Key Practice Recommendations

These key learning points summarize the consensus- and evidence-based recommendations included in this edition. The sources listed here for each statement recommend that physicians perform or implement these actions directly in a clinical setting. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patientoriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afp/2004/0201/p548.html.

1. Screen patients 21 to 29 years of age for cervical cancer with a cervical cytology (Papanicolaou) test every 3 years
Evidence Rating: SORT A
Source: Section One, references 14 and 15

2. Screen average-risk patients ages 30 to 65 years for cervical cancer with a cytology test every 3 years, with a US Food and Drug Administration-approved primary high-risk human papillomavirus (HPV) test every 5 years, or with cotesting (cytology test and high-risk HPV test) every 5 years.
Evidence rating: SORT A
Source: Section One, references 14, 15, 16, and 18

3. Any patient with new onset of postmenopausal bleeding should have a workup, including up-to-date cervical cancer screening, bimanual and speculum examinations, and if indicated, testing for sexually transmitted infections. First-line diagnostic tests include transvaginal ultrasonography to measure endometrial thickness and endometrial biopsy.
Evidence rating: SORT C
Source: Section Two, references 5, 8, 12, and 13

4. An endometrial thickness of 4 mm or less on transvaginal ultrasonography has a 99% negative predictive value for endometrial cancer but does not completely rule out malignancy. Evaluation for persistent or abnormal uterine bleeding should include endometrial biopsy.
Evidence rating: SORT C
Source: Section Two, references 7, 12, and 13

5. No high-quality evidence supports screening asymptomatic patients at average risk of developing ovarian cancer, and no major professional medical societies recommend routine screening. Various methods for ovarian cancer screening include bimanual palpation, transvaginal ultrasonography, and measurement of serum tumor marker cancer antigen 125 levels, but there is little evidence to support their use for routine screening.
Evidence rating: SORT A
Source: Section Three, reference 13

6. The presence of persistent HPV infection in at least 50% of vulvar cancers highlights the importance of primary prevention and offering HPV vaccination to patients. Research has demonstrated at least 50% efficacy against vulvar diseases such as vulvar intraepithelial neoplasia (a precursor of vulvar cancer) and vulvar carcinoma, with additional studies pending. Greatest protection is noted prior to HPV exposure, thus offer as early as age 9 and up to age 26.
Evidence rating: SORT C
Source: Section Four, references 2, 3, 4, 8, and 9

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