Name of the Procedure:

Annual Gynecological Examination, Established Patient (S0612)

• Common names: Annual Women's Health Exam, Well-Woman Exam
• Medical terms: Gynecological Examination, Preventive Gynecological Screening

Summary

An annual gynecological examination is a routine check-up designed to assess a woman's reproductive health. It includes a physical examination of the reproductive organs, breast examination, and discussion of any health concerns or symptoms. For patients who have undergone this exam before, it serves as an essential preventive care measure.

Purpose

• Address and monitor reproductive health concerns.
• Screen for gynecological cancers such as cervical, ovarian, and breast cancer.
• Evaluate and manage menstrual health, fertility, and menopause-related issues.
• Discuss and update contraception methods.
• Promote overall well-being by catching potential health issues early.

Indications

• Routine preventive care for women aged 18 and older or those who are sexually active.
• Monitoring ongoing reproductive health issues (e.g., irregular periods, abnormal discharge, pelvic pain).
• Following up on past gynecological conditions or treatments.
• Evaluating new symptoms relevant to reproductive health.

Preparation

• Schedule the exam when not menstruating for better accuracy.
• Empty the bladder before the exam.
• Keep a record of menstrual cycles, and any symptoms or health changes.
• Avoid douching or using vaginal medications 24-48 hours before the exam.
• Bring a list of current medications and any health history.

Procedure Description

1. The healthcare provider will review the patient's medical history and discuss any concerns.
2. A physical examination will be conducted, which includes:
   • Breast examination for lumps or abnormalities.
   • Pelvic examination where the provider inspects the external genitalia, and uses a speculum to view the vagina and cervix.
   • Performing a Pap smear to collect cells from the cervix if it’s due.
   • Bimanual examination to check the uterus and ovaries for size, shape, and mobility.
3. Other tests or screenings may be recommended based on age and medical history.

Tools/Equipment: Examination table, speculum, gloves, lubricant, cervical brush/spatula, slides for Pap smear.

Anesthesia/Sedation: Typically, no anesthesia or sedation is needed.

Duration

The entire appointment usually lasts about 30 minutes to 1 hour.

Setting

Performed in a clinic, outpatient healthcare facility, or doctor's office.

Personnel

• Gynecologist or primary care physician.
• Nurse or medical assistant.

Risks and Complications

• Minor discomfort or pain during the pelvic exam.
• Rarely, light spotting or cramping after a Pap smear.
• Potential for emotional discomfort or anxiety.

Benefits

• Early detection of cancers and other gynecological conditions.
• Better management of reproductive and overall health.
• Personalized health advice and update on preventive measures like vaccines (e.g., HPV).

Recovery

• Patients can resume normal activities immediately after the exam.
• Follow-up based on test results or if any issues were detected.
• Recommended to return for annual examinations unless advised otherwise.

Alternatives

• Self-examinations for breast health, though less comprehensive.
• Scheduled Pap smears and STI screenings as needed, without a full annual exam.

Patient Experience

During the exam, patients may feel slight discomfort during the speculum insertion and Pap smear, but it is usually quick. Providers strive to make the experience as comfortable as possible. Open communication with the healthcare provider can ease anxiety and ensure a more comfortable experience. Pain management usually involves just relaxation techniques, as the procedure is minimally invasive.