Women's Health Specialists of St. Louis
Obstetrics and Gynecology

Articles - The Well Woman Exam

The well woman exam, or annual exam, is often the only preventative care that women regularly receive. It is an important visit because many aspects of health, wellness, and prevention should be addressed. Unfortunately, it is a visit that many women postpone and then routine assessment is delayed or overlooked. The components of an annual health assessment vary depending on the age of the patient. This is because risk factors and leading causes of death and disease vary among age groups. Though the focus may differ slightly, a well woman exam should include a history, physical, and laboratory testing as necessary. Evaluation and counseling regarding sexuality, fitness, nutrition, psychosocial status, cardiovascular risk factors, and health/risk behaviors should also be addressed. Appropriate immunizations should be offered and additional testing should be given to women who are at high risk because of chronic illness or family history. For example, a woman who indicates that she has a family history of breast cancer should be evaluated for additional risk factors. If she is at increased risk then a plan for screening should be discussed.

There is a lot of confusion about whether a woman needs to have a pap smear annually. Because the pap smear is the part of the annual exam that most women both dread and remember the most, most women often refer to the annual exam as The Pap. This is misleading because an annual well woman exam may be performed without a Pap smear. The Pap smear is only a screening tool for cancer of the cervix. The pelvic exam is when the vulva and vagina are examined. When a pelvic exam is performed, a Pap smear can be performed, cultures can be obtained, and screening for some sexually transmitted diseases can be done. Once women become sexually active, they should be screened at least annually for sexually transmitted diseases. However, they do not need to be screened for cancer of the cervix until three years after becoming sexually active or by age 21. This is because the sexually transmitted virus that can cause cancer of the cervix needs to persistently infect the cells of the cervix over time to cause cancer. Because new technology allows physicians to test for abnormal cells on the cervix as well as the virus that causes most cervical cancers, new screening protocols are being developed. For example, women 30 years of age and older who do not have a history of abnormal pap smears may be screened with the Pap every three years. It is important that women understand that even if a Pap is not performed, they should be seen by their physician annually. The frequency of screening should be a decision by both patient and physician. For example, women who have had a complete hysterectomy (the uterus, cervix and ovaries were removed) for non-cancerous reasons may discontinue annual pap smears at the discretion of their doctor. Those women who have had a total hysterectomy still need to have an annual visit for age-appropriate screening. For example, a post-menopausal woman should also be screened for breast, ovarian and colon cancer, osteoporosis, heart disease, and diabetes. It is also appropriate to discuss sexuality and menopausal symptoms.

Sometimes the uterus and cervix are removed but the ovaries are left intact. This is often referred to by the lay term of "partial hysterectomy." Though a woman who has undergone a partial hysterectomy may forgo the Pap smear, the ovaries still need to be examined annually. This is generally done during the pelvic exam, at which time the ovaries are palpated. Ultrasound may also be used to evaluate the ovaries.

The take home message is that though there may be changes in Pap smear protocol, the annual well-woman visit is still a very important method of prevention. Women who are not receiving appropriate routine screening may be at increased risk. The old adage holds true: "An ounce of prevention is worth a pound of cure."