Evidence-Based Screening Guidelines

Screening guidelines published by the U.S. Preventive Services Task Force (USPSTF) provide an evidence-based guide for family physicians to follow. Recommendations with A and B levels of evidence for adult women are included in Table 25-1. Unfortunately, many established components of the well-woman examination are not supported by evidence. Screening for intimate-partner violence, routine breast self-examination, testing for lipid disorders in average-risk women, type 2 diabetes screening, and physical activity counseling are examples of “uncertain” recommendations, according to the USPSTF. A physician may choose to cover these areas in a well-woman visit, but it is important to ensure that the areas with stronger evidence of benefit are thoroughly discussed. USPSTF also lists areas of screening that have the potential to cause harm and therefore are not recommended. These include cervical cancer screening in women with previous hysterectomy for benign causes, screening for gonorrhea in low-risk women, and screening for ovarian cancer.

Table 25-1 USPSTF Level A and B Recommendations for Adult Women

US Preventive Services Task Force recommendations, available at www.ahrq.gov/clinic/uspstfix.htm.

∗ Strength of recommendation taxonomy (level of evidence).

Immunizations are an important part of well-woman care. All patients benefit from disease prevention, and women are often caregivers for children or elderly persons, who are at higher risk from vaccine-preventable illnesses. Vaccines recommended by the U.S. Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) include tetanus/diphtheria/pertussis (Tdap), herpes zoster, and influenza for adults over age 50 and human papillomavirus vaccine for women 26 and younger.

Pap Smear Guidelines

Key Points

Although the Pap smear is still the mainstay of cervical cancer screening, recent advances in the understanding of human papillomavirus (HPV) have revolutionized this field. HPV is the most common sexually transmitted infection (STI), with its highest prevalence among the 20- to 24-year-old age group (44.8%) (Dunne et al., 2007). Although HPV is typically spread through sexual activity, 5.2% of women in this study who reported that they had never had sex were infected with HPV. Physicians should keep in mind that some of these women may have been uncomfortable disclosing their sexual activity, even on an anonymous survey, whereas others may have had sexual contact they did not consider intercourse. Risk factors for HPV infection include lifetime number of sexual partners, age at first intercourse, smoking, and lack of condom use (Burchell et al., 2006).

Strength of recommendation taxonomy (SORT) level A recommendations for cervical cancer screening include starting Pap test screening at age 21 and repeating every 2 years. “Low-risk women” are defined as those with three consecutive normal Pap tests, no history of cervical intraepithelial neoplasia type II (CIN-II) or higher, and no immunocompromise. A screening option for women age 30 and older is to perform Pap smear and HPV testing together, with repeat Pap tests every 3 years if both are normal. The recommendations for fewer Pap tests in women under 21 and over 30 are consistent with the epidemiology of HPV. Younger women acquire HPV infections more frequently, but most will clear the infection without intervention. Older women are less likely to develop new HPV infections, and only persistent HPV is a concern for cervical cancer. Women are not required to have a Pap smear before starting hormonal contraception. Physicians can use visits when a Pap test is not needed as an opportunity to educate female patients about STIs and reproductive health, as well as perform the other, evidence-based screening recommendations previously cited (ACOG, 2003).

Adolescents

In adolescents the three most common presentations of abnormal vaginal bleeding are anovulation, menorrhagia, and amenorrhea. It is normal for menstrual cycles to be anovulatory for an average of 18 months after menarche in adolescents while the hypothalamic-pituitary axis matures. Menorrhagia (heavy bleeding) is quite common in adolescent patients and is most often caused by anovulation (Rimsza, 2002). In some young women, however, menorrhagia at menarche can be a sign of a bleeding disorder. Up to 24% of adolescents with menorrhagia may have an undiagnosed bleeding disorder (Strickland, 2004). Evaluation of menorrhagia in adolescents includes a complete blood count (CBC), coagulation profile, and von Willebrand’s screening test if clinically indicated. Treatment of both anovulation and menorrhagia in adolescents is usually hormonal contraception for cycle control.

The most common causes of primary amenorrhea include pregnancy, chromosomal abnormalities, (e.g., Turner’s or Sawyer’s syndrome); hypothalamic hypogonadism; congenital absence of the uterus, cervix, or vagina; and structural abnormalities (e.g., transverse vaginal septum or imperforate hymen). Evaluation of primary amenorrhea includes a careful history, pelvic examination, pelvic ultrasound to document the presence of pelvic organs, and chromosome analysis if clinically indicated.

Reproductive-Age Women

The most common causes of abnormal bleeding in reproductive-age women are pregnancy complications, anovulatory disorders, and benign pelvic pathology. Characteristics of ovulatory cycles include regular cycle length, presence of premenstrual syndrome (PMS) symptoms, and changes in cervical mucus. In contrast, anovulatory cycles tend to be unpredictable, with varying bleeding amounts and intervals.

Abnormal bleeding in ovulatory cycles includes menorrhagia, polymenorrhea, oligomenorrhea, and intermenstrual bleeding. Menorrhagia can be associated with structural lesions (uterine leiomyomas, endometrial polyps or hyperplasia), coagulation disorder, liver failure, or chronic renal failure. Polymenorrhea (bleeding at short intervals) can be caused by a luteal-phase disorder (not enough progesterone is produced after ovulation to stabilize the endometrium) or a short follicular phase. Oligomenorrhea (infrequent bleeding) is usually caused by a prolonged follicular phase. Intermenstrual bleeding can be caused by cervical pathology (dysplasia or infection) or an intrauterine device (IUD). Evaluation of a woman with abnormal bleeding is based on the type of bleeding (Box 25-1).

Anovulation is the most common cause of abnormal vaginal bleeding in reproductive-age women. The majority of anovulation is related to hypothalamic abnormalities or polycystic ovarian syndrome (PCOS) (Box 25-2). By definition, anovulatory cycles are unpredictable and cannot be classified by any one type of vaginal bleeding pattern. A woman may experience 14 days of heavy bleeding one month, light spotting intermittently for the next month, and then go for 3 months without a cycle. The pathologic abnormality in these cycles is a lack of ovulation, which produces an unopposed-estrogen state. The lack of progesterone production resulting from no ovulation contributes to irregular endometrial growth and non-uniform bleeding. In a normal cycle, the entire endometrium sloughs off during menstruation. In an anovulatory cycle, different sections of endometrium outgrow their blood supply at different times and bleed erratically.

Treatment of women with either ovulatory bleeding or anovulatory bleeding is not necessary unless the woman wants to become pregnant, is bothered by her bleeding pattern, or has systemic symptoms from anemia. However, anovulation is an unopposed-estrogen state, and treatment with some type of progesterone is necessary to reduce the risk of endometrial hyperplasia or carcinoma. Unopposed estrogen is a risk factor for endometrial cancer, along with obesity, diabetes, nulliparity, and age over 35. To protect against the development of endometrial hyperplasia, a precursor to endometrial cancer, all women with chronic anovulation should have a progesterone-induced withdrawal bleed at least four times a year (Albers et al., 2004). Women may take medroxyprogesterone acetate, 10 mg daily for 10 days, and then expect a withdrawal bleed within a few days of stopping the medication.

Treatment of abnormal bleeding consists of ovulation induction if pregnancy is desired or cycle control with hormonal contraceptives if it is not. In women who are not candidates for estrogen-containing contraceptives, a monthly cycling of progesterone or continuous administration of progestin contraception (e.g., depot medroxyprogesterone acetate or levonorgestrel IUD) can also be an effective treatment. For women who do not want to take hormonal medications, some nonsteroidal anti-inflammatory drugs (NSAIDs) can decrease the amount of bleeding (Ely et al., 2006) (Box 25-3).

Another common presentation of abnormal bleeding is an acute bleeding episode. In this situation, a woman is most likely anovulatory. Evaluation in an acute bleeding episode should include hemoglobin (Hb) and hematocrit (Hct), assessment of volume status, and an endometrial biopsy in women over 35.

If a woman presents with heavy bleeding and exhibits any signs or symptoms of hypovolemia, she should be admitted to hospital and either treated with intravenous (IV) estrogen to stop the bleeding or have a surgical procedure, such as dilation and curettage (D&C). If the woman is stable and her Hb and Hct are near normal, outpatient treatment with high-dose oral contraceptives (OCs), estrogen, or progesterone may be attempted (Ely et al., 2006).

A woman may also present with amenorrhea. The four most common causes of secondary amenorrhea (when a woman who previously had normal menses stops having menses for at least 6 months) are pregnancy, hyperprolactinemia, thyroid disorders, and iatrogenic (from medications). Other reasons for amenorrhea include outflow obstruction (e.g., Asherman’s syndrome, caused by scarring of uterus from instrumentation, or cervical stenosis) and primary ovarian failure. Evaluation of a woman with amenorrhea begins with a history and physical examination. Laboratory studies should include a pregnancy test and thyroid-stimulating hormone (TSH) and prolactin levels. The next step is an induced withdrawal bleed after administering progesterone for 10 to 14 days. If a woman has a menstrual bleed after the progesterone, outflow obstruction and low estrogen state (as in primary ovarian failure) are excluded as the causes of amenorrhea. If a woman does not have a withdrawal bleed after progesterone administration, a trial of estrogen supplementation for 3 weeks should be given before another course of progesterone is attempted. In this situation, if a woman has a withdrawal bleed, the diagnosis of primary ovarian failure is considered, and levels of gonadotropins (FSH, LH) should be obtained. If a woman does not have a withdrawal bleed after estrogen and progesterone administration, a hysterosalpingogram (radiograph of uterus and ovaries after dye injection) should be obtained to evaluate for outflow obstruction.

Perimenopausal Women

Abnormal bleeding in the 5 to 10 years before menopause is very common. The most common pathology is anovulation caused by declining numbers of ovarian follicles and decreasing inhibin B levels (Jain and Santoro, 2005). Perimenopausal women may also bleed from structural lesions (most often uterine fibroid tumors) or bleeding disorders. Evaluation of a perimenopausal woman with abnormal bleeding should include an endometrial biopsy to exclude endometrial hyperplasia or cancer. The risk of endometrial cancer increases in women who are nulliparous, diabetic, or obese (Espindola et al., 2007). Nonsmoking women in this age group can be effectively managed with hormonal contraception for cycle control. Smokers can use cyclic progestin to provide a monthly withdrawal bleed.

Postmenopausal Women

Menopause is defined as 12 months without a menstrual period. After that 12-month period, any bleeding is abnormal. A large Danish study found a 10% prevalence of postmenopausal bleeding (Astrup, 2004). Bleeding episodes decreased as the time since menopause increased. The main concern in a postmenopausal woman with bleeding is endometrial carcinoma. Between 10% and 20% of all postmenopausal bleeding will be caused by malignancy (Hale and Fraser, 2007). Evaluation of postmenopausal bleeding can be done effectively with either a pelvic ultrasound or an office endometrial biopsy. A pelvic ultrasound can assess the thickness of the endometrium, the endometrial stripe. A stripe less than 4 mm in diameter is the cutoff to exclude endometrial cancer (Tabor et al., 2002). An office endometrial biopsy is an excellent diagnostic test to evaluate endometrial tissue (Dijkhuizen et al., 2000). In some postmenopausal women, however, cervical stenosis precludes a successful biopsy. In this situation, if the ultrasound is nonreassuring, a surgical procedure may be indicated.

Diagnosis

A patient may report a symptomatic pelvic mass, or it may be discovered as part of a pelvic examination or ultrasound done for other reasons. A pelvic mass can be associated with the uterus, ovaries, or nongynecologic organs. The first step in evaluation is to review the patient’s age, history, and risk factors. For example, an ovarian cyst is more likely to be a functional cyst in a younger woman, but it has a higher potential to be ovarian cancer in postmenopausal women. Additional historical details include menopausal status, menstrual history, family history, STI risk, symptoms of hyperandrogenism, and dysmenorrhea.

Pelvic examination is not sensitive or specific for diagnosis of a pelvic mass, especially as body mass index (BMI) increases (Myers et al., 2006). However, pelvic examination can provide other information helpful in the diagnosis, such as location of the mass, mobility of the mass, cervical motion tenderness, pelvic tenderness, and vaginal discharge. Initial evaluation of a pelvic mass should include a pelvic ultrasound, which can be transabdominal or transvaginal, depending on the size and location of the mass. Premenopausal women should be tested to exclude pregnancy. Doppler ultrasound, cyst morphology, and CA-125 testing are useful in ruling out ovarian cancer in a postmenopausal woman with an adnexal mass. Table 25-2 lists the differential diagnosis and common features of pelvic masses.

Table 25-2 Differential Diagnosis of Pelvic Mass