Well Woman Exam Overview

Well Woman Exams

• Pap smear: collection of cervical cells during a speculum exam
• Well woman exam: head-to-toe exam of a woman, may include a clinical breast exam (CBE) and Pap smear

Pap Smear Myths and Facts

• Most women fall into routine screening categories for their age group
• Pap smears do not begin until age 21, regardless of sexual activity
• Most insurance companies cover an annual well woman exam

ASCCP & US Preventative Task Force Apps

• ASCCP mobile app free for iOS and Google devices
• US Preventative Task Force app available for free for iOS and Google devices

Patient Example: Annie

• 21-year-old female presenting for a well woman exam
• Declines need for testing and birth control
• Blood pressure 120/80, pulse 82, temperature 98.2
• Weight 120lb, height 5’5”

Clinical Breast Exam (CBE)

• Patient should lay flat with arms above head
• Palpate both breasts and axillary area using one of three patterns: wedge, vertical, circular or clockwise
• Note: Any unusual warmth or coldness, tenderness, size, shape, surface abnormalities (rashes, wounds, open areas, peeling or cracking skin, dimples, divots, unusual color changes)

Genital Urinary (GU) Exam

• Bimanual exam:
  • Ovaries & Fallopian tubes: tenderness or enlargement
  • Uterus: tenderness, enlargement and position
  • Bladder: tenderness or prolapse
  • Cervix: cervical motion tenderness
• Speculum exam:
  • Exterior: any rashes, lesions, atrophy
  • Vagina: foreign body, redness, irritation, excessive discharge, tenderness, prolapse
  • Cervix: discharge, redness, friability, bleeding, IUD strings
• Rectal exam: note lesions, bleeding, irritation

Pap Smear Results

• ASC-US (Atypical Squamous Cells of Unknown Significance): Most common abnormal finding. Can be a sign of infection such as HPV or a vaginal infection, inflammation, or low hormones in postmenopausal women. Most often benign.
• LSIL (Low Grade Squamous Intraepithelial Lesion): Can also be called mild dysplasia. Usually caused by HPV. May go away without treatment but can sometimes lead to cancer.
• ASC-H (Abnormal Squamous Cells Cannot Rule Out High Grade): May be a sign of high-grade lesions. Can become cervical cancer if left untreated.

HPV

• HPV 16, 18, and high-risk HPV strains (at least 12) are linked to cervical cancer

Patient Management

• Complete a pregnancy test
• Uterine Bleeding (AUB):
  • Regular cycle: NSAIDS
  • LUS (Levonorgestrel releasing system): Mirena
  • OCPs
  • Surgery: Hysterectomy; Ablation

Amenorrhea (Absence of Menstruation)

• Most common reason: PCOS (Polycystic Ovarian Syndrome)
• Treatment depends on the underlying cause
• May include OCPs or medication such as Clomid for pregnancy

Breast Concerns

• Most common is a lump in the breast
• Can be found in women on HRT or OCPs
• May be noted during certain points in their menstrual cycle
• Most often benign in nature (fibrocystic or mammary dysplasia)

Breast Concern Symptoms

• Tenderness
• Rapid changes in size
• Redness, dimpling, peeling

Breast Concern Testing

• Mammogram
• Ultrasound
• Breast biopsy

Breast Concern Treatment and Self Care

• Avoid trauma
• Wear well-fitting bras
• Eliminate caffeine, HRT, OCPs, progesterone supplements
• Stress importance of breast self-awareness and CBE

Dysmenorrhea (Painful Menstruation)

• Painful cramping associated with sweating, headaches, nausea/vomiting/diarrhea, leg or back pain
• Can affect up to 90% of women in their lifetime
• Primary: Teenagers to 20s, no underlying reason
• Secondary: 20s to 30s, usually a pathology

Dysmenorrhea Treatment

• Primary: NSAIDS, OCPs, heating pad, TENS unit, reassurance
• Secondary: Treatment depends on cause, refer to a specialist

Menopause

• Spontaneous: No period for 12 months
• Perimenopause: Abnormal menstrual cycle, may have symptoms
• Premature menopause: Risk for osteoporosis
• Primary Ovarian Insufficiency: Risk for osteoporosis

Menopause Treatment

• Calcium and vitamin D supplementation
• SSRIs
• HRT: Caution, must use progesterone if the patient has a uterus
  • Cannot be used with current, past, or suspected breast cancer
  • Estrogen-sensitive malignancy
  • Undiagnosed vaginal bleeding
• MenoPro Mobile App (Free)

Genitourinary Syndrome of Menopause (GSM)

• Common findings:
  • Vaginal/Vulvar changes: Dryness, irritation, painful sex, spotting or bleeding after sex
  • Vaginal Atrophy: Thin, pale, decreased elasticity
  • Bladder Issues: Increase in frequency and urgency, common to experience UTIs, incontinence
• Treatment:
  • Nonhormonal treatments
  • Hormonal treatments: Local estrogen

Patient Example: Deloris

• 53-year-old female, last menstrual period 8 months ago
• Blood pressure 138/80, weight 145 lb
• No significant family history
• History of lipid disorder
• Follow up to menopausal signs and symptoms

PCOS (Polycystic Ovary Syndrome)

• Etiology is unknown
• Common feature is hypersecretion of androgens
• Diagnosis in adult women requires 2 of the 3 following:
  • Hyperandrogenism
  • Oligo-ovulation or anovulation
  • Polycystic ovaries on ultrasound
• Treatment depends on if pregnancy is desired
• Can be a lifelong disease

Lichen Sclerosis (LS)

• Irretractable itching
• Unknown cause
• Often mistaken for yeast infection or genital herpes
• Exam: White wrinkle-appearing plaques or patches, tissue is usually red around it.
• Testing: Punch biopsy, rule out coexisting vaginal infection
• Treatment: Use ointment over cream

Vulvodynia & Dyspareunia

• Vulvodynia: Vulvar pain for 3 months with no identifiable cause
• Dyspareunia: Painful intercourse
• Etiology is unknown
• Diagnosis is based on exam and history, rule out any coexisting conditions
• Treatment: Pelvic floor therapy and referral to a gynecologist

Yeast Infection

• Most common cause of vaginal itching
• Exam: Thick discharge, thick white patches in vaginal mucosa, usually no odor
• Testing: KOH prep
• Treatment: Topical is available OTC, oral and topical may be prescribed

Well Woman Exam

• Pap smear and well-woman exam may be used interchangeably
• Pap smear is a cervical cell collection during a speculum exam
• Well-woman exam is a head-to-toe exam that may or may not include a pap smear, and includes a CBE
• Most insurance companies cover an annual well-woman exam

Pap Smear Myths and Facts

• Pap smears should not be done yearly on every woman
• Women do not need to come in yearly for a pap smear
• Women should start pap smears at age 21, regardless of sexual activity

Resources

• ASCCP and US Preventative Task Force Apps are available for free
• Hollier and Dunphy are useful texts for well woman exam information

Patient Encounter

• Annie is a 21- year old patient presenting for a well woman exam
• Annie declines testing and birth control since she is not sexually active

Clinical Breast Exam

• Patient should lay flat with arms above head
• During the exam, it is important to observe temperature, tenderness, size, shape, and surface of the breasts
• When charting abnormalities, consider a clock-face model for the location

Bimanual Exam

• Bimanual exams are done to evaluate:
  • Ovaries and fallopian tubes
  • Uterus
  • Bladder
  • Cervix

Speculum Exam

• During the speculum exam, evaluate:
  • Exterior: Rashes, lesions, atrophy
  • Vagina: Foreign objects; redness, irritation; excessive discharge; tenderness; prolapse
  • Cervix: Discharge; redness; friability; bleeding; IUD strings
  • Rectal: Lesions; bleeding; irritation

Abnormal Pap Smear Results

• ASC-US: Most common abnormal finding; most often benign
• LSIL: Low-grade squamous intraepithelial lesion; usually caused by HPV
• ASC-H: Abnormal squamous cells that cannot rule out high grade; can become cervical cancer if left untreated

HPV

• Several strains of HPV are linked to cervical cancer, including:
  • HPV 16
  • HPV 18
  • HPV HR

Patient Management

• Complete a pregnancy test
• Manage uterine bleeding with:
  • Regular cycle: NSAIDs
  • LUS
  • OCPS
  • Surgery

Amenorrhea

• Most common reason is PCOS
• Treatment depends on cause
• May include:
  • OCPS
  • Medications such as clomiphene for pregnancy

Breast Concerns

• Most common is a lump in the breast
• Can be found in women on HRT or OCPs
• Most are benign
• Women and families can be highly anxious about breast concerns

Breast Concerns Symptoms and Testing

• Symptoms include:

  • Tenderness
  • Rapid changes in size
  • Redness, dimpling, peeling

• Testing includes:

  • Mammograms
  • Ultrasounds
  • Breast Biopsy

Breast Awareness

• Advocate for breast self-awareness and regular CBEs
• Encourage a healthy lifestyle including:
  • Avoiding trauma to the breast
  • Wearing well-fitting bras
  • Eliminating substances such as caffeine, HRT, OCPs, and progesterone supplements

Dysmenorrhea

• Painful cramping associated with at least one of the following:

  • Sweating
  • Headaches
  • Nausea, vomiting, diarrhea
  • Leg or back pain

• Affects up to 90% of women

• Primary: Common in teens and 20s

• Secondary: Common in 20s and 30s, usually a pathology

• Treatment:

  • Primary: NSAIDs, OCPs, heat, TENS unit, reassurance
  • Secondary: Treatment depends on the cause, referral to specialist

Menopause

• Spontaneous- No period for 12 months

• Perimenopause- Abnormal menses with symptoms

• Premature menopause- Risk for osteoporosis

• Primary ovarian insufficiency- Risk for osteoporosis

• Treatment:

  • Calcium and Vitamin D supplementation
  • SSRIs
  • HRT with progesterone if patient has a uterus
  • MenoPro Mobile app

GSM

• Common findings:

  • Vaginal or vulvar changes: dryness, irritation, painful sex, spotting or bleeding
  • Vaginal atrophy: Thin, pale, decreased elasticity
  • Bladder issues: Increased frequency and urgency, UTIs, incontinence

• Treatment:

  • Non-hormonal and hormonal treatment options
  • Local estrogen

Deloris Patient Encounter

• Deloris is a 53-year-old patient with an LMP 8 months ago
• She has a history of a lipid disorder, BP of 138/80, and a weight of 145 lbs
• She presents for follow-up for menopausal signs and symptoms

PCOS

• Etiology is unknown

• 2 of the 3 criteria must be present for diagnosis:

  • Hyperandrogenism
  • Oligo-ovulation or anovulation
  • Polycystic ovaries on ultrasound

• Treatment depends on if pregnancy is desired

LS (Lichen Sclerosus)

• Irretractable itching

• Unknown cause

• Often misdiagnosed for yeast infections and genital herpes

• Exam Findings:

  • White wrinkle-appearing plaques or patches
  • Tissue is usually red around it

• Testing: Punch biopsy; rule out coexisting vaginal infections

• Treatment: Use ointment over cream

Vulvodynia and Dyspareunia

• Vulvodynia is vulvar pain for 3 months with no cause
• Etiology is unknown
• Many women have pain with sexual intercourse
• Diagnosis is based on exam and history
• Rule out any coexisting conditions
• Treatment: Pelvic floor therapy and referral to a gynecologist

Yeast Infection

• Most common cause of vaginal itching

• Exam Findings:

  • Thick discharge
  • Thick white patches in vaginal mucosa
  • Usually no odor

• Testing: KOH-prep

• Treatment: Topical OTC; oral and topical prescription medications

This quiz covers essential information about well woman exams, including procedures such as Pap smears and clinical breast exams. Additionally, it discusses common myths and facts regarding Pap smear screenings and the availability of related mobile apps. Perfect for those seeking a better understanding of women's health assessments.