Mar 21, 2011

ACOG Updates Routine Well-Woman Annual Screening Guidelines

The Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists (ACOG) has updated guidelines for routine screenings, laboratory tests, and immunizations for the annual examination visit of nonpregnant adolescents and women, according to a Committee Opinion published in the April issue of Obstetrics & Gynecology.

“The purpose of the annual ob-gyn visit is to detect and treat any new or ongoing health problems as well as to help prevent future ones from developing,” said Hal C. Lawrence, III, MD, ACOG vice president for Practice Activities, in a news release.

“The College urges the US Department of Health and Human Services to include these screenings, tests, and immunizations included in our well-woman exam recommendations under the preventive services that it is considering for inclusion under the new health care law.”

Recommended Health Assessments

Through use of numerous charts, the Committee Opinion groups the periodically recommended health evaluations by age range, beginning at age 13 years, and considers individual risk factors that may necessitate further tests, screenings, and/or counseling.

Required evaluations for every annual ob-gyn examination, regardless of age, include determination of current health status, nutrition, physical activity, sexual behavior, and use of tobacco, alcohol, and drugs. Adolescent girls and women of all ages should also undergo measurement of height, weight, body mass index, and blood pressure. At age 19 years, annual breast and abdominal examinations should be initiated, and routine annual pelvic examinations should start at age 21 years.

“Since the age a woman receives her first Pap [Papanicolaou] test changed two years ago to age 21, and most women can have them less frequently than previously recommended, there’s this misconception that if you don’t need a Pap then you can skip the ob-gyn visit altogether,” Dr. Lawrence said. “Nearly every woman age 21 and older needs an annual well-woman visit with her ob-gyn, regardless of whether cervical cancer screening is done. The Pap test is just one part of staying healthy.”

The updated guidelines also include charts for vaccination recommendations, by age and risk group, including the flu shot, Hepatitis A and B, human papillomavirus, and measles. All sexually active adolescents and young women up to age 25 years should undergo annual testing for chlamydia and gonorrhea. Starting at age 19 years and continuing until age 64 years, all sexually active adolescents and women should undergo routine testing for HIV infection.

The Committee Opinion offers general recommendations to guide care provided by obstetricians, gynecologists, and other clinicians who provide healthcare to women. However, these recommendations should be modified based on risk factors or other conditions that could necessitate additional or more frequent tests and interventions.

“For instance, we recommend that women have their first mammogram at age 40, and yearly beginning at 50, but a woman and her doctor may decide to have a baseline mammogram before age 40 if there is a family history of breast cancer,” Dr. Lawrence said.

Risk Factors and Interventions

Some of the specific interventions, and some of the high-risk factors that may indicate that the intervention is needed, include the following:

  • Bone mineral density screening: postmenopausal women younger than 65 years, history of prior fracture as an adult, family history of osteoporosis, Caucasian, dementia, poor nutrition, smoking, low weight and body mass index, estrogen deficiency, low lifelong calcium intake, alcoholism, impaired eyesight, history of falls, inadequate physical activity, and medical conditions and certain drugs associated with an increased risk for osteoporosis.
  • Colorectal cancer screening: family or personal history of colorectal cancer, adenomatous polyps, inflammatory bowel disease, chronic ulcerative colitis, or Crohn’s disease.
  • Diphtheria and reduced tetanus: close contact with an infant younger than 12 months and healthcare providers. When possible, women should receive diphtheria and reduced tetanus toxoids and acellular pertussis vaccine before conceiving.
  • Fasting glucose level testing: overweight, first-degree relative with diabetes mellitus, physical inactivity, high-risk race or ethnicity, history of gestational diabetes mellitus or delivery of a high-birth-weight infant, hypertension, dyslipidemia, history of impaired glucose tolerance or impaired fasting glucose level, polycystic ovary syndrome, history of vascular disease, and other clinical conditions associated with insulin resistance.
  • Fluoride supplementation: residence in area with inadequate water fluoridation.
  • Genetic testing/counseling: considering pregnancy and patient, partner, or family member with a history of genetic disorder or birth defect; exposure to teratogens.
  • Hemoglobin testing: Caribbean, Latin American, Asian, Mediterranean, or African ancestry; menorrhagia; hepatitis A virus vaccination; chronic liver disease; clotting factor disorders; use of illegal drugs.
  • Hepatitis B virus vaccination: hemodialysis, use of clotting factor concentrates, healthcare workers or students with exposure to blood in the workplace or school, use of injection drugs, multiple sexual partners, sexually transmitted diseases.
  • Hepatitis C virus testing: use of illegal injection drugs, recipients of clotting factor concentrates before 1987, long-term hemodialysis, persistently abnormal alanine aminotransferase levels, recipients of blood from donors who later tested positive for hepatitis C virus infection, multiple sexual partners.
  • HIV testing: more than 1 sexual partner since most recent HIV test, a sexual partner with more than 1 sexual partner since most recent HIV test, sexually transmitted disease in the past year, drug use by injection, invasive cervical cancer. HIV testing should be recommended to women seeking preconception evaluation.

Other interventions discussed, along with risk factors indicating their use, include lipid profile assessment, mammography, meningococcal vaccination, measles-mumps-rubella vaccination, pneumococcal vaccination, rubella titer assessment, testing for sexually transmitted diseases, skin examination, thyroid-stimulating hormone testing, tuberculosis skin testing, and varicella vaccination.

Obstet Gynecol. 2011;117:1008-1015. Extract

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