Next is Amy Hall. She is a DNP educated nurse practitioner with over 30 years of practice, with 20 of those years in the IRB subspecialty. She is a fervent leader and educator for nurses and APRNs and is the past president of the Society of Urologic Nurses and Associates, SUNA, the former chair of the SUNA Publications Committee and a two-time SUNA Planning Committee member and chair. And she will be delighting us with a talk on the well-woman exam. Thank you, Amy. Thank you. Thank you for that kind introduction. Thank you. And I just want to also thank the AUGS APP Planning Committee for allowing me to speak today. I greatly appreciate it. I'm going to switch gears a little bit with y'all and talk about just the basic well-woman exam. Not going to talk about the components of the exam, but more importantly, I think, give you an update on some of the guidance on when we should be doing what and hopefully clear some confusion because I don't know about y'all, but I get confused very easily. And I have to constantly re-update myself. So without further ado, let's see if I can do this right. All right. All right, and I have no financial disclosures. So these are our goals for our discussion. The primary focus that I hope that we get from our discussion today is to have a better understanding of when the exam is indicated and what components of the exam should we be doing when. Hopefully, we'll have time to talk about some of the different screening recommendations. And I know we don't have a whole lot of time, but hopefully, we get to most of the points that you'd be addressing when you're doing the well-woman exam. Real quickly, I did want to ask the group, how many of y'all are still doing well-woman GYN care, or are you all mostly subspecialized? OK, all right, fantastic, good. OK, so first of all, we all know this. We all know that the physical exam, it's an opportunity to screen. And we all know the components of it. I'm not going to belabor the point here, but it's important to understand that it is a thorough exam. It's an opportunity to thoroughly screen our patients and hopefully give them a lot of important education during these encounters as well. So we want to make sure we look at the head and the neck. We auscultate for heart and lungs, palpate the abdomen and pelvis, auscultate for bowel sounds. We do a good musculoskeletal exam for pain, range of motion, strength, look at their extremities for edema, check their pulses perhaps also, do a good skin exam. You'd be amazed at the things you can find. And then ultimately, a neuro and psych exam is important in that screening exam. So general physical exam, men, women, we all recommend that. What do we recommend for women? And specific components of the well woman exam, what do we do and when do we do it? And I have some quotes around routine because the question becomes, what does that mean? What is routine? And how do we determine that for our patients? So there have been changes to the well woman exam over the past few years. And to help us all out, ACOG has issued some updates to give us as much guidance as possible. Because again, there have been changes and there has been confusion on who does what, when, and why. And ultimately, if we're getting confused, you have to believe your patients are very confused. So what does routine mean? Typically, we define that as annual. So for the most part, an annual well woman exam still exists. That's still sort of how we define what routine is. Now I need to address the asterisks, the asterisks for both of those, pelvic breast exam, of course. So to address the asterisks, we want to look at the inconsistencies in the guidance. And so if you see here, we've got recommendations from different organizations. And they're all sort of similar, but sort of not. And so what I look at when I start trying to figure out what does it mean when I need to do a pelvic exam, I look at my guidance from our colleagues, ACOG. And so this is their definition of when to do it. Obstetrician, gynecologist, other gynecologic care providers should counsel, obviously asymptomatic, non-pregnant women about the benefits, harms, and lack of data for the pelvic exam. The patient and the gynecologic care provider should then decide together if an examination will be performed. And then if you look down below at our other gynecologic colleagues, our gynecologic colleagues, they say offer it to every patient presenting for a well-woman exam in the context of a balanced discussion of the risks and benefits. And so if you keep looking here, then you look at, OK, so what are the definitions of the pelvic exam? What are the components? And so you, again, start to see differences in the recommendations, which, again, we wonder why we're confused. And if you take it even further, the US Preventive Task Force Services Task Force folks say current evidence is insufficient to assess the balance of benefits and harms for performing screening pelvic exam on an asymptomatic, non-pregnant adult woman. And then the components of the exam, you know, they sort of define it. But our gynecologic colleagues don't really define the components of that pelvic exam. So suffice it to say, it can be quite confusing. And we do see some inconsistencies in our guidance. So routine pelvic exam recommendations. I went back to ACOG and pretty much wanted to make sure that I'm telling you all the right information. That's pretty much what we follow. I would imagine everybody in this room probably follows ACOG guidance. It's a shared decision process, which is really important. Because I don't know about y'all, but when I was coming up as a very young NP, everybody got a pelvic exam. Everybody got a pap smear. Didn't matter if they were under 21. Didn't matter if they were sexually active. Everybody got a breast exam. Didn't matter if they had family history, again, if they were 20 years of age. That's what you did. So I think this is important, because it is a shared decision process. And it does give patients a lot of opportunity to have that discussion with us. It is important to understand that the data is inadequate among asymptomatic, non-pregnant women who are not at risk for a GYN concern. And the annual GYN appointment is advised, even if a pelvic is not performed. So these are our recommendations from our ACOG colleagues as of 2018. So how do we determine the need to do the pelvic exam? So again, it's a shared decision with your provider. And you're the provider helping your patient make that decision, having that conversation. So if you decide, OK, this is an asymptomatic, non-pregnant, super healthy young woman, maybe I don't do the pelvic exam. But when do we decide that we need to do it? Well, our history is super important. We have to really make sure we're having a good conversation with our patients. So the current medical history and symptoms indicate the need for completion of this part of the exam. So detailed past medical history, surgical history, social history, OBGYN, everything, gynecologic history. You want to have really good information on, what is their pap smear history? And if they have IUDs, if they have history of STDs, if they have history of high risk for STDs, those are the patients, again, through very, very careful discussion, detailed history, you're going to maybe decide, yes, you need a pelvic exam. And always, always, if the patient wants a pelvic exam, there are patients out there who might say, yeah, I want that pelvic exam. That obviously would be appropriate, and you would do it then. So what do we conclude in our history? As I mentioned a few minutes ago, you want to really query the patient on, what are the risk factors that might preclude the need for this exam? What are her life stage needs? So that's another thing that we're going to discuss here in a few minutes. What medications is she on? What symptoms does she have? Does she have any concerns that she wishes to discuss today that might warrant a pelvic exam? So shifting gears a little bit, we've talked about the physical exam, well woman exam, pelvic exam. So when do you do a pap smear? Because not everybody gets a pap smear all the time anymore. Again, as I mentioned earlier, we did it every year. Didn't matter what their age was. Didn't matter if they'd ever even had intercourse. That's changed, thankfully, because we were doing a lot of unnecessary pap smears. So when do we do a pap smear? So the guidance here, again, can be a little bit confusing. It's important to know, though, ACOG did adopt the US Preventative Services Task Force guidelines. And so that's what I've provided y'all with here is our US Preventative Services Task Force recommendations. So age, if they're less than 21, you do not need to do a pap smear. If they're 21 to 29, maybe you do cytology alone every three years. If age 30 to 65, you might pick one of the following, cytology alone every three years. Or maybe you do high-risk HPV testing alone every five years. Or maybe you do both, co-testing every five years. Obviously, these recommendations change if and when you have an abnormality that might warrant further evaluation. So this is with the understanding that these patients have negative pap smear history and have, again, as I mentioned earlier, you're getting a good history. And you've determined that they have very low risks for HPV. What about the 65 and older population, which is a lot of our urogyne patients? They come in, and they don't know what they need. And they think every pelvic exam is a pap smear. They don't know what we're doing. And so what's the recommendations for them? So our recommendation is no screening after adequate negative screening history. And what do we do about the hysterectomy patient? That's another area of sort of confusion. Obviously, if the patient comes in, again, a lot of our urogyne patients have had a hysterectomy, what do we do? No screening in those individuals is recommended unless they've had a history of high-grade cervical precancerous lesions or cervical cancer or some type of other gynecology-type cancer. And so, again, ACOG did adopt this recommendation as well, and so now we're going to move on to the breast exam. So what are the recommendations for the breast exam? You know, I mean, not everybody needs a breast exam. And so, again, confusing. Always go back to our ACOG colleagues. That's what I typically follow, and this is what they say. Maybe offer it every one to three years for women who are aged 25 to 39, and then, of course, the magic number of 40. Once they hit 40, they recommend that annually. And same with our screening mammography. Once we hit that magic age of 40, we start to offer that screening mammography for those women starting at that age. And from the ages of 40 to 49, after counseling, if the patient desires, maybe we do an annual mammogram. We certainly recommend that by the age of 50, those patients are already, they're getting mammograms. They're having that guidance and that screening initiated. And this can be annual or biannual. What do we do with our urogyne patients that are getting older or 75 plus? The recommendations are beyond the age of 75 years. The decision to discontinue getting screening mammograms can be made, again, based on shared decision-making processes with the patient. Alrighty. So what do we do with our hysterectomized women? You know, again, every woman who's getting a pelvic, she always thinks she's getting a pap smear. So even our patients who've had a hysterectomy, they all think they've had a pap smear. And then you have to think about, do they have ovaries? And they all think they have ovaries, or they all think they don't have ovaries. Oh, I had a full hysterectomy. And to them, that means having their ovaries removed as well. So it's certainly, for me in my practice, it's an opportunity to try and help educate them and help them to understand the different types of surgeries that we're getting when we have a hysterectomy or oophorectomy. So I try to really make sure I educate them. Hysterectomy, are their ovaries intact? Remember, again, pelvic isn't necessarily equal pap smear. It's important to really help educate our patients. One thing I would recommend is if your patient and you both know she does have ovaries, I would recommend the bimanual because we want to make sure we don't feel anything. That's super important. And if they don't know if they have ovaries, I'd still do the bimanual because if they don't know, we may not know. So I would argue on the side of even if they've had a hysterectomy and they don't need a pap smear, I'd still do a bimanual exam. So what do we do for our osteoporosis screening? That's pretty straightforward. It's recommended for all women who are greater than 65 or 65 and greater. For women who have risk factors, they recommend starting to screen for osteoporosis less than 65 if they have a history of fracture in the family, if the patient herself has a smoking history, if she's white, increased alcohol consumption, low BMI. And I don't know, I didn't really find information on what was defined as increased alcohol consumption. I don't know if that's one glass of alcohol every day, if it's that two. Maybe some of you all know that. I didn't see that defined as to what is increased alcohol consumption, but that is a risk factor and would merit maybe some discussion with the patient about getting a DEXA before the age of 65. We also certainly want to take the opportunity during our exams to talk with our patients about preventative measures. And so weight bearing exercise, super important to have that discussion for multiple reasons. And then also consideration of medication management. That's not the purpose of this talk, but that's certainly an opportunity to have that discussion with her. Certainly if you all do order the DEXA, you see that there are some changes. It's an opportunity to have that conversation. So colon cancer screening. So that's, you know, we've again got a possibly older population with our urogyne patients. The biggest risk factor for colon cancer is age, increasing age. Nearly 94% of all new cases of colorectal cancer occur in adults 45 and older. So it's a cancer that gets, you know, certainly more problematic as we age. And then we also have to consider what are the rates of colorectal cancer among different populations. And so recommendations for screening might be younger than the age of 45 for African-American, Alaska, excuse me, American Indian population and Alaska native adults, persons with perhaps a history of colorectal cancer in the family. Maybe there's genetic syndrome, Lynch, mutations, other kinds of risks, smoking, obesity, diabetes, lots of different risk factors that might warrant need for screening sooner than the age of 45. And so what is screening? What's colon cancer screening when we're talking about that? So that might be everybody's seen the Cologuard. That might be starting with Cologuard. It doesn't necessarily mean colonoscopy. So maybe we start screening and I don't know about all y'all but I've had my Cologuard and it was negative so I haven't had to have a colonoscopy yet. Yay. And so that, you know, it doesn't necessarily mean that patients have to right out of the gate start considering colonoscopy. And that's, I think, what a lot of patients think automatically. Alrighty. Let's see. Whoops, sorry. Okay. So this is a really nice key that I got from the Women's Health Preventive Services Initiative that I thought was super duper helpful and it gives us sort of a guidance on everything that we might be doing during our well woman exam, our physical exam. And then it divides it up by age. So you'll see age at the top and then the different screening services that we should provide. So this was a really nice slide that I wanted to make sure that y'all had and this came out in 2024. They gave a really good guidance. And I also wanted to make sure that I highlighted a couple of other things for y'all because I know we're running out of time to and that I didn't, wasn't sure if I'd have a lot of time to talk with y'all about. And so you'll see here that obviously we're, you know, deal with a lot of urinary incontinence. That is one of the recommendations for screening when we're working with a patient for her screening exam. I discussed osteoporosis really quickly. I didn't discuss lipid screening. But you'll see here you have the black dots and the white dots. The black dots are the U.S. Preventive Task Force, Preventive Services Task Force recommendations. And then the white circles are the recommendations for selected groups, okay. And so you'll see here with lipid screening different groups might have different recommendations, okay. Because I know we probably wouldn't have a whole lot of time to discuss blood work. So I apologize. Other risk factors, other screening recommendations, fall prevention, that's huge. A lot of our patients getting up in the middle of the night, they're at risk for falls. So it's really important during that well woman, that screening exam to talk with them about fall prevention, figure out what are some things that we can do to mitigate that risk and look at modifiable options. Improvement of nutrition, PT, OT, helping them be a little bit better with ambulation and balance. Maybe we need to think about medication management so that they're not up and down all night. Maybe we need to look at environmental modifications. What's their, from the bed to the bathroom, or they have some little rug that's super slippery that they get their foot caught up in all the time when they're rushing to the bathroom. So things that we can do to mitigate risks, have that conversation with the patient during that exam. Obviously urinary incontinence, we all know this. And then again, lipid screening, can't really discuss too much other than evaluation of the risk factors, age, family history, BMI, adoption, maybe have a conversation with them about adoption of a heart healthy diet, exercise. And I tell patients all the time, I don't need you to go out and start running a mile every day, but I need you to get up and do something and move your body. And if they can just do that, just something, even if it's walking up and down the driveway a few times every day, that's a little bit better than not doing anything. Obviously alcohol reduction and medication might be of help to them. So super duper hard in our exam, given the constraints with time to have all of these conversations with patients. And so certainly it's an opportunity then to also screen our patients ahead of time. And so I would recommend that everybody, y'all probably are doing this, but have a really good screening questionnaire. Patients can either do that online, pre-visit, or they can come in while they're waiting for you and be completing this. You can get a lot of really good information about what their risks are, what their needs are, what you really need to focus on, again, given the fact that most of us are very, very confined to a very finite amount of time with all of our patients. So screening for depression, maybe you want to incorporate PHQ-9, some quick incontinence questionnaires, ICIQ, the short form. Maybe a quick questionnaire on bowel function, those sorts of things, as well as just other things that they can fill out. And this is just a generic example that I found online. I've hid who it was from because it really doesn't matter, but I thought it was a good, thorough bit of questioning that perhaps the patient can give us some information before we even see her. And that is all I have, and I did, I think I did pretty good. So I appreciate it. Thank you all very much. And all righty.

well-woman exams

ACOG guidelines

shared decision-making

preventative healthcare

screening recommendations

patient education