The following Women’s Health Choosing Wisely recommendations were selected due to their relevance to primary and preventive care for women. A discussion of each recommendation can be found after this summary table.

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Summary of Choosing Wisely Women’s Health Care "Don’ts"^*

Hormonal Contraceptives

Don’t require a pelvic exam or other physical exam before prescribing.

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.

General Cancer Screening

Don't recommend cancer screening in adults with life expectancy of less than 10 years.

Breast Cancer Screening

Don’t routinely use breast MRI for breast cancer screening in average risk women. Don’t perform screening mammography in asymptomatic patients with normal exams who have less than 5-year life expectancy. Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.

Cervical Cancer Screening and Abnormal Cytology Management**

Don't screen women younger than 21 years. Don't screen women who have had a hysterectomy for non-cancer disease. Don't screen women younger than 30 years with HPV testing, either alone or in combination with cytology. Don't perform annual screening for average-risk women between the ages 30-65. Don't screen women older than 65 years who have had adequate prior screening and are not at high risk. Don't perform Pap tests for surveillance of women with a history of endometrial cancer. Don't treat women with mild dysplasia of less than 2 years' duration. **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).

Ovarian Cancer Screening

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

Osteoporosis Screening

Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 with no risk factors.

Management of Benign Breast Disease

Don’t routinely surgically excise biopsy proven fibroadenomas that are smaller than 2 centimeters in size. Don’t routinely drain non-painful fluid-filled breast cysts. Don’t routinely operate for a breast abscess without an initial attempt to percutaneously aspirate or drain it.

^*Choosing Wisely Clinician Lists www.choosingwisely.org/clinician-lists

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.¹
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.²
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.³

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.¹ 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.⁴

Breast Health Recommendations

1. Don't routinely surgically excise biopsy proven fibroadenomas that are smaller than 2 centimeters in size. (ASBS) Fibroadenomas are a benign breast condition that do not need to be surgically removed unless they are large, increasing in size or bothersome to the patient.⁵
2. Don't routinely drain non-painful fluid-filled breast cysts. (ASBS) An ultrasound-confirmed simple breast cyst does not need to be drained unless there are concerning features such as complex characteristics or if it is bothersome to the patient.⁵
3. Don't routinely operate for a breast abscess without an initial attempt to percutaneously aspirate or drain it. (ASBS) For a breast abscess, initial treatment should be an attempt to remove fluid with a needle to minimize scarring and avoid more invasive procedures.⁵
4. Don't routinely use breast MRI for breast cancer screening in average risk women.(SSO) Average risk women should be routinely screened using mammography. Breast MRI should be reserved for women at increased risk which includes, but is not limited to, the following: known BRCA gene mutation carriers, those with a lifetime risk for breast cancer greater than 20%, or those who received mantle radiation before the age of 30.⁶
5. Don't perform screening mammography in asymptomatic patients with normal exams who have less than 5-year life expectancy. (ASBS) The breast cancer mortality reduction benefit from screening mammography is minimal in women with life expectancies of less than five years. In addition, mammography carries a risk of false positives and the need for follow-up procedures with no improved outcomes for patients.⁵
6. Don't perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent. (ASCO) Surveillance in breast cancer patients does not require routine imaging or serum tumor marker measurements in asymptomatic patients that have been treated with curative intent. False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.⁷

Cervical Cancer Screening and Abnormal Cytology Recommendations**

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:
   • Don’t screen low-risk women with CA-125 or ultrasound for ovarian cancer. (SGO) In low-risk asymptomatic women, ultrasound and CA-125 have not led to diagnosis of ovarian cancer in the early stages of the disease. False positive results from CA-125 or ultrasound can lead to unnecessary procedures that have risks.¹⁰
   • Don’t screen for ovarian cancer in asymptomatic women at average risk. (ACOG) Due to the low prevalence of ovarian cancer and the invasive nature of screening, it is not recommended to screen asymptomatic women, as the potential harm of screening outweighs the benefit.⁹
   • Don’t perform pelvic ultrasound in average risk women to screen for ovarian cancer.  (ACOG) Most women with a positive screening test will have a false positive result; and annual screening with transvaginal ultrasonography does not reduce mortality from ovarian cancer.⁹