Last week was a perfect storm for women’s healthcare as we know it, and many are questioning whether these changes would, in fact, be detrimental to women. Just as the debate on health care reform was beginning to heat up in the Senate, we learned from two independent agencies about radical changes in how and when two of the most effective screening tests for women may be provided.

Most health care providers who specialize in women’s health have never experienced this kind of change in preventive care recommendations, and we are reeling from these new “guidelines” that have been delivered to the media at the same time and over a five-day period. I have taken time to examine these new recommendations and discuss them with my colleagues, many of whom have serious concerns about these changes and how they may significantly affect women’s health care overall.

These two protocols for women’s cancer screening — mammograms and Pap smears — have been credited as two of our greatest triumphs, leading to lower cancer death rates for both breast and cervical cancer. With cervical cancer, the story appeared pretty straightforward: In the United States, the cervical cancer death rate declined by 65 percent between 1955 and 1992, in large part due to the effectiveness of Pap smear screening. The death rate continues to decline each year.

We’re still absorbing last week’s news that new breast cancer screening recommendations had been issued by an obscure government-sponsored group, which was recommending fewer and less frequent mammograms for most women; we were comforted to know that, at least for now, major medical institutions have stated that their yearly mammogram recommendations will not change. Still, I have already been placed on a mailing list to sign a petition to contest the new mammogram recommendations, and we have a lot of work to do to prevent their enactment.

Now, just this past Friday the American College of Obstetricians and Gynecologists (ACOG) released its most recent Pap smear screening guidelines. These guidelines were an echo of the mammogram screening guidelines: ACOG recommended less frequent Pap smears for women, stating as their overarching concern unnecessary anxiety, economic issues, and the risk of overtreatment for young women with abnormal Pap smears. Despite the fact that many physicians are concerned about this change, it is very likely that these recommendations will be more accepted; the new ACOG guidelines are more in line with previous ones issued by the American Cancer Society (2002) and the U. S. Preventive Services Task Force (2003), both of which have for some time recommended a more relaxed Pap smear regimen for women.

The new ACOG guideline sets 21 as the youngest age for which they recommend the first Pap smear, which would then be repeated every two years up to the age of 30. At 30, if a patient has had three consecutive normal Pap smears and has no history of HIV infection or abnormal “CIN 2/3” tissues (abnormal cells on the lower, narrow end of the uterus that could be pre-cancerous), she should be screened every three years with a Pap smear and screening should stop entirely at ages 65–70, if the woman has had three consecutive normal Pap smears and no abnormal results in the past 10 years. Screening should also stop for women who have had a hysterectomy and no history of cervical dysplasia. It is important to realize that these recommendations do not apply to women in which the cervix has been left in place, an increasingly popular surgical procedure.

Economic concerns, especially the performance of unnecessary procedures in younger women, are the motivation to change recommended best practices in the United States. Similar to the recent changes in mammogram screening recommendations, the data that provides support for the more relaxed Pap smear screening interval for women has been published for quite some time, and mostly dates back to the mid-1980s to 2003.

The morbidity resulting from unnecessary excision procedures, performed on young women based on Pap smear results, reflects not the performance of the Pap smear as a test but poor education on the part of physicians concerning the conservative management of the abnormal Pap in the young patient. Authors of the new recommendation also state that “earlier onset of screening may lead to increased anxiety and the emotional impact of labeling an adolescent with both a sexually transmitted infection … because adolescence is a time of heightened concern for self-esteem and emerging sexuality.”

ACOG did agree that women who are at elevated risk of cervical cancer — those with HIV infection, immunocompromised status, DES exposure, and previous treatment for CIN 2, 3 or cancer — are recommended to undergo more frequent screening. However, the American Cancer society identifies additional risk factors for cervical cancer: HPV infection, smoking, use of OCPs, obesity, poor diet, low socioeconomic status, early age at first full term birth, and numerous others.

One drawback of the major United States study, which helped ACOG to form their more relaxed guidelines, is that it did not evaluate specific cervical cancer risk factors in the populations studied. The recommendation that Pap smear screening in older woman can actually cease assumes two things: that this group may not have the same susceptibility to HPV-related changes as younger women, and that older women probably do not have the same number of sexual partners as younger women. As we all now know, this is often untrue: Many women are sexually active for many more years, given the use of erectile dysfunction drugs in their partners and a socially acceptable pattern of partners who are younger and sexually active. Indeed, older women also represent one of the groups in which the risk of STDs is increasing. Therefore, cessation of Pap smear screening in older women may not apply to all — one example as to why these new recommendations must be reviewed carefully with your gynecologist to determine how they apply to you.

While the economic impact of unnecessary procedures may be a reason to alter screening recommendations, we should look at office visits in this group of young women as an opportunity to review safe sex procedures, screening for other sexually transmitted disease and birth control education. In this age group, good health practices can be reinforced, resulting in a lifetime of health.

The annual Pap smear visit provides many opportunities for the physician to reinforce good health habits. For young patients, safer sex practices can be reinforced and STD testing conducted. For older women, the gynecologist may be the only health care practitioner to check her blood pressure, weight and height; examine her breasts; listen to her heart and lungs; and review other cancer-related screening. It is also a time to review bleeding patterns and other potential signs and symptoms of gynecologic cancer and other important health problems, including menopause and peri-menopausal issues.

If the annual Pap smear visit becomes obsolete, we will need to educate women that the annual visit to the gynecologist is still appropriate for most. As screening recommendations no longer advocate for breast self-exam and decrease the frequency, and delay the age, of mammograms, we may also begin to see a rise in later-stage breast cancers. The failure to have a yearly exam may also result in a delay in diagnosis of other malignancies such as colon and endometrial cancer.

It remains to be seen how health care practitioners and insurers will employ these new guidelines. We will only understand their impact on the overall health of women after years. As we devalue the annual Pap smear for most women, it will be important to determine in coming years if we see a shift in later-stage cancers. Not only does this potentially compromise a cure, but also the ability to perform less radical procedures in order to treat cancers. Investigators are currently developing a home Pap test. We now risk the loss of the annual gynecology visit, and with that the opportunity for women’s health specialists to impact the health of their patients.

The take-home message for you: Review with your gynecologist how these new recommendations apply to you. Assure that a reputable lab reads your Pap smear. The false negative rate of Pap smears is noted to be 10–30 percent. If we are doing fewer Pap smears, they should be as accurate as possible.

For the medical community, it remains to be seen how these recommendations will impact overall women’s health. We must assure that the ongoing dialogue between women and their healthcare providers is maintained. I look forward to the continued conversations with my gynecology colleagues in the future.

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  • baylee February 8, 2010 at 5:30 pm

    woman hood is treated like a diesase in this country informed concent is also missing with wemons health care not all wemon concent to gyn exams it is are right to informed concent

    Reply
  • Politicalguineapig November 26, 2009 at 1:49 am

    Honestly, I’m happy about this. Pap smears are painful, and the fewer I have to live through, the better.

    Reply