The Well Woman Visit

For Candace Cooley, the later years of practice tilted toward gynecology in the office and preventive care, and the well woman visit is the basic unit of that kind of medicine. One number from the wider field shows why the visit took the shape it did. When the American College of Obstetricians and Gynecologists issued its cervical cytology guideline in 2003, it reported that new cases and deaths from cervical cancer in the United States were down by close to fifty percent compared with the early 1970s, American Family Physician noted, while the yearly rate had held near eight new diagnoses for every 100,000 women.⁸ The guideline pointed to the long precancerous phase of the disease, which lets repeated tests make up for a single missed result, and to treatment that is effective once a true abnormality is found.⁸ A test done at a yearly checkup had changed the course of a cancer. Much of the story of the well woman visit since then is the story of what else belongs at that checkup, and how often.

Figure

Cervical cancer under screening, 2003

fall in cervical cancer incidence and deaths since the early 1970s

almost one half

new cases a year per 100,000 women

about 8

of new cases linked to sampling or interpretation errors

30 percent

What the visit contains

The visit is defined by purpose rather than by a list. A frequently asked questions sheet on the well woman chart of the Women’s Preventive Services Initiative, a project led by the obstetricians’ college with federal support, describes it as a clinical encounter that promotes health over a woman’s lifetime through preventive care, distinct from a problem visit aimed at new or existing symptoms.² Its services may include assessment of physical and psychosocial function, screening, risk assessment, immunizations, counseling and education, and the visit can be spread across more than one appointment.² The initiative recommends at least one preventive visit a year from adolescence onward.²

Age organizes the content. The chart is divided into age groups, and within each the services fall under general health, infectious diseases and cancer; where the initiative, the United States Preventive Services Task Force and a pediatric program overlap, it uses the most inclusive recommendation.² The 2012 committee opinion on annual visits, summarized by MDedge, listed counseling on a healthy lifestyle, vital signs, body mass index, examination of the abdomen and groin lymph nodes, and an overall assessment of health.¹ It recommended clinical breast exams every one to three years for women 20 to 39 and every year from 40, and it endorsed teaching breast self awareness at any age.¹ A women’s health researcher quoted by NBC News when the opinion appeared argued that the counseling, on smoking, physical activity and weight among other subjects, mattered as much as any single test.⁹ Family history is part of that assessment, and has an entry of its own.

Figure

What the 2012 committee opinion put in the visit

1. 01
   CounselingA healthy lifestyle and ways to reduce health risks.
2. 02
   General examVital signs, body mass index, the abdomen and the lymph nodes of the groin.
3. 03
   Pelvic examYearly from age 21; external only before 21 unless the history calls for more.
4. 04
   Breast examEvery one to three years from 20 to 39, then every year from 40.

The same opinion tied the pelvic exam to age and history rather than to the calendar alone. Before 21, testing for gonorrhea and chlamydia could be done on urine or a self collected swab, so an internal exam was not needed for that purpose.¹ In older women, the committee listed reasons for an exam such as abnormal bleeding, a change in bowel or bladder function, a vaginal bulge, incontinence or vaginal dryness, and it judged it reasonable to stop routine pelvic exams once a woman would no longer choose to act on what they might find.¹ Clinical breast exams drew a similar question. NBC News noted that the task force had found insufficient evidence that they add to what mammography provides.⁹

How the content changed

The Pap test changed first. In 2003 the obstetricians’ college tied the start of cervical cytology to roughly three years after a woman became sexually active, with 21 as the latest starting age, screening every year under 30, and allowing intervals of two to three years after 30 for women with three consecutive normal results; it added that annual examinations, including a pelvic exam, were still recommended whatever the screening interval.⁸ By its 2012 bulletin, summarized in American Family Physician, screening began at 21 regardless of sexual history, cytology was repeated every three years in the twenties, cotesting with HPV every five years was preferred from 30 to 65, and screening stopped after 65 for women with adequate negative results.⁷ Annual cytology, the bulletin said, did little more to prevent cancer and led to excess procedures.⁷ Once the Pap test no longer came every year, the question of why the visit itself should be yearly sharpened. The longer arc of those changes has its own entry.

Figure

Cervical screening by age, 2012

1. 01
   Under 21No screening, whatever the age at first sexual activity.
2. 02
   21 to 29Cytology every three years.
3. 03
   30 to 65Cytology with HPV testing every five years preferred, or cytology alone every three years.
4. 04
   Over 65Stop after an adequate record of negative results and no history of serious precancer.

The pelvic exam came next. In 2014 the American College of Physicians advised that healthy women who are not pregnant and have no symptoms no longer receive pelvic exams at well woman visits, while the obstetricians’ college kept its yearly recommendation from 21 and described the choice as one for doctor and patient to share, KFF Health News reported.⁶ A nurse writing in The New Republic warned that headlines blurred the pelvic exam with the Pap test and risked keeping women away from care.⁴ In 2017 the task force found the evidence insufficient either way, and NPR stressed that its advice on Pap tests was unchanged.³ The Association of Health Care Journalists urged reporters to make clear that a pelvic exam and an annual visit are not the same thing, and that yearly well woman care remained recommended.⁵ That dispute has a full entry.

What emerged is a visit with a stable purpose and a variable content. The initiative’s chart is meant as a starting point to be adapted to each woman, and it states plainly that not every listed service is expected at every visit; age, health, pregnancy status and risk factors decide what a given year holds.² Decisions about when to start, repeat or stop a screening are meant to come from periodic shared decision making that weighs benefits and harms with the woman’s values and health.² Even the exam itself has a range. For women under 21, the 2012 opinion described an external exam as enough to review normal anatomy and to discuss with a young patient the range of normal female anatomy.¹ Which of these services a given year calls for is something each woman sorts out with her own clinician.