This chapter should be cited as follows: This chapter was last updated:
Young, R, Dietrich, J, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10435
November 2008

Primary and preventive care

Primary Care in Obstetrics and Gynecology

Ronald L. Young, MD
Director, Division of Gynecology, Chief of Gynecology, Ben Taub General Hospital; Chief of Gynecology, Veterans Administration Hospital, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
Jennifer E. Dietrich, MD, MSc
Chief of Pediatric and Adolescent Gynecology, Fellowship Director Pediatric and Adolescent Gynecology, Chief of Gynecology Texas Children's Hospital, Departments of Obstetrics and Gynecology and Pediatrics, Baylor College of Medicine, Houston, Texas, USA


Ten years ago, when this chapter was first written, we noted that the future of office gynecology was as likely to be determined by economic, social and political pressures as by medical considerations. The intervening years have done little to gainsay that conclusion. Indeed, the pressures on our medical discipline have sharpened and intensified over that time, and both the number and percentage of people outside of the pale of adequate healthcare has increased and continues to increase. As of 2005 these figures stood at 46.6 million uninsured or 15.9% of the population in the United States.1 These facts pose significant and daunting challenges to the practicing gynecologist. The American College of Obstetrics and Gynecology (ACOG) is on record as committed to the principle of universal concern as well as universal coverage in women’s health matters, but how to move forward along that vector remains unresolved to a large extent. A decade ago we proposed that our chief task was to produce a plan for preventive medicine as well as treatment of illness that was not, by its very nature, exclusive to any large segment of our population. Again, that concept remains ethereal and the means for its translation into our everyday practice remains elusive. The rules governing our practices, therefore, are, to an ever greater extent, generated from outside of our profession, and consequently, from outside of our immediate control. Our primary concerns are to continue to increase the quality of care delivered to our patients and to expand the base of that care to include as many as possible of those not already benefiting from it. A practical approach to affordable health care for as many as possible must first be achieved so that a more ideal approach may later be realized. To better participate in the shaping of our medical future, we must offer a health care plan that is both logical and workable; that is, it must be acceptable to those who receive and to those who deliver medical care as well as to those who pay the bills and those who regulate our activities. As one can readily see, the practice of medicine is no longer merely a relationship between a physician and a patient, but, instead, an exercise with input from those two plus the insurance industry as well as the government, and, to a growing degree, the pharmaceutical industry. Importantly, we are obligated to keep pace with advances in technology as well as changes in practice guidelines in order to offer the very best care to our patients. And, finally, we must do all of this in a bottom-line-acceptable manner. A good model for studying the nature and depth of the problem, at least in the gynecological world, has been the routine care of menopausal patients. Despite increasing lip service to the problems of our aging population and the enormous raw numbers of women in, and transitioning into, the menopause, we have never connected with even a simple majority of women for adequate counseling and therapy for their menopausal problems. This field was always fraught with scientific controversy over the role and safety of hormones and enormous external pressures on our practice habits have been applied from many directions both externally and internally, and that was before the HERS2, 3 and WHI4, 5 trials further muddied the waters. True, many valid scientific conclusions were operative in this arena, but one must also concede that not too subtle financial pressures have always played a role in limiting access to Pap tests, mammograms, bone densitometries via dual-energy x-ray absorptriometry (DEXA) and other routine tests for women as they aged. The argument that money spent now is less money spent later is well taken but apt to fall on deaf ears in the USA. A past example of this is routine bone densitometry testing. At $100–300 per study, multiplied by the projected 50 million menopausal women expected in the United States by the first decade of the 21st century, the annual bill becomes a staggering $3–6 billion or more based on every other year testing. Those put off by the magnitude of such a number need only be reminded that the  direct cost of osteoporotic fractures in the USA was about $17 billion per year in 2001.6 There are approximately 1.5 million fragility fractures in the USA each year: 700,000 vertebral fractures, 300,000 hip fractures, 250,000 wrist fractures, and 250,000 at other skeletal sites. Fractures of the spine and hip are associated with chronic pain, deformity, depression, disability, and death. About 50% of patients with hip fractures will never be able to walk without assistance and 25 percent will require long term care. The mortality rate five years after a fracture of the hip or a clinical vertebral fracture is about 20 percent greater than expected.7, 8 Nevertheless, it has never been easy to extract the dollars for prophylactic measures in this country; preventative medicine gets a great deal of lip service but struggles for real support. The following discussion therefore is calculated to take rational approaches to good general coverage for patients at all stages of their lives, but with an eye to holding costs to an acceptable level. Many future battles are likely to be fought over the question of quality screening for fewer patients versus mass screening for as many as possible. Therefore, routine screening tests for the asymptomatic patient must be examined in light of cost-effectiveness as well as the type of data that may be generated. We must face the question of whether such data actually lead to prevention of, or delay in, the onset of morbidity as well as affecting the outcome of a disease process. Apparently, the era of treating and fixing surrogate markers without adequate improvement in disease outcome is rapidly coming to a close for many areas of gynecologic practice. A final exercise would be an introspective assessment of the job we are ourselves doing. Are practice guidelines getting through to our colleagues? A number of studies have shown that the overwhelming majority of patients, men and women, hospitalized for an osteoporotic fracture, get their fracture repaired and leave the hospital with neither counseling nor therapy for their osteoporosis.9, 10 This is both baffling and consternating. It is also totally unacceptable. No physician is in a better position to deal with these problems than the obstetrician-gynecologist, who represents the major source of medical care and advice for female patients for the greater part of their reproductive years. The acceptability of the Papanicolaou (Pap) smear as a routine yearly screening procedure represents an excellent starting point from which to build. The argument against the necessity of yearly Pap tests in younger women loses momentum in light of the fact that the annual visit to the gynecologist represents the only medical care enjoyed by significant numbers of women over the greater portion of their lives.11



The role of the obstetrician-gynecologist in the care of the newborn female infant primarily is limited to postpartum supportive and resuscitative routines, which are not within the scope of this chapter. Primary care of the newborn should include a thorough examination of the external genitalia at the time of delivery. Although many clinicians will rarely see an infant with ambiguous genitalia, the critical need to identify problems early, makes this an important subject to discuss. Any deviation from the normal female or male appearance should prompt immediate evaluation. In the event that ambiguity presents, referring to the infant as a "healthy baby" is important while gender assignment is being established. Premature speculation about sex assignment may cause psychological damage to parents, especially in cases where an assignment must be reversed.12 It is important to reassure parents that during the time prior to sex assignment, many important tests will help determine the infant's sex of rearing. The examination should include careful observation of the pubic, perineal, urethral and anal areas. Palpation of internal structures is not routinely indicated. However, frequently imaging studies may be necessary to further evaluate subtle internal anatomic differences.12

Neonatal vaginal discharge, vaginal bleeding or cysts are relatively common concerns voiced to the gynecologist in this age group. Typically, neonates undergo a period of estrogen withdrawal from antenatal maternal estrogen exposure. Reassurance may be given to parents and pediatricians, as such symptoms are likely to resolve spontaneously and correlate with decreasing estrogen concentrations, occurring between 4-5 months post delivery. In the case of large neonatal cysts, risk for torsion exists, therefore, close monitoring and imaging are warranted in these instances. Neonatal cysts which are complex, may be larger than 5 cm, or persist for more than 4 months, may require surgical intervention; however, reassurance may also be given to parents as the risk of malignancy is extremely low.13

Mandatory Laboratory Testing

Mandatory laboratory testing is directed by the pediatrician and/or neonatologist, and is problem-focused.


Primary care for children remains primarily in the hands of the pediatrician. Occasionally, the gynecologist is called on to see the infant or very young patient. This may be triggered by parental or provider concern. Common problems requiring a gynecologic evaluation include vaginal discharge, vaginal bleeding, precocious puberty, trauma, concern for assault, or notable external genital differences.12

The gynecologic examination of the child is one of the most difficult procedures for the inexperienced physician to master. It is important to learn examination techniques or to obtain the help of a pediatric or adolescent gynecologist. Although this is not a boarded subspecialty, growing numbers of physicians are taking the time to train and become more expert at the difficult examination techniques involved in the care and handling of patients this young. Standard adolescent gynecologic textbooks are informative, especially concerning proper instrumentation for vaginoscopy and the removal of foreign bodies.12

Mandatory Laboratory Testing

There are no routine gynecologic tests in this age group. Screening is mandatory for sexually transmitted infections (STIs) in cases with a high degree of suspicion for sexual assault. Be aware of rules regulating the reporting of positive findings in the USA (e.g. Sections 97.132, 97.134, and 97.135, Article 95, Title 25, Texas Administrative Code).


As girls begin to enter the early stages of puberty, it is important to take note of physical development. To this end, the gynecologist should be familiar with the schedule and patterns of development, including the expected appearance as well as the subsequent stages of thelarche, pubarche, and adrenarche, so that answers may be forthcoming when unexpected questions arise. The range in age for onset of thelarche is 8–13 years, however, the childhood obesity epidemic has been closely associated with earlier pubertal development. This has prompted the Lawson Pediatric Endocrine Society to modify its definition to account for excess adiposity.14 Nonetheless, one should be concerned when pubertal signs are present at less than 7 years of age for most ethnic groups, and less than 6 years of age for African Americans. The mean age of onset for pubarche closely coincides with thelarche at 10.5 years of age. Finally, the average age of menarche in the United States is 12.7 years of age. Typically, one can reassure parents that once breast development ensues, the expectation for onset of menarche is approximately 2 years following initial breast budding.12

Parents are concerned about reports of increasing sexual experience in younger children, and the gynecologist should offer advice and counseling on contraception as well as sexually transmitted infections. A pediatrician, family practitioner, obstetrician gynecologist, or pediatric gynecologist may participate in education about pending puberty and the associated bodily changes expected. Literature may be given to parents to assist in this matter.12

Mandatory Laboratory Testing

No gynecologic tests are routine in this age group, but rather are performed for specific indicated reasons. Screening for STIs is mandatory in cases with a high degree of suspicion for sexual assault.


Puberty may be the first occasion for contact between the gynecologist and the young female patient. As with prepuberty, concerns about physical development usually trigger this contact. It also is at this time that the pediatrician may begin to defer to the gynecologist and therefore, a familiarity with developmental norms is extremely important.

An area of controversy may arise over the initiation of an evaluation for primary amenorrhea. The traditional approach has been to defer such testing until 16 years of age provided that height and secondary sexual development appear to be within expected norms or 14 years of age in the absence of secondary sexual characteristics, although current trends suggest earlier evaluation at the age of 15 years since lack of menses at this age falls outside the normative range. Only 5% of teens will begin to menstruate at greater then fifteen years of age. Loss to medical follow-up, however, can result in an attainment of exaggerated height in patients with Swyer's syndrome or gonadal dysgenesis. It is therefore important to advise the patient and her parents about the potential negative aspects of excessive delay of evaluation and to follow those patients whose menarche is significantly delayed.15

In cases in which dysfunctional uterine bleeding dominates the postpubertal time period, a conservative if watchful approach is recommended initially. Menstrual cycle regularity typically occurs within 2–3 years of menarche. Abnormalities relating to heavy flow, missed cycles or lack of menstruation altogether, should be investigated. Currently, 13–15 years of age is a recommended time during which the young pubertal teen should be seen by a gynecologist.16, 17 This allows for careful review of not only pubertal development, but menses and other related symptoms. Blood counts are beneficial in cases in which heavy bleeding characterizes the menstrual pattern. Fortunately, many hormonal contraceptives are now available for acute control of heavy bleeding episodes. Uterine curettage is to be avoided when possible. One should discuss the benefits of the pill as not merely a contraceptive, but because many non-contraceptive benefits may be gained. These benefits include control of menorrhagia, regulation of menstrual cycles, suppression of ovarian cysts, relief of dysmenorrhea, alleviating PMS-symptoms, and diminishing acne, without affecting fertility, or final adult height. Furthermore, the gynecologist should be prepared to counsel and intervene in the case of the patient with severe primary dysmenorrhea, a condition that, if not handled correctly, could lead to consequential emotional and functional problems.16

Because sexual activity is evident among pubertal females with 7.1% of teens now sexually active under the age of 12 years, it is imperative that gynecologists be proactive as health care providers for these young patients. A balance should be struck between concerns for contraception and concerns for the dangers of acquiring STIs brought about by sexual intimacy. Studies demonstrate clearly that use of contraceptives among teens does not increase rates of sexual activity within this group.18 Similarly, use of contraceptives demonstrates a decrease in teen pregnancy rates among those who choose to participate in sexual activity.19 Stressing adequate protection with regular condom use and yearly screening exams is important for their health and well-being.20

Mandatory Laboratory Testing

No gynecologic tests are routine in this age group. Karyotyping is indicated in cases of delayed puberty as well as screening for premature ovarian failure, thyroid disease or hyperprolactinemia. Screening for STIs is important. A pregnancy test should not be delayed if there is genuine concern about a possible pregnancy.


The timing of a young adolescent female's first gynecologic examination is a frequent topic of discussion. This examination is not necessary for all young women presenting for gynecologic advice. The exam should be mandated by any problem that clearly falls within the gynecologic discipline. Possible problems include all types of menstrual disorders, persistent pelvic pain, and any lingering questions of physical and anatomic development, such as those dealing with the hymen, external genitalia, or the breasts.17 Studies do not support routine examination of the adolescent breast until the age of 19. However, adolescent patients with a strong family history of breast cancer should be advised to practice routine self-examination of the breasts at 18 years of age.  In the presence of a previous history of chest irradiation, breast exams should begin 10 years following radiation treatment. Proper methods of this examination should be taught and literature provided.21

If the first period has not begun by 15 or 16 years of age, evaluation for primary amenorrhea should commence. Because buccal smears are not in routine use, karyotyping is mandatory. Anxiety on the part of the parents may pressure the physician to intervene at an earlier age, but this should be avoided if possible. Absence of secondary sexual characteristics by age 14 should cause concern and intervention should then be initiated.16

In the absence of specific problems a pelvic exam is unnecessary. The initiation of contraceptives alone does not automatically  necessitate a pelvic examination.17 However, the young woman should be advised to undergo her first pelvic examination and Pap test at 21 years of age or within 3 years of sexual activity.22 Establishing baseline findings in the presence of abnormal symptoms, may help in dealing with new problems as they arise. Routine HPV-reflex testing is not currently recommended for the adolescent as literature suggests that only women 30 years of age and older should receive this routinely.23

Once pelvic and breast examinations and Pap tests are begun, yearly checkups are advisable as a minimum of care. Rubella vaccine should be administered before the patient's first gestation. Despite recent investigations that have implied increased risks of breast cancer and premalignant as well as malignant changes in the cervix in younger women taking oral contraceptives, there is no apparent reason to recommend more frequent follow-ups in young women.17, 20, 24, 25 No recommendations for changes in drug labeling or prescribing practice have been made.16

Routine screening for STIs is another controversial area. Approximately 19 million new cases of sexually transmitted infections (STIs) occurred in 2000, of which nearly 50% were diagnosed among persons aged 15–24 years.20  Many STIs are diagnosed at disproportionately high rates in the female adolescent population, especially among high-risk populations, such as those who are homeless, runaways, or in detention facilities. The Centers for Disease Control and Prevention (CDC) estimates that more than 1 in 10 sexually active female adolescents have been diagnosed with Chlamydia trachomatis infections. Similarly, of reported cases of N. gonorrheae in females in 2005, 35% were in those aged 15–19 years, representing the highest age-specific Chlamydia and gonorrhea rates among females. Confidentiality concerns frequently limit access to medical care for adolescents, therefore, adolescents are more likely to present for acute problems requiring STI testing, rather than preventative routine screening.  In the presence of one STI, an adolescent should be routinely tested for comorbid STIs. Special considerations should be undertaken for screening various teen populations, whether asymptomatic and sexually active, in the setting of sexual assault, same sex partner relationships, HIV positive status, pregnancy, or non-coital sexual activity (see the CDC website for specific population guidelines as they apply).20, 26, 27, 28, 29 Finally, both screening and testing in the presence of acute symptoms, provide an opportunity for the gynecologist to inquire about vaccination status.30 The CDC has recently updated and published a recommended catch-up vaccination schedule for adolescents, including an option to receive the quadrivalent HPV vaccination.28, 30

Beginning the use of oral contraceptives inevitably raises concerns about their effect on cardiovascular health. A great deal of research effort has gone into establishing the metabolic effects of estrogens and progestins.25 The relative safety of the newer agents and formulations has been well established and should be reinforced with the patient.25 Teen pregnancy rates have continued to decline since the 1990s. Nevertheless, information on emergency contraception should be made available to all sexually active teens.19, 31

Mandatory Laboratory Testing

As sexual activity increases, special attention should be given to screening for STIs. A pregnancy test is indicated if there is any suspicion of pregnancy. Once initiated, Pap tests should be continued annually. Obligatory safety screening for an oral contraceptive prescription should include weight and blood pressure as well as obtaining a smoking history and history of cardiovascular disease, hyperlipidemias, diabetes, and liver disease.17

Baseline values for a complete blood count (CBC) are indicated, as well as fasting blood glucose levels in addition to a lipid panel, particularly if there is a family history of diabetes or the patient has obesity. These latter two tests may be repeated periodically thereafter.


A yearly physical examination including breast and pelvic examinations and Pap smear is recommended for the female patient throughout the rest of her life. The rationale for a yearly Pap test has been debated both in this country and abroad, with financial factors often playing a role in foregoing annual testing. We believe that an annual visit, including breast and pelvic examination, merits consideration for remaining the normal routine. During the reproductive years, a woman may see no physician other than her gynecologist for long periods of time; therefore, avoidance of a once-yearly examination cannot be justified. Because the Pap test is often the linchpin consideration for the gynecologic visit, we feel that advising against annual cytological screening would result in loss of considerable numbers of patients to regular health care maintenance. Conversely, we do not believe that more frequent than annual physician visits are necessary. Some studies have shown that oral contraceptive use in younger women may be associated with increased risks of breast and cervical cancers.32, 33, 34, 35 As yet, however, no study has justified more frequent than annual examinations as an effective countermeasure. More frequent than yearly visits are thus reserved for patients with specific problems, for example, patients on follow-up protocols after treatment for higher grades of CIN dysplasia. Such patients may be seen for Pap tests semiannually for a few years as long as the tests remain normal.36, 37 The current recommendation from ACOG is for yearly cervical cytology testing beginning at age 21 or within three years of first sexual activity. After age thirty, and following three consecutive negative tests, this may continue every two to three years. Yearly medical visits for general checkups should be encouraged, and this might well be done in the gynecology office. Under these circumstances the average patient may expect a Pap test to be part of her screening. Testing for human papillomavirus (HPV) should not be routine except for cases of uncertain diagnosis with possible need for more invasive investigation. In the presence of a cytology result indicating atypical squamous cells, undetermined significance (ASC-US), reflex HPV testing might help in predicting future risk for life-threatening  pathology. A negative HPV test indicates little risk for future neoplasia whereas a positive test for an oncogenic-type HPV would direct the examiner toward further investigation with colposcopy.38 To further support the argument for continued yearly examinations, it is important to update the interval medical history and to test and record weight and blood pressure. It always is wise to take the time to counsel the patient about smoking and alcohol abuse, to query her regarding physical or emotional abuse in her social situation, as well as encourage better eating and exercise habits. Risk factors for heart disease, some of which can be lowered, have been clearly identified.39 Lowering serum cholesterol levels may lead to a decrease in the incidence of coronary heart disease.40 Vaccination against HPV is recommended up to age 26 although some controversy exists here, especially in women with a history of an abnormal Pap. Ancillary personnel, if available, are always of great help in office counseling routines especially if they have the time to visit a broader range of concerns than does the physician. The first mammogram usually falls within the reproductive age group, and the current recommendation is for a baseline examination at about forty years of age followed by yearly examinations thereafter. Alternatively, these may be recommended every 1–2 years after 40, with yearly examinations commencing after 50 years of age. A positive family history may mandate a more conservative protocol with an earlier baseline study. As women age, the frequency of all neoplastic diseases increases. The goals of screening are to reduce morbidity and mortality, but reduction of risk factors, when possible, is also important. Smoking is associated with 79% of all cases of lung cancer in women.41 The controversies regarding yearly Pap smears have already been mentioned. There were an estimated 65,000 new cases of carcinoma in situ of the cervix in 1995, and 4800 women were expected to die of cervical cancer in 1997.42, 43 The 5-year survival rate of women with carcinoma in situ is virtually 100%.41 Most studies conclude that screening every 3–5 years affords adequate protection, whereas annual or biannual Pap tests improve detection effectiveness by only 5%.42, 43 Frequent screening, then, represents a net cost to society.44 The current recommendation of the American Cancer Society is for an annual Pap test and pelvic examination for all women who are sexually active or at least 18 years of age. After three consecutive negative Pap smears, frequency of repeat cytologic screening is at the discretion of the physician.41

Mandatory Laboratory Testing

Yearly Pap tests and stool testing for occult blood are indicated.

Lipid levels should be measured every 5 years.45

CBC and blood chemistry profile are not recommended as cost-effective routine screening tests for asymptomatic patients in this age group.46 Routine urinalysis is also of questionable benefit. Annual urine dipstick tests that can detect glucose and leukocytes may be of value after 40 years of age.47

The first mammogram should be performed at age 40. Follow-up mammograms should be done yearly after 40 years of age.

Chlamydia testing is advisable for sexually active patients up to age 25. Other STD screening including for HIV, Hepatitis B, and Hepatitis C is dependent on the patient's lifestyle including drug abuse, prior history of sexually transmitted infections (STIs) and multiple sexual partners.

Vaccination schedules for adult women are seen in Table 1 (below).




The perimenopause represents a unique challenge for physicians. To begin with, there are the overlapping concepts of climacteric, menopausal transition and perimenopause to deal with. The climacteric encompasses that period of declining fertility through to the final menstrual period and a subsequent year of amenorrhea. That is to say that in the early climacteric the menses may still be regular but the chances of achieving pregnancy are greatly diminished. The menopausal transition is that period from the onset of menstrual irregularity to the final menstrual period. The perimenopause is then defined as the time period from the onset of menstrual irregularity through to the final period (early perimenopause) and further on through one year of amenorrhea (late perimenopause). It is probably not worth worrying about the clinical differences between these three concepts. As one can readily see, there is a great deal of chronological overlap. One clinical challenge is in managing that one year of amenorrhea subsequent to the final menstrual period. Not until the end of that year can one anterospectively define the postmenopause and retrospectively define the perimenopause. Also, until that year of amenorrhea has passed, one can never be sure that any therapeutic effects or side effects noted during treatment have derived from prescribed medications or from intermittent ovarian activity. As stated, the diagnosis is retrospective. The physician looks back and then decides when the patient was actually in that year of late perimenopause.48, 49 The chief health concerns of women who are approaching menopause are not significantly different from those of the preceding 20–30 years. The climacteric, however, often involves insidious changes that may be confusing and frightening as well as discomforting to the patient. It is thus a period in a woman's life that makes increasing demands of time and takes sympathetic understanding on the part of the physician. The consequential nature of her infirmities, as well as the increase in cancer risks as she gets older, makes the perimenopausal patient especially demanding of the gynecologist's time. If her concerns are met with patience and a genuine involvement, then the trust won during this time serves the doctor-patient relationship well in those subsequent menopausal years that constitute an even greater challenge. Careful counseling regarding the inevitability of loss of ovarian function, as well as a plan for routine care during the last half of her expected lifespan is mandatory at this time. This also is a time when patients often select themselves into specific groups according to how they are able to deal with middle and old age as well as how much time and money they are willing to spend on their health care. In this regard, certain patients may try the physician's resolve by demanding tests that may not yield worthwhile information or demanding that an expensive test be repeated at greater-than-recommended intervals. There is no question that tailor-made medical care becomes much more of a reality in this period than at almost any other time in a woman's life. Cancer screening does become much more important at this time and the addition of the digital rectal examination at about 40 years of age and testing for the presence of blood in the stools underscores this concern. The perimenopause also is the time to initiate counseling on the issues of osteoporosis, heart disease, and hormone replacement therapy. This can be done in a more unfocused and generalized manner than in the menopausal years and may result in a trusting relationship that will reward both physician and patient later. Employment of ancillary personnel for these tasks may conserve time and establish a broader base of support in the mind of the patient. During the perimenopause, however, another significant change in the relationship between gynecologist and patient must inevitably take place; this involves the readiness on the part of the physician to surrender more and more areas of the patient's medical concerns to specialists in other fields. The reluctance to change the primary caregiver that characterizes the evolution of the female from a pediatric to a gynecology patient must not be repeated now when she may need to be placed in the hands of the internist or other specialist. Simple screening for blood chemistries, thyroid function, or glucose metabolism may continue in the gynecologist's office, but abnormalities should be dealt with immediately and with whatever outside help is needed. Some of these problems may be mitigated through the evolution of gynecology into a specialty with more primary care concerns and with concurrent broadening of the scope of the gynecologic practice. A growing consensus among clinicians recognizes the benefits of low-dosed oral contraceptives as a primary approach to managing the perimenopause.50 These agents provide cycle regularity, contraception and prophylaxis against many of the encroaching effects of impending ovarian failure. Individualization of patients is mandatory mainly to select out those with absolute or strong relative contraindications to hormone use. These may include obesity, hypertension, smoking, diabetes, migraine headache and personal or family history of venous thrombosis. One must be careful to screen for all of these. The cardiovascular safety of oral contraceptives in this population is generally accepted.51  

Mandatory Laboratory Testing

An annual Pap test, or every 2–3 years following three consecutive negative tests. Mammogram annually or every 2 years. 

Lipid screening every 3–5 years starting with age 45. There are a variety of recommendations for colon cancer screening: annual fecal occult blood testing, flexible sigmoidoscopy every five years or colonoscopy every ten years. Double contrast barium enema every five years is also a possibility.52 Stool sample for occult blood should be taken at each visit. This test has engendered some controversy in that sensitivities with the older guaiac tests are only in the 30% range53 and mortality reduction is also low.54 However, one might also consider that the capture of even a minority of positive cases for so little an investment in time and money could be deemed worthwhile. 

It is generally agreed that mass routine screening of perimenopausal women with bone densitometries is unjustified. Thus, a baseline bone densitometry examination before the onset of menopause may be mandated only in specific cases.

Thyroid stimulating hormone baseline levels should be obtained sometime in the mid-forties. 

Day 3 FSH is necessary if fertility is an issue. 


The ideal menopausal patient is one who has been prepared for the changes secondary to loss of ovarian function by proper counseling and appropriate management during the perimenopause. Such women should enter their menopausal years with a maximum of trust and confidence in the future. The patient must be made to understand that she is not merely “going through” the menopause, but rather, once having entered it, will be menopausal and in need of routine follow-up for the rest of her life. Dealing with patients in this age category is complicated by endless debate within the medical community, not only over proper modes of care but also over the necessity for universal care. Because all aspects this debate is are avidly reported in the media, it is not unusual for patients to be confused about the risks and benefits of hormone therapy. In truth, the entire world of menopause was, within the past decade, tossed into panic and uncertainty with the publication of the results of the WHI and (to a lesser extent) HERS studies.2, 3, 4, 5 These unleashed the proverbial storms of controversy that have, as yet, not abated. The present status of menopause management remains confusing to both physicians and their patients. It also is not unusual for physicians, increasingly burdened by these insecurities in their patients, to acquiesce readily when patients refuse hormone therapy or voluntarily withdraw from further therapy after a short time. From a historical perspective the menopause has never been an easy therapeutic exercise. It has been estimated that never more than 50% of eligible women ever commenced hormone therapy and half of those dropped out before any meaningful period of therapy elapsed. It is not within the scope of this chapter to enter into the debate about whether all patients who lack contraindications should be started on hormone replacement. The consensus is that the absence of symptoms generally does not warrant hormone use. It is also a thing of the past to use hormone therapy as a general holistic and prophylactic drug for the menopause. Growing concerns about the daunting nature of the task—the fiscal challenges as well as the traditional battles over compliance—have led many clinicians to conclude that prolonged therapy is not, and probably never was, a proper goal and that it is preferable to identify those patients at highest risk for the more serious consequences of menopause and target them appropriately. This argument probably will not resolve until additional data on the long-term value of hormone replacement in areas other than lipid metabolism and osteoporosis are established. The current recommendation, derived when some of the contentiousness was resolved, is that estrogen, or estrogen plus a progestin, are indicated for specific patients but only in the lowest possible dose and for the shortest possible time. Furthermore, these drugs are to be used only for on-label conditions, and these include treatment of vasomotor symptoms, atrophy of the vagina and prevention of osteoporosis. Although there are some differences between the follow-up of patients taking hormones and those not doing so, it is important to understand that a rational and routine protocol for following all menopausal patients must be established and maintained. Careful attention must be made to understanding the entire range of symptoms that the patient attributes to her menopausal status. Yearly visits are a necessity although this is obviously not indicated in women whose internal female organs have been surgically removed for benign disease. In this case it may be debated whether the patient is in need of gynecologic care at all. A routine for cytological testing in women without a uterus is not established although we must remind ourselves of the possibility of squamous disease arising in the vaginal cuff area. Older women who have never been screened have the highest incidence of and mortality from cervical cancer, and benefit the most from screening.55  Much of this is moot and, for many women, the decision as to which physician she will visit is a personal one. She may want to continue the relationship with her gynecologist and then depend on his or her recommendations for ad hoc care elsewhere. Therefore, an increasing awareness of general medical problems is mandated on the part of the gynecologist. Counseling on diet and exercise programs should increase, and mammograms become an annual routine examination. Goals of care at this point are to promote and prolong optimal physical and mental function. To this end, a thorough update on interval medical history as well as increases in counseling time is mandatory. As the patient ages, special attention should be paid to exercise programs and fall and injury prevention. If the time or facilities are not available in the gynecologist's office, patients may be referred to menopausal or geriatric programs that offer education, activities, and support. Other areas of controversy for the gynecologist in the time of menopause may include differences about what tests should be included in routine follow-up. Before initiation of hormone replacement therapy, we do not recommend an office baseline endometrial biopsy, nor do we carry out interval biopsies on a routine basis. Instead, these interventions should be reserved for clear indications of suspicious bleeding. An arbitrary age at which the Pap test should be discontinued also has been debated. Twenty-four percent of new cases and 40% of deaths from cervical cancer occur in women older than 64 years of age.56 One study has shown that three fourths of women older than 65 years of age had been screened inadequately and one fourth not at all.57 These authors recommend continued screening of the elderly until more data are at hand. Medicare now pays for Pap tests done at 3-year intervals but will pay for yearly mammograms.58 Routine bone densitometry has been recommended increasingly in recent years. The costs of such a test may be prohibitive, even though it can be argued that the expenditures are rewarded with savings in fracture prevention. A great deal of broad-based study and data collection is necessary before universal radiographic bone screening can be recommended. The present guidelines specify that densitometry should commence at age 65 in the absence of compelling risk factors where an earlier baseline is recommended. Routine bone densitometry is then recommended every two years but may be done more frequently in certain cases or, conversely, less frequently in cases of long-term stability. In countries where DEXA machines are not readily available, reliance on a variety of clinical risk factors as well as body mass index appears to work well in predicting future fractures. Since fragility fracture predict future fractures, morbidities and mortality, a simple clinical approach to determining the presence of fractures has been suggested by Green et al. This includes an inability to touch the occiput to the wall when standing with back and heels against a wall, a weight of less than 51kg (112.4 lbs.), a distance of less than two finger breadths between the lower margin of the ribs and the superior surface of the pelvis in the mid-axillary line, a tooth count of less than 20 and self reporting of a humped back.59 Additional investigation also is called for in the area of heart and vascular disease in women. The idea that cardiovascular problems are somehow only male problems is exposed as a myth when one understands that heart disease kills more women than men annually and is by far the overall leading cause of mortality in women. Conventional wisdom long held that hormone therapy held significant cardiac benefits for women.60 Of course, the HERS results and the preliminary results of the WHI put paid to any such notion of such benefits in cardiovascular disease. The subsequent WHI data, however, have reversed some of this and do indicate potential early benefits for many women.61 Reserve also must be maintained in the face of calls for routine pelvic ultrasonography, particularly the newer color flow Doppler studies, to screen for ovarian cancers. This may have limited value even in conjunction with findings on pelvic examination and elevated levels of serum tumor markers. In the absence of more supportive data, such studies still must still be considered less than cost-effective. Finally, in this age group, women worry more about neoplastic diseases. Lung cancer has exceeded breast cancer as the leading cause of death in women, with 71,030 deaths estimated for 2008.62 The overall 5-year survival rate for lung cancer is 13%, and no screening method adequately reduces mortality.63, 64 Breast cancer incidence peaks after menopause, when 90% of cases occur.65 One in eight women will contract breast cancer over the course of their lives, and about half of these have no identifiable risk factors beyond being female and aging.66 Survival still depends on the stage of the disease at the time of diagnosis. Mammography is the only reliable screening technique and may result in decreased mortality.65 The costs of mammography, however, can be a deterrent for large segments of the population. The case for self-examination of the breasts is strongly promulgated in the United States, although the Canadian Task Force on Periodic Health Examination has questioned self-examination when its overall effects on survival are weighted against the anxiety caused by false-positive findings in healthy women.67, 68 Colon cancer incidence rates are declining in women; mortality has fallen 29% for women during the past 30 years.41 There was, however an increase between 1997 and 2008, growing from 48,600 to an estimated 54,310 new cases of colon cancer among women with 24,000 deaths in 1997 and an estimated 24,700 deaths in 2008.69 Ninety percent of cases occur in patients older than 50 years of age.70 The American Cancer Society recommends digital rectal examinations annually beginning at 40 years of age and testing stool for occult blood at 50 years of age.65 Given the relative inexpensiveness of a digital rectal examination, it can be recommended yearly beginning at 40 years of age; a digital rectal examination test kit may be purchased over the counter and is easily administered by the patient herself. Proctosigmoidoscopy is recommended beginning at about 50 years of age and every 5 years thereafter. The estimated incidence for ovarian cancer for 2008 is 21,650 new cases (3% of cancers in women) and 15,520 deaths or 6% of all deaths from cancer in women.71 Ovarian cancer is a frightening entity for which early detection would have enormous beneficial consequences. The 5-year survival rate for adequately treated stage I disease is greater than 90%, whereas the rate for stage III is 15–20% and for stage IV, less than 5%.72 A test with 80% sensitivity would reduce mortality by 50%, leading to 5000 more 5-year survivors annually.73 Unfortunately, no such test is available at this time.74 Serum CA-125 levels are elevated in 80% of ovarian cancer patients, with the levels dependent on the stage of the disease.75 False positive tests remain a problem.76  The combined use of transvaginal ultrasonography and CA-125 for ovarian cancer detection is limited by relatively poor sensitivity and specificity. The addition of color Doppler imaging has not yet been established to improve overall efficacy of the ultrasound screening.72 To date, these tests are best considered adjuncts to the pelvic examination and clinical impression in the suspicion of ovarian cancer. Table 2 lists some epidemiologic features of common cancers seen in women.

Mandatory Laboratory Testing

A Pap test may be carried out annually; an examination for occult blood in stools, as well as a mammogram, should be done annually. Less frequent scheduling of cervical cytologic screening has been discussed above. 

Thyroid-stimulating hormone testing continues at five year intervals.77

Cholesterol levels should be taken at 3–5 year intervals after 50 years of age, and a CBC should be done at 5 year intervals. Metabolic screening, including fasting glucose, may be carried out every three years.

Bone densitometry studies are recommended at periodic intervals, especially if the efficacy of therapy needs closer scrutiny. These should commence at age 65 unless there is some specific indication for an earlier start to screening. 

Ovarian tumor markers, such as CA-125, may be measured periodically or annually, particularly in instances of cancer in primary relatives. Many patients insist on this test and may be willing to pay for it out of personal funds. These may be are of some value in conjunction with physical and ultrasonagraphic findings, but, as yet, routine screening with CA125 and color-flow doppler ultrasound is not recommended.

Colorectal cancer screening continues with yearly stool occult blood testing or colonoscopy every five years. 

In general, patients tend to see their internist, gerontologist, or family physician with increased regularity as they get older, and provision must be taken to coordinate care and avoid repetition of tests. The internist may be prone to order many of the above-mentioned tests annually, which is more frequently than is recommended.  


Generating a protocol for providing routine health care throughout the life cycle of the female patient is an important consideration because obstetrician-gynecologists probably provide the most care and counseling for women during the greater part of their adult lives. We are constrained not only by the problems engendered in developing a consensus within the medical community but also by forces outside of our immediate control, such as financial, social, and political factors that may attend and influence our decisions. All of these considerations will undoubtedly provide serious challenges in the coming years. Nevertheless, a significant portion of our experience will remain within the traditional framework of the physician-patient relationship that has characterized the practice of medicine in the United States. Therefore, the decisions we make in our practices will continue to have a significant bearing on every level of health care, from the status of the solitary patient to the overall costs to society for the care of all patients. Considering this, we must practice with an eye on the practical as well as on the ideal. Mindful of some of the harm generated by the “feminine forever” philosophy that impacted the area of menopausal estrogen replacement in the past, it is important that we do not oversell the value of some of the routine screening that we recommend. Ultimately, all patients succumb to one disease or another. No amount of densitometry screening can eliminate osteoporotic fractures, and no amount of mammography screening cuts into the incidence of breast cancer. A mutually trusting and honest relationship between patient and physician should ease the journey toward our goal of providing the most beneficial care, in the most feasible manner, to the greatest number of people.  Table 3 is a summary of recommended care.  Table 1 shows recommended vaccination schedules.


 Table 1. Recommended vaccination schedules

Note: These recommendations must be read along with the footnotes. Please refer to footnotes at the web site listed below. Approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians. Complete statements from ACIP are available at
* Covered by the Vaccine Injury Compensation Program.


Table 2. Epidemiologic features of some important cancers in women











Table 3. A Synopsis of scheduled preventive health care for female patients 


Recommended care


Examine external genitalia, breasts

Prepubertal (<12 yr)

Annually: height, weight, blood pressure, external genitalia, Tanner staging

Adolescent (12–19 yr) 

Annually: basic examination*, height, Tanner staging
Pap smear if sexually active or more than 18 years old; initial test for chlamydial infection if sexually active

Reproductive (20–39 yr)

Annually: basic examination, health counseling, Pap smear
Age 35: baseline mammogram
Every 5 years: total cholesterol level
STD screen when indicated

Perimenopausal (40–49 yr)

Annually: basic examination, Pap smear, digital rectal examination, urine dipstick, health counseling
Annual or twice yearly mammogram
Every 5 years: total cholesterol level
Age 45: baseline TSH levels

Menopausal (>50 yr)

Annually: basic examination, Pap smear, digital rectal examination and occult blood, urine dipstick, mammogram
Every 5 years: sigmoidoscopy
Every 5 years: cholesterol level, blood count
Over age 60; TSH levels every 2 years
Endometrial biopsy for suspicious bleeding
Bone densitometry baseline study at age 65

*Basic examination includes a thorough history update, weight, blood pressure, pelvic examination, and breast and abdominal examinations.
TSH, Thyroid stimulating hormone.




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