The annual pilgrimage to your women’s health office has always been looked down upon by generations of women. I want to take a look at the well woman visit is different light and see if there’s not more benefit to the visit than a breast exam and a Pap smear. Let’s break the visit down from top to bottom.

Disclaimer: Midwives can care for women from adolescence to after menopause! The specifics often vary by midwife, practice and access to care, but don’t rule out seeing a midwife or a nurse practitioner for your well woman exam!

Chief complaint

This is the medical phrase for: Why are you here today?

Well woman exam? Dysplasia patient? Green, smelly vaginal discharge? Feeling great – just here for my annual check up. Any or all of these can be your chief complaint!

Your medical history

Next, it’s question and answer time. What is your past medical, surgical, gynecological, family, and obstetrical history? Do you smoke, drink or use recreational drugs? Do you have allergies to medicines, latex or food? If so, what is your reaction? What medications are you taking – both prescribed and over the counter? The more you know about your health history and your family’s health history, the more educated you and your provider are about the overall picture of your health. For example, do you have cancer in your family? If so, it’s good to know which person has cancer and what kind of cancer they have. According to ACOG’s committee guideline on the Well-Woman Exam, a comprehensive history is one of the most important parts of the visit.

A helpful tip: If you have a complicated health history or take a lot of medications, you can write or type your history on a piece of paper to keep in your wallet, or on your phone to make the review of medical history simpler. Or, do you have a complicated family history and can’t remember what type of breast cancer grandma had – or what age she was diagnosed? Write it down and update the document as you move from annual exam to annual exam.

Physical exam

The actual physical exam needed at your visit depends on your complaint and your overall health. The exam always starts with an assessment of your vital signs and your weight. Sometimes a very limited exam is indicated, sometimes a very detailed exam is indicated. Most often, the provider will check your thyroid, listen to your heart and lungs, offer a clinical breast exam and a pelvic exam. Providers can also assess for diastasis recti, vaginal prolapse, vaginal tone (kegels), vaginal infections, sexually transmitted diseases and much more. A pelvic exam isn’t always indicated but is needed to collect a pap smear, check IUD strings, place an IUD, perform a pessary fitting, etc. The details of an exam should always be discussed between the provider and the patient. Not sure if you need a pap smear? Read the guidelines here. Most women do not need a pap smear or a speculum exam every well-woman visit – and for the record, a speculum exam is not a pap smear!

Mental health

This is one of the most important facets of the visit. How are you doing day to day in your life? What do you do to relieve stress? Is that activity effective for you? Do you feel down or depressed, or are you feeling great? Are you sleeping well? If not, why?

Generally, some type of mental health assessment is also performed via screening questions, or with an actual depression screening tool like these: Patient Health Questionnaire (PHQ-9) or Edinburgh Postnatal Depression Scale (EPDS). Screening is generally done annually, or more often if there is a history of mental health disorders, but the optimal timing of screening is unknown. Screening for depression is a Grade B recommendation.

Family planning

What kind of family do you envision? How many children and how many years apart are you planning? Are you planning adoption? There isn’t right answer to these questions. The answer is whatever you and your significant other decide and desire. Sometimes family planning works out in unintended ways too. Sometimes you h e an unexpected miscarriage. Sometimes it takes much longer to get pregnant than anticipated. Sometimes people try to conceive for many years before a pregnancy is achieved, or, sometimes couples are never able to conceive despite wanting children very much. Wherever you fall, it’s healthy to discuss a family plan with your significant other and review this plan annually at your well woman visit. Want more? Check out ACNM’s Share with Women handouts on family planning and contraception.

Breastfeeding

Are you nursing? This is commonly missed unless you tell us! If you are nursing, you should expect some different things during your visit. If you are prescribed medications, you should be given guidance on the safety of that medication while you are nursing. Often times, I find that women seek out their primary care providers for an upper respiratory infection or a yeast infection. Sometimes primary care providers are unsure what medications are safe for breastfeeding. In that case, I like to remind women to utilize a free resource called LactMed. It’s easy to use and is a simple database to search. It’s helpful to use if you are taking over the counter medications at home for a cold and wondering if you can take the medications safely while breastfeeding.

Some last thoughts…
Periodic (or annual) visits are generally recommended for reproductive and well-woman care even if you don’t need a pap smear or a breast exam. The first gynecologic exam should occur between 13 and 15 years old – this visit should be primarily an EDUCATIONAL visit! Good education topics are: vaccinations, body image, weight, exercise, stress management, STD prevention/contraception, hygiene, piercings/tattoos, peer relationships, etc…read more from ACOG’s well woman recommendations here. Or check out the fun infographic below:

Want more? Check out this video on how midwives can provide care outside pregnancy and birth. If you live in Iowa, you should check out their practice!

Want more handouts on mental health? Check them out here.

What has your experience with well woman exams? How do you think midwives can make the visit better for women? What isn’t included in the exam that you would like to see more of? Did you like the infographics? I hadn’t seen those before and love them! I’m going to print them out and put them up in my exam room…

Happy Wednesday!

Jamie