Pap smears 'a waste of time'

[BillyJoe]

Pap smears 'a waste of time'

http://www.news.com.au/dailytelegraph/story/0,22049,23744816-5001028,00.html

Well that's the headline, but this is what it actually says:

A CERVICAL cancer specialist has welcomed a drop in screening among young women, saying Australians had finally realised they are "wasting their time" getting pap smears every two years.


So much for the misleading headline.

Dr Wain said he supported changing guidelines to three-yearly screening as recommended by the World Health Organisation, and called for women aged 20 to 24 to be removed from the program all together.


So it seems you can safely wait until your daughter is old enough to go to the doctor on her own.

That is certainly a relief!

[BenBurch]

My wife would not be here had she not gotten screened annually.

[BillyJoe]

My wife would not be here had she not gotten screened annually.


She is very lucky and I am happy for her.

However, that is hardly a basis upon which to formulate a protocol.


My father had a chest x-ray that was normal and six months later he had another because of pneumonia and this time it showed that he had lung cancer. Therefore we should have routine chest x-rays every six months.

I don't think so.

[rjh01]

I am sure there are many tests routinely done that are not needed for medical reasons.

This is because of a lack of studies that attempt to show a benefit. I mean how do you do a study on say how often a pap smear should be done? How many women do you sacrifice? Can you tell a woman not to have pap smears if she knows she has never had any type of STD?

[LostAngeles]

I'm sexually active and in the US, they advise a yearly screening in that case. Not to mention that I'm on hormonal birth control as well.

Along with getting a regular check-up, I also just have them run the full set of tests even though I've been in a monogamous relationship for five years.

I have had an abnormal result and that turned out to be nothing in the end, thankfully.

[fls]

I am sure there are many tests routinely done that are not needed for medical reasons.

If you are interested in the evidence behind tests that are routinely done, there are several groups who put out summaries of the information and recommendations.

The US Preventive Services Task Force (http://www.ahrq.gov/clinic/pocketgd07/index.html)
http://www.ahrq.gov/clinic/pocketgd07/gcp2.htm#Cervical

The Canadian Task Force on the Periodic Health Examination (http://www.phac-aspc.gc.ca/publicat/clinic-clinique/index.html)
http://www.phac-aspc.gc.ca/publicat/clinic-clinique/pdf/s10c73e.pdf

This is because of a lack of studies that attempt to show a benefit. I mean how do you do a study on say how often a pap smear should be done? How many women do you sacrifice? Can you tell a woman not to have pap smears if she knows she has never had any type of STD?

You start by looking at what already happens and the results.

http://www.ncbi.nlm.nih.gov/pubmed/2115753

You are correct that it would be unethical to perform a controlled trial under these circumstances.

Linda

[BillyJoe]

I'm sexually active and in the US, they advise a yearly screening in that case.


Yearly in America.
Biannually in Australia.
Triannually in Britain.

Who, I wonder is following the evidence?
(Dr. Wain seems to suggest it's Britain)

Not to mention that I'm on hormonal birth control as well.


Hmmm...how does that make a difference?

I also just have them run the full set of tests even though I've been in a monogamous relationship for five years.


I guess that's just in case your partner is not in a monogamous relationship. ;)

I have had an abnormal result and that turned out to be nothing in the end, thankfully.


By which you mean it reverted back to normal?

[BillyJoe]

I mean how do you do a study on say how often a pap smear should be done?


For a start compare the results being obtained in America, Australia, and Britain.

How many women do you sacrifice?
How many would you be willing to sacrifice?

Triannually has to involve more sacrifice than biannually.
Biannually has to involve more sacrifice than annually.
Annually has to involve more sacrifice than half yearly.

Balanced against this are the resources required for the effort and the diversion of resources from other worthwhile efforts.

Can you tell a woman not to have pap smears if she knows she has never had any type of STD?
The only women who do not need paps mears are those who have never had sex.
(And couples who have only ever had sex with each other - but that requires a degree of trust on behalf of both partners)

[rjh01]

For a start compare the results being obtained in America, Australia, and Britain.



Has anyone ever done this?
If cancer rates were different in different countries could that be the result of other things, e.g. diet.

[BillyJoe]

If cancer rates were different in different countries could that be the result of other things, e.g. diet.


I don't know if diet effects the cervical cancer rate, but I'm willing to bet that sexual activity would swamp it by several orders of magnitude.

But, in fact, the figures should be available in every country - unless you think that every female gets her pap smears done at exactly the recommended interval.

[Ivor the Engineer]

For a start compare the results being obtained in America, Australia, and Britain.


How many would you be willing to sacrifice?

Triannually has to involve more sacrifice than biannually.
Biannually has to involve more sacrifice than annually.
Annually has to involve more sacrifice than half yearly.

Balanced against this are the resources required for the effort and the diversion of resources from other worthwhile efforts.


The only women who do not need paps mears are those who have never had sex.
(And couples who have only ever had sex with each other - but that requires a degree of trust on behalf of both partners)

Careful BillyJoe, you're starting to sound like me.;)

[krazyKemist]

Not to mention that I'm on hormonal birth control as well.

Hmmm...how does that make a difference?

Many cervical, endometrial and breast cancers are ER+, meaning they are stimulated by estrogens (hormones). What may happen in that case is accelerated growth of a preexisting cancer. As somebody working on that specific subject, I think that would justify more frequent screening;).

[BillyJoe]

Careful BillyJoe, you're starting to sound like me.;)


I resemble that remark.

[BillyJoe]

Many cervical, endometrial and breast cancers are ER+, meaning they are stimulated by estrogens (hormones). What may happen in that case is accelerated growth of a preexisting cancer.


I haven't checked yet whether this is correct but, even if this is correct, how does an accelerated growth of an already existing cervical cancer justify increasing the rate of testing for a pre-cancerous condition?

As somebody working on that specific subject, I think that would justify more frequent screening;).


With all due respect for someone working on that specific subject, but wouldn't you have to quantify the effect and justify the conclusion weighed up against the diversion of resources from other worthwhile efforts ;).

regards,
BillyJoe

[LostAngeles]

..Hmmm...how does that make a difference?...

When it was the pill, they needed to write me a refill, with the shot, they wanted to make sure everything was ok, with the IUS, they make sure everything is ok and check my strings (which I do every month, but they have a better view)

Being sexually active opens you up to possible infection by HPV which is linked to cervical cancer. Hence, it's good to check.

I guess that's just in case your partner is not in a monogamous relationship. ;)

Well, I have no reason to think that he isn't. The tests are free for me and I'm in the habit of getting them done anyway. I am a responsible slut.

By which you mean it reverted back to normal?

Actually, no. It has to do with there being two different types of cells on the cervix. One is nearer to the os and generally doesn't take up that much space. On me, it takes up a little more space than usual and when they did the Pap smear, they snagged some from that area accidentally because, well, those cells aren't there on most women's cervixes. Thus the result comes up as abnormal and I had to go back in for a second Pap, getting it looked at with a really big magnifying glass, and a biopsy (which sucked) just in case.

Now when I go back, I have to report that, yes I did have an abnormal Pap result and this was what happened.

So while scary, and rather uncomfortable as I got one of those gynos that needs to give cute commentary on your ****, the best part of that was my then-boyfriend shunning me because he thought I had an STI, when they were reporting the result as dysplasic.

Many cervical, endometrial and breast cancers are ER+, meaning they are stimulated by estrogens (hormones). What may happen in that case is accelerated growth of a preexisting cancer. As somebody working on that specific subject, I think that would justify more frequent screening;).

Oh, and I guess that too. I thought I was just getting regular screenings.

[Dragon]

I haven't checked yet whether this is correct but, even if this is correct, how does an accelerated growth of an already existing cervical cancer justify increasing the rate of testing for a pre-cancerous condition?
Well, the smear test (to be pedantic it's actually liquid-based cytology these days) should also detect cancer cells. Plus there's a good chance that if there is a cancer the smear-taker will notice it.



With all due respect for someone working on that specific subject, but wouldn't you have to quantify the effect and justify the conclusion weighed up against the diversion of resources from other worthwhile efforts ;).

regards,
BillyJoeYes. Remember - the resources are not just those involved in the initial screening but also the colposcopy follow-up for abnormal smears. In the UK, where we spend public money on this, we've settled on the 3-year frequency.

[BillyJoe]

Well, the smear test (to be pedantic it's actually liquid-based cytology these days) should also detect cancer cells. Plus there's a good chance that if there is a cancer the smear-taker will notice it.


Australia hasn't converted to liquid-based cytology because it is more expensive and no better at picking up abnormalities (at least the last time I looked)

Yes. Remember - the resources are not just those involved in the initial screening but also the colposcopy follow-up for abnormal smears. In the UK, where we spend public money on this, we've settled on the 3-year frequency.

Yes, good point, there are expensive add ons.
The doctor in that article seems to be suggesting that 3 yearly is the way to go. Of course Americans always overdo everything :rolleyes:

[BillyJoe]

LostAngeles, I think I'm getting to know you very well. :)

Just as a bit of quid pro quo:
Recently I explained to my wife why the gardasil vaccine was free only for the under 26 year olds and, having explained that and made sure she understood the implications of having HPV, when I added that: "you wouldn't have any need for the vaccine would you?", she ever so faintly blushed. Oops!

[LostAngeles]

LostAngeles, I think I'm getting to know you very well. :)

:D

Just as a bit of quid pro quo:
Recently I explained to my wife why the gardasil vaccine was free only for the under 26 year olds and, having explained that and made sure she understood the implications of having HPV, when I added that: "you wouldn't have any need for the vaccine would you?", she ever so faintly blushed. Oops!

It's not free for 11-26 year olds, that's the only group it's FDA-approved for. HPV can be picked up in other ways too, I think, though I'm not really sure.

[Skeptic Ginger]

Technically after a couple normal pap's every three years is sufficient. However, one can also argue for more frequent tests because some specimens are inadequate or the lab tech reading the smear not perfect. So getting them more often decreases the chance a smear will be misread. Every two years is about right if you go by the evidence and reality.

[Skeptic Ginger]

LostAngeles, I think I'm getting to know you very well. :)

Just as a bit of quid pro quo:
Recently I explained to my wife why the gardasil vaccine was free only for the under 26 year olds and, having explained that and made sure she understood the implications of having HPV, when I added that: "you wouldn't have any need for the vaccine would you?", she ever so faintly blushed. Oops!There's always the chance one's monogamous partner isn't. That works both ways. ;)

But looking at it another way, even one's partner could have a latent infection. That means if you had a strain of HPV, it wouldn't necessarily have already spread to your partner.

I think the best thing is to read the research and wait until it is recommended for what you believe fits your profile regardless of the exact cutoff age in the vaccine guidelines.

[BillyJoe]

It's not free for 11-26 year olds, that's the only group it's FDA-approved for.


We live in different countries.

In Australia it's free up to the age of 26 and children are given the vaccine free at school at the age of 12 (year 7) with catch up for students over that age who have not yet received it.

HPV can be picked up in other ways too, I think, though I'm not really sure.


Well, you can pick it up with direct skin to skin contact. But, as that involves direct skin to skin contact in the genital area....

[BillyJoe]

There's always the chance one's monogamous partner isn't. That works both ways. ;)


Yeah well, as far as I know we are monogamous. :cool:
And maybe the blush was just the sudden realisation of her inappropriate insistence on having the vaccine for free as well. ;)


But looking at it another way, even one's partner could have a latent infection. That means if you had a strain of HPV, it wouldn't necessarily have already spread to your partner.


Well, yeah, but that is if they have had previous partners. :(


I think the best thing is to read the research and wait until it is recommended for what you believe fits your profile regardless of the exact cutoff age in the vaccine guidelines.


Perhaps you are right.

[fls]

I haven't checked yet whether this is correct but, even if this is correct, how does an accelerated growth of an already existing cervical cancer justify increasing the rate of testing for a pre-cancerous condition?

Guidelines take into consideration a less than ideal sensitivity (of those who have dysplasia or carcinoma, how many are detected) for pap tests. If the progression from dysplasia to carcinoma in situ to invasive carcinoma takes more than 10 years and you are screened every 3 years, you can have two false-negatives and still catch it before you progress to CIS. If the growth is accelerated (including acceleration in the precancerous stage), then over that same time period, it may have already progressed to invasive carcinoma.

More frequent screening results in small, incremental increases in the number of lesions discovered, and increases the number of investigations for false-positives. Some populations are more risk averse, when balanced against the consumption of resources, which seems to account for much of the variation in recommendations.

Linda

[Dragon]

Technically after a couple normal pap's every three years is sufficient. However, one can also argue for more frequent tests because some specimens are inadequate or the lab tech reading the smear not perfect. So getting them more often decreases the chance a smear will be misread. Every two years is about right if you go by the evidence and reality.Under the UK programme if the smear is inadequate then the woman is recalled. After three inadequates then they are sent for colposcopy anyway.
You have a point about the lab though - no system is perfect. One way to minimise that problem is having labs with sufficient throughput - so that they see enough abnormal smears to be good at spotting them.

[BillyJoe]

Guidelines take into consideration a less than ideal sensitivity (of those who have dysplasia or carcinoma, how many are detected) for pap tests. If the progression from dysplasia to carcinoma in situ to invasive carcinoma takes more than 10 years and you are screened every 3 years, you can have two false-negatives and still catch it before you progress to CIS. If the growth is accelerated (including acceleration in the precancerous stage), then over that same time period, it may have already progressed to invasive carcinoma.


You are saying, then, that the OCP accelerates both the progression from pre-cancer to cancer as well as the growth of the cancer itself?
In any case, shouldn't there just be a recommendation of, say, three years for those not on the OCP and, say, two years for those on the OCP?


More frequent screening results in small, incremental increases in the number of lesions discovered, and increases the number of investigations for false-positives. Some populations are more risk averse, when balanced against the consumption of resources, which seems to account for much of the variation in recommendations.



The American recommendation is annually, whereas the British recommendation is every three years. Does the difference in risk between these two populations really account for this difference in recommendations?

Also, Dr. Wain is recommending a change in Australia from 2 years to 3 years. Does this just reflect our English heritage do you think? Perhaps, seeing as we watch so many American movies, we should actually be changing to annual smears!

[krazyKemist]

I haven't checked yet whether this is correct but, even if this is correct, how does an accelerated growth of an already existing cervical cancer justify increasing the rate of testing for a pre-cancerous condition?

This is available from the american and canadian cancer societies in the case of breast cancer, the only one for which receptor status is verified on a systematic basis (because of the availability of efficient hormone-based therapy). Breast tumors are 60 to 75% ER+ depending on the data sources. The data is much less known for cervical, endometrial and ovarian cancers, since those are not subjected to systematic receptor status testing (And I think this has grave consequences on the outcome of their treatment; ovarian cancer patients, for example, are systematically put on HRT). All cancers which originate from cells which normally develop under estrogen stimulation are susceptible to be ER+.

With all due respect for someone working on that specific subject, but wouldn't you have to quantify the effect and justify the conclusion weighed up against the diversion of resources from other worthwhile efforts .

I'm not saying anything to the contrary. But 'accelerated growth' means that you may see nothing on the first screening for these people, and stage IV disease on the next screening 3 years later. Pill manufacturer do recommend regular gyne exams for this reason. But I understand the concern for the cost of such measures, since I also live in a country where we have public healthcare, and a shortage of gynes;).

[Ivor the Engineer]

<snip>

The American recommendation is annually, whereas the British recommendation is every three years. Does the difference in risk between these two populations really account for this difference in recommendations?

<snip>

Perhaps it's the different approaches to the provision of health care in the US and the UK. Medical professionals in the US market and sell their services on a patient by patient basis, while those in the UK (in general) get paid for a set number of hours per week. Thus the American system is more likely to promote and recommend treatments which offer smaller marginal benefits to patients than the UK system.

[BillyJoe]

Perhaps it's the different approaches to the provision of health care in the US and the UK. Medical professionals in the US market and sell their services on a patient by patient basis, while those in the UK (in general) get paid for a set number of hours per week. Thus the American system is more likely to promote and recommend treatments which offer smaller marginal benefits to patients than the UK system.


Most medical services in Australia are on a "fee for service" basis, but there are official recommendations for the types of tests that should be done preventatively and the frequency with which they should be done. It seems doctors here more or less follow these recommendations.

Perhaps we have the best of both worlds here. At least we seem to sit neatly between the apparent overservicing of the American system and the slighty risky cost saving British system as far as pap smears are concerned, even if Dr. Wain is trying to push us in the direction of the Brits.

[BillyJoe]

This is available from the american and canadian cancer societies in the case of breast cancer, the only one for which receptor status is verified on a systematic basis (because of the availability of efficient hormone-based therapy). Breast tumors are 60 to 75% ER+ depending on the data sources. The data is much less known for cervical, endometrial and ovarian cancers, since those are not subjected to systematic receptor status testing (And I think this has grave consequences on the outcome of their treatment; ovarian cancer patients, for example, are systematically put on HRT). All cancers which originate from cells which normally develop under estrogen stimulation are susceptible to be ER+.


Okay, so you would expect the OCP to increase the rate of progression of pre-cancerous lesions to cancer as well as the rate of cancer growth. But, if and when my daughter goes on the pill I still don't know what to recommend to her. One two or three yearly?


I'm not saying anything to the contrary. But 'accelerated growth' means that you may see nothing on the first screening for these people, and stage IV disease on the next screening 3 years later.


Still nothing quantitative here though. How often would this happen? Does it happen often enough to warrant a change from three to two yearly pap smears? What about two to one yearly?

Pill manufacturer do recommend regular gyne exams for this reason.


I'm a little hesitant to accept what the pill manufacturers say. I mean great that they invented the pill but, as for the facts about the pill, I would much prefer some independant advice.

But I understand the concern for the cost of such measures, since I also live in a country where we have public healthcare, and a shortage of gynes;).


And across the board, the limited health dollar has to be spent wisely otherwise someone doesn't get a life saving kidney because some others want their risk of cervical cancer reduced from 1/120 to 1/119.

[krazyKemist]

Okay, so you would expect the OCP to increase the rate of progression of pre-cancerous lesions to cancer as well as the rate of cancer growth. But, if and when my daughter goes on the pill I still don't know what to recommend to her. One two or three yearly?

She should get one complete gyne exam at the very least before starting the pill. Some women have disorders which make it riskier to be on the pill. As for the optimal test rate, I frankly have no idea. I think the way to use the data is to try to point out some groups according to risk. For example, data for women on the pill should be separated from data on women at large. Same for menopaused women (the majority of "feminine" cancers are diagnosed after menopause), those with a family history of breast/ovarian/endometrial/cervical cancers (most notorious are the BRCA-1 and BRCA-2 mutation cases), ect. So I think the resources should be spent on the groups presenting the most risk.

Still nothing quantitative here though. How often would this happen? Does it happen often enough to warrant a change from three to two yearly pap smears? What about two to one yearly?

That's very difficult problem, because cancer is very far from an homogenous disease, even when we're speaking about one single type of cancer. This guy (http://scienceblogs.com/insolence/2008/05/the_variability_of_cancer_behavior.php#more) explains it well, using breast cancer as an example. And it's also important for the treatment decision. When is it better to do nothing ? When is adjuvant therapy most indicated ? The truth is that knowledge is still very vague in this area. And when it will become more detailed, enriching your screening will probably involve genetic testing. So the 1 million dollar question : will at large genetic testing costs exceed more frequent PAP test for a greater population :o?

I'm a little hesitant to accept what the pill manufacturers say. I mean great that they invented the pill but, as for the facts about the pill, I would much prefer some independant advice.

In this case, they are herring on the side of caution. That's not always the case in the pharmaceutical industry. This is a relatively old product however, and there are plenty of data on the risks pertaining to its use.

And across the board, the limited health dollar has to be spent wisely otherwise someone doesn't get a life saving kidney because some others want their risk of cervical cancer reduced from 1/120 to 1/119.

Yes, I agree. And I think it underlines the necessity to separate the data according to risk factor groups.

[Dr. Imago]

Many cervical, endometrial and breast cancers are ER+, meaning they are stimulated by estrogens (hormones). What may happen in that case is accelerated growth of a preexisting cancer. As somebody working on that specific subject, I think that would justify more frequent screening;).

Just a side point, but no. This is not true for cervical cancer, which is an epithelial neoplasia that typically does not respond to hormonal manipulation.

-------------------------------------------------------

What the "bottom line" is you guys are hedging around here is the most efficient use of finite resources and the benefit/cost ratio of routine screening. This is going to get more and more complicated as the dollar (or euro or yen or Australian dollar) gets tighter, and more people enter the healthcare system.

My personal bias is that routine screening is money well spent. The testing has gotten so good that false-positives are not problematic, and therapy is not "knee-jerk" when a borderline (say, CIN I diagnosis) is made. This type of screening, furthermore, has a very high benefit-to-cost ratio. I feel the same way about routine colonoscopy.

What I think we have to focus on (and this is clearly a seperate argument), at least in the U.S., is continuing to expend exorbitant resources on futile cases. I can't begin to count and recall for you the number of 80+ year-olds with poor quality of life (e.g., post-CVA, Alzheimer's, etc.) who are warehoused in nursing homes with a variety of nosocomial/iatrogenic problems who subsequently fall down stairs, break a variety of body parts, come to our hospital, get untold thousands spent on them (the bill of which the taxpayers foot), and either subsequently die a miserable death in the hospital or are simply sent back to the human warehouse a little worse off than when they came, but certainly no better. This is, literally, several hundreds of patients per year at just my one institution.

To me, annual screening exam costs, even across a broad population, pales in comparison to what we spend as a nation on futile care. The benefit to society, not to sound Orwellian, vastly weighs in favor of routine screening of otherwise healthy patients. What we have to get a little more circumspect on is how we choose to spend dollars (or yen or pesos) on people whose life quality is gone, and probably would not want to live the way they are living.

I can put a tracheostomy and a PEG tube in any variety of patient without meaningful brain function, give them aggressive nursing care, appropriately feed and medicate them, and keep them alive for much longer than they would've had nature taken its appropriate course. But, who is this really benefitting? Certainly not the patient. You can clearly remain alive without having anything resembling a life.

-Dr. Imago

[The SkepDoc]

The US standard is not annual Pap smears for everyone. The ACOG says,

"Women younger than 30 years should have a Pap test every year. If you are older than 30 years and have had three normal Pap tests in a row, you may not need a Pap test every year. You may only need one every 2 or 3 years."

For when to do the first test, "You are 21 years of age or older or
You became sexually active at least 3 years ago, even if you are younger than 21 years of age or are not having sex now."

More details, and exceptions for high risk patients, can be found at http://www.acog.org/publications/patient_education/bp085.cfm

[krazyKemist]

Just a side point, but no. This is not true for cervical cancer, which is an epithelial neoplasia that typically does not respond to hormonal manipulation.

:confused: I thought HeLa cells were derived from cervical cancer, and they do respond to estrogens. Can you point me to a paper describing estrogen receptor status in cervical tumors ? It happens to be of immediate interest to our work. Thanks :D

[jli]

Can you point me to a paper describing estrogen receptor status in cervical tumors ? It happens to be of immediate interest to our work. Thanks :D

In this (very small) study -> http://clincancerres.aacrjournals.org/cgi/content/full/7/9/2656 they found that about half the cervical carcinomas were ER+ (= more than 10% positive stained cells using immunohistochemistry) . It is true that HeLa cells are from a cervical cancer, but they are all derived from a single tumor from a single patient.

[BillyJoe]

She should get one complete gyne exam at the very least before starting the pill.


Let me get this straight. A young teenage girl has been going out for the first time with some young teenage buck and senses that the relationship is likely to become sexual. She decides that she should to go on the pill just in case and attends her doctor to obtain a prescription. Are you saying that the doctor is going to perform a complete gynaecological examination on her before precribing her the pill?

For the record, here in Australia, the recommended practice is for a girl to have her first pap smear at 20, or 2 years after the onset of sexual activity, whichever occurs later.

Some women have disorders which make it riskier to be on the pill.


What gynaecological disorders make it riskier for a woman to be on the pill that would make it necessary for her to have a complete gynaecological examination before commencing sexual activity and going on the pill?

As for the optimal test rate, I frankly have no idea.


Seems you are not alone. :(

I think the way to use the data is to try to point out some groups according to risk. For example, data for women on the pill should be separated from data on women at large....So I think the resources should be spent on the groups presenting the most risk.


That makes sense.
It's a pity that there seem to be no guidelines linking frequency of pap smears to risk group. Of course I think I know why there is not and why there never will be. Imagine this scenario:

Females who have never had sex: none required.
Females who have only ever had one sexual partner: three years.
Females who have had two or three sexual partners: two years.
Females who have had lots of sexual partners: one year.

I don't think so.

In this case, they are erring on the side of caution. That's not always the case in the pharmaceutical industry. This is a relatively old product however, and there are plenty of data on the risks pertaining to its use.


Yes, so why listen to what the pharmaceutical industry have to say, seeing as you will have no idea whether they are dressing up their product or protecting their legal ass.

[BillyJoe]

What the "bottom line" is you guys are hedging around here is the most efficient use of finite resources and the benefit/cost ratio of routine screening.


We are not hedging around it, we are saying it.
...just not as eloquently.

My personal bias is that routine screening is money well spent.


You won't get any argument from us.
...but we would like to know how often.

I feel the same way about routine colonoscopy.


Hmmm...they're trying that out in Australia just now.
Everyone over 50 is encouaged to get a blood-in-faeces test every two years, and very person turning 55 and 65 gets a kit sent to them free.
All positives are encouraged to get a colonoscopy.
Fat chance, fortunately, because I doubt there are enough colonoscopists to take the load, so to speak.

I can put a tracheostomy and a PEG tube in any variety of patient without meaningful brain function,


Why don't you flat out refuse to commit that crime.

regards,
BillyJoe

[ZirconBlue]

In this case, they are herring on the side of caution.

Hmm. There's something fishy about this post.

:p

[jli]

Hmmm...they're trying that out in Australia just now.
Everyone over 50 is encouaged to get a blood-in-faeces test every two years, and every person turning 55 and 65 gets a kit sent to them free.
All positives are encouraged to get a colonoscopy.
Fat chance, fortunately, because I doubt there are enough colonoscopists to take the load, so to speak.

In Denmark we have tried it in two districts, each wih a population of 90,000 in the age group 50-74 years. During a two year period everyone in that age group recieved a test kit. And everyone with a positive test was invited for a colonoscopy within two weeks of positive test. Not everybody took the test of course, and a few positives refused to have the colonoscopy. Right now we are waiting for the politicians do decide wether to do colorectal cancer screening nationwide or not. At least we have seen that it can be done.

[fls]

You are saying, then, that the OCP accelerates both the progression from pre-cancer to cancer as well as the growth of the cancer itself?
In any case, shouldn't there just be a recommendation of, say, three years for those not on the OCP and, say, two years for those on the OCP?

Estrogen receptors are also associated with increased likelihood of HPV infection, which starts the whole process. I don't know how sure we are of the reasons for an increased risk of cervical cancer with OCP use, though.

The recommendations seem to be tailored to the individual - at least that's how they are presented and what I am familiar with in practice. So OCP use could be taken into consideration when trying to decide whether or not to use a shorter screening period.

The American recommendation is annually, whereas the British recommendation is every three years. Does the difference in risk between these two populations really account for this difference in recommendations?

There may also be a difference in risk between these two populations, but I was thinking that there are cultural differences in perception of risk, and how averse people are to accepting risk.

Linda

[Ivor the Engineer]

<snip>

There may also be a difference in risk between these two populations, but I was thinking that there are cultural differences in perception of risk, and how averse people are to accepting risk.

Linda

The latter half of that sentence does not sound like a rational way to decide how to distribute resources.

[The SkepDoc]

From the subsequent comments, it sounds like no one read my previous post.
The American recommendations are NOT yearly for everyone.
After 2 normal Pap smears, low risk women are advised to have one every 2-3 years. High risk women are advised to have Paps more often.
See http://www.acog.org/publications/pat...tion/bp085.cfm
Also, I have been reading in my family practice journals that it is acceptable to provide birth control pills to young women (at least those at low risk) without first doing a pelvic exam and Pap smear.

[Beerina]

She is very lucky and I am happy for her.

However, that is hardly a basis upon which to formulate a protocol.


My father had a chest x-ray that was normal and six months later he had another because of pneumonia and this time it showed that he had lung cancer. Therefore we should have routine chest x-rays every six months.

I don't think so.

QFT

In the case of X-rays, they have to balance the statistical likelihood of benefit and saving lives vs. the statistical likelihood of inducing cancer and costing lives.

Ideally, the dividing line would be where the likelihood of death was exactly equal to maximize the lives saved. (Of course you can weight this to give slightly higher importance to younger people, i.e. more "living" saved. Also, other vigilance techniques can be used to ameliorate lack of X-ray tests, etc.)

[Beerina]

I'm sexually active and in the US, they advise a yearly screening in that case. Not to mention that I'm on hormonal birth control as well.

Heheh, I could've sworn in another thread you said you were a gay man. If that's the case, something in "gay man" has to give. :)

[Ivor the Engineer]

<snip>

After 2 normal Pap smears, low risk women are advised to have one every 2-3 years. High risk women are advised to have Paps more often.

<snip>

Does cervical cancer in high risk women progress faster than in low risk women?

[LostAngeles]

Heheh, I could've sworn in another thread you said you were a gay man. If that's the case, something in "gay man" has to give. :)

I might have joked about people thinking I'm a man, somewhere.

Several people here can vouch that I am not a gay man.

[The SkepDoc]

Does cervical cancer in high risk women progress faster than in low risk women?

I don't think so. It's just more likely to develop in the first place.
Every screening test is a trade-off between the accuracy of the test and the prevalence of the disease in the population being tested.

[Ivor the Engineer]

Here's something that may be of interest:

http://www.nhs.uk/news/2008/05May/Pages/HPVtestalternativetosmear.aspx

“Hope over smear test alternative” is the headline from BBC News today. It reports that testing for the common sexually transmitted infection human papillomavirus (HPV) may be a better screening tool for cervical cancer than smear tests. In addition, “testing for HPV was so sensitive it only needed to be done every six years - compared to three years for smears”, the BBC adds.

[BillyJoe]

From the subsequent comments, it sounds like no one read my previous post.
The American recommendations are NOT yearly for everyone.
After 2 normal Pap smears, low risk women are advised to have one every 2-3 years. High risk women are advised to have Paps more often.
See http://www.acog.org/publications/pat...tion/bp085.cfm
Also, I have been reading in my family practice journals that it is acceptable to provide birth control pills to young women (at least those at low risk) without first doing a pelvic exam and Pap smear.


I have read it - and thank you for that information.

But I was still persuing a certain poster on this thread who seems to have posted nonsense whilst claiming to have some expertise. :mad:

[fls]

I have read it - and thank you for that information.

But I was still persuing a certain poster on this thread who seems to have posted nonsense whilst claiming to have some expertise. :mad:

And I thought we were getting along so well!

Hmmph (sp?).

<stomps off in a huff>

Linda

[Chris Haynes]

From the subsequent comments, it sounds like no one read my previous post.
The American recommendations are NOT yearly for everyone.
After 2 normal Pap smears, low risk women are advised to have one every 2-3 years. ....

At my last annual exam there was no PAP smear. I'm fifty years old, married for 28 years to the only man ever (a Canadian engineer, of extremely boring but talented character, ;)), we define monogamy.

(now there was the dreaded cholesterol screen, and sigh... after initially lowering my LDL, my liver has decided that it was too low and compensated by producing more even though my fat consumption was reduced to a small fraction of my previous life... and since my mother, an only and possibly adopted child, died in a plane crash, we don't know how protective my HDL of 75 is, so I am now on a very low dose of statins... sigh --- oh, and while I was talking to family doc, daughter was getting her third HPV vaccine)

[Ivor the Engineer]

At my last annual exam there was no PAP smear. I'm fifty years old, married for 28 years to the only man ever (a Canadian engineer, of extremely boring but talented character, ;)), we define monogamy.

(now there was the dreaded cholesterol screen, and sigh... after initially lowering my LDL, my liver has decided that it was too low and compensated by producing more even though my fat consumption was reduced to a small fraction of my previous life... and since my mother, an only and possibly adopted child, died in a plane crash, we don't know how protective my HDL of 75 is, so I am now on a very low dose of statins... sigh --- oh, and while I was talking to family doc, daughter was getting her third HPV vaccine)

I thought the important factor was TC/HDL. If the ratio is less than 5 (4.5 for women), there is no elevated risk of CHD.

This is another subject where the general opinion of medical professionals in the UK and US seem to differ.

[BillyJoe]

I thought the important factor was TC/HDL. If the ratio is less than 5 (4.5 for women), there is no elevated risk of CHD.


My sister, who had a heart attack before her 40th birthday, was told to keep her TC below 4.0, and her LDL below 2.0. That's all her cardiologist was interested in....

...well, apart from treating her high blood pressure, keeping her diabetes under control, stopping her 40 cigarettes a day habit, and reducing her weight by 50% :eek:

[BillyJoe]

And I thought we were getting along so well!

Hmmph (sp?).

<stomps off in a huff>

Linda


Oh yeah, it was you. I forgot to say. :D

(Looks like the phlaky pharmacist is off the hook now.)

[Dr. Imago]

Also, I have been reading in my family practice journals that it is acceptable to provide birth control pills to young women (at least those at low risk) without first doing a pelvic exam and Pap smear.

The simple and practical reason for this is that many female teenagers may balk at starting birth control if they have to subject themselves to a gynecologic exam. In our profession, we call this a trade-off.

-Dr. Imago

[BillyJoe]

The simple and practical reason for this is that many female teenagers may balk at starting birth control if they have to subject themselves to a gynecologic exam. In our profession, we call this a trade-off.


Oh, for god's sake, how important can it be?

You would not really actually entertain doing gynaecological examinations on girls who have not yet had sexual intercourse, would you? Tell me you wouldn't. Or do you encourage them to have a bit of sexual intercourse first before coming in to be put on the pill?

:eek:

And what exactly are you trading off?
What rare gynaecological condition aggravated by the pill are you trading off being detected early by deferring the first gynaecological examination untill the age of 21?

I am in absolute despair of the experts around here lately. :(


regards,
BillyJoe

[fls]

Oh, for god's sake, how important can it be?

You would not really actually entertain doing gynaecological examinations on girls who have not yet had sexual intercourse, would you? Tell me you wouldn't. Or do you encourage them to have a bit of sexual intercourse first before coming in to be put on the pill?

:eek:

And what exactly are you trading off?
What rare gynaecological condition aggravated by the pill are you trading off being detected early by deferring the first gynaecological examination untill the age of 21?

I am in absolute despair of the experts around here lately. :(

regards,
BillyJoe

I'm with you on this. I started to ask the same thing, but erased it as I was not so nice as you.

Linda

[krazyKemist]

In this (very small) study -> http://clincancerres.aacrjournals.org/cgi/content/full/7/9/2656 they found that about half the cervical carcinomas were ER+ (= more than 10% positive stained cells using immunohistochemistry) . It is true that HeLa cells are from a cervical cancer, but they are all derived from a single tumor from a single patient.

Thanks !

mmm... 50% chance of tumor response to estrogen would be enough for me to refuse HRT (premarin) if I had the bad luck to be diagnosed with cervical cancer. It may not respond to antiestrogen, for whatever reason, but that's no warranty that it won't start multiplying like pheromone-crazed rabbits if you give it estradiol.

I knew that the HeLa line was from a single patient (and I also know of its infamous reputation of being able to cause cancer from a needle prick). I was just wondering if it was representative or atypical. We generally use several cell lines for our tests. This is an exploratory project.

[krazyKemist]

Hmm. There's something fishy about this post.



hehe... Yep. English isn't my mother tongue.:blush:

[krazyKemist]

Let me get this straight. A young teenage girl has been going out for the first time with some young teenage buck and senses that the relationship is likely to become sexual. She decides that she should to go on the pill just in case and attends her doctor to obtain a prescription. Are you saying that the doctor is going to perform a complete gynaecological examination on her before precribing her the pill?

I should have said "ideally". That is possible if the girl can talk it out with her parents or guardians (it often is not, granted:o). And no, you don't need a gynecological exam to get a prescription for the pill over here. Even more extreme, a school nurse can prescribe it to all girls over 14 on demand, no questions asked.

Yes, it sounds like a great way to make contraception available to everyone, but the truth is that you will probably have to get medical advice regarding this, even if you do not develop a rare severe complication. This is a drug, a hormone, and one size definitely does not fit all. Most girls on the pill will tell you that the first one they tried wasn't a perfect match. My own experience includes unusual side effects, e.g. an increased frequency and severity of asthma attacks and a sun allergy. Other girls had dangerous ophtalmic migraines which could have made them go blind if unchecked (I personnally know two women who cannot take OCP for that reason).

What gynaecological disorders make it riskier for a woman to be on the pill that would make it necessary for her to have a complete gynaecological examination before commencing sexual activity and going on the pill?

A preexisting cancerous lesion springs to mind. Yes, it is rare at such a young age. But getting a gynecological exam at the start of your sex life does not strike me as extreme. Indeed, it might make it easier for women to respond favorably to screening programs later in life (taking out the ick factor, making those a normal part of life) and it establishes a baseline for later exams.

[Ivor the Engineer]

<snip>

A preexisting cancerous lesion springs to mind. Yes, it is rare at such a young age. But getting a gynecological exam at the start of your sex life does not strike me as extreme. Indeed, it might make it easier for women to respond favorably to screening programs later in life (taking out the ick factor, making those a normal part of life) and it establishes a baseline for later exams.

What do you think the ratio of true positives to false positives would be?

[The SkepDoc]

[QUOTE=Ivor the Engineer;3739866]I thought the important factor was TC/HDL. If the ratio is less than 5 (4.5 for women), there is no elevated risk of CHD.QUOTE]

That's only one of many risk factors.

[The SkepDoc]

What do you think the ratio of true positives to false positives would be?

I think the chances of picking up a significant abnormality on a teenage pre-sex Pap smear are very small, and the false positives or questionable results might lead to more harm than good. On the other hand, a pelvic exam might pick up the occasional physical abnormality and might serve as an opportunity for sex education and safe-sex instruction. I wouldn't require it, but I don't think it's a bad idea either. The exam need not be embarrassing or painful: I have done pelvic exams on children as young as 5 or 6, using a tiny speculum and reassuring them, and they were quite comfortable with it.

A pre-sex exam might have saved one couple a world of trouble. They saw their doctor for infertility and it turned out the woman was still a virgin. She had a very tough hymen that the husband was unable to penetrate. They had tried and tried, and eventually the woman's urethra was forced open and they had been having what they thought was normal intercourse - in the woman's bladder instead of her vagina!!

[Ivor the Engineer]

I thought the important factor was TC/HDL. If the ratio is less than 5 (4.5 for women), there is no elevated risk of CHD.

That's only one of many risk factors.

I should have been more specific.;)

[Ivor the Engineer]

I think the chances of picking up a significant abnormality on a teenage pre-sex Pap smear are very small, and the false positives or questionable results might lead to more harm than good. On the other hand, a pelvic exam might pick up the occasional physical abnormality and might serve as an opportunity for sex education and safe-sex instruction. I wouldn't require it, but I don't think it's a bad idea either. The exam need not be embarrassing or painful: I have done pelvic exams on children as young as 5 or 6, using a tiny speculum and reassuring them, and they were quite comfortable with it.

I was quite comfortable running around naked when I was 5 or 6. I think I'd have been a bit more anxious about having a genital exam at age 16.

How do you make examining someone's genitals not embarrassing for them? It's amazing what people will put up with if a doctor is doing it to them.

A pre-sex exam might have saved one couple a world of trouble. They saw their doctor for infertility and it turned out the woman was still a virgin. She had a very tough hymen that the husband was unable to penetrate. They had tried and tried, and eventually the woman's urethra was forced open and they had been having what they thought was normal intercourse - in the woman's bladder instead of her vagina!!

:eye-poppi

It's having stories like that to tell where a career in electronic engineering just can't compete with medicine.

[The SkepDoc]

[QUOTE=Ivor the Engineer;3741137] How do you make examining someone's genitals not embarrassing for them? QUOTE]

The trick is not to be embarrassed yourself. Then you can put the patient at ease and explain what you are doing in very matter-of-fact terms and proceed as though everything was perfectly natural. I never had a problem.

One thing I did object to was when the doctor doing my Pap smear touched the speculum to my inner thigh first and said, "Now I'm touching your leg so you know what the speculum feels like, and now I'm going to insert the speculum." I thought that was unnecessary and condescending.

[JJM]

The trick is not to be embarrassed yourself. Then you can put the patient at ease and explain what you are doing in very matter-of-fact terms and proceed as though everything was perfectly natural. I never had a problem.But, SkepDoc, men are not used to getting nekkid in front of a woman ... who is sober. (I stole that.)

[jli]

mmm... 50% chance of tumor response to estrogen

I think the only thing we can deduce from this study is that some cervical cancers are ER+ and some are ER-.

I knew that the HeLa line was from a single patient (and I also know of its infamous reputation of being able to cause cancer from a needle prick). I was just wondering if it was representative or atypical. Well, if you look at the microphotographs in the article you can see that the (carcinoma) cells in the tumor are morphologically very heterogeneous. Although they show some common features it is hard (impossible?) to spot two identical carcinoma cells in the tumor. It would be very atypical for a cevical cancer to be made of only HeLA-appearing cells. Remember also that the criterion of ER+ is that at leat 10% of the cells are postive.

[LostAngeles]

Oh, for god's sake, how important can it be?

You would not really actually entertain doing gynaecological examinations on girls who have not yet had sexual intercourse, would you? Tell me you wouldn't. Or do you encourage them to have a bit of sexual intercourse first before coming in to be put on the pill?

:eek:

And what exactly are you trading off?
What rare gynaecological condition aggravated by the pill are you trading off being detected early by deferring the first gynaecological examination untill the age of 21?

I am in absolute despair of the experts around here lately. :(


regards,
BillyJoe

We're really going to get familiar here.

I was brought in as a teenage girl before I was having sex because of painful periods and my mother's history of endometriosis. I'd been having my period for 5 years at that point and it was my first gyno exam.

Before plastic speculums were common.

And I had a hymen.

No Pap smear, no need.

However, the pill is generally very useful in treating endometriosis and they wanted to make sure I didn't have anything more serious.

[fls]

We're really going to get familiar here.

I was brought in as a teenage girl before I was having sex because of painful periods and my mother's history of endometriosis. I'd been having my period for 5 years at that point and it was my first gyno exam.

Before plastic speculums were common.

And I had a hymen.

No Pap smear, no need.

However, the pill is generally very useful in treating endometriosis and they wanted to make sure I didn't have anything more serious.

It's one thing to do a pelvic exam for specific indications and another thing to do one 'just because'.

Linda

[Chris Haynes]

I thought the important factor was TC/HDL. If the ratio is less than 5 (4.5 for women), there is no elevated risk of CHD.

That's only one of many risk factors.

(A more complete family history would have helped... yet another reason for me to be upset about my mother (an only and possibly adopted child) being killed in a plane crash when I was 11)

[Dr. Imago]

Oh, for god's sake, how important can it be?

First off, you obviously have more trust (dare I say "faith") in the veracity of teenage girls than I do. Secondly, a routine pelvic/vaginal exam does not exists solely to do a Pap smear in order to detect cervical cancer. Lastly, if they are old enough to consider sexual intercourse and ask for birth control, I think teaching them and instilling in them the responsibility of routine gynecologic health, including examination, is not unreasonable.

Of course, when every patient comes to me for pre-operative evalution, I always believe everything the tell me... that they don't smoke, don't do drugs, always wear their seatbelts... :rolleyes: I think it was Ronald Reagan who said, "Trust... but verify."

-Dr. Imago

ETA: Of course, if it's a matter of access and not getting birth control because they are afraid of the exam, that makes it more difficult. But, do you necessarily think that OCP form of birth control is safe in every patient? I don't, for a multitude of reasons (e.g., is it safe to give OCP to a teenage girl with a familial history of Factor V Leiden or antithrombin deficiency?). At the very least, a full health history and education session about safe sex practices should occur, preferably between a trusted healthcare provider and the girl before OCP's are prescribed. And, that health/sex education should include the use of condoms.

[BillyJoe]

First off, you obviously have more trust (dare I say "faith") in the veracity of teenage girls than I do.


So you just assume that they have been sexually active for about 2 years before they come in for the pill?

Secondly, a routine pelvic/vaginal exam does not exists solely to do a Pap smear in order to detect cervical cancer.


But you still won't say what rare disorder you are hoping to detect.

Lastly, if they are old enough to consider sexual intercourse and ask for birth control, I think teaching them and instilling in them the responsibility of routine gynecologic health, including examination, is not unreasonable.


No argument, and that would include advising them (according to the guidelines) that the first pap smear should be done at age 20 or 2 years after the onset of sexual intercourse whichever occurs later (or whatever the guidelines are over there).


ETA: Of course, if it's a matter of access and not getting birth control because they are afraid of the exam, that makes it more difficult. But, do you necessarily think that OCP form of birth control is safe in every patient? I don't, for a multitude of reasons (e.g., is it safe to give OCP to a teenage girl with a familial history of Factor V Leiden or antithrombin deficiency?). At the very least, a full health history and education session about safe sex practices should occur, preferably between a trusted healthcare provider and the girl before OCP's are prescribed. And, that health/sex education should include the use of condoms.


But you have yet to explain why that examination is even necessary.
The rest I have no argument with.

regards,
BillyJoe

[Dr. Imago]

But you have yet to explain why that examination is even necessary.

Are you overlooking the obvious?

Every level of the health care system is needed to provide adequate gynecological services for young females. Preventive medicine and a conclusion of normal gynecological findings are important in pediatric gynecology.

http://acta.uta.fi/english/teos.phtml?10506

Hard to sometimes determine what constitutes clinically-relevant disease when you don't have a baseline.

-Dr. Imago

[fls]

It's pretty clear we should be doing an annual pelvic exam on girls starting at a young age, then. Say 5 or 6?

Linda

[BillyJoe]

I seem to have unearthed a sort of gung-ho approach towards gynaecological examinations in young females without clear justification for such an approach.

Apart from the question of the effective use of resources, I wonder where that stands medico-legally?

[Skeptic Ginger]

...Well, you can pick it up with direct skin to skin contact. But, as that involves direct skin to skin contact in the genital area....Which on a rare occasion can be an infection acquired from the birth canal during delivery.

[Skeptic Ginger]

Under the UK programme if the smear is inadequate then the woman is recalled. After three inadequates then they are sent for colposcopy anyway.
You have a point about the lab though - no system is perfect. One way to minimise that problem is having labs with sufficient throughput - so that they see enough abnormal smears to be good at spotting them.It isn't that one is never recalled here for a repeat pap when the specimen is inadequate, that is routine. All lab tests are subject to mechanical error, human error, and the sensitivity and specificity inherent in the test.

[Skeptic Ginger]

.....

The American recommendation is annually, ....We don't have national health care. There is no such thing as "the American recommendation".

There are other organizations which do make recommendations.

The American Cancer Society has one (http://www.cancer.org/docroot/PED/content/PED_2_3X_Chronological_History_of_ACS_Recommendati ons_on_Early_Detection_of_Cancer.asp?sitearea=PED) . That is where I got the three normals then every 3 years from.

I see in 2003 they adjusted the recommendation to the same for over age 30, but for those under 30, Start 3 years after first vaginal intercourse but no later than 21 - Yearly with conventional Pap test or every 2 years with liquid-based Pap test

I imagine other organizations also have standing recommendations.

(Edited to add, I see this was already posted.)

(Edited to add, I see it was posted twice. :D )

[Skeptic Ginger]

Perhaps it's the different approaches to the provision of health care in the US and the UK. Medical professionals in the US market and sell their services on a patient by patient basis, while those in the UK (in general) get paid for a set number of hours per week. Thus the American system is more likely to promote and recommend treatments which offer smaller marginal benefits to patients than the UK system.Well there you go making false assumptions because of your biases against for profit health care.

It is the opposite actually. We have those nasty insurance reviewers who won't pay for excessive care. They dictate what will be reimbursed which more often results in too little care. But even before third party payers started limiting coverage, seeing people for unneeded medical care was fairly rare.

[Skeptic Ginger]

Does cervical cancer in high risk women progress faster than in low risk women?Tsk tsk, and you are the one always analyzing cost benefit...

To review for you the principles of determining which screening tests to recommend for people, in this example you would look at how many cancers you would expect to detect by how many screening tests you would need to do. So you have a different cost benefit balance screening people more often.

Now add to that the risk of lab error and/or insensitive result.

High risk X low chance of test failure is a higher number than low risk X the chance of test failure. In other words the odds of a test failure are higher in a high risk group just due to the sample statistics.

Put another way, what are the chances if I had a low risk of cancer that I would also be the rare person who had a test failure? But if I had a higher risk of cancer then the chances of having cancer and a test failure are a little higher.

[Skeptic Ginger]

I might have joked about people thinking I'm a man, somewhere.

Several people here can vouch that I am not a gay man.I can vouch for you. :D

I met her at TAM. She looked, walked, talked and dressed like a female.

[Skeptic Ginger]

I thought the important factor was TC/HDL. If the ratio is less than 5 (4.5 for women), there is no elevated risk of CHD.

This is another subject where the general opinion of medical professionals in the UK and US seem to differ.
[Takes on the admirable role of fls]I assume you can cite the definitive study which supports that recommendation, then?[/role of fls]

[BillyJoe]

Which on a rare occasion can be an infection acquired from the birth canal during delivery.


Well done, I thought I was going to get away with that one for a while there. :D

[Dr. Imago]

It's pretty clear we should be doing an annual pelvic exam on girls starting at a young age, then. Say 5 or 6?

Linda

Come on, Linda. Reductio ad absurdum is a poor man's philosophical refuge.

If you have a 13-year-old girl who's coming in for birth control, there are only two reasons: (1) she started her menses and is having some sort of "abnormal" cycle, or (2) she is contemplating sexual intercourse.

In both instances, a routine baseline gynecological exam is not unreasonable. The only argument I have, and it's similar to the RU-486 one, is one of access. If avoidance of proper family planning because of fear of the exam is the issue, then you have a much better argument for open access without the exam. As I said before, in the medical profession we call this a trade-off.

-Dr. Imago

[Dr. Imago]

Let me put it another way...

When any woman of reproductive age comes in for elective surgery, we require a urine HCG (human chorionic gonadotropin), or "pregnancy", test. This is done whether or not they tell us they are sexual active.

Is this a waste of money?

-Dr. Imago

[fls]

Come on, Linda. Reductio ad absurdum is a poor man's philosophical refuge.

If you have a 13-year-old girl who's coming in for birth control, there are only two reasons: (1) she started her menses and is having some sort of "abnormal" cycle, or (2) she is contemplating sexual intercourse.

In both instances, a routine baseline gynecological exam is not unreasonable. The only argument I have, and it's similar to the RU-486 one, is one of access. If avoidance of proper family planning because of fear of the exam is the issue, then you have a much better argument for open access without the exam. As I said before, in the medical profession we call this a trade-off.

-Dr. Imago

I hope we both agree that it is a sensitive issue for a 13-year-old. If you do not, then you need not consider the rest of my post.

Given that it's a sensitive issue, I would hope that it wouldn't be undertaken lightly or just because a young woman happens to be in a vulnerable position. Especially as erecting barriers to contraception or adequate care is likely to lead to avoidance of both.

The arguments that have been put forward that were specific to a routine pelvic exam - establishing a baseline and normal range, picking up physical abnormalities, establishing a routine - are relevant at any age. You found my suggestion absurd, yet you have given no reason why you would hold back from performing a pelvic exam on a 5-year-old. After all, they could also have physical abnormalities, it is important to establish a baseline for future disease, and why not establish the routine when they are less likely to be sensitive about their body than an adolescent?

I do think it's reasonable to ask whether any of those potential benefits outweigh the potential harm. Especially since you are not talking about offering these benefits to all young girls/women, but just those who are vulnerable.

It's not a trade-off if it doesn't occur to you to offer it when the situation isn't somewhat coercive.

Note: I am not talking about pelvic exams done to address specific concerns, such as the menstrual abnormalities you mentioned above.

Linda

[fls]

Let me put it another way...

When any woman of reproductive age comes in for elective surgery, we require a urine HCG (human chorionic gonadotropin), or "pregnancy", test. This is done whether or not they tell us they are sexual active.

Is this a waste of money?

-Dr. Imago

The ways in which this situation is not analogous:

Peeing into a cup is less invasive than a speculum exam.

The yield is higher.

You are not taking advantage of a coercive situation in order to discover something unrelated to the needs of elective surgery.

Linda

[Dr. Imago]

I do think it's reasonable to ask whether any of those potential benefits outweigh the potential harm.

I entreat you to detail to me the "potential harm" of a routine gynecological exam, especially one where a teenager is seeking birth control because she is considering engaging in sexual intercourse.

-Dr. Imago

[fls]

I entreat you to detail to me the "potential harm" of a routine gynecological exam, especially one where a teenager is seeking birth control because she is considering engaging in sexual intercourse.

-Dr. Imago

I already stated that if you did not agree that a pelvic exam is a sensitive issue for a 13-year-old, you need not consider the rest of my post.

However, under those circumstances, I entreat you to detail to me why you would consider a routine pelvic exam in a 5-year-old absurd.

Linda

[BillyJoe]

I entreat you to detail to me the "potential harm" of a routine gynecological exam, especially one where a teenager is seeking birth control because she is considering engaging in sexual intercourse.


What amazes me is that you can ask that with a straight face.

If you have a 13-year-old girl who's coming in for birth control, there are only two reasons: (1) she started her menses and is having some sort of "abnormal" cycle, or (2) she is contemplating sexual intercourse.

In both instances, a routine baseline gynecological exam is not unreasonable.


And, despite several invitations to do so, you still have not provided any justification for this view.

[Ivor the Engineer]

[Takes on the admirable role of fls]I assume you can cite the definitive study which supports that recommendation, then?[/role of fls]

Here's a study which indicates what I stated earlier, which was the TC:HDL ratio is more predictive of the risk of developing CHD than TC on its own, and that TC:HDL below a certain level makes it a insignificant risk factor, assuming you are otherwise healthy and don't smoke. I've seen others, but can't find them at the moment.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=27307

[LostAngeles]

...
And, despite several invitations to do so, you still have not provided any justification for this view.

I think case 1 speaks for itself. There is no requirement for a pelvic exam before getting the pill, though.

[Ivor the Engineer]

Tsk tsk, and you are the one always analyzing cost benefit...

To review for you the principles of determining which screening tests to recommend for people, in this example you would look at how many cancers you would expect to detect by how many screening tests you would need to do. So you have a different cost benefit balance screening people more often.

Now add to that the risk of lab error and/or insensitive result.

High risk X low chance of test failure is a higher number than low risk X the chance of test failure. In other words the odds of a test failure are higher in a high risk group just due to the sample statistics.

Put another way, what are the chances if I had a low risk of cancer that I would also be the rare person who had a test failure? But if I had a higher risk of cancer then the chances of having cancer and a test failure are a little higher.

How about for high-risk women two samples are taken at the same appointment and sent to different labs for analysis?

Wouldn't that compensate for their increased risk of having cervical cancer but it not being detected on any one test?

[Dr. Imago]

I hope we both agree that it is a sensitive issue for a 13-year-old. If you do not, then you need not consider the rest of my post.

Not any more sensitive than a man having his prostate checked for the first time or being told that he has to have a cystoureteroscopic inserted through his penis to remove any variety of genitourinary stones.

For me, it's all about how you approach the patient, Linda. You don't "dive into the deep end" right after you shake their hand. It starts with a conversation. You gage the emotional response from the patient. You establish a rapport. Have we forgotten that in our "quick fix" modern society, or is that just not valued anymore? Sadly, I think it's both. I'm getting the feeling the more and more training I do and the more I'm learning my game that we just don't alot the time needed anymore to develop meaningful patient relationships. It's becoming "McMedicine", and we are more focused on keeping the interview/encounter short and giving the patient what they want than being a true consultant with our patient's best interests at the forefront. More and more compromises, evidenced-based or not, are creeping in to daily practice...

Given that it's a sensitive issue, I would hope that it wouldn't be undertaken lightly or just because a young woman happens to be in a vulnerable position. Especially as erecting barriers to contraception or adequate care is likely to lead to avoidance of both.

I thought this synopsis of this supplement to Women Health beautifully and eloquently covers my thoughts...

The first pelvic examination is a rite of passage into American womanhood. Indicators and special considerations for performing a pelvic examination for a teenaged female are reviewed. Factors in the history, physical examination, and laboratory evaluation of the adolescent are presented. The sequence of pubertal events before, during, and after menarche is discussed so that menstrual disorders are presented in the context of normal development. The author presents a synthesis of her approach to caring for adolescents with a review of current literature and resources available to health professionals.

PIP: Indicators and special considerations of performing a 1st pelvic examination for a teenaged female -- a rite of passage into American womanhood -- are reviewed and factors in the history, physical examination, and laboratory evaluation are presented. The completeness of the pelvic examination depends upon the indication. A simple inspection examination of the external genitalia should begin on the 1st day of life and be continued routinely at each health maintenance examination throughout childhood. A table lists specific reasons for internal examination. The examiner cannot reassure the patient that she is developing normally unless the secondary sexual characteristiss are seen first. The excuse that the patient would be too embarrassed to have a genital examination usually denotes reluctance on the part of the examiner rather than the patient. The general the 2 main reasons to perform an internal examination are to answer specific questions that are raised by the physician or the patient herself. A verbal contract between the health care provider and patient must be established before the exam is performed. The examiner should discuss and assure the patient of confidentiality regarding sexual matters. The general categories in the history and physical examination of the teenager to be covered in the remaining portion of the visit should be outlined in the beginning. The adolescent sees herself as a teenager first rather than as a gynecologic patient. Asking additional information about other spheres of activities such as friends, family, and interests gives the feeling that the health care provider sees her as a person. At the initial interview visual aids in the form of plastic models, pictures, or illustrations should be introduced. There is no need to accomplish the entire interview, educational process, and complete pelvic examination in 1 session. Having taken the time to explain the reasons for the internal examination and familiarizing the teenager with the equipment should make the speculum exam no more uncomfortable or unpleasant than the speculum exam of the ears of the child. Baimanual examination is performed to feel the size, shape, and mobility of internal structures that cannot be visualized. Rectovaginal palpation also is necessary. At each step of the examination explanations are given to the patient about what structures are being palpated and reassurances offered as the exam progresses. The sequence of events in puberty is usually predictable but the chronological age at which they occur varies greatly. In adolescence the most common gynecologic complaints have to do with the onset, frequency, or duration of periods. No menses (amenorrhea), infrequent menses (oligomenorrhea), too much bleeding at the time of menses (menorrhagia), too frequent episodes of bleeding (metrorrhagia), or painful periods (dysmenorrhea) constitute the most frequent complaints. Because menstrual irregularities are so frequent during adolescence, all health professionals caring for teenagers should be familiar with the usual spectrum and problems associated with menarche and subsequent menses.

http://www.ncbi.nlm.nih.gov/pubmed/6464481

I can think of other reasons... imperforate hymen, bifid uterus, potential for vaginismus (or other pain manifestations, and what constitutes "normal"), yeast infection (which many women don't know what it is the first time they have it), other common non-STD infections, reproductive education.... We're talking about a young female who is seeking reproductive counseling and, therefore, is "at risk" for reproduction. I'm having a hard time seeing providing birth control to them because they may fear, and therefore avoid, the exam as anything other than a trade-off.

You found my suggestion absurd, yet you have given no reason why you would hold back from performing a pelvic exam on a 5-year-old.

If a 5-year-old experienced menarche, then I wouldn't think it absurd.

I do think it's reasonable to ask whether any of those potential benefits outweigh the potential harm. Especially since you are not talking about offering these benefits to all young girls/women, but just those who are vulnerable.

Again, we are talking about girls, in my example a 13-year-old, seeking reproductive counseling. Is that not the very definition of vulnerable?

It's not a trade-off if it doesn't occur to you to offer it when the situation isn't somewhat coercive.

Again, I'm going to have to ask you to explain to me what you mean by "coercive"? Does "coercive" mean that you either get the exam, or you don't get the pill? If so, I think this speaks to the limitations of the clinician, not the patient.

What amazes me is that you can ask that with a straight face. And, despite several invitations to do so, you still have not provided any justification for this view.

No offense, BillyJoe, but after you complete your medical degree, pass your licensure exams, and do a residency, we can have a more meaningful discussion. Your sentiment is not one that is all that uncommon among laypeople when you don't know the possible things that can go wrong, or the fiduciary (in every sense of that word) responsibility you have to your patients.

Don't mistake this: providing BCP to a teenager without adequate medical care (which includes establishing an effective doctor-patient relationship with a properly trained clinician - preferable a gynecologist, taking a full medical history, and performing an appropriate exam) is a trade-off. I think it's appaling that a 13-year-old girl can potentially walk into a Family Practice doctor and get a script for BCP without all of the aforementioned.

-Dr. Imago

[The SkepDoc]

How about for high-risk women two samples are taken at the same appointment and sent to different labs for analysis?

Wouldn't that compensate for their increased risk of having cervical cancer but it not being detected on any one test?

Probably not. Cancer can be missed on Pap smears for various reasons. The lab may misinterpret a smear as normal, and having the smears read by two independent labs might decrease the false-negative rate. But it might also increase the false positive rate, where a normal smear is over-interpreted as a possible cancer. What is probably more important is sampling error. The Pap smear picks up random cells, and sometimes the cancerous cells are there and simply are not picked up. Careful technique improves results, but is not foolproof. And then there are the precancerous cells that might not show on today's Pap smear but might have developed further and be evident a year from now. I don't know of any research to back it up, but my guess is that 2 Pap smears done on separate occasions and sent to the same lab would be better than 2 done on the same day and sent to different labs.

[Ivor the Engineer]

No offense, BillyJoe, but after you complete your medical degree, pass your licensure exams, and do a residency, we can have a more meaningful discussion. Your sentiment is not one that is all that uncommon among laypeople when you don't know the possible things that can go wrong, or the fiduciary (in every sense of that word) responsibility you have to your patients.

Do you have the above attitude with your patients when you are building a rapport with them, or do you hide your contempt for their relative level of ignorance?

[Ivor the Engineer]

Probably not. Cancer can be missed on Pap smears for various reasons. The lab may misinterpret a smear as normal, and having the smears read by two independent labs might decrease the false-negative rate. But it might also increase the false positive rate, where a normal smear is over-interpreted as a possible cancer. What is probably more important is sampling error. The Pap smear picks up random cells, and sometimes the cancerous cells are there and simply are not picked up. Careful technique improves results, but is not foolproof. And then there are the precancerous cells that might not show on today's Pap smear but might have developed further and be evident a year from now. I don't know of any research to back it up, but my guess is that 2 Pap smears done on separate occasions and sent to the same lab would be better than 2 done on the same day and sent to different labs.

I'd have thought the error in detection would have been reduced by about 1.414 times.

[Dr. Imago]

Do you have the above attitude with your patients when you are building a rapport with them, or do you hide your contempt for their relative level of ignorance?

The word "doctor" is rooted in Latin for "teacher", which is what I'm trying to do here. My response was only a reflection the disdain for educated opinion initially demonstrated towards me. Furthermore, I adequately and fully answered his query as to my rationale.

And, yes, when met with outright hostility by a patient and am unable to uncover/get past the source of it, I have suggested and even offered to help them find find another clinician to take care of them, because such an attitude inevitably and effectively interferes with developing a meaningful doctor-patient relationship.

-Dr. Imago

[Ivor the Engineer]

What this thread proves is men are motivated by holes.

The line: "The first pelvic examination is a rite of passage into American womanhood." reminds me of the film "The Road to Wellville".:D

[total derail]

The roots of the word engineer:

http://www.eweek.org/site/News/Features/root.shtml

John Lienhard, professor of mechanical engineering and history at the University of Houston and host of National Public Radio's Engines of Our Ingenuity, traces the word engineer to the Latin word ingeniare, which means to devise. Several other words are related to this word, including ingenuity.

The word technology is derived from the Latin word techni. According to Lienhard, "Techni is the art and science of making anything from an engine to an etching. It's a wonderful word. It acknowledges that engineers and artists are yoked in the same enterprise."

The word machine is similarly rooted in the arts. It comes from the Greek theater, where the deus ex machina, or "god out of the machine," appears at the end of the play to solve the problem. Lienhard notes, "That's what we call any cheap theatrical device. An unexpected god steps out of a clever stage machine to save a hero at the last second. A fairy godmother appears in a puff of smoke to pay the mortgage. It broadly refers to devices that carry out functions."

"The words science and engine have very different roots. Science comes from the Latin word scienta, which means knowledge. And engine, like engineer, comes from the Latin word, ingeniare. However, engine is one word whose meaning has changed. It used to mean any product of the mind or innate mental power. Today it usually means a physical machine, although the original meaning is sometimes still applied. In computers, a search engine is software that seeks out information. That's quite a bit different than a car engine," Lienhard says.

Lienhard notes, "Chaucer once said that our wisdom takes three forms. They are memorie, engin, and intellect. By memorie and intellect, he meant the same things we do. But by engin, he meant creative right- brain wit. He meant invention."

[/total derail]

[fls]

Not any more sensitive than a man having his prostate checked for the first time or being told that he has to have a cystoureteroscopic inserted through his penis to remove any variety of genitourinary stones.

For me, it's all about how you approach the patient, Linda. You don't "dive into the deep end" right after you shake their hand. It starts with a conversation. You gage the emotional response from the patient. You establish a rapport. Have we forgotten that in our "quick fix" modern society, or is that just not valued anymore? Sadly, I think it's both. I'm getting the feeling the more and more training I do and the more I'm learning my game that we just don't alot the time needed anymore to develop meaningful patient relationships. It's becoming "McMedicine", and we are more focused on keeping the interview/encounter short and giving the patient what they want than being a true consultant with our patient's best interests at the forefront. More and more compromises, evidenced-based or not, are creeping in to daily practice...

I don't understand how this is relevant.

I thought this synopsis of this supplement to Women Health beautifully and eloquently covers my thoughts...

http://www.ncbi.nlm.nih.gov/pubmed/6464481

Perhaps it says something different in the fulltext, but from the abstract it looks to me like the author is saying that an internal exam is performed in order to address specific questions.

I can think of other reasons... imperforate hymen, bifid uterus, potential for vaginismus (or other pain manifestations, and what constitutes "normal"), yeast infection (which many women don't know what it is the first time they have it), other common non-STD infections, reproductive education....

Do you have some specific reason for withholding these benefits from 13-years-old girls who don't ask for OCP? Or do you recommend that all 13-year-old girls have an internal exam? Isn't the request pretty much independent of those issues?

We're talking about a young female who is seeking reproductive counseling and, therefore, is "at risk" for reproduction. I'm having a hard time seeing providing birth control to them because they may fear, and therefore avoid, the exam as anything other than a trade-off.

I mentioned before that it would be a trade-off if you would offer it in the absence of a request for OCP (I hadn't seen anything specific to OCP use on your list of reasons). Is that the case?

Again, we are talking about girls, in my example a 13-year-old, seeking reproductive counseling. Is that not the very definition of vulnerable?

Yes. That was my point.

Again, I'm going to have to ask you to explain to me what you mean by "coercive"? Does "coercive" mean that you either get the exam, or you don't get the pill? If so, I think this speaks to the limitations of the clinician, not the patient.

She is placed in a situation where whether or not she is asked to submit to a procedure depends upon whether or not she requests OCP. She is less likely to have a parent or guardian with her. She is vulnerable. I think she is more likely to think that she is obligated to go along with it than if it was brought up as part of an annual examination with her mother present.

I don't mean anything like "take the exam or else".

Don't mistake this: providing BCP to a teenager without adequate medical care (which includes establishing an effective doctor-patient relationship with a properly trained clinician - preferable a gynecologist, taking a full medical history, and performing an appropriate exam) is a trade-off. I think it's appaling that a 13-year-old girl can potentially walk into a Family Practice doctor and get a script for BCP without all of the aforementioned.

-Dr. Imago

Why? She is asking for birth control, not for medical care. Once you've taken care of those issues specific to OCP, are you entitled to impose on her for stuff that falls outside of the recommendations for routine care of adolescents?

Linda

[BillyJoe]

No offense, BillyJoe, but after you complete your medical degree, pass your licensure exams, and do a residency, we can have a more meaningful discussion. Your sentiment is not one that is all that uncommon among laypeople when you don't know the possible things that can go wrong, or the fiduciary (in every sense of that word) responsibility you have to your patients.


No offense taken.
But I'm still waiting for the antidote to the sentiment referred to above.


Don't mistake this: providing BCP to a teenager without adequate medical care (which includes establishing an effective doctor-patient relationship with a properly trained clinician - preferable a gynecologist, taking a full medical history, and performing an appropriate exam) is a trade-off.



So you said before, but perhaps even a half intelligent layman should be capable of understanding why if you explain it carefully and slowly. :rolleyes:


I think it's appaling that a 13-year-old girl can potentially walk into a Family Practice doctor and get a script for BCP without all of the aforementioned.



And, still, I have seen no reasons for this view.

As for a pelvic examination being the "rite of passage to womanhood".
And as for a 40 year old man's prostate examination being analogous to a 13 year old girl's pelvic examination.

I hope you don't take offence but, again, how can you say those things with a straight face?

[BillyJoe]

The word "doctor" is rooted in Latin for "teacher", which is what I'm trying to do here. My response was only a reflection the disdain for educated opinion initially demonstrated towards me.


The intuitive opinion of an experienced expert is not a sufficient reason to adopt the particular protocol advanced by that experienced expert. It needs to be backed by evidence. We still have not seen that evidence, just that experienced expert's intuitive opinion.

Furthermore, I adequately and fully answered his query as to my rationale.


I'm sorry, but you have still not done that.


And, yes, when met with outright hostility by a patient and am unable to uncover/get past the source of it, I have suggested and even offered to help them find find another clinician to take care of them, because such an attitude inevitably and effectively interferes with developing a meaningful doctor-patient relationship.


Maybe a good start is to accept that a particular patient's decision does not have to accord with what you think is best practice. Specifically, your female patients do not have to have smear tests before commencing the pill if they don't want to. Having put the view that they should do so, and having explained why they should do so, if they still choose not to do so, there is no reason why you should not happily presribe the pill for that patient and plenty of reasons why you should. With this attitude towards the patient, it is hard to see how you could end up with a hostile patient.

regards,
BillyJoe

[Ivor the Engineer]

...Asking additional information about other spheres of activities such as friends, family, and interests gives the feeling that the health care provider sees her as a person...

Does anyone actually believe this when it happens to them? Fortunately my GP doesn't pretend to be interested in my life (other than what is relevant to why I'm there), but I've found dentists often engage in this disingenuous behaviour.

[Silly Green Monkey]

There's no reason to assume that the healthcare provider can't care about the person they are asking, that they are always lying about being interested.

[BillyJoe]

Dr. Imago,

"The word "doctor" is rooted in Latin for "teacher", which is what I'm trying to do here. My response was only a reflection the disdain for educated opinion initially demonstrated towards me."


I was reading a transcript of an interview with Steven Pinker today and came across the following quote which immediately reminded me of this thread and your quote above.

"...one of the reasons science advances is that we try to negate the social realtionships of dominance and authority that we often wield in our everyday life. If I propose a theory and someone criticises it, I can't respond that he has no right to criticise, because I am a full professor and he is just a student, for instance. This is because in science we choose to subordinate dominance, authority, and status to the disinterested pursuit of truth..."


Something for you to ponder I think.

regards,
BillyJoe