Well Woman Visit
The annual health assessment (“annual examination”) is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the clinician–patient relationship. New recommendations and improving technologies continue to influence guidelines and the necessary components of the annual health assessment of women.
The Importance of the Annual Visit
Obstetrician–gynecologists have a tradition of providing preventive care to women. An annual visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. The annual health assessment should include screening, evaluation and counseling, and immunizations based on age and risk factors. The performance of a physical examination is a key part of an annual visit, and the components of that examination may vary depending on the patient’s age, risk factors, and physician preference. In general, the physical examination will include obtaining standard vital signs, determining body mass index, palpating the abdomen and inguinal lymph nodes, and making an assessment of the patient’s overall health. Many, but not all, women will have a pelvic examination and a clinical breast examination as a part of the physical examination.
The pelvic examination includes three elements: 1) inspection of the external genitalia, urethral meatus, vaginal introitus, and perianal region (external examination); 2) speculum examination of the vagina and cervix; and 3) bimanual examination of the uterus, cervix, and adnexa (the latter two elements constitute the internal examination).
Annual pelvic examination of patients 21 years of age or older is recommended by The American Congress of Obstetricians and Gynecologist (ACOG).
Patients Younger Than 21 Years
- First visit to the obstetrician–gynecologist for screening and the provision of preventive services and guidance take place between the ages of 13 years and 15 years. This visit does not include pelvic examination.
- No evidence supports the routine internal examination of the healthy, asymptomatic patient before age 21 years. For patients younger than 21 years with problems, such as menstrual disorders, vaginal discharge, or pelvic pain, an internal examination may be necessary.
- ACOG guidelines published in May 2009 now recommend beginning cervical cancer screening at age 21 years, irrespective of sexual activity of the patient.
- Testing for STIs is recommended for sexually active adolescents. Nucleic acid amplification testing on urine samples are now an acceptable form for screening gonorrhea and chlamydial infections.
Patients Aged 21 Years and Older
- The College guidelines recommend that a pelvic examination be performed on an annual basis in all patients aged 21 years and older.
- A pelvic examination always is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract problems. Patients with menstrual disorders, vaginal discharge, infertility, or pelvic pain should receive a pelvic examination.
- Perimenopausal patients with abnormal uterine bleeding, changes in bowel or bladder function, or symptoms of vaginal discomfort should have a pelvic examination.
- Pelvic symptoms related to later reproductive years and menopause, such as abnormal bleeding, vaginal bulge, urinary or fecal incontinence, or vaginal dryness, warrant a pelvic examination.
Clinical Breast Examination
No data exist regarding the ideal age at which to begin clinical breast examinations in the asymptomatic, low-risk patient. Expert opinion suggests that the value of clinical breast examination and the ideal time to start such examinations is influenced by the patient’s age and known risk factors for breast cancer. The occurrence of breast cancer is rare before age 20 years and uncommon before age 30 years. Based on available evidence, the College, the American Cancer Society (ACS), and the National Comprehensive Cancer Network recommend that clinical breast examination be performed annually in women aged 40 years and older.
Although the value of a screening clinical breast examination for women with a low prevalence of breast cancer (eg, women aged 20–39 years) is not clear, the College, ACS, and the National Comprehensive Cancer Network continue with these recommendations.
- Clinical breast examination for these women.
- Recommend the teaching of breast self-awareness and inquiry into medical history and family history of risk factors for breast disease. Breast self-awareness educates patients about the normal feel and appearance of their breasts, and include performing breast self-examinations.
Mammography is the primary tool for breast cancer screening, and the roles of the clinical breast examinations and breast self-examinations have been questioned by some experts. The 2009 U.S. Preventive Services Task Force report on breast cancer screening states that “current evidence is insufficient to assess the additional benefits and harms of clinical breast examinations beyond screening mammography in women 40 years and older”. The data evaluated by the U.S. Preventive Services Task Force in its 2009 recommendation suggest that teaching breast self-examination does not reduce the mortality rate of breast cancer and it recommends against clinicians teaching women how to perform breast self-examination. However, 8–17% of cases of breast cancer are missed by mammography.
- The clinical breast examination and breast self-awareness, which includes breast self-examination, have the potential to detect a palpable cancer.
- Some studies show that clinical breast examination and mammography together have a better sensitivity than mammographic screening alone for detecting breast cancer.
- Clinical breast examination still is recommended as part of the periodic health examination of women, especially those with known risk factors for breast cancer.
Shared Communication and Decision Making
The decision to perform an internal pelvic examination, breast examination, or both should be made by the physician and the patient after shared communication and decision making. Concerns, such as individual risk factors, patient expectations, or medical–legal concerns may influence the decision to perform an internal pelvic examination or clinical breast examination. In these situations, the medical record should reflect the pertinent details of the patient’s medical and family history and overall condition, documentation of the physical examination, and the issues discussed between the patient and physician. The decision to perform any type of pelvic or breast examination should always be made with the consent of the patient.
Well Woman Visit Recommendations
- An annual visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks.
- The annual health assessment should include screening, evaluation and counseling, and immunizations based on age and risk factors.
- Speculum examinations for cervical cancer screening should begin at age 21 years, irrespective of sexual activity of the patient.
- A pelvic examination always is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract, pelvic, urologic, or rectal problems.
- Breast self-awareness, which for many patients also may include performing breast self-examination, is recommended. The patient should immediately report changes in her breast to her physician.
- Based on available evidence, the College, ACS, and the National Comprehensive Cancer Network recommend that a clinical breast examination be performed annually in women aged 40 years and older. In women aged 20–39 years, the College, ACS, and the National Comprehensive Cancer Network continue to recommend a clinical breast examination every 1–3 years.
- The decision to perform any type of pelvic or breast examination should always be made with the consent of the patient.