1. The 21 st - Century Well Woman Exam Honor MacNaughton, MD, Linda Prine, MD, Ruth Lesnewski, MD Beth Israel Institute for Urban Family Health, New York NY 10011  Create rapport, build therapeutic relationship  Identify risk factors to allow for targeted screening and counseling  Identify and evaluate patient concerns Goals of the “Check Up”  Prioritizing practice based on evidence rather than on tradition  Focusing on woman-centered rather than provider-centered care  Health promotion  Early detection of disease  Risk reduction Purpose of the History and Physical Why a New Model? Lucia, a 17-year-old high school senior, wants a pregnancy test & a school physical form. She began having sex last month, using withdrawal for birth control. Definitely needs:  BMI/BP  Immunizations Urine GC/chlamydia, HIV test Pregnancy test Contraception and safer sex counseling Screen for tobacco, alcohol, drug use Doesn’t need: Scoliosis screen CBC Urinalysis Pelvic exam / Pap smear Self –breast exam Katie, a healthy 38-year-old bartender, wants to be “checked for everything.” She smokes 5 cigarettes/day, has had 4 male sexual partners this year, and uses condoms “sometimes.” Definitely needs: BMI/BP Immunizations STI testing Pap smear (and HPV test?) every 3 years Smoking cessation counseling Contraception and safer sex counseling Doesn’t need: Cholesterol screen Baseline mammogram Self breast exam Bimanual exam Sarita, 53, is a sedentary, lactose-intolerant academic who eats few fruits/vegetables. She last saw a doctor 5 years ago. Menopause at age 51. She requests a dexa scan. Definitely needs: BMI/BP Immunizations Pap smear Mammogram Colon cancer screening ASA for prevention of CHD Counseling re: weight-bearing exercise, healthy eating, calcium/Vit D Doesn’t need: Dexa scan Ovarian cancer screening TSH Celia, a 77-year-old widow, is new to your practice - she wants her yearly Pap smear. All previous Pap smears have been normal. She denies hypertension or risk factors for CHD. Definitely needs: BMI/BP Immunizations Mammogram Colon cancer screening ASA for prevention of CHD Dexa scan and counseling re: weight-bearing exercise, calcium / VitD Doesn’t need: Pap smear Diabetes screening Cholesterol screening Screening TestUSPSTF / AAFPACOGACS Bimanual examRecommend against (D)Yearly pelvic examNo recommendation Pap smear: Interval At least every 3 yrs in women who have been sexually active (A) Age <30: yearly Age 30+: every 2-3 yrs Age <30: Yearly or every 2 yrs if liquid-based Pap Age 30+: every 2-3 yrs Pap smears: When to stop Age 65No recommendation due to limited studies Age 70 HPV testingInsufficient evidence (I)Age 30+ can use HPV and pap every 3 years No recommendation Self Breast Exam Insufficient evidence (I)Optional Clinical Breast Exam Insufficient evidence (I)YearlyAge 20-39: every 3 yrs Age 40+: yearly MammogramEvery 1-2 yrs, age 40+ (B)Age 40-49: every 1-2 yrs Age 50+: yearly Age 40+: yearly USPSTF /AAFPACOG Fasting glucoseBP <135/80: insufficient evidence (I) BP >135/80: screening recommended (B) Age 45+: Fasting glucose every 3 yrs LipidsNo risk factors for CHD: recommended against (C) Age 20+ at increased risk for CHD : screening recommend (A,B) Age 45+: every 5 years Earlier screening in women at risk for CHD TSHInsufficient evidence ( I)Age 50+: TSH every 5 yrs Dexa ScanAge 65+ average risk : every 2 yrs (B) Age 60+ high risk : every 2 yrs (B) Age 65+: every 2 yrs Earlier screening in postmenopausal women at high risk Differences Among Major Groups’ Recommendations  A – Recommend service: high certainty that net benefit is substantial  B – Recommend service: moderate-high certainty that net benefit moderate-substantial  C – Recommend against routinely providing service: moderate-high certainty of no net benefit or harm outweighs risk; consider in certain individuals  D – Recommend against service: moderate-high certainty harms outweigh benefits  I – Insufficient evidence: if service offered patients should understand uncertainty about balance of harms / benefits USPSTF Levels of Recommendation  Tobacco Use: screen all patients, provide smoking cessation counseling to those who use (A)  Alcohol Use: screen all patients, provide interventions for those who misuse (B)  Obesity: screen all patients, provide intensive weight loss counseling to obese patients (B)  Depression: screen all patients in settings that have systems to provide treatment and follow up  Exercise / Diet / Drug Use / Domestic Violence: insufficient evidence to recommend for or against routine screening and counseling (I) USPSTF on Risk Reduction  Scoliosis  Herpes Simplex Virus  Ovarian Cancer  Pap after benign hysterectomy  Asymptomatic bacteriuria  Bladder cancer  CHD with low risk (<5-10% 10 yr risk)  Hep B and C, Gonorrhea, Syphilis with low risk  Lead levels in pregnant women Screening Recommended Against (USPSTF “D”)