Barbara S. Levy, MD It’s time to re-tool the Medical Director, Women’s Health Center, Franciscan Health System, Federal Way, Wash. Dr. Levy is a annual exam: Here’s how member of the OBG MANAGEMENT Board of Editors and serves on ACOG’s Coding and Nomenclature Committee. Capitalize on patients’ habit of visiting your offi ce She is also ACOG’s representative to the AMA’s RBRVS (resource-based once a year to implement appropriate services relative value system) Update Committee. The author reports no fi nancial relationships relevant to this article. ecent advances in the understand- vention—came into question with the ing and detection of cervical cancer rise of evidence-based medicine in the Rhave resulted in a recommenda- mid-1970s and, eventually, became un- tion to increase the screening interval with supportable. In 1979, the Canadian Task a Pap smear from annually to every 2 or® 3 DowdenForce on the PeriodicHealth Health Media Examina- years for low-risk patients. We know that tion concluded that the value of only a cervical cancer requires the persistence of few preventive interventions was sup- high-risk human papillomavirusCopyright (HPV)For personalported by data. use In 1989, only Oboler and col- types to develop, and this knowledge has leagues concluded that “comprehensive provided high-level evidence that annual annual exams in asymptomatic adults cervical cancer screening is not benefi cial have little screening value…”1 for most women. The American College of Physicians, IN THIS ARTICLE Where does this shift in the surveil- American Medical Association, US Pre- lance strategy for cervical cancer leave ventive Services Task Force (USPSTF), and ❙ H & P items us? Implementing new screening inter- US Public Health Service all concur: The to include on a vals gives us a wonderful opportunity to routine, annual, comprehensive physical screening form reevaluate the annual exam, and to edu- exam is unnecessary. Instead, physicians Page 66 cate ourselves and patients about inter- should institute a selective approach to ventions that make an impact on health. identifying and preventing health prob- ❙ Pillars of an annual lems in all patients—one based on gender, screening program age, health history, and risk factors. Eliminate the annual exam? Page 69 Do we still need routine encounters with Some interventions have helped ❙ our patients? In this article, I address 2 The incidence of, and mortality from, Metabolic topics that can help answer the question: cervical cancer dropped strikingly in the syndrome—well I review the evidence that supports an- United States with the advent of annual worth investigating nual “well-woman” visits and outline the screening with the Pap smear. Mam- Page 70 interventions that have proven benefi t. mography has recently been proved to increase the early detection rate of Time to retire a time-honored tradition breast cancer and to reduce the rate The utility of an annual health visit—ie, of death from breast cancer. The chal- a comprehensive head-to-toe physical lenge we face, therefore, is to determine exam coupled with a battery of tests for which screening tests and interventions early identifi cation of disease and inter- are valuable and will translate into

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TABLE 1 from the typical ObGyn visit—one that Remember to provide includes a breast and pelvic examina- lifestyle counseling! tion, cervical cancer screening, and mam- mography—to an evidence-based, annual Don’t smoke well-woman visit that can be rapidly im- Drink alcohol in moderation plemented and easily documented, using Eat healthy—ie, high-fi ber, low-fat foods, a paper or an electronic medical record? including fruits and vegetables I recommend creating templates for Exercise often—ie, aerobic, weight-bearing, the annual well-woman visit that are age- and balance activities specifi c and include check boxes for the Maintain healthy weight* age-appropriate history, physical exam, testing, and counseling that you’ll pro- Use a condom during sexual intercourse vide. You can create a distinct form for Use a contraceptive each of the various age and risk groups *Be prepared to provide strategies for effective, or, more simply, devise a single form that sustainable weight loss to your patients includes all guidelines for screening, from which you choose the appropriate areas improved health outcomes. The USPSTF based, again, on age and risk status. has set out broad recommendations on 10 areas of screening for women: Build a screening form • monitor blood pressure What should you include on the template • screen for cervical and colorectal that you create? Here are possible items, cancers, depression, diabetes, based on what I use in my practice: and osteoporosis History. Document the patient’s age, aller- • test for chlamydial infection gies, medications, contraceptive method, • measure the cholesterol level and risk factors (eg, smoking, a history • perform mammography. of infection with high-risk HPV types, and a signifi cant family history of colon, FAST TRACK New tool helps you develop an exam breast, and ovarian cancer and of heart Create templates Available for you is an excellent on- disease and diabetes). Develop a problem line resource developed by the Agency list of concerns that the patient, and you, for the annual well- for Healthcare Research and Quality have. Note: I ask the patient to complete woman visit that are (AHRQ) for adopting the USPSTF screen- a checklist review of systems at every an- age-specifi c and ing recommendations. AHRQ has created nual visit; doing so helps identify specifi c that include check the “electronic preventive services select” health concerns she may want to discuss. boxes for the history, (or ePSS) Web site (http://epss.ahrq.gov), Physical exam. Measure height, weight, which is searchable by patient sex, age, body mass index, and blood pressure. physical, testing, and and behavioral risk factors. The evidence Check off items included in the exami- counseling for various preventive services is graded, nation of breast, abdominal, and pelvic guiding you on both interventions that structures, and elaborate on abnormal are strongly recommended and those that fi ndings in a space provided. Include an should not be offered routinely because area on the form for noting “other” con- they lack data to support utility. cerns, such as fi ndings of skin, musculo- skeletal, upper respiratory, and cardiac assessments—any of which is performed Make the transition with as indicated. a systematic approach Lab testing. Document routine testing We can capitalize on the habit that patients with 1) a check box to indicate which tests have established and have them come in have been ordered and 2) a line on which annually for appropriate, evidence-based to note the tests that were identifi ed as services. How do we make the change appropriate but were not performed or CONTINUED

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were deemed inappropriate—and why. TABLE 2 Such documentation is helpful when cod- ing pay-for-performance measures. The pillars of an annual primary screening program Counseling. Develop a list that includes smoking cessation, weight loss, exercise, ESSENTIAL contraception, and prevention of osteo- • Sexually transmitted infection • Diabetes porosis and sexually transmitted infec- (Chlamydia trachomatis) and • Colorectal cancer tion. The list helps you recall, and discuss, cervical cancer (HPV) • Osteoporosis essential areas (TABLE 1, page 66). • Breast health • Depression The goal in developing and using a • Cardiovascular health template? It provides a single, easy-to- OPTIONAL use form that is fl exible and applicable to all women, and that encourages consis- • Bladder health (incontinence) • Domestic violence tent adherence to guidelines for screen- • Thyroid disease ing and prevention. years after the onset of sexual activity and continuing until 30 years of age. Routine With a format in place, testing for high-risk HPV subtypes may screen in 7 areas be undertaken with the Pap smear for What do guidelines recommend that we women older than 30 years. embrace as interventions to make a dif- For most women who test negative ference in patients’ long-term health? for HPV and who have negative Pap Research and consensus have established smear cytology, Pap smear testing should that the annual well-woman visit be or- be repeated no more often than every ganized around clinical areas of concern, 3 years. Women who are positive for a comprising 7 primary intervention areas high-risk HPV type despite a negative Pap and 3 optional areas of general health smear should continue to be screened an- (TABLE 2). In addition, ObGyns are well- nually with cytology and HPV testing. positioned to add several areas of coun- Breast health. Many groups recommend FAST TRACK seling, support, and intervention: training women to perform monthly breast I tell patients not • lifelong contraception self-examination (BSE), although the management and planning USPSTF states that there is “insuffi cient ev- to ignore an obvi- • pre-pregnancy counseling idence to recommend for or against” BSE. ous change in the • prevention of sexually transmitted All groups do, however, advise an annual breast—but also infection breast examination by a clinician, along that they should not • identifi cation of sexual concerns with annual or biennial mammography feel it’s necessary to • management of menopause. beginning at 40 years of age and annual Prevention of cervical Ca. With approval mammography beginning at 50 years. perform a standard- last year of the vaccine against several Although many women do detect a ized breast exam HPV types, we are in an unprecedent- breast lump when performing a BSE, it monthly ed position to recommend vaccination is unclear whether BSE improves survival against HPV—and other diseases. from breast cancer. That’s because many Chlamydial infection. “Grade-A” evidence lumps that women discover are benign. supports annual screening for Chlamyd- Generally, therefore, I tell patients ia trachomatis for 1) all sexually active to pay attention to their breasts as they women 25 years and younger and 2) would other body parts: Don’t ignore an older women who engage in high-risk be- obvious change but don’t feel it is neces- havior (eg, more than one sex partner). sary to perform a standardized examina- Pap smear and HPV typing. ACOG and tion of the breasts monthly; evidence just the American Cancer Society recommend does not support such a need. annual Pap smear testing beginning 3 Cardiovascular health. Assess blood

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pressure in every patient at every visit. reduction and exercise, my experience is Persistently high readings (>130/80 mm that providing a message to patients con- Hg) should prompt action—whether life- sistently about a healthy lifestyle is more style modifi cation or medication. Many effective than almost any other medical physicians are slow to treat young women intervention. To have an impact on car- with so-called labile or borderline hyper- diovascular health, however, it is impera- tension because the onset of cardiovascu- tive that we have basic knowledge about lar disease is generally at an older age in nutrition and exercise physiology—which women, but evidence shows that women were not taught in medical school. suffer from proportionately more strokes It is, clearly, not useful to simply tell a at a young age than men do. Aggressive patient to lose weight. Evidence does sup- management of persistent hypertension port sustained weight loss when a person may improve outcome. participates in an organized program, • Aspirin therapy is recommended for such as Weight Watchers. Even moderate prevention of stroke in women 45 to 65 weight loss is associated with a reduction years who are at risk. Do not recommend in the risk of hypertension, an improve- aspirin routinely, however, for women ment in lipid levels, and a substantial re- younger than 65 years as a means of duction in the risk of breast cancer. preventing myocardial infarction. I fi nd that this last statistic—namely, ObGyns are in an excellent posi- that lifetime physical activity and main- tion to identify women, at an early age, tenance of normal body weight is asso- who have metabolic syndrome—when ciated with a 20% to 40% reduction in intervention may truly have an impact the risk of breast cancer compared with on the disorder. When you see a patient the risk in women who do not exercise or who has adolescent-onset obesity, oli- who gain 10 kg or more above their high gomenorrhea, acne, and hirsutism, you school weight—is a huge motivator. Why? should not only manage her abnormal It’s well-known that women are more bleeding and infertility but also screen concerned about breast cancer than about FAST TRACK her for hyperlipidemia and glucose in- cardiovascular disease—even though sta- Flexible sigmoidos- tolerance. tistics demonstrate that heart disease is the • Perform a baseline lipid profi le on all leading cause of death among women. copy may be less women older than 45 years. A woman Diabetes. Women who have a history of useful in women who has a risk factor for cardiovascu- gestational diabetes also have a mark- because polyps and lar disease—smoking, hypertension, edly increased risk of type II diabetes cancers are more obesity or overweight, a family history within 5 years of the pregnancy. Clearly, likely to present on of early-onset cardiovascular disease— these women, as well as those who are should be screened at any age. obese, have a strong family history of the right (ascending) • Screening may be performed as a ran- diabetes, or have abnormal lipid levels, side of the colon dom lipid profi le to eliminate the barrier should be screened with a random glu- of returning after an 8-hour fast. Only cose measurement. Women who suffer women who have a signifi cant abnor- chronic monilial infection should also be mality need to return for repeat testing assessed for diabetes. after an overnight fast. Colorectal cancer. The second leading • I usually intervene with lifestyle modi- cause of cancer death and the fourth most fi cation recommendations fi rst—more common cancer in the United States car- exercise, weight loss, more monoun- ries the same risk for women as it does for saturated fats and omega-3 fats in the men. Polyps and cancers are more likely diet—and have the patient return for a to present on the right (ascending) side fasting lipid profi le after 3 to 6 months. of the colon in women, however, making Although quality evidence is lacking screening with fl exible sigmoidoscopy on the benefi t of counseling about weight potentially less useful. CONTINUED

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Sixty-fi ve percent of the US popula- than in men. Any patient who has vague tion has not been adequately screened for somatic symptoms, chronic pain, fatigue, colorectal cancer. This is regrettable, be- decreased libido, and sleep disturbances, cause good-quality data support an asso- or such “hormonal” complaints as pre- ciation between screening and a reduction menstrual syndrome and hot fl ashes, in mortality—even simple screening with should be screened for depression. annual fecal occult blood testing. Ideally, I have found that the Beck Depression colon cancer testing in people of average Inventory is easy and quick to admin- risk should begin at 50 years with either ister if indicated. This screening instru- • colonoscopy every 10 years ment can be downloaded from several • fl exible sigmoidoscopy every 5 years Web sites (search the terms Beck/Depres- with or without annual fecal occult sion/Inventory). For patients who screen blood testing positive, provide a resource sheet that in- • dual-contrast barium enema every cludes a listing of specialist referrals and 5 years local depression hotline numbers. • fecal occult blood testing annually or • perhaps, virtual colonoscopy or Plus 3 at your discretion stool-based DNA testing for patients The USPSTF has listed 3 optional areas who decline traditional evaluation. for annual assessment: thyroid disease, Data demonstrate a signifi cant reduc- bladder health, and domestic violence. tion in risk of death from colorectal cancer Thyroid. Because thyroid abnormalities with annual fecal occult blood testing. Al- are more common in women and because though a single test is only 30% to 50% they may have an impact on the regular- sensitive (like a Pap smear), a program of ity of the menstrual cycle and on weight repeated annual testing detects colorectal and hair loss, it seems sensible and appro- cancer in 92% of cases. Offered annually, priate to screen on a selected basis with a fecal occult blood testing reduces deaths test of thyroid-stimulating hormone. from colorectal cancer by 33% at 13 years. Incontinence. You should defi nitely in- Osteoporosis. For most women, screen- clude this problem in the review-of-sys- FAST TRACK ing for osteoporosis should begin at 65 tems questionnaire. Doing so will not Initiate screening years with a test of bone mineral density. only help the patient identify an embar- Younger women who have a signifi cant rassing problem that she may be reluc- for osteoporosis for risk factor (weight, less than 127 pounds; tant to bring up, but will also help drive most women with a hyperthyroidism; steroid use; a strong fam- additional services in your practice—such test of bone mineral ily history) might benefi t from screening at as urodynamic evaluation and surgery. density at 65 years an earlier age. All women who take more than 7.5 mg of prednisone daily or who have sustained a nontraumatic fracture Build a relationship should be treated to prevent osteoporosis The annual visit should reinforce the phy- regardless of fi ndings on a dual energy x- sician–patient relationship by educating ray absortiometry (DEXA) scan. women about the appropriate screening (Note: It is vital for you to provide os- tests and supporting them as active par- teoporosis screening to Medicare patients ticipants in their health care. Take a con- because this is 1 of only 2 offi ce-based per- sistent, balanced approach that complies formance measures in the voluntary Medi- with guidelines but that also addresses the care pay-for-performance list for 2007 patient’s concerns by incorporating edu- that are applicable to gynecology practice; cation and appropriate interventions. ■ the other is screening for incontinence.) Depression. We know that depression is Reference more common, and tends to present with 1. Oboler SK, LaForce FM. The periodic physical ex- amination in asymptomatic adults. Ann Intern Med. more physical complaints, in women 1989;110:214–226.

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