Good morning, Pinkies. I just heard the news (calm down, Lissa. Breathe…) In the wake of the U.S. Preventative Services Task Force’s new guidelines for mammography screening, the American College of Obstetricians and Gynecologists just announced new recommendations that cut back on Pap smear screening. My blood is boiling, Pinkies. WHAT IS GOING ON? Why are we recommending cutting back on women’s health screening? Don’t get me started (yet). Let me fill you in on the news.
New Pap Smear Guidelines:
- Instead of recommending that Pap smear screening begin after you’re sexually active, new guidelines say that even a sexually active 13 year old should wait until 21 for her first Pap.
- After 21, Pap smears are recommended every 1-2 years until age 30.
- After 30, if you’ve had three consecutively normal Pap smears with no history of a seriously abnormal Pap, new guidelines say you only need to do Paps every three years.
- If you’ve total hysterectomy for benign reasons, new guidelines say you can skip Paps altogether.
- New guidelines recommend quitting Paps sometime between 65-70 if you’ve had three consecutively normal Paps with no abnormal Paps in the past 10 years.
Why the Change?
There is evidence to support the changes. The truth is that you’re unlikely to go from having a normal Pap smear to having cervical cancer in 3 years, even if you contract HPV. Because cervical cancer grows slowly, it’s still likely to be precancerous by the time it gets picked up. And yearly screening does increase the number of procedures performed, and some of those procedures- such as cryotherapy and LEEP procedure can affect fertility and pregnancy in rare cases. Plus, cutting back on Pap smears saves precious health care dollars. And if we’re not saving lots of lives and potentially causing harm by implementing procedures that may not be necessary, why do annual Pap smears?
So these guidelines aren’t positively ludicrous like the new mammogram guidelines that threaten to kill hundreds of thousands of women. I understand why they’re recommending pushing back the age of first Pap smear. HPV, the virus that causes cervical cancer and abnormal Pap smears, is almost ubiquitous among teens. As such, doing Paps will lead to many abnormal results and require colposocopies, biopsies, and possibly treatment such as LEEP procedures, which can affect their pregnancies in the future, leading to scarred cervixes and preterm labor. And many of those abnormalities, if left untreated, would have resolved themselves without treatment.
I can also see why they’ve said that women who have had a hysterectomy can stop getting Paps. After all, they don’t have a cervix. And while there may be scant cervical cells left at the surgical scar inside the vagina, the risk of cervical cancer is exceedingly low.
BUT (and this is a gigantic BUT) there is a GINORMOUS problem here that carries far-reaching consequences for women’s health, and I can’t keep this quiet. Though women come to the gynecologist under the guise of their annual Pap smear, they actually come for WAY more than that.
Here are some examples of issues I handle under the guise of an annual Pap smear exam:
- Sexual problems that threaten your relationship
- Debilitating depression and anxiety
- Chronic fatigue that prevents you from living vitally
- Pelvic pain, often as the result of sexual abuse you have never confessed to anyone until I hold the sacred space for you and invite you to tell the truth
- Urinary incontinence that causes so much shame and embarrassment that you might not leave the house, much less exercise or pursue your dreams
- Menstrual disorders like hemorrhaging or menstrual cramps that cause you to miss work and other important life functions.
- PMS/PMDD that may be hampering a happy life
- Interstitial cystitis symptoms that make you feel like you constantly have a UTI
- Menopausal symptoms that threaten a woman’s relationships, sleep, work, and life
- Relationship counseling
- Parenting advice
- Losing your mojo
And that doesn’t even include the oh-so-necessary annual breast exam, internal pelvic exam to check for ovarian tumors and such, and the opportunity to make sure a woman is up to date on other cancer prevention procedures, such as colonoscopy in older women, or the HPV vaccine for teens.
Now, ACOG does say you should still talk to your doctor about getting an annual pelvic exam. (Thank you ACOG.) But are insurance companies going to cover a routine pelvic exam in the absence of a Pap smear? Are women going to go? So many women will hear these new guidelines and think, “Cool! I can skip the gyno for 3 years!”
By changing its guidelines, ACOG is going against the other main authorities on cervical cancer. The American Cancer Society and the U. S. Preventative Services Task Force both recommend that women get their first Pap test within three years of having sex, or at age 21- whichever comes first.
I respect evidence-based medicine and understand the rationale for these guidelines. I went to Duke and Northwestern and learned all the ivory tower beliefs about practicing based on evidence, not anecdotal speculation or emotion-based care. BUT….
What Do I Think?
Hmmm…I guess I think all the guidelines that have come out this week are missing something critically important in medicine. As leaders in women’s health, what messages are we putting out there? Somewhere along the way, governing bodies in medicine have forgotten the most vital aspect of what we doctors do. When they are reviewing data to make these guidelines, they are focusing only on what “cures” someone. But they have forgotten that there is a difference between healing and curing.
Let’s take a huge leap and assume that cancer screening is completely worthless and doesn’t prevent cancer at all. Is there not some value to the other types of healing work we doctors provide under the pretext of the annual Pap smear? Women don’t make separate appointments to talk about their sex life or whether they’re living as vitally as they might. They lump those things under the umbrella of a Pap smear. Many women feel like they’ve been handed a “You’re worthless” card at birth. I try to extract that card and replace it with a hot pink one that says, “You’re lovable, valuable, beautiful, and worthy.” This kind of work cannot be proven in a scientific study. But is taking away a woman’s excuse to visit her gynecologist taking away that hot pink card as well?
I’m not suggesting we do unnecessary testing or procedures just for the sake of getting a woman in the door. Ultimately, you have to be your own advocate for your health and wellness. But I worry about the far-reaching effects these kinds of guidelines will have for women who misunderstand and fail to hear the part about annual exams still being a critical part of women’s wellness. What if they get lost in the system? Especially underprivileged women, who may not be educated enough to advocate for their own well-being.
My fear is that cutting back on cancer screening will not only increase a woman’s risk of cancer. It may also limit a woman’s access to the kind of healing good doctors can provide. For most of my young patients, I am their primary care provider. The Pap smear is what gets them in the door. If you hear that you only need a Pap smear every three years, you may go three years without anyone talking to you about whether you’re living as healthfully and joyfully as you possibly can.
And you can be sure that insurance will cut back your coverage. If ACOG says you don’t need a Pap smear, your visit will likely only get covered if you have an ICD-9 code diagnosis like endometriosis or fibroids. And let me tell you- there’s no ICD-9 diagnosis for losing your mojo or cancer prevention.
You may think I’m biased. After all, I’m a gynecologist. It’s my business to have people come in for Pap smears, so of course, I would oppose these new guidelines. But the truth is that most gynecologists lose money by doing a Pap smear. The cost of the visit exceeds what insurance companies will reimburse most of the time. And since Medicare already doesn’t cover annual Paps, we usually eat the cost for older women who want to get Pap smears but don’t have coverage. So trust me, for most gynecologists, this is not about money. One of my dear friends in San Francisco (a total Pink God) is closing his practice- declaring bankruptcy- because he simply can’t make ends meet with a busy insurance-based practice. It breaks my heart. He is one of those doctors who, like me, practices love, with medicine on the side. Why does the system not embrace him? Why have we replaced doctors like him with technology, scientific data, and task forces? (*crying now*)
And why are they cutting back on only women’s health screening? Why not PSA testing for men? Not to be all conspiracy-theorist on you, but you can’t convince me that there aren’t some sexual politics caught up in all this. With all the advances we’ve made in women’s rights and women’s health over the years, why are we going backwards? Won’t somebody please stand up and shine the light on the Emperor’s new clothes?
I get that we need to cut back on health care costs. But come on, people. Must we do it at the expense of women? Can’t we focus our energy on tort reform or capping profits for insurance companies. Is this really the way?
For me, it’s all about advocating for holistic women’s health- the big kind, the kind that looks at a whole human being, not just a breast or a cervix. The only way we can help women holistically is to get them into our offices, provide a safe, sacred space for healing, and show up- fully present- to help them get in touch with what their body needs to be whole.
What Will I Do In My Practice?
I think you should be given a choice. The way I see it, it’s my job to present the data and help you understand the risks and benefits of cancer screening. If you want to get a yearly Pap smear and mammograms after 40- Fine. If you’d prefer to stretch out your screening or skip it altogether, no problem. It’s your body- your choice. I’m just here to help you understand your options and deal with whatever comes up.
The Bottom Line
Please, Pinkies, regardless of what you decide to do about your Pap smear or your mammogram, please don’t stop seeing a doctor every year.
Our Broken System
Thinking of how these new guidelines may limit your access to health care breaks my heart.
This system is so BROKEN. Hand me the suture and a needle driver. I want to stitch the fragmented, fractured, hemorrhaging heart of medicine back together again.
Waiting, with hand outstretched- “Suture, please,”
Lissa
