Annual Preventive Screening
Women's Health Screening
Across the Lifespan
Adolescence · Middle Age · Perimenopause · Menopause
Nwaozichi Onyeije, CNM | Current Evidence Review 2024–2025
Learning Objectives
01 · Adolescence
Ages 13–21
Identify screening priorities for mental health, STIs, and cervical dysplasia in the adolescent female.
02 · Adulthood
Ages 22–49
Apply guidelines for cervical cancer, breast cancer, and cardiometabolic risk screening in reproductive-age women.
03 · Perimenopause
Ages 40–54
Recognize emerging screening needs as hormonal transition begins, including bone health and cardiovascular risk.
04 · Menopause
Ages 55+
Detail osteoporosis, colorectal, and lung cancer screening; understand the clinical implications of each.
USPSTF Evidence Grading
Understanding the strength behind each recommendation
A
High Certainty
Substantial net benefit. Offer or provide the service.
B
Moderate Certainty
Moderate to substantial net benefit. Offer or provide.
C
Small Net Benefit
Offer selectively based on individual circumstances.
I
Insufficient Evidence
Balance benefits and harms; clinical judgment required.
A & B recommendations are mandated without cost-sharing under the ACA (Section 2713)
Screening Across the Female Lifespan
13
Adolescence
Ages 13–21
Mental health
STIs · HPV
22
Early Adulthood
Ages 22–39
Cervical · STIs
Cardiometabolic
40
Middle Age
Ages 40–49
Mammography
BP · Lipids · DM
50
Perimenopause
Ages 45–55
Colorectal
Bone density
65
Menopause
Ages 55–75+
DEXA · Lung CT
Falls prevention
Annual well-woman visit recommended across all age groups · WPSI/HRSA
Section 1
Adolescence
Ages 13–21 · Establishing the foundation for lifelong health
The Initial Reproductive Health Visit
ACOG recommends first visit between ages 13–15
Purpose
- Establish patient-provider relationship
- Confidential history-taking
- Counseling on puberty & development
- No pelvic exam required at first visit
Screening Initiated
- Blood pressure measurement
- BMI & weight assessment
- Anxiety & depression screening
- Substance use (CRAFFT tool)
- Intimate partner violence
Immunizations
- HPV vaccine series (age 11–12, catch-up to 26)
- Tdap booster
- Meningococcal vaccine
- Annual influenza
Mental Health Screening
Depression and anxiety are the leading mental health conditions in adolescent females
Depression (MDD)
- Screening: Ages 12–18 annually
- Tool: PHQ-A (Patient Health Questionnaire — Adolescent)
- Prevalence: ~17% of adolescent females
- USPSTF Grade B
- Must have adequate systems for diagnosis, treatment, and follow-up
Anxiety Disorders
- Screening: Ages 8–18 (USPSTF); Ages 13+ (WPSI)
- Tools: GAD-7, SCARED, MASC
- Prevalence: ~32% lifetime risk in females
- USPSTF Grade B
- Includes generalized anxiety, social anxiety, panic disorder
Sexually Transmitted Infection Screening
Highest STI burden occurs in women aged 15–24
| Infection |
Who to Screen |
Interval |
Method |
Grade |
| Chlamydia |
All sexually active women <25 |
Annually |
NAAT (urine or vaginal swab) |
A |
| Gonorrhea |
All sexually active women <25 |
Annually |
NAAT (urine or vaginal swab) |
B |
| HIV |
All women 15–65; high-risk from age 13 |
At least once; annually if high-risk |
4th-generation Ag/Ab combination test |
A |
| Syphilis |
Persons at increased risk |
Annually if high-risk |
RPR or VDRL (treponemal confirmation) |
A |
| Hepatitis B |
Adolescents & adults at increased risk |
As indicated by risk |
HBsAg, anti-HBc, anti-HBs |
B |
| Hepatitis C |
Adults 18–79 years |
Once; more if high-risk |
Anti-HCV antibody |
B |
Cervical Cancer Screening: Age 21
Screening begins at age 21 regardless of sexual history
Why Not Before Age 21?
- HPV infections in adolescents are almost universally transient
- Cervical cancer is exceedingly rare <21 years
- Early screening leads to overtreatment of benign lesions
- LEEP/CKC may impair future cervical competence
- Harms outweigh benefits before age 21
Age 21–29: Cytology Only
- Pap smear (cervical cytology) every 3 years
- HPV co-testing NOT recommended <30 years
- High-risk HPV prevalence is high in this age group but mostly clears spontaneously
- USPSTF Grade A
- Abnormal results managed per ASCCP 2019 guidelines
Section 2
Early & Middle Adulthood
Ages 22–49 · Cancer screening, cardiometabolic health, and reproductive wellness
Cervical Cancer Screening: Ages 30–65
Updated WPSI/HRSA guidelines effective 2027 — primary hrHPV preferred
| Strategy |
Interval |
Rationale |
Status |
| Primary hrHPV testing |
Every 5 years |
More sensitive than cytology; detects high-risk HPV types 16/18 and 12 others |
Preferred (2027) |
| Co-testing (hrHPV + Pap) |
Every 5 years |
High sensitivity and specificity; well-validated in large cohorts |
Acceptable |
| Cytology alone (Pap) |
Every 3 years |
Acceptable if hrHPV testing unavailable; lower sensitivity |
Alternative |
| Self-collected hrHPV |
Every 5 years |
New 2026 HRSA update; improves access and uptake; non-inferior to clinician-collected |
New Option 2027 |
Discontinue at age 65 with adequate prior negative screening · USPSTF Grade A
Breast Cancer Screening
Updated USPSTF 2024: Screening begins at age 40 for all women
Who & When
- All women: begin at age 40
- Biennial mammography through age 74
- WPSI: initiate no earlier than 40, no later than 50; annual or biennial
- Continue beyond 74 based on individual health status
USPSTF Grade B (2024)
Why It Matters
- Breast cancer: leading cancer diagnosis in women
- Mammography reduces breast cancer mortality by ~20–40%
- Earlier initiation (40 vs. 50) prevents ~1.3 additional deaths per 1,000 women
- Shared decision-making for 40–49 age group
High-Risk Considerations
- BRCA1/2 mutation: annual MRI + mammogram from age 25–30
- Prior chest radiation: annual MRI + mammogram from age 25
- Lifetime risk ≥20%: supplemental MRI recommended
- Dense breasts: consider supplemental ultrasound or MRI
BRCA-Related Cancer Risk Assessment
Identify women who may benefit from genetic counseling and testing
Who to Refer for Genetic Counseling
- Personal or family history of breast, ovarian, tubal, or peritoneal cancer
- Breast cancer diagnosed ≤50 years
- Male breast cancer in family
- Ashkenazi Jewish ancestry with any breast/ovarian cancer
- Positive risk assessment tool (e.g., Ontario Family History Assessment Tool, Manchester Scoring System)
USPSTF Grade B
Clinical Implications
- BRCA1/2 carriers: lifetime breast cancer risk 50–72%
- BRCA1: lifetime ovarian cancer risk 44–46%
- BRCA2: lifetime ovarian cancer risk 17–23%
- Risk-reducing options: prophylactic salpingo-oophorectomy, mastectomy, chemoprevention
- Enhanced surveillance with MRI + mammogram annually
Cardiometabolic Screening
Cardiovascular disease remains the leading cause of death in women
| Test |
Age / Population |
Interval |
Rationale |
Grade |
| Blood Pressure |
All adults ≥18 |
Annually ≥40; every 3–5 yrs if normal 18–39 |
Hypertension is the leading modifiable CVD risk factor; often asymptomatic |
A |
| Lipid Panel |
Women ≥45 at increased CVD risk; AHA: begin at 20 |
Every 5 years if normal |
Dyslipidemia is a major modifiable risk factor for atherosclerotic CVD |
B |
| Diabetes (Type 2) |
Adults 35–70 with overweight or obesity (BMI ≥25) |
Every 3 years if normal |
Early detection prevents microvascular and macrovascular complications |
B |
| BMI / Obesity |
All adults |
Annually |
Obesity is a risk factor for DM, HTN, CVD, and multiple cancers |
B |
| Statin Use |
Adults 40–75 with ≥1 CVD risk factor + 10-yr risk ≥10% |
Individualized |
Preventive statin therapy reduces CVD events in intermediate-risk patients |
B |
Mental Health Screening: Adulthood
Women are twice as likely as men to experience depression and anxiety
Depression Screening
- All adults ≥18, including pregnant and postpartum persons
- Tools: PHQ-2 (initial), PHQ-9 (follow-up)
- Must have adequate systems for diagnosis, treatment, and follow-up
- Peripartum depression: screen at multiple time points
USPSTF Grade B
Anxiety Screening
- All women ≥13, including pregnant and postpartum (WPSI)
- Adults ≤64 years (USPSTF)
- Tools: GAD-7, GAD-2, PRIME-MD
- Frequency: at least annually; clinical judgment for rescreening
USPSTF Grade B
Intimate Partner Violence (IPV)
- Screen all women of reproductive age annually (WPSI)
- Tools: HITS, HARK, PVS
- Provide or refer to intervention services when positive
USPSTF Grade B
Unhealthy Alcohol Use
- Screen all adults ≥18 in primary care settings
- Tool: AUDIT-C (3 questions)
- Brief behavioral counseling for risky/hazardous drinkers
USPSTF Grade B
Colorectal Cancer Screening
Screening now begins at age 45 — updated USPSTF 2021
Who & When
- Average-risk adults: begin at age 45
- Continue through age 75 (Grade A)
- Ages 45–49: Grade B (moderate certainty)
- Ages 76–85: individualized decision
- High-risk (FH, IBD): earlier and more frequent
Stool-Based Tests
- FIT (fecal immunochemical test): annually
- gFOBT: annually (high-sensitivity)
- Stool DNA (Cologuard): every 1–3 years
- Non-invasive; high patient acceptance
- Positive result requires colonoscopy
Structural Tests
- Colonoscopy: every 10 years (gold standard)
- CT colonography: every 5 years
- Flexible sigmoidoscopy: every 5 years
- Allows direct visualization and polypectomy
- Preferred for high-risk patients
Section 3
Perimenopause
Ages 40–54 · Hormonal transition and emerging chronic disease risk
The Perimenopausal Transition
A critical window for preventive intervention
2–8
Years of perimenopausal transition on average
51
Median age of final menstrual period (US)
75%
Women experiencing vasomotor symptoms
↑ CVD
Cardiovascular risk accelerates post-menopause
Perimenopause is an opportune time to intensify screening for cardiometabolic disease, bone health, and cancer — before the accelerated risk of the postmenopausal period.
Osteoporosis Screening: Early Identification
Up to 20% of trabecular bone lost in the first 5 years post-menopause
USPSTF 2025 Recommendations
- Women ≥65: Screen all with DEXA scan (Grade B)
- Postmenopausal women <65: Screen if risk factors present (Grade B)
- Risk assessment tools: FRAX, SCORE, OST
- FRAX score ≥9.3% (10-yr hip fracture risk) triggers DEXA in younger women
Risk Factors Warranting Early Screening
- Low body weight (BMI <20)
- Current smoking or excessive alcohol use
- Parental history of hip fracture
- Glucocorticoid use ≥3 months
- Rheumatoid arthritis
- Prior fragility fracture
- Premature ovarian insufficiency (POI)
- Malabsorption syndromes (celiac, IBD)
DEXA Scan: Interpretation & Implications
Dual-energy X-ray absorptiometry — the gold standard for BMD measurement
| T-Score |
Diagnosis |
Fracture Risk |
Clinical Action |
| ≥ −1.0 |
Normal BMD |
Baseline |
Lifestyle counseling; repeat DEXA in 15 years if low risk |
| −1.0 to −2.5 |
Osteopenia (Low BMD) |
Moderately elevated |
Calcium + Vit D supplementation; weight-bearing exercise; repeat DEXA in 1–5 years |
| ≤ −2.5 |
Osteoporosis |
Substantially elevated |
Pharmacotherapy (bisphosphonates, denosumab, romosozumab); MHT if symptomatic <60 |
| ≤ −2.5 + fracture |
Severe Osteoporosis |
Very high |
Urgent pharmacotherapy; fall prevention; orthogeriatric co-management |
Sites measured: lumbar spine (L1–L4), femoral neck, total hip · Use lowest T-score for diagnosis
Cardiovascular Screening in Perimenopause
CVD risk accelerates with estrogen decline — the perimenopausal window is critical
Intensified Screening
- Blood pressure: Annually from age 40
- Fasting lipid panel: Every 5 years (sooner if abnormal)
- Fasting glucose / HbA1c: Every 3 years if BMI ≥25
- BMI & waist circumference: Annually
- 10-year ASCVD risk: Calculate at each visit (PCE)
Female-Specific CVD Risk Factors
- History of preeclampsia (2× lifetime CVD risk)
- History of gestational diabetes
- Premature menopause (<40 years)
- Autoimmune disease (SLE, RA)
- Polycystic ovary syndrome (PCOS)
- History of preterm birth or IUGR
AHA/ACC 2019: Female-specific risk factors should be incorporated into ASCVD risk assessment
Additional Screening in Perimenopause
Conditions that mimic or compound menopausal symptoms
Thyroid Disease
- Hypothyroidism prevalence: 5–10% in women >50
- Symptoms overlap with menopause: fatigue, weight gain, mood changes
- USPSTF: Insufficient evidence (Grade I) for universal screening
- Screen if symptomatic or high-risk (autoimmune disease, prior thyroid disease, family history)
- Test: TSH (serum)
Urinary Incontinence
- WPSI: Screen all women annually
- Affects 25–45% of perimenopausal women
- Ask: "Do you experience urine leakage? Does it affect your activities?"
- Types: stress, urgency, mixed
- Refer for pelvic floor PT, urogynecology if indicated
Obesity Prevention
- WPSI: Counsel women 40–60 with normal/overweight BMI to prevent obesity
- Perimenopausal weight gain: average 1.5 kg/year
- Visceral fat accumulation increases CVD and DM risk
- Individualized counseling: diet, physical activity
- Refer to intensive behavioral intervention if BMI ≥30
Section 4
Menopause
Ages 55+ · Chronic disease prevention and quality of life
Osteoporosis: Universal Screening at 65
USPSTF 2025: Grade B recommendation for all women ≥65
1 in 2
Women >50 will have an osteoporosis-related fracture
20%
Trabecular bone lost in first 5 years post-menopause
30%
1-year mortality after hip fracture in women >65
$57B
Annual US cost of osteoporotic fractures
DEXA screening is the single most impactful preventive intervention in postmenopausal women. Early identification allows pharmacologic intervention before fracture occurs.
Colorectal Cancer Screening: Ages 50–75
Grade A recommendation — highest evidence level for this age group
Why Screening Saves Lives
- CRC is the 2nd leading cause of cancer death in women
- Incidence rises sharply after age 50
- Colonoscopy detects and removes adenomatous polyps before malignant transformation
- FIT annually reduces CRC mortality by 15–33%
- Colonoscopy every 10 years reduces CRC incidence by 60–90%
USPSTF Grade A (50–75)
Discontinuation & High-Risk Management
- Ages 76–85: individualized decision (Grade C)
- Discontinue if life expectancy <10 years
- High-risk: Lynch syndrome, FAP, IBD — colonoscopy every 1–2 years
- Prior adenoma: surveillance per ACG/USMSTF guidelines
- Positive stool test always requires colonoscopy follow-up
Lung Cancer Screening
Lung cancer is the leading cause of cancer death in women
USPSTF 2021 Recommendation
- Annual low-dose CT (LDCT) of the chest
- Ages 50–80 years
- ≥20 pack-year smoking history
- Currently smoke OR quit within the past 15 years
- Discontinue if >15 years since quitting or if health limits curative treatment
USPSTF Grade B
Clinical Implications
- NLST trial: LDCT reduced lung cancer mortality by 20% vs. chest X-ray
- NELSON trial: 24% mortality reduction in women (higher than men)
- Women have higher lung cancer risk per pack-year than men
- Shared decision-making required: discuss benefits, harms (false positives, radiation), and smoking cessation
- Cessation counseling must accompany screening referral
Falls Prevention & Sensory Screening
Falls are the leading cause of injury death in women ≥65
Falls Prevention
- Offer exercise interventions to community-dwelling adults ≥65 at increased fall risk
- USPSTF Grade B
- Risk factors: prior fall, gait instability, polypharmacy, osteoporosis, visual impairment
- Tools: Timed Up and Go (TUG), 30-second chair stand
- Vitamin D supplementation: Grade D for fall prevention alone
Vision Screening
- No USPSTF recommendation for routine screening in asymptomatic adults
- AAO recommends comprehensive eye exam every 1–2 years ≥65
- Screen for: glaucoma, macular degeneration, cataracts, diabetic retinopathy
- Impaired vision significantly increases fall risk
Hearing Screening
- USPSTF: Insufficient evidence (Grade I) for routine hearing screening in adults ≥50
- Hearing loss affects ~1 in 3 adults ≥65
- Associated with cognitive decline, depression, social isolation
- Ask: "Do you have difficulty hearing in conversations?"
- Refer to audiology if positive
Cognitive Health in the Postmenopausal Woman
Women account for nearly two-thirds of all Alzheimer's disease cases
Current Screening Guidance
- USPSTF: Insufficient evidence (Grade I) for routine cognitive screening in asymptomatic adults
- Assess cognitive function if patient or family reports concerns
- Tools: Mini-Cog, MMSE, MoCA
- Annual Medicare Wellness Visit includes cognitive assessment
- Distinguish normal aging from MCI and dementia
Modifiable Risk Factors to Address
- Hypertension (midlife) — strongest modifiable risk factor
- Type 2 diabetes — 2× dementia risk
- Depression — bidirectional relationship
- Physical inactivity, obesity, smoking
- Hearing loss — treat early
- Social isolation
- Sleep disorders (OSA, insomnia)
Lancet Commission 2024: 14 modifiable risk factors account for ~45% of dementia cases
Comprehensive Screening Summary
| Screening Test |
Adolescence
13–21 |
Adulthood
22–49 |
Perimenopause
40–54 |
Menopause
55+ |
| Blood Pressure |
✓ Annually |
✓ Annually ≥40; q3–5y if normal |
✓ Annually |
✓ Annually |
| Cervical Cancer (Pap/HPV) |
Begins at 21 |
✓ q3y (Pap) or q5y (HPV/co-test) |
✓ Continue through 65 |
Stop at 65 if adequate history |
| Breast Cancer (Mammogram) |
— |
✓ Begins at 40; biennial |
✓ Biennial (annual if high-risk) |
✓ Continue through 74+ |
| Colorectal Cancer |
— |
✓ Begins at 45 |
✓ Continue |
✓ Through 75; individualized 76–85 |
| Osteoporosis (DEXA) |
— |
— |
✓ If risk factors present |
✓ All women ≥65 |
| Diabetes (HbA1c/FPG) |
— |
✓ 35–70 if overweight/obese |
✓ Continue |
✓ Continue |
| Lung Cancer (LDCT) |
— |
— |
✓ If ≥20 pack-year history (50+) |
✓ Through 80 |
| Depression / Anxiety |
✓ Annually |
✓ Annually |
✓ Annually |
✓ Annually |
| STIs (Chlamydia/Gonorrhea) |
✓ Annually if sexually active |
✓ <25 annually; ≥25 if high-risk |
If high-risk |
If high-risk |
Clinical Implications: Adolescent Screening
Why these tests matter — and what to do with results
🧠
Mental Health: Early Detection Changes Trajectories
Untreated adolescent depression and anxiety predict adult psychiatric disorders, substance use, and academic failure. Screening creates an entry point for CBT, SSRIs, and school-based support — interventions with strong evidence of efficacy.
🔬
STI Screening: Prevents Sequelae and Transmission
Undetected chlamydia leads to PID, tubal factor infertility, and ectopic pregnancy. Annual NAAT screening in sexually active women <25 is the most cost-effective intervention in reproductive health. Treatment prevents transmission and long-term morbidity.
💉
HPV Vaccination: Primary Prevention of Cervical Cancer
The 9-valent HPV vaccine prevents 90% of cervical cancers. Vaccination at ages 11–12 (before sexual debut) provides the highest immunogenicity. Catch-up vaccination through age 26 is recommended; shared decision-making for ages 27–45.
Clinical Implications: Adulthood Screening
Screening in the reproductive years shapes long-term health outcomes
🔴
Cervical Cancer Screening: Interval Matters
The shift to primary hrHPV testing every 5 years (preferred from 2027) reflects superior sensitivity (96% vs. 53% for cytology alone) for detecting CIN2+ lesions. Extending intervals reduces overtreatment while maintaining cancer prevention. Adherence to ASCCP 2019 guidelines for abnormal results is essential.
🩻
Mammography at 40: A Paradigm Shift
The 2024 USPSTF update lowering the start age to 40 (from 50) is projected to prevent an additional 1.3 deaths per 1,000 women screened. Clinicians must counsel on false-positive rates (~60% over 10 years of biennial screening) and the rare risk of overdiagnosis to support informed decision-making.
❤️
Cardiometabolic Screening: Female-Specific Risk Factors
Pregnancy complications (preeclampsia, GDM) are now recognized as independent CVD risk factors. Women with these histories warrant earlier and more intensive cardiometabolic screening. The PCE calculator underestimates CVD risk in women — supplement with female-specific risk enhancers.
Clinical Implications: Peri- & Menopausal Screening
The postmenopausal period demands a proactive, multisystem approach
🦴
Osteoporosis: Screen Before the Fracture
The first fracture is often the first clinical sign of osteoporosis. DEXA screening at age 65 (or earlier with risk factors) identifies women who benefit from bisphosphonates, denosumab, or romosozumab — agents that reduce fracture risk by 30–70%. MHT is an effective alternative for women <60 with concurrent VMS.
🫁
Lung Cancer LDCT: Women Benefit More Than Men
The NELSON trial demonstrated a 24% lung cancer mortality reduction in women (vs. 6% in men) with LDCT screening. Women develop lung cancer at lower cumulative tobacco exposures. Clinicians should actively identify eligible women and integrate screening with smoking cessation counseling.
🧬
Colorectal Cancer: Adherence is the Challenge
Despite Grade A evidence, CRC screening adherence remains below 70% in the US. Offering patient choice among equivalent strategies (FIT, colonoscopy, Cologuard) significantly improves uptake. Stool-based tests are particularly valuable for patients with mobility limitations or colonoscopy aversion.
Shared Decision-Making in Preventive Screening
Evidence-based screening requires patient-centered communication
When SDM is Essential
- Grade C recommendations (small net benefit)
- Grade B with significant tradeoffs (mammography 40–49)
- Competing screening strategies (CRC modalities)
- High-risk individuals (BRCA, Lynch syndrome)
- Patients with limited life expectancy
- Patients with prior false-positive results
Key Communication Principles
- Communicate absolute risk reduction (not just relative)
- Discuss harms: false positives, overdiagnosis, procedural risks
- Elicit patient values and preferences
- Use decision aids when available
- Document the conversation
- Revisit decisions at subsequent visits
SDM does not mean offering less — it means offering more thoughtful, individualized care
Key Takeaways
Adolescence
Mental health screening (depression, anxiety) and STI screening are the highest-yield interventions. HPV vaccination is primary cancer prevention. Cervical screening begins at 21.
Adulthood
Mammography now begins at 40. Primary hrHPV testing (preferred from 2027) is more sensitive than cytology. Female-specific CVD risk factors must be incorporated into cardiometabolic screening.
Perimenopause
A critical window for intensifying cardiometabolic and bone health screening. Thyroid disease and urinary incontinence mimic menopausal symptoms and should be actively screened.
Menopause
DEXA at 65 is universal. Colorectal cancer screening (Grade A) through age 75 saves lives. LDCT for lung cancer benefits women disproportionately. Falls prevention is an underutilized intervention.
🌿
Thank You
Questions & Discussion
Nwaozichi Onyeije, CNM
Evidence-Based Women's Health · Preventive Care Across the Lifespan
Slides prepared using current literature (2021–2025) · For educational purposes · USPSTF · ACOG · WPSI/HRSA · CDC · ACS