Back to Basics: The Well-Woman Visit

April 17, 2014

Don’t let time constraints and large patient loads prevent you from providing a thorough well-woman visit. Are you covering all the bases?

The old adage, “An ounce of prevention is worth a pound of cure,” becomes more meaningful every day.

As ob/gyns, we are often the primary care providers for many of our patients. This designation allows us the unique privilege and responsibility of providing optimal medical care to women of all ages and all walks of life. In doing so, we must help women recognize that preventive care is just as important as point of care.

The Affordable Care Act (ACA) has made it even easier for women to obtain and afford an annual well-woman visit. As providers, we should also have mechanisms in place that not only remind women when it’s time for their “annuals” but also facilitates the appointment process.

The annual health assessment is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the clinician-patient relationship. Many of the buzz words in the health industry today, such as prevention, nutrition, life coach, wellness centers, physical therapy, and yoga, have a cornerstone in the annual wellness exam.

The ACA mandates that insurers cover key preventive services without co-pays or deductibles. Among the gynecological services covered are:

- Well Woman Visits (at least 1 annually).
- All FDA-approved contraceptive methods and contraceptive counseling.
- Mammograms.
- Pap tests.
- HIV and other STD screening and counseling.
- Domestic violence screening and counseling.

Additional preventive services that must be “offered” but can involve co-pays are:

- BRCA testing and counseling.
- Osteoporosis screening after age 60 for women without risk factors.
- Tobacco use screening, treatments, and counseling.

 

The Annual Well-Woman Exam

It’s beneficial to women that an annual gynecological exam is covered fully. As gyn providers, the annual visit is the perfect opportunity to detect and help correct medical problems. Every visit also provides physicians the opportunity to counsel and even teach patients how to maintain their health.

To that end, each well-woman visit should have 4 components:

1.  Screening.
2.  Laboratory and other tests.
3.  Evaluation and counseling.
4.  Immunizations.

There are age-specific tests for women 13 to 18 years, 19 to 39 years, 40 to 64 years, and older than 65 years explained in detail here

The Physical Exam

The physical exam (PE) is integral to the evaluation portion of the annual visit. The actual components of the PE will vary depending on the patient’s age, risk factors, and preferences. In general, however, the PE should include:

- Updated personal history (medical and social).
- Updated family history (particularly of cancer, cardiovascular disease, and psychiatric).
- Weight, height, and BMI.
- Assessment of overall health.
- Abdominal exam.
- Clinical breast exam. (Note: ACOG and the American Cancer Society both agree that a clinical breast exam should be done annually in women 40 and older. I perform it on every patient regardless of age, since breast self-awareness education is for all ages.)
- Pelvic exam.

The Pelvic Exam

An annual pelvic exam is recommended by ACOG for women 21 years and older. This exam has 3 components: 

1.  The external exam, which consists of inspection of the external genitalia, urethral meatus, vaginal introitus, and perineal region.
2.  The speculum exam of the vagina and cervix.
3.  A bimanual (BM) exam of the uterus, cervix, and adnexa, and a rectal vaginal exam when indicated.

The speculum and BM exams are both considered part of the internal exam and should be performed with the patient’s permission.

For women younger than 21 years, only an external exam is necessary. An internal exam at this age is indicated if a patient has a gynecological complaint or symptoms such as pain, abnormal bleeding, abnormal discharge, or a family history of disorders. It should also be done prior to any procedure, including insertion of an IUD.

While it may go against some of the training of more senior gynecologists, data does not support the necessity of performing an internal pelvic exam before initiating hormonal contraception in an otherwise healthy asymptomatic woman. Even STD screening can be done without an internal pelvic exam via nucleic acid amplification tests (NAAT) on urine or vaginal swabs.

The First Well-Woman Visit
ACOG recommends the first well-woman visit should occur between the ages of 13 and 15 years. This visit does not require an internal pelvic exam unless STD screening is indicated or unless the patient reports abnormal symptoms. This early encounter is a key opportunity to establish a healthy physician-patient relationship and to discuss relevant issues, such as body image, weight, diet, exercise, STD prevention, contraception, and risk behaviors. It also is an opportunity to ensure that our young patients are receiving recommended immunizations, including the HPV vaccine.

 

Time-Saving Tips

As gynecologists, we constantly are struggling with time constraints involving face time with patients. A few time-saving tips for covering all of the components of the well-woman visit are:

- Have the patient fill out an updated history prior to seeing you (electronically or paper).
- Have your nurse/med techs work up the patients’ vital signs and BMI before you enter the room.
- Have all screening tests ready for use in the exam rooms, including Pap, HPV, STD, and urine.
- Use eScripts.
- Appoint a designated “educator” in the office who can explain how to take medications and how to properly use birth control or other devices, as well as who can counsel patients on test results and prevention practices.
- Keep additional educational materials and models quickly available so you can use them in real time with patients.
- Allow a few moments before and after the PE for the patient to ask questions or share any concerns she may have. Schedule a follow-up visit if the concerns require more involved counseling.

We need to remind ourselves what a privileged profession we have, and at the annual well woman visit, it’s all about her.