ACOG Committee Opinion No. 356: Routine cancer screening

Obstetrician-gynecologists serve as primary care physicians for many women. Because the obstetrician-gynecologist may be the only physician providing routine care, clinicians should be able to provide recommendations for routine cancer screenings, including those for nongynecologic cancers. This document summarizes recommendations of the American College of Obstetricians and Gynecologists for routine cancer screening for the average-risk American woman. The obstetrician-gynecologist should discuss both benefits and limitations of screening tests with the patient.     

ACOG Committee Opinion No. 389, December 2007. Human immunodeficiency virus

Because human immunodeficiency virus (HIV) infection often is detected through prenatal and sexually transmitted disease testing, an obstetrician-gynecologist may be the first health professional to provide care for a woman infected with HIV. Universal testing with patient notification and right of refusal ("opt-out" testing) is recommended by most national organizations and federal agencies . Although opt-out and opt-in testing (but not mandatory testing) are both ethically acceptable, the former approach may identify more women who are eligible for therapy and may have public health advantages . It is unethical for an obstetrician-gynecologist to refuse to continue providing health care for a patient solely because she is , or is thought to be, seropositive for HIV. Health care professionals who are infected with HIV should adhere to the fundamental professional obligation to avoid harm to patients. Physicians who believe that they have been at significant risk of being infected should be tested voluntarily for HIV.     

ACOG Committee Opinion. Number 335, May 2006: The initial reproductive health visit

The American College of Obstetrician and Gynecologists (ACOG) recommends the first visit to the obstetrician-gynecologist take place between the ages of 13 and 15 years. This visits will provide health guidance, screening, and preventive health care services and provide an excellent opportunity for the obstetrician-gynecologist to start a physician-patient relationship. This visit generally does not include an internal pelvic examination.     

ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention

The American College of Obstetricians and Gynecologists advocates assessing for psychosocial risk factors and helping women man-age psychosocial stressors as part of comprehensive care for women. Psychosocial screening of all women seeking pregnancy evaluation or pre-natal care should be performed regardless of social status, educational level,or race and ethnicity. Because problems may arise during the pregnancy that were not present at the initial visit, it is best to perform psychosocial screen-ing at least once each trimester to increase the likelihood of identifying important issues and reducing poor birth outcomes. When screening is completed, every effort should be made to identify areas of concern, validate major issues with the patient, provide information, and, if indicated, make suggestions for possible changes. When necessary, the health care provider should refer the patient for further evaluation or intervention. Psychosocial risk factors also should be considered in discharge planning after delivery. Many of the psychosocial issues that increase the risk for poor pregnancy outcome also can affect the health and welfare of the newborn. Screening should include assessment of barriers to care, unstable housing, unintended pregnancy, communication barriers, nutrition, tobacco use, substance use,depression, safety, intimate partner violence, and stress.     

ACOG Committee Opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer

The purpose of this Committee Opinion is to define the role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Currently, it appears that the best way to detect early ovarian cancer is for both the patient and her clinician to have a high index of suspicion of the diagnosis in the symptomatic woman. In evaluating symptoms, physicians should perform a physical examination, including a pelvic examination. In premenopausal women with symptoms, a CA 125 measurement has not been shown to be useful in most circumstances. In postmenopausal women with a pelvic mass, a CA 125 measurement may be helpful in predicting a higher likelihood of a malignant tumor than a benign tumor, which may be useful in making consultation or referral decisions or both. A woman with a suspicious or persistent complex adnexal mass requires surgical evaluation by a physician trained to appropriately stage and debulk ovarian cancer. Data suggest that currently available screening tests do not appear to be beneficial for screening low-risk, asymptomatic women. An annual gynecologic examination with an annual pelvic examination is recommended for preventive health care.     

Reported ovarian cancer screening among a population-based sample in Washington state

OBJECTIVE: To assess the prevalence of reported ovarian cancer screening among a population-based sample of women from Washington state and identify factors that influence the decision to be screened. METHODS: A population-based sample of 6749 women aged 54-84 years, living in 40 predominately rural communities in Washington state, was surveyed about their utilization of ultrasonography and CA 125 for ovarian cancer screening. We also assessed relevant demographic, family history, psychosocial, and health behavior variables. RESULTS: After exclusions, data from 4938 respondents were available. Two percent (n = 96) reported having been screened. Multiple logistic regression identified ovarian cancer worry, contact with an obstetrician-gynecologist, and family history of ovarian cancer as independently associated with screening. Based on self-reported family histories, 27 women had pedigrees consistent with high risk of ovarian cancer, but none of those women reported having been screened. CONCLUSION: Ovarian cancer screening is rare. Women at high risk of it might not be getting recommended screening.     

NUTRITIONAL CONCERNS IN WOMEN'S PRIMARY CARE

The midwife needs to be aware of current guidelines for nutritional monitoring, including those in Healthy People 2000, to provide primary care screening for nutritional factors that affect the health status of women. This article reviews the relationship between dietary habits and specific health concerns, including cardiovascular disease, obesity, osteoporosis, cancer, and diabetes; special attention is paid to high-risk groups. It also examines the relationship between improved nutritional status and the reduction of the major causes of morbidity in women.     

Women's cardiovascular health. An official position statement of the Association of Women's Health, Obstetric & Neonatal Nursing

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) maintains that nurses and other clinical professionals should include routine cardiovascular health screening,provide education, and promote awareness at health care visits for women across the lifespan.Advocacy for preventive measures should begin early, and adolescent girls and young women should be encouraged to adopt heart-healthy habits. For adult and senior women, nurses should work to increase patient awareness about risk factors,symptoms and treatment options associated with cardiovascular disease (CVD) and CVD risk.Efforts should extend to women of every age and health status.     

Cervical carcinoma: contemporary management.

Cervical carcinoma is prevented easily with proper screening. Unfortunately, many women in industrialized countries continue to have poor access to adequate medical care. In many third-world countries, cervical cancer is one of the top malignancies diagnosed. Screening should be provided for all women to prevent or diagnose cervical cancer at an early, treatable stage.     

Limitations in Correspondence Programs for Cervical Cancer Screening: Who Are the Women We Are Missing?

ObjectiveThis study sought to identify factors associated with gaps in the correspondence program and the characteristics of those women who are not reached with a mailed invitation to screening within an organized cervical cancer screening program.MethodsThis population-based, retrospective observational study examined the factors associated with failed correspondence mailings as part of the Ontario cervical cancer screening program. Administrative databases were used to identify eligible women who were overdue for screening or never screened yet did not receive an invitation to screening as a result of a failed mailing. These women were further characterized on the basis of age, affiliation with a primary care physician, and use of other health services (Canadian Task Force Classification II-2).ResultsA total of 1 350 425 women were eligible, of whom 1 064 637 had a successful mailing (78%). Women who were overdue for screening and who had a failed correspondence were more likely to be younger than 50 (72.5%) and associated with a primary care physician (61.2%), and 66.7% had three or more health care encounters in the preceding 3 years. Underscreened and never-screened women were also more likely to be younger than 50, but only 15% were associated with a primary care physician and only 18.2% had health care encounters in the previous 3 years.ConclusionThis is one of the first studies to evaluate the incidence of failed mailings within correspondence in organized screening programs. Women who are underscreened or never screened are infrequent users of health care services and tend not to have a primary care physician, thus making them less accessible to traditional outreach methods and at further risk of being non-compliant with screening.     

Training and function of a women's health-care specialist, a physician's assistant, or nurse practitioner in obstetrics and gynecology.

Serious manpower shortages exist in the United States. Proposed corrective measures indicate the need for nonphysicians to provide medical care for well or worried well patients. We have tested this proposed solution in the field of obstetrics and gynecology using allied health personnel to provide health maintenance services to well women, and feel that the experiment has been a success. Using principles of pattern recognition allied health workers recognize normal and abnormal findings. Patients with abnormalities are referred to the supervising physician for diagnosis and therapy. Allied health workers can also perform technical health-maintenance tasks such as inserting intrauterine devices and obtaining Pap smears. This article describes the historical evolution of our allied health personnel workers, called women's health-care specialists (WHCS), the selection and training of students, functions and levels of performance of the specialists, and the future role of such individuals in obstetrics and gynecology. We feel that with appropriate preparation of the physician, co-workers, and patients, the integration of the WHCS into the health-care system is both desirable and appropriate and will offer significant advantages to the patient and the practicing obstetrician-gynecologist in either the clinic or private practice setting.     

Genital human papillomavirus infection in women who have sex with women: a review

Sexual transmission of human papillomavirus between women has been postulated on the basis of reports of abnormal Papanicolaou smears in women who reported no prior sex with men and by studies using amplified deoxyribonucleic acid technology for human papillomavirus detection. To review the current knowledge of the epidemiology of human papillomavirus and the Papanicolaou smear screening practices among women who have sex with women, studies were identified from a search of the MEDLINE database from January 1980-June 1999. Several factors, including prior or concurrent sex with men and sexual behaviors between women, validate the possibility of human papillomavirus infection among women who have sex with women, and data support that human papillomavirus transmission also occurs. Limited data indicate that the frequency of routine Papanicolaou smear screening among women who have sex with women may be suboptimal relative to heterosexual women. Education of women who have sex with women and the providers of their health care should counter any assumptions that sex between women confers no risk of human papillomavirus transmission. Women who have sex with women should receive Papanicolaou smear screening in accord with current guidelines.     

Breast cancer screening in women at average risk and high risk

Recent controversies over the recommendations for breast cancer screening have created some uncertainty about the best methods of providing this care for women, particularly women at average risk for breast cancer. This article reviews the current recommendations for breast cancer screening from various national organizations and the scientific data behind these recommendations, and it highlights some of the controversies and the reasons behind the differing viewpoints. This article focuses on providing the obstetrician-gynecologist with evidence-based recommendations for counseling and screening women who are at average and high risk for breast cancer. The ability to identify women at higher risk for breast cancer and the appropriate clinical use of mammography, ultrasonography, MRI, clinical breast examination, and self-breast examination ("breast self-awareness") for breast cancer screening in these different populations are discussed. Finally, incorporating specific recommendations for breast cancer screening in women at average and high risk into practice are included.     

Automobile passenger safety education for pregnant women and infants. Attitudes and practices of obstetrician-gynecologists

Attitudes and practices regarding automobile passenger safety education for pregnant women and infants were surveyed in a random sample of 236 certified obstetrician-gynecologists in California. A majority of respondents stated that maternal passenger safety (71.6%) and infant/child passenger safety (63.6%) should be "routinely discussed by the obstetrician-gynecologist during the prenatal period." Nevertheless, one of four respondents could not give an opinion or had doubts about the safety of seat belt use in pregnant women. Fewer than one of three discussed maternal passenger safety, and fewer than one of four discussed infant/child passenger safety when giving prenatal care. There was a scarcity of patient education materials in the practitioners' offices. Given the obstetrician-gynecologists' support for promoting passenger safety, there is need for increased health education activities in offices, clinics, hospitals and prenatal classes.     

Social inequality in Pap smear coverage: identifying under-users of cervical cancer screening in Argentina

In Argentina, the unequal distribution of the burden of cervical cancer is striking: the mortality rate of the province of Jujuy (15/100,000) is almost four times higher than that of the city of Buenos Aires (4/100,000). We aimed to establish the socio-demographic profile of women who were under-users of Pap smear screening, based on an analysis of a representative sample of Argentinean women from the First National Survey on Risk Factors in 2005. We found that in Argentina, women who are poor, unmarried, unemployed or inactive, with lower levels of education and reduced access to health care, and women over the age of 65, were under-users of screening. Screening must not remain opportunistic. Strategies must incorporate the needs and perceptions of socially disadvantaged women, and increase their access to screening. Of utmost importance is to provide good quality screening and treatment services that reach women who are at risk. Pilot projects using new, alternative technologies should be encouraged in less developed parts of the country. Promotion among health professionals of the scientific basis and effectiveness of each screening modality is essential to reduce wasteful practices such as annual screening and screening of young women that waste resources and fail to reduce cervical cancer incidence and mortality rates.     

Prenatal Screening for and Diagnosis of Aneuploidy in Twin Pregnancies

ObjectiveTo provide a Canadian consensus document with recommendations on prenatal screening for and diagnosis of fetal aneuploidy (e.g., Down syndrome and trisomy 18) in twin pregnancies.OptionsThe process of prenatal screening and diagnosis in twin pregnancies is complex. This document reviews the options available to pregnant women and the challenges specific to screening and diagnosis in a twin pregnancyOutcomesClinicians will be better informed about the accuracy of different screening options in twin pregnancies and about techniques of invasive prenatal diagnosis in twins.EvidencePubMed and Cochrane Database were searched for relevant English and French language articles published between 1985 and 2010, using appropriate controlled vocabulary and key words (aneuploidy, Down syndrome, trisomy, prenatal screening, genetic health risk, genetic health surveillance, prenatal diagnosis, twin gestation). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. Searches were updated on a regular basis and incorporated in the guideline to August 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies The previous Society of Obstetricians and Gynaecologists of Canada guidelines regarding prenatal screening were also reviewed in developing this clinical practice guideline.ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).Benefits, harms, and costsThere is a need for specific guidelines for prenatal screening and diagnosis in twins These guidelines should assist health care providers in the approach to this aspect of prenatal care of women with twin pregnancies.Summary StatementsFetal nuchal translucency combined with maternal age is an acceptable first trimester screening test for aneuploidies in twin pregnancies. (II-2)First trimester serum screening combined with nuchal translucency may be considered in twin pregnancies It provides some improvement over the performance of screening by nuchal translucency and maternal age by decreasing the false-positive rate. (II-3)Integrated screening with nuchal translucency plus first and second trimester serum screening is an option in twin pregnancies. Further prospective studies are required in this area, since it has not been validated in prospective studies in twins (III)Non-directive counselling is essential when invasive testing is offered (III)When chorionic villus sampling is performed in non-monochorionic multiple pregnancies, a combination of transabdominal and transcervical approaches or a transabdominal only approach appears to provide the best results to minimize the likelihood of sampling errors. (II-2)RecommendationsAll pregnant women in Canada, regardless of age, should be offered, through an informed counselling process, the option of a prenatal screening test for the most common clinically significant fetal aneuploidies. In addition, they should be offered a second trimester ultrasound for dating, assessment of fetal anatomy, and detection of multiples. (I-A)Counselling must be non-directive and must respect a woman's right to accept or decline any or all of the testing or options offered at any point in the process. (III-A)When non-invasive prenatal screening for aneuploidy is available, maternal age alone should not be an indication for invasive prenatal diagnosis in a twin pregnancy. (II-2A) If non-invasive prenatal screening is not available, invasive prenatal diagnosis in twins should be offered to women aged 35 and over. (II-2B)Chorionicity has a major impact on the prenatal screening process and should be determined by ultrasound in the first trimester of all twin pregnancies (II-2A)