2012 ACOG Recommendations for the Annual Well-Woman Visit

The American College of Obstetricians and Gynecologists (ACOG) released an updated statement in August 2012 with new recommendations for the annual well-woman visit. Medical advancements in research and technology have played a role in guiding the implementation of these new guidelines and recommendations. This statement from ACOG reviews the changes made to the physical exam aspect of the visit, including when to perform pelvic exams in asymptomatic women, when to start internal pelvic and speculum exams, and when to initiate formal clinical breast exams.

PELVIC EXAMINATION
Women ≥21 Years of Age

• Annual pelvic exam is recommended
• Bimanual exam is better for evaluating the uterus than the adnexa; has a low sensitivity for detecting adnexal masses
• Begin speculum exams for cervical cytology screening at 21 years of age, irrespective of sexual activity
• Internal pelvic exams are not necessary prior to initiating oral contraceptives in otherwise healthy, asymptomatic women
• Internal pelvic exams are not necessary to screen for sexually transmitted infections (STIs) as screening can be performed using nucleic acid amplification testing from urine samples or vaginal swab specimens. However, cultures for STIs can be obtained at this time from the cervix.
• The decision to receive an internal exam is up to the patient if she is asymptomatic and has undergone a total hysterectomy and bilateral salpingo–oophorectomy for benign indications and has no history of vulvar intraepithelial neoplasia, cervical intraepithelial neoplasia 2 (CIN2), CIN3, or cancer; is not infected with HIV; is not immunocompromised; and was not exposed to diethylstilbestrol in utero. Cytology testing is not recommended in these women. Annual examination of the external genitalia should continue.

Women <21 Years of Age

• First obstetrician-gynecologist visit for screening and preventive services should occur between the ages of 13 to 15 years
• The first visit should focus on patient education and generally does not include pelvic exam
• External-only genital exam can be performed to evaluate for normal external genital anatomy and to identify issues of personal hygiene and abnormalities of the vulva, introitus, and perineum
• Pelvic exam is recommended only when indicated by medical history (e.g., menstrual disorders, vaginal discharge, or pelvic pain)
• Testing for STIs is recommended for sexually active adolescents. Screening can be performed using nucleic acid amplification testing from urine samples or vaginal swab specimens.

CLINICAL BREAST EXAMINATION

• No data exists indicating the ideal age at which to start clinical breast exams in the asymptomatic, low-risk patient and should be determined by age and known risk factors for breast cancer
• It is recommended that women 20–39 years receive a clinical breast exam every 1–3 years
• It is recommended that women ≥40 years receive an annual clinical breast exam. Breast self-awareness, including breast self-examination, is recommended. ACOG does not support the 2009 U.S. Preventive Services Task Force report that there is insufficient evidence to assess the additional benefits and harms of clinical breast exams beyond screening mammography in women ≥40 years and that teaching self-breast examination does not reduce the mortality rate of breast cancer.

REFERENCE
Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421–424.