Women’s Health Care: The Importance of Choosing Wisely

Rita Singhal, MD, MPH

Raul Sobero, DrPH, MPH

November-December 2017

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Evidence shows that many of the tests and screenings commonly used in women’s health care are unnecessary under certain circumstances and may also be harmful. Cervical cancer screening, for instance, has decades of evidence that shows that annual screening, as well as testing among the youngest and oldest populations, is more harmful than beneficial.1

For the Choosing Wisely campaign, specialty societies, including the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), the Society of Gynecologic Oncology (SGO), and the Society of General Internal Medicine (SGIM), have developed evidence-based recommendations for what care should not be provided.2 In developing these recommendations, the goal was to follow the primary tenet of medicine: first, do no harm. The Choosing Wisely recommendations that pertain to women’s health and focus on primary and preventive care are presented and discussed below. The Women’s Health Care Don’ts at the end of this article provides a summary of these recommendations.

 

General Women’s Health Recommendations

  1. Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.(AAFP) Evidence does not support the necessity of performing a pelvic examination or breast examination prior to prescribing oral contraceptives. It is recommended that prescription of hormonal contraceptives be based on medical history and blood pressure measurement.3

  2. Don’t obtain follicle-stimulating hormone (FSH) levels in women in their 40s to identify the menopausal transition as a cause of irregular or abnormal menstrual bleeding. (ASRM) During the menopause transition, FSH levels vary between women and from day to day, and do not predict or diagnose the transition to menopause. In addition, the treatment for women with irregular or abnormal menstrual bleeding does not change based on the FSH level.4

  3. Don’t recommend cancer screening in adults with life expectancy of less than 10 years. (SGIM) Patients with a low life expectancy are unlikely to derive the same benefits from cancer screening than otherwise healthy patients.  They are, however, more likely to be susceptible to the complications of testing and treatments.  The potential harm outweighs the potential benefit for cancer screening among patients with a life expectancy of less than 10 years and, therefore, it is not recommended.5

  4. Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65. (AAFP) DEXA is cost effective in older patients, but not in younger low-risk patients.3 Women should have a bone scan at age 65. The test can be considered for women younger than 65 whose fracture risk is equal to or greater than that of an average 65 -year -old white woman who has no additional risk factors.6
 

Cervical Cancer Screening and Abnormal Cytology Recommendations*

*These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).

  1. Don’t perform Pap tests on women younger than 21 or who have had a hysterectomy for non-cancer disease. (AAFP) Women who are younger than 21 (even those with early coitarche or who are sexually active) have a low-risk for cervical cancer. It is not recommended to perform Pap tests on women younger than 21 because most abnormalities for women in this age group regress spontaneously. Pap tests are not beneficial for women who have had a hysterectomy unless the hysterectomy was performed because cancer cells or pre-cancer cells were detected.3,7

  2. Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, either alone or in combination with cytology. (AAFP) There is evidence that the harm of human papillomavirus (HPV) testing, alone or in combination with cytology, is moderate in women younger than 30. The associated harms include more frequent testing, invasive diagnostic procedures such as cervical biopsy, and psychological harm such as anxiety and distress.3

  3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30-65 years of age. (ACOG) It is recommended that women between the ages of 30-65 who are at average risk have a Pap test every 3 years. The average time for a high-grade precancerous lesion to progress to cervical cancer is 10-20 years and, therefore, it is not beneficial to screen women in this age group annually.7,8

  4. Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high-risk for cervical cancer.3 (AAFP) Cervical cancer is rare in women older than 65 who have previously had normal results with regular Pap tests.7

  5. Don’t perform Pap tests for surveillance of women with a history of endometrial cancer. (SGO) Detection of local recurrence is not improved by Pap testing of the top of the vagina in women treated for endometrial cancer. Furthermore, false positive Pap tests in these women can lead to unnecessary actions such as biopsy and colposcopy.9

  6. Don’t treat patients who have mild dysplasia of less than 2 years in duration. (ACOG) Mild dysplasia is associated with HPV infection and does not require treatment in average-risk women. The majority of women with mild dysplasia have a transient HPV infection that will generally clear on its own in less than 12 months and, therefore, does not require treatment.8

 

Ovarian Cancer Screening Recommendations

  1. Don’t screen for ovarian cancer in asymptomatic women at low/average risk.

Both ACOG and SGO have made this recommendation with subtle differences as shown below:

 

Summary of Choosing Wisely Women’s Health Care Don’ts

Hormonal Contraceptives
  • Don’t require a pelvic exam or other physical exam before prescribing.3
Irregular or Abnormal Menstrual Bleeding
  • Don’t obtain FSH levels in women in their 40s to identify menopause transition as a cause of irregular or abnormal menstrual bleeding.4
Cervical Cancer Screening and Abnormal Cytology Management.*
  • Don’t screen women younger than 21 years.3
  • Don’t screen women who have had a hysterectomy for non-cancer disease.3
  • Don’t screen women younger than 30 years with HPV testing, either alone or in combination with cytology.3
  • Don’t perform annual screening for average-risk women between the ages 30-65.8
  • Don’t screen women older than 65 years who have had adequate prior screening and are not at high-risk.3
  • Don’t perform Pap tests for surveillance of women with a history of endometrial cancer.9
  • Don’t treat women with mild dysplasia of less than 2 years’ duration.8

*These recommendations do not apply to women who are at increased risk for cervical cancer (see text for details)

Ovarian Cancer Screening
  • Don’t screen for ovarian cancer in asymptomatic women at low/average risk.8,9
Cancer Screening
  • • Don’t recommend cancer screening in adults with life expectancy of less than 10 years.5
Osteoporosis Screening
  • Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 with no risk factors.3

 

Patient-Physician Communication Techniques for Women’s Health

The American Academy of Family Physicians communication module describes and demonstrates communication techniques for some of the women’s health recommendations presented in this article.

Patient Resources

There are several Choosing Wisely patient education materials that are specific to women’s health - Pap tests (AAFP), Pelvic exams, pap tests, and oral contraceptives (AAFP), Bone density tests (AAFP), and Screening tests for ovarian cancer (SGO)

 

Conclusion - Why You Should Choose Wisely for Women’s Health Care

The Choosing Wisely campaign aims to promote a dialogue between clinicians and patients in choosing care that is supported by evidence, truly necessary, and free from harm. Choosing Wisely is a part of being a responsible administrator of medical resources. For example, just because a test can be ordered does not mean that it should be ordered. This is a shift in how health care providers think about health care delivery, and is necessary to ensure the right care is being delivered at the right time and patient outcomes are being maximized.

 

More than 200 medical actions have been identified and questioned by the medical societies that have partnered with the Choosing Wisely campaign. Only those relevant to women’s health care have been discussed in this article. To view other recommendations and learn more about the Choosing Wisely campaign, read our companion piece in the September issue of Rx for Prevention or visit http://www.choosingwisely.org/.

 

References

  1. Kulasingam SL, Havrilesky L, Ghebre R, Myers ER. Screening for cervical cancer: a decision analysis for the U.S. Preventive Services Task Force. AHRQ Publication No. 11-05157-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
  2. Choosing Wisely Website: About Us. http://www.choosingwisely.org/about-us/ Accessed June 9, 2017.
  3. American Academy of Family Physicians: Fifteen Things Physicians and Patients Should Question. http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians/ Accessed June 22, 2017.
  4. American Society for Reproductive Medicine: Ten Things Physicians and Patients Should Question. http://www.choosingwisely.org/doctor-patient-lists/american-society-for-reproductive-medicine/ Accessed June 22, 2017.
  5. Society of General Internal Medicine: Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/doctor-patient-lists/society-of-general-internal-medicine/ Accessed June 22, 2017.
  6. U.S. Preventive Services Task Force. Screening for Osteoporosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2011;154:356-364.
  7. Sawaya GF, Kulasingam S, Denberg TD, Qaseem A. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015;162:851-859.
  8. The American College of Obstetricians and Gynecologist: Ten Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/american-college-of-obstetricians-and-gynecologists/ Accessed June 22, 2017.
  9. Society of Gynecologic Oncology: Five Things Physicians Should Question. http://www.choosingwisely.org/doctor-patient-lists/society-of-gynecologic-oncology/ Accessed June 22, 2017.
 

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Author Information:

Rita Singhal, MD, MPH
Medical Director

Raul Sobero, DrPH, MPH
Program Manager

Office of Women’s Health

County of Los Angeles
Department of Public Health

risinghal@ph.lacounty.gov

publichealth.lacounty.gov/owh/


Rx for Prevention, 2017
November-December;7(4).