Preventative and primary care for women through the ages

The female annual examination is a primary part of medical care and is valuable in identifying medical problems, recognizing risk factors and promoting preventive practices. The physical exam is a key part of the yearly visit, and the exam may vary according to the patient’s age, risk factors, and patient and physician preferences.

Obstetricians/gynecologists have long provided preventative and primary care to women. Physician extenders (nurse practitioners and physician assistants) are now also primary care providers of women’s health.

The yearly assessment should include screening, evaluation, counseling and immunizations based on age and risk factors. The physical exam, in general, will include collecting standard vital signs, an abdominal exam and, usually, a pelvic and breast exam.

A woman’s first visit to the OB-GYN is usually during her teen years. This visit generally does not include a physical and pelvic exam. The primary purpose of this visit is education. The provider can take a basic history and answer any questions. Proper nutrition, exercise, immunizations — including the human papillomavirus (HPV) vaccine — contraception and prevention of sexually transmitted infections (STI’s) are discussed during this visit.

Gardasil-9 is a nine-valent vaccine that protects against nine types of HPV viruses that cause up to 90% of cervical cancers, and the majority of genital warts. It is almost 100% effective in protecting against these viruses. Studies show a 50% reduction in pre-cancerous lesions with the vaccination, and we expect a significant decrease in cervical cancers as studies continue. The vaccination is given using a two to three dose schedule for ages 9-14 and a threedose schedule for ages 15-45.

Birth control pills, contraceptive patches, vaginal rings and Depo Provera injections have long been used as contraception for women of all ages. The trend now is to offer long-acting, reversible contraception (LARC) to young women and adolescents. LARC is the most effective reversible contraception and is easily inserted during an office procedure. A major advantage of LARC, compared to other reversible contraceptive measures, is that the LARCs do not require ongoing use by the patient to be effective. One example of a LARC is the intrauterine device (IUD), which is inserted in the uterus and lasts three to five years. Another type of LARC is a small rod, containing a type of hormone, that is inserted under the skin in the arm and lasts three years. Also, when the device is removed, normal menses and fertility resume promptly.

It is recommended that pelvic exams be done only when indicated by the medical history for patients younger than 21. A pelvic exam would be done for problems such as menstrual disorders, vaginal discharge or pelvic pain. Usually, a pelvic ultrasound will also be done if the patient is having pain. Sexually active adolescents should be tested for STI’s. Pap smears are usually not done before 21 years of age.

Patients 21 and older have a pelvic exam with the annual examination. A Pap smear is done at repeated intervals per guidelines. After age 30, an HPV test is done with the Pap smear. Deaths from cervical cancer are significantly reduced by doing Pap smears. Cervical cancer is very unusual in someone who is having regular Pap smears. Most cervical cancers are diagnosed in patients who have not had a Pap smear in 10-15 years.

The annual examination is the time when issues including birth control, irregular bleeding, vaginal discharge, pelvic pain, STI exposure and infertility are discussed. Asymptomatic problems dealing with the external genitalia, uterus and ovaries may be detected by the health-care provider.

Information regarding nutrition, mental health (depression) and healthy lifestyles are discussed, as well. The HPV vaccination (Gardasil-9) age limit has been increased to 45 years old, making more patients eligible. Also, genetic testing for familial cancers is becoming more specific and affordable.

During perimenopause and later, other problems may include irregular bleeding, hot flashes and painful intercourse. An ultrasound and a biopsy of the uterus can be done in the office to test for endometrial cancer. Hormone replacement is used for hot flashes and problems with painful intercourse.

Your doctor may recommend screening lab and tests at different ages:

1.) Mammography – usually started at age 40 and performed yearly. Mammography has helped reduce breast cancer mortality in the U.S. by 40% since 1990.

2.) Colonoscopy – Screening is started at age 45-50 in most instances. Most colon cancer is preventable by detecting and removing pre-cancerous polyps.

3.) Bone density – This test checks for osteoporosis (thin bones). This condition is treated with calcium, vitamin D and more specific medications if indicated.

4.) Lab tests – Blood tests are done to check for anemia, diabetes and cholesterol problems.

The well-woman annual exam can identify problems throughout the life cycle when treatment is possible and a solution is optimal. Take advantage of this excellent opportunity to seek information and treatment for you and your family members.

Dr. E.B. Robinson is a gynecologist at Highland Clinic. He provides gynecologic services for women of all ages from adolescence to menopause. Dr. Robinson focuses on well-woman care, pre-conceptual counseling, cervical cancer prevention – HPV, treatment for perimenopause through menopause and osteoporosis. He is accepting new patients and can be reached at (318) 798-4400; located at 1455 East Bert Kouns Industrial Loop, Suite 305, Shreveport, LA 71105. Visit https://www.highlandclinic.com/staff/e-b-robinson-m-d for more information.