Recently revised guidelines say that women don't need to get Pap tests every year anymore. But a group of doctors says that women do need an annual exam. The advice comes from the American College of Obstetricians and Gynecologists. These doctors are often called ob-gyns. A committee of the college says that women should have an annual "well-woman" visit with their ob-gyn. After age 21, the group says, this visit should include a pelvic exam. This is an internal and external exam of female organs. Pap tests may be included in some years, depending on age and risk level. For women 40 and older, the visit should include a breast exam, the group says. These exams may be done every 1 to 3 years for younger women. Tests for sexually transmitted diseases may be done. The ob-gyn group also says doctors should talk to women about healthy lifestyle, take a blood pressure reading and measure weight and height. The journal Obstetrics and Gynecology published the advice. HealthDay News wrote about it July 24.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

The American College of Obstetricians and Gynecologists says that all women should have a yearly exam with their ob-gyn. I am very surprised by this advice. It's a poor use of resources for two reasons.

• Annual physicals are a thing of the past without evidence to support their benefit.
• Even if a yearly physical for women had any proof of health benefit, any primary care health professional could do it. Family doctors, internists, nurse practitioners and physician assistants regularly perform female exams. Ob-gyns don't have to do them.

The American Medical Association first proposed an annual physical for healthy people 90 years ago. It became part of American culture.

In the 1970s, the Kaiser Permanente health plan designed a study to look at the effectiveness of yearly check-ups. The plan offered all members a free complete physical and a large panel of tests yearly. Kaiser researchers examined the outcome for people who took part in the program. The exams did not improve health outcomes or prevent disease.

Forty years later, we still have no evidence that the yearly check-up leads to better quality of life or longer survival. Yet the Committee of Gynecologic Practice recommends this relic. The latest advice appears in the August issue of the journal Obstetrics and Gynecology.

The annual physical historically includes the collecting of a standard set of information. It is based on standard questions, measurements and examination of body parts. It is costly and time-consuming for the patient and the health practitioner.

The committee members themselves acknowledge the lack of evidence for performing yearly pelvic exams on women with no symptoms and no special risks for genital or pelvic problems. They recommend it anyway. But they do state that doing a pelvic exam should be a shared decision after a discussion of the potential benefits. The reality is that it's quicker for the health professional to do the exam than it is to have an informed discussion.

During routine physicals, health professionals perform the same tasks on everyone. Then they repeat this yearly. This is clearly not very effective. Instead, health promotion and prevention should reflect the needs of each person. And the only tasks performed should be supported with medical evidence that shows benefit.

What Changes Can I Make Now?

Here's my alternative to the annual physical. At least once a year, ask yourself the following questions:

• Are my lifestyle choices the best ones to keep me healthy and help prevent certain diseases?
• For my sex and age, have I had the appropriate screening tests within the recommended time intervals?
• Does my family medical history put me at increased risk of any diseases?
• Are my shots up to date?

Here are some of the lifestyle choices known to promote better health:

• Don't smoke.
• Don't have more than an average of two alcoholic drinks per day for men or one drink per day for women. Also, avoid binge drinking.
• Maintain a healthy weight, or lose weight if needed.
• Eat a diet rich in fruits and vegetables with minimal amounts of saturated fat and sugar.
• Stay physically active, with at least 150 minutes per week of dedicated exercise time.

General screening tests include:

• Blood pressure
• Height and weight to calculate body mass index (BMI)
• Waist size (measured at the navel)
• Lipid profile (total cholesterol, LDL and HDL cholesterol, triglycerides)
• Blood sugar test

Cancer screening tests include:

• Screening for colon polyps and cancer after age 50
• Regular Pap smears -- usually once every 3 years for women at average risk of cervical cancer
• Mammograms -- every 1 to 2 years for women ages 50 through 74. Some experts suggest doing this test yearly, starting at age 40.

Know as much as you can about your family medical history.

If you are not sure about what shots you have had and what you may need, call or e-mail your doctor's office.

Write down your answers to the questions above. Now you are ready for a visit with your primary care doctor, nurse practitioner or physician assistant. The visit will focus on what needs to be done for you personally. And the time can be used to address any lifestyle issues that are a struggle for you.

What Can I Expect Looking to the Future?

The annual physical will be relegated to medical history. Staying healthy and preventing disease must be tailored to fit the needs and desires of each person.