Well-patient care (GYN): Clinical sciences

Well-patient gynecologic care focuses on screening and prevention of disease in otherwise healthy individuals. All patients benefit from basic preventative care, which is focused on counseling on a variety of topics including substance use, mental health, contraception, interpersonal and domestic violence, obesity, urinary incontinence, sexually transmitted infections or STIs, and age-appropriate immunizations and cancer screenings. Additional recommendations are based on the patient’s age and health risks.

When a patient presents for well-patient care, begin with a complete history and physical exam.This includes your patient's obstetrical, gynecological, menstrual, and contraceptive history, along with their family and social history. Key factors that will guide your screening include age, past and current sexual activity, smoking status, and review of medical conditions like hypertension, dyslipidemia, diabetes mellitus, and cancers like cervical, breast, colorectal, and skin cancer. Next, complete an age-appropriate physical exam including height, weight, and vital signs.

Now let’s talk about the recommended screening and counseling that applies to all patients. Screening for alcohol, tobacco, and substance abuse can be completed either through a direct conversation with your patient or by using a validated questionnaire. Regarding alcohol use, the recommended limits for alcohol are one drink or less per day or seven drinks per week. Additional alcohol use beyond this is a common cause of preventable diseases such as alcoholic liver disease, injuries from events like motor vehicle crashes, and overall premature mortality.

Likewise, tobacco use and substance abuse are significant preventable causes of disease, disability, and death. As needed, provide counseling for patients and connect them to resources and referrals for further intervention and support.

Next, screen for anxiety and depression - both of which are common conditions - using a validated questionnaire. A positive screening for either condition should prompt further evaluation. Counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, can be effective, as well as medical management.

Also discuss birth control for your patients of reproductive age, which allows patients to control their reproductive health and prevent unintended pregnancy. Provide education and counseling on contraceptive options, including the benefits and risks of each. Also, provide education on daily folic acid supplementation before and during pregnancy to prevent neural tube defects like spina bifida.

Then, screen for interpersonal and domestic violence, which is common but often goes undetected. Be alert for certain risk factors that can increase the risk of violence, such as economic hardships, social isolation, and substance abuse. Provide counseling and referrals, as needed.

Moving on, complete blood pressure screening for all patients, and assess for risk factors for high blood pressure, such as excess weight and lifestyle factors, including smoking, lack of physical activity, and high fat and high sodium diet. Provide counseling to reduce the incidence of cardiovascular and kidney disease. Similarly, screen for elevated lipids, calculate your patient’s 10-year risk of a cardiovascular event, and prescribe a statin to prevent cardiovascular disease, as needed.

Also, screen for obesity, which is defined as a body mass index, or BMI, of 30 or greater. Obesity increases the risk of chronic health conditions like cardiovascular disease, type 2 diabetes, gallstones, and certain types of cancers, such as endometrial cancer. As needed, provide individualized counseling on weight reduction and healthy eating.

Next screen for urinary incontinence, which is often unreported or ignored but adversely impacts quality of life. There are several types of urinary incontinence, which are managed differently, but the first step is to identify the issue. Then, provide counseling, as well as referrals for further diagnostic evaluation, as needed.

Finally, screen for STIs. Most STIs, like gonorrhea, chlamydia, hepatitis B, hepatitis C, HIV, and syphilis can be asymptomatic. Screening is key, as these can cause serious issues including pelvic inflammatory disease, infertility, and cervical cancer. Counsel on safe sexual practices to prevent STIs and prescribe treatment, as needed.

Okay, now let’s review additional topics to cover for high-risk patients. A patient is considered high-risk and is in need of increased screening and counseling if they have certain risk factors. Diabetes screening is indicated every 3 years beginning at age 35 for patients who have risk factors like being overweight, obese, or a history of gestational diabetes. Next, patients who would benefit from tuberculosis screening include those who have immigrated from countries with increased prevalence of tuberculosis, and those living in high-risk congregate settings such as homeless shelters, correctional facilities, or long-term care facilities.

Other risk factors include being in close contact with individuals who have active tuberculosis, or having a medical condition that weakens the immune system, like diabetes or HIV, as well as conditions that require treatment with corticosteroids or chemotherapy. Screening can pick up a small percentage of individuals with latent tuberculosis before it progresses to active disease.