Choosing Wisely: Medical Recommendations Specifically for Women

Jennifer Yttri, PhD
August 2013

 

Women tend to put other people’s needs before their own, but they need to make their own health a priority.  Many changes happen between puberty, child bearing, and menopause, and with those changes come more questions. What tests should you get to make sure you stay healthy and how often? Does your medical history, or family history, put you at risk for diseases later in life? It can be difficult to make choices about screening, prevention, and treatment but those decisions are personal. Not every test, procedure, or medication is appropriate for every patient, and many are over-used. What is beneficial for one woman isn’t worth the risks for another.

The best health decisions can be made when doctors take time to talk with their patients and patients ask questions rather than just assuming the doctor always knows best.

The ABIM Foundation and Consumer Reports collaborated with specialty medical societies to create lists of “5 Things Physicians and Patients Should Question” as part of a national effort called Choosing Wisely (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists contain evidence-based recommendations made by experts. Here is the list of their recommendations that are important for women.

 

Birth control exams

Women should not be required to have a pelvic exam or other physical exam to get a prescription for oral contraceptives. For most women, it is safe to be prescribed birth control based on medical history and blood pressure measurement.

Breast cancer screening

Breast cancer screening is done through mammograms, which are like x-rays.  A breast cancer diagnosis involves giving the cancer a stage (0 through 4, with 4 being the most advanced) based on the size of the tumor, how advanced it is, and how likely it is to spread. Other imaging tests, like PET, CT, and bone scans are not recommended for screening early stage breast cancer (stages 0-3), patients newly diagnosed with Ductal Carcinoma In Situ (DCIS), or people without symptoms. This testing does not benefit patients, and false-positives (test results that indicate cancer when no cancer is present) can lead to unnecessary procedures and misdiagnosis. For anyone who has been treated for early-stage breast cancer and is symptom free, mammograms and regular clinical exams are the best ways to check that the cancer has not come back.  Advanced imaging tests and tumor marker tests should only be used for patients with later-stage breast cancer.

Cervical cancer screening

Women over 65 should stop being screened for cervical cancer if they have not previously shown risk for disease. Women under 30 should not have HPV tests to screen for cervical cancer. Women with mild dysplasia or cervical intraepithelial neoplasia (CIN1) for less than two years should not be treated for cervical cancer, as CIN1 is usually caused by a short-term HPV infection and goes away within a year.   See below for information about HPV testing. Pap smears (see below) should be used to screen for cervical cancer.

Early labor induction or Cesarean delivery

Unless there is a clear medical reason, do not schedule delivery before 39 weeks and avoid scheduling delivery before 41 weeks. Babies born before 39 weeks are not fully developed and are at increased risk for learning disabilities, illness, and death. Mothers who deliver early are more likely to experience postpartum depression and may have complications from medicines needed to start labor.

HPV testing

HPV testing is not recommended for low risk infections, such as for HPV associated with genital warts. HPV testing should be used to identify high risk infections in patients with abnormal Pap smears or other clinical symptoms associated with high risk HPV infections.

Ovarian cancer screening

Women at average risk who do not have symptoms should not be screened for ovarian cancer. Screening using ultrasound or blood serum testing might detect early signs of cancer, but ovarian cancer is uncommon in women of average risk without symptoms. An abnormal result that isn’t cancer might require invasive follow-up, and those risks outweigh the benefit of early detection.

Ovarian cysts

Small, simple cysts are common in women and usually won’t affect their health. If one is found, the doctor will schedule an ultrasound to determine if the cyst is benign (not cancer). If the cyst is not cancerous, a follow up ultrasound and surgery is not recommended unless the cyst causes symptoms, like pelvic pain. If the cyst is suspected to be cancerous, a follow up ultrasound is not recommended because the cyst should just be surgically removed.  A second ultrasound is only recommended for larger cysts that the doctor could not be sure about.

Pap smears

Pap smears detect cervical cancer. They are not recommended for women under 21. They also are not recommended for women who have had their cervix removed during a hysterectomy and have no history of cancer. Most abnormalities in young women go away without treatment. For women who have had a hysterectomy for reasons unrelated to cancer, Pap smears do not provide any useful information. Pap smears are recommended every 3 years for women aged 21-65. Women over 65 who have had normal Pap tests can stop having them done.