Download Well-Woman Task Force

Well-Woman Task Force
A collaborative initiative hosted by the American College of Obstetricians & Gynecologists
Final Report
April 18, 2014
Well-Woman Task Force
Jeanne Conry, MD, PhD, FACOG
ACOG President 2013-2014
Kaiser Permanente
Roseville, CA
Haywood Brown, MD, FACOG, Chair
Duke Univ Medical Center
Durham, NC
Sandra Adamson Fryhofer, MD, MACP, FRCP
American College of Physicians
Victoria Green, MD, MHSA, JD, MBA, FACOG
National Medical Association
Sue Kendig, JD, MSN, WHNP-BC, FAANP
National Association of Nurse Practitioners in Women’s
Health
Elizabeth M. Alderman, MD, FAAP
American Academy of Pediatrics
Chiara Benedetto, Professor
European Board & College of Obstetrics and
Gynaecology
Molly Brewer, DVM, MD, MS
Society of Gynecologic Oncology
Octavia Cannon, DO, FACOOG
American College of Osteopathic Obstetricians &
Gynecologists
Merry-K Moos, BSN, MPH, FAAN
Preconception Health and Health Care Clinical Work
Group
Mimi Pomerleau, DNP, MSN, RNC-OB
Association of Women’s Health, Obstetric and Neonatal
Nurses
George Saade, MD, FACOG
Society for Maternal-Fetal Medicine
Robert M. Wah, MD, FACOG
American College of Obstetricians & Gynecologists
David Chelmow, MD
Society for Academic Specialists in General Obstetrics
and Gynecology
Judy Waxman
National Women’s Law Center
Vanessa Cullins, MD, MPH, MBA
Planned Parenthood Federation for America
Ruth E. Zielinski, PhD, CNM
American College of Nurse-Midwives
Diana D’Amelio, PA-C
American Academy of Physician Assistants
R. Louise Floyd, DSN, RN
National Center on Birth Defects and Developmental
Disabilities
Karen Davenport
National Women’s Law Center
Mark DeFrancesco, MD, MBA, FACOG
American College of Obstetricians & Gynecologists
Linda Dominguez, RN-C, NP
Association of Reproductive Health Professionals
Patricia L. Fontaine, MD, MS, FAAFP
American Academy of Family Physicians
Nancy Lee, MD
Office on Women’s Health
Janet L. McCauley, MD, FACOG
Committee on Health Economics & Coding, American
College of Obstetricians and Gynecologists
Timothy C. McFarren, MD, MS, FACOG
Committee on Practice Management, American College
of Obstetricians & Gynecologists
American College of Obstetricians & Gynecologists Staff
Gerald F. Joseph Jr, MD, Vice President of Practice Activities
Nancy O’Reilly, MHS
Caitlin Phelps, MA
Lyndona Charles
Table of Contents
Introduction……………………………………………………………………………….. 1
Topics ……………………………………………………………………………………... 11
Abdominal Exam
11
Alcohol Misuse
14
Anemia
21
Bacteriuria
22
Blood Pressure Screening
24
Breast Cancer, Chemoprevention
26
Self Breast Exam
28
Breastfeeding
32
Cervical Cancer Screening and Prevention
34
Clinical Breast Examination
44
Colorectal Screening
50
Contraception, STIs, & Reproductive Health
57
Dyslipidemia/Cardiovascular Disease
66
Depression
70
Diabetes
76
Diabetes Postpartum
78
Diet, Fitness, Nutrition
79
Domestic and Intimate Partner Violence
81
Drug Use
84
Genetic Screening
88
Hearing
93
Hepatitis B Screening
94
Hepatitis C Screening
96
Hypothyroidism
99
Immunizations
104
Injury Prevention
105
Kidney Disease
108
Mammography
110
Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment
113
Metabolic Syndrome
118
Neural Tube Defects
120
Obesity
121
Oral Cavity Exam
124
Oral Hygiene
125
Osteoporosis
128
Ovarian Cancer
130
Pelvic Examination
133
Pelvic Floor Disorders
138
Piercing and Tattooing
140
Preconception, Interconception Care
141
Sexual Health
148
Skin Cancer
150
Sleep Disorders
154
Tobacco Use
155
Visual Acuity/Glaucoma
160
Glossary…………………………………………………………………………………… 163
Well-Woman Task Force
Components of the Well-Woman Visit
Background
The well-woman visit promotes health through disease prevention and preventive health care
over the course of a woman’s lifetime. As outlined by the Institute of Medicine 1, the Patient
Protection and Affordable Care Act (ACA) of 2010 ushered in a paradigm shift from a reactive
health care system that responds to acute and urgent needs to one that fosters optimal health and
well-being. Under the ACA, well-woman care is a covered benefit (with no copayment required)
and may be provided by an assortment of providers, including family physicians, internists, nurse
midwives, nurse practitioners, obstetrician-gynecologists, pediatricians, and physician assistants.
The selection of a provider for well-woman care will be determined as much by a woman’s
needs and preferences as by her access or health plan availability.
The focus on well-woman health care is a particularly timely topic given the ACA’s strong wellwoman health care provisions. The law covers a range of preventive services, from cancer
screening to contraceptive care. It does not, however, address definitional and practice issues
across providers and health plans, nor does it adequately look at preventive services across a
woman’s life span from a holistic perspective.
Purpose
1
IOM (Institute of Medicine). 2011. Clinical Preventive Services for Women: Closing the Gaps.
Washington, DC: The National Academies Press.
1
The American Congress of Obstetricians and Gynecologists (ACOG) convened the Well-Woman
Task Force to develop a consensus about the basic elements that make up the well-woman visit
and can be used by any provider who cares for adolescent girls or women. Organizations were
invited to participate in this collaborative effort to ensure that women receive consistent, highquality health care to the full extent intended by the ACA. Composed of leading professional
associations representing women’s health clinicians, the Well-Woman Task Force aimed to focus
on delineating the well-woman visit throughout the life span, across all providers and health
plans. The Well-Woman Task Force believes that its joint voice will be powerful, reflecting the
collective wisdom of all of the professional associations represented and, ultimately, the needs of
women throughout the United States.
The task force recognized that many recommendations from medical societies and government
agencies already exist and provide guidelines about the basic elements of women’s health. Such
recommendations are based on evidence and expert opinion but are not consistent across
organizations or health plans. The task force also acknowledged that a variety of providers will
deliver care, and they must be skilled in the elements of well-woman care to meet the minimum
requirements of well-woman visits. The task force sought to provide a forum in which to reach
consensus on well-woman care and to develop and submit recommendations to the U.S.
Department of Health and Human Services (HHS) and others as the ACA is fully implemented.
Components of the Well-Woman Visit identifies needs across a woman’s life span—from
adolescence through the reproductive years and into maturity. It describes age-specific elements
of care with a goal of improving health outcomes. (Other terms for such primary care approaches
2
to overall health evaluations are “adolescent health visit,” “health risk assessment,” and “health
maintenance.”)
Methodology
To ensure a broad range of perspectives, ACOG reached out to the following organizations to
participate in the Well-Woman Task Force:
•
American Academy of Family Physicians
•
American Academy of Pediatrics
•
American Academy of Physician Assistants
•
American College of Nurse-Midwives
•
American College of Osteopathic Obstetricians & Gynecologists
•
American College of Physicians
•
Association of Reproductive Health Professionals
•
Association of Women’s Health, Obstetric and Neonatal Nurses
•
National Association of Nurse Practitioners in Women’s Health
•
National Medical Association
•
Planned Parenthood Federation of America
•
Society for Maternal–Fetal Medicine
•
Society of Academic Specialists in General Obstetrics and Gynecology
•
Society of Gynecologic Oncology
3
This collaborative effort proceeded in three phases: compilation of existing guidelines, review of
existing guidelines, and development of joint recommendations.
Compilation of Existing Guidelines
As a preliminary step, ACOG compiled existing guidelines from HHS, the Institute of Medicine,
the U.S. Preventive Services Task Force, and each of the participating organizations, as well as
from other authoritative organizations not represented. Then, ACOG provided all participants
with a summary of the guidelines organized according to the level of agreement. The topics to be
reviewed were sorted into five agreement categories:
•
Single source (eg, abdominal exam)
•
No agreement (eg, breast cancer/mammography screening)
•
Limited agreement (eg, pelvic examination)
•
General agreement (eg, hypertension, osteoporosis)
•
Sound agreement (eg, screening for sexually transmitted infections)
Participants were asked to verify the guidelines from their own organizations and supplement as
necessary before the first meeting of the task force. For example, ACOG submitted the
methodology for the development of its Practice Bulletins that described the process for
evaluating evidence and crafting recommendations. To ensure that the recommendations
addressed key issues of concern, task force members provided their organizations’ top three
priorities for well-woman care. For example, ACOG identified reproductive health management,
obesity prevention, and smoking cessation as its top three priorities.
4
Task Force Review
The task force reviewed all recommendations. The foundation for the final recommendations
relied on evidenced-based guidelines, evidence-informed guidelines, uniform expert opinion, or
some combination of these.
•
Evidenced-based recommendations were derived primarily from guidelines of the U.S.
Public Health Services Task Force, the Institute of Medicine, and the Centers for Disease
Control and Prevention.
•
Evidenced-informed recommendations were derived from guidelines published by
medical societies and professional organizations.
•
Uniform expert agreement recommendations were derived from deliberations of the task
force intended to resolve conflicting guidelines or to supplement evidence-based and
evidence informed guidelines.
In many areas, there were conflicting recommendations across organizations. In most instances,
differences were small. In such cases, task force members negotiated a consensus, typically
based on the strength of the evidence, the ease of implementation of the recommendation, or
current prevailing practice.
The strength of each recommendation in Components of the Well-Woman Visit is identified.
Recommendations were considered “strong” if they rely primarily on evidence-based or
evidence-informed guidelines or “qualified” if they rely primarily on expert consensus.
5
Special Considerations
In developing recommendations for the components of the well-woman visit, task force members
balanced many considerations. The recommendations focus on what should be done to optimize
health for women at average risk. The task force did not examine data supporting the concept of
an annual visit in general but rather accepted that the annual visit is an essential part of
preventive health care for women. In determining the appropriate components, the task force
took into account a number of limitations and special considerations.
Age Ranges
Preventive guidelines are often presented in general categories based on age and reproductive
potential. For the purpose of this report, the task force sought to categorize the recommendations
in Components of the Well-Woman Visit as follows:
•
Adolescents (13–18 years)
•
Reproductive-aged women (19–45 years)
•
Mature adults (46–64 years)
•
Women over age 64 years
It is important to note that many organizations use different age ranges and categories, and many
evidence-based recommendations for screening or preventive care do not use the categories
above at all. When evidence supported specific ages for screening or prevention strategies, the
task force included these ages, even if they were inconsistent with the initial age categories
identified for the purpose of this report or conflicted with a category of a given organization.
6
State and Local Laws and Regulations
For a number of topics, local laws and regulations apply to screening or to conditions uncovered
during screening. While the most significant relate to intimate partner violence, child abuse, and
sexually transmitted infections (including human immunodeficiency virus [HIV]), they can also
apply in unexpected areas, such as reporting of breast density on mammography. The task force
did not take these requirements into account because they vary from region to region. Providers
should be aware of regulations and laws that apply to their patients and include them in
counseling when they may affect the patient’s decisions regarding screening or provision of
information. The task force felt strongly that appropriate consideration be given to the impact of
regulations and laws on well-woman care when they are drafted.
Insurance Coverage
The task force understood that not every patient will have insurance coverage for all of the care
included in the recommendations, and some patients may not have coverage for any. The
recommendations were developed to include elements that optimize health of a well woman.
Providers may have to modify the elements based on the individual patient’s resources. The task
force recommends that insurers cover all components described in the recommendations.
Costs and Cost-Effectiveness of Preventive Care
The Task Force did not consider cost or cost-effectiveness. Many recommendations were
developed using formal guidelines published by major medical and professional societies that
explicitly did not include cost as a factor in guideline development. Moreover, many of the
7
recommendations involve low-cost screening methods based on a patient’s history or physical
exam. Where laboratory tests are recommended, these recommendations stem from consensus
across multiple organizations, some of which do consider cost-effectiveness. They generally
were already recommended by major societies, including the U.S. Preventative Services Task
Force or Institute of Medicine.
Evidence Base
The task force considered several levels of evidence. When available, the task force relied on
high-quality evidence. In general, screening that involves laboratory testing and imaging was
only included if it was supported by high-quality evidence previously reviewed and accepted by
other organizations. Approaches that involve low-cost screening methods (eg, history or physical
exam) were included when the task force felt that detecting the outcome was clearly important
(eg, identifying domestic violence), even if high-quality evidence was not available. When highquality evidence was not available but the task force felt a recommendation should be included,
the recommendation was phrased to be permissive as opposed to prescriptive.
Timeliness
The recommendations are an amalgam of guidelines from major medical and professional
societies and government organizations, all of which are updated systematically but at irregular
intervals. Similarly, we realize that some subjects were not addressed, so their review will take
place in updates. Given the number of recommendations, it is expected that some of the
recommendations made at the initial task force meetings will rapidly become out of date.
Components of the Well-Woman Visit is intended to be a living document. Regular update of
8
components is planned, as is the ability to remove recommendations no longer relevant and add
new ones as necessary.
Availability of Referral Services
Abnormal screening results must be appropriately managed. Management can be by the provider
or referral, depending on local resources and the individual provider’s expertise and training. The
task force advocates that patients should not be denied recommended screening because of any
limitation of local resources. Rather, providers should have plans for referral, even if it means the
patient will have to travel outside her community. Providers are encouraged to develop initial
management skills that are within the scope of their specialty and practice to meet local patient
needs. Patients should be counseled about limitations in local resources at the time of testing.
Delivery of Care
While Components of the Well-Woman Visit envisions at least one annual well-woman visit,
there is no requirement that all the recommended components be performed at the same visit or
by the same provider. Care models such as patient-centered medical homes will allow delivery in
more flexible formats. In developing the recommendations, the task force focused on delineating
the services that should be provided and the overall frequency at which they should be provided,
rather than the specifics of how and when they should be provided.
Finalizing and Disseminating Joint Recommendations
At the end of the process, the task force finalized its recommendations. Components of the WellWoman Visit will be submitted to HHS, participating organizations, and all agencies tasked with
9
implementation and enforcement of the ACA. This information will also assist the National
Women’s Law Center as they advocate for women and wellness care.
Incorporating Recommendations Into Practice
The charge of the Well-Woman Task Force was to provide guidance to women and clinicians
with age-appropriate recommendations for a well woman visit. Well-woman care comprises
history, physical examination, counseling, and screening intended to maintain physical, mental,
and social wellness and general health throughout a woman’s lifetime. The foundation for the
final Task Force recommendation for each topic was derived using evidence-based, evidenceinformed, uniformed expert opinion, or some combination. Clinicians and patients must be
informed and educated to ensure that a well-woman visit meets the standards of care for each
recommendation, as well as the indications and rationale for that recommendation for prevention,
wellness, and general health.
10
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Abdominal Exam
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
Adolescents (13-21)
Evidence-Based
Standard physical exam taught
in medical school and
advanced practice programs
includes abdominal exam as
part of a routine periodic
exam. The elements can
include four-quadrant/nineregion abdominal inspection,
auscultation, percussion, and
palpation. The inspection can
reveal distension, both
operative and traumatic scars,
striae, pubic hair distribution,
jaundice, and distended veins.
Auscultation can reveal bowel
sounds and fetal heart.
Percussion can reveal ascites.
Palpation can assess
An abdominal exam is an appropriate
component of the well-adolescent visit.
(Qualified)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
superficial or deep
tenderness, guarding,
rebound, and rigidity.
ACOG: Abdominal exam is
recommended as part of wellwoman physical exam
regardless of age. (Committee
Opinion
534, http://www.acog.org/Res
ources_And_Publications/Co
mmittee_Opinions/Committe
e_on_Gynecologic_Practice/W
ell-Woman_Visit; Guidelines
for Women’s Health,
http://www.acog.org/Resourc
es_And_Publications/Guidelin
es_for_Womens_Health_Care
/Patient_Care)
AAP Bright Futures: Annual
well-child assessment and
physical exam is
recommended. At this visit, an
age-appropriate physical exam
is essential. The older child
(11-21 years) will be
undressed and suitably
draped. (Recommendations
for Preventive Pediatric Health
Care,
http://brightfutures.aap.org/p
dfs/AAP_Bright_Futures_Perio
dicity_Sched_101107.pdf)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Adults (22 and older)
See also Alcohol Misuse; Diet, Fitness, and Nutrition; Drug Use; Hepatitis C Screening; Skin Cancer
Evidence-Based
Evidence-Informed
Standard physical exam taught
in medical school and
advanced practice programs
includes abdominal exam as
part of a routine periodic
exam. An abdominal exam can
assess a woman’s risk of
exposure to hepatitis C; drug
and alcohol use/abuse;
dietary, hereditary, or lifestyle
risks for gastrointestinal
disorders; and cancers of the
skin and internal organs.
Uniform Expert Agreement
Final WWTF Recommendation
An abdominal exam is an appropriate
component of the well-woman visit.
(Qualified)
ACOG: Abdominal exam is
recommended as part of wellwoman physical exam
regardless of age. (Committee
Opinion
534, http://www.acog.org/Res
ources_And_Publications/Co
mmittee_Opinions/Committe
e_on_Gynecologic_Practice/W
ell-Woman_Visit; Guidelines
13
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
for Women’s
Health, http://www.acog.org/
Resources_And_Publications/
Guidelines_for_Womens_Heal
th_Care/Patient_Care)
14
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Alcohol Misuse
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Uniform Expert Agreement
Final WWTF Recommendation
Adolescents (13-18)
See also Preconception/Interconception Care
Evidence-Based
Evidence-Informed
USPSTF: There is inconclusive
evidence that counseling is
effective in adolescents. (Screening
and Behavioral Counseling
Interventions in Primary Care to
Reduce Alcohol Misuse, grade B
recommendation; U.S. Preventive
Services Task Force. Screening and
Behavioral Counseling Intervention
in Primary Care to Reduce Alcohol
Misuse: Recommendations
Statement. AHRQ Publication No.
12-05171-EF3. http://www.uspreventiveservice
staskforce.org/uspstf12/alcmisuse/
alcmisusefinalrs.htm)
AAP Bright Futures:
Recommends annual
evaluation and counseling for
alcohol use in adolescents.
(Performing Preventive
Services: A Bright Futures
Handbook)
Annual screening of adolescents for alcohol
use by questionnaire or history or both but
not by testing is recommended. Provide or
refer patient to counseling about alcohol
use. (Strong)
AAP: Strongly advises against
the use of alcohol, tobacco,
and other illicit drugs by
youth. (AAP Policy
Statement: Alcohol use by
Youth and Adolescents: A
Pediatric Concern, Pediatrics
Vol. 125 No. 5 May 1, 2010
15
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
pp. 1078 -1087; Alcohol Use
by Youth and Adolescents: A
Pediatric Concern. )
ACOG: Recommends annual
screening for alcohol use in
teens. (GAHC, p. 104)
ACOG: Recommends
screening by
questionnaire/history (not
testing) at least yearly. (CO
#496)
PCHHC: All women of
childbearing age should be
screened for alcohol use, and
brief interventions should be
provided in primary care
settings, which should
include advice regarding the
potential for adverse health
outcomes. Women who
show signs of alcohol
dependence should be
educated about the risks of
alcohol consumption; for
women who are interested in
modifying their alcohol use
patterns, efforts should be
made to identify programs
that would assist them in
achieving cessation and longterm abstinence. (The Clinical
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Content of Preconception
Care [B I-a])
PCHHC: Assess at least
annually for alcohol use
patterns and risky drinking
behaviors and provide
appropriate counseling; all
women should be advised of
the risks to the embryo/fetus
of alcohol exposure in
pregnancy and that no safe
level of consumption has
been established. (The
Clinical Content of
Preconception Care [A III])
AAFP: The evidence is
inconclusive that counseling
is effective in adolescents.
Recommends screening and
behavioral counseling
interventions to reduce
alcohol misuse, in primary
care settings. (AAFP, Alcohol
Misuse)
CDC: Binge drinking increases
the risk for unintended
pregnancy, delayed
pregnancy recognition, STIs,
and adverse pregnancy
outcomes including fetal
alcohol spectrum disorder.
Assess patterns of risky drinking
at least annually and counsel the
teenager on the harm to self
and, should she become
pregnant, to her embryo/fetus.
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
(http://www.cdc.gov/Feature
s/VitalSigns/bingedrinkingfe
male/index.html)
NIAAA: Recommends alcohol
screening and brief
intervention for youth.
(http://pubs.niaaa.nih.gov/p
ublications/Practitioner/Yout
hGuide/YouthGuide.pdf)
Adults (19 and older)
See also Preconception/Interconception Care
Evidence-Based
Evidence-Informed
USPSTF: Recommends that
clinicians screen adults aged 18
years or older for alcohol misuse
and provide persons engaged in
risky or hazardous drinking with
brief behavioral counseling
interventions to reduce alcohol
misuse. (Screening and Behavioral
Counseling Interventions in Primary
Care to Reduce Alcohol Misuse;
grade B recommendation)
AAFP: Recommends
screening and behavioral
counseling interventions to
reduce alcohol misuse, in
primary care settings. (AAFP,
Alcohol Misuse)
ACOG: Recommends
screening by
questionnaire/history (not
testing) at least yearly. (CO
#496)
Uniform Expert Agreement
Final WWTF Recommendation
Annual screening of adults for alcohol
misuse by questionnaire or history or both
but not by testing is recommended. Provide
or refer persons engaged in risky or
hazardous drinking to brief behavioral
counseling interventions to reduce alcohol
misuse. (Strong)
PCHHC: All women of
childbearing age should be
18
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
screened for alcohol use, and
brief interventions should be
provided in primary care
settings, which should
include advice regarding the
potential for adverse health
outcomes. Women who
show signs of alcohol
dependence should be
educated about the risks of
alcohol consumption; for
women who are interested in
modifying their alcohol use
patterns, efforts should be
made to identify programs
that would assist them in
achieving cessation and longterm abstinence. (The Clinical
Content of Preconception
Care [B I-a])
PCHHC: Assess at least
annually for alcohol use
patterns and risky drinking
behaviors and provide
appropriate counseling; all
women should be advised of
the risks to the embryo/fetus
of alcohol exposure in
pregnancy and that no safe
level of consumption has
been established. (The
Clinical Content of
Preconception Care [A III])
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
AAP Bright Futures:
Recommends annual
evaluation and counseling for
alcohol use in adolescents
(through age 21).
(Performing Preventive
Services: A Bright Futures
Handbook)
20
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Anemia
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents and Adults (all ages)
Evidence-Based
Evidence-Informed
USPSTF: Evidence is insufficient to recommend for or against routine
screening for iron deficiency anemia in asymptomatic children ages 6 to 12
months. Grade: I Statement. (USPSTF, Screening for Iron Deficiency Anemia,
Topic Page. U.S. Preventive Services Task
Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsiron.htm)
There is no
recommendation for
routine screening for
anemia in
asymptomatic girls or
women.
Uniform Expert
Agreement
Final WWTF
Recommendation
Routine screening for
anemia is not
recommended. (Qualified)
21
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Bacteriuria
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13–18)
Evidence-Based
Evidence-Informed
Uniform Expert
Agreement
USPSTF: Recommends against screening for asymptomatic bacteriuria in
AAFP: Recommends There is evidence of
men and nonpregnant women.
against screening
harm resulting from
for asymptomatic
treatment of
(Screening for Asymptomatic Bacteriuria in Adults, Topic Page. July 2008.
bacteriuria in men
asymptomatic
U.S. Preventive Services Task
bacteriuria in
Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm; and nonpregnant
women. (AAFP
nonpregnant
grade D recommendation)
women. There is no
Bacteriuria,
evidence of benefit
Asymptomatic)
to screening older,
asymptomatic
nonpregnant
women.
Recommend
following USPSTF
guidelines.
Final WWTF
Recommendation
Screening for bacteriuria
in asymptomatic,
nonpregnant women is
not recommended.
(Strong)
22
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Adults (19–64)
Evidence-Based
Evidence-Informed
USPSTF: Recommends against screening for asymptomatic
bacteriuria in men and nonpregnant women. (Screening for
Asymptomatic Bacteriuria in Adults, Topic Page. July 2008. U.S.
Preventive Services Task
Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsba
ct.htm;
grade D recommendation)
AAFP: Recommends
against screening for
asymptomatic
bacteriuria in men and
nonpregnant women.
(AAFP Bacteriuria,
Asymptomatic)
Uniform Expert
Agreement
There is evidence of
harm resulting from
treatment of
asymptomatic bacteriuria
in nonpregnant women.
Final WWTF
Recommendation
Screening for bacteriuria in
asymptomatic, nonpregnant
women is not recommended.
(Strong)
Adults (65+)
Evidence-Based
EvidenceInformed
USPSTF: Recommends against screening for asymptomatic bacteriuria in
ACOG: Perform
men and nonpregnant women.
urinalysis.
(Annual
(Screening for Asymptomatic Bacteriuria in Adults, Topic Page. July 2008.
U.S. Preventive Services Task
Women's Health
Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm; Care)
grade D recommendation)
Uniform Expert
Agreement
There is evidence of
harm resulting from
treatment of
asymptomatic
bacteriuria in
nonpregnant
women. Recommend
following USPSTF
guidelines.
Final WWTF
Recommendation
Screening for bacteriuria in
asymptomatic women is not
recommended. (Strong)
23
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Blood Pressure Screening
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents and Adults (all ages)
See also Cardiovascular Disease
Evidence-Based
Evidence-Informed
USPSTF: Screen for high
blood pressure in adults
age 18 years or older.
Current evidence is
insufficient to assess the
balance of benefits and
harms of screening for
hypertension in
asymptomatic children
and adolescents to
prevent subsequent
cardiovascular disease in
childhood or adulthood.
(Screening for high blood
pressure: U.S. Preventive
Services Task Force
AAFP: There is insufficient evidence to recommend for or against
screening children and adolescents for high blood pressure to
reduce risk of CVD.
(http://www.aafp.org/dam/AAFP/documents/patient_care/
clinical_recommendations/October2012SCPS.pdf)
Uniform Expert
Agreement
Final WWTF
Recommendation
Routine blood pressure
screening is
recommended.
(Strong)
AAP Bright Futures: Recommends routine blood pressure
measurement for adolescents.
(http://brightfutures.aap.org/pdfs/preventive%20services%20pdfs/
physical%20examination.pdf)
24
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
reaffirmation
recommendation
statement. Ann Intern
Med. 2007 Dec
4;147(11):783-6;
Moyer VA; U.S.
Preventive Services Task
Force. Screening for
primary hypertension in
children and adolescents:
U.S. Preventive Services
Task Force
recommendation
statement. Pediatrics.
2013 Nov;132(5):907-14.
doi: 10.1542/peds.20132864. Epub 2013 Oct 7.)
25
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Breast Cancer, Chemoprevention
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF
Recommendation and
Strength of Recommendation
“Strong” = Based on evidencebased or evidence-informed
guidelines
“Qualified” = Based on expert
opinion alone
Evidence-Informed
Uniform Expert
Agreement
Final WWTF
Recommendation
Adults (All ages)
Evidence-Based (source)
26
USPSTF: Recommends that
clinicians engage in shared,
informed decision-making with
women who are at increased risk
for breast cancer about
medications to reduce their risk.
For women who are at increased
risk for breast cancer and at low
risk for adverse medication effects,
clinicians should offer to prescribe
risk-reducing medications, such as
tamoxifen or raloxifene.
(B recommendation 2013;
http://www.uspreventiveservicesta
skforce.org/uspstf13/breastcanme
ds/breastcanmedsrs.htm)
ACOG: Counsel women aged 35 Recommend following USPSTF
years and older at high risk.
guidelines.
(http://www.acog.org/About_A
COG/ACOG_Departments/Annu
al_Womens_Health_Care/Asses
sments_and_Recommendations
)
For women who are at
increased risk for breast cancer,
it is recommended that clinicians
engage in shared, informed
decision-making about
medications to reduce their
risk. (Strong)
AAFP: Recommends that
clinicians engage in
shared, informed
decision-making with
women who are at
increased risk for breast
cancer about medications
to reduce their risk. For
women who are at
increased risk for breast
cancer and at low risk for
adverse medication
effects, clinicians should
offer to prescribe riskreducing medications
such as tamoxifen or
raloxifene. (2013,
http://www.aafp.org/pati
ent-care/clinicalrecommendations/all/bre
ast-cancer.html)
It is recommended that women
who are at increased risk for
breast cancer and at low risk for
adverse medication effects be
offered risk-reducing
medications, such as tamoxifen
or raloxifene. (Strong)
27
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Self Breast Exam
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (All ages)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
28
USPSTF: Recommends against
teaching breast self-examination.
(http://www.uspreventiveservicest
askforce.org/uspstf09/breastcancer
/brcanrs.htm; grade D
recommendation; Evidence review
at
http://www.uspreventiveservicesta
skforce.org/uspstf09/breastcancer/
brcanes.pdf)
AAP Bright Futures: Does not
recommend breast selfexamination.
(https://brightfutures.aap.org/
pdfs/Guidelines_PDF/13Rationale_and_Evidence.pdf )
ACOG: Because other
screening methods can have
false-negative results, and
because breast cancer can
occur in unscreened women,
breast self-examination and
breast self-awareness have a
role in breast cancer
screening. Physicians should
consider teaching breast selfexamination to high-risk
patients. Recommend
educating women about
breast self-awareness. (2003,
http://www.guideline.gov/
content.aspx?id=34275;
Breast cancer screening.
Practice Bulletin No. 122.
American College of
Obstetricians and
Gynecologists. Obstet
Gynecol 2011;118:372–82)
Physicians should educate women about
breast self-awareness, encouraging them to
understand the normal appearance and feel
of their breasts and to report any changes in
their breasts to their health care providers.
Breast self-awareness can include breast
self-examination. (Qualified)
NCCN: Breast awareness
is encouraged. (2013,
http://www.nccn.org/def
ault.aspx)
ACS: Starting at age 20,
women should be
counseled on the benefits
29
and limitations of breast
self-examination. (2013,
http://www.cancer.org/acs
/groups/cid/documents/we
bcontent/003165-pdf.pdf)
Cochrane Collaborative: The
review of data from two large
population-based studies
involving 388,535 women
compared breast selfexamination with no
intervention did not find a
beneficial effect of screening in
terms of improvement in
breast cancer mortality. The
trials showed that women who
were randomized to breast
self-examination were almost
twice as likely to undergo a
biopsy of the breast. The
authors suggest that the lack
of supporting evidence from
the two major studies should
be discussed with these
women to enable them to
make an informed decision.
Women should, however, be
aware of any breast changes.
(http://summaries.cochrane.or
g/CD003373/regular-selfexamination-or-clinicalexamination-for-earlydetection-of-breastcancer.#sthash.UIO2ZUcf.dpuf)
30
31
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Breastfeeding
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Uniform Expert Agreement
Final WWTF Recommendation
All Women of Reproductive Capacity
Evidence-Based
Evidence-Informed
IOM: Recommends women’s
preventive services include
comprehensive lactation support
and counseling and costs of
renting breastfeeding equipment.
A trained provider should provide
counseling services to all pregnant
women and to those in the
postpartum period to ensure the
successful initiation and duration
of breastfeeding.
(Clinical Preventive Services for
Women: Closing the Gaps)
ACNM: Provide timely and
ongoing counseling and
support for breastfeeding.
Maternity/newborn facilities
must follow lactation-friendly
policies. (Breastfeeding)
AAFP: Recommends
interventions during
pregnancy and after birth to
promote and support
breastfeeding.(Breastfeeding)
Promotion of breastfeeding and counseling
is recommended for all pregnant and
postpartum women to ensure successful
initiation and duration of breastfeeding.
Provide interventions such as
comprehensive lactation support and
counseling and information on the costs of
renting breastfeeding equipment to
promote and support breastfeeding.
(Strong)
USPSTF: Recommends
interventions during pregnancy
and after birth to promote and
support breastfeeding. (Grade B
32
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
recommendation; http://www.usp
reventiveservicestaskforce.org/us
pstf/uspsbrfd.htm)
33
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Cervical Cancer Screening and Prevention
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
USPSTF: Screening is not
recommended for cervical cancer
in women younger than age 21
years. The recommendation does
not apply to women who have
received a diagnosis of a highgrade precancerous cervical lesion
or cervical cancer, women with in
utero exposure to
diethylstilbestrol, or women who
are immunocompromised (such as
those who are HIV-positive).
(http://www.uspreventiveservices
taskforce.org/uspstf11/cervcancer
/cervcancerrs.pdf)
ACOG: Screening is not
Healthy women under 21 years
recommended for
old should not be screened.
adolescents.
(http://www.acog.org/Resour
ces_And_Publications/Practice
_Bulletins/Committee_on_Pra
ctice_Bulletins_-_Gynecology/Screening_for_C
ervical_Cancer)
Adolescents (13-20)
ACS/ASCCP/ACSP: Cervical cancer
screening should begin at age 21.
Screening for cervical cancer is not
recommended for women under 21. (Strong)
AAFP: Screening is not
recommended for
adolescents.
(http://www.aafp.org/patientcare/clinicalrecommendations/all/cervical
-cancer.html)
34
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Women under 21 should not be
screened regardless of the age of
sexual initiation or other risk
factors.
(http://journals.lww.com/jlgtd/Pu
blishingImages/ASCCP%20Guidelin
es.pdf#zoom=80)
ACIP: Women ages 10-26 should
receive bivalent or quadrivalent
human papillomavirus (HPV)
vaccine.
(http://www.cdc.gov/vaccines/hc
p/acip-recs/vaccspecific/hpv.html)
CDC: For those who are HIVpositive, a Pap test should be
obtained twice during the first
year after diagnosis of HIV
infection and, if the results are
normal, annually thereafter.
(http://www.cdc.gov/mmwr/pdf/r
r/rr5804.pdf)
AAFP, ACP, ACOG, ACNM:
ACIP adult and childhood
vaccines schedules endorsed.
(ACOG CO #467; ACOG, AAFP,
ACNM, ACP:
http://www.aafp.org/content/
dam/AAFP/documents/patien
t_care/immunizations/hpvrecommendation-letter.pdf)
AWHONN: HPV vaccine is
recommended.
(http://www.awhonn.org/awh
onn/binary.content.do;jsessio
nid=18DC4DFDA7A95EA82E7A
FB308008EF63?name=Resour
ces/Documents/pdf/5_HPV.pd
f)
ACOG: Annual cytology
screening starting at age 21
years is reasonable for this
group.
(http://www.acog.org/Resour
ces_And_Publications/Practice
_Bulletins/Committee_on_Pra
ctice_Bulletins_-_Gynecology/Screening_for_C
Adolescents should receive HPV
vaccine prior to the initiation of
sexual activity.
HPV vaccine is recommended for
adolescents, preferably before the initiation
of sexual activity, and according to the ACIP
schedule. (Strong)
There are conflicting guidelines for HIVinfected girls and women under 21.
Compliance with either of the guidelines is
acceptable. (Qualified)
35
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
ervical_Cancer)
Adults (21-29 with cervix and without history of DES exposure, immunocompromise, or prior high-grade lesion)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
36
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
USPSTF: Recommends cytology
every 3 years. Recommends
against screening for cervical
cancer with HPV testing, alone or in
combination with cytology. The
recommendations do not apply to
women who have received a
diagnosis of a high-grade
precancerous cervical lesion or
cervical cancer, women with in
utero exposure to
diethylstilbestrol, or women who
are immunocompromised (such as
those who are HIV-positive).
(http://www.uspreventiveservicest
askforce.org/uspstf11/cervcancer/
cervcancerrs.pdf)
ACS/ASCCP/ASCP: Recommend
cytology alone every 3 years. HPV
testing should not be used for
screening in this age group.
(http://journals.lww.com/jlgtd/Pub
lishingImages/ASCCP%20Guideline
s.pdf#zoom=80)
ACIP: For adolescents and women
ages 10-26, bivalent or
quadrivalent HPV vaccine is
recommended. (Bridges CB, CoyneBeasley T; Immunization Services
Division, National Center for
Immunization and Respiratory
Diseases, CDC. Advisory committee
on immunization practices
ACOG, AAFP: For women
ages 21-29, cytology alone
every 3 years is
recommended. (ACOG:
http://www.acog.org/Resour
ces_And_Publications/Practic
e_Bulletins/Committee_on_P
ractice_Bulletins_-_Gynecology/Screening_for_
Cervical_Cancer; AAFP:
http://www.aafp.org/patient
-care/clinicalrecommendations/all/cervica
l-cancer.html)
AAFP, ACP, ACOG, ACNM:
ACIP adult and childhood
vaccine schedules endorsed.
(http://www.aafp.org/conte
nt/dam/AAFP/documents/pa
tient_care/immunizations/hp
v-recommendationletter.pdf)
ACOG, ACS, and USPSTF
guidelines are all similar and
appropriate for this age group.
Screening for cervical cancer is
recommended with cytology alone every 3
years in women with a cervix who have not
had DES exposure or prior high-grade lesion
or cancer and who are not
immunocompromised. (Strong)
Screening with HPV testing is not
recommended. (Strong)
HPV vaccine is recommended for women
aged 26 and under according to the ACIP
schedule. (Strong)
37
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
recommended immunization
schedule for adults aged 19 years
or older - United States, 2014.
MMWR Morb Mortal Wkly Rep.
2014 Feb 7;63(5):110-2; AkinsanyaBeysolow I; Immunization Services
Division, National Center for
Immunization and Respiratory
Diseases, CDC. Advisory committee
on immunization practices
recommended immunization
schedules for persons aged 0
through 18 years - United States,
2014. MMWR Morb Mortal Wkly
Rep. 2014 Feb 7;63(5):108-9.)
Adults (30-65 with cervix and without history of DES exposure, immunocompromise, or prior high-grade lesion)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
38
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
IOM: Recommends the addition of
high-risk HPV DNA testing in
addition to cytology testing in
women with normal cytology
results. Screening should begin at
30 years of age and should occur
no more frequently than every 3
years.
(http://www.iom.edu/Reports/201
1/Clinical-Preventive-Services-forWomen-Closing-theGaps/Recommendations.aspx)
USPSTF: Recommends cytology
every 3 years. For women who
want to lengthen the screening
interval, combine cytology and HPV
testing every 5 years. The
recommendation does not apply to
women who have received a
diagnosis of a high-grade
precancerous cervical lesion or
cervical cancer, women with in
utero exposure to
diethylstilbestrol, or women who
are immunocompromised (such as
those who are HIV-positive).
(http://www.uspreventiveservicest
askforce.org/uspstf11/cervcancer/
cervcancerrs.pdf)
ACOG: Cytology alone every
3 years is acceptable.
Cotesting (HPV test plus
cytology) is preferable.
(http://www.acog.org/Resou
rces_And_Publications/Practi
ce_Bulletins/Committee_on_
Practice_Bulletins_-_Gynecology/Screening_for_
Cervical_Cancer)
Despite conflicting opinions
among the major sources of
recommendations, cotesting is
an acceptable strategy that
allows lengthening of screening
intervals.
Screening for cervical cancer with a
combination of cytology and HPV testing
(cotesting) is recommended every 5 years in
women with a cervix who have not had DES
exposure or a prior high-grade lesion or
cancer and who are not
immunocompromised. Screening with
cytology alone every 3 years is acceptable.
(Strong)
AAFP: Cytology alone every 3
years is recommended. For
women who want to
lengthen the screening
interval, cotesting every 5
years is recommended.
(http://www.aafp.org/patien
t-care/clinicalrecommendations/all/cervica
l-cancer.html)
ACS/ASCCP/ASCP: HPV and
cytology "cotesting" every 5 years
is the preferred approach. Cytology
39
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
alone every 3 years is acceptable.
Screening by HPV testing alone is
not recommended for most clinical
settings.
(http://journals.lww.com/jlgtd/Pub
lishingImages/ASCCP%20Guideline
s.pdf#zoom=80)
Adults (over 65 with cervix and without history of DES exposure, immunocompromise, or prior high-grade
lesion)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
40
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
USPSTF: Recommends against
screening for cervical cancer in
women older than age 65 years
who have had adequate prior
screening and are not otherwise at
high risk for cervical cancer. The
recommendation does not apply to
women who have received a
diagnosis of a high-grade
precancerous cervical lesion or
cervical cancer, women with in
utero exposure to
diethylstilbestrol, or women who
are immunocompromised (such as
those who are HIV-positive).
(http://www.uspreventiveservicest
askforce.org/uspstf11/cervcancer/
cervcancerrs.pdf)
ACS/ASCCP/ASCP: Screening is not
recommended following adequate
negative prior screening. Women
with a history of CIN 2 or a more
severe diagnosis should continue
routine screening for at least 20
years.
(http://journals.lww.com/jlgtd/Pub
lishingImages/ASCCP%20Guideline
s.pdf#zoom=80)
ACOG: Discontinue screening
in women older than 65
years with evidence of
adequate negative prior
screening and no history of
CIN 2 or greater.
(http://www.acog.org/Resou
rces_And_Publications/Practi
ce_Bulletins/Committee_on_
Practice_Bulletins_-_Gynecology/Screening_for_
Cervical_Cancer)
Screening for cervical cancer is not
recommended for women over 65 who
have had adequate prior screening with
negative results. (Strong)
Routine screening for at least 20 years is
recommended for women with a history of
CIN 2 or a more severe diagnosis. (Strong)
AAFP: Do not screen women
65 and over who have had
adequate prior screening and
are not otherwise at high risk
for cervical cancer.
(http://www.aafp.org/patien
t-care/clinicalrecommendations/all/cervica
l-cancer.html)
Adults (21 and over without cervix)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
41
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
USPSTF: Screening for cervical
cancer is not recommended in
women who have had a
hysterectomy with removal of the
cervix and who do not have a
history of a high-grade
precancerous lesion (cervical
intraepithelial neoplasia grade 2 or
3) or cervical cancer. The
recommendation does not apply to
women who have received a
diagnosis of a high-grade
precancerous cervical lesion or
cervical cancer, women with in
utero exposure to
diethylstilbestrol,
or women who are
immunocompromised (such as
those who are
HIV-positive).
(http://www.uspreventiveservicest
askforce.org/uspstf11/cervcancer/
cervcancerrs.pdf)
ACOG: Do not screen women
after total hysterectomy who
have no history of CIN 2 or
higher.
(http://www.acog.org/Resou
rces_And_Publications/Practi
ce_Bulletins/Committee_on_
Practice_Bulletins_-_Gynecology/Screening_for_
Cervical_Cancer)
Screening for cervical cancer is not
recommended for women who have had a
hysterectomy provided they have no history
of CIN 2 or more severe diagnosis in the
past 20 years or cervical cancer ever.
(Strong)
AAFP: Do not screen women
who have had hysterectomy
with removal of cervix and
who do not have a history of
high-grade precancerous
lesion (CIN 2 or 3) or cervical
cancer.
(http://www.aafp.org/patien
t-care/clinicalrecommendations/all/cervica
l-cancer.html)
ACS/ASCCP/ASCP: After
hysterectomy, screening is not
recommended. The
recommendation applies to
women without a cervix and
without a history of CIN 2 or a
more severe diagnosis in the past
20 years or cervical cancer ever. (
http://journals.lww.com/jlgtd/Publ
ishingImages/ASCCP%20Guidelines
42
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
.pdf#zoom=80)
43
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Clinical Breast Examination
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Uniform Expert Agreement
Final WWTF Recommendation
Adults (All Women)
Evidence-Based
Evidence-Informed
44
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
USPSTF: Current evidence is
insufficient to assess the additional
benefits and harms of clinical
breast examination (CBE) beyond
screening mammography in
women 40 years or older.
(2009, http://www.uspreventiveser
vicestaskforce.org/uspstf09/breast
cancer/brcanrs.htm; Evidence
review at
http://www.uspreventiveservicesta
skforce.org/uspstf09/breastcancer/
brcanes.pdf)
ACOG: CBE should be
performed every 1 to 3 years
for women ages 20–39 years
and annually for women ages
40 years and older.
(2011, http://www.guideline.
gov/content.aspx?id=34275;
recommendations are based
primarily on consensus and
expert opinion [Level C])
ACOG: CBE should be
performed annually for
women 40 or older. Although
the value of screening CBE
for women with low
prevalence of breast cancer
(i.e., women ages 20–39) is
not clear, CBE for these
women is recommended
every 1-3 years (Breast
cancer screening. Practice
Bulletin No. 122. American
College of Obstetricians and
Gynecologists. Obstet
Gynecol 2011;118:372–82.
http://www.acog.org/~/medi
a/Practice%20Bulletins/Com
mittee%20on%20Practice%2
0Bulletins%20-%20Gynecology/pb122.pdf?d
mc=1&ts=20140312T091822
4010)
CBE should be offered to
asymptomatic women without
breast cancer risk factors in the
context of a shared decisionmaking approach that takes into
account a woman's personal
preferences and the balance of
benefit to harm. CBE should be
performed annually for women
aged 40 years and older. For
women aged 20-39 years, CBEs
are recommended every 1-3
years.
Clinical breast exam (CBE) may be offered to
women in the context of a shared decisionmaking approach that recognizes the
uncertainty of additional benefits and harms
of CBE beyond screening mammography.
(Qualified)
CBE may be offered to women ages 19–39
every 1 to 3 years. (Qualified)
CBE may be offered to women ages 40 and
older annually. (Qualified)
Routine CBE is not recommended for
adolescents (ages 13–18). (Qualified)
45
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
AAFP: Current evidence is
insufficient to assess the
benefits and harms of CBE for
women aged 40 years and
older. (2009;
http://www.aafp.org/patient
-care/clinicalrecommendations/all/breastcancer.html)
ACS: Recommends CBE about
every 3 years for women in
their 20s and 30s and every
year for women 40 and over.
(http://www.cancer.org/heal
thy/findcancerearly/cancersc
reeningguidelines/americancancer-society-guidelines-forthe-early-detection-ofcancer)
Susan G Komen: CBE can be
helpful in finding tumors in
women under age 40 for
whom mammography is not
indicated. In women 40 and
older, CBE and
mammography may find
more cancers than
mammography alone (i.e.,
when used together fewer
breast cancers are missed).
CBE is not a substitute for
mammography in women
46
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
over 40. (Oestreicher N,
Lehman CD, Seger DJ, Buist
DS, White E. The incremental
contribution of clinical breast
examination to invasive
cancer detection in a
mammography screening
program. AJR Am J
Roentgenol. 184(2):428-32,
2005; Chiarelli AM, Majpruz
V, Brown P, Thriault M,
Shumak R, Mai V. The
contribution of clinical breast
examination to the accuracy
of breast screening. J Natl
Cancer Inst. 101(18):1236-43,
2009. Cited
at http://ww5.komen.org/Br
eastCancer/ClinicalBreastExa
m.html )
CTFPHC: Recommends not
routinely
performing clinical breast exa
minations alone or in
conjunction with
mammography to screen
for breast cancer. (Weak
recommendation; low-quality
evidence; Canadian Task
Force on Preventive Health
Care, Tonelli M, Gorber SC,
Joffres M, Dickinson J, Singh
H, Lewin G, Birtwhistle R.
47
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Recommendations on
screening for breast cancer in
average-risk women aged 4074 years. CMAJ. 2011 Nov
22;183(17):1991-2001.)
WHO: The only breast cancer
screening method that has
proved to be effective is
mammography screening.
Research is underway to
evaluate CBE as a low-cost
approach to breast cancer
screening that can work in
less affluent countries.
(http://www.who.int/cancer/
detection/breastcancer/en/)
Cochrane Collaborative: The
only large population-based
trial of clinical breast
examination combined with
breast self-examination that
was identified was
discontinued because of poor
compliance with follow up.
(http://summaries.cochrane.
org/CD003373/regular-selfexamination-or-clinicalexamination-for-earlydetection-of-breastcancer.#sthash.UIO2ZUcf.dpu
f
48
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
KPCMI: Recommends CBE be
offered to asymptomatic
women without breast
cancer risk factors, in the
context of a shared decisionmaking approach that takes
into account a woman's
personal preferences and the
balance of benefit to harm.
(http://www.guideline.gov/s
yntheses/synthesis.aspx?id=3
9251)
49
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Colorectal Screening
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Uniform Expert Agreement
Final WWTF Recommendation
Adults (45–75)
Evidence-Based
Evidence-Informed
ACP: Individualized
assessment for risk of
colorectal cancer is
recommended.
(http://annals.org/article.asp
x?articleid=1090701)
USPSTF: Screening for colorectal
cancer should begin at age 50 and
continue to age 75.
(http://www.uspreventiveservicest
askforce.org/uspstf/uspscolo.htm)
ACP: All adults at average risk
for colorectal cancer should
be screened.
(http://annals.org/article.asp
x?articleid=1090701)
Individualized assessment of risk, including
family history and individualized counseling,
is recommended. (Strong)
Screening for all adults at
average risk should begin at age
50, except for African
Americans, for whom screening
should begin at age 45.
Screening for colorectal cancer is
recommended beginning at age 50. For
African American women, screening should
begin at age 45. (Strong)
ACG: Screening should start
at age 50. For African
Americans, begin screening
age 45.
(http://gi.org/guideline/color
50
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
ectal-cancer-screening/)
ACOG: Screening should start
at age 50. For African
Americans, begin screening
at age 45.
(http://www.acog.org/About
_ACOG/ACOG_Departments/
Annual_Womens_Health_Car
e/Assessments_and_Recom
mendations)
USPSTF: The following methods of
screening are recommended:
-Fecal occult blood testing
-Sigmoidoscopy
-Colonoscopy
There is insufficient evidence to
assess the benefits or harms of
computed tomographic
colonography and fecal DNA
testing as screening modalities.
(http://www.uspreventiveservicest
askforce.org/uspstf/uspscolo.htm)
AAFP: The following methods
of screening are
recommended:
-Fecal occult blood testing
-Sigmoidoscopy
-Colonoscopy
There is insufficient evidence
to assess the benefits or
harms of computed
tomographic colonography
and fecal DNA testing as
screening modalities.
(http://www.aafp.org/patien
t-care/clinicalrecommendations/all/colore
ctal-cancer.html)
Screening is recommended by one of the
following methods:
-Colonoscopy every 10 years
-FOBT or FIT annually
-Flexible sigmoidoscopy every 5 years
-Double contrast barium enema every 5
years
-Computed tomography colonography every
5 years
-Stool DNA (no interval determined)
Screening should not be performed using inoffice FOBT or FIT with sample collected
during digital rectal exam.
(Strong)
ACP: The following methods
of screening are
recommended:
51
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
–Stool-based test
-Flexible sigmoidoscopy
-Optical colonoscopy
(http://annals.org/article.asp
x?articleid=1090701)
ACOG: The following
approach is recommended:
Colonoscopy every 10 years
OR alternative methods:
- Fecal occult blood testing or
fecal immunochemical test
annually
-Flexible sigmoidoscopy
every 5 years
-Double contrast barium
enema every 5 years
-Computed tomography
colonography every 5 years
-Stool DNA (no interval
determined)
Do not use in-office FOBT or
FIT with sample collected
during digital rectal exam.
(http://www.acog.org/About
_ACOG/ACOG_Departments/
Annual_Womens_Health_Car
e/Assessments_and_Recom
mendations)
ACG: Screening by
colonoscopy is
recommended. If
52
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
colonoscopy is not available
or affordable:
-Flexible sigmoidoscopy
every 5-10 years
-Computed tomography
colonography every 5 years
-Cancer detection test (fecal
immunochemical test for
blood)
(http://gi.org/guideline/color
ectal-cancer-screening/)
Adults (76 and older)
Evidence-Based
USPSTF: Routine screening is not
recommended for those ages 76 to
85. There may be considerations to
support screening in individual
patients. Screening is not
recommended in adults older than
85 years.
(http://www.uspreventiveservicest
askforce.org/uspstf/uspscolo.htm)
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
ACP: Individualized
assessment for risk of
colorectal cancer is
recommended.
(http://annals.org/article.asp
x?articleid=1090701)
Individualized assessment of risk, including
family history and individualized counseling,
is recommended. (Strong)
ACP: Do not screen over age
75 or with a life expectancy
of less than 10 years.
(http://annals.org/article.asp
x?articleid=1090701)
Routine screening is not recommended for
women ages 75-85, but individual
considerations may support screening in
some patients following informed, shared
decision-making. (Strong)
AAFP: There may be
considerations that support
colorectal cancer screening
Screening is not recommended for women
over age 85. (Strong)
53
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
in an individual patient. Do
not screen patients over age
85.
(http://www.aafp.org/patien
t-care/clinicalrecommendations/all/colore
ctal-cancer.html)
Women at Increased Risk
Evidence Based
Evidence-Informed
Uniform Expert Opinion
ACP: Screen via optical
colonoscopy starting at age
40 or 10 years younger than
the age at which the
youngest affected relative
was diagnosed with
colorectal cancer.
(http://annals.org/article.asp
x?articleid=1090701)
Final WWTF Recommendation
Screening for colorectal cancer with optical
colonoscopy is recommended for women at
increased risk, beginning at age 40 (or 10
years younger than the age at which the
youngest affected relative was diagnosed
with colorectal cancer). (Strong)
AAFP: Do not use aspirin or
NSAIDs to prevent colorectal
cancer in individuals at risk for
colorectal cancer.
(http://www.aafp.org/patientcare/clinicalrecommendations/all/colorectal
-cancer.html)
Prophylactic treatment is not recommended
for women at increased risk of colorectal
cancer. (Strong)
54
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
AAFP: Genetic testing for
Lynch syndrome is
recommended for patients
with newly diagnosed
colorectal cancer to reduce
morbidity and mortality to
relatives. Those with Lynch
syndrome should be offered
earlier and more frequent
screening, and their firstdegree relatives should be
offered genetic testing.
(http://www.aafp.org/patien
t-care/clinicalrecommendations/all/colore
ctal-cancer.html)
ACG: Patients who are
hereditary nonpolyposis
colorectal cancer (Lynch
syndrome) carriers may be
offered genetic counseling
and should undergo
colonoscopy every 2 years
beginning at age 20-25 years
until age 40 years, then
annually thereafter.
Patients with familial
adenomatous polyposis (FAP)
should undergo
adenomatous polyposis coli
(APC) mutation testing and, if
negative, MYH mutation
testing. Patients with FAP or
Women with newly diagnosed colorectal
cancer should be offered genetic testing for
Lynch syndrome to reduce morbidity and
mortality to relatives. (Strong)
Women who are HNPCC carriers may be
offered genetic counseling and should
undergo colonoscopy every 2 years
beginning at age 20-25 until age 40, then
annually thereafter. (Strong)
For women with FAP, APC mutation testing
is recommended; if negative, MYH mutation
testing is recommended. For women with
FAP or at risk of FAP based on family
history, annual flexible sigmoidoscopy or
colonoscopy is recommended until such
time when colectomy is deemed
appropriate by the patient and her
physician. (Strong)
55
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
at risk of FAP based on family
history should undergo
annual flexible
sigmoidoscopy or
colonoscopy until such time
when colectomy is deemed
the best treatment by the
patient and provider.
(http://gi.org/guideline/color
ectal-cancer-screening/
56
Topic: Contraception, STIs, & Reproductive Health
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Alcohol Misuse, Preconception/Interconception Care, Sexual Health
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
IOM, CDC: Recommends that
women with reproductive
capacity have access to the full
range of FDA-approved
contraceptive methods,
sterilization procedures, and
patient education and counseling.
(IOM: Clinical Preventive Services
for Women: Closing the Gaps;
CDC: U.S. Selected Practice
Recommendations for
Contraceptive Use, 2013 –
Adapted from the world Health
Organization Selected Practice
Recommendations for
Contraceptive Use, 2nd Edition.
ACOG: Recommends preventing
unwanted and unintended
pregnancy by postponing sexual
involvement or using
contraceptive options, including
emergency contraception.
(Emergency Contraception.
Practice Bulletin No. 112.
American College of Obstetricians
and Gynecologists. Obstet
Gynecol 2010;115:1100–
9. http://www.acog.org/About_A
COG/ACOG_Departments/Annual
_Womens_Health_Care)
ACOG: Recommends first
reproductive care visit at ages 1315, prior to sexual activity (usually
does not include a pelvic exam.)
(ACOG Committee Opinion.
Number 335, May 2006: The
initial reproductive health visit.
Obstet Gynecol 2006;107:12159.)
Adolescents of reproductive
capacity should be counseled
regarding contraceptive methods
(including postponing sexual
activity); ensured access to basic
contraceptive services, either
within their office setting or by
referral to appropriate services;
and offered appropriate follow-up
to ensure compliance and
monitor for adverse effects and
complications.
(Strong)
AAP Bright Futures: Integrate
Hoover et al: Adolescent visit
provides an opportunity to
establish a relationship. Content
of visit can include screening,
education, and guidance on
sexual development, menses, HPV
57
MMWR Recommendations and
Reports. Vol. 62, No. 5:1-60.)
sexuality education into the
longitudinal relationship
developed through care
experiences with the
preadolescent child, the
adolescent, and the family.
(http://brightfutures.aap.org/pdfs
/Guidelines_PDF/11_8_Sexuality.
pdf)
CDC: Routine screening for N.
gonorrhoeae in all sexually active
women at risk for infection is
recommended annually. Women
aged <25 years are at highest risk
for gonorrhea infection. Routine
screening for C. trachomatis of all
sexually active females aged ≤25
years is recommended annually.
(Sexually transmitted diseases
treatment guidelines, 2010.
Workowski KA, Berman S; Centers
for Disease Control and
Prevention (CDC). MMWR
Recomm Rep. 2010 Dec 17;59(RR12):1-110. Erratum in: MMWR
Recomm Rep. 2011 Jan
14;60(1):18.)
ACOG: Recommends chlamydia
and gonorrhea testing (if sexually
active). (Urine-based STI
screening is an efficient method
without a speculum examination.)
(http://www.acog.org/About_AC
OG/ACOG_Departments/Annual_
Womens_Health_Care/Assessme
nts_and_Recommendations)
vaccine, preventing pregnancy,
STDs, and other issues on sexual
health. (Hoover, KW, et al.
Utilization of Health Services in
Physician Offices and Outpatient
Clinics by Adolescents and Young
Women in the U.S. Journal of
Adolescent Health 46; 2010:324330. [A CDC report])
Annual chlamydia and gonorrhea
testing is recommended for those
who are sexually active. (Strong)
USPSTF: Recommends that
clinicians screen all sexually active
women, including those who are
pregnant, for gonorrhea infection
if they are at increased risk for
58
infection (that is, if they are young
or have other individual or
population risk factors). Women
and men under the age of 25—
including sexually active
adolescents—are at highest risk
for genital gonorrhea infection.
(Grade B recommendation;
http://www.uspreventiveservices
taskforce.org/uspstf05/gonorrhea
/gonrs.htm)
USPSTF: Recommends screening
for chlamydial infection for all
sexually active, nonpregnant
young women aged 24 and
younger and for older
nonpregnant women who are at
increased risk (
http://www.uspreventiveservices
taskforce.org/uspstf07/chlamydia
/chlamydiars; grade A
recommendation).
USPSTF: Recommends highintensity behavioral counseling to
prevent STIs for all sexually active
adolescents and for adults at
increased risk for STIs.
(http://www.uspreventiveservices
taskforce.org/uspstf08/sti/stirs.pd
f; grade B recommendation)
59
CDC: Prevent
unwanted/unintended pregnancy
by assessing the woman’s need
for contraceptive methods and
those that are available for her.
(CDC (2010). Medical Eligibility
Criteria for Contraceptive Use.
MMWR;59(RR04):1–85; (CDC.
(2009) Contraceptive use among
postpartum women – 12 states
and New York City, MMWR, 58,
821-826.; CDC. (2011). Update to
U.S. Medical Eligibility Criteria for
Contraceptive Use, 2010)
Adults (All ages)
See also Alcohol Misuse, Preconception Care, Sexual Health
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
IOM, CDC: Recommends that
women with reproductive
capacity have access to the full
range of FDA-approved
contraceptive methods,
sterilization procedures, and
patient education and counseling.
(IOM: Clinical Preventive Services
for Women: Closing the Gaps;
CDC: U.S. Selected Practice
Recommendations for
Contraceptive Use, 2013 –
Adapted from the world Health
ACOG: Prevent
unwanted/unintended pregnancy
by assessing the woman’s need
for contraceptive methods and
those that are available for her.
(http://www.acog.org/Resources_
And_Publications/Guidelines for
Women’s Health Care)
Time to counsel, educate, and
solve problems regarding
contraceptive needs and
management should be part of
any given visit. Alternatively,
arrangements should be made for
a separate visit for contraception
follow-up.
Adult women of reproductive
capacity should be evaluated at
least annually regarding
contraceptive method use and
satisfaction. Women with
reproductive capacity should have
access to the full range of FDAapproved contraceptive methods,
sterilization procedures, and
patient education and counseling
appropriate to their childbearing
intentions. (Strong)
60
Organization Selected Practice
Recommendations for
Contraceptive Use, 2nd Edition.
MMWR Recommendations and
Reports. Vol. 62, No. 5:1-60.)
CDC: Prevent
unwanted/unintended pregnancy
by assessing the woman’s need
for contraceptive methods and
those that are available for her.
(CDC (2010). Medical Eligibility
Criteria for Contraceptive Use.
MMWR;59(RR04):1–85; (CDC.
(2009) Contraceptive use among
postpartum women – 12 states
and New York City, MMWR, 58,
821-826.; CDC. (2011). Update to
U.S. Medical Eligibility Criteria for
Contraceptive Use, 2010: Revised
recommendations for the use of
contraceptive methods during the
postpartum period. MMWR,
60(26, 878-883; CDC/OPA ( In
press. Due to be published in
MMWR Feb. 2014;
Recommendations for Quality
Family Planning Services)
CDC: Safety, efficacy, availability,
and acceptability should be
considered by women, men, or
couples when choosing the most
appropriate contraceptive
61
method. Voluntary informed
choice of contraceptive methods
is an essential guiding principle,
and contraceptive counseling,
where applicable, may be an
important contributor to the
successful use of contraceptive
methods. Assessment as to the
safety of a given contraceptive
method for a person with a
particular characteristic or
medical condition should be
included in counseling. (CDC
(2010). Medical Eligibility Criteria
for Contraceptive Use.
MMWR;59(RR04):1–85.)
CDC: In choosing a method of
contraception, the risk for
sexually transmitted infections
(STIs), including human
immunodeficiency virus (HIV),
also must be considered.
Although hormonal
contraceptives and IUDs are
highly effective at preventing
pregnancy, they do not protect
against STIs. Consistent and
correct use of the male latex
condom reduces the risk for STIs.
When a male condom cannot be
Women who use contraceptive
methods other than condoms
should be counseled about the
use of condoms and the risk for
STIs. (Strong)
62
used properly for infection
prevention, a female condom
should be considered. (CDC STD
Treatment Guidelines (2006),
MMWR, (55-R11), 1-94.
(http://www.cdc.gov/std/treatme
nt; CDC, (2009.Contraceptive use
among postpartum women – 12
states and New York City, MMWR,
58, 821-826; CDC, 2011. Update
to U.S. Medical Eligibility Criteria
for Contraceptive Use, 2010:
Revised recommendations for the
use of contraceptive methods
during the postpartum period.
MMWR, 60(26, 878-883;
CDC/OPA ( In press. Due to be
published in MMWR Feb. 2014).
Recommendations for Quality
Family Planning Services).
CDC: Unintended pregnancy and
short interpregnancy birth
spacing contribute to poor
maternal and newborn outcomes.
Initiation of contraception during
the postpartum period is
important to prevent unintended
pregnancy and short birth
intervals, which can lead to
negative health outcomes for
mother and infant. Venous
thromboembolism risk should be
Evidence-based guidance should
be used in contraceptive
counseling and prescribing during
the immediate postpartum
period. (Qualified)
63
assessed when recommending
and prescribing contraception
during the immediate postpartum
period. (CDC, 2009.
Contraceptive use among
postpartum women – 12 states
and New York City, MMWR, 58,
821-826.; CDC. (2011). Update to
U.S. Medical Eligibility Criteria for
Contraceptive Use, 2010: Revised
recommendations for the use of
contraceptive methods during the
postpartum period. MMWR,
60(26, 878-883; CDC/OPA ( In
press. Due to be published in
MMWR Feb. 2014).
Recommendations for Quality
Family Planning Services)
USPSTF: Recommends highintensity behavioral counseling to
prevent STIs for all sexually active
adolescents and for adults at
increased risk for STIs.
(http://www.uspreventiveservices
taskforce.org/uspstf08/sti/stirs.pd
f)
CDC: Health care providers should
routinely and regularly obtain
sexual histories from their
patients and address
management of risk reduction for
STIs. (Sexually transmitted
diseases treatment guidelines,
A sexual history and risk
assessment for STD exposure
should be incorporated into each
well-woman visit. Screening
should be instituted according to
the CDC STD Treatment
Guidelines. (Qualified)
64
2010; Workowski KA, Berman S;
Centers for Disease Control and
Prevention (CDC). MMWR
Recomm Rep. 2010 Dec 17;59(RR12):1-110. Erratum in: MMWR
Recomm Rep. 2011 Jan
14;60(1):18; http://www.cdc.gov/
StD/treatment/2010/default.htm)
USPSTF: Recommends screening
for chlamydial infection for all
sexually active, nonpregnant
young women aged 24 and
younger and for older
nonpregnant women who are at
increased risk (
http://www.uspreventiveservices
taskforce.org/uspstf07/chlamydia
/chlamydiars; grade A
recommendation; USPSTF.
Screening for chlamydial
infection: U.S. Preventive Services
Task Force recommendations
statement. Ann Intern Med 2007;
147:128-34.)
65
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Dyslipidemia/Cardiovascular Disease*
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (18–44)
See also Blood Pressure Screening; Genetic Screening (Other than BRCA); Diet, Fitness, and Nutrition; Obesity; Preconception
Care; Tobacco Use
Evidence-Based
USPSTF: Recommends against screening for asymptomatic carotid
artery stenosis in the general adult population. (Grade D
Recommendation,
Ann Intern Med. 2007 Dec 18;147(12):854-9.
Screening for carotid artery stenosis: U.S. Preventive Services Task
Force recommendation statement.
U.S. Preventive Services Task Force.
http://www.uspreventiveservicestaskforce.org/uspstf07
Evidence-Informed
Uniform
Final WWTF
Expert
Recommendation
Agreement
AAP: Recommends dyslipidemia screening once
Dyslipidemia
between ages 18 and 21 years.
screening is
(http://www.aap.org/en-us/professionalrecommended onc
resources/practicebetween ages 18
and 21 years.
support/Periodicity/Periodicity%20Schedule_FINAL.pdf)
(Qualified)
Screening for
asymptomatic
carotid artery
stenosis in the
general adult
population is not
recommended.
(Strong)
66
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
/cas/casrs.pdf)
USPSTF: Recommends against screening with resting or exercise
electrocardiography for the prediction of coronary heart disease
events in asymptomatic adults at low risk for CHD events. (Grade
D Recommendation,
Screening for coronary heart disease with electrocardiography:
U.S. Preventive Services Task Force recommendation statement.
Moyer VA; U.S. Preventive Services Task Force.
Ann Intern Med. 2012 Oct 2;157(7):512-8.
http://www.uspreventiveservicestaskforce.org/uspstf11
/coronarydis/chdfinalrs.pdf)
USPSTF: Recommends against routine screening for abdominal
aortic aneurysm in women. (Grade D
Recommendation, http://www.uspreventiveservicestaskforce.org/
uspstf05/aaascr/aaars.pdf)
USPSTF: Recommends against the use of beta-carotene
supplements, either alone or in combination, for the prevention of
cancer or cardiovascular disease. (Grade D Recommendation, Ann
Intern Med. 2014 Feb 25. doi: 10.7326/M14-0198. [Epub ahead of
print]
Vitamin, Mineral, and Multivitamin Supplements for the Primary
Prevention of Cardiovascular Disease and Cancer: U.S. Preventive
Services Task Force Recommendation Statement. Moyer
VA. http://www.uspreventiveservicestaskforce.org/uspstf14
/vitasupp/vitasuppfinalrs.pdf)
Screening with
resting or exercise
electrocardiograph
for the prediction
of coronary heart
disease (CHD)
events in
asymptomatic
adults at low risk
for CHD events is
not recommended
(Strong)
Routine screening
for abdominal
aortic aneurysm in
women is not
recommended.
(Strong)
The use of betacarotene
supplements, eithe
alone or in
combination, for
the prevention of
cancer or
cardiovascular
disease is not
recommended.
(Strong)
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*Note: The USPSTF make no recommendations to screen adolescents for hypertension or dyslipidemia. It finds insufficient evidence to make a
recommendation.
Adults (20-54)
See also Blood Pressure Screening; Diet, Fitness, and Nutrition; Obesity; Preconception Care; Tobacco Use
Evidence-Based
USPSTF: Recommends screening women ages 20–45 for lipid disorders if they are
at increased risk for coronary heart disease. (Grade B Recommendation,
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm)
EvidenceInformed
USPSTF: Recommends against the use of aspirin for stroke prevention in women
younger than age 55 years. (Grade D Recommendation, Ann Intern Med. 2009
Mar 17;150(6):396-404. Aspirin for the prevention of cardiovascular disease: U.S.
Preventive Services Task Force recommendation statement. US Preventive
Services Task Force.
http://www.uspreventiveservicestaskforce.org/uspstf09/aspirincvd/aspcvdrs.pdf)
Uniform Expert
Agreement
Final WWTF
Recommendation
Screening for lipid
disorders in women ages
20–45 who are at
increased risk for coronary
heart disease is
recommended. (Strong)
The use of aspirin for
stroke prevention in
women younger than age
55 years is not
recommended. (Strong)
Adults (45 and older)
See also Blood Pressure Screening; Diet, Fitness, and Nutrition; Obesity; Tobacco Use
Evidence-Based
EvidenceInformed
Uniform
Final WWTF Recommendation
Expert
Agreement
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Well-Woman Task Force 2013-2014
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USPSTF: Recommends screening women aged 45 and older for lipid disorders if
they are at increased risk for coronary heart disease. (Grade A Recommendation,
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm)
USPSTF: Recommends the use of aspirin for women ages 55 to 79 years when the
potential benefit of a reduction in ischemic stroke outweighs the potential harm
of an increase in gastrointestinal hemorrhage. (Grade A Recommendation,
Ann Intern Med. 2009 Mar 17;150(6):396-404. Aspirin for the prevention of
cardiovascular disease: U.S. Preventive Services Task Force recommendation
statement. US Preventive Services Task Force.
http://www.uspreventiveservicestaskforce.org/uspstf09/aspirincvd/aspcvdrs.pdf)
Screening for lipid disorders in
women ages 45 years and older
who are at increased risk for
coronary heart disease is
recommended. (Strong)
The use of aspirin is
recommended for women ages
55 to 79 years when the potential
benefit of a reduction in ischemic
stroke outweighs the potential
harm of an increase in
gastrointestinal hemorrhage.
(Strong)
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Topic: Depression
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment; Preconception/Interconception Care
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
USPSTF: Recommends screening
adolescents (12–18 years of age)
for major depressive disorder
when systems are in place to
ensure accurate diagnosis,
psychotherapy (cognitivebehavioral or interpersonal), and
follow-up.
(Screening and Treatment for
Major Depressive Disorder in
Children and Adolescents [Grade
B])
AAP: Primary care clinicians
should assess for depression
in adolescents at high risk and
those presenting with
emotional problems.
(Performing Preventive
Services: A Bright Futures
Handbook)
Patients should not be denied
recommended screening
because of any limitation of
local resources. Rather,
providers should have plans for
referral, even if it means the
patient will have to travel
outside her community.
Providers are encouraged to
develop initial management
skills that are within the scope
of their specialty and practice to
meet local patient needs.
Patients should be counseled
about limitations in local
resources at the time of testing.
Annual screening of adolescents for
depressive disorders, using a validated tool,
is recommended. (Qualified)
AMA: Screen adolescents who
may be at risk as a result of
family problems, drug or
alcohol use, or other
indicators of risk. (Guidelines
for Adolescent Preventive
Services (GAPS):
Screening postpartum adolescents for
depression, using a validated tool, is
recommended. (Qualified)
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Recommendations
Monograph. American
Medical Association. Chicago:
American Medical Assoc;
1997; cited in USPSTF 2002
recommendations for
screening for
depression, http://annals.org/
article.aspx?articleid=715291#
r13-12; also cited in 2009
update of USPSTF
recommendations but the
AMA source is not provided.)
AAP: Ask questions about
depression in routine historytaking throughout
adolescence. Patients with
depression risk factors should
be identified and
systematically monitored over
time for the development of a
depressive disorder.
(Guidelines for Adolescent
Depression in Primary Care I.)
AAFP: Screen for major
depressive disorder when
systems are in place to ensure
accurate diagnosis,
psychotherapy (cognitivebehavioral or interpersonal),
and follow-up. (AAFP,
Depression)
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AWHONN: Health care
facilities that serve pregnant
women, new mothers and
newborns should have routine
screening protocols and
educational mechanisms for
staff training and education
related to postpartum mood
and anxiety disorders. (The
Role of the Nurse in
Postpartum Mood and Anxiety
Disorders)
ACOG: Recommends asking
annually about emotions and
behaviors that indicate
recurrent or severe
depression and thoughts of
killing or harming themselves.
(GAHC p. 37)
ACOG: Recommends
screening in practices that
have systems in place to
ensure accurate diagnosis,
treatment, and follow up.
(GWHC 2014, Chapter 3Z)
ACNM: Recommends
universal screening, treatment
and/or referral for depression
as part of routine primary
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Well-Woman Task Force 2013-2014
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health care. Recommends
increasing the number of
postpartum visits for all
women. (ACNM Position
Statement: Depression in
Women)
Adults (19 and older)
See also Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment; Preconception/Interconception Care; Sleep
Disorders
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
USPSTF: Recommends against
routinely screening adults for
depression when staff-assisted
depression care supports are not in
place. There may be considerations
that support screening for
depression in an individual patient.
(Screening for Depression in Adults
[Grade C])
AWHONN: Health care
facilities that serve pregnant
women, new mothers and
newborns should have routine
screening protocols and
educational mechanisms for
staff training and client
education related to
postpartum mood and anxiety
disorders. (The Role of the
Nurse in Postpartum Mood
and Anxiety Disorders)
Patients should not be denied
recommended screening
because of any limitation of
local resources. Rather,
providers should have plans for
referral, even if it means the
patient will have to travel
outside her community.
Providers are encouraged to
develop initial management
skills that are within the scope
of their specialty and practice to
meet local patient needs.
Patients should be counseled
about limitations in local
resources at the time of testing.
USPSTF: Recurrent screening may
be most productive in patients with
a history of depression,
unexplained somatic symptoms,
comorbid psychological conditions
(eg, panic disorder or generalized
anxiety), substance abuse, or
chronic pain. Recommends
AAFP: Do not screen when
staff-assisted depression care
supports are not in place.
(AAFP, Depression)
Final WWTF Recommendation
Annual screening for depression, using a
validated tool, is recommended. (Qualified)
Screening postpartum women for
depression, using a validated tool, is
recommended. (Qualified)
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Well-Woman Task Force 2013-2014
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screening adults for depression
when staff-assisted depression care
supports are in place to assure
accurate diagnosis, effective
treatment, and follow-up.
(Screening for Depression in Adults
[Grade B])
AAFP: Screen when staffassisted depression care
supports are in place to assure
accurate diagnosis, effective
treatment, and follow-up.
(AAFP, Depression)
ACOG: Evaluate and counsel
women for suicide and
depressive symptoms. (Annual
Women's Health Care)
ACOG: Recommends
screening in practices that
have systems in place to
ensure accurate diagnosis,
treatment, and follow up.
(GWHC 2014, Chapter 3Z)
ACNM: Recommends
universal screening, treatment
and/or referral for depression
as part of routine primary
health care. Recommends
increasing the number of
postpartum visits for all
women. (ACNM Position
Statement: Depression in
Women)
PCHHC: Providers should
screen and be vigilant for
depression and anxiety
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Well-Woman Task Force 2013-2014
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disorders among women of
reproductive age because
treating or controlling these
conditions before pregnancy
may help prevent negative
pregnancy and family
outcomes. Women of
reproductive age with
depressive and anxiety
disorders who are planning a
pregnancy or who could
become pregnant should be
informed about the potential
risks of an untreated illness
during pregnancy and about
the risks and benefits of
various treatments during
pregnancy.
(The Clinical Content of
Preconception Care [B III])
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Individual Recommendation Evidence Grid
Topic: Diabetes
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Cardiovascular Disease; Diabetes Postpartum; Diet, Fitness, and Nutrition; Obesity
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
There is no recommendation for
routine screening in
asymptomatic adolescents.
Routine screening for diabetes in
adolescents is not recommended except for
those who are obese (ie, BMI of 30 or
higher). (Qualified)
Adults (Women of Reproductive Age; Perimenopause/Menopause])
See also Cardiovascular Disease; Diabetes Postpartum; Diet, Fitness, and Nutrition; Obesity
Evidence-Based
Evidence-Informed
Uniform
Final WWTF
Expert
Recommendation
Agreement
76
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
USPSTF: Screen for diabetes in adults with
blood pressure over 130/85 mm Hg. (Ann
Intern Med. 2008 Jun 3;148(11):846-54.
Screening for type 2 diabetes mellitus in adults:
U.S. Preventive Services Task Force
recommendation statement. U.S. Preventive
Services Task Force.
http://www.uspreventiveservicestaskforce.org/
uspstf08/type2/type2rs.pdf)
AAFP: Screen asymptomatic adults with sustained blood
pressure (either treated or untreated) greater than 135/80 mm Hg..
(http://www.aafp.org/dam/AAFP/documents/patient_care/
clinical_recommendations/October2012SCPS.pdf)
ACOG: Begin screening every 3 years beginning at age 45, more
frequently if risk factors are present.
(http://www.acog.org/About_ACOG/ACOG_Departments/
Annual_Womens_Health_Care/Assessments_and_Recommendations)
Currently
there is no
expert
consensus.
Screening for
diabetes is
recommended
every 3 years
beginning age 45
or earlier for
those with risk
factors for
diabetes. (Strong)
American Diabetes Association: Begin screening every 3 years
beginning at age 45, more frequently if risk factors are present.
(Executive summary: Standards of medical care in diabetes--2013.
Diabetes Care. 2013 Jan;36 Suppl 1:S4-10. doi: 10.2337/dc13-S004.
http://care.diabetesjournals.org/content/36/Supplement_1/S4.full)
AACE: Begin screening at age 30.
(http://outpatient.aace.com/prediabetes/screening-and-monitoringprediabetes)
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Topic: Diabetes Postpartum
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
All Women of Reproductive Capacity
See also Diabetes
Evidence-Based
Evidence-Informed
ACOG: Recommends screening 6–12 weeks postpartum, then every
3 years. (Gestational diabetes mellitus. Practice Bulletin No. 137.
American College of Obstetricians and Gynecologists. Obstet
Gynecol 2013; 122:406–16.)
American Diabetes Association: Recommends screening 6–12
weeks postpartum, then every 3 years. (Executive summary:
Standards of medical care in diabetes--2013. Diabetes Care. 2013
Jan;36 Suppl 1:S4-10. doi: 10.2337/dc13-S004.
http://care.diabetesjournals.org/content/36/Supplement_1/S4.full)
Uniform Expert
Agreement
Final WWTF Recommendation
Laboratory screening for
diabetes is recommended at
6–12 weeks postpartum. For
patients with a history of
gestational diabetes, follow-up
screening at least every 3
years is recommended.
(Strong)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Diet, Fitness, Nutrition
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents and Adults (All ages)
See also Cardiovascular Disease, Obesity, Preconception/Interconception Care
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
USPSTF: Recommends intensive
behavioral dietary counseling for
adult patients with hyperlipidemia
and other known risk factors for
cardiovascular and diet-related
chronic disease. All adult patients
should be screened for obesity
and offered intensive counseling
and behavioral interventions.
(http://www.uspreventiveservices
taskforce.org/3rduspstf/diet/dietr
r.pdf, Behavioral counseling in
primary care to promote a healthy
diet: recommendations and
rationale. U.S. Preventive Services
Task Force et al. Am Fam
Physician. (2003)
ACOG: Recommends intensive
behavioral dietary counseling
for adult patients with
hyperlipidemia and other
known risk factors for
cardiovascular and dietrelated chronic disease. All
adult patients should be
screened for obesity and
offered intensive counseling
and behavioral interventions.
Also recommends evaluation
and counseling on physical
activity.
(http://www.acog.org/About_
ACOG/ACOG_Departments/
Annual_Womens_Health_Car
All agree that diet, nutrition,
exercise are keys to good health
and improved health and can
prevent illness. However, the
science on how this is best
accomplished is debatable.
Routine weight assessment using BMI
calculation is recommended. For
women with risk factors for dietrelated chronic disease, BMI <19, or
BMI >25, assessment of diet,
nutritional status, and physical
activity, followed by intensive
counseling and behavioral
interventions, is recommended.
(Qualified)
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Well-Woman Task Force 2013-2014
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e/Assessments_and_Recomm
endations)
American Dietetic Association:
Recommends intensive
behavioral dietary counseling
for adult patients with
hyperlipidemia and other
known risk factors for
cardiovascular and dietrelated chronic disease. All
adult patients should be
screened for obesity and
offered intensive counseling
and behavioral interventions.
Also recommends evaluation
and counseling on physical
activity. (Maillet JO, Young EA.
Nutrition education for
healthcare professionals:
Position of the ADA. J Am Diet
Assoc 1998;98:343-346.)
AAP Bright Futures:
Recommends assessing BMI
annually.
(http://www.aap.org/enus/professionalresources/practicesupport/Periodicity/Periodicit
y%20Schedule_FINAL.pdf)
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Topic: Domestic and Intimate Partner Violence
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
USPSTF: Current evidence
is insufficient to assess the
balance of benefits and harms of
primary care interventions to
prevent child maltreatment (0-18
years). (Primary Care
Interventions to Prevent Child
Maltreatment [I statement])
AAP: Consider screening
adolescents if they say they
have a new intimate partner,
when signs or symptoms raise
concerns, or during any
prenatal visits. (Performing
Preventive Services: A Bright
Futures Handbook.)
USPSTF: Recommends that
clinicians screen women of
childbearing age for intimate
partner violence such as domestic
violence and provide or refer
women who screen positive to
intervention services. (Screening
for Intimate Partner Violence and
ACOG: Screen periodically in
all women (eg, annual visit,
new patient, and postpartum
visit) and in women at risk
(signs of depression,
substance abuse, mental
health problems, requests for
repeat pregnancy tests when
AAP: Screen for intimate partner
violence and sexual coercion at
least annually and with each
new partner (if a patient has
multiple repeat visits for
pregnancy testing, STI testing,
etc, consider these as clinical
indictors to assess more
frequently). (Performing
Preventive Services: A Bright
Futures Handbook.)
Adolescents (13-18)
See also Preconception Care
Screening is recommended at least
annually for intimate partner violence,
such as domestic violence or reproductive
or sexual coercion. Provide or refer
women who screen positive to
intervention services. (Strong)
ACOG/FWV: Signs or symptoms
of abuse or neglect should
prompt risk assessment.
Evidence of neglect or abuse
must be reported to law
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Abuse of Elderly and Vulnerable
Adults [Grade B])
woman does not wish to be
pregnant, new or recurrent
STDs or requesting STD test,
expressing fear when
negotiating condom use). (CO
518)
enforcement agencies as
required by state or federal laws
and regulations. (Futures
Without Violence)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
IOM: Screening and counseling
involve elicitation of information
from women and adolescents
about current and past violence
and abuse in a culturally sensitive
and supportive manner to address
current health concerns about
safety and other current or future
health problems. (Clinical
Preventive Services for Women:
Closing the Gaps)
ACOG: Screen periodically in
all women (eg, annual visit,
new patient, and postpartum
visit) and in women at risk
(signs of depression,
substance abuse, mental
health problems, requests for
repeat pregnancy tests when
woman does not wish to be
pregnant, new or recurrent
STDs or requesting STD test,
AAP: Screen for intimate partner
violence and sexual coercion at
least annually and with each
new partner (if a patient has
multiple repeat visits for
pregnancy testing, STI testing,
etc, consider these as clinical
indictors to assess more
frequently). (Performing
Preventive Services: A Bright
Futures Handbook.)
IOM: Screening and counseling
involve elicitation of information
from women and adolescents
about current and past violence
and abuse in a culturally sensitive
and supportive manner to address
current health concerns about
safety and other current or future
health problems. (Clinical
Preventive Services for Women:
Closing the Gaps)
Adults (All ages)
See also Preconception Care
Final WWTF Recommendation
Screening is recommended at least annually
for intimate partner violence, such as
domestic violence or reproductive or sexual
coercion. Provide or refer women who
screen positive to intervention services.
(Recommended)
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USPSTF: Recommends that
clinicians screen women of
childbearing age for intimate
partner violence such as domestic
violence, and provide or refer
women who screen positive to
intervention services. (Screening
for Intimate Partner Violence and
Abuse of Elderly and Vulnerable
Adults; grade B)
USPSTF: Current evidence is
insufficient to assess the balance of
benefits and harms of screening all
elderly or vulnerable adults
(physically or mentally
dysfunctional) for abuse and
neglect. (Screening for Intimate
Partner Violence and Abuse in
Elderly and Vulnerable Adults;
grade I)
expressing fear when
negotiating condom use). (CO
518 )
AAFP: Screen women of
childbearing age for intimate
partner violence and provide
or refer women who screen
positive to intervention
services; this applies to
women who do not have signs
or symptoms of abuse.
(Intimate Partner Violence and
Abuse of Elderly and
Vulnerable Adults; grade B)
ACOG/FWV: Signs or symptoms
of abuse or neglect should
prompt risk assessment.
Evidence of neglect or abuse
must be reported to law
enforcement agencies as
required by state or federal laws
and regulations. (Futures
Without Violence)
AAFP: There is insufficient
evidences to asses the
benefits and harms of
screening elderly and
vulnerable adults for abuse
and neglect. (Intimate Partner
Violence and Abuse of Elderly
and Vulnerable Adults; grade
I)
83
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Topic: Drug Use
Evidence Based
Evidence Informed
Uniform Expert Agreement
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Additional guidelines from
medical societies used for
developing consensus
recommendations.
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Preconception Care
Evidence-Based
USPSTF: Current evidence is
insufficient to assess the balance
of benefits and harms of
screening adolescents, adults, and
pregnant women for illicit drug
use. (Screening for Illicit Drug Use
(I statement)
ACOG: Recommends annual
screening by
questionnaire/history (not
testing) for illicit drugs,
prescription and nonprescription
medications, and performanceenhancing drugs. (ACOG
Guidelines for Adolescent Health
Care)
ACOG: Evaluate and counsel on
substance use other than alcohol
and tobacco. (GAHC p. 104)
Final WWTF Recommendation
AHRQ: Screen by history for
substance use at every health
maintenance exam or initial
pregnancy visit (repeat as
indicated), using a validated
screening tool (improves accuracy
of detecting substance abuse or
dependence). (Screening,
diagnosis and referral for
substance use disorders. Grade D)
At least annual screening for
substance abuse by history (not
lab testing) is recommended.
Provide or refer patients to
counseling as needed. (Strong)
NCQA: HEDIS discusses
engagement in treatment and
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AAP: Evaluation and
counseling/screening are part of
an age-appropriate
comprehensive history.
Recommends annual screening
for alcohol, tobacco, and
substance abuse. Strongly advise
against the use of alcohol,
tobacco, and other illicit drugs by
youth. (Performing Preventive
Services: A Bright Futures
Handbook)
referral for smoking
cessation/alcohol and marijuana
dependence. (Summary Table Of
Measures, Product Lines And
Changes)
PCHHC: A careful history should
be obtained to identify use of
illegal substances as part of the
preconception risk assessment.
Men and women should be
counseled about the risks of using
illicit drugs before and during
pregnancy and offered
information on programs that
support abstinence and
rehabilitation. Contraception
services should be offered, and
pregnancy should be delayed until
individuals are drug-free. (The
Clinical Content of Preconception
Care [C III])
AAFP: Current evidence is
insufficient to assess the balance
of benefits and harms of
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screening adolescents, adults, and
pregnant women for illicit drug
use. (Illicit Drug Use (Grade I)
NAHIC: Recommends annual
screening and counseling for
substance abuse. (Summary of
Recommended Guidelines for
Clinical Preventive Services)
Adults (All ages)
See also Preconception Care
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
USPSTF: Current evidence is
insufficient to assess the balance
of benefits and harms of screening
adolescents, adults, and pregnant
women for illicit drug use.
(Screening for Illicit Drug Use (I
statement)
ACOG: Evaluate and counsel
on substance use other than
alcohol and tobacco. (Annual
Women's Health Care)
AHRQ: Screen by history for
substance use at every health
maintenance exam or initial
pregnancy visit (repeat as
indicated), using a validated
screening tool (improves
accuracy of detecting substance
abuse or dependence).
(Screening, diagnosis and
referral for substance use
disorders, Grade D.)
At least annual screening for substance
abuse by history (not lab testing) is
recommended. Provide or refer patients to
counseling as needed. (Strong)
PCHHC: A careful history
should be obtained to identify
use of illegal substances as
part of the preconception risk
assessment. Men and women
should be counseled about
the risks of using illicit drugs
before and during pregnancy
and offered information on
programs that support
abstinence and rehabilitation.
Contraception services should
NCQA: HEDIS discusses
engagement in treatment and
referral for smoking
cessation/alcohol and marijuana
dependence. (Summary Table Of
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be offered, and pregnancy
should be delayed until
individuals are drug-free. (The
Clinical Content of
Preconception Care (C III)
Measures, Product Lines And
Changes)
AAFP: Current evidence is
insufficient to assess the
balance of benefits and harms
of screening adolescents,
adults, and pregnant women
for illicit drug use. (Illicit Drug
Use (Grade I)
NAHIC: Recommends annual
screening and counseling for
substance abuse. (Summary of
Recommended Guidelines for
Clinical Preventive Services)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Genetic Screening
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
EvidenceBased (source)
Evidence-Informed (source)
ACOG: If medical or psychosocial
benefits of a genetic test will not accrue
until adulthood, as in the case of carrier
status or adult-onset diseases, genetic
testing generally should be deferred.
(Hereditary breast and ovarian cancer
syndrome. ACOG Practice Bulletin No.
103. American College of Obstetricians
and Gynecologists. Obstet Gynecol
2009;113:957–66.
http://www.acog.org/Resources_And_Pu
blications/Practice_Bulletins/Committee_
on_Practice_Bulletins_-_Gynecology/Hereditary_Breast_and_Ov
arian_Cancer_Syndrome)
Uniform Expert Agreement
Final WWTF Recommendation
For adolescents, if medical or psychosocial
benefits of a genetic test will not accrue until
adulthood (eg, for carrier status or adult-onset
diseases), testing generally should be deferred
until adulthood or until the adolescent has
developed mature decision-making capacities.
(Qualified)
AAP/ACMGG: Genetic testing for adultonset conditions generally should be
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
deferred until adulthood or until an
adolescent interested in testing has
developed mature decision-making
capacities. It is inappropriate to test for
late-onset disorders when genetic
information has not been shown to
reduce morbidity and mortality through
interventions initiated in childhood.
Routine carrier testing in minors is not
supported when such testing does not
provide health benefits in childhood.
(Ethical and Policy Issues in Genetic
Testing and Screening of Children
http://pediatrics.aappublications.org/con
tent/131/3/620.full.html)
Adults (All ages)
See also Dyslipidemia/Cardiovascular Disease, Ovarian Cancer
Evidence-Based (source)
Evidence-Informed
BRCA Screening
ACOG: Recommends that all
women receive a family history
evaluation as a screening tool for
inherited risk. Family history
information should be reviewed
and updated regularly, especially
when there are significant
changes to family history. Where
appropriate, further evaluation
should be considered for positive
USPSTF: Recommends that women who have family
members with breast, ovarian, tubal, or peritoneal cancers
be screened with one of several screening tools designed to
identify increased risk for potentially harmful mutations in
BRCA1 or BRCA2 genes. Women with positive screening
results should receive genetic counseling and, if indicated,
BRCA testing.
(2013, http://www.uspreventiveservicestaskforce.org/uspstf
Uniform Expert
Agreement
Final WWTF
Recommendation
Genetic screening for
BRCA1 or BRCA2 is
recommended for women
whose personal or family
history is associated with
an increased risk for
potentially harmful
mutations in BRCA1 or
BRCA2 genes. Women
with positive screening
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Well-Woman Task Force 2013-2014
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/uspsbrgen.htm; grade B recommendation)
responses, with referral to
genetic testing and counseling as
needed. (Family history as a risk
assessment tool. Committee
Opinion No. 478. American
College of Obstetricians and
Gynecologists. Obstet Gynecol
2011;117:747–50.)
results should receive
genetic counseling and, if
indicated after counseling,
BRCA testing. (Strong)
AAFP: Recommends referral for
genetic counseling and
evaluation for BRCA testing for
women whose family history is
associated with an increased risk
for deleterious mutations in
BRCA1 or BRCA2.
(http://www.aafp.org/patientcare/clinicalrecommendations/all/breastcancer.html)
ACOG: Genetic risk assessment is
recommended for women with
greater than an approximate 2025% chance of having an
inherited predisposition to breast
cancer and ovarian cancer.
Genetic risk assessment may be
helpful for women with greater
than an approximate 5-10%
chance of having an inherited
predisposition to breast and
ovarian cancer. (Hereditary
breast and ovarian cancer
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
syndrome. ACOG Practice
Bulletin No. 103. American
College of Obstetricians and
Gynecologists. Obstet Gynecol
2009;113:957–66.
http://www.acog.org/Resources_
And_Publications/Practice_Bullet
ins/Committee_on_Practice_Bull
etins_-_Gynecology/Hereditary_Breast_
and_Ovarian_Cancer_Syndrome)
USPSTF: Recommends against routine referral for genetic
counseling or routine breast cancer susceptibility gene
(BRCA) testing for women whose family history is not
associated with an increased risk for deleterious mutations
in breast cancer susceptibility gene 1 (BRCA1) or breast
cancer susceptibility gene 2 (BRCA2). (2013,
http://www.uspreventiveservicestaskforce.org/uspstf/uspsb
rgen.htm; grade D recommendation)
AAFP: Recommends against
routine referral for genetic
counseling for BRCA testing for
women whose family history is
not associated with increased risk
for deleterious mutation in
BRCA1 or BRCA2.
(http://www.aafp.org/patientcare/clinicalrecommendations/all/breastcancer.html)
Genetic Screening for Cardiovascular Disease
AAFP: Recommends against
genomics profile to assess risk for
CVD.
(http://www.aafp.org/patientcare/clinicalrecommendations/all/cvd.html)
EGAPP: There is insufficient
evidence to recommend testing
for the 9p21 genetic variant or 57
Routine genetic
counseling or BRCA testing
is not recommended for
women who do not have a
personal or family history
associated with an
increased risk for
potentially harmful
mutations in BRCA1 or
BRCA2 genes. (Strong)
Recommend
against genomics
profile to asses
risk for CVD, as
current evidence
finds the net
health benefit to
be negligible.
Testing for genetic
variants to assess for risk
of cardiovascular disease
in the general population
is not recommended.
(Strong)
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Well-Woman Task Force 2013-2014
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other variants in 28 genes to
assess risk for cardiovascular
disease (CVD) in the general
population, specifically heart
disease and stroke. The
magnitude of net health benefit
from use of any of these tests
alone or in combination is
negligible. Clinical use is
discouraged unless further
evidence supports improved
clinical outcomes. Based on the
available evidence,
the overall certainty of net health
benefit is deemed “low.”
(Recommendations from the
Evaluation of Genomic
Applications
in Practice and Prevention
Working Group: Genomic
profiling to assess cardiovascular
risk to
improve cardiovascular health
Evaluation of Genomic
Applications in Practice and
Prevention (EGAPP) Working
Group* Genetics IN Medicine •
Volume 12, Number 12,
December 2010)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Hearing
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (All ages)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
USPSTF: There is insufficient
evidence to assess the benefits or
harms of screening for hearing loss
in asymptomatic adults
50 and older (who show no signs or
symptoms of hearing loss).
(http://www.uspreventiveservicest
askforce.org/uspstf11/adulthearin
g/adulthearrs.htm)
AAFP: There is insufficient
Hearing screening in adults who Hearing screening in adults who show no
show no signs or symptoms of
signs or symptoms of hearing loss is not
evidence to assess the
benefits or harms of screening hearing loss is not recommended. recommended. (Strong)
for hearing loss in
asymptomatic adults 50 and
older (who show no signs or
symptoms of hearing loss).
http://www.aafp.org/patientcare/clinicalrecommendations/all/hearing)
h l
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Topic: Hepatitis B Screening
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Uniform Expert Agreement
Final WWTF Recommendation
Adolescents and Adults (All ages)
See also Immunization
Evidence-Based (source)
USPSTF: Recommends against
routinely screening the general
asymptomatic population for
chronic hepatitis B virus infection.
(2004,
http://www.uspreventiveservicest
askforce.org/uspstf/uspshepb.htm
; grade D recommendation)
Evidence-Informed
(source)
Routine screening of the general population
for chronic hepatitis B infection is not
recommended. (Strong)
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USPSTF: Recommends
ACOG: Recommends routine
screening pregnant women for
prenatal screening of all
hepatitis B infection at their
pregnant women by hepatitis B
first prenatal visit. (2009,
surface antigen (HBsAg) testing.
http://www.uspreventiveservic
(2007, Practice Bulletin no. 86,
estaskforce.org/uspstf/uspshep
reaffirmed 2012,
bpg.htm; grade A
http://www.guideline.gov/cont
recommendation)
ent.aspx?id=12627; level A
recommendation)
Screening pregnant women for hepatitis B
infection is recommended at the first
prenatal visit. (Strong)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Hepatitis C Screening
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents and Adults (All ages)
Evidence-Based (source)
USPSTF: Recommends screening
for hepatitis C virus infection in
persons at high risk for infection.
Recommends offering one- time
screening for HCV infection to
adults born between 1945 and
1965. (2013,
http://www.uspreventiveservicest
askforce.org/uspstf12/hepc/hepcfi
nalrs.htm; grade B
recommendation)
Evidence-Informed (source)
AAFP: Recommends
screening for hepatitis C
virus (HCV) infection in
persons at high risk for
infection. Recommends
offering one-time screening
for HCV infection to adults
born between 1945 and
1965. (2013,
http://www.aafp.org/patien
t-care/clinicalrecommendations/all/hepat
itis.html)
Uniform Expert
Agreement
Final WWTF Recommendation
Screening for hepatitis C virus
is recommended for women at high risk
for infection. (Strong)
One-time screening for HCV infection
should be offered to women born between
1945 and 1965. (Strong)
ACOG: Recommends onetime testing for persons
born from 1945 through
1965 and unaware of
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
their infection status.
(http://www.acog.org/Ab
out_ACOG/ACOG_Depart
ments/Annual_Womens_
Health_Care/Assessment
s_and_Recommendation
s)
CDC: Adults born during
1945 through 1965 should
be tested once for hepatitis
C virus (HCV) infection
without prior ascertainment
of HCV risk factors.
Recommends routine testing
of asymptomatic persons at
high risk for HCV infection
(see risk factors in:
Recommendations for
Prevention and Control of
Hepatitis C Virus (HCV)
Infection and HCV-Related
Chronic Disease; MMWR
1998;47(RR-19)).
(Recommendations for the
Identification of Chronic
Hepatitis C Virus Infection
Among Persons Born During
1945–1965 (MMWR
2012;61(RR04);118; http://www.cdc.gov/hep
atitis/HCV/GuidelinesC.htm)
PCHHC: Recommends
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
screening for high-risk
women. Women who are
positive for hepatitis C and
desire pregnancy should be
counseled regarding the
uncertain infectivity, the link
between viral load and
neonatal transmission, the
importance of avoiding
hepatotoxic drugs, and the
risk of chronic liver disease.
(Floyd RL, Johnson KA,
Owens JR, Verbiest S, Moore
CA, Boyle C. A national action
plan for promoting
preconception health and
health care in the United
States (2012-2014). J
Womens Health (Larchmt).
2013 Oct;22(10):797-802.)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Hypothyroidism
Evidence Based
Foundation for WWTF
recommendations. Primarily USPSTF,
IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion
alone
USPSTF: There is fair evidence that
the thyroid-stimulating hormone
(TSH) test can detect subclinical
thyroid disease in people without
symptoms of thyroid dysfunction but
poor evidence that treatment
improves clinically important
outcomes in adults with screendetected thyroid disease. The
evidence is insufficient to
recommend for or against routine
screening for thyroid disease in
adults.
(http://www.uspreventiveservicesta
skforce.org/uspstf/uspsthyr.htm)
AAFP: The evidence is
insufficient to recommend
for or against routine
screening for thyroid disease
in adults. Ultrasound
screening for thyroid cancer
in asymptomatic patients is
not recommended.
(http://www.aafp.org/patien
t-care/clinicalrecommendations/all/thyroid
.html)
There is insufficient evidence for
routine screening for
hypothyroidism in
asymptomatic low-risk women,
as available evidence does not
show that diagnosis and
treatment improves outcome.
Routine screening is not recommended for
asymptomatic women at low risk. (Strong)
ACOG: In women 19 and
older, examine thyroid.
Thyroid-stimulating hormone
(TSH) screening is
recommended for women
ages 19–49 at high risk (ie,
strong family history of
thyroid disease, autoimmune
disease). TSH screening is
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
recommended every 5 years
beginning at age 50.
(http://www.acog.org/About
_ACOG/ACOG_Departments/
Annual_Womens_Health_Car
e/Assessments_and_Recom
mendations)
AACE/ATA: Screening for
hypothyroidism should be
considered in patients over
the age of 60. “Aggressive
case finding” (rather than
universal screening) should
be considered in those at
increased risk for
hypothyroidism.
(http://thyroidguidelines.net
/hypothyroidism; Endocr
Pract. 2012 NovDec;18(6):988-1028. Clinical
practice guidelines for
hypothyroidism in adults:
cosponsored by the American
Association of Clinical
Endocrinologists and the
American Thyroid
Association. Garber JR1,
Cobin RH, Gharib H,
Hennessey JV, Klein I,
Mechanick JI, Pessah-Pollack
R, Singer PA, Woeber KA;
American Association of
Clinical Endocrinologists and
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
American Thyroid Association
Taskforce on Hypothyroidism
in Adults.)
AACE/ATA: Universal
screening is not
recommended for patients
who are pregnant or are
planning pregnancy,
including those undergoing
assisted reproduction.
“Aggressive case finding”
(rather than universal
screening) should be
considered for patients who
are planning pregnancy.
(http://thyroidguidelines.net
/hypothyroidism)
AACE/ATA: “Aggressive case
finding” (rather than
universal screening) should
be considered in those at
increased risk for
hypothyroidism. Screening is
suggested for those with the
following:
-Autoimmune disease, such
as type 1 diabetes
-Pernicious anemia
-A first-degree relative with
autoimmune thyroid disease
-A history of neck radiation to
While there is evidence to
suggest that subclinical
hypothyroidism in early
pregnancy may be associated
with impaired intellectual and
psychomotor development, a
randomized control trial did not
demonstrate improvement with
levothyroxine supplementation.
(Lazarus JH, Bestwick JP,
Channon S et al. Antenatal
thyroid screening and childhood
cognitive function. NEJM
2012;366:493-501)
Universal screening is not recommended
for patients who are pregnant or are
planning pregnancy, including those
undergoing assisted reproduction.
(Qualified)
Screening for hypothyroidism is
recommended in symptomatic and highrisk patients. (Strong).
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
the thyroid gland, including
radioactive iodine therapy for
hyperthyroidism and external
beam radiotherapy for head
and neck malignancies
-A prior history of thyroid
surgery or dysfunction
-An abnormal thyroid
examination
-Psychiatric disorders
-Taking amiodarone or
lithium
-Additional diagnoses:
Adrenal insufficiency
Alopecia
Anemia, unspecified
deficiency
Cardiac dysrhythmia,
unspecified
Changes in skin texture
Congestive heart failure
Constipation
Dementia
Diabetes mellitus, type 1
Dysmenorrhea
Hypercholesterolemia
Hypertension
Mixed hyperlipidemia
Malaise and fatigue
Myopathy, unspecified
Prolonged QT interval
Vitiligo
Weight gain
(http://www.thyroidguidelin
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Individual Recommendation Evidence Grid
es.net/sites/thyroidguideline
s.net/files/file/thy.2012.0205
.pdf)
103
Well-Woman Task Force 2013–2014
Individual Recommendation Evidence Grid
Topic: Immunizations
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents and Adults (All Ages)
See also Cervical Cancer, Hepatitis B, Preconception/Interconception Care
Evidence-Based
ACIP: Recommends routine vaccines for children, adolescents, and
adults according to its published immunization schedule. (Birth-18
Years & "Catch-up" Immunization
Schedules, http://www.cdc.gov/vaccines/schedules/hcp/childadolescent.html; Recommended Adult Immunization Schedule, by
Vaccine and Age
Group, http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html)
Evidence-Informed
Uniform Expert
Agreement
Recommend following
ACIP guidelines for all
immunizations.
Final WWTF
Recommendation
Immunization is
recommended according
to the schedule and
protocols outlined by
the ACIP. (Strong)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Injury Prevention
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Alcohol Misuse, Domestic and Intimate Partner Violence, Drug Use, Tobacco Use
Evidence-Based
Evidence-Informed
USPSTF: There is insufficient
evidence to assess the
incremental benefit, beyond the
efficacy of legislation and
community-based interventions,
of counseling in the primary care
setting in improving rates of
proper use of motor vehicle
occupant restraints (child safety
seats, booster seats, and lap-andshoulder belts).
(http://www.uspreventiveservices
taskforce.org/uspstf07/mvoi/mvoi
rs.pdf; Ann Intern Med. 2007 Aug
7;147(3):187-93; Counseling
AAP: Integrate counseling about preventing
unintentional injury into every well-child visit.
Adolescent counseling should be part of a broader
discussion of healthy lifestyle choices, especially the
avoidance of alcohol, tobacco, or other drug use.
(http://pediatrics.aappublications.org/content/119/1/20
2.full?sid=ac96961f-52bf-4f1d-9da1-1744e9a2e0f9#sec5)
Uniform
Expert
Agreement
Recommend
incorporating
AAP
guideline.
Final WWTF Recommendation
Discussion of injury prevention is
recommended as part of every wellchild visit. Adolescent counseling
should be part of a broader
discussion of healthy lifestyle
choices, especially the avoidance of
alcohol, tobacco, or other drug use.
(Strong)
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Well-Woman Task Force 2013-2014
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about proper use of motor vehicle
occupant restraints and avoidance
of alcohol use while driving: U.S.
Preventive Services Task Force
recommendation statement.)
Adults (65 and older)
See also Domestic and Intimate Partner Violence
Evidence-Based
USPSTF: Recommends exercise or physical therapy and
vitamin D supplementation to prevent falls in
community-dwelling adults aged 65 years or older
who are at increased risk for falls. There is insufficient
evidence for or against vision correction, medication
discontinuation, protein supplementation, education
or counseling, and home hazard modification. (Grade
B Recommendation; Ann Intern Med. 2012 Aug
7;157(3):197-204. Prevention of falls in communitydwelling older adults: U.S. Preventive Services Task
Force recommendation statement,
http://www.uspreventiveservicestaskforce.org/uspstf
11/fallsprevention/fallsprevrs.pdf)
USPSTF: Recommends against automatically
performing an in-depth multifactorial risk assessment
in conjunction with comprehensive management of
identified risks to prevent falls in community-dwelling
adults aged 65 years or older because the likelihood of
benefit is small. In determining whether this service is
Evidence-Informed
Uniform Expert
Agreement
Final WWTF Recommendation
Recommend following
the USPSTF approach
and individualizing
assessment.
Automatically performing an in-depth
multifactorial risk assessment in
conjunction with comprehensive
management of identified risks to
prevent falls in community-dwelling
adults aged 65 years or older is not
Clinicians should recommend exercise
or physical therapy and vitamin D
supplementation to prevent falls in
community-dwelling adults aged 65
years or older who are at increased risk
for falls. (Strong)
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Well-Woman Task Force 2013-2014
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appropriate in individual cases, patients and clinicians
should consider the balance of benefits and harms on
the basis of the circumstances of prior falls, comorbid
medical conditions, and
patient values. (Grade C Recommendation, Ann Intern
Med. 2012 Aug 7;157(3):197-204. Prevention of falls in
community-dwelling older adults: U.S. Preventive
Services Task Force recommendation statement.
Moyer VA1; U.S. Preventive Services Task Force.
http://www.uspreventiveservicestaskforce.org/uspstf
11/fallsprevention/fallsprevrs.pdf)
recommended because the likelihood
of benefit is small. Individual factors
such as history and circumstances of
prior falls and comorbidities should be
considered In determining whether this
service is appropriate in individual
cases (Qualified)
107
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Kidney Disease
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (All ages)
Evidence-Based
Evidence-Informed
Uniform Expert
Agreement
Final WWTF
Recommendation
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USPSTF: There is
ACP: Recommends against screening for chronic kidney disease
insufficient evidence in asymptomatic adults without risk factors.
to assess the balance (http://www.sciencedaily.com/releases/2013/10/13102121170
of benefits and
8.htm)
harms of routine
screening for chronic ASN: Strongly recommends screening even in the absence of
kidney disease in
risk factors.
asymptomatic adults. (http://www.nephrologynews.com/articles/109817-asn(http://www.uspreve disagrees-with-new-guidelines-says-adults-should-bentiveservicestaskforc screened-for-kidney-disease)
e.org/uspstf12/kidne
y/ckdfinalrs.htm)
NKF: Recommends screening for at-risk individuals
18 years or older (risks include diabetes,
hypertension, family history of kidney disease).
(https://www.kidney.org/professionals/kdoqi/guidel
ines_ckd/p4_class_g3.htm)
Recommend against screening for
chronic kidney disease in
asymptomatic adults without risk
factors, based on lack of evidence to
assess the balance of benefits and
harms.
Routine screening for
chronic kidney disease
in asymptomatic adults
is not recommended.
(Qualified)
The major risk factors include
diabetes, hypertension, and
cardiovascular disease. The current
evidence is insufficient to evaluate
the benefits and harms of screening
in asymptomatic adults with risk
factors.
109
Topic: Mammography
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC
guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or
outlines expert opinion that
does not have a strong
evidence foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based
or evidence-informed guidelines
“Qualified” = Based on expert
opinion alone
Adults (All Ages)
These mammography guidelines are not intended to apply to women at increased risk of breast cancer, symptomatic women undergoing
diagnostic mammography, or women with a history of breast cancer receiving follow-up mammograms.
Evidence-Based
Evidence-Informed
Age < 50 years
ACOG: Women aged 40 years and older should have
annual mammograms.
(http://www.guideline.gov/content.aspx?id=34275)
USPSTF: The decision to
start regular, biennial
screening
mammography before
the age of 50 years
should be an individual
one and take patient
context into account,
including the patient's
values regarding
specific benefits and
harms. (Grade C
recommendation;
ACP: Breast cancer risk is not evenly distributed in women
between the ages of 40 and 49. Thus, the benefits of
screening mammography are not uniformly applicable in
women in this age group. For women ages 40 to 49,
individualized assessment of risk for breast cancer to
guide decisions about mammography screening is
recommended. Base screening on benefits and harms,
women's preference, and risk. (Qaseem A, Snow V, Sherif
K et al, Clinical Efficacy Assessment Subcommittee of the
American College of Physicians; Screening Mammography
Uniform Expert
Agreement
The WWTF agrees
with the USPSTF that
“Mammography
screening reduces
breast cancer
mortality for women
aged 39-69 years: data
are insufficient for
older women. Falsepositive
mammography and
results and additional
imaging are common.”
(Nelson HD, Tyne K,
Final WWTF
Recommendation
For women aged 40
and older, the decision
to start or terminate
regular screening
mammography should
be individualized and
should take into
account patient
context, including an
assessment of breast
cancer risk,
comorbidities, and the
patient's values
regarding specific
110
Nelson HD, Tyne K, Naik
A, Bougatsos C, Chan
BK, Humphrey L.
Screening for breast
cancer: an update for
the U.S. Preventive
Services Task Force. U.S.
Preventive Services
Task Force. Ann Intern
Med 2009;151:727-37;
W237–42.)
Ages 50–74 years
USPSTF: Recommends
biennial screening
mammography for
women between the
ages of 50 and 74 years.
(Grade B
recommendation;
Nelson HD, Tyne K, Naik
A, Bougatsos C, Chan
BK, Humphrey L.
Screening for breast
cancer: an update for
the U.S. Preventive
Services Task Force. U.S.
Preventive Services
Task Force. Ann Intern
Med 2009;151:727-37;
W237–42.)
for Women 40 to 49 Years of Age: A Clinical Practice
Guideline from the American College of Physicians. Annals
of Internal Medicine. 2007 Apr;146(7):511-515.)
AAFP: Mammography before age 50 should be
individualized and take into account patient context,
including risks, values, and harms.
(http://www.aafp.org/patient-care/clinicalrecommendations/all/breast-cancer.html)
AWHONN: Supports access for women to screening
mammography and other health care services based on
an assessment for breast cancer risk. (AWHONN Position
statement on breast cancer screening. JOGNN 2010,
39:608-610.)
CTFPHC: Current evidence regarding the effectiveness of
screening mammography does not suggest the inclusion
of the manoeuvre or its exclusion from the periodic
health examination of women aged 40-49 years at
average risk of breast cancer (grade C recommendation).
Upon reaching the age of 40, Canadian women should be
informed of the potential benefits and risks of screening
mammography and assisted in deciding at what age they
wish to initiate the manoeuvre (every 12–18 months).
(Ringash J, with the Canadian Task Force on Preventive
Health Care. Preventive health care 2001 update:
screening mammography among women aged 40-49
years at average risk of breast cancer. CMAJ 2001 ;
164(4): 469)
AWHONN: “Risk assessment for breast cancer includes
Naik A, et al.
Screening for breast
cancer: an update for
the US preventive
services task force.
Ann Intern Med
2009;151:727-737.
Page 727).
Biennial screening
achieves most, but not
all, of the benefit of
annual screening with
less harm. “Decisions
about the best
strategy depend on
program and
individual objectives
and the weight placed
on benefits, harms
and resource
considerations.”
(Mandelblatt JS,
Cronin KA, Bailey S, et
al. Effects of
mammography
screening under
different screening
schedules: model
estimates of potential
benefits and harms.
Ann Intern Med.
benefits and harms of
screening. (Strong)
Routine screening
mammography should
occur by age 50.
(Strong)
The frequency of
routine screening
should take into
account patient context
and should be either
annual or biennial.
(Qualified)
111
Age > 75 years
USPSTF: There is
insufficient evidence to
assess the additional
benefits and harms of
screening
mammography in
women 75 years or
older. (Nelson HD, Tyne
K, Naik A, Bougatsos C,
Chan BK, Humphrey L.
Screening for breast
cancer: an update for
the U.S. Preventive
Services Task Force. U.S.
Preventive Services
Task Force. Ann Intern
Med 2009;151:727-37;
W237–42.)
age; hormonal factors such as early age of menarche,
late age of menopause, late age of first pregnancy,
nulliparity, and use of hormonal therapies; familial
factors including family history of breast cancer and
genetic test results for BRCA mutations; and personal
factors such as personal history of breast cancer, findings
from earlier breast biopsies, and past exposure to chest
irradiation. Other associated risk factors include
postmenopausal obesity, lack of exercise, and alcohol
use.” (AWHONN Position statement on breast cancer
screening. JOGNN 2010, 39:608-610. Page 608. From
American Cancer Society Breast Cancer Facts and Figures
2009-2010. Atlanta, GA 2009)
2009;151:738-747)
ACS: Screening decisions in older women should be
individualized by considering the potential benefits and
risks of mammography in the context of current health
status and estimated life expectancy. As long as a woman
is in reasonably good health and would be a candidate
for treatment, she should continue to be screened with
mammography. (Smith RA, Saslow D, Andrews K, et al.
American Cancer Society Guidelines for breast cancer
screening: Update 2003 Ca J Clin 2003; 54: 141-169)
AAFP: There is insufficient evidence about the benefits
and harms of mammography for women over 75.
(http://www.aafp.org/patient-care/clinicalrecommendations/all/breast-cancer.html)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Depression, Domestic and Intimate Partner Violence, Preconception/Interconception Care
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
AAP: Recommends annual
screening for depression,
suicide, and mental health.
Surveillance at yearly health
supervision visits: continuous
monitoring of a child's
developmental and behavioral
status. May include historytaking and use of structured
parent questionnaires.
(Performing Preventive
Services: A Bright Futures
Handbook.)
During annual preventive care
visits, all adolescents should be
screened for any mental
health disorder by asking
questions (such as those found
in Bright Futures, Third Edition)
that address depressive
symptoms; interpersonal/family
relationships; sexual orientation
and gender identity; personal
goal development;
behavioral/learning disorders;
emotional, physical, and sexual
abuse by family or partner;
school experience; peer
relationships; acquaintance rape
Annual screening of all adolescents for mental
health disorders is recommended. (Strong).
ACOG: Assess and provide
health guidance on
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
psychosocial development
annually. (GAHC p. 30-31)
ACOG: Recommends
psychosocial evaluation for
suicide: depressive symptoms;
interpersonal/family
relationships; sexual
orientation and gender
identity; personal goal
development; behavioral/
learning disorders; emotional,
physical, and sexual abuse by
family or partner; school
experience; peer
relationships;
acquaintance rape prevention,
bullying. (Annual Women's
Health Care)
ACOG: Ask annually about
emotions and behaviors that
indicate recurrent or severe
depression and thoughts of
killing or harming themselves.
(ACOG, GAHC p. 37)
prevention; and bullying.
Annual assessment for emotions and behaviors
that indicate recurrent or severe depression and
thoughts of killing or harming themselves is
recommended. (Strong).
Adults (19-64)
See also Depression, Domestic and Intimate Partner Violence, Preconception/Interconception Care, Sleep
Disorders
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Evidence-Based
Evidence-Informed
ACOG: Evaluate psychosocial aspects of
health: interpersonal/family relationships,
intimate partner violence, work satisfaction,
lifestyle/stress, sleep disorders (all women);
acquaintance rape prevention (19-39);
advance directives (women 40 and older);
neglect/abuse; depression. (Annual Women's
Health Care)
USPSTF: The evidence is insufficient to
recommend for or against routine screening
by primary care clinicians to detect suicide
risk in the general population. (USPSTF,
Screening for Suicide Risk (Grade I)
AAFP: There is insufficient evidence to
recommend for or against routine screening
by primary care clinicians to detect suicide risk
in general population. (AAFP, Suicide (Grade I)
Uniform Expert
Agreement
Final WWTF
Recommendation
Evaluation of psychosocial
aspects of health
(interpersonal/family
relationships, intimate
partner violence, work
satisfaction, lifestyle/stress,
sleep disorders [all women];
acquaintance rape
prevention [ages 19-39
years]; advance directives
[women 40 years and older];
neglect/abuse; depression) is
recommended as part of
routine health assessment.
(Strong)
Routine screening for suicide
risk in asymptomatic general
populations is not
recommended. (Strong)
ACOG: Evaluate and counsel women for
suicide and depressive symptoms. (ACOG,
Annual Women's Health Care)
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Adults (65 and older)
See also Depression, Domestic and Intimate Partner Violence, Sleep Disorders
Evidence-Based
Evidence-Informed
USPSTF, AHRQ: The evidence is insufficient to
recommend for or against routine screening for
dementia in older adults. (USPSTF: Screening for
Dementia; AHRQ: Screening for Dementia
Systematic Evidence Review Number 20)
NICE: Primary healthcare staff should consider
referring people who show signs of mild cognitive
impairment (MCI) for assessment by memory
assessment services to aid early identification of
dementia, because more than 50% of people with
MCI later develop dementia. Mild cognitive
impairment is a syndrome defined as cognitive
decline greater than expected for an individual’s age
and education level, which does not interfere
notably with activities of daily living. It is not a
diagnosis of dementia of any type, although it may
lead to dementia in some cases. (Supporting People
With Dementia And Their Careers In Health And
Social Care)
Uniform Expert
Agreement
Final WWTF Recommendation
Routine screening of
asymptomatic adults ages 65
and older for dementia is not
recommended. (Strong)
Screening adults ages 65 and
older for mild cognitive
impairment is recommended.
Refer those with signs of mild
cognitive impairment for
memory assessment services
to aid in early identification of
dementia. (Strong)
ACOG: Evaluate psychosocial
aspects of health:
interpersonal/family relationships,
intimate partner violence,
Evaluation of psychosocial
aspects of health
(interpersonal/family
relationships, intimate partner
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
lifestyle/stress, sleep disorders;
advance directive; neglect/abuse,
depression, and family
relationships. (Annual Women's
Health Care)
violence, work satisfaction,
lifestyle/stress, sleep disorders
[all women]; advance
directives [women 40 years
and older]; neglect/abuse;
depression) is recommended
as part of routine health
assessment.
(Strong)
117
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Metabolic Syndrome
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Cardiovascular Disease, Diabetes, Obesity
Evidence-Based
Evidence-Informed
USPSTF: Screen children aged 6
years and older for obesity and offer
or refer to comprehensive, intensive
behavioral interventions to promote
improvement in weight status.
(Grade B recommendation;
Pediatrics. 2010 Feb;125(2):361-7.
doi: 10.1542/peds.2009-2037. Epub
2010 Jan 18. Screening for obesity in
children and adolescents: US
Preventive Services Task Force
recommendation statement.
US Preventive Services Task Force,
Barton M.
http://www.uspreventiveservicestas
kforce.org/uspstf10/childobes/chobe
AAP: Assess BMI and screen for dyslipidemia.
Screening for dyslipidemia is recommended once
in late adolescence for all patients regardless of
risk factors.
(http://brightfutures.aap.org/pdfs/Other
3/D.Adol.MST.Adolescence.pdf)
Uniform Expert
Agreement
Screen patients with
elevated BMI for
dyslipidemia and
hyperglycemia.
Final WWTF
Recommendation
Screening for dyslipidemia is
recommended once in late
adolescence for all patients
regardless of risk factors .
(Strong)
Screening for dyslipidemia
and hyperglycemia is
recommended for patients
with elevated BMI. Provide or
refer patients to counseling
about appropriate lifestyle
modifications and/or medical
treatment. (Strong)
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Individual Recommendation Evidence Grid
srs.pdf)
Adults (19-65)
See also Cardiovascular Disease, Diabetes, Obesity
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
CDC: Diagnosis of metabolic syndrome requires at
least three of the following traits:
1) Abdominal obesity: waistline >40” for men,
>35” for women
2) Triglycerides >150 or on medications to treat
3) HDL cholesterol <40 in men, <50 in women or
on medications to treat
4) Blood pressure >130/85 or on medications to
treat
5) Fasting glucose >100 or on medications to treat
(http://www.cdc.gov/nchs/data/nhsr/nhsr013.pdf)
AHA, USPSTF, NIH, ADA:
Identify appropriate
lifestyle modifications
and medications.
Screen patients via physical
exam and blood work, then
help patient identify
appropriate lifestyle
modifications and/or
medical treatment.
Screening is recommended for
patients with elevated BMI for
dyslipidemia and hyperglycemia.
Provide or refer patients to
counseling about appropriate lifestyle
modifications and/or medical
treatment. (Strong)
119
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Neural Tube Defects
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
All Women of Reproductive Capacity
Evidence-Based
Evidence-Informed
USPSTF, CDC: Recommend that all women
planning or capable of pregnancy take a
daily supplement containing 0.4 to 0.8 mg
(400 to 800 mcg) of folic acid. (USPSTF:
Grade A Recommendation; Ann Intern
Med. 2009 May 5;150(9):626-31. Folic acid
for the prevention of neural tube defects:
U.S. Preventive Services Task Force
recommendation statement. U.S.
Preventive Services Task
Force. http://www.uspreventiveservicesta
skforce.org/uspstf09/folicacid/folicacidrs.
pdf; CDC:
http://www.cdc.gov/ncbddd/orders/pdfs/
09_202063-a_nash_neural-tube-bd-guidefinal508.pdf)
AAP, AAFP, HMHB, MoD: All women planning or capable
of pregnancy should take a daily supplement containing
0.4 to 0.8 mg (400 to 800 mcg) of folic acid. Increase to 4
mg in patients with prior NTD baby, a history of NTD
herself, or taking anticonvulsant medications.
(AAP: http://pediatrics.aappublications.org/content/104/
2/325.full; AAFP: http://www.aafp.org/patientcare/clinical-recommendations/all/neural-tubedefects.html;
HMHB: http://www.hmhb.org/press_release/mothersday-call-to-action/; MoD:
http://www.marchofdimes.com/baby/neural-tubedefects.aspx#)
Uniform Expert
Agreement
Adopt the
evidenceinformed
guideline and
recommend
increased levels
for patients at
high risk.
Final WWTF
Recommendation
Counsel all women
planning or capable of
pregnancy to take a
daily supplement
containing 0.4 to 0.8 mg
(400 to 800 mcg) of folic
acid. The recommended
dose should be
increased to 4 mg per
day in those taking
anticonvulsant
medications or who
have a personal history
of NTD or who have
delivered a baby
affected by NTD in an
earlier pregnancy.
(Strong)
120
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Obesity
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
See also Cardiovascular Disease; Diet, Fitness, and Nutrition; Preconception Care
Evidence-Based
Evidence-Informed
USPSTF: Recommends screening all adults for obesity.
Clinicians should offer or refer patients with a body mass
index (BMI) of 30 kg/m2 or higher to intensive,
multicomponent behavioral interventions. (Grade B
recommendation; Pediatrics. 2010 Feb;125(2):361-7. doi:
10.1542/peds.2009-2037. Epub 2010 Jan 18.
Screening for obesity in children and adolescents: US
Preventive Services Task Force recommendation
statement. US Preventive Services Task Force, Barton M.
http://www.uspreventiveservicestaskforce.org/uspstf10/
childobes/chobesrs.pdf)
ACOG: Screen annually
for obesity/overweight
with BMI for age
percentile, ask about
body image, eating
patterns, activity levels,
and sedentary behavior.
(GAHC p. 148)
Uniform Expert
Agreement
The USPSTF approach is
reasonable. At the very
least, BMI should be
calculated and some
counseling should take
place recommending
local solutions.
Final WWTF Recommendation
Routine weight assessment using
BMI calculation is recommended.
Results should be explained to
the patient. For those with BMI
greater than 30, provide or refer
patients to intensive
multicomponent behavioral
interventions. (Strong)
AAP: For overweight and
obese adolescents,
choose interventions
according to the patient’s
age, BMI, weight goals,
and health risks. AAP
interventions are
categorized as
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
prevention counseling;
Stage 1, Prevention Plus;
Stage 2, Structured
Weight Management;
Stage 3, Comprehensive
Multidisciplinary
Intervention; and Stage
4, Tertiary Care
Intervention.
(Recommendations for
Prevention of Childhood
Obesity; Expert
Committee
Recommendations
Regarding the
Prevention, Assessment
and Treatment of Child
and Adolescent
Overweight and Obesity,
see Table 8)
Adults (All ages)
See also Cardiovascular Disease; Diet, Fitness, and Nutrition; Preconception Care
Evidence-Based
Evidence-Informed
Uniform Expert
Agreement
Final WWTF
Recommendation
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USPSTF: Recommends
screening all adults for
obesity. Clinicians
should offer or refer
patients with a body
mass index of 30 kg/m2
or higher to intensive,
multicomponent
behavioral
interventions. (Ann
Intern Med. 2012 Sep
4;157(5):373-8.
Screening for and
management of obesity
in adults: U.S.
Preventive Services
Task Force
recommendation
statement.
Moyer VA; U.S.
Preventive Services
Task Force. Screening
for and Management of
Obesity in Adults; grade
B)
AAFP: Refer patients with BMI of 30 or higher to intensive,
multicomponent behavioral interventions. (Obesity; grade B)
The USPSTF
approach is
reasonable. At the
very least, BMI
ACOG: Determine BMI and evaluate and counsel on physical activity,
should be calculated
dietary/nutrition assessment, and obesity as cardiovascular risk
and some counseling
factor.
should take place
(http://www.acog.org/About_ACOG/ACOG_Departments/
Annual_Womens_Health_Care/Assessments_and_Recommendations) recommending local
solutions.
PCHHC: Calculate BMI at least annually. All women with BMI of 26 or
more should be counseled about the risks to their own health, the
risks for exceeding the overweight category, and the risks to future
pregnancies, including infertility. These women should be offered
specific behavioral strategies to decrease caloric intake and increase
physical activity and be encouraged to consider enrolling in structured
weight loss programs. (The Clinical Content of Preconception Care; A
III)
Routine weight assessment
using BMI calculation is
recommended. Results
should be explained to the
patient. For those with BMI
greater than 30, provide or
refer patients to intensive
multicomponent
behavioral interventions.
(Strong)
123
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Oral Cavity Exam
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (All ages)
See also Oral Hygiene, Tobacco Use
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
USPSTF: There is insufficient evidence
to make a recommendation on oral
cancer screening. (2013,
http://www.uspreventiveservicestask
force.org/uspstf13/oralcan/oralcanfin
alrec.htm)
ACS: Physicians should
There is insufficient evidence to
recommend a distinct oral
examine the mouth and
throat during routine cancer- cavity exam.
related check-ups.
(http://www.cancer.org/acs/
groups/cid/documents/webc
ontent/003128-pdf.pdf)
Final WWTF Recommendation
Examination of the mouth and throat may be
performed as part of an assessment of overall
health and oral hygiene. (Qualified)
American Dental
Association: Clinicians
should “remain alert” for
signs of malignancy when
performing routine visual
and tactile examination of
dental patients. (2013,
http://jada.ada.org/content/
141/5/509.full.pdf+html)
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Topic: Oral Hygiene
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13–18)
See also Oral Cavity Exam, Tobacco Use
125
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Evidence-Based
USPSTF: Recommends that
primary care clinicians
prescribe oral fluoride
supplementation at currently
recommended doses to
preschool children older than
6 months of age whose
primary water source is
deficient in fluoride. (Grade B
Recommendation; http://ww
w.uspreventiveservicestaskfo
rce.org/uspstf/uspsdnch.htm)
USPSTF: The evidence is
insufficient to recommend
for or against routine risk
assessment of preschool
children by primary care
clinicians for the prevention
of dental disease. (Grade I
Statement; http://www.uspr
eventiveservicestaskforce.org
/uspstf/uspsdnch.htm)
Evidence-Informed
Uniform Expert Agreement
Final WWTF
Recommendation
Caries risk assessment is not Fluoride
AAFP: For children 6 months to 16 years, fluoride
supplementation is recommended to prevent dental caries supported by the literature, supplementation
in areas with inadequate fluoride in the water supply.
should be
and no reliable risk
(http://www.aafp.org/patient-care/clinicalrecommended for
assessment tool exists.
recommendations/all/dental-caries.html)
adolescents up to age
“Oral health risk
16
who live in areas
assessment” could
ACOG: Counsel on fluoride supplementation and dental
with inadequate
conceivably include
fluoride in water
hygiene.
asking about smoking
supplies. (Strong)
(http://www.acog.org/About_ACOG/ACOG_Departmen (oral cancer risk).
ts/Annual_Womens_Health_Care/Assessments_and_R
ecommendations)
AAP: Recommends oral health risk assessment. Dietary
counseling for optimal oral health should be an intrinsic
component of general health counseling. Administration
of all fluoride modalities should be based on individual's
caries risk. Supervised use of fluoride toothpaste is
recommended for all children with teeth. The application
of fluoride varnish by the medical practitioner is
appropriate for patients with significant risk of dental
caries who are unable to establish a dental home.
(Preventive Oral Health Intervention for
Pediatricians, http://pediatrics.aappublications.org/conte
nt/122/6/1387.full.html)
Adults (All ages)
See also Oral Cavity Exam, Tobacco Use
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Evidence-Based (source)
Evidence-Informed
ACOG: Counsel on hygiene, including dental hygiene.
(http://www.acog.org/About_ACOG/ACOG_Departments
/Annual_Womens_Health_Care/Assessments_and_Reco
mmendations)
Uniform Expert Agreement
Final WWTF
Recommendation
Caries risk assessment is not Oral health risk
supported by the literature, assessment and dietary
counseling for optimal
and no reliable risk
assessment tool exists. Oral oral health may be
health risk assessment and performed as part of an
assessment of overall
dietary counseling for
optimal oral health may be health and oral hygiene.
(Qualified)
recommended as part of
general health counseling.
“Oral health risk
assessment” could
conceivably include asking
about smoking (oral cancer
risk).
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Topic: Osteoporosis
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
USPSTF: Recommends screening
for osteoporosis in women aged
65 years or older and in younger
women whose fracture risk is
equal to or greater than that of a
65-year-old white woman who has
no additional risk factors.
(B Recommendation; Screening
for Osteoporosis:
Recommendation Statement.
AHRQ Publication No. 10-05145EF-2, January
2011. http://www.uspreventivese
rvicestaskforce.org/uspstf10/oste
oporosis/osteors.htm)
AAFP: Recommends screening
for osteoporosis in women
aged 65 years or older and in
younger women whose
fracture risk is equal to or
greater than that of a 65-year
old white woman who has no
additional risk factors.
(http://www.aafp.org/patientcare/clinicalrecommendations/all/osteopo
rosis.html)
Adults (65 and older)
Screening for osteoporosis in women aged
65 years or older is recommended. (Strong)
ACOG: Bone density screening
for women should begin at
age 65 years. Dual-energy Xray absorptiometry screening
can be used selectively for
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Well-Woman Task Force 2013-2014
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women younger than 65 years
if they are postmenopausal
and have other significant risk
factors for osteoporosis or
fracture. (Osteoporosis.
Practice Bulletin No. 129.
American College of
Obstetricians and
Gynecologists. Obstet Gynecol
2012;120:718–34.
http://www.acog.org/Resourc
es_And_Publications/Practice
_Bulletins/Committee_on_Pra
ctice_Bulletins_-_Gynecology/Osteoporosis )
ACP: Follow USPSTF
guidelines.
(http://www.acponline.org/cli
nical_information/guidelines/
guidelines/)
129
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Ovarian Cancer
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (Women of Reproductive Age; Perimenopause/Menopause)
See also Genetic Screening
Evidence-Based
Evidence-Informed
Women at Low Risk
AAFP: The USPSTF
recommends against routine
screening for ovarian cancer.
(http://www.aafp.org/afp/20
05/0215/p759.html)
USPSTF: Screening for ovarian
cancer is not recommended in
women without known genetic
mutations that increase the risk of
ovarian cancer. There is at least
moderate certainty that the harms
of screening for ovarian cancer
outweigh the benefits.
(http://www.uspreventiveservicest
askforce.org/uspstf/uspsovar.htm)
Uniform Expert Agreement
Final WWTF Recommendation
Screening for ovarian cancer is not
recommended for women at low risk.
(Strong)
ACOG: Because of the low
prevalence of epithelial
ovarian cancer, reported to
be approximately one case
per 2,500 women per year, it
has been estimated that a
test with even 100%
sensitivity and 99% specificity
would have a positive
predictive value of only 4.8%,
which means 20 of 21
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Women at High Risk
women undergoing surgery
would not have primary
ovarian cancer. There is
currently no effective
strategy for ovarian cancer
screening.
(http://www.acog.org/Resou
rces_And_Publications/Com
mittee_Opinions/Committee
_on_Gynecologic_Practice/T
he_Role_of_the_Obstetrician
_Gynecologist_in_the_Early_
Detection_of_Epithelial_Ovar
ian_Cancer)
ACOG: Women with BRCA1
or BRCA2 mutations should
be offered risk-reducing
salpingo-oophorectomy by
age 40 years or after the
conclusion of childbearing. It
is reasonable to offer women
with HNPCC risk-reducing
hysterectomy and bilateral
salpingo-oophorectomy
between ages 35 and 40 if
childbearing is no longer
desired.
(http://www.acog.org/Resou
rces_And_Publications/Practi
ce_Bulletins/Committee_on_
Practice_Bulletins_-_Gynecology/Hereditary_Bre
ast_and_Ovarian_Cancer_Sy
ndrome)
Women with BRCA1 or BRCA2 mutations or
HNPCC should be offered risk-reducing
surgery (Strong).
Women with hereditary ovarian cancer
syndromes who choose not to have riskreducing surgery may be offered
surveillance with a combination of
transvaginal ultrasonography and CA-125.
(Qualified)
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NCCN: For those patients
who elect not to have riskreducing salpingooophorectomy, consider
concurrent transvaginal
ultrasound (preferably day 110 of menstrual cycle in
premenopausal women) plus
CA-125 testing (preferably
after day 5 of menstrual
cycle in premenopausal
women). Note: There are
data that show that annual
transvaginal ultrasound and
CA-125 are not effective
strategies for screening for
ovarian cancer in high-risk
women. There are limited
data regarding the
effectiveness of a 6-month
screening interval. Thus, until
such data are available it is
reasonable to consider this
approach in high-risk
women, especially in the
context of a clinical research
setting. (NCCN Guidelines
Version 4.2013 Hereditary
breast and/or ovarian cancer
syndrome)
132
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Pelvic Examination
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Uniform Expert Agreement
Final WWTF Recommendation
Adolescents (13-20)
Evidence-Based
Evidence-Informed
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ACOG: Recommends pelvic
examinations be performed only
when indicated by the medical
history for patients younger
than 21 years. An “externalonly” genital examination can
provide the health care provider
with the opportunity to evaluate
the patient for normal external
genital anatomy; issues of
personal hygiene; and
abnormalities of the vulva,
introitus, and perineum that
might require further
investigation.
(http://www.acog.org/Resource
s_And_Publications/Committee
_Opinions/Committee_on_Gyne
cologic_Practice/WellWoman_Visit)
Internal and speculum examinations should
be reserved for symptomatic patients or
those with specific indications (eg, IUD
placement) and need not be part of the well
visit in this age group. (Qualified)
An external examination is an appropriate
component of the well visit in this age group
at some point in the adolescent’s
development. (Qualified)
AAP: Examination of the
external genitalia should be
included as part of the annual
comprehensive physical
examination of children and
adolescents of all ages.
Routinely explaining and
including this examination
normalizes the experience
rather than setting it apart as
something that is only
performed as an exception.
Most adolescents do not need
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Individual Recommendation Evidence Grid
an internal examination
involving a speculum or
bimanual examination. More
extensive examination, which
may include internal or
speculum examination, is
appropriate in the primary care
setting for patients with
persistent vaginal discharge,
dysuria or urinary tract
symptoms in a sexually active
female, dysmenorrhea
unresponsive to NSAIDs,
amenorrhea, abnormal vaginal
bleeding, lower abdominal pain,
suspected/reported rape or
sexual abuse, or pregnancy. It is
also appropriate as part of
contraceptive counseling about
use of an intrauterine device or
diaphragm and in conjunction
with a Pap test.
(http://pediatrics.aappublication
s.org/content/126/3/583.full)
Adults (21 and older)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
ACOG: Recommends pelvic
examination be performed on
an annual basis in all patients
aged 21 years and older. The
decision whether to perform a
Speculum and/or bimanual exam is
recommended for symptomatic patients
and asymptomatic patients with specific
indications (eg, IUD placement and cervical
cancer screening). External examinations
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Individual Recommendation Evidence Grid
complete pelvic examination at
the time of the periodic health
examination for the
asymptomatic patient should be
a shared decision after a
discussion between the patient
and her health care provider.
may be performed annually in healthy
patients. Inclusion of speculum and/or
bimanual exam in other well women should
be a shared decision between patient and
provider. (Qualified)
The decision to receive an
internal examination can be left
to the patient if she is
asymptomatic and has
undergone a total hysterectomy
and bilateral salpingo–
oophorectomy for benign
indications and has no history of
vulvar intraepithelial neoplasia,
cervical intraepithelial neoplasia
2 or 3, or cancer; is not HIVinfected; is not
immunocompromised; and was
not exposed to diethylstilbestrol
in utero. Annual examination of
the external genitalia should
continue. Also, it is reasonable
to stop performing pelvic
examinations when a woman’s
age or other health issues reach
a point where the woman would
not choose to intervene on
conditions detected during the
routine examination,
particularly if she is
discontinuing her other routine
health care maintenance
136
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
assessments.
(http://www.acog.org/Resource
s_And_Publications/Committee
_Opinions/Committee_on_Gyne
cologic_Practice/WellWoman_Visit)
137
Well Woman Task Force 2013-2014
Model: Recommendation Evidence Grid
Topic: Pelvic Floor Disorders
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (50 and older)
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
CDC: Health care
providers should
routinely ask patients
65 and older about
urinary incontinence.
(http://www.cdc.gov
/mmwr/preview/mm
wrhtml/00039261.ht
m)
WHO: All women age 50 and
older should be screened for
urinary incontinence. (2008, AgeFriendly Primary Health Care
Centres Toolkit, WHO Press:
Geneva, Switzerland)
Branch et al: Health care providers should
routinely ask patients 65 and older about
urinary incontinence. (Knowledge,
Attitudes, and Practices of Physicians
Regarding Urinary Incontinence in Persons
Aged greater than or equal to 65 Years -Massachusetts and Oklahoma, 1993.
MMWR 1995;44(40):753–754)
For women 50 and older, screening for
urinary and fecal incontinence is
recommended. (Qualified)
ACOG: Functional assessment of
the elderly woman includes
evaluation of bowel and bladder
function. (Guidelines for
Women's Health)
ACOG: For all adults 18 years and
older, screening history of urinary
and fecal incontinence is
Urinary and fecal incontinence has
profound effects on quality of life and is
associated with depression and anxiety,
work impairment, social isolation, and
sexual dysfunction.
138
Well Woman Task Force 2013-2014
Model: Recommendation Evidence Grid
recommended. (CO 483, Primary
and preventative care: periodic
assessments)
AMA/CCP/NCQA: Recommend
assessment of presence or
absence of urinary incontinence
in women age 65 or older. (PQRS
2013 measures list, AMA-CCPNCQA)
139
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Piercing and Tattooing
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13-18)
Evidence-Based
Evidence-Informed
ACOG: Recommends annual evaluation and
counseling. Educate adolescents about concerns
(infections, scars, allergies, permanence of body
art) associated with piercing and tattooing.
(ACOG Guidelines for Adolescent Health
Care, GAHC p. 31)
Uniform Expert
Agreement
Final WWTF Recommendation
Annual evaluation and counseling
adolescents about concerns
associated with piercing and tattooing
is recommended. (Strong)
AAPD: Provide anticipatory guidance/counseling on
intraoral/oral piercing beginning at age 12 years or
older annually. (Clinical guideline on periodicity of
examination, preventive dental services,
anticipatory guidance/counseling and oral
treatment for infants, children, and adolescents.
Chicago (IL): American Academy of Pediatric
Dentistry (AAPD); 2009; Guideline on adolescent
oral health care. Chicago (IL): American Academy of
Pediatric Dentistry (AAPD); 2010)
140
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Preconception/Interconception Care
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Uniform Expert Agreement
Additional guidelines from
medical societies used for
developing consensus
recommendations.
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
All Women of Reproductive Capacity
See also Alcohol Misuse; Depression; Diabetes; Diabetes Postpartum; Mental Health and Psychosocial Issues/Suicide/Behavioral
Assessment; Reproductive Health; Sexual Health; Tobacco Use
Evidence-Based
Evidence-Informed
IOM: Provide evidence-based
tests, procedures, and screening
for nonpregnant women to
optimize reproductive outcomes
and prevent or optimize
treatments for chronic conditions
as well as topics for counseling
and guidance for preconception
health. (Clinical Preventive
Services for Women; Closing the
Gaps. 2011. Washington, DC: The
National Academy of Sciences, p.
129; http://www.iom.edu/Report
s/2011/Clinical-Preventive-
ACOG, AAP, PCCHC: Counsel
patients about preventing
unwanted and unintended
pregnancy by postponing
sexual involvement or using
contraceptive options,
including emergency
contraception. (ACOG/AAP:
Guidelines for Perinatal Care.
7th ed. , 2012; pp. 95-105;
PCHHC Initiative:
Preconception Health and
Health Care: The Clinical
Content of Preconception
Uniform Expert Agreement
Final WWTF Recommendation
Risk assessment, education, and health
promotion counseling, based on the
individual woman’s desire for pregnancy, are
recommended for all women to prevent
unintended pregnancy, reduce risks, and
improve pregnancy outcomes. (Strong)
141
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
services-for-Women-Closing-theGaps.aspx)
IOM, CDC: Ensure access to the
full range of FDA-approved
contraceptive methods,
sterilization procedures, and
patient education and counseling
for women with reproductive
capacity. (IOM: Clinical Preventive
Services for Women; Closing the
Gaps. 2011. Washington, DC: The
National Academy of Sciences, p.
102–
110; http://www.iom.edu/Reports
/2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx; CDC: MMWR. U.S.
Selected Practice
Recommendations for
Contraceptive Use,
2013.; http://www.cdc.gov/repro
ductivehealth/UnintendedPregna
ncy/USSPR.htm)
IOM: Obtain a history of
pregnancy complications,
including preeclampsia,
gestational hypertension, and
gestational diabetes mellitus, from
all women who have had at least
one pregnancy. (Clinical
Preventive Services for Women;
Care. Obstet Gynecol. 2008
;199(6 Suppl 2)S257S395; http://www.beforeandb
eyond.org/uploads/Clinical%2
0content%20of%20preconcep
tion%20care%20overview.pdf)
AHA: Health care
professionals who meet
women for the first time later
in their lives (ie, after their
reproductive years) should
take a careful and detailed
history of pregnancy
complications with focused
For women with risks identified in pregnancy
that have implications for subsequent
pregnancies, as well as chronic disease
development (e.g., PIH, GDM) or
management (e.g., clotting disorders,
hepatitis), postpartum screening and
development of a plan for continuing care are
recommended. (Strong)
142
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Closing the Gaps. 2011.
Washington, DC: The National
Academy of Sciences; p.
128; http://www.iom.edu/Reports
/2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx)
questions about a history of
gestational
diabetes mellitus,
preeclampsia, preterm birth,
or birth of an infant who was
small for gestational age. (J
Am Coll Cardiol. 2011 Mar
22;57(12):1404-23. doi:
10.1016/j.jacc.2011.02.005.
CDC: Safety, efficacy, availability,
Effectiveness-based guidelines
and acceptability should be
for the prevention of
considered by women, men, or
cardiovascular disease in
couples when choosing the most
women--2011 update: a
appropriate contraceptive
guideline from the American
method. Voluntary informed
Heart Association. Mosca L1,
choice of contraceptive methods
Benjamin EJ, Berra K,
is an essential guiding principle,
Bezanson JL, Dolor RJ, Lloydand contraceptive counseling,
Jones DM, Newby LK, Piña IL,
where applicable, may be an
Roger VL, Shaw LJ, Zhao D,
important contributor to the
Beckie TM, Bushnell C,
successful use of contraceptive
D'Armiento J, Kris-Etherton
methods. Assessment of the
PM, Fang J, Ganiats TG,
safety of a given contraceptive
Gomes AS, Gracia CR, Haan
method for a person with a
particular characteristic or medical CK, Jackson EA, Judelson DR,
Kelepouris E, Lavie CJ, Moore
condition should be included in
A, Nussmeier NA, Ofili E,
counseling. (2010. Medical
Oparil S, Ouyang P, Pinn VW,
Eligibility Criteria for
Sherif K, Smith SC Jr, Sopko G,
Contraceptive Use.
Chandra-Strobos N, Urbina
MMWR;59(RR04):1–
85; http://www.cdc.gov/mmwr/p EM, Vaccarino V, Wenger NK;
American Heart Association.)
df/rr/rr59e0528.pdf)
AHA/ASA: Because of the
increased risk of future
143
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
hypertension and stroke one
to 30 years after delivery in
women with a history of
preeclampsia (Level of
Evidence B), it is reasonable to
(1) consider evaluating all
women starting 6 months to 1
year post partum, as well as
those who are past
childbearing age, for a history
of preeclampsia/eclampsia
and document their history of
preeclampsia/eclampsia as a
risk factor, and (2) evaluate
and treat for cardiovascular
risk factors including
hypertension, obesity,
smoking, and dyslipidemia
(Class IIa; Level of Evidence C).
(Stroke. 2014 Feb 6. [Epub
ahead of print] Guidelines for
the Prevention of Stroke in
Women: A Statement for
Healthcare Professionals From
the American Heart
Association/American Stroke
Association. Bushnell C,
McCullough LD, Awad IA,
Chireau MV, Fedder WN, Furie
KL, Howard VJ, Lichtman JH,
Lisabeth LD, Piña IL, Reeves
MJ, Rexrode KM, Saposnik G,
Singh V, Towfighi A, Vaccarino
V, Walters MR; on behalf of
144
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
the American Heart
Association Stroke Council,
Council on Cardiovascular and
Stroke Nursing, Council on
Clinical Cardiology, Council on
Epidemiology and Prevention,
and Council for High Blood
Pressure Research.)
IOM, USPSTF: Clinicians should ask
all adults about tobacco use and
provide tobacco cessation
interventions for those who use
tobacco products (IOM: Clinical
Preventive Services for Women;
Closing the Gaps. 2011. p. 128,
Washington, DC: The National
Academy of
Sciences; http://www.iom.edu/Re
ports/2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx; USPSTF: Counseling
and Interventions to Prevent
Tobacco Use and Tobacco-Caused
Disease in Adults and Pregnant
Women; http://www.uspreventiv
eservicestaskforce.org/uspstf/usp
stbac2.htm; grade A
recommendation)
For women with lifestyle behaviors (e.g., use
of tobacco, alcohol, or Illicit drugs) or mental
health issues (e.g., antepartum/postpartum
depression) identified during pregnancy that
increase health risks, postpartum screening,
follow-up, and development of a plan for
continuing care are recommended. (Strong).
IOM, USPSTF: Screening and
behavioral counseling
interventions are recommended
to reduce alcohol misuse by
adults, including nonpregnant and
145
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
pregnant women, in primary care
settings. (IOM: Clinical Preventive
Services for Women; Closing the
Gaps. 2011. p. 126, Washington,
DC: The National Academy of
Sciences;
http://www.iom.edu/Reports/201
1/Clinical-Preventive-services-forWomen-Closing-the-Gaps.aspx;
USPSTF: Screening and Behavioral
Counseling Interventions in
Primary Care to Reduce Alcohol
Misuse,
http://www.uspreventiveservices
taskforce.org/uspstf/uspsdrin.htm
; grade B recommendation)
PCHHC Initiative, USDHHS: Assess
at least annually for alcohol use
patterns and risky drinking
behaviors and provide appropriate
counseling. All women should be
advised of the risks to the
embryo/fetus of alcohol exposure
in pregnancy and that no safe
level of consumption has been
established. (PCHHC: The Clinical
Content of Preconception Care (A
III); USDHHS: 2005 Advisory on
Alcohol and
Pregnancy; http://www.cdc.gov/n
cbddd/fasd/documents/sgadvisory.pdf)
146
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
PCHHC, USDHHS: Assess for
tobacco use at each encounter
with healthcare system. Women
who smoke should be counseled,
using the 5 A’s, to limit exposure.
(PCHHC; The Clinical Content of
Preconception Care (A II-2);
USDHHS/PHS: Treating Tobacco
Use and Dependence. Clinical
Practice Guideline (Evidence level
A for screening, B and C for
interventions; Fiore MC, et al.
Treating Tobacco Use and
Dependence: 2008 Update.
Clinical Practice Guideline.
Rockville, MD: U.S. Department of
Health and Human Services. Public
Health Service. May 2008.)
IOM: Screen for suicide ideation
and postpartum depression in
women who are pregnant or who
have recently given birth. (Clinical
Preventive Services for Women;
Closing the Gaps. 2011; p. 188193, Washington, DC: The
National Academy of
Sciences; http://www.iom.edu/Re
ports/2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx)
147
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Sexual Health
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adolescents (13–18)
See also Reproductive Health
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
Satcher: Open and respectful dialogue by health care providers is
recommended; while adolescents desire this, providers are
reluctant to discuss sexual health more broadly with adolescents
(rather than simply avoidance of unplanned pregnancy and STIs).
(Satcher, 2013;
http://www.publichealthreports.org/issueopen.cfm?articleID=29
46)
Providers should offer the
opportunity for respectful and open
dialogue about sexual health and
sexuality that includes sexual
orientation, gender identity, and
sexual dysfunction at every
comprehensive health visit.
(Qualified)
Douglas & Fenton: A more holistic approach with adolescents to
sexual health that includes issues of desire and relationships may
increase healthy sexual behavior. (Douglas, Fenton,
2013; http://www.publichealthreports.org/issueopen.cfm?articleI
D=2933)
Nystrom, Duke, & Victor: Sexuality is a normal and healthy part of
adolescent development. (Public Health Reports, 2013 (Suppl 1),
vol 28
148
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
http://www.publichealthreports.org/issueopen.cfm?articleID=29
43)
Hoover et al: Obstetrician-gynecologists and family practitioners
should be targeted for interventions to improve the quality and
availability of reproductive health services. (Hoover, KW, Tao G,
Berman S, Kent, CK. Utilization of Health Services in Physician’s
Offices in Outpatient Clinics by Adolescents and Young Women in
the U.S.: Implications for Improving Access to Reproductive
Health Services. Journal of Adolescent Health 46. 2010:324-330.)
Adults (All ages)
See also Reproductive Health
Evidence-Based
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
WHO: Sexual health is a state of physical,
mental, and social well-being in relation to
sexuality. It requires a positive and respectful
approach to sexuality and sexual
relationships, as well as the possibility of
having pleasurable and safe sexual
experiences, free of coercion, discrimination,
and violence.
(http://www.who.int/topics/sexual_health/e
n/)
Ford et al: Patient interactions addressing
sexual health should occur and evolve over the
life course, depending on the target age and
personal circumstances, such as relationship
status, sexual orientation, gender identity, and
pregnancy intent.
(Ford et al., 2013,
http://www.publichealthreports.org/issueopen.
cfm?articleID=2944)
Address sexual
health/sexuality as part of
every comprehensive health
assessment (annually).
Sexually active women can be
screened for sexual health
issues with one or two
questions, such as “Are you
satisfied with your sex life?” or
“Do you have any questions or
concerns about sex?”
(Qualified)
ACOG: Obtain a sexual history if women
present with a potential sexual problem.
(Practice Bulletin 119 (2011) Female Sexual
Dysfunction)
Farrell & Belza: Patients, regardless of age want
to discusses sexual health issues with their
providers. (Are older patients comfortable
discussing sexual health with nurses? Nursing
Research 61(1) 51-57)
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Skin Cancer
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Evidence-Informed
AAFP: Counsel children,
adolescents and young adults
(10-24) who have fair skin
about minimizing their
exposure to ultraviolet
radiation to reduce risk for
skin cancer. (Skin Cancer
[Grade B])
Uniform Expert Agreement
Final WWTF Recommendation
Counseling adolescents about minimizing
their exposure to ultraviolet radiation is
recommended to reduce risk for skin cancer.
(Strong)
Adolescents (Ages 13-18)
Evidence-Based
USPSTF: Recommends counseling
children, adolescents, and young
adults aged 10 to 24 years who
have fair skin about minimizing
their exposure to ultraviolet
radiation to reduce risk for skin
cancer. (Behavioral Counseling to
Prevent Skin Cancer [Grade B])
AAP: Incorporate advice about
UVR exposure into healthsupervision practices for all
children, especially for
children at high risk of
developing skin cancer:
children with light skin, those
with nevi and/or freckling, and
those with a family history of
melanoma. Aim to incorporate
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UVR exposure advice into at
least one health-maintenance
visit per year, beginning in
infancy. Because melanoma
occurs in teenagers and is a
common cancer among young
adults, it seems prudent to
recommend that clinicians
caring for these groups
include a skin examination as
part of a complete physical
examination.
(Ultraviolet Radiation: A
Hazard to Children and
Adolescents.)
ACOG: Counsel about skin
exposure to ultraviolet rays.
(http://www.acog.org/About_
ACOG/ACOG_Departments/A
nnual_Womens_Health_Care/
Assessments_and_Recommen
dations)
ACOG: Encourage regular use
of sunscreen and avoidance of
artificial tanning. (GAHC p. 29)
Adolescents should be encouraged to use
sunscreen regularly and avoid artificial
tanning. (Strong)
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Well-Woman Task Force 2013-2014
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Adults (19 and older)
Evidence-Based
USPSTF: Recommends counseling
children, adolescents, and young
adults aged 10 to 24 years who
have fair skin about minimizing
their exposure to ultraviolet
radiation to reduce risk for skin
cancer. (Behavioral Counseling to
Prevent Skin Cancer (Grade B)
Evidence-Informed
AAFP: Counsel children,
adolescents and young adults
(10-24) who have fair skin about
minimizing their exposure to
ultraviolet radiation to reduce
risk for skin cancer. (Skin Cancer
[Grade B])
USPSTF: Current evidence is
insufficient to assess the balance of
benefits and harms of screening for
skin cancer by primary care
clinicians or by patient skin selfexamination. (Screening for Skin
Cancer (Grade I)
AAFP: There is insufficient
evidence to assess benefits and
harms of using whole-body skin
examination by primary care
clinician or patient skin selfexamination for the early
detection of cutaneous
melanoma, basal cell cancer, or
squamous cell skin cancer in the
adult population. (Skin Cancer
[Grade I])
Uniform Expert Agreement
Final WWTF Recommendation
Counseling young adults aged 19-24 years
about minimizing their exposure to
ultraviolet radiation is recommended to
reduce risk for skin cancer. (Strong)
Routine whole-body skin examination or
patient skin self-examination for detection
of skin cancers is not recommended.
(Strong)
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Well-Woman Task Force 2013-2014
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USPSTF: Current evidence is
insufficient to assess the balance of
benefits and harms of counseling
adults older than 24 years about
minimizing risks to prevent skin
cancer. (Behavioral Counseling to
Prevent Skin Cancer [Grade I])
AAFP: There is insufficient
evidence to assess benefits and
harms of counseling adults older
than 24 years. (Skin Cancer
[Grade I])
Adults should be encouraged to use
sunscreen regularly and avoid artificial
tanning. (Strong)
ACOG: Encourage regular use of
sunscreen and avoidance of
artificial tanning. (GAHC p. 29)
153
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Individual Recommendation Evidence Grid
Topic: Sleep Disorders
Evidence-Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence-Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Adults (65 years and older)
See also Depression
EvidenceBased
Evidence-Informed
Uniform Expert Agreement
ACOG: Recommends assessing for sleep disorders as part of an
assessment for depression in those 65 and over and “psychosocial
issues” for those of other ages.
http://www.acog.org/About_ACOG/ACOG_Departments/
Annual_Womens_Health_Care/Assessments_and_Recommendations
The 2006 IOM report “Sleep
Disorders and Sleep
Deprivation: An Unmet Public
Health Problem” focuses on
research needs.
(Institute of Medicine (US)
Committee on Sleep Medicine
and Research; Colten HR,
Altevogt BM, editors.
Washington (DC): National
Academies Press (US); 2006.)
Final WWTF
Recommendation
Assessment for sleep
disorders is recommended
as part of depression
screening or evaluation of
other psychosocial issues.
(Qualified)
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Well-Woman Task Force 2013-2014
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Topic: Tobacco Use
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Uniform Expert Agreement
Final WWTF Recommendation
Adolescents (13-18)
See also Oral Cavity Exam, Oral Hygiene
Evidence-Based
Evidence-Informed
USPSTF: Recommends that primary
care clinicians provide
interventions, including education
or brief counseling, to prevent
initiation of tobacco use in schoolaged children and
adolescents.
(Counseling to
Prevent Tobacco Use and Tobacco
Caused Disease in Children and
Adolescents (Grade I)
Grade: B Recommendation.)
AAFP: Strongly recommends
counseling to smoking
parents with children in the
house regarding the harmful
effects of smoking on
children's health. (Second
Hand Smoke)
AAP: Screen annually for
tobacco use and tobacco
smoke exposure, encourage
tobacco use cessation, and
provide tobacco use
cessation strategies and
resources at most visits.
(Performing Preventive
Providing annual education or brief
counseling to prevent initiation of tobacco
use is recommended. (Strong)
Screening annually for tobacco use and
tobacco smoke exposure is recommended.
For those who use tobacco products,
encourage tobacco use cessation and
provide cessation strategies. (Strong)
Provide effective interventions for treating
tobacco use and dependence among
adolescents. (Strong)
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Well-Woman Task Force 2013-2014
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Services: A Bright Futures
Handbook)
AAFP: Effectiveness of
physician's advice and
counseling in this area is
uncertain; avoidance of
tobacco products by children
and adolescents is desirable.
(Tobacco Use [Grade I])
ACOG: Ask about use of
tobacco products. (GAHC p.
34)
AAP: Counseling should be
developmentally appropriate
and relevant across various
age groups. (Technical
Report-Tobacco as a
Substance of Abuse
PEDIATRICS Vol. 124 No. 5
November 1, 2009, Tobacco
as a Substance of Abuse)
ACOG: Recommends annual
screening for tobacco use
and evaluation and
counseling at unspecified
periodicity. (Annual Women's
Health Care)
PCHHC: Assess for tobacco
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
use at each encounter with
health care system; women
who smoke should be
counseled, using the 5 As, to
limit exposure. (The Clinical
Content of Preconception
Care [A II-2])
PCHHC: All women of
childbearing age should be
screened for tobacco use.
Brief interventions should be
provided to all tobacco users
and should include brief
counseling that describes the
benefits of not smoking
before, during, and after
pregnancy; discussion of
medication; and referral for
more intensive services
(individual, group, or
telephone counseling) if the
woman is willing to use these
services. For pregnant
women, augmented
counseling interventions
should be used. (The Clinical
Content of Preconception
Care [A I-a])
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Well-Woman Task Force 2013-2014
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Adults (19 and older)
See also Oral Cavity Exam, Oral Hygiene
Evidence-Based
Evidence-Informed
USPSTF: Screen annually for tobacco use and
provide tobacco cessation education and
treatment. (Counseling and Interventions to
Prevent Tobacco Use and Tobacco-Caused
Disease in Adults and Pregnant Women [Grade
A])
AAFP: Strongly
recommends counseling
to smoking parents with
children in the house
regarding the harmful
effects of smoking on
children's health. (Second
Hand Smoke)
USPSTF: Evidence is insufficient to recommend
for or against screening asymptomatic persons
for lung cancer with either low-dose
computerized tomography (LDCT), chest x-ray
(CXR), sputum cytology, or a combination of
these tests. (Lung Cancer Screening (Grade I)
Systematic Review to Update USPSTF Recs:
http://annals.org/article.aspx?articleid=1721248)
AAFP: Screen for tobacco
use and provide tobacco
cessation interventions
for those who use
tobacco products.
(Tobacco Use [Grade A])
Uniform Expert Agreement
Final WWTF Recommendation
Screening all women annually for
tobacco use is recommended. For
those who use tobacco products,
provide tobacco cessation education
and treatment. (Strong)
Routine screening for lung cancer in
asymptomatic women is not
recommended. (Strong)
ACOG: Recommends
annual screening for
tobacco use, evaluation
and counseling at
unspecified periodicity.
(Annual Women's Health
Care)
PCHHC: Assess for
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Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
tobacco use at each
encounter with health
care system; women who
smoke should be
counseled, using the 5 As,
to limit exposure. (The
Clinical Content of
Preconception Care [A II2])
PCHHC: All women of
childbearing age should
be screened for tobacco
use. Brief interventions
should be provided to all
tobacco users and should
include brief counseling
that describes the
benefits of not smoking
before, during, and after
pregnancy; discussion of
medication; and referral
for more intensive
services (individual,
group, or telephone
counseling) if the woman
is willing to use these
services. For pregnant
women, augmented
counseling interventions
should be used (The
Clinical Content of
Preconception Care [A Ia])
159
Well-Woman Task Force 2013-2014
Individual Recommendation Evidence Grid
Topic: Visual Acuity/Glaucoma
Evidence Based
Foundation for WWTF
recommendations. Primarily
USPSTF, IOM, and CDC guidelines.
Evidence Informed
Additional guidelines from
medical societies used for
developing consensus
recommendations.
Uniform Expert Agreement
WWTF expert consensus:
Describes resolution of
conflicting guidelines or outlines
expert opinion that does not
have a strong evidence
foundation.
Final WWTF Recommendation and
Strength of Recommendation
“Strong” = Based on evidence-based or
evidence-informed guidelines
“Qualified” = Based on expert opinion alone
Evidence-Informed
Uniform Expert Agreement
Final WWTF Recommendation
AAP: Screen one time per year
for years 3-6, 8, 10, 12, 15, 18,
at other health supervision
visits based on risk
assessment or any concern on
the part of the families or the
child. (Performing Preventive
Services: A Bright Futures
Handbook)
Visual acuity screening should
be performed once a year at
ages 15 and 18, if a screen was
performed at age 12. If no
screen at age 12, then screen
when seen at age 13 or 14, then
15 and 18. Any abnormality or
suspicion of abnormality should
be referred to an optometrist or
ophthalmologist.
Screening for visual acuity is recommended
twice: once in early adolescence (less than
15 years) and once in late adolescence (15–
18 years). Refer patients with any
abnormality or suspicion of abnormality to
an optometrist or ophthalmologist.
(Qualified)
Adolescents (13-18)
Evidence-Based
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Well-Woman Task Force 2013-2014
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Adults (All ages)
Evidence-Based
Evidence-Informed
USPSTF: There is insufficient
evidence to recommend for or
against screening adults for
glaucoma. (Screening for
Glaucoma)
AAFP: There is insufficient
evidence to recommend for or
against screening for adults
for glaucoma.
http://www.aafp.org/patientcare/clinicalrecommendations/all/glauco
ma.html
Uniform Expert Agreement
Final WWTF Recommendation
Routine screening by primary care providers
for glaucoma is not recommended.
(Qualified)
Adults (65 years and older)
Evidence-Based
Evidence-Informed
USPSTF: Current evidence is
insufficient to assess the balance
of benefits and harms of screening
for visual acuity for the
improvement of outcomes in
older adults (age 65+). (Screening
for Impaired Visual Acuity in Older
Adults)
ACOG: Recommends
evaluation and counseling.
(Annual Women's Health
Care)
Uniform Expert Agreement
Final WWTF Recommendation
Routine screening by primary care providers
for visual acuity in adults ages 65 years and
older is not recommended. (Qualified)
AAFP: There is insufficient
evidence to assess
benefit/harms of screening for
visual acuity for the
improvement of outcomes in
older adults.
http://www.aafp.org/dam/AA
FP/documents/patient_care/cl
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inical_recommendations/cpsrecommendations.pdf
162
Glossary
This glossary defines terms related to screening or well woman care that may not be familiar
across all specialties. It does not include terms generally understood by clinicians. It also
describes standard thresholds or values for some commonly used clinical measurements.
Aggressive case finding: As an alternative to universal screening or population screening,
testing on the basis of a broad range of variably defined risk factors.
Behavioral counseling: Targeted intervention aimed at changing patient behavior to improve
health, typically involving a clinician with expertise in the area of focus. Intensity of behavioral
counseling may be assessed on the basis of factors such as the number and length of counseling
sessions, the magnitude and intensity of educational materials provided, and the use of
supplemental interventions such as support group sessions or classes 1. For example, the Expert
Committee on preventing childhood obesity described a detailed, stepwise approach
to behavioral counseling of increasing intensity.
Birth interval, birth spacing 2: The time between the birth date of one child and the birth date of
the next child.
Body mass index 3: Weight-to-height ratio defined as mass in kilograms divided by height in
meters squared. For adults, BMI is categorized as follows:
• Underweight: Less than 18.5
• Normal: 18.5-24.9
• Overweight: 25–29.9
• Obese: 30 or higher
Additionally, there are 3 classes of obesity: class II, 35-39.9; and class III, “40 and over.” The
interpretation of BMI is both age- and sex-specific for children and teens.
Breast self-awareness 4: A woman’s understanding of the normal appearance and feel of her
own breasts.
Breast self-examination 5: A woman’s systematic and regular examination of her own breasts.
CA-125 testing 6: A tumor marker that may be elevated in the blood of patients with some types
of cancer, particularly ovarian. Testing for CA-125 is primarily used to monitor patients during
and after ovarian cancer treatment. It may also be helpful in screening women at particularly
1
From http://www.uspreventiveservicestaskforce.org/3rduspstf/diet/dietrr.htm
From http://health.utah.gov/mihp/pregnancy/preged/afterpreg/Pregnancy_Spacing.htm
3
From: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html
4
From
https://www.acog.org/About_ACOG/News_Room/News_Releases/2011/Annual_Mammograms
_Now_Recommended_for_Women_Beginning_at_Age_40
5
From
https://www.acog.org/About_ACOG/News_Room/News_Releases/2011/Annual_Mammograms
_Now_Recommended_for_Women_Beginning_at_Age_40
6
http://www.nlm.nih.gov/medlineplus/ency/article/007217.htm
2
163
Glossary
high risk for ovarian cancer, but is limited by false negatives and false positives, particularly in
women at average risk.
Catch-up immunization: Vaccines given to ensure that an individual who has missed a
vaccination(s) is on par with the schedule of vaccinations for his or her peers, as opposed to
booster vaccines 7, which are given to ensure that earlier doses remain effective.
Cervical lesions 8: Cervical intraepithelial neoplasia (CIN) is characterized as either CIN1 (mild
dysplasia), CIN2 (moderate to marked dysplasia), or CIN3 (severe dysplasia to carcinoma in
situ). CIN1 generally reflects transient viral infection with little risk of progression to cancer,
while CIN2 and CIN3 are high-grade lesions with risk of cancer. This nomenclature was
recently revised at the Lower Anogenital Squamous Terminology (LAST) conference as LSIL
(low grade) and HSIL (high grade).
Chemoprevention 9: The use of medication to prevent disease or slow the progress of disease.
Cotesting: Screening for cervical cancer and its precursors with a combination of cytology (Pap
test) and high-risk human papillomavirus (HPV) testing.
Diethylstilbestrol (DES) 10: Drug once prescribed during pregnancy to prevent miscarriages or
premature deliveries. In utero exposure to DES poses several health risks, such as uterine and
cervical anomalies and certain cancers in women.
Dyslipidemia: Cholesterol levels out of the normal range. Desirable cholesterol levels 11 are as
follows:
• Total cholesterol: Less than 200 mg/dL
• Low-density lipoprotein (LDL): Less than 100 mg/dL
• High-density lipoprotein (HDL): 60 mg/dL or higher
• Triglycerides: Less than 150 mg/dL
Emergency contraception 12: The use of certain methods to prevent pregnancy after a woman
has had sex. Also referred to as postcoital contraception.
Evidence of immunity: Varies by disease and vaccine, but typically includes such factors as
documentation of administration of vaccine, laboratory evidence of immunity or laboratory
confirmation of disease, or diagnosis or verification of history of disease by a health care
provider.
7
http://wordnetweb.princeton.edu/perl/webwn?s=booster%20shot
http://www.nlm.nih.gov/medlineplus/ency/article/001491.htm
9
http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancertopics/prevention-and-screening/chemoprevention/index.html
10
http://www.cdc.gov/des/index.html
11
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm
12
http://www.acog.org/~/media/For%20Patients/faq114.pdf?dmc=1&ts=20140324T1522108735
8
164
Glossary
Familial adenomatous polyposis (FAP) 13: An inherited disorder characterized by cancer of the
large intestine (colon) and rectum.
Functional assessment 14: Evaluation of an individual’s ability to function in the arena of
everyday life. Functional assessment in an elderly woman, for example, includes evaluation of
cognitive and affective mental functions, vision, hearing, motor function, gait and balance, bowel
and bladder function, activities of daily living, and environmental risks and support systems.
Gender identity 15: According to the American Psychological Association, a person’s basic
sense of self as male, female, or transgender.
Gestational diabetes 16: Glucose intolerance first occurring during pregnancy and resolving after
delivery.
Hyperglycemia 17: High blood sugar; in most people, more than 140 mg/dl (before meals).
Interconception care 18: Interventions between pregnancies to identify and modify risk to a
woman’s health or pregnancy outcomes.
Intimate partner violence 19 (also called domestic violence): A pattern of assaultive behavior
and coercive behavior that may include physical injury, psychologic abuse, sexual assault,
progressive isolation, stalking, deprivation, intimidation, and reproductive coercion.
Lactation support: Interventions and counseling designed to increase initiation and continuation
of breastfeeding.
Lynch syndrome/Hereditary nonpolyposis colorectal cancer 20: An inherited disorder that
increases the risk of many types of cancer, particularly cancers of the colon (large intestine) and
rectum. Patients are also at increased risk of endometrial, ovarian, and breast cancers.
Metabolic syndrome 21: A group of risk factors that raises the risk for heart disease and other
health problems, such as diabetes and stroke. Metabolic syndrome is defined by the presence of
13
http://ghr.nlm.nih.gov/condition/familial-adenomatous-polyposis
ACOG Guidelines for Women’s Health Care, 2nd ed., 2002, p. 178 (please verify against
current edition)
15
http://www.apa.org/pi/lgbt/resources/guidelines.aspx?item=2
16
http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-andreports/?productid=1296&pageaction=displayproduct
17
http://www.cdc.gov/diabetes/pubs/tcyd/ktrack.htm
14
18
http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/healthfollowingpregnan
cy.pdf
19
http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Repro_Guide.pdf
20
http://ghr.nlm.nih.gov/condition/lynch-syndrome
21
http://www.nhlbi.nih.gov/health/health-topics/topics/ms/
165
Glossary
at least three of the following risk factors: large waistline, high triglyceride level, low HDL
cholesterol level, high blood pressure, and high fasting blood sugar level.
Preconception care 22: Interventions before a pregnancy to identify and modify risk to a
woman’s health or pregnancy outcomes.
Postpartum 23: A period of time after the delivery of a newborn during which certain events may
occur. This may be as short as 6 weeks.
Postpartum depression 24: Intense feelings of sadness, anxiety, or despair after giving birth that
prevent a woman from being able to do her daily tasks. Postpartum depression can occur up to 1
year after having a baby, but it most commonly starts about 1–3 weeks after childbirth. By
contrast, postpartum blues may occur about 2-3 days after childbirth and manifest as feelings of
depression, anxiety, anger, or other emotions, but the feelings resolve within 1-2 weeks with no
treatment.
Reproductive coercion 25: Behavior intended to maintain power and control in a relationship by
someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult
or adolescent. Specifically, reproductive coercion is behavior that interferes with contraception
use and pregnancy. The most common forms of reproductive coercion include sabotage of
contraceptive methods, pregnancy coercion, and pregnancy pressure.
Screening 26: Tests, examinations, or other procedures used to find evidence of otherwise
unrecognized disease or defects. Screening test are usually not definitive. Positive screening
tests usually require further diagnostic testing to confirm the abnormality.
Sexual coercion 27: A range of behavior that a partner may use related to sexual decision-making
to pressure or coerce a person to have sex without using physical force. This behavior includes
repeatedly pressuring a partner to have sex, threatening to end a relationship if the person does
not have sex, forcing sex without a condom or not allowing other prophylaxis use, intentionally
exposing a partner to a sexually transmitted infection (STI), including human immunodeficiency
virus (HIV), or threatening retaliation if notified of a positive STI test result.
22
http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/healthfollowingpregnan
cy.pdf
23
http://www.aafp.org/afp/2005/1215/p2491.html
24
https://www.acog.org/~/media/For%20Patients/faq091.pdf?dmc=1&ts=20140324T1627086079
25
http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health
_Care_for_Underserved_Women/Reproductive_and_Sexual_Coercion
26
http://www.who.int/cancer/detection/variouscancer/en/
27
http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health
_Care_for_Underserved_Women/Reproductive_and_Sexual_Coercion#1
166
Glossary
Sexual health 28: A state of physical, mental, and social well-being in relation to sexuality. It
requires a positive and respectful approach to sexuality and sexual relationships, as well as the
possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination,
and violence.
Sexual orientation 29: Refers to the sex of those to whom one is sexually and romantically
attracted.
Sexually active: To be engaged physically in sexual activity, including but not exclusively
including manual, oral, vaginal, or anal contact.
Shared decision-making 30: A process in which patients and their clinicians discuss options and
decide the best course of action on the basis of the available evidence and the patient’s
preferences and values.
Suicide ideation 31: Thinking about, considering, or planning for suicide.
Abbreviations
AACE: American Association of Clinical Endocrinologists
AAFP: American Academy of Family Physicians
AAP: American Academy of Pediatrics
AAPD: American Academy of Pediatric Dentistry
ACG: American College of Gastroenterology
ACIP: Advisory Committee on Immunization Practices
ACNM: American College of Nurse-Midwives
ACOG: American Congress of Obstetricians and Gynecologists
ACP: American College of Physicians
ACS: American Cancer Society
ACSP: American Society for Clinical Pathology
ADA: American Dental Association
ADA: American Diabetes Association
ADA: American Dietetic Association
AHA: American Heart Association
AHRQ: Agency for Healthcare Research and Quality
AMA: American Medical Association
APC: Adenomatous polyposis coli (gene)
ASCCP: American Society for Colposcopy and Cervical Pathology
ASN: American Society of Nephrology
http://www.who.int/topics/sexual_health/en/
http://www.apa.org/pi/lgbt/resources/guidelines.aspx?item=2
30
http://www.innovations.ahrq.gov/content.aspx?id=3868
31
http://www.cdc.gov/violenceprevention/suicide/definitions.html
28
29
167
Glossary
ATA: American Thyroid Association
AWHONN: Association of Women’s Health, Obstetric and Neonatal Nurses
BMI: Body mass index
BRCA: Breast cancer (genes)
BSE: Breast self-examination
CBE: Clinical breast examination
CCP:
CDC: Centers for Disease Control and Prevention.
CHD: Coronary heart disease
CIN: Cervical intraepithelial neoplasia
CSF: Cerebrospinal fluid
CTFPHC: Canadian Task Force on Preventive Health Care
CVD: Cardiovascular disease
DES: Diethylstilbestrol
DTaP: Diphtheria, tetanus, and pertussis (vaccine)
EGAPP: Evaluation of Genomic Applications
FAP: Familial adenomatous polyposis
FDA: U.S. Food and Drug Administration
FOBT: Fecal occult blood test
FWV: Futures Without Violence
GDM: Gestational diabetes mellitus
HEDIS: Healthcare Effectiveness Data and Information Set
HIV: Human immunodeficiency virus
HCV: Hepatitis C virus
HDL: High-density lipoprotein
HMHB: National Healthy Mothers Healthy Babies Coalition
HNPCC: Hereditary nonpolyposis colorectal cancer
HPV: Human papillomavirus
IOM: Institute of Medicine
IPV: Intimate partner violence
IUD: Intrauterine device
KPCMI: Kaiser Permanente Care Management Institute
LDL: Low-density lipoprotein
MoD: March of Dimes
MYH:
NAHIC: National Adolescent and Young Adult Health Information Center
NCCN: National Comprehensive Care Network
NCQA: National Committee for Quality Assurance
NIH: National Institutes of Health
NKF: National Kidney Foundation
NSAIDs: Nonsteroidal anti-inflammatory drugs
NTD: Neural tube defect
PCHHC: Preconception Health and Health Care Steering Committee
PIH: Pregnancy-induced hypertension
SASGOG: Society for Academic Specialists in General Obstetrics and Gynecology
STD: Sexually transmitted disease
in Practice and Pre
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Glossary
STI: Sexually transmitted infection
Tdap: Tetanus, diphtheria, and pertussis (vaccine)
TSH: Thyroid-stimulating hormone
USDHHS: U.S. Department of Health and Human Services
USPSTF: U.S. Preventive Services Task Force
UVR: Ultraviolet ray
WHO: World Health Organization
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