Well Woman Examinations
Why do we go to these anyway?
The annual well woman examination is an important part of every woman’s medical care. It is designed to include an assessment of overall health including physical and mental wellbeing, to identify risk factors for disease, to provide age appropriate screening tests and vaccinations, and to counsel women on maintaining a healthy lifestyle. There are constantly improvements in technologies and recommendations of multiple societies that affect the guidelines for the individual components of this visit.
When do young women need to start seeing the gynecologist?
The American College of Obstetricians and Gynecologists (ACOG) currently recommends for the initial well woman visit to occur between the ages of 13 and 15. Young adolescents are undergoing many changes involving their reproductive health, and this visit focuses primarily on education and identifying the potential for them to become involved in high risk behaviors. It is also a time to provide contraception and STD screening as indicated. Young girls should be reassured that an internal pelvic examination is not needed until age 21 unless it is indicated by a specific problem she is having. It is not required to undergo this type of examination prior to obtaining contraception.
What about pap smears?
Current guidelines for pap smear screening recommend this part of the pelvic examination begin at age 21. A pap smear is a screening tool for cervical cancer. In order to perform a pap smear, a speculum examination is required. This involves placing a small instrument internally to help the physician visualize the cervix. A thin plastic spatula or a small broom is then used to wipe across the cervix and collect cells. This type of examination is not necessary until age 21 regardless of sexual activity. This recommendation is based on our understanding of the human papilloma infection and of invasive cervical cancer. Pap smears should be performed every 2-3 years until age 29. After age 30 they will be performed at least every 3 years as long as they are normal. If co-screening for high risk HPV takes place and both are negative, these examinations can be spaced out to as far as 5 years. Timing of pap smears should be discussed with your physician and will be individualized based on your history. Screening should continue until age 65, and can then be discontinued with a history of normal pap smears. Pap smears may also be discontinued after hysterectomy if it was done for reasons other than cancer, and if the patient does not have a history of abnormal pap smears that required intervention, does not have a weakened immune system or have HIV, and was not exposed with DES while their mother was pregnant with them.
What about breast exams?
When to start breast examinations and how frequently they should be done prior to age 40 is something that will need to be discussed with your physician, and will be based upon personal and family history. General guidelines recommend beginning by age 20 and for them to take place every 1-3 years. After age 40 it is well established that women should undergo annual clinical breast examinations as well as mammograms for breast cancer screening. One out of every eight women will develop breast cancer in their lifetime, and early diagnosis will significantly improve outcome and can decrease the amount of interventions required. Mammograms will miss 8-17% of breast cancers, and therefore clinical breast examinations as well as self breast awareness is important. Women should be taught during their examination how to practice self breast awareness. This may or may not include self breast examinations. Women should notify physician if they notices changes in their breast including not only breast masses or lumps, but also changes in shape/size, changes in the skin, dimpling, inversion of the nipple, or leakage from the nipple that is not white or clear.
How about blood work?
The need for blood work will be determined based on individual history. Routine screening of cholesterol, glucose and thyroid typically begins between ages 45 and 50. Reasons for additional labs or earlier screening may be indicated based on patients individual symptoms, nutritional status, menstrual cycles, or weight/height ratio.
Other important screening exams…
It is currently recommended that women initiate colonoscopy for colorectal screening beginning at age 50 and to be repeated every 10 years. Bone density screening should begin at age 65 and be repeated every 2 years. This should be initiated early if risk factors are identified. Risk factors for osteoporosis include advancing age, previous fracture, smoking, thin/small frame, menopausal status, sedentary lifestyle, excessive alcohol use, and rheumatoid arthritis.
Other things to discuss with your gynecologist during an annual exam
Menstrual Cycles: You should review with your doctor your periods. It is important to let them know if these are not occurring regularly each month, if they seem to be too heavy, or if they are associated with significant pain, mood alterations, headaches, or changes in bowel patterns.
Pregnancy Plans: If you are hoping for a pregnancy in the near future, it is important to review these desires with your physician so that they can help identify medical conditions that can impact pregnancy, discuss any medications you may be taking and their safety in pregnancy, and review appropriate nutrition and vitamin intake in the months prior to pregnancy.
Contraception: If you desire to prevent pregnancy this is also a good time to discuss contraceptive options. There are a wide range of options available and you and your doctor can tailor this around your lifestyle and specific needs.
Sexually transmitted infections: Your well woman exam is a good time to discuss with your physician any concerns you may have about exposure to STDs, and screening can be done easily at the same time as your routine exam. If it is not otherwise indicated for you to have a pelvic examination, this type of screening can also be done from your urine.
Depression: Signs and symptoms of depression include changes in your sleeping patterns, changes in your eating patterns, feelings of sadness or guilt, inability to get things done, lack of desire to participate in activities that were once enjoyable for you. If you have any of these concerns it is important to discuss them with your physician as there are available interventions to improve these symptoms, and prevent risks to you associated with depression.
Sexual function: Many women experience problems with sexual function including pain, lack of desire, or inability to achieve orgasm. All of these things are appropriate to discuss with your doctor, who can help identify a cause and make recommendations to improve these problems.
Bladder problems: Women of all ages can have problems with incontinence. Leaking urine when you cough or sneeze is not uncommon but should not be considered normal. There are multiple causes for this problem and various treatments that can be used. Burning when you use the bathroom, or the urge to go too frequently should also be discussed with your doctor.
Skin Health: Skin cancer is the number one cancer diagnosed in this country and the importance of sunscreen and skin health may be discussed. If you have noticed new or changing areas on your skin these should be pointed out to your doctor for evaluation.
Substance Abuse: Problems with alcohol, drugs and tobacco use should be discussed with your doctor. It is important to be aware of the health consequences associated with these behaviors and to be informed of opportunities to help you overcome an addiction you may have developed.
Safety at Home: Women of all ages and all social circles have experienced abuse. It is important to notify your doctor of conditions which make you feel unsafe. Abuse can be physical or emotional. Your doctor can talk to you about appropriate interventions and available resources to help you overcome these issues.
While going for an annual gynecologic exam can be uncomfortable, they are a foundation for women’s health and disease prevention. These visits are designed to promote overall well being and are tailored to each individual based upon their personal, family and social histories.
