Some days, I get so frustrated at work. Yes, we all have our frustrations. Maybe traffic is slow and you get to work late. Maybe you spill your coffee on your work clothes as you walk into your office. Maybe someone calls in sick and you are short help at work. But this frustration has to do with not being able to properly care for my patients because they believe coming to the gynecologist is only about getting a PAP smear.
With healthcare reform on the forefront today, more than ever women’s healthcare needs must be addressed. Let’s start with PAP smears. Many of you have heard that you don’t need a PAP smear every year, that you just need one every 3 or 5 years. These recommendations are shared by social media, and pushed by insurance companies and politicians, but don’t reflect individual patient needs. Currently, HPV (human papilloma virus) is the most common sexually transmitted infection (STI). It is a virus that you can carry without knowing you have it because there are no symptoms; this makes it easy to spread unknowingly. A PAP smear can detect HPV and since different women have different sexual histories, the timing of a PAP smear is an individual decision between you and your gynecologist. Beyond detecting HPV, a PAP can also screen for other STIs and cervical cancer.
But a visit to your gynecologist isn’t just about a PAP smear. There is more to your female health care than that. And so, I just want to shout –
Ladies! It’s not just about the PAP smear!
Recently, I diagnosed 3 uterine cancers and a vulvar cancer within a 4 month time span. They all had the same story, they all hadn’t seen me in years because they heard they didn’t need a PAP smear yearly. Sadly, these are not isolated stories, but are becoming more common as women see their gynecologist less. These stories are not meant to scare you, but to give you an idea of the hole in health care when your gynecologist is taken out of the picture.
This spate of diagnoses started in November, when I walked into my office and greeted my new patient sitting with her back to me. As she turned, I realized she was my patient from years ago. “Where have you been?” I asked her with a smile. “You disappeared on me,” I teased her. Although she had put on some weight, she looked well at 60. As I sat down, I noticed her face was tense and she was fidgeting in the chair.
“I heard I only need a PAP every few years…something like that anyway. And my internist said she would do my PAP whenever it was due. It seemed easier that way.”
“So what brings you in to see me today?”
“I had spotting a while ago, sometime last year. And then I had some more bleeding recently. I finally decided maybe it was time to see you again.”
As I probed her with questions, I finally was able to get the whole story and fill in her health history. She now had diabetes and high blood pressure, and over the years, the weight just gradually came on. As she talked, alarm bells were going off in my mind. My concern, uterine cancer. Her story fit the signs and symptoms, but I would need to do more tests to confirm my suspicions. After her exam, I explained my concerns and the tests that would tell us what was causing the bleeding. “I was afraid you were going to tell me something like that. I should have come sooner, but I thought if I didn’t need a PAP, I didn’t need to see my gynecologist.”
So within a month, I was sending her to a gynecologist oncologist for cancer treatment. If only she had come in earlier, maybe she would have been diagnosed earlier, even perhaps at a precancerous state rather than stage 3. Somewhere along the line, the medical community failed her in letting her believe she didn’t need to see a gynecologist anymore. Her PCP (primary care physician), who had been doing her PAP smears may not have known signs to identify uterine cancer or known that with her diabetes, high blood pressure and obesity she was higher risk for uterine cancer, or that any spotting after menopause needs to be addressed. Or the patient might not have known the importance of telling her PCP about the spotting and forgot to mention it.
Gynecologists do more than just PAP smears. Birth control counseling, STI counseling, screening and treatment, preconceptual counseling, genetic counseling, cancer screening, osteoporosis screening, monitoring fibroids, ovarian cysts are just a few examples. In questioning you during the visit, we are searching for any signs or symptoms of problems with your health or health issues that we may be able to improve. This includes managing vaginal atrophy that leads to painful sex, fibroids that lead to anemia, ovarian cysts that can torse or twist, breast lumps that are cancerous, weak pelvic floors that lead to incontinence, irregular or heavy bleeding that cause you to miss work. No other type of doctor will do a comprehensive pelvic exam which includes more than your cervix.
Nearing 80 years old, she slowly made her way down the hall with her walker. Before she even came into view, I overheard her talking to my medical assistant and I realized that I knew her from before. She had been a patient for many years with my previous partners and gradually switched her care to me. Watching her walk, I knew her health had declined in the years since I had seen her. She always struggled with her weight, but despite that, was active and involved in her community. Today, she looked defeated, huffing and puffing with the effort it took her to walk down the hall.
“I had a PAP smear 3 years ago with my primary care. I felt like he pinched something on my skin and ever since then I have bleeding once in awhile when I wipe. I didn’t want to go back to him, it hurt too much. Since I was told I didn’t need PAP smears anymore, I never came back here.”
When I asked her more about how she was doing, every sentence started with a sigh. She went on to describe her medical issues, the struggles getting her medications paid for by Medicare, how she moved into a senior living apartment and hated it. “No one wants to do anything!” She looked tired and worn out from life. Her usual animated and energized demeanor was extinguished. How sad it was for me to see her like this.
In the exam room, it took no time for me to figure out where this spotting was coming from. She had a marble size mass extruding from her vulva near the clitoris. This beefy red, angry looking mass easily bled when I barely touched it. “I can see what is causing the bleeding and it isn’t because of your last exam. You have something growing here that I need to biopsy.” She didn’t want me to do the biopsy that day. “I have too many things to do today.” But it seemed she was postponing the biopsy out of fear.
A month later, she finally came back for the biopsy. I helped her make a follow up appointment since I was nearly certain the growth was cancer. When I got the biopsy results my first thought was “this could have been caught so much earlier if she had yearly gyn exams.” But here she was, with multiple health issues, difficulty getting around, and now vulvar cancer with a disfiguring, painful surgery ahead of her.
Don’t let politicians, insurance companies, social media dictate your health care needs and interfere with your relationship with your doctor. Don’t let them take away your right to have regular preventive health visits, family planning choices and cancer screenings. Listen to your body, listen to the signals it is giving you, listen to your gut telling you “go see your doctor.” Don’t get fixated on whether you need a PAP smear or not. Your gynecologist will tell you if you do need one and, in the process, will also take care of your other female health needs.