Well-Woman Visits

Periodic well-woman visits may be provided by a gynecologist, other women's health clinician, or primary care clinician. The American College of Obstetricians and Gynecologists recommends that preventive care visits include screening, evaluation, counseling, immunizations, and shared decision-making based on age and risk factors (1). Taking a gynecologic history during a well-woman visit may also be relevant for patients who are gender diverse (2).

Women's health care should be considered an ongoing, longitudinal process of preventive and screening care across the lifespan, rather than a single annual event consisting of unvarying content at every visit. Some patients may benefit from annual visits, but the interval may differ across patients, and the specific services provided should be individualized based on age, risk factors, symptoms, and patient needs or priorities. Social determinants of health, reproductive planning, and sexual health should be addressed as part of preventive gynecologic care (1).

Well-woman visits should include taking a comprehensive medical history, including current symptoms or concerns as well as medical, surgical, gynecologic, obstetric, sexual, family, and social history; medications and allergies should also be tracked. This history should be obtained using inclusive language and a medical interpreter, if the clinician and patient cannot communicate effectively in the same language. Taking a gynecologic history may also be relevant for transgender, nonbinary, and other gender-diverse patients depending on anatomy, hormone use, and individual health needs (1).

During a well-woman visit, patients may be screened for or counseled about

• Breast cancer

• Cervical cancer

• Endometrial cancer

• Sexually transmitted infections (STIs)

• Safer sex practices

• Contraception

• Preconception care

• Perimenopause and menopause

• Osteoporosis screening and prevention

Immunizations, mental health, intimate partner violence, sexual trauma (3), eating disorders, substance use, and general health risks such as obesity, hypertension, diabetes, and dyslipidemia should also be addressed directly or coordinated with the patient's primary care clinician.

Future reproductive planning—including whether the patient desires pregnancy in the next year—should be reviewed periodically; doing so helps guide choice of contraception, preconception counseling, and optimization of care of chronic disease (4).

Sexually active women who use contraceptive methods other than condoms should be counseled about STI-prevention measures. These include HPV vaccination, preexposure prophylaxis (PrEP) for HIV, postexposure prophylaxis (PEP) for HIV and other STIs, limiting the number of sex partners, and the correct and consistent use of condoms.

Depending on history of vaccination for human papillomavirus (HPV) and age of the patient, HPV vaccination should be offered. Catch-up HPV vaccination is routinely recommended through age 26 years; for adults aged 27 through 45 years, vaccination may be offered using shared decision-making (5).

Women's health clinicians should routinely discuss HIV prevention and offer testing. Preexposure prophylaxis with antiretrovirals (PrEP) should be offered within 72 hours to all patients who are not infected with HIV but are at high risk for contracting it (eg, because they have a partner who is living with HIV, engage in high-risk sexual behaviors, or inject illicit drugs) (5). For patients with a nonoccupational (eg, sexual, needle-related) exposure to nonintact skin or mucous membranes, the U.S. Centers for Disease Control and Prevention (CDC) recommends nonoccupational postexposure prophylaxis (nPEP) when the exposure occurred within the past 72 hours, presents a substantial risk for HIV transmission, particularly if the source has HIV without sustained viral suppression or their viral suppression information is not known (6, 7).

In addition, doxycycline postexposure prophylaxis (doxyPEP) to prevent chlamydia, gonorrhea, and syphilis is recommended for selected patient populations (men who have sex with men and transgender women who have had a bacterial STI diagnosed in the past 12 months). The efficacy of doxyPEP in other patient populations has not been proven. Clinicians should use clinical judgment and shared decision-making to guide counseling about and use of doxyPEP with women and other patient populations that are not specifically mentioned in the CDC recommendations.

Pelvic Examination

Pelvic examination is performed if indicated based on symptoms, such as pelvic pain, abnormal vaginal bleeding, vaginal discharge, or vulvovaginal symptoms (eg, pruritus) or the need to perform a gynecologic procedure.

The question of whether to perform pelvic examinations for detection of ovarian cancer, bacterial vaginosis, trichomoniasis, and genital herpes in asymptomatic women has been studied, but data are inadequate to recommend for or against this practice (8). Thus, screening pelvic examinations are not required, but they may be performed if this decision is made based on shared decision-making between the patient and clinician. Also, pelvic examination is not indicated for initiation or renewal of contraception, except for an intrauterine device.

The components of the pelvic examination—including external genital examination, speculum examination, and bimanual examination—should be explained to the patient, who may consent to certain components and refuse others.

Women with risk factors for gynecologic cancer (eg, history of cervical dysplasia, in-utero exposure to diethylstilbestrol [DES]), or prior gynecologic malignancy may require more frequent pelvic examination and should be managed according to current guidelines.

Pelvic Examination With Speculum

Image

This illustration shows a pelvic examination with a speculum.

JOHN FOSTER/SCIENCE PHOTO LIBRARY