Expert Panel Says Healthy Women Don’t Need Yearly Pelvic Exam

The annual pelvic exam often dreaded by women may be antiquated and now unnecessary.
Ask any woman about getting a pelvic exam and they will tell you that it is uncomfortable, embarrassing, and seldom yields any results that impact a woman’s healthcare. Now a recent report by the American College of Physicians suggests that the annual pelvic exam is unnecessary.

For decades, doctors have believed this exam may detect problems like ovarian cancer or a bacterial infection even if a woman had no symptoms. And sometimes it does. But recently experts have questioned whether the yearly ritual adds value to a woman’s health.

In the new guidelines, published in the Annals of Internal Medicine, an expert panel appointed by the American College of Physicians recommends that healthy, low-risk women not have routine annual pelvic exams. The panel based this advice on a systematic review of prior studies. They not only found no benefit from the annual pelvic exam, they found that it often causes discomfort and distress. Sometimes it also leads to surgery that is not needed.

The new guidelines only apply to the pelvic exam, and only in healthy women. The panel urged women to keep getting checked for cervical cancer. Also, the experts emphasized that pelvic exams remain a necessary part of the evaluation in any woman with symptoms that could be related to a problem with the vagina, cervix, uterus, Fallopian tubes, or ovaries.

A test women do need
Although seemingly healthy women may not need a pelvic exam every years, being tested regularly for cervical cancer can save a woman’s life. Here are the recommendations for women at average risk of cervical cancer:
• ages 21 to 29: a Pap smear once every 3 years.
• ages 30 to 65: a Pap smear every 3 years or a combination of a Pap smear and HPV test every 5 years.
• over age 65: routine Pap screening not needed if recent tests have been normal.
Keep in mind that these are guidelines. For personal reasons, you and your doctor may wish to choose HPV testing first or have more frequent Pap smears than recommended.
If during a routine appointment your doctor wants to perform a pelvic exam, and you aren’t keen on the idea, feel free to ask why you need it and what he or she is looking for. That’s not a challenge. Based on current evidence, there should be a reason for doing a routine pelvic exam.

Bottom Line: The annual pelvic exam should be a shared decision between doctor and patient. It is reasonable for women to ask their doctor whether a routine pelvic exam is necessary, and to ask for more information on the possible benefits and risks of the examination.

Medical Tests That You Can Do Without

I just had my annual physical examination. I am without any symptoms; take a baby aspirin and a vitamin; have no co morbid conditions. I asked myself did I really need a chest x-ray when I am exposed to so much radiation during my work at the hospital or did I need an EKG with no symptoms and a negative family history? I found my answer in a recent AARP article about “10 Tests To Avoid”.

1. Nuclear stress tests, and other imaging tests, after heart procedures
If you have had heart bypass, stent or other heart procedure, you don’t need nuclear stress test or other tests that their hearts are beating strong and the results rarely change the plan of management. Instead, patients and doctors should focus on what does make a difference in keeping the heart healthy: managing weight, quitting smoking, controlling blood pressure and increasing exercise.

2. Yearly electrocardiogram or exercise stress test
Someone at low risk for heart disease could be 10 times more likely to get a false-positive result than to find a true problem with their heart. The stress test could lead to unnecessary heart catheterization and stents. Instead, it is important to have your blood pressure and cholesterol checked at least once a year. And if you’re at risk for diabetes, have your blood glucose level checked as well.

3. PSA to screen for prostate cancer
Cancer is always scary, but the PSA test often finds slow-growing cancers that won’t kill men. An estimated 75 percent of tests that show high PSA levels turn out to be false alarms.
The American Urological Association, of which I am a member, supports the use of PSA testing, but should be considered mainly for men ages 55 to 69. I also believe that no testing is required in the man without any symptoms if the man is more than 75 years of age. However, men with a positive family history of prostate cancer and African American men should have an annual PSA test and a digital rectal examination.

4. PET scan to diagnose Alzheimer’s disease
In the last few years, doctors have begun using PET scans with a radioactive dye to look for beta-amyloid protein that is found in the brains of people with the Alzheimer’s disease. Even if a PET scan could accurately diagnose the disease, it’s untreatable. If you’re concerned about your memory, the better course is to have a complete medical evaluation by a doctor who specializes in diagnosing and treating dementia.

5. X-ray, CT scan or MRI for lower back pain
Back pain is incredibly common — 80 percent of people will suffer from back pain some time in their lives. It can be both excruciating and debilitating. Naturally, people want to know what’s wrong. Here’s the catch: The best imaging machines in the world often can’t tell them. Many older people with no back pain can have terrible-looking scans.
Most back pain goes away in about a month and imaging tests tend to lead to expensive procedures that often don’t help or shorten recovery. If you don’t feel better in a month, talk to your doctor about other options such as physical therapy, yoga or massage. But if your legs feel weak or numb, you have a history of cancer or you have had a recent infection, see your doctor.

6. Yearly Pap tests
The yearly Pap smear is a common part of women’s health checklists, but it doesn’t need to be. Women at average risk only need them every three years, since cervical cancer generally takes 10 to 20 years to develop. If women have also had negative tests for the human papillomavirus (HPV), which is now known to cause the cancer, they only need a Pap test along with the HPV test every five years. And women older than 65 who have had several normal Pap tests in a row can stop having them altogether. Also, if you have had a total hysterectomy for a benign condition such as uterine fibroids and the entire uterus and cervix have been removed, you do not need any further Pap test. Do note, however, that a yearly visit to an ob-gyn stays on the to-do list.

7. Bone density scan for women before age 65 and men before age 70
For the estimated 10 million people — mainly women —in the United States who have osteoporosis, bone-strengthening medications can lower the chances of breaking a bone. But many experts argue that for those ages 50 to 65 who have osteopenia — mild bone loss — testing and subsequent drug prescriptions may be a waste of time and money. Not only is the risk of fracture often quite low, medications such as Fosamax (alendronate) and Boniva (ibandronate) have been linked to throat or chest pain, difficulty swallowing, heartburn, muscle pain, bone loss in the jaw and thigh-bone fractures. And there’s scant evidence that people with osteopenia get much benefit from the drugs.
To help keep your bones strong, try walking and weight-bearing exercises,. Get enough calcium, 1000mg\day, and vitamin D, 1000IU\day, in your diet. If you smoke, quit.

8. Follow-up ultrasounds for small ovarian cysts
Many women receive repeated ultrasounds to verify that ovarian cysts have not become cancerous, but current research says that these tests aren’t necessary. For one thing, premenopausal women have harmless ovarian cysts regularly. For another, about 20 percent of postmenopausal women also develop harmless cysts.
The likelihood of these small simple cysts ever becoming cancer is exceedingly low.

9. Colonoscopy after age 75
Most people should have screening for colon cancer at 50 and then every five to 10 years after that, if the first test is normal. By age 75 — if you’ve always had normal colonoscopies — you can stop taking this test altogether. That should be good news, because a colonoscopy can cause serious complications in older people.
To protect your colon, eat plenty of fruits, vegetables and whole grains for fiber. Cut down on fatty foods, red meat and processed meats. Lose weight if you’re overweight and exercise. Sound familiar? It should, because that’s the best advice for protecting the rest of your body — and mind — as well.

10. Yearly physical
There’s little evidence that having an annual checkup can keep you healthy. Now I they tell me! Many tests that doctors regularly perform — to diagnose anemia, liver disease or urinary tract infections, for example — don’t make sense unless there’s a reason to suspect a problem.
Certainly, if you have an illness that needs treatment, you should see your physician. And do talk to your doctor about how often you need to have your blood pressure and cholesterol tested.

Bottom Line: Use good judgment about your health and your visit to the doctor. Ask the doctor if the test is really necessary and if the results will change how he\she is taking care of you. My message is that patients, including myself, need to become involved in their healthcare.
This article was inspired and modified from AARP, 10 Test to Avoid, by Elizabeth Agnvall, http://www.aarp.org/health/conditions-treatments/info-2014/choosing-wisely-medical-tests-to-avoid.3.html

Breast Cancer Screening- Does Screen Save Lives?

In 2013 there will be nearly 250,000 new cases of breast cancer and 40,000 deaths from breast cancer. Now there is a move to decrease screening for this most common cancer in women. This blog will discuss the guidelines from the Task Force on Preventive Healthcare.

Summary of the task force guidelines. Women 50-69 years of age should have mammograms every 2-3 years instead of every year. Women under 50 should not have mammograms. Clinical examinations by a doctor and breast self-exams have no benefit. Routine screening with MRI scans is not recommended.

These guidelines do not apply to women at high risk. These are women with a family history of breast cancer. Also includes women who test positive for the BRCA gene 1 or 2.

Self-examination has been the suggestion for women for decades. Experts say it is not a good idea.

Screening for women is not the lifesaver it was once thought to be. The task force looked at 2100 women between 40 and 59 years of age would have to be screened every 2-3 years for an eleven year period to prevent one breast cancer death. This suggests a very small benefit over a very large number of screenings. The task force even pointed out that screenings more do more harm than good. Nearly 700 of the 2100 women would have had a false mammogram requiring further imaging. 75 of these 700 women would have a biopsy just to confirm that they do not have breast cancer and at least 10 women would have part or all of their breast removed. This does not include all the anxiety that surrounds a positive mammogram and the waiting and discomfort associated with the biopsy.

What’s my advice? Certainly if a woman is in the high-risk group, mammography and screening is imperative. Women should have a discussion with their doctor and make an informed decision and weight the risks vs. the benefits of screening. This is not a doctor only decision it is a doctor-patient decision. Patients who become informed and have a discussion with their doctor will be the ones that make the best decision. Finally, I am not agreement with the recommendation on the breast self-exam. I still believe this a low cost valuable test that can detect small lesion in the breast before they become clinically relevant.

My next blog will discuss the guidelines on prostate cancer screening.

How Often Do You Need To See Me?

You may wonder how the decision is made to making the next appointment for a patient. Is there a book, or now a website with guidelines, that guide physicians on when to make the patients’ next appointments? No, there is not. It is not something we learn in medical school but is something that is part of the art of medicine. Some patients really need to be seen in a few days or a few weeks such as the patient with a urinary tract infection where the urine has to be checked to be sure the infection has cleared even after the symptoms have subsided. Then there is the asymptomatic patient who is on no medications and probably needs to be seen only for a screening annual or even a biannual exam. Then there is the majority that fall somewhere in the middle of those two extremes.

What if you had diabetes, coronary disease, hypertension, high cholesterol, and sleep apnea, but no symptoms to indicate any acute problems? You’d probably see your primary doctor fairly routinely (mostly for management of diabetes) and maybe your cardiologist every six months or so.

Here’s the big question: When you’re coasting along pretty well with no actively changing symptoms but with chronic medical problems, how often do you need to see your doctors? Let’s take the example above: with those particular problems, should you see your cardiologist yearly, biannually, quarterly, monthly, or what? In the non-hypothetical world a patient’s follow-up is likely to be dictated by the doctor and set at the end of each appointment. “Okay, Mrs. X, it looks like you’re doing well. Let’s plan to see you again in 6 months.”

How does the doctor know when to see you next? There are a few ground rules to take into consideration. The pharmaceutical industry doesn’t allow us to write prescriptions with refills that extend past 12 months, and many clinics have a policy of not providing new prescriptions after the 12-month mark unless they’ve at least laid eyes on the patient (apparently to make sure the patient is indeed alive), and so most people with chronic problems will likely have to be seen at least once a year. It is amazing how many men using erectile dysfunction drugs will keep that annual appointment in order to obtain a refill of their medications! The other ground rule is common sense.

So, routine follow-up will most likely fall somewhere between “less often than weekly” and “at least once yearly or more frequently.” But within those limits, as a doctor I’m pretty much free to choose whatever I like.

I don’t know how other doctors do it, but I like to burden healthy patients with as few doctor visits as possible, so I mostly try to set my return appointments for a year. This works well for most people, but there are clearly exceptions. I see a lot of men with prostate cancer. Many of them are on medications to decrease the testosterone level and receive injections every 3-6 months. If it is possible, I try to convert these men to injections that can be given once a year. Most of the men with prostate cancer like the idea of getting a yearly injection and coming in every six months for a blood test, a PSA level. However, there are some men that want that more often and I allow them to make appointments to be seen more frequently. This, again, is where the art of medicine is used to guide how often a patient returns for an appointment.

There are patients with certain conditions like bladder cancer that should have a cystoscopy or look into their bladder with a lighted tube every 3 months. This guideline is written in all urologic textbooks and is good medicine to see these patients on a frequent basis.

I commonly ask certain patients to see me more frequently. Any patient who is on medications that is having side effects is asked to come back more frequently until I can get the dosage or the medication straightened out that provides them with the beneficial effect and with manageable side effects.

Bottom Line: How often should you be seeing your doctor? I have no clue. Between you and your doctor you’ll come up with some type of balance that works. Just understand that none of this is written in stone….i.e., a kidney stone!

This blog was inspired and modified from a blog by Dr. Eric Van de Graaf, which appeared in Patient on January 17, 2011.

To Screen Or Not Screen-That’s the Question, What’s the Answer?

Annual cancer tests are becoming a thing of the past. New guidelines for cervical cancer screening have experts at odds over some things, but they are united in the view that the common practice of getting a Pap test for cervical cancer every year is too often and probably doing more harm than good.
A Pap smear once every three years is the best way to detect cervical cancer. Recently it was recommended against prostate cancer screening with PSA tests, which many men get every year.
Two years ago, it said mammograms to check for breast cancer are only needed every other year starting at age 50, although the American Cancer Society still advises annual tests starting at age 40. A large study found more false alarms for women getting mammograms every year instead of every other year.
It’s a fact that the more tests that you do, the more likely you are to be faced with a false-positive test that leads to unnecessary biopsies and possible harm. We see an emerging consensus that annual Pap tests are not required for us to see the benefits that we have seen from screening.
Those benefits are substantial. Cervical cancer has declined dramatically in the United States, from nearly 15 cases for every 100,000 women in 1975 to nearly 7 per 100,000 in 2008. About 12,200 new cases and 4,210 deaths from the disease occurred last year, most of them in women who have never been screened or not in the past five years.
The cancer society and other groups say using Pap smears together with tests for HPV, the virus that causes cervical cancer, could improve screening. Instead, reaching women who are not being adequately screened now probably could save more lives.
Bottom Line: Patients need to be informed about the benefits vs. the risks of screening. By being knowledgeable about the screening tests and having a discussion with your doctor is the best way to come to a decision about screening in your situation.

Choosing a Family Physician-One of the Most Important Decisions You Will Ever Make

People are not just an amalgam of their body parts.  Men are not composed of large prostate glands, sclerosed coronary arteries, and rusty libidos, although sometimes it feels that way. We come in complex packets of various sizes, shapes and colors, and attached to families, jobs, communities and cultures. Just like everyone else, we need primary care physicians as our allies and advocates in staying healthy, and getting the best possible health care.

Your primary care doctor — either a family physician or a general internist — should be the captain of your healthcare ship. Primary care physicians not only can handle the majority of illnesses that you may experience, but they can work with you to keep you healthy. They can help you decide what makes sense in a world where numerous entities are hawking remedies for life’s ills, from pills to diets to operations. The primary care doctor can help you select from this bewildering array of options, and then be your advocate when you do need specialized care beyond his or her repertoire.

So what should the average man do to get the most out of the health care system? The following are my suggestions distilled from over 30 years of being a doctor:

1) Select a primary care doctor.

The time to choose a primary care doctor is before you need one. Ask your friends whom they go to. Check with local clinics and hospitals and see which primary care doctors work near your home or your job. Check and see if your wife or significant other or child has a family doctor who would take you into his or her practice.

Then go and interview the doctor, find out whether their philosophy of medical care jibes with yours. Discuss your approach to health and illness, and see whether they will support you in your quest. Check their training and references to make sure that they have the training and skill that you need. Make sure that they are board certified in their respective specialty. There are advantages to seeing the same doctor as other members of your family. But probably the personal chemistry between you and your doctor is the most important factor in this choice.

2) Visit your primary care physician before you’re sick.

Almost all doctors have health maintenance protocols that are aimed at men your age, and consist of a schedule of regular visits and diagnostic tests designed to catch important problems as early as possible. Make sure your health maintenance protocol is up to date. For most patients, this will involve a visit every year or two, depending on your age, back­ground, and the medical problems you may have accumulated along the way.

3) Negotiate a plan with your doctor.

Medicine is a team sport, you and your doctor share the quarterback duties. Your doctor has a set of guidelines that are based on medical science and the evidence it produces. You have a set of values and preferences that will determine which of those guidelines make sense for you. Work with your doctor to come up with an approach that makes sense for you.

4) When you do need specialty care, work through your primary care physician.

Specialists will give you their honest opinion about the best therapy for your problem, but your primary care physician will help you put it into context. Primary care doctors can also help to coordinate care among multiple providers, watch out for interactions among drugs or therapies, and will still be available to care for you after a more specific problem is resolved.

Bottom Line: It is almost impossible these days to sort out the best approach to health care. Your primary care physician is the strong­est ally in choosing a path that makes sense for you.  The few minutes you take to make this very important selection may just be the most important decision of your life.