High-Risk Factors

Certain risk factors may influence additional assessments and interventions. Physicians should be alert to high-risk factors (listed in the table below). During evaluation, the patient should be made aware of high-risk conditions that require targeted screening or treatment.




Bone mineral density screening

Bone density should be screened in postmenopausal women younger than 65 years if any of the following risk factors are noted: medical history of a fragility fracture; body weight less than 127 lb; medical causes of bone loss (medications or diseases); parental medical history of hip fracture; current smoker; alcoholism; or rheumatoid arthritis.

Practice Bulletin #129: Osteoporosis

U.S. Preventive Services Task Force: Screening for Osteoporosis



Breast self-examination

Women who are estimated to have a lifetime risk of breast cancer of 20% or greater, based on risk models that rely largely on family history, but who are either untested or test negative for BRCA gene mutations

Women who test positive for BRCA1 or BRCA2 mutations. Women who have first-degree relatives with these mutations but who are untested are generally managed as if they carry these mutations until their BRCA status is known.

 Women with a personal history of high-risk breast biopsy results, including atypical hyperplasia and lobular carcinoma in situ.

Women and girls who received thoracic irradiation between age 10 years and 30 years have an increased risk of cancer and should be advised to receive the following screening regimen beginning 8–10 years after they received treatment or at age 25 years, whichever occurs last: annual mammography, annual breast magnetic resonance imaging (MRI), and screening clinical breast examination every 6–12 months.

Practice Bulletin #179: Breast Cancer Risk Assessment and Screening in Average-Risk Women

Practice Bulletin #182: Hereditary Breast and Ovarian Cancer Syndrome

Committee Opinion #607: Gynecologic Concerns in Children and Adolescents With Cancer

Cardiovascular Disease Screening

 For women with a medical history of preeclampsia who gave birth preterm (less than 37 0/7 weeks of gestation) or who have a medical history of recurrent preeclampsia, yearly assessment of blood pressure, lipids, fasting blood glucose, and body mass index is suggested.  Hypertension in Pregnancy

Colorectal Cancer Screening

Older age (50 and above); Colorectal cancer or adenomatous polyps in first-degree relative younger than age 60 years or in two or more first-degree relatives of any ages; family history  of familial adenomatous polyposis or hereditary nonpolyposis colon cancer; history of colorectal  cancer, adenomatous polyps, inflammatory bowel disease, chronic ulcerative colitis, or Crohn disease; Black race

Committee Opinion #609: Colorectal Cancer Screening Strategies

Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology

Screenings for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement

Diphtheria and reduced tetanus toxoids and acellular pertussis vaccine

Health-care personnel should administer a dose of Tdap during each pregnancy irrespective of the patient’s prior history of receiving Tdap.

Centers for Disease Control and Prevention:

Updated Tdap Vaccine Recommendations from the ACIP, 2010

Preventing Tetanus, Diphtheria, and Pertussis Among Adolescents: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccines 

Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccines

Updated Recommendations for Use of Tdap in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged <12 Months -- ACIP, 2011  

Current CDC immunization schedules

Diabetes testing

Testing to detect type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes (Physical inactivity; First-degree relative with diabetes; High-risk race/ethnicity [eg, African American, Latino, Native American, Asian American, Pacific Islander]; Women who delivered a baby weighing 9 lbs or more or were diagnosed with GDM and normal postpartum screening test results, repeat testing every 1 to 3 years; Hypertension [≥140/90 mmHg or on therapy for hypertension]; HDL cholesterol level,35 mg/dL [0.90mmol/L] and/or a triglyceride level.250 mg/dL [2.82 mmol/L]; Women with polycystic ovary syndrome; A1C ≥5.7%, IGT, or IFG on previous testing; Other clinical conditions associated with insulin resistance [eg, severe obesity, acanthosis nigricans]; History of CVD) 

American Diabetes Association.Classification and diagnosis of diabetes. Diabetes Care. 2015;38 Suppl:S8-S16

Practice Bulletin #190: Gestational Diabetes Mellitus (July 2017)

Fluoride supplementation

Live in area with inadequate water fluoridation (less than 0.7 ppm)


Genetic testing/counseling

Fragile X premutation carrier screening is recommended for women with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant.

If a woman has unexplained ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years, fragile X carrier screening is recommended. 

Screening for Tay–Sachs disease should be offered when considering pregnancy or during pregnancy if either member of a couple is of Ashkenazi Jewish, French–Canadian, or Cajun descent. Those with a family history consistent with Tay–Sachs disease also should be offered screening.

Committee Opinion #691: Carrier Screening for Genetic Conditions

Hemoglobin level assessment

Caribbean, Latin American, Asian, Mediterranean, or African ancestry; history of excessive menstrual flow


Hepatitis A vaccination

Persons who use injection or noninjection illicit drugs; persons working with HAV-infected primates or with HAV in a research laboratory setting; persons with chronic liver disease and persons who receive clotting factor concentrates; persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A; and unvaccinated persons who anticipate close personal contact (e.g., household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity.

Current CDC immunization schedules

Hepatitis B vaccination

Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection-drug users; health-care personnel and public-safety workers who are potentially exposed to blood or other infectious body fluids; persons with diabetes younger than age 60 years as soon as feasible after diagnosis; persons with diabetes who are age 60 years or older at the discretion of the treating clinician based on increased need for assisted blood glucose monitoring in long-term care facilities, likelihood of acquiring hepatitis B infection, its complications or chronic sequelae, and likelihood of immune response to vaccination; persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease; household contacts and sex partners of hepatitis B surface antigen-positive persons; clients and staff members of institutions for persons with developmental disabilities; and international travelers to countries with high or intermediate prevalence of chronic HBV infection; and all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services; health-care settings targeting services to injection-drug; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; institutions and nonresidential daycare facilities for persons with developmental disabilities; and any person seeking protection from HBV infection.

Committee Opinion #572: Reproductive Health Care for Adolescents with Human Immunodeficiency Virus 

Centers for Disease Control and Prevention:

 Hepatitis B Vaccination of Infants, Children, and Adolescents (ACIP Recommendations)

A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States, CDC, 2006

Current CDC immunization schedules


Hepatitis C testing

All persons with human immunodeficiency virus (HIV) infection, history of injecting illegal drugs, recipients of  clotting factor concentrates before 1987, chronic (long-term) hemodialysis, persistently abnormal alanine aminotransferase levels, recipients of blood from donors who later tested positive for hepatitis C virus infection, recipients of blood or blood-component transfusion or organ transplant before July 1992, occupational percutaneous or mucosal exposure to hepatitis C virus-positive blood

Committee Opinion #572: Reproductive Health Care for Adolescents with Human Immunodeficiency Virus  

Centers for Disease Control and Prevention:

Sexually Transmitted Diseases Treatment Guidelines, 2010

Human immunodeficiency virus (HIV) testing

More than one sexual partner since most recent HIV test or a sexual partner with more than one sexual partner since most recent HIV test, have received a diagnosis of another sexually transmitted infection in the past year, drug use by injection, exchange sex for money or drugs, past or present  sexual partner who is HIV positive or injects drugs, long-term residence or birth in an area with high prevalence of HIV infection, history of transfusion from 1978 to 1985, invasive cervical cancer, adolescent entering detention facilities. Recommend to women seeking preconception evaluation.

Committee Opinion #596 Routine Human Immunodeficiency Virus Screening 

Committee Opinion #389 Human Immunodeficiency Virus


Lipid profile assessment

Family history suggestive  of familial hyperlipidemia; family history of premature cardiovascular disease (age younger than 50 years for men, age younger than 60 years for women); previous personal history of coronary heart disease or noncoronary atherosclerosis (eg, abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis); obesity (body mass index greater than 30); personal and/or family history of peripheral vascular disease; diabetes mellitus; multiple coronary heart disease risk factors (eg, tobacco use, hypertension)

Women with a medical history of preeclampsia who gave birth preterm (less than 37 0/7 weeks of gestation) or who have a medical history of recurrent preeclampsia should have an annual lipid assessment. 










Hypertension in Pregnancy


Women who have had breast cancer or who have a first-degree relative or multiple other relatives who have a history of premenopausal breast or breast and ovarian cancers, women who test positive for BRCA1 or BRCA2 mutations, women who received thoracic irradiation (typically as a treatment for lymphoma) between the ages 10 years and 30 years, women with a personal history of high-risk breast biopsy results, including atypical hyperplasia and lobular carcinoma in situ

Practice Bulletin #179: Breast Cancer Risk Assessment and Screening in Average-Risk Women 

Meningococcal vaccination

Adults with anatomic or functional asplenia or terminal complement component deficiencies, first-year college students living in dormitories,  microbiologists routinely exposed to Neisseria  meningitides isolates, military recruits, travel to  hyperendemic or epidemic areas

Centers for Disease Control and Prevention:

Prevention and Control of Meningococcal Disease

Updated Recommendations for Use of Meningococcal Conjugate Vaccines -- ACIP, 2010

Current CDC immunization schedules

Measles–mumps–rubella (MMR) vaccination

Adults born in 1957 or later should be offered  vaccination (one dose of MMR) if there is no proof of immunity or documentation of a dose given after first birthday; individuals vaccinated in 1963–1967 should be offered revaccination (two doses); health care workers, students entering college, international travelers, and rubella-negative postpartum patients should be offered a second dose.

Centers for Disease Control and Prevention:

MMR -- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps

Current CDC immunization schedules

Pneumococcal vaccination

Chronic illness, such as cardiovascular disease,  pulmonary disease, diabetes mellitus, alcoholism, chronic liver disease, cerebrospinal fluid leaks,  Hodgkin disease, lymphoma, leukemia, kidney  failure, multiple myeloma, nephrotic syndrome, functional asplenia (eg, sickle cell disease) or splenectomy; exposure to an environment where pneumococcal outbreaks have occurred; immunocompromised patients (eg, human immunodeficiency virus [HIV]  infection, hematologic or solid malignancies, chemotherapy, steroid therapy); Alaskan Natives and certain Native American populations. Revaccination after 5 years may be appropriate for certain high-risk groups.

Centers for Disease Control and Prevention:

Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23)

Current CDC immunization schedules


Rubella titer assessment

Childbearing age and no evidence of immunity

Current CDC immunization schedules


Sexually transmitted infection (STI) testing

History of multiple sexual partners or a sexual partner with multiple contacts; sexual contact with individuals with culture-proven STI; history of repeated episodes of STIs; attendance at clinics for STIs;

Chlamydia: Women 25 years and older with risk factors (new sexual partner or multiple sexual partners);

Gonorrhea: Sexually active women 24 years and older if at increased risk for infection (a previous gonorrhea infection, the presence of other STIs, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use);

Syphilis: Sexually active adolescents who exchange sex for drugs or money, use intravenous drugs, are entering a detention facility, or live in a high-prevalence area

Centers for Disease Control and Prevention:

Sexually Transmitted Diseases Treatment Guidelines, 2015

Thyroid-stimulating hormone testing

Strong family history of thyroid disease; autoimmune disease (evidence of subclinical hypothyroidism may be related to unfavorable lipid profiles)


Tuberculosis skin testing

Human immunodeficiency virus [HIV] infection; close contact with individuals known or suspected to have tuberculosis; medical risk factors known to increase risk of disease if infected; born in country with high tuberculosis prevalence; medically underserved; low income; alcoholism; intravenous drug use; resident of long-term care facility (eg, correctional institutions, mental institutions, nursing homes and facilities); health professional working in high-risk health care facilities; recent tuberculin skin test converter (individuals with baseline testing results who have an increase of 10 mm or more in the size of the tuberculin skin test reaction within a 2-year period); radiographic evidence of prior healed tuberculosis


Varicella vaccination

Students in all grade levels, and persons attending college or other postsecondary educational institutions; susceptible persons who have close contact with persons at high risk for serious complications, including health care workers; household contacts of immunocompromised individuals; teachers; day care workers; residents and staff of institutional settings, colleges, prisons, or military installations; adolescents and adults living in households with children; international travelers

Centers for Disease Control and Prevention:

Prevention of Varicella

Current CDC immunization schedules