I have been a practicing OB-GYN for more than 15 years, and although I think of my patients as unique individuals, certain subjects come up repeatedly. Here are seven questions I hear from many of my patients — and my answers.
1. How often do I really need a pap smear?
Yes, your prayers have been answered. You don’t need a pap smear every year. Pap-smear guidelines state that after three normal annual paps you only need one every three years. Many women, even though they hate having it done, are skeptical when I tell them the recommendations have changed and most likely they do not need a pap every year. Some even insist I do the test after I have just told them they don’t need it.
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Why the switch? We discovered that doing paps more frequently did not lead to fewer cases of cervical cancer, which is the only reason for performing the test. Instead, it detected more abnormalities that required invasive and uncomfortable follow-up without any benefit.
What has made these new recommendations possible is a better understanding of the biology of cervical cancer and the addition of HPV testing. HPV, or human papillomavirus, is the source of most pap-smear abnormalities. For women between 30 and 65, co-testing — performing a pap with HPV — is recommended. If your pap is normal and HPV is negative, you don’t need a pap for five years. Screening should begin at age 21. Women younger than 21 do not need a pap, and women older than 65 don’t need to continue if their paps within the last 10 years have been normal. Women in the 21-30 age group should have just the pap smear, not co-testing, every three years.
Of course, if you have an abnormal pap, the screening schedule changes based on the kind of abnormality. There are some exceptions as well, including HIV infection, immune-system compromise, exposure to DES (diethylstilbestrol) and prior history of cervical cancer. If you have any of these, be sure to discuss it with your physician.
2. How often should I have a pelvic exam?
A pap smear and pelvic exam are not synonymous. The pap smear refers to the collection of cells from the cervix to screen for cervical cancer. The pelvic exam refers to the inspection and palpation of the pelvic organs, including the vulva, vagina, cervix, uterus, bladder and rectum.The American College of Obstetricians and Gynecologists (ACOG) recommends having a pelvic exam every year, as it screens for other problems that can arise in the pelvis. With the exception of ovarian cancer, most problems that occur in that region will be symptomatic. Unfortunately, the pelvic exam on its own does not detect ovarian cancer early enough to make a difference in its outcome. Thus, the American College of Physicians does not recommend annual pelvic exams in asymptomatic women.
So, should you still see your gynecologist every year? I think so, because it is an opportunity to discuss your health questions or concerns. There is so much health information out there — some is good, some not so good. Your annual exam is the time to check in with a knowledgeable professional about current health recommendations and be evaluated if necessary for any ongoing health concerns.
3. When should I start screening mammograms?
This is a loaded question, with more than a little controversy and some very heated opinions. Here is my opinion, which you should consider as a starting point for a discussion with your own doctor, so that you can make the best decision for yourself: The U.S. Preventive Services Task Force (USPTF) in 2009, after reviewing the available evidence, recommended screening mammography be done every two years starting at age 50, after determining there was not enough evidence to support annual mammograms in women between the ages of 40 and 50.
These guidelines were widely ignored, and organizations such as ACOG continued to recommend annual mammograms starting at 40. The USPTF reaffirmed these standards last year, and again it was met with resistance. However, in October 2015, the American Cancer Society changed its recommendations and now says to begin annual mammography at 45, continue until 55, then go to every other year. I want my patients to be aware of the risks and benefits of mammography and then decide for themselves.
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4. How safe is the birth control pill?
Birth control pills are very safe, have some noncontraceptive benefits and can be continued until menopause in women who do not smoke. It has often been stated that birth control pills changed the world. Being able to control fertility has allowed women the freedom to pursue education, a career and financial independence. It has separated sex and reproduction. The Economist stated it was one of the seven wonders of the world and defines the 20th century.
In addition to excellent contraception, the pill provides a number of benefits. It regulates your periods so they’re light and predictable with minimal cramping. It decreases the amount of blood loss during your period, which improves anemia. You can choose to have no period at all by taking the pill continuously. It reduces acne and undesired hair growth. It significantly reduces your risk of endometrial cancer (which occurs in the lining of the uterus), ovarian cancer and even colon cancer.
There is an increased risk of blood clots, approximately 3–9 per 10,000 women compared with 1–5 per 10,000 women for nonusers, according to ACOG. So, the risk is increased but still very low. Birth control pills increase the risk of heart attack and stroke in women over 35 who smoke or have high blood pressure.
5. How can I make my horrible period better?
If your periods suck, you can do something about it. I am always surprised by the number of women who have awful periods. Sometimes they are so heavy as to soak through their clothes at an unpredictable time or so crampy and painful they have to miss work and other activities due to discomfort. This is where modern medicine can help. As described above, the pill can be a good choice for some women to manage their periods, even if they don’t need the contraception. The Mirena IUD is another excellent choice to help control your periods. It works, using the hormone progestin, by preventing the endometrium or lining of the uterus from proliferating. Most women then have either a very light period or nothing at all.
Depending on your circumstance, you might benefit from a minor surgery, either a dilation and curettage (D&C) or an endometrial ablation. These are day procedures, can often be done in your doctor’s office and have minimal recovery times, usually a day or two. Life is too short to lose a few days every month to deal with your period, especially when there are some straightforward ways to fix the problem.
6. Does natural family planning really work?
Natural family planning — or fertility awareness — works well with a surprisingly high success rate and can be a great option for some women. After all of this talk about hormonal therapies, not everyone can or wants to take hormones. Many women have for years relied on fertility awareness for contraception. This allowed them to prevent pregnancy successfully, and the knowledge they gained about their fertility could be used to help them conceive when the time was right.
The two-day method is a way to think about your fertility using cervical secretions. When you are fertile, your cervical secretions change. It becomes like the consistency of raw egg white — clear, smooth and slippery. Once you are familiar with your fertile cervical secretion, you can use the two-day method. Ask yourself two questions: Do I have fertile secretions today, and did I have them yesterday? If the answer to both of those questions is yes, you are fertile. If the answer is no, you are likely not fertile. This method has a very high satisfaction and success rate. There’s a learning curve, but many women like feeling in touch with their bodies, their cycles and their fertility. It can be very empowering. Remember, though, as with all methods of contraception, it can fail.
7. What’s one thing my OB-GYN wishes I wouldn’t do?
Don’t lie. Why do people do this? I can’t help you if I don’t know what’s going on. It’s not so much that people consciously lie, although there is some of that, but most of the time I think patients just leave out stuff. Sometimes when pressed for details, if there is time, patients will open up. But time is usually limited, so I know many leave without addressing their underlying problems. I guess they think I will judge them or disapprove. It’s not my job to judge or disapprove — it is my job to understand what your health issues are so I can work with you to be healthy, feel good and live well. The best way for me to do that is to have all your information. No one’s perfect. Everyone has a vice or an unhealthy habit that crops up here and there. Let your doctor work with you to improve your health habits.
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