ACOG updates its Recommendations for Well-Woman Care

The American College of Obstetrics and Gynecology (ACOG) recently updated its guidance on well- women care with an emphasis on the vital role an Ob/Gyn plays in maintaining the overall health of women from menarche to menopause and beyond.

The update coincides with the release of ACOG-led Women’s Preventive Services Initiative’s (WPSI) new Well-Woman Chart. The guidance titled “Well Women Visit” was published in the October issue of Obstetrics and Gynecology and replaces the earlier opinion released in August 2012.

The new guidance emphasizes the performance of physical examination (breast and pelvic examination) when indicated by age-group, history or symptoms. The committee also identified the Well-Woman Chart from the WPSI, U.S. Preventive Services Task Force (USPSTF) and Bright Futures, as an important tool to identify the different components of the comprehensive preventive services offered.

Looking at the chart, the Ob/Gyn or other women’s health care providers can prioritize the component for a timely and detailed approach for continuous preventive care throughout the entire lifespan. The Well-Woman Chart provides a list of all the preventive services recommendations for women from the WPSI, US Preventive Services Task Force, and Bright Futures.

The services are advised according to age groups and start at age 13 and end at 75 years with services categorized into general health, infectious disease, and cancer. The chart also has separate services listed for pregnancy and postpartum period.

Much has changed in the last 10 years to shift the focus of patients and practitioner when it comes to yearly well-women visit. The decade has seen a change in the recommendation about the frequency of yearly pap smears, growing popularity of long-acting reversible contraceptive methods and the mandate of performing the pelvic examination in every visit.

The recommendations also recognize that it may not be possible for the patient to complete all the services with one health care provider; hence a team-based approach will facilitate the completion of the services.

The practitioner should begin by a comprehensive medical, family, and reproductive history to individualize physical examination, immunization, and risk assessment. 

The decision to perform a breast and pelvic examination at each visit should be based on detailed family history, reproductive history, and shared decision making. The ACOG recent guidance recommends that pelvic and breast examinations be performed when indicated by medical history or symptoms.

The provider should also counsel the women about essential lifestyle choices and behaviors that have a detrimental effect on women’s’ health like smoking, alcohol, poor diet, and lack of exercise.  These factors also predispose women to high risk for cardiovascular diseases, gynecological cancers, and type 2 diabetes.

All women should be screened for obesity and overweight, and the opportunity should not be lost for counseling the women about maintaining ideal weight and exercising regularly. 

The provider should also discuss with reproductive age women about their reproductive life plan to ensure that all the immunizations are timely complete if planning a pregnancy. Matters like infertility and contraception should also be discussed as appropriate.

The authors further write that discussion about bone health, vulvovaginal symptoms, and sexual health are seldom done during the well-woman visit. The recommendations encourage discussing these issues based on the woman’s phase of life.

In all, an obstetrician and gynecologist should play a crucial role in providing primary and preventive care services to women of all ages.

Christopher Zahn, MD, ACOG vice president of Practice Activities, said in an ACOG news release, “Increasingly, women look to their ob-gyn for both reproductive and primary health care, which creates an exciting opportunity for ob-gyns to build even deeper and longer lasting relationships with our patients,” said Zahn.

“An ob-gyn may care for a patient as an adolescent, through her reproductive years, and as she experiences menopause and beyond. These resources are here to ensure that these ongoing updates to well-woman recommendations are manageable and positive for women’s health care providers and the women who are in their care,” he added further.

Committee opinion

Well-Woman Chart

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U.S. Preventive Services Task Force issues important update on annual pelvic exams!

Courtesy: NBC.news.

The U.S. Preventive Services Task Force (USPSTF) today released final recommendation statement and evidence summary for performing pelvic examination for screening asymptomatic adult women who are not at increased risk of any specific gynecological conditions.

The recommendations and evidence summary published online on March 7,2017 in online edition of JAMA.

The USPSTF recommends that the current evidence is insufficient to endorse or refute for routine pelvic screening in asymptomatic adult women. (I statement). This is not a recommendation against performing a routine pelvic examination, but an acknowledgement that more research is needed.   

This statement does not hold good for specific conditions like screening for cervical cancer with a “Pap” test and screening for gonorrhea and chlamydia for which screening is already advocated.

The recent recommendations are based on a systematic review conducted by USPSTF to focus on benefits, harms and accuracy of screening pelvic examination for four major conditions like ovarian cancer; bacterial vaginosis; genital herpes; and trichomoniasis.

Pelvic examination is a routine part of physical examination and in 2012 an estimated 44.2 million pelvic examinations were performed in USA. Many gynecological conditions like pelvic malignancy, infections of the genital tract and benign conditions like polyps, endometriosis and uterine fibroid are detected by pelvic examination. No studies evaluated the effectiveness of early diagnosis and treatment of screen-detected, asymptomatic gynecologic conditions compared with the diagnosis and treatment of symptomatic gynecologic conditions.

 But evidence does not favor performing a screening pelvic examination in asymptomatic women to reduce morbidity and mortality. USPSTF could find few studies that supported performing pelvic examination to reduce all-cause mortality, disease-specific morbidity or mortality, or improve quality of life.

Similarly, USPSTF found very few studies that documented the harm of screening pelvic examination. Studies reported false-positive rates for ovarian cancer, between 1.2% to 8.6%, and false-negative rates, between 0% to 100%.

The USPSTF does recognize that research gap exists in areas evaluating benefits and harms of screening pelvic examination. Future research is needed to develop risk assessment tools to identify women that can benefit from pelvic examination. These studies when done may influence the future recommendation by USPSTF.

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) concluded that performing screening pelvic examinations in asymptomatic, nonpregnant adult women is not recommended.

The American College of Obstetricians and Gynecologists ( ACOG)  is reviewing the USPSTF  recommendations and evidence to issue its take on the matter. It has  issued a practice advisory for screening pelvic exams today. 

Currently  ACOG recommends performing pelvic examinations annually in all patients 21 years and older.

ACOG further quotes" The Task Force recommendation does NOT apply to pregnant women, and it does NOT apply to women who present to their obstetrician-gynecologists with signs or symptoms. This recommendation applies only to asymptomatic, non-pregnant women. It is critically important for obstetrician-gynecologists to elicit accurate and complete medical, surgical, and family histories and to conduct thorough reviews of systems as part of the well-woman visit. Some women may not recognize that certain signs or symptoms are truly abnormal; these signs and symptoms may be interpreted as "normal" for them, when, in fact, they should prompt evaluation, which may include a pelvic examination."

 ACOG concluded that “the decision to perform a complete examination at the time of the periodic health examination should be a shared decision between the patient and clinician.”

USPSTF also further recognizes that the decision should be individualized according to each patient and clinical situation. The policy and insurance coverage is also taken into consideration when making a decision.  

Full text of the recommendations can be accessed here.

Full text of the evidence summary can be accessed here.