In a previous post I covered the well-woman visit framework. This post drills deeper into the screening guidelines themselves — the timing, the test choices, the exceptions. The FNP boards loves nuance here. You'll be expected to know not just that mammograms exist, but at what age to start them by which guideline.
Let's settle the confusion.
Multiple guidelines exist for almost every screening. The exam usually follows USPSTF unless it tells you otherwise.
Cervical Cancer Screening — The Details
The current USPSTF/ACS-aligned recommendations:
- Under 21: No screening, regardless of sexual debut.
- 21–29: Cytology (Pap) alone every 3 years.
- 30–65: Three options — Pap + HPV co-test every 5 years (preferred per ACS), Pap alone every 3 years, or HPV alone every 5 years.
- Over 65: Stop if adequate negative prior screening (3 consecutive negative cytologies or 2 negative co-tests in past 10 years, with most recent within 5 years).
Abnormal Pap management — abbreviated
- ASC-US: If HPV positive → colposcopy. If HPV negative → repeat co-test in 3 years.
- LSIL: Colposcopy.
- HSIL: Colposcopy (or immediate excision in some cases).
- AGC: Colposcopy + endometrial sampling if >35 or risk factors.
Breast Cancer Screening
- USPSTF (2024): Biennial mammogram for women 40 to 74.
- ACS: Annual from 45 to 54; biennial from 55+ (or continue annually based on preference).
- ACOG: Annual from 40.
For exam purposes, the simplest answer when not specified: USPSTF — biennial starting at 40.
Genetic risk
If family history suggests BRCA mutation, refer for genetic counseling. BRCA carriers start MRI + mammogram at younger ages. Hereditary breast/ovarian cancer questions are increasingly common on the exam.
Ovarian Cancer Screening
Not recommended in the general population. CA-125 and pelvic ultrasound have high false-positive rates without mortality benefit. Only screen in BRCA carriers and very high-risk patients.
Endometrial Cancer
No routine screening. Evaluate any postmenopausal bleeding with transvaginal ultrasound or endometrial biopsy. Endometrial stripe >4 mm in postmenopausal women warrants biopsy.
Bone Density
- Women 65+: routine DEXA.
- Younger postmenopausal women: screen if risk factors (low body weight, prior fracture, family history, glucocorticoid use, smoking, alcohol use).
- Use FRAX calculator if 50+ to estimate 10-year fracture risk.
Osteoporosis treatment
- Bisphosphonates (alendronate, risedronate, ibandronate, zoledronic acid): first-line for most. Counsel on esophageal precautions and rare jaw osteonecrosis.
- Denosumab: SC every 6 months. Don't miss doses — rebound fracture risk.
- Calcium 1000–1200 mg/day + Vitamin D 800–1000 IU/day.
- Weight-bearing exercise.
STI Screening
- Chlamydia and gonorrhea: annually for sexually active women <25 or older with risk factors.
- HIV: at least once for all adults 15–65.
- Syphilis: if at risk.
- Hepatitis B and C: at least once in adulthood.
- Pregnancy: screen for HIV, hepatitis B, syphilis, chlamydia at first prenatal visit.
Intimate Partner Violence
USPSTF recommends screening women of reproductive age. HITS, WAST, or RADAR are validated tools.
Reproductive Counseling
- Preconception counseling: folic acid 400–800 mcg/day starting BEFORE conception. 4 mg/day for women with history of neural tube defect or on antiseizure medication.
- Contraception: offered at every visit if pregnancy is a possibility. LARC (IUDs, implants) are first-line for most women.
- Rubella status: check in women of reproductive age, vaccinate if non-immune (NOT during pregnancy).
Mental Health and Substance Use
- PHQ-2 or PHQ-9 for depression — recommended at every well-visit.
- AUDIT or single-question alcohol screen.
- Tobacco screening and cessation counseling.
Cardiovascular Screening
- BP at every visit.
- Lipid panel every 4–6 years starting age 20, more often if risk factors.
- Diabetes screening 35–70 with overweight/obesity.
How the Exam Tests This
The classic question: "A 47-year-old woman comes in for an annual exam. She last had a Pap 3 years ago (normal), mammogram 2 years ago (normal), colonoscopy not yet done. What screening is appropriate today?"
You walk through the list. Pap due (3-year cycle). Mammogram every 2 years — due. Colonoscopy — she's 47, screening starts at 45. Order it.
The exam likes well-rounded patients. Practice walking through their entire screening picture for any age.