Berek and Novak's Gynecology 15th Ed.

8 Preventive Health Care and Screening

Paula J. Adams Hillard

• Preventive health services that encompass screening and counseling for a broad range of health behaviors and risks are important components of general obstetric and gynecologic care.

• Traditional gynecologic care—including cervical cytology testing, pelvic and breast screening examinations, and the provision of contraceptive services—is considered primary preventive care.

• Routine health care assessments for healthy women include a medical history, physical examination, routine and indicated laboratory studies, assessment and counseling regarding healthy behaviors, and relevant interventions, taking into account the leading causes of morbidity and mortality within different age groups.

• Evidence-based guidelines for the provision of periodic health evaluations, screening, and counseling have been developed by the American College of Obstetricians and Gynecologists (ACOG) and other organizations; these guidelines provide the basis for routine preventive health assessment and screening recommendations.

• Preventive services for adolescents should be based on knowledge of the behavioral and medical health risks that place their future health at risk, including substance use and abuse, sexual behaviors that increase the risks of unintended pregnancy and sexually transmitted diseases (STDs), and impaired mental health.

• Obesity, smoking, and alcohol abuse are preventable problems that have a major impact on long-term health; assessment, counseling, and referral for these health risks is a component of periodic health assessment and primary care.

Although obstetricians-gynecologists have focused on the management of abnormal gynecologic conditions, they also have a traditional role of providing primary and preventive care to women, particularly for women of reproductive age. The obstetrician-gynecologist often serves as a woman’s point of entry into the health care system, her primary care clinician, and a source of continuity of care (1). Primary care emphasizes health maintenance, preventive services, early detection of disease, and availability and continuity of care. The value of preventive services is apparent in such trends as the reduced mortality rate from cervical cancer that resulted, in large part, from the increased use of cervical cytology testing. Neonatal screening for phenylketonuria (PKU) and hypothyroidism are examples of effective mechanisms for prevention of mental retardation. Women often regard their gynecologist as their primary care provider; indeed, many women of reproductive age have no other physician. Obstetricians-gynecologists estimated that at least a third of their nonpregnant patients rely on them for primary care (2). As primary care physicians, obstetricians-gynecologists provide ongoing care for women through all stages of their lives—from reproductive age to postmenopause. In this role, some gynecologists include as a routine part of their practices screening for certain medical conditions, such as hypertension, diabetes mellitus, and thyroid disease, and management of those conditions in the absence of complications.

Some traditional aspects of gynecologic practice, such as family planning and preconception counseling, are recognized as effective preventive health measures, although clear and coherent national guidelines and goals for preventing unintended pregnancies have not been a high priority in the United States (3). Preventive medical services encompass screening and counseling for a broad range of health behaviors and risks, including sexual practices; prevention of sexually transmitted diseases (STDs); use of tobacco, alcohol, and other drugs; diet; and exercise.

The Institute of Medicine defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (4). Integrated care is further defined as being comprehensive, coordinated, and continuous. The definition states that primary care clinicians have the appropriate training to manage most problems that afflict patients (including physical, mental, emotional, and social concerns) and to involve other practitioners for further evaluation or treatment when appropriate. Using data from the National Ambulatory Medical Care Surveys, physician specialty groups were analyzed in a study to determine how well these Institute of Medicine primary care definitions applied to the care delivered by each specialty (5). In this analysis, obstetrics and gynecology as a specialty demonstrated some characteristics of primary care that applied to the traditional specialties of internal medicine, family and general physicians, and pediatrics. As a category, however, obstetrics and gynecology was more closely related to medical and surgical subspecialties (5). This analysis would be accepted by many practicing obstetricians and gynecologists who state that the specialty provides both primary and specialty care.

The Institute of Medicine definition includes referral, coordination, and follow-up care, but specifically does not include the function of “gatekeeper” as essential for a primary care clinician. As the US health care system has evolved, health maintenance organizations and insurers have responded to women’s resolute support of direct access to obstetricians-gynecologists, a concept also strongly supported by the American Congress of Obstetricians and Gynecologists (6).

There is an increasing emphasis on women’s health and gender-specific medicine. Physicians have become more knowledgeable about the differences in pathophysiologic aspects of diseases in women compared with men and thus better equipped to manage them. One example is an increasing emphasis on women’s cardiovascular health with preventive care and screening for risk factors.

Gynecologist as Primary Care Provider

The obstetrician-gynecologist frequently serves as a primary medical resource for women and their families, providing information, guidance, and referrals when appropriate. Routine health care assessments for healthy women are based on age groups and risk factors. Health guidance takes into account the leading causes of morbidity and mortality within different age groups. Patient counseling and education require an ability to assess individual needs, to assess stages of readiness for change, and to use good communication skills, including motivational interviewing to encourage behavioral changes and ongoing care (7). A team approach to care is frequently helpful, utilizing the expertise of medical colleagues, such as nurses; advanced practice nurses, including nurse midwives and nurse practitioners; health educators; other allied health professionals, such as dieticians or physical therapists; relevant social services; and other physician specialists. All clinicians, regardless of the extent of their training, have limitations to their knowledge and skills and should seek consultation at appropriate times for the benefit of their patients in providing both reproductive and nonreproductive care.

The National Ambulatory Care Surveys from the Centers for Disease Control and Prevention include obstetrician-gynecologists among primary care specialties as opposed to medical or surgical subspecialties (8). Women’s needs for primary care vary across their lifespan. One survey of women’s satisfaction with primary care found that women in their early reproductive years (ages 18–34) were more satisfied with care coordination and comprehensiveness when their regular provider was a reproductive health specialist, primarily an obstetrician-gynecologist physician as compared to a generalist, a generalist clinician plus an obstetrician-gynecologist, or no regular provider (9). The scope of services provided by obstetricians-gynecologists varies from one practice or clinician to another and may include more or fewer aspects of well-woman and reproductive health care. It is important to establish with each patient whether she has a primary care clinician and who will be providing primary care and preventive health services (1).

Guidelines for primary and preventive services are issued by a number of medical bodies including the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the U.S. Preventive Services Task Force (USPSTF), and the American Medical Association (1,10–14). The guidelines from various organizations differ somewhat in their specific details, and a national guideline clearinghouse for evidence-based clinical practice guidelines, sponsored by the Agency for Healthcare Research and Quality (AHRQ), is available to provide comparisons between guidelines for a given medical condition or intervention (15).

In 2006 in the United States, there were approximately 660 million visits by women to ambulatory medical care providers (16). In the past, approximately eighteen percent of the visits were made to gynecologists (17). Less than a third of ambulatory visits were made by individuals between the ages of 15 and 44 years, and this percentage is declining with an aging population (16). Normal pregnancy and gynecologic examination were among the most common reasons for care.

When asked to characterize the nature of an office or clinic visit, obstetricians-gynecologists may or may not identify themselves as primary care providers, depending on a number of variables (18). Those variables may include the patient’s age, pregnancy status, whether it is a new versus a return visit, the diagnosis, insurance or referral status, and even geographic practice region. Primary and preventive services clearly within the realm of obstetricians and gynecologists include cervical cytology testing, pelvic examination and breast examination, and family planning services including contraception. When compared with other physicians, obstetricians-gynecologists are more likely than other physicians to perform cervical cytology testing, pelvic examination, and breast examination.

Approaches to Preventive Care

In health care, the focus is shifting from disease to prevention. Efforts are under way to promote effective screening measures that can have a beneficial effect on public and individual health. Following is a brief description of programs developed by American College of Obstetricians and Gynecologists (ACOG), the USPSTF, and the American Medical Association to provide guidelines for preventive care.

Guidelines for Primary and Preventive Care

The initial evaluation of a patient involves a complete history, physical examination, routine and indicated laboratory studies, evaluation and counseling, appropriate immunizations, and relevant interventions. Risk factors should be identified and arrangements should be made for continuing care or referral, as needed. The ACOG recommendations for periodic evaluation, screening, and counseling by age groups, and the leading causes of death and morbidity within different age groups are shown inTables 8.1 through 8.4 (10). These tables include recommendations for patients who have high-risk factors that require targeted screening or treatment; patients should be made aware of any high-risk conditions that require more specific screening or treatment (Table 8.5). Recommendations for immunizations, indicated according to age group, are available from the U.S. Centers for Disease Control and Prevention (CDC). The CDC recommends HIV screening for pregnant women, adults, and adolescent patients in all health care settings after the patient is notified that testing will be performed, unless the patient declines (opt-out screening) (19). Subsequent care should follow a specific schedule, yearly or as appropriate, based on the patient’s needs and age.

Table 8.1 Periodic Assessment Ages 13--18 Years

Guide to Clinical Preventive Services

The USPSTF was commissioned in 1984 as a 20-member nongovernmental panel of experts in primary care medicine, epidemiology, and public health. The USPSTF, comprising primary care providers, now includes nonfederal experts in prevention and evidence-based medicine (such as internists, pediatricians, family physicians, gynecologists-obstetricians, nurses, and health behavior specialists); the task force conducts and publishes scientific evidence reviews on a variety of preventive health services with administrative and research support from the AHRQ. Initial and subsequent reviews and recommendations are being revised and periodically released on the Web site sponsored by the AHRQ (15). The charge to the panel was to develop recommendations for the appropriate use of preventive interventions based on a systematic review of evidence of clinical effectiveness. The panel was asked to rigorously evaluate clinical research to assess the merits of preventive measures, including screening tests, counseling, immunizations, and medications.

Table 8.2 Periodic Assessment Ages 19–39 Years

The task force uses systematic reviews of the evidence on specific topics in clinical prevention that serve as the scientific basis for recommendations. The task force reviews the evidence, estimates the magnitude of benefits and harms, reaches consensus about the net benefit of a given preventive service, and issues a recommendation that is assigned a grade from “A” (strongly recommends), to “B” (recommends), “C” (no recommendations for or against), “D” (recommends against), to “I” (insufficient evidence to recommend for or against) (Table 8.6). The grading system includes suggestions for practice, recommending that the service should be provided, discouraged, or that the uncertainty about the balance of benefits versus harms should be discussed. The levels of certainty regarding net benefit are ranked from high to moderate to low. The task force evaluates services based on age, gender, and risk factors for disease, making recommendations about which preventive services should be included in routine primary care for which populations. Primary preventive measures are those that involve intervention before the disease develops, for example, quitting smoking, increasing physical activity, eating a healthy diet, quitting alcohol and other drug use, using seat belts, and receiving immunizations. Secondary preventive measures are those used to identify and treat asymptomatic persons who have risk factors or preclinical disease but in whom the disease itself has not become clinically apparent. Examples of secondary preventive measures are well known in gynecology, such as screening mammography and cervical cytology testing.

Table 8.3 Periodic Assessment Ages 40–64 Years

Table 8.4 Periodic Assessment Ages 65 and Older

The USPSTF is supported by an Evidence-Based Practice Center (EPC), which conducts systematic reviews of the evidence that serve as the scientific basis for USPSTF recommendations. These reviews analyze the effectiveness of various screening measures and tests. Preventive medicine and the discipline of evidence-based medicine have grown and evolved since the release of the first Guide to Clinical and Preventive Services in 1989. This document accelerated the trend to replace consensus or expert opinion in clinical recommendations with a more systematic and explicit review of the evidence. The USPSTF has recognized that scientific evidence, including evidence derived from a variety of research designs other than randomized clinical trials, does not permit “even moderated certainty” about the net benefit of the preventive service. The role of judgment in the domains of the potential preventable burden of suffering from the condition, the potential harm of the intervention, the cost, the context of current practice, and the potential role of other domains are recognized by the task force, with the conclusion that “decision making under conditions of uncertainty is a recurring issue in medicine” (20).

Table 8.5 High-Risk Factors

Table 8.6 U.S. Preventive Services Task Force Ratings

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms). After May 2007, updated definitions of the grades it assigns to recommendations are noted below with “suggestions for practice” with each grade (50).
Grade	Definition	Suggestions for Practice
A	The USPSTF recommends the service. There is high certainty that the net benefit is substantial.	Offer or provide this service
B	The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.	Offer or provide this service
C	The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.	Offer or provide this service only if other considerations support the offering or providing the service in an individual patient
D	The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.	Discourage the use of this service
I Statement	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.	Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

International efforts to categorize the effectiveness of treatments include the Cochrane Library, which produces and disseminates high-quality systematic reviews of health care interventions. These reviews and abstracts are published monthly and are available online and on DVDs by subscription (21). The Cochrane Library provides searchable databases online and through institutional purchase of licenses. Evidence-based guidelines are published in journals available in print and online by discipline (i.e., medicine, mental health, and nursing). Another source of evidence-based information is Clinical Evidence, a subscription service published by the British Medical Journal in print, via PDA, and online (22). This service describes its content as driven by important clinical questions rather than by the availability of research evidence. The advantages of Web-based sites are the ease of updating and the availability of evidence to clinicians in clinical practice sites throughout the world. Other Web sites that provide tools and information about evidence-based health care include the Oxford Centre for Evidence-Based Medicine, the Database of Abstracts of Reviews of Effects (DARE), and the American College of Physicians (ACP) Journal Club (23–25).

Guidelines for Adolescent Preventive Services

Around the same time that clinicians were evaluating the primary health care needs of adults, clinicians who practice adolescent medicine (with backgrounds in pediatrics, internal medicine, family medicine, gynecology, nursing, psychology, nutrition, and other professions) recognized that the guidelines for adult and pediatric health services did not always fit the needs and health risks of adolescence. Neither the ACOG Guidelines for Primary Preventive Care nor the USPSTF recommendations is sufficiently comprehensive or focused on this age group, although both documents include many important aspects of adolescent health care (10,13). The American Medical Association, with the assistance of a national scientific advisory board, developed the Guidelines for Adolescent Preventive Services (GAPS) in response to this perceived need for recommendations for delivering comprehensive adolescent preventive services (13,14,26).

Obstetricians-gynecologists typically see adolescents in crisis to provide care for unintended pregnancies or STDs, including pelvic inflammatory disease. The urgency for preventing these crises is evident. The GAPS report extends the framework of services provided to adolescents. The impetus for developing GAPS was the belief that a fundamental change in the delivery of adolescent health services was necessary. This concept is strongly supported by the Society for Adolescent Medicine, the American Academy of Pediatrics, and the American Academy of Family Physicians (27). Gynecologists could easily provide most, if not all, of the recommended services. The American College of Obstetricians and Gynecologists developed a “Tool Kit” on primary and preventive health care for female adolescents in recognition of the needs of this population, and recommended that the “first visit to the obstetrician-gynecologist for health guidance, screening, and the provision of preventive health care services should take place between the ages of 13 years and 15 years” (28,29). Subsequent annual visits are recommended by ACOG to provide preventive guidance and services including contraception and STD treatment as required. The guidelines and recommendations for adolescent health care address the delivery of health care, focus on the use of health guidance to promote the health and well-being of adolescents and their families, promote the use of screening to identify conditions that occur relatively frequently in adolescents and cause significant suffering either during adolescence or later in life, and provide guidelines for immunizations for the primary prevention of specific infectious diseases. Considerable barriers exist to adolescents' accessing these services, including barriers inherent in the US health care system and legal barriers (30).

The recommendations for adolescent preventive services stem from the conclusion that the current health threats to adolescents are predominantly behavioral rather than biomedical, that more of today’s adolescents are involved in behaviors with the potential for serious health consequences, that adolescents are involved in health-risk behaviors at younger ages than previous generations, that many adolescents engage in multiple health-risk behaviors, and that most adolescents engage in at least some type of behavior that threatens their health and well-being (26). Gynecologists are in a good position to detect high-risk behaviors and to determine whether multiple risk-taking behaviors exist; for example, the early initiation of sexual activity and unsafe sexual practices are associated with substance use(30,31). Adolescents who are sexually active are much more likely than are adolescents who are not sexually active to have used alcohol (6.3 times greater risk), to have used drugs other than marijuana (four times greater risk), and to have been a passenger in a motor vehicle with a driver who was using drugs (nearly 10 times greater risk) (32). Thus, by being aware of comorbidities, gynecologists can screen for these behaviors and potentially intervene before serious harmful health consequences occur. In recognition of the role that obstetricians-gynecologists could play in providing preventive services for adolescents, ACOG issued guidelines that suggest an initial visit (not necessarily including gynecologic examination) to the obstetrician-gynecologist for health guidance, screening, and the provision of preventive health care service between the ages of 13 and 15 years and subsequent annual preventive health care visits (29).

Counseling for Health Maintenance

During periodic assessments, patients should be counseled about preventive care based on their age and risk factors. Obesity, smoking, and alcohol abuse are associated with preventable problems that can have major long-term impacts on health. Patients should be counseled about smoking cessation and moderation in alcohol use and directed to appropriate community resources as necessary. Positive health behaviors, such as eating a healthy diet and engaging in regular exercise, should be reinforced. Adjustments may be necessary based on the presence of risk factors and the woman’s current lifestyle and condition. Efforts should focus on weight control, cardiovascular fitness, and reduction of risk factors associated with cardiovascular disease and diabetes (1).

Nutrition

Patients should be given general nutritional information and referred to other professionals if they have special needs (1). Assessment of the patient’s body mass index (BMI; weight [in kilograms] divided by height [in meters] squared [kilograms per square meter]) will give valuable information about the patient’s nutritional status. Tables and methods to calculate BMI are available in print and electronic resources. Patients who are 20% above or below the normal range require evaluation and counseling and should be assessed for systemic disease or an eating disorder. Of adult women in the United States, 64% are overweight (BMI 25.0–29.9) or obese (BMI ≥30) 36% are obese (33,34). Overweight and obesity substantially increase the risk of morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and cancers of the endometrium, breast, and colon (35). ACOG has emphasized the role of the obstetrician-gynecologist in the assessment and management of obesity (36).

Central obesity—measured as waist-to-hip ratio—is an independent risk factor for disease. Women with a waist circumference greater than 35 inches are at higher risk of diabetes, dyslipidemia, hypertension, and cardiovascular disease (37). Metabolic syndrome is a complication of obesity that, while somewhat variably defined, includes a clustering of atherogenic dyslipidemia, elevated blood pressure, elevated plasma glucose, and abdominal obesity and confers an increased risk for cardiovascular disease and diabetes (38). One-third to one-half of premenopausal women with polycystic ovarian syndrome (PCOS) meet the criteria for metabolic syndrome (39).

Key nutritional recommendations were issued by the Dietary Guidelines Advisory Committee to the U.S. Department of Agriculture (40). These recommendations are included in the MyPlate 2010 Guidelines, which has an emphasis on fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products (Fig. 8.1) (41). The guidelines include recommendations to balance food and physical activity and stay within daily calorie requirements.

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Figure 8.1 MyPlate Icon. This is a new communications initiative based on 2010 Dietary Guidelines for Americans, replacing the Food Pyramid. It is designed to remind Americans to eat healthfully, and illustrates the five food groups using a familiar the familiar mealtime visual of a place setting. (From the United States Department of Agriculture, http://www.ChoseMyPlate.gov)

Fiber content of the diet is being studied for its potential role in the prevention of several disorders, particularly colon cancer. It is recommended that the average diet for women contain 25 g of fiber per day (40). Whole-grain foods, and vegetables, citrus fruits, and some legumes, are high in fiber and are emphasized in the guidelines for healthy foods.

Adequate calcium intake is important in the prevention of osteoporosis. A postmenopausal woman should ingest 1,500 mg per day. Adolescents require 1,300 mg per day. Because it may be difficult to ingest an adequate amount of calcium daily in an average diet, supplements may be required.

The U.S. Public Health Service has recommended that women of reproductive age who are capable of becoming pregnant take supplemental folic acid (0.4 mg daily) to help prevent neural tube defects in their infants.Surveys indicate that in 2007, 40% of women of childbearing age consumed a supplement, a percentage that is only half of the Healthy people 2010 objective of 80% (42). Women who are contemplating pregnancy should be counseled about the risk of fetal neural tube defects and the role of folic acid supplementation prior to conception in their prevention (43).

Alcohol

Alcoholic beverages should be limited to one drink per day for women (40). A simple device called the T-ACE questionnaire (Tolerance; been Annoyed by criticism of drinking; felt need to Cut down; need for Eye-opener) can be used to elicit information about alcohol use and identify problem drinkers (44). Women should be questioned in a nonjudgmental fashion about their alcohol use and directed to counseling services as required.

Exercise

Exercise can help control or prevent hypertension, diabetes mellitus, hypercholesterolemia, and cardiovascular disease and helps to promote overall good health, psychological well-being, and a healthy body weight. Moderate exercise along with calcium supplementation can help retard bone loss in postmenopausal women. During early menopause, weight-bearing exercise alone is not sufficient to prevent bone loss, although it will slow the rate of bone loss (45). Exercise helps promote weight loss, strength and fitness, and stress reduction. Federal exercise guidelines from the U.S. Department of Health and Human Services note that “regular physical activity reduces the risk of many adverse health outcomes; some physical activity is better than none; for most health outcomes, additional benefits occur as the amount of physical activity increases through higher intensity, greater frequency, and/or longer duration; most health benefits occur with at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity physical activity, such as brisk walking. Additional benefits occur with more physical activity; both aerobic (endurance) and muscle-strengthening (resistance) physical activity are beneficial; health benefits occur for children and adolescents, young and middle-aged adults, older adults, and those in every studied racial and ethnic group; the health benefits of physical activity occur for people with disabilities; and the benefits of physical activity far outweigh the possibility of adverse outcomes” (46). To sustain weight loss in adulthood, 60 to 90 minutes of daily moderate-intensity physical activity are recommended. Cardiovascular conditioning, stretching exercises for flexibility, resistance exercises, or calisthenics for muscle strength and endurance are recommended for most people. Most healthy adults do not need to see a physician before starting a moderate-intensity exercise program, although those with chronic diseases and women over 50 who plan a vigorous program have been advised to do so (40). Women should be counseled about safety guidelines for exercise. Factors that should be considered in establishing an exercise program include medical limitations, such as obesity or arthritis, and careful selection of activities that promote health and enhance compliance (1).

Cardiovascular fitness can be evaluated by measurement of heart rate during exercise. As conditioning improves, the heart rate stabilizes at a fixed level. The heart rate at which conditioning will develop is called the target heart rate (1). The traditional formula for calculating the target heart rate is 220 minus the patient’s age times 0.75. A 2010 study examined the definition of a normal heart rate response to exercise stress testing in women and noted that the traditional male-based calculation of target heart rate may not be appropriate for women (47). The new formula for target heart rate, based on this research, is 206 minus the patient’s age times 0.88.

Smoking Cessation

Smoking is a major cause of preventable illness, and every opportunity should be taken to encourage patients who smoke to quit. Patient education about the benefits of smoking cessation, clear advice to quit smoking, and physician support improve smoking cessation rates, although 95% of smokers who successfully quit do so on their own. Self-help materials are available from the National Cancer Institute, and community-based support groups and local chapters of the American Cancer Society and the American Lung Association. The combination of counseling and medication (nicotine and nonnicotine options) is more effective than either used alone, and Clinical Practice Guidelines on treating tobacco use and dependence from the U.S. Department of Health and Human Services provide recommendations (48).

The “5 As”—Ask, Advise, Assess, Assist, and Arrange—are designed to be used with smokers who are willing to quit (49). The Assist component typically includes first-line pharmacotherapy with bupropionor nicotine replacement in the form of gum, inhaler, nasal spray, or patch. In addition, ongoing visits for counseling and support are essential and may include practical counseling and assistance with problem-solving skills and social support during and after treatment. Relapse prevention is important, with congratulations for any successes and encouragement to remain abstinent. Patients who use tobacco but are unwilling to quit at the time of the visit should be treated with the “5 Rs” motivational intervention: Relevance, Risks, Rewards, Roadblocks, and Repetition (48).

References

1. ACOG Editorial Committee for Guidelines for Women’s Health Care. Guidelines for women’s health care: a resource manual. 3rd ed. Washington, DC: ACOG, 2007:573.

2. Coleman VH, Laube DW, Hale RW, et al. Obstetrician-gynecologists and primary care: training during obstetrics-gynecology residency and current practice patterns. Acad Med 2007;82:602–607.

3. Taylor D, Levi A, Simmonds K. Reframing unintended pregnancy prevention: a public health model. Contraception 2010;81:363–366.

Donaldson M, Yordy N, Vanselow N, eds. Defining primary care: an interim report. Institute of Medicine. Washington, DC: National Academy Press, 1994.

5. Franks P, Clancy CM, Nutting PA. Defining primary care. Empirical analysis of the National Ambulatory Medical Care Survey. Med Care 1997;35:655–668.

6. American College of Obstetricians and Gynecologists. ACOG Legislative Priorities. ACOG, 2011. Available at http://www.acog.org/departments/dept_web.cfm?recno = 44

7. ACOG Committee. ACOG Committee Opinion No. 423: motivational interviewing: a tool for behavioral change. Obstet Gynecol 2009; 113:243–246.

8. Hing E, Burt CW. Characteristics of office-based physicians and ther practices: United States, 2003–04. Hyattsville, MD: National Center for Health Statistics, 2007.

9. Henderson JT, Weisman CS. Women’s patterns of provider use across the lifespan and satisfaction with primary care coordination and comprehensiveness. Med Care 2005;43:826–833.

10. ACOG Committee. ACOG Committee Opinion No. 452: Primary and preventive care: periodic assessments. Obstet Gynecol 2009;114:1444–1451.

11. American College of Obstetricians and Gynecologists. Primary and preventive health care for female adolescents. In: Health care for adolescents. Washington, DC: American College of Obstetricians and Gynecologists, 2003:1–24.

12. American Academy of Family Physicians. Summary of recommendations for clinical preventive services. 2010. Available online from: http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/CPS/rcps08–2005.Par.0001.File.tmp/February2011CPS03142011.pdf.

13. U.S. Preventive Services Task Force. Recommendations for adults. 2010. Available online at: http://www.ahrq.gov/clinic/uspstfix.htm

14. American Medical Association. Guidelines for adolescent preventive services (GAPS). Chicago, IL: American Medical Association, 1997:8.

15. Agency for Healthcare Research and Quality. National guideline clearinghouse. 2010. Available online at: htp://www.guideline.gov.

16. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report 2008;8:1–29.

17. Brett KM, Burt CW. Utilization of ambulatory medical care by women: United States, 1997–98. Atlanta: U.S. Centers for Disease Control, 2001:1–17.

Scholle SH, Chang J, Harman J, et al. Characteristics of patients seen and services provided in primary care visits in obstetrics/gynecology: data from NAMCS and NHAMCS. Am J Obstet Gynecol 2004;190:1119–1127.

Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55[RR14]:1–17.

Petitti DB, Teutsch SM, Barton MB, et al. Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med 2009;150:199–205.

21. The Cochrane Collaboration. The Cochrane Library. 2010. Available online at: http://www.thecochranelibrary.com

22. British Medical Journal. Clinical evidence. 2010. Available online at: http://www.clinicalevidence.bmj.com

23. University of Oxford. Oxford Centre for Evidence Based Medicine. 2010. [Aim to develop, teach and promote evidence-based health care and provide support and resources ot doctors and health care professionals to help maintain the highest standards of medicine]. Available online at: http://www.cebm.net/

24. Centre for Reviews and Dissemination. Database of abstracts of reviews of effects (DARE). 2010. [Contains 15,000 abstracts of systematic reviews including over 6000 quality assessed reviews and details of all Cochrane reviews and protocols. The database focuses on the effects of interventions used in health and social care.] Available online at: http://www.crd.york.ac.uk/crdweb/Home.aspx?DB=DARE

25. American College of Physicians. ACP Journal Club. 2010. [Quality-assessed, clinically rated original studies and reviews from over 130 clinical journals.] Available online at: http://www.acpjc.org/

26. Elster AB, Kuznets NJ. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore: Williams & Wilkins, 1994:1–191.

Rosen DS, Elster A, Hedberg V, et al. Clinical preventive services for adolescents: Position paper of the society for adolescent medicine. J Adolesc Health 1997;21:203–214.

28. American College of Obstetricians and Gynecologists. Tool kit for teen care. Washington, DC: ACOG, 2010.

29. ACOG Committee on Adolescent Health Care. The initial reproductive health visit. Committee Opinion. Washington, DC: ACOG, 2010.

30. English A, Ford CA, Santelli JS. Clinical preventive services for adolescents: position paper of the Society for Adolescent Medicine. Am J Law Med 2009;35:351–364.

31. Zabin LS, Hardy JB, Smith EA, et al. Substance use and its relation to sexual activity among inner-city adolescents. J Adolesc Health Care 1986;7:320–331.

32. Orr DP, Beiter M, Ingersoll G. Premature sexual activity as an indicator of psychosocial risk. Pediatrics 1991;87:141–147.

Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010;303:235–241.

34. Centers for Disease Control and Prevention. Vital signs: state-specific obesity prevalence among adults—United States, 2009. MMWR Morb Mortal Wkly Rep 2010;59:951–955.

Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003;289:76–79.

36. ACOG Committee. ACOG Committee Opinion No. 319, October 2005. The role of obstetrician-gynecologist in the assessment and management of obesity. Obstet Gynecol 2005;106:895–899.

37. National Heart, Lung, and Blood Institute Obesity Education Initiative. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. Obesity Education Initiative 2000. Available online at: http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm

Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;120:1640–1645.

39. Essah PA, Wickham EP, Nestler JE. The metabolic syndrome in polycystic ovary syndrome. Clin Obstet Gynecol 2007;50:205–225.

40. U.S. Department of Agriculture. Dietary guidelines for Americans. 2005. Available online at: http://www.health.gov/dietaryguidelines

41. U.S. Department of Agriculture. My pyramid. 2005. Available online at: http://www.mypyramid.gov

42. Centers for Disease Control and Prevention. Use of supplements containing folic acid among women of childbearing age—United States, 2007. MMWR Morb Mortal Wkly Rep 2008;57:5–8.

43. ACOG Committee. ACOG Committee Opinion No. 313: the importance of preconception care in the continuum of women’s health care. Obstet Gynecol 2005;106:665–666.

44. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol 1989;160:865.

45. American College of Obstetricians and Gynecologists. Osteoporosis. Washington, DC: American College of Obstetricians and Gynecologists, 2004.

46. U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services, 2008:76.

Gulati M, Shaw LJ, Thisted RA, et al. Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project. Circulation 2010;122:130–137.

Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. In: Clinical practice guideline. Washington, DC: U.S. Department of Health and Human Services, 2008. Available online at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf.

49. Agency for Healthcare Research and Quality. Five major steps to intervention (the “5A’s”). Available online at: http://www.ahrq.gov/clinic/tobacco/5steps/htm

50. U.S. Preventive Services Task Force. U.S. preventive services task force grade definitions and levels of certainty regarding net benefit. 2008. Available online at: http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm