ACOG Releases New Guidance for Well-Woman Visit

Janis C. Kelly

September 11, 2015

The Well-Woman Task Force convened by the American Congress of Obstetricians and Gynecologists has developed new recommendations for well-woman appointments to guide providers caring for adolescents or adult women.

Jeanne A. Conry, MD, PhD, past president of the American College of Obstetricians and Gynecologists, and Haywood L. Brown, MD, from the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, provided an executive summary of the well-woman visit recommendations, published online September 3 and in the October issue of Obstetrics & Gynecology. They write, "In developing recommendations for the components of the well-woman visit, task force members focused on what should be done to optimize health for the average women. The task force did not examine data supporting the concept of an annual visit but accepted that the annual visit is an essential part of preventive health care."

Dr Brown told Medscape Medical News that three areas warrant special attention from clinicians: the recommendations on breast screening, pelvic examination, and screening for depression and for domestic violence.

The recommendations are based on age and reproductive potential, categorized as adolescents (aged 13 - 18 years), reproductive-aged women (aged 19 - 45 years), mature women (aged 46 - 64 years), and women older than 64 years. They were drawn from evidence-based guidelines, evidence-informed guidelines, and uniform expert agreement. The final recommendations were compiled in a consensus document by members of the task force. These included members from the American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American College of Nurse-Midwives, American College of Osteopathic Obstetricians and Gynecologists, American College of Physicians, Association of Reproductive Health Professionals, Association of Women's Health, Obstetric and Neonatal Nurses, National Association of Nurse Practitioners in Women's Health, National Medical Association, Planned Parenthood Federation of America, Society for Maternal–Fetal Medicine, Society of Academic Specialists in General Obstetrics and Gynecology, and Society of Gynecologic Oncology.

"For women of 40 to 45 who do not have risk factors for breast cancer, the recommendation is that the clinician and patient decide together whether to do mammography and whether to repeat it at 1 to 2 years. However, for patients at high risk (especially if there is a family history of breast cancer), clinicians should follow the standard recommendations," Dr Brown said.

The recommendations on pelvic examination were influenced by recent changes in cervical cancer screening guidelines that dropped the recommendation for annual Papanicolaou tests. Dr Brown said there is ongoing concern within the American College of Obstetricians and Gynecologists that women will misinterpret this to mean that regular medical examinations are no longer necessary.

"Even if you are not doing a speculum or bimanual pelvic examination during the well-woman visit, it is important to inspect the external genitalia for vulvar lesions (including cancer)," Dr Brown said.

Finally, Dr Brown emphasized the importance of screening for domestic violence and for depression during every well-woman visit. "Unless you ask the right questions, you may not get the answer. But you can't just look at a woman and tell whether she is struggling with these issues. Physicians, nurse practitioners, and other clinicians who might be conducting the well-woman visit have to take the time to develop a relationship so the patient feel likes she can talk to you," he said.

In an accompanying editorial, George F. Sawaya, MD, from the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, acknowledged the work done by the Well-Woman Task Force, but suggested that "clinicians may find the list overwhelming and difficult to navigate." Dr Sawaya compared the recommendations with the web-based application from the Agency for Healthcare Quality and Research, which includes both an "Electronic Preventive Services Selector," available on the website, and a free smartphone app.

Dr Sawaya writes, "Although the recommendations of the U.S. Preventive Services Task Force are a subset of those suggested by the Well-Woman Task Force, they provide an easy starting point for clinicians interested in prioritizing evidence-based recommendations for prevention, at least until this current list can be organized similarly."

Dr Brown told Medscape Medical News that the medical groups that helped develop the well-woman visit recommendations are in the process of developing a new website that will facilitate access to and use of the recommendations. "We also need to include these recommendations in residency training, continuing medical education, and electronic medical records," he said.

Dr Brown and Dr Sawaya have disclosed no relevant financial relationships.

"Well-Woman Recommendations." American Congress of Obstetricians and Gynecologists. Full text

Obstet Gynecol. 2015;126:695-701. Executive summary extract, Editorial extract

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