Health maintenance for women of reproductive age (generally defined as 15 to 44 years of age) comprises counseling and screening tests, with the goal of prevention and early detection of common diseases such as cancer, infections, and mental health issues. A systematic review found no evidence that general preventive visits (outside of condition-based screening recommendations) reduce overall mortality or deaths from conditions such as cancer or heart disease¹; however, it is still important for family physicians to continue evidence-based preventive services, whether part of a routine physical examination or separately.² This article focuses on screening and counseling for conditions that are more prevalent in women of this age or that have a unique impact on women. In most cases, recommendations from the American Academy of Family Physicians (AAFP) are aligned with those from the U.S. Preventive Services Task Force (USPSTF); this article states when recommendations differ. A full list of USPSTF recommendations is published on their website.³ Grade A and B recommendations (https://www.uspreventiveservicestaskforce.org/uspstf/grade-definitions) have the strongest evidence of benefit and are the focus of this article. Physicians can also sign up to receive regular email updates with new or draft recommendations. A list of smart-phone apps related to preventive care is provided in Table 1.

Although this article uses the term “women” for simplicity, these recommendations apply to transgender men and nonbinary individuals as well. A previous American Family Physician article addresses health care for transgender and nonbinary patients in more detail.⁴ This article does not address recommendations that are specific to the antepartum or postpartum period.

Disparities exist in the provision of preventive care and are more common in people who belong to racial, ethnic, and sexual minority groups; people who are transgender; people who are uninsured; younger adults; and people who live in rural areas.^5,6 Although some types of preventive care, such as breast cancer screening, have improved, disparities continue to exist, especially related to screening for sexually transmitted infections (STIs), HIV, and cervical cancer and to vaccination against human papillomavirus (HPV).⁷

Reproductive Planning

PREGNANCY INTENTION

In 2011, 45% of pregnancies in the United States were unintended at the time of conception.⁸ The Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists recommend screening for pregnancy intention as part of primary care visits.^9,10 One method of screening that has been studied is the One Key Question.¹¹ Patients are asked whether they would like to become pregnant in the next year. Those who answer yes should be offered preconception counseling. For those who answer no, physicians should initiate a contraceptive options discussion. For patients who are okay either way or are unsure, physicians should initiate further discussion of the patient's goals and preferences. Pilot studies have demonstrated the feasibility of using One Key Question in the primary care setting and found that its use leads to higher rates of contraception use and preconception counseling¹¹; however, more evidence is needed to support this intervention as a population-based screening recommendation.

CONTRACEPTION

Women who want to have children often wish to plan the timing of their pregnancies. This makes the availability of effective contraception an important factor in achieving a person's goals.⁹ The CDC has developed a tool called the U.S. Medical Eligibility Criteria for Contraceptive Use, available as an app and on the CDC website; it allows physicians to easily determine eligibility or contraindications to various contraceptive methods based on the patient's health status.¹²

PRECONCEPTION AND INTERCONCEPTION CARE

If a woman desires pregnancy or is not actively trying to avoid pregnancy, preconception care is appropriate to try to reduce health risks and to maximize the chances of a healthy pregnancy, delivery, and infant. Interpregnancy or interconception care extends the concept of preconception care to maintain a woman's health across her reproductive life span. The AAFP has a position paper with evidence-based recommendations addressing preconception care.¹³ The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have published a guideline that includes topics such as avoiding interpregnancy intervals of less than six months, breastfeeding recommendations, counseling about family planning, and screening for and prevention of other medical conditions, as recommended in this article.¹⁴ The USPSTF recommends prescription of folic acid for people who may become pregnant.¹⁵

Screening Pelvic Examinations

The AAFP recommends against screening pelvic examinations in asymptomatic women because there are potential harms of overtreatment and unnecessary testing and no known benefits from screening asymptomatic patients.¹⁶ The USPSTF found insufficient evidence to make a recommendation for or against screening pelvic examinations.¹⁷ The USPSTF recommends against screening for ovarian cancer, and screening pelvic examinations have been studied primarily for the purpose of ovarian cancer screening.¹⁸ The Prostate, Lung, Colorectal, and Ovarian cancer screening trial dropped pelvic examinations from its ovarian cancer screening algorithm after no cases of ovarian cancer were detected by pelvic examination.¹⁹

Obesity and Cardiovascular Risk

Obesity, defined as a body mass index (BMI) of 30 kg per m² or higher, is more prevalent among women (40%) than men (35%) in the United States.²⁰ Studies show a correlation between increased BMI in women 30 to 55 years of age and increased risk of mortality, as well as morbidities such as cardiovascular disease later in life.²¹ In women, obesity affects the reproductive cycle and is associated with an increased risk of infertility and polycystic ovary syndrome.²² Current USPSTF guidelines recommend that adults with a BMI of 30 kg per m² or higher be provided with or referred for intensive multicomponent behavioral interventions.²⁰ The USPSTF also recommends screening for obesity in adolescents.²³

The USPSTF addresses screening recommendations for other cardiovascular disease risk factors, including hypertension, diabetes mellitus, and overall cardiovascular risk. These recommendations are summarized in eTable A.

Depression

Major depressive disorder is the leading cause of disability in women.²⁴ The prevalence of depression in women is approximately two times higher than in men.^25,26 This difference holds true among adults 20 years of age to older than 60 years, with the highest prevalence of depression occurring in women 40 to 59 years of age.²⁶ The reasons for higher risk and prevalence of depression in women are not fully understood and are hypothesized to involve multiple biologic and environmental factors that are simultaneously at play.^24,26 Current USPSTF guidelines recommend screening for depression in adults and adolescents when systems are in place to ensure follow-up, such as case management, direct depression care or coordination of care, and mental health treatment.^27–29 Screening tests recommended by the USPSTF are the Patient Health Questionnaire for adults and the Geriatric Depression Scale for older adults.

Intimate Partner Violence

Intimate partner violence (IPV) is defined by the USPSTF as physical or sexual violence, psychological aggression, or stalking by a person with whom one has a close personal relationship (e.g., a spouse).²⁹ In the 2015 National Intimate Partner and Sexual Violence Survey, 4.7% of women were found to have experienced sexual violence, physical violence, and/or stalking in the past year, and 43.6% of women had experienced sexual violence during their lifetime.³⁰ The prevalence of IPV is highest among women of reproductive age. Current USPSTF guidelines recommend screening for IPV in all women of reproductive age and provision or referral of ongoing support services for those who screen positive.²⁹ Validated screening instruments for IPV include the HARK (Humiliation, Afraid, Rape, Kick), HITS (Hurt, Insult, Threaten, Scream), E-HITS (Extended HITS), PVS (Partner Violence Screen), and WAST (Woman Abuse Screen Tool).²⁹ Examples of the screening tools are reviewed in a previous American Family Physician article on IPV (https://www.aafp.org/afp/2016/1015/p646.html). The recommendations for screening were based predominantly on limited evidence showing benefit of interventions for pregnant and postpartum women²⁹ but have been generalized to apply to nonpregnant women given the potential benefits of screening and the absence of harms.

Cancer Screening

CERVICAL CANCER

The CDC estimates that 93% of cervical cancers could be prevented by vaccination and screening.³¹ As of 2015, however, an estimated 14 million women 21 to 65 years of age had not been screened for cervical cancer within the past three years.³² Evidence suggests that in women 30 years and older, HPV infection is a better predictor of cervical cancer than cytology. In women younger than 30 years, HPV tends to be more transient, and the cervix has a greater potential for regeneration, making cytology more appropriate for screening. This difference is reflected in the USPSTF cervical cancer screening recommendations as well as recent interim clinical guidance from the American Society for Colposcopy and Cervical Pathology.^33,34 The inclusion of primary HPV testing without cytology for women 30 years and older is a change from previous guidelines. USPSTF guidelines³⁴ for cervical cancer screening are summarized in eTable B.

Emerging research shows that using patient self-collection of samples for HPV testing may be equally effective and increase screening rates compared with samples collected by a health care professional.³⁵ However, at this time, neither the USPSTF nor the American Society for Colposcopy and Cervical Pathology recommends self-sampling until more data are available.

BREAST CANCER

According to the USPSTF, the greatest benefit from breast cancer screening occurs from biennial screening with mammography between 50 and 74 years of age for women at average risk.³⁶ The decision to start screening before 50 years of age should be a shared one, weighing the small chance of avoiding breast cancer–related death against the relatively more common risks of overdiagnosis, false-positive results, unnecessary biopsies, and radiation-induced breast cancer. USPSTF and AAFP recommendations for breast cancer screening are summarized in Table 2.^36–42

OTHER CANCERS

Recommendations on screening for and counseling about skin cancer and colorectal cancer are the same for women as for men. Table 3 summarizes recommendations for cancer screening in women of reproductive age.^1,14,43,44

Sexually Transmitted Infections

The USPSTF recommends routine screening for HIV in people 15 to 65 years of age and for hepatitis C virus infection in people 18 to 79 years of age.^45,46 Patients at higher risk of contracting HIV should be offered preexposure prophylaxis.⁴⁷ All women 24 years and younger and older women at increased risk should be screened for gonorrhea and chlamydia; screening for syphilis and hepatitis B virus is recommended only in women at elevated risk.^48–50 Local prevalence data and risk factors are important when deciding which women to screen for syphilis because 90.8% of all cases of primary and secondary syphilis in 2014 occurred in men.⁴⁹

Risk factors for STI acquisition include multiple sex partners; history of incarceration; current or past STIs, including HIV infection; injection drug use; and engaging in transactional sex. People initiating treatment for tuberculosis and those presenting for care at STI clinics are also more likely to have STIs, and race (Black, Hispanic, Native American, and Alaska or Hawaii Native) is a marker for elevated risk because of social and health inequities.⁵¹ The USPSTF recommends against routine serologic screening for herpes simplex virus.⁵² eTable C summarizes USPSTF recommendations for STI screening.

Substance Use

The USPSTF recommends screening for the use of tobacco and the unhealthy use of alcohol and drugs and providing interventions to help users quit.^53–55 These recommendations are the same in women and men of the same age; however, there are some differences in susceptibility to and treatment of these conditions. In terms of smoking cessation, although women are less likely to smoke cigarettes than men, women who use tobacco have more difficulty quitting and have higher relapse rates.⁵⁶ Women may not respond as well to nicotine replacement therapy and may be more affected by concerns about weight gain and by lack of social support; these factors should be taken into consideration when counseling patients.⁵⁷ Women are considered to be engaging in risky alcohol use at lower levels of consumption compared with men. In women, risky alcohol use is defined as more than three drinks in a day or more than seven drinks in a week.⁵⁸ Behavioral counseling interventions are effective for tobacco use, unhealthy alcohol use, and unhealthy drug use. Pharmacotherapy is also recommended as an option for tobacco and opioid use. Substance use screening recommendations are summarized in Table 4, including the AAFP's differing position on unhealthy drug use screening.^{56,57,59–64}

Immunizations

Immunization recommendations are the same for men and nonpregnant women of the same age.⁶⁵ Table 5 lists immunization recommendations in adults.⁶⁵ A summary of vaccine recommendations is available on the CDC website at https://www.cdc.gov/vaccines/adults/index.html and is also available via the smartphone apps listed in Table 1.

The CDC does not recommend routine or catch-up vaccination for HPV in adults 27 to 45 years of age; rather, it recommends HPV vaccination based on shared clinical decision-making in this age group.⁶⁵

This article updates a previous article on this topic by Riley, et al.⁶⁶

Data Sources: We searched the Agency for Healthcare Research and Quality, American Academy of Family Physicians (AAFP) website, Cochrane Library, Essential Evidence Plus, American College of Obstetricians and Gynecologists, Centers for Disease Control and Prevention, and Women's Preventive Services Initiative for recommendations on the following terms: preventive care, health maintenance, screening recommendations, reproductive health, reproductive age, obesity, depression, intimate partner violence, substance use, cervical cancer screening, sexually transmitted infections, immunizations, and substance use. We also searched the Choosing Wisely website for recommendations from the AAFP. Search dates: December 1, 2019, through January 9, 2020; June 2020; and January 4, 2021.

Editor's Note: This article was finalized prior to FDA Emergency Use Authorization for vaccines for the prevention of COVID-19. For information about these vaccines, see this article on Outpatient Management of COVID-19.—Kenny Lin, MD, Deputy Editor