What am I talking about? I am talking about gynecological care guidelines. Most recent guidelines from the USPSTF recommend pap smears every three years from ages 21 to 65 if using just the pap smear or every 5 years between 30 and 65 if using the pap smear and HPV testing. These recommendations are based on epidemiological data and costs. The few issues that may be caught before the age of 21 and after the age of 65 are too few and far between to be considered economical to screen for.
I have a problem with this in both the translational sense and the practical sense. With regard to the translational sense, these recommendations have the tendency to confuse adult women based upon terminology. Most women equate getting their pap and their annual check up as one and the same. They are not! In my office, the pap smear is about a 10 second clip of what I do. It is just one small piece of the puzzle. The real meat and bones is in the head to toe exam that I offer which allows me to check for anything that could be wrong in all body parts. You see when you tell most women they don’t need a pap but every three years, if at all, they think sweet! I am off the hook for any gynecologic exams for three years at a time and they don’t come in at all. In the practical sense, this lack of clarification is both irresponsible and potentially deadly. Obgyn is blessed to have some of the best preventative tools in the business but we become crippled by these recommendations because the patients don’t show up. Add to that the fact that insurance companies jump on the bandwagon and start trying to refuse to cover paps/annuals and these women are potentially really screwed. In the practical sense,, the thing is that most gyn conditions do not present with symptoms until the condition is pretty advanced. A little itch on the vulva could actually be a vulvar cancer. A little feeling of fullness in the abdomen could actually be an ovarian tumor. But, unless someone is looking(i.e me), the patient doesn’t know, the condition goes unrecognized and the situation goes from simple and treatable to serious and deadly. In addition, I would challenge the academicians that sit behind the desks and formulate these recommendations to sit down with the patients whose diagnosis you missed and explain to them how it’s ok because the cost/returns ratio was just not in their favor to justify screening. I am not sure that quoting guidelines will help the patient or the family feel any better either.
The bottom line is that I am a fan of the annual exam, whether or not the pap is performed. It is definitely the most bang for your buck way to be watchful for your patients. It really goes back to the OPPOSITE of the old adage: what you don’t know or can’t see CAN hurt you! Have a great day everybody!