Health Maintenance for Women of Reproductive Age

 

Health maintenance for women of reproductive age includes counseling and screening tests that have been demonstrated to prevent disease and improve health. This article focuses mainly on conditions that are more common in women or have a unique impact on female patients. Family physicians should be familiar with evidence-based recommendations for contraception and preconception care and should consider screening patients for pregnancy intention. The American Academy of Family Physicians recommends against screening pelvic examinations in asymptomatic women; the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to make a recommendation for or against screening pelvic examinations. The USPSTF recommendations for women in this age group include screening for obesity and other cardiovascular risk factors, depression, intimate partner violence, cervical cancer, HIV, hepatitis C virus, tobacco use, and unhealthy alcohol and drug use as part of routine primary care. Breast cancer screening with mammography is recommended for women 50 years and older and should be individualized for women 40 to 49 years of age, although other organizations recommend earlier screening. Screening for sexually transmitted infections is based on age and risk factors; women younger than 25 years who are sexually active should be screened routinely for gonorrhea and chlamydia, whereas screening for syphilis and hepatitis B virus should be individualized. Immunizations should be recommended according to guidelines from the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices; immunizations against influenza; tetanus; measles, mumps, and rubella; varicella; meningococcus; and human papillomavirus are of particular importance in women of reproductive age. To have the greatest impact on health, physicians should focus on USPSTF grade A and B recommendations with patients.

Health maintenance for women of reproductive age (generally defined as 15 to 44 years of age) comprises counseling and screening tests, with the goal of prevention and early detection of common diseases such as cancer, infections, and mental health issues. A systematic review found no evidence that general preventive visits (outside of condition-based screening recommendations) reduce overall mortality or deaths from conditions such as cancer or heart disease1; however, it is still important for family physicians to continue evidence-based preventive services, whether part of a routine physical examination or separately.2 This article focuses on screening and counseling for conditions that are more prevalent in women of this age or that have a unique impact on women. In most cases, recommendations from the American Academy of Family Physicians (AAFP) are aligned with those from the U.S. Preventive Services Task Force (USPSTF); this article states when recommendations differ. A full list of USPSTF recommendations is published on their website.3 Grade A and B recommendations (https://www.uspreventiveservicestaskforce.org/uspstf/grade-definitions) have the strongest evidence of benefit and are the focus of this article. Physicians can also sign up to receive regular email updates with new or draft recommendations. A list of smart-phone apps related to preventive care is provided in Table 1.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Screening pelvic examinations are not recommended for asymptomatic women.16,17

C

Systematic review of cohort studies and one RCT showed no benefit of screening pelvic examinations, and low-quality cohort studies demonstrated harms (e.g., pain, embarrassment, false-positive results) U.S. Preventive Services Task Force found insufficient evidence to make a recommendation for or against screening pelvic examinations

Screen for obesity in adolescents and adults; refer adults with a body mass index of 30 kg per m2 or more to intensive behavioral interventions focused on healthy diet and exercise.20,23

B

Systematic review of RCTs demonstrated increased weight loss in intensive behavioral intervention groups compared with control groups

Screen for depression in adolescents and women when systems are in place for diagnosis, follow-up, and treatment.27,28

B

Systematic review of RCTs demonstrated reduced prevalence of depression following screening in primary care settings when treatment supports are in place

Screen for intimate partner violence in women of reproductive age.29

B

Systematic review of RCTs showed inconsistent benefits of interventions, including counseling and home visits, and no harms of interventions

Individualize breast cancer screening with mammography in women 40 to 49 years of age.36

C

Meta-analysis showed no significant change in breast cancer–related mortality or advanced cancer outcomes when younger women are screened

Screen for HIV in people

The Authors

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HEATHER L. PALADINE, MD, MEd, FAAFP, is the director of the New York Presbyterian–Columbia Family Medicine Residency Program and an assistant professor in the Center for Family and Community Medicine at Columbia University Irving Medical Center, New York, NY....

HIMABINDU EKANADHAM, MD, MS, is an inpatient family medicine hospitalist and an assistant professor in the Center for Family and Community Medicine at Columbia University Irving Medical Center.

DANIELA C. DIAZ, MD, is the associate director of the Primary Care Clerkship and an assistant professor in the Center for Family and Community Medicine at Columbia University Irving Medical Center.

Address correspondence to Heather L. Paladine, MD, MEd, 610 W. 158 St., New York, NY 10032 (email: hlp222@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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