It’s time to re-tool the annual exam: Here’s how
Capitalize on patients’ habit of visiting your office once a year to implement appropriate services
IN THIS ARTICLE
Physical exam. Measure height, weight, body mass index, and blood pressure. Check off items included in the examination of breast, abdominal, and pelvic structures, and elaborate on abnormal findings in a space provided. Include an area on the form for noting “other” concerns, such as findings of skin, musculoskeletal, upper respiratory, and cardiac assessments—any of which is performed as indicated.
Lab testing. Document routine testing with 1) a check box to indicate which tests have been ordered and 2) a line on which to note the tests that were identified as appropriate but were not performed or were deemed inappropriate—and why. Such documentation is helpful when coding pay-for-performance measures.
Counseling. Develop a list that includes smoking cessation, weight loss, exercise, contraception, and prevention of osteoporosis and sexually transmitted infection. The list helps you recall, and discuss, essential areas (TABLE 1).
The goal in developing and using a template? It provides a single, easy-to-use form that is flexible and applicable to all women, and that encourages consistent adherence to guidelines for screening and prevention.
TABLE 1
Remember to provide lifestyle counseling!
| Don’t smoke |
| Drink alcohol in moderation |
| Eat healthy—ie, high-fiber, low-fat foods, including fruits and vegetables |
| Exercise often—ie, aerobic, weight-bearing, and balance activities |
| Maintain healthy weight* |
| Use a condom during sexual intercourse |
| Use a contraceptive |
| *Be prepared to provide strategies for effective, sustainable weight loss to your patients |
With a format in place, screen in 7 areas
What do guidelines recommend that we embrace as interventions to make a difference in patients’ long-term health? Research and consensus have established that the annual well-woman visit be organized around clinical areas of concern, comprising 7 primary intervention areas and 3 optional areas of general health (TABLE 2). In addition, ObGyns are well-positioned to add several areas of counseling, support, and intervention:
- lifelong contraception management and planning
- pre-pregnancy counseling
- prevention of sexually transmitted infection
- identification of sexual concerns
- management of menopause.
Chlamydial infection. “Grade-A” evidence supports annual screening for Chlamydia trachomatis for 1) all sexually active women 25 years and younger and 2) older women who engage in high-risk behavior (eg, more than one sex partner).
Pap smear and HPV typing. ACOG and the American Cancer Society recommend annual Pap smear testing beginning 3 years after the onset of sexual activity and continuing until 30 years of age. Routine testing for high-risk HPV subtypes may be undertaken with the Pap smear for women older than 30 years.
For most women who test negative for HPV and who have negative Pap smear cytology, Pap smear testing should be repeated no more often than every 3 years. Women who are positive for a high-risk HPV type despite a negative Pap smear should continue to be screened annually with cytology and HPV testing.
Breast health. Many groups recommend training women to perform monthly breast self-examination (BSE), although the USPSTF states that there is “insufficient evidence to recommend for or against” BSE. All groups do, however, advise an annual breast examination by a clinician, along with annual or biennial mammography beginning at 40 years of age and annual mammography beginning at 50 years.
Although many women do detect a breast lump when performing a BSE, it is unclear whether BSE improves survival from breast cancer. That’s because many lumps that women discover are benign.
Generally, therefore, I tell patients to pay attention to their breasts as they would other body parts: Don’t ignore an obvious change but don’t feel it is necessary to perform a standardized examination of the breasts monthly; evidence just does not support such a need.
Cardiovascular health. Assess blood pressure in every patient at every visit. Persistently high readings (>130/80 mm Hg) should prompt action—whether lifestyle modification or medication. Many physicians are slow to treat young women with so-called labile or borderline hypertension because the onset of cardiovascular disease is generally at an older age in women, but evidence shows that women suffer from proportionately more strokes at a young age than men do. Aggressive management of persistent hypertension may improve outcome.
- Aspirin therapy is recommended for prevention of stroke in women 45 to 65 years who are at risk. Do not recommend aspirin routinely, however, for women younger than 65 years as a means of preventing myocardial infarction.
- Perform a baseline lipid profile on all women older than 45 years. A woman who has a risk factor for cardiovascular disease—smoking, hypertension, obesity or overweight, a family history of early-onset cardiovascular disease—should be screened at any age.
- Screening may be performed as a random lipid profile to eliminate the barrier of returning after an 8-hour fast. Only women who have a significant abnormality need to return for repeat testing after an overnight fast.
- I usually intervene with lifestyle modification recommendations first—more exercise, weight loss, more monounsaturated fats and omega-3 fats in the diet—and have the patient return for a fasting lipid profile after 3 to 6 months.
