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Am Fam Physician. 2021;103(4):209-217

Related letter: Well-Woman Chart Is Useful in Guiding Preventive Care

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

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.

Clinical recommendationEvidence ratingComments
Screening pelvic examinations are not recommended for asymptomatic women.16,17 CSystematic 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 BSystematic 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 BSystematic 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 BSystematic 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 CMeta-analysis showed no significant change in breast cancer–related mortality or advanced cancer outcomes when younger women are screened
Screen for HIV in people 15 to 65 years of age.45 ASystematic review including RCTs and observational studies (with some inconsistent results) demonstrated lower risk of death and AIDS-related events in people who started antiretroviral therapy at higher CD4 counts
Screen for hepatitis C virus in adults 18 to 79 years of age.46 BSystematic review of RCTs showed sustained virologic response with newer treatments for hepatitis C virus infection
Screen for gonorrhea and chlamydia in sexually active women younger than 25 years.48 BRCT showed decreased incidence of pelvic inflammatory disease in screened women who were at higher risk of infection
Screen adults for tobacco use, unhealthy alcohol use, and unhealthy drug use.5355 A (tobacco use)Multiple systematic reviews demonstrated effectiveness of counseling and pharmacotherapy for tobacco cessation
Meta-analysis showed effectiveness of counseling to decrease unhealthy alcohol use
Meta-analysis showed effectiveness of counseling for unhealthy drug use and pharmacotherapy for opioid use
B (alcohol and drug use)
RecommendationSponsoring organization
Do not perform annual cervical cytology (Papanicolaou [Pap] test) or annual human papillomavirus screening of immunocompetent women with a history of negative screening.American Society for Colposcopy and Cervical Pathology
Do not perform Pap tests in patients younger than 21 years or in women after hysterectomy for benign disease.American Academy of Family Physicians
Do not perform pelvic examinations on asymptomatic nonpregnant women unless necessary for guideline-appropriate screening for cervical cancer.American Academy of Family Physicians
Do not require a pelvic examination or other physical examination to prescribe oral contraceptives.American Academy of Family Physicians
Do not screen for genital herpes simplex virus infection in asymptomatic adults, including pregnant patients.American Academy of Family Physicians
Do not routinely use breast magnetic resonance imaging for breast cancer screening in average-risk women.Society of Surgical Oncology
PurposeName of appOrganizationWebsite
Cervical cancer screening recommendations and management of abnormal resultsAmerican Society for Colposcopy and Cervical Pathology Management Guidelines app*American Society for Colposcopy and Cervical Pathologyhttps://www.asccp.org/mobile-app
Immunization recommendationsShots Immunizations appAmerican Academy of Family Physicians, Society of Teachers of Family Medicinehttps://www.stfm.org/Resources/Shots
CDC Vaccine Schedules appCenters for Disease Control and Preventionhttps://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html
Medical eligibility for contraception and select practice recommendations related to reproductive healthU.S. Medical Eligibility Criteria for Contraceptive Use/U.S. Selected Practice Recommendations for Contraceptive UseCenters for Disease Control and Preventionhttps://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
U.S. Preventive Services Task Force recommendations for preventive carePrevention Task Force appAgency for Healthcare Research and Qualityhttps://epss.ahrq.gov/

Although this article uses the term “women” for simplicity, these recommendations apply to transgender men and nonbinary individuals as well. A previous American Family Physician article addresses health care for transgender and nonbinary patients in more detail.4 This article does not address recommendations that are specific to the antepartum or postpartum period.

Disparities exist in the provision of preventive care and are more common in people who belong to racial, ethnic, and sexual minority groups; people who are transgender; people who are uninsured; younger adults; and people who live in rural areas.5,6 Although some types of preventive care, such as breast cancer screening, have improved, disparities continue to exist, especially related to screening for sexually transmitted infections (STIs), HIV, and cervical cancer and to vaccination against human papillomavirus (HPV).7

Reproductive Planning

PREGNANCY INTENTION

In 2011, 45% of pregnancies in the United States were unintended at the time of conception.8 The Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists recommend screening for pregnancy intention as part of primary care visits.9,10 One method of screening that has been studied is the One Key Question.11 Patients are asked whether they would like to become pregnant in the next year. Those who answer yes should be offered preconception counseling. For those who answer no, physicians should initiate a contraceptive options discussion. For patients who are okay either way or are unsure, physicians should initiate further discussion of the patient's goals and preferences. Pilot studies have demonstrated the feasibility of using One Key Question in the primary care setting and found that its use leads to higher rates of contraception use and preconception counseling11; however, more evidence is needed to support this intervention as a population-based screening recommendation.

CONTRACEPTION

Women who want to have children often wish to plan the timing of their pregnancies. This makes the availability of effective contraception an important factor in achieving a person's goals.9 The CDC has developed a tool called the U.S. Medical Eligibility Criteria for Contraceptive Use, available as an app and on the CDC website; it allows physicians to easily determine eligibility or contraindications to various contraceptive methods based on the patient's health status.12

PRECONCEPTION AND INTERCONCEPTION CARE

If a woman desires pregnancy or is not actively trying to avoid pregnancy, preconception care is appropriate to try to reduce health risks and to maximize the chances of a healthy pregnancy, delivery, and infant. Interpregnancy or interconception care extends the concept of preconception care to maintain a woman's health across her reproductive life span. The AAFP has a position paper with evidence-based recommendations addressing preconception care.13 The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have published a guideline that includes topics such as avoiding interpregnancy intervals of less than six months, breastfeeding recommendations, counseling about family planning, and screening for and prevention of other medical conditions, as recommended in this article.14 The USPSTF recommends prescription of folic acid for people who may become pregnant.15

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