Lippincott Nursing Pocket Card - July 2021

Well-Woman Exam

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Introduction

The well-woman examination is a medical exam offered to women to review and assess their reproductive health. It is also an excellent opportunity to contribute to the overall health and well-being of women throughout the lifespan. The well-women visit provides the opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. The visit should include screening, evaluation, diagnosis, treatment, management, and counseling based on age, risk factors and findings. A comprehensive history is one of the most important aspects of a well-woman visit and it is of great importance that the history be obtained in a relaxed, sensitive and private setting.

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History

General History

  • Current/past medical problems
  • Past surgeries – general and OB/GYN
  • Medications (including supplements/vitamins)
  • Allergies
  • Current primary care provider and specialists
  • Social and family history 
Obstetric/Gynecologic History
All women:
  • Age at menarche
  • Gravida/Para – gestation and type of delivery(ies)
  • History (and treatment) of sexually transmitted infections (STI)
  • Sexual activity
  • Date/result of most recent cervical cytology (including history of abnormal Pap)
  • Date/result of most recent mammogram, if age appropriate
  • Past or current gynecological problems
Women of reproductive age and perimenopausal women:
  • Date of last menstrual period (LMP)
  • Menstrual cycle length, duration, flow, pain
  • Birth control method
  • Fertility plans
Postmenopausal women:
  • Age of last menses
  • History or current postmenopausal bleeding
  • History or current hormonal therapy

Pelvic Examination

There is currently no defined age at which the first gynecologic visit is recommended. The American College of Obstetricians and Gynecologists (ACOG) recommends a first reproductive health visit between the ages of 13 and 15 years, with the scope of the visit dependent on the individual needs of the patient, focusing more on sexual education. A pelvic exam is not included unless the patient has specific health concerns or symptoms that warrant the exam.

Generally, in nonpregnant women, screening pelvic examinations begin at the age of 21 when cervical cancer screenings are recommended to start. Traditionally, a yearly pelvic examination combined with a Pap test was standard practice in all adult women; however, currently this practice is questioned and as a result most professional societies are no longer recommending yearly pelvic examinations in asymptomatic women.

The consensus for pelvic examination in nonpregnant, asymptomatic women 21 years and older include:

  • To perform a Pap test
  • To screen for STIs
  • If a gynecological condition is suspected by history or risk factors
  • If the patient desires a routine check-up
  • In women with a history of precancerous lesions of the cervix, vagina, or vulva
  • As part of ovarian cancer screening in high-risk women (BRCA gene, Lynch syndrome)
  • As part of post-treatment surveillance after genital tract cancer
The pelvic exam includes evaluation of the internal and external genitalia as well as the pelvic organs. A comprehensive exam includes evaluation of the urethra, anus, and rectum. A breast and abdominal exam may be indicated to provide a complete evaluation.

Equipment
  • Exam table, preferably with stirrups
  • Patient gown/drape
  • Stethoscope if evaluating lung, heart, and/or bowel sounds
  • Light source
  • Speculum of appropriate size
  • Disposable gloves
  • Water soluble lubricant
  • Cotton swabs
  • Supplies to obtain specimens for cervical cytology or STI testing
  • Supplies to assess vaginal discharge, as needed 
  • Tests kits for fecal occult blood, if applicable                                                 
Well-Woman Physical Examination
Abdomen Examine for abnormalities in skin, hernia, organomegaly, masses, tenderness, and bowel sounds.
Breasts Assess skin and examine for palpable breast, nipple, and/or axillary abnormalities.
External genitalia Evaluate skin, labia, perineal body, clitoris, urethral meatus, vestibule and introitus; assess Bartholin and paraurethral glands.
Vagina With inserted speculum, assess for lesions or anomalies, observe for discharge or abnormalities, and assess vaginal wall tone. Obtain vaginal discharge sampling as necessary.
Cervix Note any lesions or discharge, and observe for tenderness on bimanual examination. Obtain Pap or cultures, if appropriate.
Uterus During bimanual exam, assess for size, shape, symmetry, mobility, position, tenderness and consistency.
Adnexa Examine for size, mobility and extreme tenderness; it is common for woman to have some tenderness on exam.
Rectovaginal If indicated, note any abnormal findings such as hemorrhoids or rectal mass; test for occult blood.

Clinical Considerations

The well-woman exam should be performed in a safe and private environment. Open-ended questions should be used when inquiring about gynecologic health, contraception and safe sex practices. Domestic violence and mental health assessments should be performed as part of the annual exam. Although no universal chaperone guidelines exist, providers should consider utilizing a chaperone during the pelvic exam.

A pelvic exam as a prerequisite to begin hormonal contraceptives is no longer current practice. In addition, cervical cancer screening guidelines have changed, and the recommended frequency of Pap tests has been updated. Regardless of whether a pelvic examination is performed, a well-woman visit is still recommended annually. Reasons to perform a pelvic exam should be considered by the provider and reviewed with the patient. Permission should be requested prior to starting the pelvic exam.
References:

Carusi, D. (2021, July 29). The gynecologic history and pelvic examination. UpToDate. www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination

American College of Obstetricians and Gynecologists. (2018; reaffirmed 2020). ACOG committee opinion: Well-Woman Visit. Number 755. Washington, DC: American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/well-woman-visit