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When to See Your Gynecologist

By , MD
Thursday, January 31, 2013
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If you haven’t been to a gynecologist lately, things have changed!  In March of 2012, the United States Preventive Services Task Force released new guidelines for cervical and breast cancer screening that are quite different from previous ones.

Pap Smears
Replacing guidelines last issued in 2003, the new guidelines for Pap smears focus on four topics: the age of first screening, age of last screening, frequency of screening and testing for the sexually transmitted cervical cancer-causing human papillomavirus (HPV).

Under the new guidelines, women should be first screened within three years of becoming sexually active, but no later than age 21. Screening of women past 65 years of age isn’t recommended as long as they have had prior screenings and aren’t in a high risk group for cervical cancer. New and multiple sexual partners, for example, increase risk. In between 21 and 65 years of age, the task force advises women be tested with a Pap smear no more frequently than once every three years.

Regular screening for HPV is not recommended for women under 30, because many women with the virus will eliminate it naturally from their system over time. However, HPV testing should be used in cases of atypical Pap test results.

In addition, the recommendations allow for women over age 30 who don’t wish to have a Pap test every three years to elect to get one every five years along with an HPV test.  This is largely because it takes many years to go from a normal Pap smear to slight abnormality to pre-cancer (called dysplasia) and finally to cancer. In too many cases, women were being over-treated for minor Pap abnormalities, causing harm, when these issues often resolve on their own.

Breast Cancer
The task force recommended against routine mammograms between the ages of 40 and 49 and only biennial screening for women between the ages of 50 and 74, concluding that current evidence is insufficient to determine feasibility of mammograms in women 75 years and older.

Mammograms do carry a small risk of over-treatment because of the increased exposure to radiation. Although these risks have been overblown in some media circles, there is no need for over-exposure. It’s important to discuss any abnormal findings for all options with a breast cancer specialist, not your gynecologist, to avoid being over-treated. Parenthetically, although some experts promote thermography as an alternative, this test is simply not as accurate as the mammogram and isn’t as good for early detection.

Interestingly, the task force also recommended against the practice of teaching breast self-examination. Having said that, you should still be aware of changes occurring anywhere in your body, including your breasts. Anything suspicious should prompt a visit to your doctor because screening tests aren’t perfect and an ultrasound to focus on a suspicious area may be required.

These recommendations, however, apply to healthy women only and shouldn’t affect advice for women with unusual symptoms, an abnormal Pap test result or a history of cervical cancer, dysplasia, human immunodeficiency virus (HIV) and other immune suppressive illnesses.

Pelvic Exams
Annual pelvic examinations are also important to determine uterine or ovarian abnormalities, which may include benign or cancerous changes. We don’t have a good screening method for early ovarian cancer yet, but many physicians still offer periodic ultrasounds especially if the ovaries cannot be felt on examination.

Also, you should be aware a blood test called the CA-125 has been erroneously recommended as a screening test. The problem is it doesn’t pick up early ovarian cancer very well, is elevated in many inflammatory conditions from arthritis to a bad migraine and too many women have suffered and even died from unnecessary surgery related to this test. This is highly controversial and some are at higher risk for ovarian cancer than others, so while we await an effective screening strategy this is a great discussion point to bring up with your gynecologist.

Other Times to See a Gynecologist
Aside from these screenings, there are other physical changes you should report to your physician for further examination, including:

  • Changes in your menstrual cycle during reproductive years -- Check with your gynecologist right away if your menstrual cycle ceases, indicating you may be pregnant. Your gynecologist can help you prepare for a healthy pregnancy, or provide other alternatives.
  • You’re approaching menopause -- Some women may have lighter periods when entering menopause, while some have a heavier flow. Periods may become very irregular which may require a simple office biopsy to ensure there is no cancer. Pap smears are only good for cervical cancer screening and don’t detect uterine or ovarian cancer. If you’re approaching menopause and begin to miss your period, have your gynecologist rule out the possibility of pregnancy, which would be considered high risk, requiring extensive discussion and planning.
  • Irregular bleeding -- Bleeding not associated with your period, such as during and post intercourse or between periods should be checked out as soon as possible, as it may indicate injury to the cervix, uterine polyps, fibroids or even uterine or cervical cancer.
  • Unusual or persistent vaginal discharge -- A small amount of thin discharge may be normal, but if it increases, changes color or carries a foul odor, there may be an infection with yeast, parasites or bacteria. Testing should be done before starting treatment to determine the type of infection.
  • Pain or discomfort -- Vaginal itching and burning may also be a sign of a bacterial, yeast or parasitic infection, a urinary tract infection and maybe a sexually transmitted disease. Persistent pain may be related to endometriosis or other inflammatory conditions.

Other reasons may include possible exposure to sexually transmitted disease through unprotected sex, prolonged infertility, hot flashes or premenstrual syndrome. Much of the above can be initially evaluated by a primary care doctor, but any persistent issues or concerns should be taken to a gynecologist.

Making Your Appointment
For routine visits, the best time to make an appointment is one to two weeks following your period (or anytime if you are post-menopausal). The most accurate test results will be obtained if you abstain from sexual intercourse for at least 24 hours prior to the examination. Finally, if you follow a douching routine (which is never recommended) avoid this prior to your visit.

While Pap smears and mammograms are no longer annual requirements, a yearly well-woman checkup is always a good idea and is a great time to discuss any concerns you may have about birth control, sexuality concerns, your menstrual cycle, breast tenderness and other women’s health issues.

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