Well i am glad you asked! Being a gynecologist myself, I am ALL OVER this one with wise tips and safe knowledge. First let me say that yes, I have seen all the newsflash and articles about teens suffering through unnecessary exams too early. Yes yes. I have read them all. I am also well-versed in all the national recommendations. Having said that, let me break this down according to my perspective and explain how I go about the practice of adolescent gynecology.
I want to first start off by saying that, to my knowledge, no teen has suffered at my office that I know of….or at least they have not spoken up. Usually they leave the office relieved that it wasn’t as awful as their friends, google, or the random promiscuous acquaintance said it would be.
Ok let’s clarify some current national recommendations on pap smears. The USPSTF( United States Preventative Services Task Force) recommends screening for cervical cancer in women ages 21 to 65 years with a pap smear every 3 years or, for women age 30 to 65 who want to lengthen the screening interval, screening with a pap smear and hpv testing every 5 years. Women over the age of 65 with adequate prior screening do not require further screening. Women who have had a hysterectomy with the removal of the cervix and who do not have a history of high grade dysplasia also do not require further screening. Now that we have all that settled there are a few caveats and things to clarify. First, these recommendations are based on statistics, costs( how expensive it is to identify and take care of someone with cervical cancer versus how much it costs to screen everybody) and epidemiology( how long it would take abnormal cervical cells to progress into something serious. Second, these recommendations often come from a panel of folks who may or may not have seen actual patients in a clinical setting in a very long time. Third, these recommendation ONLY refer to the pap smear guidelines. This can be very confusing for women because when they hear no pap smear required, they tend to think that means no exam is required. I cannot speak for other offices, but in my office, the pap smear is a mere 30 second portion of the entire head to toe exam that I perform on my patients and is by no means the end all be all. This is, in my opinion, potentially very dangerous because there are many gynecologic conditions that do not present with symptoms until late stage and increased severity. If the average woman gets no check up and just waits for symptoms, she could already be facing a life-threatening condition that could have otherwise been picked up on and treated. Ovarian cancer symptoms can be as vague as some bloating and decreased appetite. Vulvar cancer can present with just a minor itch. Without significant contortionist abilities, a head lamp, and some Superman x ray vision, I find it difficult to believe that the majority of women could accurately self- diagnose at an early stage. I recommend at least getting an exam every year…all pap smear recommendations aside. The other thing that I find difficult to swallow about these recommendations is that they seem to be attempting to weigh what a human life is worth. It feels like we are saying,” It’s just too expensive to watch out for all of you long term and actually use our technology to catch everything early, so we are just going to hedge our bets and go for the cheapest option because it will likely end up in our favor. For that handful or more of patients that get missed, oh well. I would challenge any actively practicing physician to look a patient whose preventable diagnoses was delayed and hide behind these recommendations with no regret.
Now, back to the teenagers. Let me preface again before we go on that what I am about to say is based on fact and my personal opinion combined. I will try to be very clear on which part is which. Here is what I tell parents when they ask when they should bring their teenage daughters to me. I first recommend that a patient start visiting me when she first starts having a period. This is a good time to have an honest, CLOTHING ON, discussion with the adolescent about her body, what to expect, evaluate whether she is having any menstrual difficulties, etc. If applicable, we can also have an open discussion about sexual pressures and peer pressure. I also use this as an opportunity to offer myself as an unlimited resource for any future questions she might have. This visit does not necessarily involve getting an exam. These kinds of visits can be carried out on an annual basis, accounting for good decision-making, until the patient reaches 21 and screening can begin. However, we all know that age of first intercourse in the United States is getting lower and lower. I have 12 and 13 year olds in my practice that are already experimenting with sex. A lot of the time, the parents either do not know or are not prepared or comfortable to deal with this situation and therefore the patient goes unchecked, high risk behaviors evolve out of lack of resources and information, and lots of potential problems arise. I truly feel that if these patients were to have the opportunity to establish with me, I could help tackle some of these issues and at least attempt to help keep the patient safe. If I have an adolescent patient that is engaging in high risk behaviors( multiple partners, unprotected sex, etc), I may want to do an exam for several reasons. First, even tho I realize that some sexually transmitted infections can be screened with urine and blood, there are some that cannot. For example, I cannot determine if a patient has genital warts that need to be treated without an actual examination. Second, it is my personal opinion that there is a certain amount of responsibility that should accompany the decision to be sexually active and part of that should include the patient being actively involved with being healthy like getting an exam rather than peeing in a cup and waiting for results. I think that when we foster a disconnect between our teenagers and their decisions, it only compounds the potential for disaster. Third, this subgroup of teenagers is at higher risk of HPV and eventually cervical cancer. I realize that, according to statistics and epidemiology, it is likely to take years and years for this HPV or cervical dysplasia to develop into something serious like cancer and that it has a chance of resolving on its own. I also realize that part of the logic in these recommendations is that the teenage population would be more at risk for having unnecessary procedures for conditions that may resolve spontaneously in time. I assure you that I am very cognizant of not doing just that in my practice. Even understanding all that, do we really want to just throw the dice and wait and not even involve the adolescent in her own gynecologic well- being until she is 21? I just have a hard time with it. Welp, those are my thoughts on the subject. Have a fantastic day!