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Am Fam Physician. 2021;104(1):9-10

Original Article: Health Maintenance for Women of Reproductive Age

Issue Date: February 15, 2021

See additional reader comments at:

To the Editor: The article by Dr. Paladine and colleagues included recommendations from the U.S. Preventive Services Task Force (USPSTF) and other groups but did not include recommendations issued by the Women's Preventive Services Initiative (WPSI).1 The WPSI recommendations are incorporated as covered benefits for preventive services without cost-sharing under the Affordable Care Act.2 New recommendations on screening for anxiety 3 and urinary incontinence,4 and previous recommendations on contraceptive care, breastfeeding, and other services,2 were not mentioned. The section on contraception, which focuses primarily on the U.S. Medical Eligibility Criteria for Contraceptive Use, does not include the WPSI recommendation that “women have access to the full range of female-controlled contraceptives to prevent unintended pregnancy and improve birth outcomes.” Family physicians may find the WPSI Well-Woman Chart useful in guiding preventive care in their practices ( The Well-Woman Chart is a free resource and clinical guide that outlines preventive services recommended by the WPSI, USPSTF, and Bright Futures. The chart is based on patient age, health status, and risk factors. Information in the chart is updated when new and revised recommendations are issued. The WPSI recommendations and Well-Woman Chart information should be included in future summaries of preventive service recommendations for women to provide a more comprehensive reference for family physicians.

Editor's Note: This letter was submitted on behalf of the Women's Preventive Services Initiative, Advisory Panel.

In Reply: We thank Drs. Cantor and Nelson for highlighting the recommendations from the WPSI. Unfortunately, recommendations from all groups could not be included in our article because of space constraints, and we chose to focus on American Academy of Family Physicians (AAFP) and USPSTF recommendations. Readers should note that many of the WPSI recommendations differ from the A and B ratings used by the USPSTF.

Editor's Note: Drs. Cantor and Nelson note the importance for family physicians to know that the clinical preventive services recommendations from WPSI are legislatively mandated to be covered by private insurance plans without cost-sharing (as with grade A and B recommendations from the USPSTF). However, unlike recommendations from the USPSTF and AAFP, the WPSI recommendations are not consistently evidence based. For example, the systematic review performed to support the WPSI recommendation to screen women annually for urinary incontinence concluded that “evidence is insufficient on the overall effectiveness and harms of screening for urinary incontinence in women.”1 Similarly, the systematic review performed to support the WPSI recommendation to screen adolescent girls and adult women concluded that “evidence on the overall effectiveness and harms of screening for anxiety is insufficient.”2 Although the WPSI recommendation on breast cancer screening for women who are at average risk aligns with the USPSTF's age range to begin screening (between 40 and 50 years based on shared decision-making), the WPSI diverged from the USPSTF by endorsing annual and biennial screening mammography.3,4 Readers should be aware that although the AAFP participates in WPSI, such participation does not constitute an endorsement of individual WPSI recommendations or its Well-Woman Chart.— Kenny Lin, MD, MPH, Deputy Editor


1. Nelson HD, Cantor A, Pappas M, et al. Screening for urinary incontinence in women: a systematic review for the Women's Preventive Services Initiative. Ann Intern Med. 2018;169(5):311–319.

2. Nelson HD, Cantor A, Pappas M, et al. Screening for anxiety in adolescent and adult women: a systematic review for the Women's Preventive Services Initiative. Ann Intern Med. 2020;173(1):29–41.

3. Women's Preventive Services Initiative. Breast cancer screening for average-risk women. Accessed April 21, 2021.

4. U.S. Preventive Services Task Force. Final recommendation statement. Breast cancer: screening. January 11, 2016. Accessed April 21, 2021.

Email letter submissions to Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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