Screening recommendation changes confuse providers, patients
Do changing recommendations for pap smears and pelvic exams send the wrong message to patients about routine care?
Sifting through the changes in screening recommendations
When I started in the business of providing women's health care, the basic recommendations for what I was supposed to do were pretty clear: women got yearly Pap smears and pelvic exams once they were sexually active, and they started annual mammograms at age 40.
But over the past few years, there has been much change and even great controversy about who needs what, when, and how often.
The Pap smear guidelines have seen the most change. Currently, we don't start doing Pap smears until age 21 and there is a series of complex algorithms to determine how often women are screened for cervical cancer. The usefulness of routine annual screening mammograms starting at age 40 years came into question back in 2009 and again this year. Now, the frequency of pelvic exams is being scrutinized.
In June, the American College of Physicians, a large organization of internal medicine physicians, stated that biannual pelvic exams should no longer be done on healthy, non-pregnant, asymptomatic women. Their reasoning was that the exam offers little to no benefit for ovarian cancer screening, while causing pain, trauma and even unnecessary surgery for many women.
Although agreeing that there is no real evidence to support routine pelvic exams, the American College of Obstetricians and Gynecologists (ACOG) continues to support and find clinical value in yearly pelvic exams.
In reading ACOG's response to the American College of Physician's statement, it seems that ACOG finds true value in the annual visit with patients more than the actual biannual pelvic exam.
I think the underlying fear of providers is that if there are no mandatory annual screenings, patients will be less likely to come in for health maintenance visits. I worry about this myself, because I find value in annual well-woman visits, especially when there are no urgent complaints or medical problems. These visits are great opportunities for education and often open up discussions that aren't possible during a “problem” visit.
I find myself agreeing that routine pelvic exams are probably not necessary, but I'm more concerned over the confusion caused by all of the recent changes in women's healthcare guidelines. My patients read the headlines but aren't sure what to believe, and what choice is best for their healthcare needs.
I still have patients, who despite never having an abnormal pap smear, demand an annual screening. On the opposite end of the spectrum, I have patients who refuse yearly mammograms because they feel the risk of radiation exposure from annual mammograms is too great, with little benefit to their overall health. Most of my patients fall somewhere in the middle between these two extremes.
As a provider, the best thing I can do is outline the most recent guidelines and evidence for my patients, let them make the best choice for themselves, and encourage them to come see me every year for well-woman visit.
It can be difficult to discern the fine line between unnecessary exams and testing for screening purposes and what the patient really wants and needs to receive the best healthcare possible.