Ladies, you may find that your gynecologist is a bit more hands-off after you put on that little cloth johnny for your annual exam. Recent recommendations from the American Cancer Society and the American College of Physicians that challenge the status quo for breast, cervical, and pelvic exams are starting to reshape routine women’s reproductive health in the United States.
Not so long ago, the annual trip to the gynecologist meant having both breasts examined for lumps, a Pap smear to collect a sample of cervical cells for cancer screening, and a two-handed pelvic exam to check the shape and position of ovaries and uterus through the vaginal and abdominal walls. Women older than 40 also got a breast-squishing cancer-screening mammogram.
Now, doctors are being advised that many of these exams can be given less frequently to women who have only an average risk of developing cancers of the reproductive system.
Today, the American Cancer Society published updated recommendations for breast cancer screening in the Journal of the American Medical Association. The new guidelines no longer recommend a clinical breast screening exam on most women during the annual gynecology exam, leaving it up to a woman and her doctor to determine whether it’s appropriate for her health.
Women who have an average chance of developing breast cancer can wait until age 45 to start annual mammograms. After women turn 55, they can switch to a mammogram every two years as long as they’re expected to live another 10 years.
And while age divisions are a convenient way to explain when to start screening and when to switch to less frequent screening, another study published today in JAMA Oncology suggests that menopause could be a more effective clue for deciding when it’s safest to switch away from annual exams. The team, led by UC Davis statistician Diana L. Miglioretti, examined the cases of 15,440 women between the ages of 40 and 85 who had been diagnosed with breast cancer and determined that while premenopausal women had a larger chance of being diagnosed with a more advanced cancer when they were screened every 2 years than when they were screened annually, the same was not true of postmenopausal women.
Those results suggest that women who go through menopause early but do not pursue hormone replacement therapy may safely choose to have their mammograms less often.
Guidelines released by the American College of Physicians earlier this year and the US Preventative Task Force in 2012 recommend Pap tests for cervical cancer screening every three years after a woman turns 21. Women between 30 and 65 can move to screening every 5 years if both Pap and HPV tests come back negative. Women over 65 can stop having Pap tests altogether.
But since the swab for the Pap test was often paired with screening for sexually transmitted infections like chlamydia and gonorrhea, fewer of those ‘little pinches’ may put more young women at risk for living with untreated STIs. In a recent Canadian study, the number of women receiving STI screens fell by 50% the year after the Pap test recommendations changed. Routine screening for chlamydia and gonorrhea is now recommended for sexually active women under 25 by the CDC.
The American College of Physicians thinks that asymptomatic nonpregnant women with an average risk for cancer can skip the bimanual pelvic exam, arguing that it isn’t particularly effective at detecting early-stage ovarian or uterine cancers. But the American College of Obstetricians and Gynecologists disagrees. In a discussion at the Beth Israel Deaconess Medical Center published in the Annals of Internal Medicine last week, gynecologist Hope Ricciotti argued that while the pelvic exam isn’t an effective tool for finding ovarian cancer, there’s still no data on whether it is better than other tests for detecting benign abnormalities or other gynecological cancers. Until those data are in, many doctors will probably keep doing them.
Women should still see a gynecologist each year to assess the health of their ladybits: there may be less poking and prodding than in the past, but doctors will still check for abnormalities, screen for domestic abuse, test for STIs, prescribe contraceptives, and answer questions about sexual health. Every three (or five) years, they’ll throw in that Pap test.
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