Pocket ObGyn 2015 – Well-Woman (annual) exam
See Abbreviations
Well-woman Visit (Obstet Gynecol 2012;120:421)
- Purpose: Promote healthy lifestyle, minimize health Screen, evaluate, counsel, & immunize. Identify reproductive concerns. Address age-specific risks. Offer contraception & preconception planning. Optimize primary care health. Age-related exam components at www.acog.org/About_ACOG/ACOG_Departments/ Annual_Womens_Health_Care/Assessments_and_Recommendations.
- Screening: Diet/nutrition/exercise, safety/seat belts, diabetes, obesity, metabolic syn, osteoporosis, thyroid dz, breast cancer, cervical dysplasia, colon cancer, & skin
- Timing: 1st Ob/Gyn visit at 13–15 yo
- Hx for well-woman visit:
Chief complaint/HPI w/ review of systems/PMH/PSH
Ob hx: Including dates, gestational age, infant wt, deliv mode, complications
Gyn hx: LMP: certain?
Menstrual hx: Age at menarche? Regular cycles? Cycle length (days)? Days of flow? Degree of flow (light, mod, heavy)? Dysmenorrhea? Assoc sx?
STIs: Gonorrhea, chlamydia, herpes, syphilis, HIV, other? Rx? Abn pap smears ever? Date of last pap smear?
# lifetime sexual partners? Current sexual partners (men, women, or both)? Past & current forms of birth control?
Any h/o physical, sexual, or emotional abuse?
Incontinence: Urinary or fecal?
Sexual fxn: Desire? Pain? Other concerns? Current meds w/ dose, route, schedule, indication
Allergies, including nondrug & environmental allergens, w/ rxn & severity
Soc hx: Including tobacco, EtOH, & illicit drug use
FHx: Specifically address Gyn cancers including cervical, endometrial, ovarian, breast. Also colon cancer, bleeding/clotting disorders, fetal anomalies/birth defects.
- Physical exam for well-woman visit:
VS, ht, wt, BMI, general appearance, general physical exam, breast, thyroid, cardio- vascular, pulmonary, abdominal, rectal, & pelvic (speculum/bimanual).
Pelvic exam: Annual pelvic exam for ³21 yo (no supporting data). Not req for OCPs. External only <21 yo unless indicated; exam under anesthesia for very young.
| Leading causes of death among females of all races in the United States (2010) | |||||
| Age 15–24 | Age 25–34 | Age 35–44 | Age 45–54 | Age 55–64 | Age 65+ |
| Unintentional injury | Unintentional injury | Cancer | Cancer | Cancer | Heart dz |
| Suicide | Cancer | Unintentional injury | Heart dz | Heart dz | Cancer |
| Homicide | Suicide | Heart dz | Unintentional injury | Chronic
respiratory dz |
Stroke |
| Cancer | Heart dz | Suicide | Chronic liver dz | Stroke | Chronic
respiratory dz |
| Heart dz | Homicide | Stroke | Stroke | Diabetes
mellitus |
Alzheimer dz |
| Pregnancy complication | Pregnancy complications | ||||
| From CDC Leading Causes of Death in Females. At http://www.cdc.gov/women/lcod. Accessed March 20, 2014. | |||||
Cancer Screening Guidelines
- Cervical dysplasia: See below
- Breast cancer: See below (Obstet Gynecol 2011;118:372)
| Breast cancer screening modalities | ||
| Screening | Performance | Guidelines |
| Mammogram | Sens 74–95%
Spec 89–99% |
ACOG: >40 yo annual screening, or 10 y younger than 1st-degree affected relative. Stop at age 75.
USPSTF: <50 yo screening every 2 y based on individual pts; 50–74 yo every 2 y ACS: >40 yo annual screening NCI: >40 yo, screen every 1–2 y |
| Ultrasound | Sens 80–85%
Spec 60–70% |
Adjunct to mammography, esp in young women w/ dense breast tissue. Used for bx guidance. Not 1st line. |
| Clinical breast exam (5+ min/ breast in studies) | Sens 40–70%
Spec 86–99% PPV 3–4% |
ACOG: 20–39 yo every 1–3 y; >40 yo annually USPSTF: Insuff data to recommend
ACS: 20–39 yo every 1–3 y; >40 yo annually |
| Self breast exam (monthly exam, day 7–10 of cycle) | Sens 20–30% Difficult to assess | Breast awareness education, all ages. ACOG: Consider for high-risk pts USPSTF: Not recommended
ACS: Optional for >20 yo Up to 70% of breast cancer found on self-exam |
| Breast MRI | Sens 71–100%
Spec 37–97% (in younger w/ denser breast tissue) |
For >20% lifetime risk, or known BRCA1 or BRCA2, 1st-degree relative w/ BRCA & no personal testing, h/o chest radiation btw 10 & 30 yo, genetic syndromes (eg, Li-Fraumeni, Cowden). Not recommended for personal h/o breast cancer or dysplasia, & not for
avg risk women. |
- Colorectal cancer: Begin age 50 Consider 45 yo if AA.Younger if FHx. Prefer colonoscopy q10y; other acceptable methods:
Fecal occult bld or fecal immunochemistry testing q1y w3 collected samples Flexible sigmoidoscopy q5y
Combination of fecal occult bld & flexible sigmoidoscopy Double contrast barium enema q5y
- Skin cancer: Counsel regarding ultraviolet Consider annual skin exam & referral for high risk. Use asymmetry/border/color/diameter/enlargement criteria.
- There are no recommended guidelines for routine screening for ovarian, endometrial, or lung H&P guide investigation.