Changes In Women's Healthcare

[joreth]

So you've probably all already heard, but for those who haven't, there have been big news in women's healthcare this week.

Both the Pap Smear guidelines and mammogram guidelines have been adjusted. In both cases, they are now recommending that we don't get screened as often as we used to.

http://health.usnews.com/articles/health/healthday/2009/11/20/new-pap-test-guidelines-start-later-have-fewer.html

For the pap smear, they are now recommending that you don't need to start getting one until 21, and to get them every other year, not annually. The reasoning is that research suggests that younger women, even if they do get HPV, are pretty able to take care of it themselves. Even if it starts to progress to cervical dysplasia, younger women, apparently, are able to treat themselves without the need for biopsies or surgical procedures. And, women who have had surgical procedures for dysplasia have a higher incidence of premature births later on.

But, doctors and research scientists are very careful to point out that this is not a MANDATORY screening schedule. They recommend discussing with your individual doctor your individual health needs and adjusting your screening schedule accordingly. They also stress that a reduction in pap smears does not mean we should reduce how often we get tested for STDs. I, for instance, as a sexually active adult with multiple partners, who in turn have multiple partners, will continue to get screened annually and/or 3 months after the introduction of any new partners.

http://skepchick.org/blog/2009/11/no-ladies-the-new-breast-cancer-guidelines-arent-patronizing/

Now the mammogram guidelines say that we don't have to get screened until age 50 (it was previously age 40) and we can get it done every 3 years. That's a scary thought, that someone who had cancer at age 40 will now not be getting screened for it. But, once again, the experts have very clearly stated that each individual woman should discuss her own needs with her doctor and plan an INDIVIDUAL screening schedule based on risk factors. Plus, if you're doing a self breast exam, like we're all still supposed to be doing, if you find anything unusual, a doctor won't refuse to screen you just because you're under 50.

I have to admit that my knee-jerk reaction to hearing this news was negative, to put it mildly. I have had it drilled into me from before puberty that I have to be rigorous in my health standards, I have to get tested often, and I have to knock a few medical heads to get it done because the bureaucratic machine doesn't care about us and will try to whisk us through as quickly as possible, even at the expense of adequate medical care.

I'm still not sure how I feel about this. My emotions continue to rage at the idea that doctors are telling me not to worry my pretty little head about something I don't understand. But I really don't think that's what they're doing. Between social awareness of women's health issues, and the recommendation that each woman develop a personalized screening schedule based on her risk factors, I think they are legitimately trying to calm down hysteria and panic.

People are getting all up in arms over the phrase "causes anxiety" as if that was the only reason to stop screening regularly. I know that I was certainly pissed when I had doctors tell me that I didn't need to get screened for HPV or herpes because I probably already had it, so why worry about it until it actually does something? Let ME decide what I'll worry about or not and just give me my damn test, thank you very much. Even receiving a positive result is less worrisome than an unknown!

But it's not just anxiety. It's unnecessary medical procedures that go along with false positives and positives for things that the body will deal with on its own that are the problem here. Not only is it more expensive for no real gain, but it's also invasive and sometimes harmful for the body.

But we need to strike a balance between avoiding unnecessary medical procedures and catching stuff while the survival rate is still high. And as long as the guidelines continue to say, EXPLICITLY, that it does not PROHIBIT more frequent screenings, and that individual risk levels should be considered when developing a screening schedule, I can see the value of avoiding cutting into my body when my body might take care of it on its own.

Bottom line here is that I have mixed feelings about it. I'll probably write more as it plays out in real life and we see how it actually affects women's health.

Comments

[phyrra.livejournal.com]

Considering there was a 2 year period of time where I had at least once pap smear a month, I think that getting a pap done every damn year is important.

I had a breast cancer scare at 23. I had a lump. I noticed it on a self exam. I went to see my doctor. She blew it off. I went to another dr. She wanted to do surgery. So I got it taken out. It was benign, but god did it give me piece of mind to have it out.

[aclaro.livejournal.com]

This is what concerns me.. we've just raised the age under which women who want biopsies and mammograms will get blown off.

[leora.livejournal.com]

I spoke to my father, a retired doctor, about this and he says the reporting is really misleading. They're saying that women without risk factors for cancer should now wait longer. That means women with a family history of cancer are still on an earlier and more frequent screening schedule. He also says that pretty much all countries have already been doing this and the US has been an anomaly.

This actually makes sense to me. Cancer doesn't run in my family. There has been very little of it and what there has been hasn't been breast cancer. We're low risk. I don't smoke or otherwise have risk factors. It's just really unlikely that I will have breast cancer.

According to the net, 1 in 10 mammograms has a false positive. This means it is expected that if you have annual mammograms you're likely to false positive at some point. That's a pretty high risk, and then there is a biopsy. And apparently mammograms are more accurate on older breast tissue, because of changes in the structure of the breast with aging.

The not teaching women to self-check is also interesting. Apparently it's not based on the idea of self-exams being useless, but that even if you don't do self-exams, women tend to notice new lumps in their breast. They just don't tend to get missed. The woman or a partner of hers will tend to notice a lump even if you don't teach women to self-check. That seems fairly reasonable.

Basically, they did studies and found that these weren't have any measurable health benefit. It wasn't that it wasn't cost effective. It was that it literally provided no health benefit. The problem is that countless people are giving stories about women who "would have died" under these new guidelines, but they're not stating things like did they have any risk factors, because if they did, then the new guidelines aren't that they should wait as long as someone who has no risk factors. And they talk about women who found a lump during a breast exam, but they don't know whether she would have found it anyway in the shower or her partner would have found it in bed or whatever.

The real problem is people are trying to spin this as the first steps in rationing health care. But the study wasn't even looking at costs. They were looking purely at whether or not something actually benefits a woman's health.

[aclaro.livejournal.com]

Basically, they did studies and found that these weren't have any measurable health benefit. It wasn't that it wasn't cost effective. It was that it literally provided no health benefit

For the breast self exams, this is true. And I appreciated this change actually because I have long felt that just being comfortable touching your breasts and being aware of them was at least as good as a specific self exam. My understanding too, from what I heard on NPR, is that by the time a lump is big enough to feel it, it's probably too late anyways :(.

However with mammograms, it's not true that there are no health benefits. There's a significant decrease in cancer related deaths through early detection. What I would much rather see here is a reduction in biopsies from suspicious mammograms. If anxiety and unnecessary biopsies are the problem, then fix those problems! This is not the mammogram's fault :).

I have risk factors, and it's like pulling teeth to get doctors to give me a mammogram at 32. My breasts are full of lumps, so I'm sure I wouldn't notice a new one. Someone less aggressive than me would just be ignorant for the next 20 years. When yearly mammograms were advised for women over 40, you could still blow it off, but at least if you wanted one, your doctor didn't give you shit about it. Now there are a lot of women who are going to have to fight to get the tests they want because they aren't "recommended".

[leora.livejournal.com]

Then when the mammogram returns a positive, how do they determine whether or not to do a biopsy?

[aclaro.livejournal.com]

I suspect it would be similar to getting an abnormal pap. Your doctor advises you that usually these are benign or slow growing, and advises you of the risks of a biopsy. You decide to either get the biopsy or watch and wait (like with an abnormal pap where you can watch and wait or get a colposcopy/treatment).

The alternative is complete ignorance as to what is going on in your breasts. This is fine for some women, especially if they are in an extremely low risk category. I would rather know if something is going on, and watch and wait if it's not alarming. A mammogram takes no more than 15 minutes - and I just feel good knowing.

[joreth]

Actually, the procedure for an abnormal pap is to automatically do an HPV-DNA test (even though the research community thinks it should be the other way around - do a DNA test to see if you're at risk for abnormal pap smears, then, if you have HPV, do paps more often (annually or bi-annually) to catch it when the HPV develops into dysplasia).

The doctors don't really advise you of what an abnormal pap means, they do the pap, if it's abnormal, they do the DNA test automatically, then, if that comes back positive for HPV, *then* you get told that you should have a LEEP, where they hack out part of your cervix, thereby increasing your risk of complications during childbirth.

There's got to be a happy medium somewhere.

[aclaro.livejournal.com]

Hmm.. not my experience at all. They did a colposcopy, but it was my decision, and they have simply watched and waited since.