain, or discomfort during pelvic examinations 1
• Women reporting pain are less likely to return for follow-up care 1
• Fear of examination may cause women, especially adolescents, to delay or avoid obtaining contraceptives 1
• Can lead to unnecessary surgery in ~1.5% of screened women with surgical complication rates up to 15% 1
• Annual cost of preventive gynecologic examinations in the U.S. is $2.6 billion 1

Shared Decision-Making: If performing a screening pelvic examination at the time of cervical cytology collection in asymptomatic average-risk women, this should be a shared decision weighing potential benefits (patient education, addressing unvoiced concerns, practitioner skill maintenance) against harms (discomfort, false positives/negatives, unnecessary interventions) 5, 2

Special Population: Adolescents

• Gynecologic care should begin when clinically indicated, not based solely on need for cervical screening 3, 4
• External genital examination should be part of routine annual physical examination at all ages 3
• Pelvic examination not required for asymptomatic adolescents; STI screening can be done via urine or self-collected swabs 3, 4
• Confidential discussions about sexuality, sexual orientation, gender identity, and contraception in nonjudgmental manner 4
• Encourage parental involvement while maintaining confidentiality 4