CommitteeOpinion2017
Number 755
(Replaces Committee Opinion Number 534, August 2012)


Committee on Gynecologic Practice
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice in collaboration with committee member Catherine Witkop, MD, MPH.

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Well-Woman Visit

ABSTRACT: A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. Given the shifting and complex landscape of care, in which many women may not receive all the recommended preventive services, obstetrician–gynecologists have an opportunity to contribute to the overall health and well-being of women throughout the lifespan by providing recommended preventive services and counseling. Taking a comprehensive history (specifically obtaining detailed information on symptoms and past medical and gynecologic history) will inform if certain components of the physical examination, including breast or pelvic examination, are indicated at that visit and will inform shared decision making for these examinations. Family history should be used as a risk assessment tool and should be completed and updated regularly to ensure the most comprehensive assessment of a woman’s personal risk factors. Another key component of a well-woman visit for a reproductive-aged woman is the development and discussion of her reproductive life plan to ensure that medical testing and treatments provided are aligned with her current and future plans. Obstetrician–gynecologists provide care for women across the lifespan, and periodic well-woman visits are appropriate and necessary for perimenopausal women and postmenopausal women as well. This Committee Opinion has been revised to reflect updated guidance on components of the physical examination and new sources for well-woman preventive services.


Recommendations and Conclusions

The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:

  • A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks.
  • The periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors.
  • The interval for specific individual services may differ for individual patients, and the scope of services provided may vary in different ambulatory care settings.
  • Team-based care, including obstetrician–gynecologists, physician assistants, nurse practitioners, and other health care professionals, may facilitate meeting the needs of preventive care for women.
  • A comprehensive history is one of the most important aspects of a well-woman visit.
  • Although components of a physical examination may not be required at a well-woman visit, obstetrician–gynecologists can play a critical role in engaging patients in shared decision making, encouraging and facilitating healthy behaviors, and counseling about a wide array of effective preventive health practices.

The purpose of this document is to describe the importance of the periodic women’s health visit and provide a general overview of women’s preventive services and care. The scope of this Committee Opinion does not allow for a detailed review of all services and examinations that may be covered in a well-woman visit. This document will highlight resources and tools to assist obstetrician–gynecologists in the provision of comprehensive well-woman care. See Table 1 for sources of specific well-woman preventive health services. This Committee Opinion has been revised to reflect updated guidance on components of the physical examination and new sources for well-woman preventive services.

Background

Obstetrician–gynecologists have a tradition of providing preventive care to women. A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. Periodic visits for reproductive and well-woman care are recommended, even if individual components of that visit (eg, cervical cancer screening) may not be indicated each year. The periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors. The interval for specific individual services may differ for individual patients, and the scope of services provided may vary in different ambulatory care settings.

Obstetrician–gynecologists have the opportunity to provide preventive health services to women, in addition to managing reproductive health care. Data from medical records of national representative visits from 2007 to 2010 showed that, although more than 50% of preventive care visits for women (ages 18 years and older) were to obstetrician–gynecologists, these visits were primarily focused on screening for cervical and breast cancer (1). Family medicine clinicians, general practitioners, and internists covered a wider range of clinical preventive services (including screening for colorectal cancer, cholesterol, and diabetes mellitus) and counseling for diet, exercise, and obesity (1).

In a survey of obstetrician–gynecologists, when asked about their role in well-woman care, 61% defined well-woman care as “overall health and primary care”; however, they largely focused on reproductive health issues (2). Another study showed that even though most obstetrician–gynecologists reported that they provided well-woman care, there were gaps in the provision of some clinical preventive services during such visits, such as screening for intimate partner violence and sexual abuse and counseling about folic acid (3).

Because patient preferences may affect use of health care services, it is important to understand where women prefer to get their reproductive, primary, and preventive care. A 2015 study that examined the preferred and usual source of reproductive health care (including cervical cancer screening, contraception, and sexually transmitted infection services) showed that women’s health care specialists (including obstetrician–gynecologists and family planning clinics) were the most used, and often the preferred, source of care compared with family medicine, internal medicine, and general medicine clinicians (4). Another 2017 paper suggests changes in cervical cancer screening recommendations and the increase in provision of long-acting reversible contraceptive methods may contribute to women seeking care from obstetrician–gynecologists less frequently (5).

The Patient Protection and Affordable Care Act of 2010 identified essential sources of recommended women’s preventive health services and required coverage for these services without cost-sharing (Table 1). Subsequently, the Institute of Medicine (now known as the National Academy of Medicine) was tasked by the U.S. Department of Health and Human Services to identify additional evidence-based clinical preventive services for women (Table 1) (6). Given the shifting and complex landscape of care, in which many women may not receive all the recommended preventive services, obstetrician–gynecologists have an opportunity to contribute to the overall health and well-being of women throughout the lifespan by providing recommended preventive services and counseling.

Management of Well-Woman Visits

As the number of recommended clinical preventive services increases, it is essential that obstetrician–gynecologists and other health care providers have access to high-quality resources that provide current information regarding these services. Existing repositories of well-woman recommendations are limited in usability and comprehensiveness; ultimately, a framework such as the one Bright Futures provides for children and adolescents would be helpful for adult women as well. Obstetrician–gynecologists should offer and recommend clinical preventive services to patients based on their age and risk factors; however, it may not be possible to complete all recommended services in one visit or with one health care provider. Team-based care, including obstetrician–gynecologists, physician assistants, nurse practitioners, and other health care professionals, may facilitate meeting the needs of preventive care for women. Providing patients with visuals, such as infographics (https://www.acog.org/Patients/FAQs/Annual-Well-Woman-Exam-Infographic and https://www.acog.org/Patients/Especially-for-Teens/21-Reasons-Infographic), can help women understand the scope of services obstetrician–gynecologists can provide.

Comprehensive History and Physical Examination

A comprehensive history is one of the most important aspects of a well-woman visit. This history includes symptoms; medications; allergies; and medical, surgical, family, social, and gynecologic history, including questions on reproductive, sexual, and mental health (using screening tools as indicated). Taking a comprehensive history (specifically obtaining detailed information on symptoms and past medical and gynecologic history) will inform if certain components of the physical examination, including breast or pelvic examination, are indicated at that visit and will inform shared decision making for these examinations. The American College of Obstetricians and Gynecologists recommends that pelvic and breast examinations be performed when indicated by medical history or symptoms (7, 8). Some specific topics that are sometimes overlooked, but that should be addressed at well-woman visits throughout the lifespan, include bone health, vulvovaginal symptoms, and sexual health.

Table 1. Sources for Recommended Preventive Services Without Patient Cost-Sharing Under the Affordable Care Act* image 1

Table 1. Sources for Recommended Preventive Services Without Patient Cost-Sharing Under the Affordable Care Act* image 2

Table 1. Sources for Recommended Preventive Services Without Patient Cost-Sharing Under the Affordable Care Act* image 3

Table 1. Sources for Recommended Preventive Services Without Patient Cost-Sharing Under the Affordable Care Act* image 4

Table 1. Sources for Recommended Preventive Services Without Patient Cost-Sharing Under the Affordable Care Act* image 6

Table 1. Sources for Recommended Preventive Services Without Patient Cost-Sharing Under the Affordable Care Act* image 5

 

Family history should be used as a risk assessment tool and should be completed and updated regularly to ensure the most comprehensive assessment of a woman’s personal risk factors (9). For example, the family history may be used to identify a woman at increased risk of cancer, allowing her to be referred for genetic testing, counseling, or both, and for further preventive care as indicated.

Certain risk factors and behaviors have a profound negative effect on the health of women and should be addressed during a well-woman visit. Smoking, poor diet, and lack of physical activity are associated with cardiovascular disease, type 2 diabetes, and multiple types of cancer, among other conditions that cause significant morbidity and are the leading causes of mortality in the United States (10). These behaviors also can contribute to conditions frequently treated by obstetrician–gynecologists (eg, menstrual irregularities; polycystic ovary syndrome; infertility; and endometrial, breast, and cervical cancer) and can increase the risk of maternal and surgical complications as well as adverse effects to future offspring (11). Obstetrician–gynecologists have the opportunity to counsel women about the effect of lifestyle choices on overall health, specifically reproductive health, and to guide them in decision-making related to behavior change, potential interventions, and treatment options, if indicated. The obstetrician–gynecologist can educate, screen, monitor, and treat women to reduce their risk of morbidity and mortality from cardiovascular disease, such as from myocardial infarction and stroke. All women should be screened for tobacco use and counseled about options for smoking cessation (12) as well as at-risk drinking and alcohol dependence (13). Women also should be screened for overweight and obesity, counseled, and offered treatment options or referral (14–16). The American College of Obstetricians and Gynecologists’ Obesity Toolkit offers practical information for the obstetrician–gynecologist (https://www.acog.org/About-ACOG/ACOG-Departments/Toolkits-for-Health-Care-Providers/Obesity-Toolkit).

Another key component of a well-woman visit for a reproductive-aged woman is the development and discussion of her reproductive life plan to ensure that medical testing and treatments provided are aligned with her current and future plans. A discussion of a reproductive life plan may include prepregnancy counseling, infertility assessment, or the full range of contraceptive options. The Centers for Disease Control and Prevention has published tools to assist health care providers in addressing a woman’s family planning needs at all periods in her reproductive life (17). Providing Quality Family Planning Services, developed by the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs, provides guidance on contraceptive services, prepregnancy health, achieving pregnancy, basic infertility services, and health care related to sexually transmitted infections (18, 19). Endorsed by the American College of Obstetricians and Gynecologists, the U.S. Medical Eligibility Criteria for Contraceptive Use and the U.S. Selected Practice Recommendations for Contraceptive Use offer important information on how best to provide patient-specific contraception counseling and management (20, 21). Obstetrician–gynecologists provide care for women across the lifespan, and periodic well-woman visits are appropriate and necessary for perimenopausal women and postmenopausal women as well.

Conclusion

Obstetrician–gynecologists have the opportunity to provide holistic care for their patients. This includes taking a comprehensive history, diagnosing and treating conditions that are identified with a comprehensive history and focused examinations, and providing evidence-based and evidence-informed clinical preventive services. Although components of a physical examination may not be required at a well-woman visit, obstetrician–gynecologists can play a critical role in engaging patients in shared decision making, encouraging and facilitating healthy behaviors, and counseling about a wide array of effective preventive health practices. There is great variability in how these services are offered among health care delivery systems, and obstetrician–gynecologists should work within their local systems to promote their role in providing primary and preventive care services for women.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/WellWoman.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

References

  1. Stormo AR, Saraiya M, Hing E, Henderson JT, Sawaya GF. Women's clinical preventive services in the United States: who is doing what? JAMA Intern Med 2014;174:1512–4.
  2. Morgan MA, Lawrence HI, Schulkin J. Obstetrician-gynecologists' approach to well-woman care. Obstet Gynecol 2010;116:715–22.
  3. Morgan MA, Anderson BL, Lawrence H, Schulkin J. Well-woman care among obstetrician-gynecologists: opportunity for preconception care. J Matern Fetal Neonatal Med 2012;25:595–9.
  4. Stidham Hall K, Patton EW, Crissman HP, Zochowski MK, Dalton VK. A population-based study of US women's preferred versus usual sources of reproductive health care. Am J Obstet Gynecol 2015;213:352.e1–14.
  5. Simon AE, Uddin SFG. Trends in seeing an obstetrician-gynecologist compared with a general physician among U.S. women, 2000-2015. Obstet Gynecol 2017;130:677–83.
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  17. Centers for Disease Control and Prevention. Planning for pregnancy. Atlanta (GA): CDC; 2018.
  18. Gavin L, Moskosky S, Carter M, Curtis K, Glass E, Godfrey E, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63(RR-4):1–54.
  19. Gavin L, Pazol K, Ahrens K. Update: providing quality family planning services - recommendations from CDC and the U.S. Office of Population Affairs, 2017. MMWR Morb Mortal Wkly Rep 2017;66:1383–5.
  20. Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG, Zapata LB, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65(RR-3):1–104.
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Published online on September 24, 2018.

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Well-woman visit. ACOG Committee Opinion No. 755. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e181–86.

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