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!
A family practitioner colleague of mine used to say this all the time to patients. ” I am a physician, not a magician.” Initially it always made me laugh because I am generally a fan of quippy sayings. But then, the truth of it really began to sink in…….A truer statement was never uttered. We are physicians not magicians. We are here to guide and provide evidence-based recommendations to attempt to better the lives of our patients. We are not here to bully or coerce. We cannot force anyone to do anything. The only time that I really get bossy is when it is a matter of life or death, which I feel is reasonable…lol When we take the time to advise a patient on their next move, it is essential that we are not in the game by ourselves. There needs to be a team effort relationship between the doctor and the patient in order to be successful and mold the desired outcome. This holds true for every type of patient that I care for: aesthetic patients, addiction patients and obgyn patients. In order for the doctor patient team relationship to remain stable and fruitful, there has to be personal investment on both sides. For me, that is guaranteed. I would not be in this profession if I were not invested in every single patient in every single scenario. That is the whole reason I got into the practice of medicine: to improve and save lives and to help as many patients as my faculties allow for as long as I can.
From the patient side, however, nothing is guaranteed. I have many wonderful patients that seem to value my advice, attempt to follow it to the best of their ability and actually are able to achieve the outcomes that they want to a reasonable extent. These patients are truly a joy to care for. They are the kind of patients that you reflect on to get you through a tough day and remind you why you are doing this in the first place.
Then, there is the other subgroup of patients. These are the ones that come in after years of absence and personal neglect with high expectations that you will be able to wave your magic wand and fix all of their issues with a single sweep of your arm. These are the morbidly obese diabetics who have never even attempted to modify their lifestyles or their mental relationships with food and demand that you refer them for a gastric bypass and are outraged when you hesitate. You try to explain to them how important it is to change their mental views about food and stick with some sort of weight loss plan and even psychological counselling for six months to increase their chances of success. This just further infuriates them since they are already frustrated and blinded by their quest for a quick fix for a problem that is many many years in the making. These are the patients that request CoolSculpting ( a non-invasive fat freezing procedure) thinking that it will shrink them from a size 24 to a size 2 with absolutely no effort on their part in terms of diet and exercise and then get angry when you advise them against it, because you are not out to take their money by doing something that you know won’t work. Shame on you right? Wrong. These are the kind of patients that frustrate you, make you second guess yourself, and leave you questioning if you will ever be able to make a difference in their lives. Every interaction with them is like walking an agonizingly fine tightrope. Fall off on one side and you may satisfy them for a second, but you compromise your ethics. Fall off on the other side and you have done what’s right but they may leave and never come back. Either way someone loses, whether it is you or the patient.
The bottom line is that the doctor and the patient have to be a team. It makes sense doesn’t it? Both parties should have the same goal: the well-being of the patient. It is ideal if both parties are on the same page, but not always possible. However, even if both sides are not in agreement, goals can be achieved as long as there is a personal investment on both sides. Both parties have to play an active role in order to achieve the desired outcome. The doctor has to be actively engaged in researching and recommending solutions for the patient and the patient has to be willing to take the necessary steps to attempt to follow those recommendations in order to achieve their goals. The doctor cannot wave a magic wand any more than the patient can just sit and wish for change without taking any action. It just won’t work. Have a great day everyone.
Hi everybody! We have been doing so many updates about all aspects of this virus and it’s effects lately. It seems to be all we can talk about. However, I feel like we have forgotten about the preggies. It’s time to review a little bit about what we know about COVID and pregnancy. Please keep in mind that whatever I explain right now this minute could still change tomorrow. The following is a break down of the recent commentary about COVID and pregnancy in the journal Obstetrics and Gynecology.
First, let’s keep in mind that the WHO only declared a global pandemic as of March 11th, so there hasn’t been a ton of time or pregnant women to study since then. Let’s go over what we do know and what we have seen. Keep in mind that this situation is changing rapidly. As of March 17th, more than 189,000 people have been diagnosed with COVID globally with more than 7,500 deaths and more than 150 countries involved. Realistically, this is probably just the tip of the iceberg because of the limitations of testing so far. We know the common symptoms of dry cough, fever, and fatigue. We know that the incubation period is up to two weeks. We know some of the findings on chest x-ray and in lab tests that can occur with COVID and we are working on a serum test instead of the nasal swab. We also know that there are multiple very similar coronaviruses that have been around since the 1980s! Hmm. How new is this thing really? I am asking for purely academic interest only I promise. Has it really been around all this time in bats like the other viruses and somebody just finally ate the right/wrong bat in a soup so it could make the jump to humans?
Ok. I am getting distracted. I was supposed to talk about COVID and pregnancy. So, what do we know about the preggies anyway? So far, there have been three case series for a total of 31 pregnancies affected by COVID that have been published. We also have a WHO report from China with some limited information on 147 pregnancies. We also have reviews looking at features of other coronaviruses like SARS(Severe Acute Respiratory Syndrome-Associated Coronavirus) and MERS( Middle East Respiratory Syndrome-Related Coronavirus) in pregnancy. The American College of Obgyn has already published guidelines for pregnancy and the CDC has posted answers to frequently asked questions about COVID and pregnancy, but there is still a lot we do not know for sure right now.
So, what are the answers and what are the questions? One of the biggest questions is the case-related fatality of the disease in pregnancy. It is hard to sort through the data on the fatalities because the fatality rate really depends on the co-morbidities of the patients, the quality of the health care provided and the age and health of the patients affected. It’s not just straight numbers. So far, rates around the world have been reported in a range from .9% to 9%. But remember, these rates are overall rates, not adjusted for the variables mentioned above. Plus, mild or asymptomatic cases can be missed so the fatality numbers can actually be overestimated. We don’t fully know the fatality rate in the United States yet and as of yesterday, we do not have any fatalities reported in pregnant women that I am aware of.
We still have questions about all the routes of transmission of COVID as well. We are still looking at how long the virus survives on surfaces. So far, 9 days is the magic number, depending on the surface and the particular coronavirus. We are still looking at whether asymptomatic people can transmit the virus. For a pregnant woman, the biggest question if there is vertical transmission of the virus. Vertical transmission refers to transmission of the virus from a pregnant woman to her fetus. We really haven’t had enough pregnant women yet to compare to nonpregnant women of similar age. There was a small study comparing SARS in similar aged pregnant and non-pregnant women that suggested that pregnant women may have a greater incidence of severe disease and death, but we are not seeing that so far with COVID.
As far as vertical transmission, we really don’t know the answer yet. SO FAR, we have not seen it yet in the small number of COVID pregnancies reported up until this point. This sounds great, but I don’t think we can count on this just yet. I am going to hang on to this bit of potential good news anyway for now. I will say that the in the group of pregnancies studied so far, the vast majority of women were infected in the third trimester and most of them had delivery by c section. We don’t really have any pregnancies to refer to at this point where the women were infected in the first or second trimester.
There is a question about pregnant health care workers and COVID. Should they be given special consideration? In the past, the CDC has recommend different guidelines for different viruses. For H1N1, they recommended that pregnant workers follow the same precautions as other workers, but maybe avoid any procedures that could generate aerosols( infected respiratory droplets). A different systemic review of 1862 publications rated the following as the aerosol-inducing procedures with the highest risk of infection transmission of SARS: tracheal intubation, tracheotomy care, airway care, and cardiac resuscitation, non-invasive ventilation and manual ventilation before intubation. Results were mixed as far as nebulizer treatments. With Ebola, the CDC recommended that pregnant workers not even care for those patients. We just don’t have enough data yet to make specific recommendations for pregnant workers and COVID.
Currently, hospitals are recommending immediate separation of newborns from COVID positive mothers postpartum. At our hospital currently, COVID positive mothers will remain in negative airborne isolation throughout their stay. Immediately after birth, the neonate is put into an isolette, separated from the mother and moved into the nursery under negative airborne isolation. Those mothers that choose to have their infants remain in the room for bonding must wear PPE( personal protective equipment) and the infant must stay in the mother’s room throughout the entire stay. Remember that so far, we have not seen vertical transmission (mother to fetus in the womb), but the neonate could still get infected after exposure to the mother after birth. Luckily, so far, it looks like children in general are mildly affected by COVID, but we really don’t know about neonates.
So, where does that leave breastfeeding? We have a very small amount of data that suggests that SARS is not transmitted through breastmilk, but we really don’t know about COVID. Even the SARS data is too limited to apply on a broad scale.
I get it. I just basically said that we really don’t know anything solid about COVID and pregnancy. The situation is just evolving too fast. We do have some possibly good news about the lack of vertical transmission but we need to keep watching. At this point, the best thing to do regarding pregnancy and COVID is to keep using the same methods that we already are to prevent the spread of other viruses like the flu. Tell patients to not go around known ill persons. Tell them to wash their hands frequently and not touch their face. Tell them to cover their coughs and sneezes and not just blast into the open air. Screen pregnant patients for upper respiratory symptoms, travel, cough and fever and triage accordingly. Separate ill patients from well patients. Limit visitors to labor and delivery and postpartum. Cancel mass gatherings and concerts. Maintain social distance. The reality is that pregnancy care does not truly lend itself to telehealth as a rule. These patients need regular visits. We need to take every universal precaution, like we should anyway. Give patients copies of their records frequently in case their care gets disrupted.
Basically, this situation is going to keep changing until it runs it’s course. This is the best info we have available right now. Until we have more data on more pregnant women, this is all I have to offer you right now. I think the key for now is to use common sense and universal precautions and to stay tuned for more updates as they arise. Hang in there and try to have a great day.
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!
