Loyola University Health System



Revised 10/25/04

Loyola University Health System

Women’s Health Screening

& Counseling Preventive Guidelines

2004

Objectives:

To develop recommended standards for screening and counseling for the health maintenance of women throughout the LUHS network in order to improve the quality and consistency of services offered.

To enhance the ability to attract payor contracts through high quality and consistent standards of practice.

To define screening and counseling standards that will serve as precursors for future women’s health initiatives and programs.

Process:

The 2004 Women’s Health Preventive Guideline’s Committee members reviewed and compared screening recommendations from numerous sources. In addition, recommendations were reviewed with appropriate disciplines within LUHS. Committee members reached consensus based on recommendations and best-practice evidence from medical literature. The format of the U.S. Preventative Services Taskforce is used to present the guidelines. This guideline is a revision of the document originally developed by the 1999 Loyola Women’s Health Task Force. The level of evidence based on the USPSTF is as follows.

A. Strongly recommended - good evidence concludes this will improve health outcomes.

B. Recommended based on fair evidence.

C. Evidence is inconclusive but favor benefit.

D. Good evidence to recommend against screening asymptomatic patients.

I. Insufficient evidence – evidence is lacking, poor quality or conflicting.

2004 Women’s Health Guideline Committee

Richard Besinger – OB Gyne

Pauline Camacho – Endocrine

Cheyanne Casas – Family Medicine

Rani Chintam – Gastroenterology

Nicole Cirino – Psychiatry

Sheryl Gabram – Breast Care Division

Mary Jo Liszek – Internal Medicine/Pediatrics

Shelly Lo –Oncology

Robert Mittendorf – OB Gyne

Ronald Potkul – Gyneoncology

Bridgid Steele – Internal Medicine

Amy Stoeffler – OB Gyne

LUHS Women’s Health Preventive Guidelines

2004

|SCREENING |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

|CATEGORY | | | |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older |Level of Evidence | |

|Height, Weight, BMI |Height: Measure at least yearly |Height: Measure & record at |Same as 19-39 |Compare height to |B |The AAFP recommends periodic |

| |Weight: Measure at least yearly |least once in the chart | |baseline. | |measurements; ACOG & USPSTF recommend |

| |BMI: Assess yearly |Weight: Measure yearly or as | | | |yearly or as appropriate. |

| | |appropriate | | | | |

| | |BMI: Assess yearly | | | | |

|Blood Pressure |At least every 2 years |Measure at least annually or |Same as 19–39 |Same as 40-64 |A |The AAP recommends screening at every |

| | |at each visit. | | | |visit or minimally every 2 years; the |

| | | | | | |ACP, AAP & USPSTF recommend screening |

| | | | | | |every 1-2 years. |

|Cholesterol |High risk patients only |Consider total and HDL |Screen every 2 years or |Same as 40-64 | |The AAFP, ACP & USPTF recommend |

| | |cholesterol level or fasting |more frequently with | | |periodic screening for ages 45-65. The|

| | |Lipid profile starting at age|additional risk factors. | | |AAP recommends selective screening of |

| | |20; then every 5 years. | | | |patients at risk. The NCEP recommends |

| | | | | | |FLP starting at age 20; then every 5 |

| | | | | | |years. |

|EKG & Stress Testing |No routine screening |No routine screening |EKG: In women over 50 with|Same as 40-64 |D |The ACC/AHA recommend screening with |

| | | |multiple cardiac risk | | |multiple risk factors and informed |

| | | |factors, the clinician may| |The USPSTF recommends against |consent regarding the pros and cons of |

| | | |order if results may | |routine testing of asymptomatic |testing. |

| | | |influence treatment. | |patients at average risk but finds| |

| | | |Stress Testing: At the | |insufficient evidence regarding | |

| | | |clinician discretion in | |asymptomatic high risk patients. | |

| | | |women over 50 with | | | |

| | | |multiple cardiac risk | | | |

| | | |factors. | | | |

| | | | | | | |

|SCREENING |RECOMMENDTIONS BY AGE GROUP |COMMENTS |REFERENCES |

|CATEGORY | | | |

| |Ages 11-18 years |Ages 19-39 years |Ages 40-64 years |Ages 65 & Older |Level of Evidence | |

|Colorectal |No routine screening |No routine screening unless |FOBT: Annually in women over |Same as 40-64 |A |The AGA recommends colonoscopy as the |

| | | |50.and/or | | |preferred strategy. The AAFP, NCI, ACP|

| | | |Flexible Sigmoidoscopy: | | |& USPSTF recommend choosing any of the |

| | | |Offered every 5 years starting | | |strategies listed. |

| | | |at age 50 | | | |

| | | |-or- | | | |

| | | |Colonoscopy every 10 years | | | |

| | | |-or- | | | |

| | | |Double Contrast Barium Enema | | | |

| | | |every 5 years. | | | |

|Bone Density |No routine screening |No routine screening |Selectively screen women with |All women ≥ 65 should be |B |USPSTF & the Nat’l Osteoporosis Fdn |

| | | |the following risk factors: |screened then tested every| |recommend routine screening in all |

| | | |- Women with ≥ 1 risk factor |2 years. | |women > 65 years. Testing in women < |

| | | |other than menopause | | |65 is recommended if one or more risk |

| | | |- All postmenopausal women | | |factors are identified. |

| | | |with fractures | | | |

|Pap Smear |Routine screening should |Same as 11-18 |Same as 19-39 |Women over 65 with no |A |The AAFP, ACP & USPSTF recommend |

| |begin at age 21 or within 3 | | |previous screening should | |screening for all sexually active women|

| |years for patients with a | | |have three annual normal |More frequent screening should be |at least every 3 years. The ACOG, ACPM|

| |positive history of sexual | | |smears prior to |considered for women with risk |& NCI recommend at least 2-3 normal |

| |activity, whichever comes | | |discontinuing screening. |factors: Age of first sexual |screenings at one-year intervals prior |

| |first. For women with at | | |Screening may be |intercourse is < 18 yrs; multiple |to moving to the three-year screening |

| |least 3 normal smears, the | | |discontinued at 65 years |sexual partners: smoking, or low |interval. |

| |screening interval may be | | |if the woman was regularly|SES; Pap smear is not recommended | |

| |extended, at the discretion | | |screened, has had 3 normal|in women with hysterectomy for | |

| |of the clinician & client, | | |pap smears and has had no |reasons other than precancerous or| |

| |but should not exceed three | | |abnormal smears in the |cancerous conditions. | |

| |years. | | |previous 9 years. | | |

| | | | | | | |

|SCREENING |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

|CATEGORY | | | |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older |Level of Evidence | |

|Ovarian Cancer |No routine screening |Annual pelvic exam with |Same as 19-39 |Same as 40-64 |I |ACOG, AMA & NCI recommend annual pelvic|

| | |palpation of the adnexae should| | | |exam with palpation of the adnexa; the |

| | |be performed. | | | |ACS recommends every 1-3 years until |

| | | | | | |the age of 40; then annually. |

| | |A careful family history for | | | | |

| | |ovarian cancer should be | | | | |

| | |obtained. | | | | |

|Breast Examination & |No routine screening |Clinical breast exam: In |Mammography: Between 40-49 |Mammography: Annual |B |The ACOG, NCI, AAFP, & USPSTF recommend|

|Mammography | |patients 40, fasting |Same as 40-64 |B |The ACP, ACOG and USPSTF recommend |

| |high risk. |high risk. |glucose is recommended every | |Risk factors are: Positive family |universal testing for gestational |

| | | |5 years, more often if high | |history in parents or siblings, |diabetes testing in pregnancy. The |

| | | |risk. | |obesity HTN, hyper-lipidemia, |USPSTF recommends plasma glucose levels|

| | | | | |history of glucose intolerance. |in women over 40 with strong family |

| | | | | |Gestational diabetes or infant |history of disease, American Indian, |

| | | | | |weight > 4000 gm., American |Hispanic, or African American heritage.|

| | | | | |Indian, Hispanic, or African |A compilation of several groups |

| | | | | |American races, PCOS. |recommend using USPSF’s age of 40 to |

| | | | | | |begin screening. |

|Iron Deficiency Anemia |No routine screening |No routine screening |No routine screening |No routine screening | |The ACP, ACOG and USPSTF offer no |

| | | | | | |recommendation for routine screening. |

| | | | | | |ACOG recommends Hct & Hgb during |

| | | | | | |pregnancy and in women with history of |

| | | | | | |excessive menstrual flow. |

|Vision & Hearing |Vision: Assessed annually |Vision: Same as 11-18 |Vision: |Vision: Same as 40-64. | |The AAFP, ACOG recommend annual vision |

| |using the Snellen chart | |Same as 19-39. Glaucoma |Glaucoma screening should | |screening; the AAO & USPSTF recommend |

| | |Hearing: No routine screening |screening should be performed|be offered annually in all| |glaucoma screening in populations at |

| |Hearing: No routine screening| |every 2 years in all patients|women 65 & older. | |risk & age 65+. |

| | | |>40 with the following risk |Hearing: Should be | | |

| | | |factors: |assessed in all women 65 &| |The AAFP, ACOG & USPSTF recommend |

| | | |- African American |older using single | |questioning older adults about hearing;|

| | | |race |question about hearing or | |the CTEPHE recommends questioning |

| | | |- Diabetes |the whispered voice | |and/or the whispered voice technique. |

| | | |- Severe myopia |technique outside the | | |

| | | |- Family history of |patient’s view. | | |

| | | |glaucoma |Otoscopic exam & | | |

| | | | |audiometry should be | | |

| | | |Hearing: No routine screening|performed in patients with| | |

| | | | |an identified loss. | | |

|SCREENING |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

|CATEGORY | | | |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older | | |

|Substance Use Alcohol, |Alcohol: The CAGE questions |Same a 11-18 |Same as 19-39 |Same as 40-64 |Questions about the physical signs|The CAGE tool is used to assess alcohol|

|Drugs & Tobacco |should be asked at least | | | |of substance use may provide |use; in addition, the AAFP, ACOG & |

| |annually. |Screening questions to detect | | |insight into dependent behaviors, |USPSTF recommend annual assessment of |

| | |problem drinking or drug use is| | |include questions about frequent |drug and tobacco use. |

| |Drugs: A history should be |recommended. | | |headaches, absences from work | |

| |elicited at least annually. | | | |based on vague somatic complaints,| |

| | |Pregnant women should avoid | | |insomnia, unexplained mood | |

| |Tobacco: Ask about tobacco |drinking alcohol or using drugs| | |changes, GI disorders, | |

| |use at every visit, including|during the pregnancy. | | |uncontrolled HTN, impotence and/or| |

| |type, current use, past use, | | | |other sexual disorders and | |

| |and calculated packs per |Avoid alcohol use while | | |neuropathies. | |

| |year. If positive for |driving, boating, swimming, | | | | |

| |current smoking, offer |etc. | | |CAGE questions: | |

| |counseling. | | | |1. During the past month have you| |

| | | | | |thought you should cut down on | |

| |Screening questions for drug | | | |your drinking of alcohol? | |

| |and alcohol use are strongly | | | |2. Has Anyone complained about | |

| |recommended. Clinicians | | | |your drinking during the past | |

| |should be alerted to signs | | | |month? | |

| |and symptoms of physiologic | | | |3. During the past month have you| |

| |dependence or withdrawal, | | | |felt Guilty or upset about your | |

| |such as craving, compulsive | | | |drinking? | |

| |alcohol or drug-seeking | | | |4. In the past month was there | |

| |behavior, tremulousness, | | | |Ever a single day in which you had| |

| |agitation, weight loss, | | | |5 or more drinks of beer, wine, or| |

| |headaches, and changes in | | | |liquor? | |

| |mental status. | | | | | |

| | | | | |Note: Any “yes” answer should be | |

| | | | | |considered a positive screening | |

| | | | | |result. | |

| | | | | | | |

|SCREENING |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

|CATEGORY | | | |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older |Level of Evidence | |

|STD’s |All adolescents should be |Women should be assessed for |Same as 19-39 |Same as 40-64 |A |The AAP, AAFP, AMA & USPSTF recommend |

| |asked annually about |sexual behaviors that might | | | |annual counseling about sexual |

| |involvement in sexual |result in STD’s, including HIV.| | | |practices & risks for sexually |

| |behaviors that may result in |All women ≤ 25 should be | | | |transmitted diseases. Patients at risk|

| |unintended pregnancy & STD’s,|screened for GC and chlamydia. | | | |should receive information about |

| |including HIV. Sexually | | | | |transmission, prevention, and safe |

| |active adolescents should be |All women at risk should be | | | |reproductive health. |

| |screened annually for GC & |counseled and offered an | | | | |

| |chlamydia. In addition, |opportunity to receive | | | | |

| |high-risk adolescents should |screening for syphilis, HIV, | | | | |

| |be offered screening for |Hepatitis B & C. | | | | |

| |syphilis, HIV, Hepatitis B & | | | | | |

| |C. | | | | | |

|Pregnancy |First Trimester |Same as 11-18 |Same as 19-39 |N/A |A |The ACOG recommendations for prenatal |

| |Hgb or Hct U/A incl. Micro | | | | |assessment are suggested. |

| |urine C&S ABO & Rh typing | | | | | |

| |Antibody screening | | | | | |

| |Rubella titre | | | | | |

| |Syphilis screen | | | | | |

| |Pap smear | | | | | |

| |HSAg | | | | | |

| |HIV counseling & testing. | | | | | |

|Domestic Violence |The patient is asked the |Same as 11-18 |Same as 19-39 |Same as 40-64 |Children - B |Recommendations are excerpts from the |

| |following series of questions| | | |Adults - I |HITS Domestic Violence Screening tool |

| |annually: | | | | |and the Abuse Assessment Screen by the |

| |1. Have you ever been | | | | |Nursing Research Consortium on Violence|

| |pushed, slapped, hit, kicked,| | | | |& Abuse. |

| |or otherwise hurt by your | | | | | |

| |partner or someone important | | | | | |

| |to you? | | | | | |

| |2. Have you ever been | | | | | |

| |insulted or | | | | | |

|SCREENING |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

|CATEGORY | | | |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older |Level of Evidence | |

|Domestic Violence |talked down to by your | | | | | |

| |partner or someone important | | | | | |

|(continued) |to you? | | | | | |

| |3. Has our partner or anyone| | | | | |

| |important to you ever forced | | | | | |

| |you to have sexual | | | | | |

| |activities? (incl. | | | | | |

| |intercourse, fondling, or | | | | | |

| |touching)? | | | | | |

| |4. Has your partner or | | | | | |

| |anyone important to you | | | | | |

| |screamed or cursed at you? | | | | | |

|Depression |See attached checklist PHQ-9.|Same as 11-18 |Same as 19-39 |Same as 40-64 |B |Prime – MD (Primary Care Evaluation of |

| | | | | |Positive responses will require |Mental Disorders) |

| | | | | |further follow up and confidential| |

| | | | | |discussion. | |

|Anxiety & Panic |The patient is asked the |Same as 11-18 |Same as 19-39 |Same as 40-64 |Positive responses will require |PRIME-M tool; (Primary Care Evaluation |

| |following series of questions| | | |further follow up and confidential|of Mental Disorders). |

| |annually: | | | |discussion. | |

| |1. During the past month, | | | | | |

| |have you been bothered a lot | | | | | |

| |by “nerves” or feeling | | | | | |

| |anxious or on edge? | | | | | |

| |2. During the last month, | | | | | |

| |have you been worrying about | | | | | |

| |a lot of different things? | | | | | |

| |3. During the past month, | | | | | |

| |have you had an anxiety | | | | | |

| |attack (suddenly feeling fear| | | | | |

| |or panic)? | | | | | |

|SCREENING |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

|CATEGORY | | | |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older |Level of Evidence | |

|Eating Disorders |The patient is asked the |Same as 11-18 |Same as 19-39 |Same as 40-64 | |ESP – 4 |

| |following series of 4 | | | | |(Eating Disorder Screen for Primary |

| |questions annually: ESP – 4 | | | | |Eating Disorders) |

| |1. Are you satisfied with | | | | |J GEN INT MED 2003; |

| |your eating patterns? | | | | |18:53–56. |

| |2. Do you ever eat in | | | | | |

| |secret? | | | | | |

| |3. Does your weight affect | | | | | |

| |the way you feel about | | | | | |

| |yourself? | | | | | |

| |4. Do you currently suffer | | | | | |

| |with or have you ever | | | | | |

| |suffered in the past with an | | | | | |

| |eating disorder? | | | | | |

|Immunizations |dT q 10 years; |Same as 11-18 |dT q 10 years; Influenza |dT q 10 years; |A |Recommendations are taken from the CDC,|

| |Hepatitis B for adult women | |yearly over 50 and/or high |Influenza yearly; | |ACOG & USPSTF. |

| |with risk factors of IVDA, |Consider Influenza and |risk comordities (Diabetes, |Pneumococcal vaccine at | | |

| |blood transfusion, health |Pneumococcal if high risk. |CHF, renal or liver disease, |least once. | | |

| |related job, multiple sexual | |resident of chronic care | | | |

| |partners, and household or | |facilities, chronic lung | | | |

| |sexual contact with Hepatitis| |disease). | | | |

| |B carriers. | | | | | |

| | | | | | | |

| |Verify Varicella & MMR at | | | | | |

| |ages 11-12. | | | | | |

| | | | | | | |

| |Rubella at childbearing age | | | | | |

| |if no evidence of immunity. | | | | | |

|SCREENING CATEGORY |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older |Level of Evidence | |

|Dental & Oral Hygiene |Daily brushing with a |Same as 11-18 |Same as 19-39 |Same as 40-64 |A |Recommendations are taken from the ADA,|

| |fluoride-containing | | | | |ACOG, CTF & USPSTF. |

| |toothpaste and flossing. | | | | | |

| | | | | | | |

| |Encourage to see an oral | | | | | |

| |health provider annually for | | | | | |

| |preventative care. | | | | | |

|Injury Prevention |Age-specific safety |Same as 11-18 |Same as 19-39 |Same as 40-64 | |AAFP, ACOG, USPSTF, AMA. |

| |counseling should be provided| | | | | |

| |as part of routine care. |Women should be screened and | |Elderly women should be | | |

| | |counseled on domestic violence | |counseled on measure to | | |

| |The following are recommended|as part of the periodic | |reduce the risk of falls. | | |

| |in order to prevent |evaluation. | |The physical exam should | | |

| |unintentional injuries: | | |include observations that | | |

| |Lap/shoulder belts, | | |my indicate signs of elder| | |

| |bicycle/motorcycle helmets, | | |abuse. | | |

| |smoke & CO detectors, safe | | | | | |

| |storage/removal of firearms, | | |Encourage setting hot | | |

| |infant care seats, | | |water tank at less than | | |

| |back-to-sleep infant | | |120-130 degrees | | |

| |positioning, poison control | | |Fahrenheit. | | |

| |numbers, traffic, sports, and| | | | | |

| |water safety. | | |Encourage CPR training for| | |

| | | | |household members. | | |

|Sexual Behavior |Clinicians should routinely |Counsel on STD prevention and |Same as 19-39 |Counsel on sexuality and | | |

| |counsel adolescents in the |avoiding high-risk sexual | |effects of normal aging. | | |

| |prevention of unintended |behaviors. Counsel on | |Counsel on STD prevention.| | |

| |pregnancies, responsible |responsible reproductive | | | | |

| |sexual behavior, abstinence, |health. | | | | |

| |and education on high-risk | | | | | |

| |behaviors, and STD’s. | | | | | |

|SCREENING CATEGORY |RECOMMENDATIONS BY AGE GROUP |COMMENTS |REFERENCES |

| |Ages 11-18 Years |Ages 19-39 Years |Ages 40-64 Years |Ages 65 & Older |Level of Evidence | |

|Chemo Prevention |Multivitamins with folic acid|Same as 11-18 |Counsel about the |Same as 40-64 |B |ACOG; WHI; ASCO indicate that the |

| |should be taken by women | |benefits/risks of HRT and | | |potential risks of HRT may outweigh |

| |planning pregnancy. |Preventive therapy Tamoxifen |calcium supplements, | |* For Gail Scoring, see |benefits for asymptomatic women. |

| | |should be discussed with women |otherwise same as 19-39. | |.bcra.brc | |

| | |at increased risk* of breast | | | |*Breast cancer risk assessment; high |

| | |cancer ages ≥ 35. | | | |risk Gail Score ≥ 1.66%. |

|Food & Nutrition |Clinicians should routinely |Same as 11- 18 |Same as 19-39 |Same as 40-64 | |USPSTF, ACOG, AAFP. |

| |provide nutritional | | | | | |

| |assessment and counseling. | | | | | |

| | | | | | | |

| |Counsel on the need for a | | | | | |

| |balanced diet that includes a| | | | | |

| |wide variety of foods. | | | | | |

| | | | | | | |

| |Adolescents should be | | | | | |

| |encouraged to follow a diet | | | | | |

| |that will provide adequate | | | | | |

| |calcium and folic acid | | | | | |

| |intake. | | | | | |

| | | | | | | |

| |Adequate dietary intake and | | | | | |

| |nutritional consideration | | | | | |

| |should be discussed for | | | | | |

| |lactating women. | | | | | |

| | | | | | | |

|Exercise |Adolescents should receive |Providers should routinely |Same as 19-39 |Same as 40-64 | | |

| |annual counseling about the |assess activity practices and | | | | |

| |benefits of exercise and |counsel in engaging in a |Women should receive | | | |

| |should be encouraged in safe |program of regular exercise |counseling | | | |

| |exercise on a regular basis. |that is tailored to their |re: weight-bearing exercise | | | |

| | |health status and lifestyle. |to help prevent | | | |

| | | |post-menopausal osteoporosis.| | | |

Abbreviations for Recommending Organizations

AAFP American Academy of Family Physicians

AAO American Academy of Ophthalmologists

AAP American Academy of Pediatrics

ACC American College of Cardiology

ACOG American College of Obstetricians & Gynecologists

ACP American College of Physicians

ACPM American College of Preventive Medicine

ACR American College of Radiologists

ACS American Cancer Society

ADA American Dental Association

AGA American Gastroenterological Association

AHA American Hospital Association

AMA American Medical Association

ASCO American Society of Clinical Oncology

CDC Centers for Disease Control & Prevention

CTEPHE Canadian Task Force on the Pediatric Health Examination

CTF Canadian Task Force

NCEP National Cholesterol Education Program

NCI National Cancer Institute

USPSTF U.S. Preventative Services Taskforce

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