It may sound like a silly question to some. But when I recently sat down to watch Hoda and Jenna on The Today Show discuss annual physicals with their inhouse medical expert, I had a classic ‘Wait, what?!’ moment…
The doctor first listed what to discuss at your PCP annual (Check! I’d just had mine in person after a zoom version in 2020) and then went on to describe what should be checked at your OB-GYN annual physical.
It quickly dawned on me that the last time I remember seeing an OB-GYN was when I gave birth to my youngest daughter eight years ago. And she was great. So relatable and personable as she guided me smoothly through my ‘geriatric’ pregnancy, while calming any fears I had of being pregnant at the grand old age of 42.
I remember going for a follow up post-birth but because all was good ‘down there’, I never saw or heard from Dr. Miller again. I remember thinking that I was actually going to miss her. I also assumed this was all totally normal. After all, don’t you only see an OB-GYN when you are referred by your PCP for a related problem? I have my Pap smear done by my PCP doctor but was I missing something important?
The show didn’t mention any particular ages of women but considering things start deteriorating somewhat with age, I could only assume as a 50 year old, I was missing something by not having a specific check up by an OB-GYN. I have both breast cancer and ovarian cancer in my family and worry set in. Was I missing out on important tests?
I spoke with Dr Kathryn Macaulay, Professor of Obstetrics, Gynecology, and Reproductive Sciences at UC San Diego Health, to get the facts…
Should all women have an annual physical with OB-GYN? If not, at what age do you recommend women start having one?
All women should have an annual exam but whether they choose to have that with an OB-GYN or their PCP is a choice each woman can make. Most insurers in the US will cover both annuals as a preventative care offering. Studies show that women tend to choose their OB-GYN to do it because they have more women’s health related specialized questions like about contraception, or if they have family history of gynecological cancers. Many women also may have a male PCP but want a female OB-GYN for the internal exams, so different factors weigh in.
Other things that impact if women have an OB-GYN annual physical is if they are due to have Pap smears or HPV testing. A Pap smear is what most women link with an OB-GYN visit, so many think ‘why come every year if I don’t need a Pap test?’ It’s a challenge to educate women because the testing guidelines have changed so much.
How do you mean?
The guidelines for screening for cervical cancer with Pap smears and HPV testing have changed and evolved over the last 10 years. This is due to advancements in technology and our ability to screen for HPV, which is a more sensitive indicator for the risk for pre-cancer of the cervix compared to just looking at the cells from the cervix in the old-fashioned Pap smear.
Now that we do HPV testing, we can extend the interval between Pap smears in women over the age of 30 if they’re low risk. But I still like to see patients annually. and the burden fell on the doctors to inform the women I feel robotic about the new guidelines.
What else do you check for in an annual physical?
Regularity of periods, monitoring with contraception, STD screenings. We also screen for depression, and smoking and alcohol abuse, so it’s a general preventative care visit. But we don’t do other parts of the body outside the pelvic area, for things like sinuses or shoulder pain.
I haven’t seen an OB-GYN at all since giving birth 8 years ago. Is that normal?
It differs. Your PCP should keep track of when your Pap smear is due but some providers will have nurse practitioners who can do the screenings rather than the doctor. Check your healthcare plan and follow their recommendations on your online portal.
So it’s an and/or?
I would do both physicals if you have the resources to do so. I don’t run to my gyno with back pain! As you get older you also need screening for cardiovascular disease. With pelvic exams, if you’re asymptomatic and you have a good relationship with your PCP and feel comfortable having it done by them that’s reasonable too.
What does a pelvic exam entail? And what red flags are you looking for?
A pelvic exam is a speculum exam. A speculum is a device we put in the vagina to open up the vaginal walls so we can see the cervix, which is at the mouth of the uterus. We look at the outside labia, vulva and vaginal opening first and then put the speculum inside the vagina to look at the cervix and vaginal walls. Whether we collect other tests during that exam depends on whether you have symptoms or whether you’re due for a cervical cancer screening. We then take the speculum out and the second part of the exam is an internal bimanual exam. This is where we put two fingers (generally) in the vagina and place the other hand on the outside of the pelvis, on the skin. In-between the two hands we’re trying to feel the pelvic organs – the uterus, fallopian tubes and ovaries, and check that they’re the normal size and that there’s no excess pain or tenderness during the exam or feeling of any masses.
Does the pelvic exam need to be performed at every annual visit?
No. With an asymptomatic woman it’s not a very useful exam if she’s not feeling any problems. Discuss it with your doctor. Some women find the exams painful so it should be a shared decision between doctor and patient. But make sure to come in every year and decide during the discussion.
What are warning signs that you should have a pelvic exam?
If you’re due for a Pap smear or are having any symptoms indicating vaginal infection or an STD, and if you’re having abnormal periods or irregular bleeding, or any pelvic pain. There’s a big misconception that a pelvic exam is a Pap smear. It’s not.
How is a breast exam performed?
During a clinical breast exam, the patient lies on the bed with one arm above her head and the doctor palpates all around the breast feeling for any masses or checking for nipple discharge. We also palpate and check the armpit for any lymph nodes.
Should women who have breast and/or ovarian cancer in their family in particular book an OB-GYN physical in addition to their PCP one?
Yes, in terms of their risk assessment for both of these cancers. If there’s a concern for hereditary breast or ovarian cancer syndrome there would be a need for genetic testing or more high risk breast screening.
*Please note, this article is for informational purposes only. As with all medical issues, speak to your own doctor to make an informed decision about your health.
Dr. Katherine Macaulay is a Professor of Obstetrics, Gynecology, and Reproductive Sciences at UC San Diego School of Medicine, where she also heads up the Menopause Health Program.