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The Well Woman Exam. The Pap, the Myth, the Legend.

The Well Woman Exam is my specialty. I named my practice after it because it is the cornerstone of health in women of all ages. It is my goal for every woman I meet to become “well”.

Most women equate the “well woman” with an annual pap smear because historically women were told they need a pap every year. Back in the 1990s a pap was required for birth control, regardless of your age or whether or not you were sexually active. In the early 2000s the guidelines changed and recommended a pap starting at the age of 21 yo and then every three years if they were normal. This was the first time there was a break in the recommendations—just because you went to your well woman, did not mean you needed a pap. More Recently, in 2012, the pap guidelines changed again and have remained unchanged since then; cervical cancer screening starts at the age of 21 yo and is every 3 years as long as the results are normal. Then from ages 30-65 yo paps are done every 5 years, again, as long as they are normal. After the age of 65 years old, women no longer need pap smears if they meet certain criteria, such as a history of normal pap smears.

The common question I get from patient’s is “If I don’t need a pap, then why am I here? What is the point of the well woman visit?”

The truth is, you do not always need a pelvic exam at every gynecology visit. Traditionally, a pelvic examination is performed for asymptomatic women as a screening tool for gynecologic cancer, infection, and asymptomatic pelvic inflammatory disease, though the evidence says it does not actually assist in these areas. The latest recommendations from the American College of Obstetricians and Gynecologists is that pelvic exams should be done if the patient history or current symptoms necessitate one. Common reasons that a pelvic exam would be needed are a history of abnormal pap, abnormal vaginal discharge, pelvic pain, abnormal bleeding, history of gynecologic cancer, etc. Gone are the days where you need a pelvic exam just to get birth control. The decision to do a pelvic exam should be shared between the patient and the doctor, just as all medical decisions should be.

Just because you might not get a pelvic exam at every annual well woman, does not mean you should skip them all together. What so many women do not realize, is that during that visit your doctor is looking at so much more. Moreover, with regards to your gynecologic anatomy, it is a body part that is difficult for most women to evaluate on their own. Below is a list of items I review during your well woman exam (even if you don’t know it):

1) Your menstrual cycles-What many women think is normal, is not actually normal or healthy. On the flip side, I have many women tell me about their “abnormal” periods that are actually completely normal. It is a great time for me to education on the matter.

2) Education on Screening for Gynecologic Cancers-This includes breast, ovarian, uterine, cervical, vaginal and vulvar cancer. Some of these have screening tests that depend on your personal health and family health history. Some of these we cannot even screen for, so it is important to educate about each one. A pap does NOT check for any other cancers besides cervical cancer. I like to educate my patients about all of their options for cancer screening.

3) Skin Disorders-Most women do not look “down there”. Ever. And that is okay. But someone who knows what they are looking at needs to check the skin of the vulva (the area outside the vagina that a pad touches) and the skin of the vagina at least every year or so. There are some skin disorders that are common as we age and can be easily treated. I cannot tell you how many times I have diagnosed lichen sclerosus in women who never admitted to the symptoms. Lichen sclerosis has a small risk of turning into cancer, so definitely something that needs to be followed.

4) High Risk Lifestyle Choices

Society encourages women to engage in sexual behavior that is high risk. Unfortunately, what society and the media don’t tell you is that women bear the burden of all the risks of sex. Men have little to no health risk. Whichever way you choose to live your life is your business and your choice! But my job is to educate my patient’s on how to stay safe and healthy, regardless of their life choices. This can be a delicate subject and is often best discussed in a safe space with a doctor you trust. At Texas Well Woman we provide ample time with the provider so you are comfortable discussing sensitive topics.

5) What is Coming Next

Women have many stages in life:prepubescent, pubescent and menarche, reproductive years, perimenopausal, menopause, and post-menopausal.Each of these stages are unique and will likely define each season of your life.Women are often left in the dark on how and when each stage is supposed to unfold. Your gynecologist should be preparing and guiding you through each of these stages.I often find myself advising women on how to counsel their young daughters or teen daughters.While I almost never do a gynecologic exam on women under 21 years of age, it is still important for them to come in for a visit once they start their cycles to start the education process.

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