Well-woman exams: the road to poorer health is paved with good intentions

For each full day that I see patients, I generally perform 3 to 4 physical examinations in well children and adults. I am well aware of the evidence that general health checks may not improve health outcomes in adults, as well as the limitations of such studies (which are decades old and included many screening tests that are now known to be ineffective). My sense is that most of the health benefits my patients derive from checkups are not from the examination itself, but from listening and counseling. In a recent Medscape commentary, I observed that guidelines for well-woman care have appropriately moved away from largely pro forma gynecologic exams since the turn of the century:

At that time, it was not unusual for me to screen for cervical cancer in a sexually active teenager, and to advise most women to return for a Pap smear and clinical breast exam every year. I remember our clinic's medical director admonishing the residents not to skip routine breast and pelvic exams in women without symptoms.

However, I am concerned that this positive movement - de-intensifying or eliminating components of the well-woman exam that don't benefit women - appears to have stalled:

Recent federal regulations and recommendations now threaten to replace discontinued components of the well-woman exam with other well-intentioned services that unfortunately have little basis in evidence.

I discussed three examples in my commentary:

FDA-mandated language about breast density in mammography reports, leading to further testing in women with dense breasts: "While we do know that additional testing in women with dense breasts increases false-positive rates, we don't know if it improves breast cancer outcomes or only leads to more anxiety, more biopsies, and more overdiagnosis."

Annual screening for urinary incontinence, "even though the [Women's Preventive Services Initiative] group's own review found insufficient evidence that systematic annual screening improves health outcomes."

Screening for anxiety in all adolescent and adult women, "which has a similar dearth of supporting evidence on benefits and harms."

Each of these recommendations is intended to address a known problem: mammograms are less likely to identify breast tumors in women with higher breast density; urinary incontinence is common, frequently bothersome, and underreported; and anxiety reduces quality of life in many women (and men, for that matter). But a high prevalence of unidentified disease and the availability of effective treatments aren't enough to warrant screening on their own. Women deserve better than preventive care based on good intentions, which in the past led to mistakes such as prescribing menopausal hormone therapy for millions of women who either did not benefit or experienced harm. Instead, they deserve evidence-based, data-driven care.