Rx for Prevention Choosing Wisely Women's Health Summary

The following Womenís 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.

Click here to download a one-page printable version of this table.

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

Hormonal Contraceptives

  • Donít require a pelvic exam or other physical exam before prescribing.

Irregular or Abnormal Menstrual Bleeding

  • Donít 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

  • Donít routinely use breast MRI for breast cancer screening in average risk women.
  • Donít perform screening mammography in asymptomatic patients with normal exams who have less than 5-year life expectancy.
  • Donít 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

  • Donít use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 with no risk factors.

Management of Benign Breast Disease

  • Donít routinely surgically excise biopsy proven fibroadenomas that are smaller than 2 centimeters in size.
  • Donít routinely drain non-painful fluid-filled breast cysts.
  • Donít 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 Womenís 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**

  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.1,8
  2. Donít 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.1
  3. Donít 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.8,9
  4. Donít 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.1 (AAFP) Cervical cancer is rare in women older than 65 who have previously had normal results with regular Pap tests.8
  5. Donít 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.10
  6. Donít 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.9

**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 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:

Patient-Physician Communication Techniques for Womenís Health

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

Patient Resources

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

 

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 womenís health care have been discussed here. To view all Choosing Wisely recommendations visit http://www.choosingwisely.org/clinician-lists/. To learn more about the campaign and read examples of local implementation, see the September 2017 ďRx for PreventionĒ article, ďThe Choosing Wisely CampaignĒ.


References

  1. 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.
  2. 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.
  3. 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.
  4. U.S. Preventive Services Task Force. Screening for Osteoporosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2011;154:356-364.
  5. American Society of Breast Surgeons - Benign Breast Disease: Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/american-society-of-breast-surgeons-benign-breast-disease/. Released January 8, 2018. Accessed February 14, 2018.
  6. Society of Surgical Oncology: Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/society-of-surgical-oncology/. Released July 12, 2016. Accessed February 14, 2018.
  7. American Society of Clinical Oncology: Ten Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/american-society-of-clinical-oncology/. Released April 4, 2012 (1-5) and October 29, 2013 (6-10). Accessed February 14, 2018.
  8. 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.
  9. 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.
  10. 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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