Well Woman Exams

A preventative care visit is recommended annually and may or may not include the following elements in addition to a head to toe women's wellness exam and preventative counseling:

PAP (recommended at regular intervals for woman ages 20 to 75)
Please note that a PAP is not a pelvic exam - it is just one small part of a pelvic exam in which cells from the outside of the cervix are collected to test for precancer. So when you hear us say that PAPs may be recommended every 2 or 3 years instead of every year, that doesn't mean that you shouldn't come in for an annual every year - it just means that the collection of the outside cervical cells may not need to be done every year as part of the pelvic exam.
HPV testing is recommended for:
1. all women over age 30 as a screen
2. women with a history of an abnormal PAP at any time in the past
3. women who may have been exposed to an STD
4. women who have symptoms such as vaginal discharge, genital lesions/warts, cervicitis, post-coital bleeding, irregular bleeding, vaginitis
STD testing - Chlamydia and Gonorrhea
- All women age 25 and under, who are sexually active (please note that this test can be collected off a PAP or from a urine sample), whether or not they have symptoms, every year
- All women who have never been tested, regardless of age
- All women who have a new sexual partner since last test, or whose partner might have had a new partner
- Women who have symptoms such as vaginal discharge, genital lesions/warts, cervicitis, post-coital bleeding, irregular bleeding, vaginitis
Other STD testing - HSV (herpes), HIV, Hepatitis, Syphilis
These STDs are not tested for as routinely as the others are, but are recommended whenever another STD (including HPV) is found. The American College of Obstetricians and Gynecologists now recommends an HIV test every year on every woman as a screen, and most insurances cover for this reason. In addition, the following symptoms are indications for testing: fatigue, nightsweats, fever, skin lesions, among many others.
Affirm Testing
If there is any vaginal discharge that appears slightly unusual or excessive, we generally test it for candidiasis (yeast), gardnerella (overgrowth of potential pathologic bacteria) and trichomonas (parasitic STD).
Mammograms
Currently controversial, there are a few sets of competing recommendations about mammograms. Women's Health Connection follows the American College of Obstetricians and Gynecologists recommendations for mammograms every 1-2 years after age 40 and every year after age 50. Where there is a family history of breast cancer, we start mammograms at those ages, or 10 years before the youngest first degree relative with breast cancer, whichever comes first. A “baseline” mammogram in one's late 30s is no longer recommended - too many false positives.
Bone Density
We believe strongly in prevention and encourage a healthy diet with plenty of protein, vitamin D and calcium, and lots (ie 30 minutes a day, 6 days a week) of weight bearing exercise beginning in one's teenage years or younger, and continuing for a lifetime to prevent osteoporosis in later years. Bone loss begins in one's mid-30s, and takes a rapid decline after menopause. Bone density screening for most women begins around the time of menopause, although may be earlier or later in certain circumstances. May be earlier in the following circumstances:
- prolonged use of steroids (including inhaled)
- prolonged use of thyroid medications
- prolonged use of synthetic progestins such as Depo-Provera
- prolonged use of anti-seizure medication
- prolonged use of Depo-Lupron for endometriosis
- poor calcium intake
- high caffeine intake
- unexplained fractures
- strong family history of osteoporosis
Urinalysis
- all women more than 40 (screen for blood, protein and infection)
- all women with urinary symptoms
Colorectal Cancer Screening
Colonoscopy recommended every 10 years beginning at age 50 or every 10 years beginning 10 years before the age at which your youngest first degree relative had colon cancer, or more often if you've been diagnosed with colon polyps.

Every year after age 40 that a colonoscopy is not done, we recommend screening the stool for occult blood which we do at the time of your exam. This is NOT meant to replace a colonoscopy as a screen every 10 years, but is a useful adjunct.
Immunizations
- Gardasil (the HPV vaccine) is recommended for all women up to age 26.
- A tetanus booster is recommended every 10 years.
- Hepatitis A and B is recommended for all women under age 25 or those in high risk situations.
Skin
At every annual exam, a skin exam is conducted and we may recommend a shave biopsy for some lesions.
Cholesterol Screening
As a baseline at age 30 (lower in those with risk factors for heart disease, such as obesity, smoking, hypertension, diabetes, family history of high cholesterol or heart disease at a relatively young age).
Thyroid Screening
A good thyroid screen consists of TSH, T3 and T4 and should be done with any symptoms of thyroid disease and every few years as a screen in most women of reproductive age.
Other Bloodwork
It is fairly routine to do a comprehensive metabolic panel, a complete blood count and a vitamin D as screens or with symptoms suggesting an underlying problem. Other labwork depends on your risk factors.
EKG and Stress Testing
EKGs are recommended routinely every year after age 50 as heart disease can be atypical in women. Referral for stress testing with any symptoms that sound like they might be cardiac.
Fasting Insulin and Diabetes Testing
When indicated based on family history or personal symptoms.
Contraceptive Counseling +/- Prescriptions
Refills of medications for stable problems
Identification of Need for Further Management of New or Evolving Problems
1. Hormonal Problems
2. Abnormal Bleeding Problems
3. Bladder Problems (Urgency, Frequency, Leaking)
4. Prolapse Problems
5. Sexual Problems
6. Weight/Metabolic Problems
7. Gastro-Intestinal/Irritable Bowel Problems
8. Sleep/Energy/Fatigue Problems
9. Bone Density Problems
10. Cholesterol and/or High Blood Pressure Problems
11. Skin Problems - lesions, acne, sun damage
12. Problems that Could Benefit from Medical Massage
13. Nutritional Problems
14. Fertility Problems
15. Other gynecologic problems
16. Other primary care problems
17. Problems that require a referral out of the clinic.

Primary Care Problems we Manage

Your Ob/Gyn is often the only physician that women see between the ages of 20 and 55. As a result, we handle a variety of primary care problems in addition to your gynecologic concerns. These may include, but are not limited to the following:

Hypertension	Skin Problems	Smoking Cessation
High Cholesterol	"Irritable bowel"	Difficulty Sleeping
Thyroid Disease	Urinary tract infections
Osteopenia/Osteoporosis	Colds and minor infections
Depression /Anxiety	Joint and muscle aches

and many others...

Here are links to a number of other helpful resources for general women's Health:

Difference Between Problem and Preventative Visits

An annual preventative exam is an important part of an overall good health care plan and is covered by most private insurance plans, although different rules apply.

A preventative exam is different than a problem visit in that its focus is on screening for health problems in a person who feels well. Sometimes it is known as a well woman exam. PAPs, cholesterol screening, arranging mammograms, colonoscopies, bone densities, screening for STDs , screening for blood in the stool, doing a general exam and gyn exam in a well woman, a skin survey, a breast exam and education about prevention of problems that have not yet occurred but for which the patient is at risk, are all parts of a preventative exam.

A problem exam focuses on a symptoms or sign or problem that the patient is experiencing. It generally includes a history, a physical exam, discussing of the problem, forming and initial impression, ordering tests and arranging follow-up.

Why make a distinction between problem and preventative exams?

Most insurance payers provide coverage for both problem and preventative exams, but gnerall there is a limit to preventative care and how often it can be done. Often policies and deductibles are different. Some insurance companies allow both a problem visit and a preventative visit on the same day, and some do not. The person who initially takes your call to our clinic will help guide you as to whether your visit is booked as a problem visit, a preventative visit, or both.

Can a provider at Women's Health Connection be my main primary care provider?

Absolutely. Comprehensive training in primary care is part of a board certified Ob/Gyn's training and for many women, their ObGyn is the only physician that they see for several decades of their life unless they develop a complex medical problem. It really depends on your comfort level. Some women appreciate being able to have everything looked after in one place, while others prefer to see us for gynecologic care, problem and preventative, and see another primary care physician for other parts of their care.

What are the common problems that people are seen for at Women's Health Connection?

The providers at Women's Health Connection see a variety of general problems and problems specific to gynecology and urogynecology.

General: Skin problems, cholesterol problems, osteopenia/osteoporosis, thyroid problems, colds/sore throats, insulin resistance, high blood pressure, irritable bowel, low back pain, depression/anxiety, gastro-esophageal reflux, fatigue, chronic pain, urinary tract infections, interstitial cystitis, allergies

Gynecologic: heavy periods, painful periods, ovarian cysts, endometriosis, vaginitis, menopausal symptoms and hormone problems, contraception, sexual problems, fertility problems, polycystic ovarian syndrome, hirsutism, pelvic floor problems, STD checks, fibroids, ectopic pregnancy, recurrent early pregnancy loss, chronic pelvic pain, vulvar itching and dermatitis, vaginal atrophy

Urogynecologic: urinary stress incontinence (leaking), urinary urgency and frequency, overactive bladder, pelvic prolapse (cystocele, rectocele, enterocele, etc)

Does booking my visit as a problem visit or a preventative visit mean that's how it will be billed?

Often, but not always. It depends what actually happens at your visit. If your visit is booked as a preventative, but a significant amount of time is spent on a problem or symptoms, then both will be reported to your insurance payer.

What does a preventative exam usually consist of?

For those under ages 13 to 20:

A preventative exam typically consists of a survey of skin exam, thyroid exam, breast exam, abdominal exam and possibly a pelvic exam. A pelvic exam (hyperlink) is usually done on a regular (usually annual) basis if a person under the age of 16 has been sexually active in the past. Preventative counseling may include any number of a variety of topics suggested by the American College of Obstetricians and Gynecologists for this age group. Chlamydia and gonorrhea testing are automatically done unless specifically declined. HPV is automatically done on any PAPs that are slightly abnormal (see “Abnormal PAP smears” hyperlink). Other tests are done as indicated based on past medical history, family history, review of systems and physical exam. Prior to sexual activity, this may consist of a discussion of general reproductive function and what to expect in terms of body changes and a frank and open discussion of questions related to future gynecologic and sexual concerns. Contraceptive counseling and vaccinations and STD prevention are common topics at this age. Smoking cessation and substance abuse are also not infrequent topics.

For those ages 21 to 39

A preventative exam typically consists of a skin exam, thyroid exam, breast exam, abdominal exam and pelvic exam. Until age 25, Chlamydia and Gonorrhea are checked automatically unless specifically declined. After that it is done as indicated and requested. Cervical screening, ie collection of a PAP smear or screening HPV test, is recommended as a part of the pelvic exam on most patients in this age group on a regular basis. Other tests are recommended ordered as indicated based on past medical history, family history, review of systems and physical exam. Preventative counseling may include any number of a variety of topics suggested by the American College of Obstetricians and Gynecologists for this age group and among other topics include contraceptive counseling, smoking cessation, self breast exams, vaccinations, and other topics.

For those age 40 to 64

A preventative exam typically consists of a skin exam, oral cavity exam, thyroid exam, hearing screen, breast exam, heart and lung exam, abdominal exam, and pelvic exam. Cervical screening, ie collection of a PAP smear or screening HPV test, is recommended as a part of the pelvic exam on most patients in this age group on a regular basis. Mammograms are typically recommended every one to two years after age 40 and yearly after age 50. Bone densities are done based on current guidelines, but usually begin around the age of menopause for most women. Colonoscopies are recommended every 10 years, earlier if risk factors present. Regular cholesterol screening, glucose screening, and thyroid screening are recommended. Chlamydia and gonorrhea are done if indicated based on symptoms or new partners. Cervical screening, ie collection of a PAP smear or screening HPV test, is recommended as a part of the pelvic exam on most patients in this age group on a regular basis. Other tests are ordered on an as needed basis. A variety of preventative health topics may be addressed in counseling around these visits.

For those ages 65 plus

A preventative exam, ideally is similar to those ages 40 to 64, except that for many women, Medicare rules now apply. Medicare doesn't cover preventative care, except for a breast and pelvic exam every year and a PAP smear every 2 years (every year if high risk factors present). The rest of the preventative care exam is either paid for out of pocket, or not done. However Medicare does cover problem visits and many women by this point in time have developed some forms of stable chronic problems, or are having symptoms of new problems, and if so these are addressed at the same time, since Medicare does allow a problem visit to be combined with the breast and pelvic exam and PAP.

Especially for Teens

Teenagers often have many questions about the changes happening to their body, about their menstrual period, about their sexuality, about birth control and sexually transmitted diseases.

For these reasons it is useful to for them to connect with a gynecologist and establish a trusting relationship in a safe environment where they can ask any questions on their mind, knowing that everything is confidential and there is no such thing as a silly or embarrassing question.

From a preventative point of view, the annual gynecology exam actually does not include a PAP smear and pelvic exam until age 21, unless a teenager requests it specifically. There is no reason for a pelvic exam and PAP until age 21. Almost every STD can be screened for in the urine or blood without a pelvic exam. PAPs to look for and prevent cervical cancer are not necessary because cervical cancer is unheard of in teenagers. Delaying the first preventative PAP and pelvic exam is also the current recommendation of the American College of Obstetricians and Gynecologists.

If there is a problem with heavy or irregular periods, or pelvic pain, or abnormal vaginal discharge, a pelvic exam may be done to evaluate. Usually this is only done to evaluate gynecologic problems for teenagers who are already sexually active. Otherwise, we evaluate the pelvis with transabdominal ultrasound instead, with a few rare exceptions in special circumstances.

So there is no need for a teenager to be fearful that they will have to have a pelvic exam if they come to the gynecologist. There are lots of reasons for teenagers to see the gynecologist and establish care, mostly to have questions answered and also to evaluate problems from time to time. For more information, see Your First Gynecologic Visit - Especially for Teens.

Washington State mandates that teenagers can make their own decisions, independent of their parents, and without their parents knowledge or consent, when it comes to STD and HIV screening and management, and for anything to do with birth control or pregnancy medical needs. We do always let teenagers know that the codes and costs for the visits and tests and treatments are still accessible to whoever is the "Guarantor" of their insurance (ie whoever is paying the bills).

We encourage teenage patients and their parents to be feel free to have open conversations, non-judgmental, about issues concerning sexuality, STDs, birth control and pregnancy. When parents accompany their teenagers, we usually excuse them from the room for at least some of the time, to allow for confidentiality for the teenager and freedom to say what is on their mind, unless the teenager specifically requests that their parent stay with them.

Abnormal Periods in Teens

Periods can be somewhat irregular and at times heavy as the ovaries begin to ovulate and the reproductive processes get started. For more information, please see Menstruation - Especially for Teens. Parents and teens often wonder what is normal and what is not and when to be concerned. Here are some "red flags" that should prompt a visit to the gynecologist:

You are aged 15 years and have not had a menstrual period
Your periods were regular and occurred monthly and then they became irregular
Your period occurs more often than every 21 days or less often than every 45 days
Your periods occur 90 days apart (even if only for one cycle)
Your periods last more than 7 days
Your periods require frequent pad or tampon changes (soaking more than one every 1–2 hours)

Great Resources to Find Out More

There are many great resources for teenagers to find out more, and we encourage you to read the following:

Growing Up - Especially for Teens
Menstruation - Especially for Teens
You and Your Sexuality - Especially for Teens
Your First Gynecologic Visit - Especially for Teens
Birth Control - Especially for Teens
The SexualityandU website has some good information as well.
Kids Health for Teens

Hypertension (High Blood Pressure)

Useful links:

What is high blood pressure?

Arteries are small tube like structures that carry blood from your heart to the rest of your body. High blood pressure (also called hypertension) occurs when your blood moves through your arteries at a higher pressure than normal.

What does the blood pressure reading mean?

Blood pressure is really two measurements, separated by a slash when written, such as 120/80. You may also hear someone say a blood pressure is "120 over 80."

The first number is the systolic blood pressure. This is the peak blood pressure when your heart is squeezing blood out. The second number is the diastolic blood pressure. It's the pressure when your heart is filling with blood--relaxing between beats.

A normal blood pressure is less than 120/80. High blood pressure is 140/90 or higher. If your blood pressure is between 120/80 and 140/90, you have what is called "prehypertension," which means that if you don’t take important steps, your blood pressure can turn into high blood pressure.

How is high blood pressure diagnosed?

Blood pressure is measured by placing a blood pressure cuff around your arm, inflating the cuff and listening for the flow of blood. There are some automated cuffs which can do the same thing at home. Your primary health care provider will measure your blood pressure at more than one visit to see if you have high blood pressure.

How often should I have my blood pressure checked?

Women’s Health Connection recommends that it be checked annually as part of your preventative exam. If we find a high reading, we repeat it. If it’s still high, we recommend keeping a blood pressure diary for a few weeks. If it is consistently high, we recommend lifestyle and sometimes medications to prevent long term serious consequences.

What problems does high blood pressure cause?

Both high blood pressure and prehypertension damage your blood vessels. This in turn raises your risk of stroke, kidney failure, heart disease and heart attack.

What symptoms does high blood pressure cause?

Usually none. This is why it's so important to have your blood pressure checked regularly.

How is it treated?

Treatment begins with changes you can make to your lifestyle to help lower your blood pressure and reduce your risk of heart disease (see below). If these changes don't work, you may also need to take medicine.

Even if you need to take medicine, making some changes in your lifestyle can help reduce the amount of medicine you must take.

Lifestyle changes

Don't smoke cigarettes or use any tobacco product.
Lose weight if you're overweight.
Exercise regularly.
Eat a healthy diet that includes lots of fruits and vegetables and is low in fat.
Limit your sodium, alcohol and caffeine intake.
Try relaxation techniques.

How do tobacco products affect blood pressure?

The nicotine in cigarettes and other tobacco products causes your blood vessels to constrict and your heart to beat faster, which temporarily raises your blood pressure. It also makes your blood more concentrated and difficult for your heart to pump. If you quit smoking or using other tobacco products, you can significantly lower your risk of heart disease and heart attack, as well as help lower your blood pressure.

What about losing weight and exercising?

If you're overweight, losing weight usually helps lower blood pressure. Regular exercise is a good way to lose weight. It also seems to lower high blood pressure by itself.

Do I need to limit my salt intake?

Not everyone is affected by sodium, but sodium can increase blood pressure in some people. Most Americans with healthy blood pressure should limit the sodium in their diet to 2,300 mg per day. African Americans, older Americans and people with high blood pressure should limit the sodium in their diet to 1,500 mg per day. Your primary health care provider may tell you to limit your sodium even more.

Don't add salt to your food. Check food labels for sodium. While some foods obviously have a lot of sodium, such as potato chips, you may not realize how much sodium is in food like bread, canned vegetables, soups and cheese. Also be aware that some medicines contain sodium.

Do I need to quit drinking alcohol altogether?

In some people, alcohol causes blood pressure to rise quite a lot. In other people, it doesn't. If you drink alcohol, limit it to no more than 1 drink per day for women or 2 drinks per day for men. One drink is a can of beer, a glass of wine (4-5 oz.), or 1 shot (jigger) of liquor. If your blood pressure increases with alcohol, it's best not to drink any alcohol.

Does stress affect my blood pressure?

Stress may affect blood pressure. To help combat the effects of stress, try relaxation techniques such as Tai Chi, meditation, yoga, massage, or other techniques you find helpful. Try to do them on a regular basis.

What about medicine?

Many different types of medicine can be used to treat high blood pressure These are called antihypertensive medicines.

The goal of treatment is to reduce your blood pressure to normal levels with medicine that's easy to take and has few, if any, side effects. This goal can almost always be met.

If your blood pressure can only be controlled with medicine, you'll need to take the medicine for the rest of your life. You may need to take more than one medicine to help control your blood pressure. Don't stop taking the medicine without talking with your physician or you may increase your risk of having a stroke or heart attack.

Types of antihypertensive medications

Diuretics: These drugs help your body get rid of extra sodium and fluid so that your blood vessels don't have to hold so much fluid.
Beta-blockers: These drugs block the effects of adrenaline. (They also block beta-lipolysis of the fat cells, so may not be the best choice if you are overweight.)
Alpha-blockers: These drugs help your blood vessels stay open.
ACE inhibitors: These drugs prevent your blood vessels from constricting by reducing how much angiotensin II your body makes. Angiotensin II is a chemical that constricts blood vessels (makes them more narrow).
ARBs: These drugs work by blocking the effect of angiotensin II on cells
Calcium channel blockers: These drugs help prevent your blood vessels from constricting by blocking calcium from entering your cells.
Combinations: These drugs combine two medicines, like an ACE inhibitor or a beta-blocker plus a diuretic.

What are the possible side effects of medicine?

Different drugs have different side effects for different people. Side effects of antihypertensive drugs can include feeling dizzy when you stand up after lying down or sitting, lowered levels of potassium in your blood, problems sleeping, drowsiness, dry mouth, headaches, bloating, constipation and depression. In men, some antihypertensive drugs can cause problems with having an erection.

Talk to your primary care provider about any changes you notice. If one medicine doesn't work for you or causes side effects, you have other options. Let your provider help find the right medicine for you.

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