Make an Annual Commitment to Your Health

Make sure your women’s health annual visit includes all the essential components.

Alexandra F. Gehring, FNP

If you’re like most women, you’re familiar with the women’s health annual visit. It is a medical visit that most women consider an important part of their routine health maintenance. But do you really know what elements should be included in the appointment—which screenings you should undergo and what other areas of your overall health should be addressed?

If you’re not quite sure what to expect from your annual visit, you’re not alone. In recent years many of the elements of this visit have changed. New recommendations for when to begin both cervical and breast cancer screening, how often to undergo these tests, and at what age to stop them have led to patient confusion about what the new recommendations mean for individual care. As a result, many women are now unclear about what to expect from their healthcare provider during their annual appointment.

A look at the new American College of Obstetricians and Gynecologists (ACOG) screening recommendations for cervical cancer and breast cancer, along with a review of the other essential components of the visit, can shed some light on what should, ideally, be included.

Cervical Cancer Screening

Perhaps the most widely recognized component of the women’s health annual visit, the Papanicolaou (Pap) test has served to screen women for cervical cancer for more than 60 years. The goal of screening is to identify cell changes on the cervix early, when they are either preinvasive lesions or early-stage invasive lesions, so that treatment can be initiated and, ideally, progression of the disease can be avoided. Numerous studies show that among women diagnosed with cervical cancer, more than 50 percent have never had a Pap test and another 10 percent have not received a Pap test in the past five years.1

Since the advent of the Pap test, deaths from cervical cancer in the United States have declined by more than 70 percent.2 In 2007, the most recent year for which cervical cancer statistics are available, 12,280 women were diagnosed with new cases in the United States. In the same year, 4,021 women in the United States died from the disease.3

The role of (human papillomavirus) HPV infection in the development of cervical cancer is now better understood. To develop cervical cancer, a woman must have a persistent HPV infection. Understanding the significance of persistent HPV infection, along with the new testing technologies, has led to new recommendations for Pap screening intervals.

For women who have never had an abnormal Pap test result, the current recommendation is that the interval between Pap tests be increased from every year to every two years for women ages 20 to 29 and to every three years for women ages 30 and older. Women ages 30 and older should have HPV co-testing done with each Pap test. The newest recommendations from ACOG state that Pap testing should begin in women starting at age 21, regardless of the age at which sexual activity begins.4

Even with the longer Pap test screening intervals, persistent HPV infection will be detected and can be managed accordingly.

Breast Cancer Screening

Breast cancer screening is another major component of the women’s health annual visit. In the Unites States, breast cancer remains the second-leading cause of cancer-related deaths among women.5 According to American Cancer Society estimates, in 2008 approximately 182,460 women were diagnosed with breast cancer and 40,480 women died from the disease.2

During the annual visit, a clinical breast exam (CBE), performed by the healthcare provider, is often followed by a mammogram, depending on the patient’s age and risk factors for the development of breast cancer. The recommendations for CBEs include annual clinical breast exams in women 40 and older and every one to three years in women ages 20 to 39.6

Along with CBEs, breast self-awareness is recommended. In the past women were told to perform monthly breast exams, ideally in the week just after their periods ended. The new ACOG recommendations take a more general approach. Breast self-awareness means that women should have a general sense of how their breasts normally look and feel so that if breast changes occur, women can discuss those changes with their healthcare provider.

In the past few years, recommendations for mammograms have also changed. On July 20, 2011, ACOG issued new breast cancer screening guidelines that recommend that beginning at the age of 40, all women should be offered mammography on an annual basis. The previous ACOG guidelines recommended that women have mammograms every one to two years starting at age 40 and then annually beginning at age 50.6

The new ACOG recommendations are based on three factors: breast cancer incidence, the sojourn time (the window of time between when breast cancer can be detected by mammography and when it becomes symptomatic), and the potential to reduce the number of deaths from breast cancer. In women ages 40 to 49, the sojourn time averages about 2 to 2.4 years. Women ages 70 to 74 have an average sojourn time of 4 to 4.1 years.6 Early detection of breast cancer in younger women leads to more-rapid diagnosis and better treatment outcomes. As a result, annual mammography is recommended beginning at age 40.

Cardiovascular Health

Every visit with a healthcare provider is an opportunity to discuss cardiovascular health. The women’s health annual visit is no exception. Although cardiovascular risk reduction is not the primary focus of the annual visit, a brief risk assessment should include a discussion about smoking cessation, diet and exercise, and a blood pressure check. Women who have significant cardiovascular risk factors or who need further evaluation should see their primary care provider for a more comprehensive evaluation.

Reproductive Health

The women’s health annual visit provides a woman with an opportunity to discuss her reproductive health with her healthcare provider. It is an essential component of this visit. Most providers will ask their patients about numerous elements of their reproductive health. This includes questions about a woman’s menstrual history and, depending on her age, whether she is experiencing any perimenopausal or menopausal symptoms; a woman’s sexual history, including whether she is currently sexually active; any concerns she has about her sexual functioning; her need for screening for sexually transmitted infections; her need for contraception; and her need for preconception counseling if she is planning to become pregnant. Depending on the woman’s age, reproductive goals, and specific health history, the recommendations and the goals of her reproductive health plan will vary.

Vaccinations

Any well visit to a healthcare provider is an opportunity to discuss and review routine vaccinations that may be due. The women’s health annual visit is an excellent opportunity for a woman to discuss the vaccinations she may need. Tetanus, influenza, shingles, HPV, hepatitis A and B, and pneumonia vaccinations may be indicated, depending on the age and the health status of the individual. The Centers for Disease Control and Prevention website (www.cdc.gov) has excellent information about each of these vaccinations.

Conclusion

The women’s health annual visit is a well-established healthcare routine that most women are aware of and view as an important part of their overall health maintenance. This appointment should reinforce the patient/provider relationship and support a woman as an active participant in determining and maximizing her overall health. Appropriate screening tests and their intervals should be discussed at each annual visit, as a woman’s specific healthcare needs and screening recommendations may change from year to year. Health promotion and disease prevention strategies, including cardiovascular health, reproductive health, and vaccinations, should be discussed every year.

References

1. American College of Obstetricians and Gynecologists. ACOG practice bulletin No 45: Cervical cytology screening. International Journal of Gynecology and Obstetrics. 2003;83(2):237-47.

2. Cancer Facts and Figures 2008. American Cancer Society website. Available at: http://www.cancer.org/acs/groups/content/@nho/documents/document/2008cafffinalsecuredpdf.pdf. Accessed September 22, 2011.

3. Cervical Cancer Rates by Race and Ethnicity. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/Features/dsCervicalCancer. Accessed September 22, 2011.

4. American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 109: Cervical cytology screening. Obstetrics and Gynecology. 2009;114(6):1409-20.

5. Breast Cancer Statistics. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/cancer/breast/statistics. Accessed September 22, 2011.

6. American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 122: Breast cancer screening. Obstetrics and Gynecology. 2011;118(2 Part 1):372-82.