Guidelines concerning the important elements of annual well-woman visits, such as when to perform pelvic exams in asymptomatic patients and when to begin formal breast exams, are now available from the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice.
At the annual visit, ob.gyns. should counsel women about maintaining a healthy lifestyle and minimizing their health risks. A physical examination also is key and should include obtaining vital signs, determining body mass index, palpating the abdomen and the inguinal lymph nodes, and assessing overall health, according to ACOG Committee Opinion No. 534.
Pelvic examinations and breast examinations are important at these visits for many, but not for all, women, the Committee on Gynecologic Practice stated (Obstet. Gynecol. 2012;120:421-4).
For example, pelvic exams are recommended annually for all women aged 21 and older, and are "an appropriate component of a comprehensive evaluation" for all women who report symptoms that suggest problems of the genital tract, pelvis, urinary tract, or rectum. Some of these include menstrual disorders, vaginal discharge, infertility, or pelvic pain.
However, pelvic exams are not recommended for women younger than 21 unless indicated by the medical history. "External-only" exams are adequate to assess and discuss with the patient the normal external genital anatomy, issues of person hygiene, and any abnormalities of the vulva, introitus, or perineum that may require further assessment. An external-only exam also gives the ob.gyn. an opportunity to discuss with these young patients the range of normal female anatomy.
For women younger than 21, pelvic exams are not necessary for conducting sexually transmitted infection screening for gonorrhea or chlamydia because nucleic acid amplification testing can be done on urine samples or self-collected vaginal swab specimens.* This method is also adequate for diagnosing yeast infections, trichomoniasis, and bacterial vaginosis in these young women.
Speculum examination for cervical cancer should commence at age 21, "irrespective of sexual activity of the patient," according to the committee opinion.
For older and perimenopausal women, pelvic exams are recommended if there is abnormal uterine bleeding, a change in bowel or bladder function, a vaginal bulge, urinary or fecal incontinence, or vaginal dryness or discomfort. They may be indicated by a woman’s personal or family history, especially for gynecologic malignancies. But otherwise, pelvic exams may be unnecessary in older women.
"It would be reasonable to stop performing pelvic examinations when a woman’s age or other health issues reach a point where the woman would not choose to intervene on conditions detected during the routine examination, particularly if she is discontinuing her other routine health care maintenance assessments," according to the opinion. "Sound clinical judgment always must be the guiding factor in determining when a pelvic examination is needed."
There are no data concerning the age at which to begin clinical breast examinations in asymptomatic, low-risk women, but expert opinion suggests that it depends on the woman’s age and risk factors for breast cancer. The committee members recommend breast exams every 1-3 years for women aged 20-39 years and annually for women aged 40 and older.
Teaching women breast self-awareness is appropriate at any age. This includes educating them about the normal feel and appearance of their breasts, as well as inquiring into their medical history and family history for factors related to breast disease. For many women, it also includes encouraging breast self-examination.
ACOG has made the comprehensive recommendations for annual health assessments available here.
All ACOG committee members are required to follow the college’s guidelines for relationships with the health care industry, according to the ACOG website.
* clarification made 8/15/2012