It's been a double whammy for preventative screenings and women's health lately. We got news of the new mammogram recommendations a few weeks ago and then the American College of Obstetrics and Gynecology came out with new recommendations about the frequency of pap smears. Via Yahoo:
The guidelines from the American College of Obstetricians and Gynecologists or ACOG now say women younger than 30 should undergo cervical cancer screening once every two years instead of an annual exam. And those age 30 and older can be screened once every three years.
It seems most providers are on-board with the new recommendations (unlike the mammogram changes, which were met with serious criticism) but it still leaves some questions for me.
First off, it is going to take a lot of work to modify all the education that has been done to drill the message of "annual pap" into women's heads. Secondly, I still think women should see their provider every year, for physicals but also to do routine STI testing, birth control exams and other health needs. Will a woman go to the doctor if she doesn't feel pressure to get a pap? I think all of us would benefit from regular doctor's visits (including men and folks of all genders).
The most difficult thing about these changing guidelines is understanding how they fit into the current standards for treatment, and what they mean for individuals and their health care needs. I think the movement away from unnecessary interventions (even preventative screenings) is a good one, but I'd like to see these screenings replaced with meaningful relationships with providers.
What if we took that 20 or so minutes the yearly pap smear takes and instead had a conversation with our provider about our sexual health, our concerns, our lifestyle and health needs? Unfortunately with the way our health care system works now, getting rid of these screenings will probably mean shorter and less frequent visits to the doctor.
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On the plus side, as explained to me by my GP, this means that womens birth control perscriptions will no longer be held hostage to a Pap exam.
What troubles me most about the whole PAP thing is this: While HPV is sexually transmitted, only women are screened or treated for it. As far as I know, men are never tested for it, and I don't think I've heard a peep from the medical community requesting that men be tested or even notified by their doctors that they may be carrying and/or spreading a virus that can turn out to be fatal. Why is this? PAP smears have been around for 40+ years, why is there no male screening?
I think this is an excellent point and just point out the huge degree to which women's bodies are subject to such a huge degree of medical monitoring/intervention as compared to men's. Its all about plain sexism for me...the idea women are easier to control and more willing to follow official directions, and their bodies/bodily integrity somehow less inviolate than men's, and they should thus bear the burden of preventing the transmission of disease and unwanted pregnancy by being subject to annual tests and having to be the ones solely responsible for taking hormone pills.
This is not to say that its not hugely empowering and a core human right to be able to take your pill if you want it, and get tested for diseases whenever you think necessary. The point is that men and women should have this privilege/burden equally, both in people's perceptions and in medical reality.
On the HPV point, though, I think they only came out with a blood test for the virus itself a few years ago. Query why that was not developed earlier, but I think that's the easy answer.
Men can't really BE tested for HPV. Warts can be detected, and I've read a bit about anal swabbing as well, but men don't have cervices and thus can't be tested with the ease that way women can. I've read vague things about HPV tests for men being developed, but I know almost nothing about them and what stage the development is in. My personal approach has been to just assume that my male partners have HPV, since it's SO common, and make choices about safer sex practices accordingly (consistent condom use can help decrease the chances of transmission, though after my current partner and I were tested for practically every other STI we decided together to stop using condoms, but that's me going by my own comfort level).
Men can be tested for HPV. There are blood tests for it. My friend asked his doctor to get tested just a few months ago.
There is very little point in testing men for HPV. As someone else said, the virus has no cure. We can only treat the SYMPTOMS (removing warts, etc.). Unfortunately women are at MUCH higher risk from HPV infection. Although men can get penile and anal cancer from HPV, that is rare, and usually happens later in life. Meanwhile thousands of (usually young) women get cervical cancer from HPV every year. So there isn't a lot of benefit for testing men.
Here is what the CDC has to say about HPV and its risks: CDC HPV fact sheet
For me, the current recomendations controversy just highlight that YOU are responsible for your own health care decisions, and YOU should be making decisions on what tests and procedures you want done to your body based on the evidence of the risks and benefits of those procedures and how you personally perceive thos erisks and benefits - one thing I have learned from spending a huge amout of time thinking about maternity care is that the people who make these recommendations are not gods, and they always have some economic or other interest at play that could possibly be influencing the recommendation. You could easily argue the old recos (since they were not evidence-based and diverged so much from consensus in countries with non-profit/liability driven systems) were all about making money and covering dr's asses at the expense of over-treating and overly compromising the bodily integrity of women; as we've seen, the new recos can also be attacked/impeached on other grounds.
I know that the economics of the situation with health insurance do not allow for unfettered choice here, but I have also been a little shocked lately at women's visceral, angry reaction to these new recos, which are, after all, more in line with evidence and international standards than our old recos. IMO what we need is better information for each woman to have when she makes her choices, and more opportunity for individually tailored care that matches the needs and wants of each woman, instead of getting angry when the "experts" change their opinion yet again. In my experience living here and abroad, there is MORE room for choice and better, more unbiased info given by the medical establishment to make those choices on in societies with socialized medicine.
I had a close friend in college who was not in any way sexually active until she was 21. She had regular pap screenings before and never had problems. The pap screening a year after her new relationship? Not only had she been infected with HPV, but the infected cells were already cancerous. She had to deal with a couple years of both internal and external radiation therapy, which caused her a great deal of pain and serious upheaval in her personal life. How much worse would it have been if she'd waited an additional year to get the pap smear?
I'm not buying the whole "only every two years" BS. Unlike mammograms, in which there is SOME risk involved in having them, there is absolutely NO argument for having less frequent pap smears - regular pap smears hurt nothing except the insurance companies' wallets.
And rubysecret, I completely agree. HPV is something that isn't even on most men's radar. And they didn't even bother testing/approving Gardasil for use with men? Unconscionable.
Sorry about what your friend went through - I had a similar experience. Not once in my case did the health practitioners ever suggest that the partner involved get screened or treated.
That is for two reasons:
(1) most people have some form of HPV and screening between the types can be expensive
(2) One doesn't treat HPV, it is a virus for which there is no known treatment or cure. One can treat the symptoms, say burning off genital warts or removing pre-cancerous cells, but not the virus itself.
So its not that doctors are being misogynistic in this case, just that the technology is not there.
Kessi, there is DEFINITELY a risk:
According to the ACOG, only 0.1 percent of cervical cancer occurs in women under 21 years of age. This is due, at least in part, to the fact that young women have stronger immune systems that are usually able to fight off HPV -- a sexually transmitted disease linked with cervical cancer -- before it causes cancer. Up to 90 percent of HPV infections in adolescents clear up on their own. Moreover, the procedure to remove precancerous tissue caused by HPV can scar the cervix and complicate any future pregnancies. Women who've had the procedure are at an increased risk for needing a Cesarean-section, and approximately one in 18 women who've had the procedure will go on to give birth prematurely.
The United States actually lags behind European countries who long ago switched to these new guidelines. Unlike the new mammogram guidelines, doctors actually support this change.
Do you have sources for the stats about Cesarean sections and premature births? I don't mean to derail and I'm asking not because I doubt you, I've read similar things, but I've been doing a lot of research on the industrialization of birth and on interventions into birth, and looking at other procedures that impact birth could be an interesting direction to take.
paperispatient: I write for change.org (women's rights section) and I recently wrote an article about this, so you can look there. Also, the stats come from studies done by the American College of Gynecologists, so check out their website.
Never apologize for asking where someone got their facts! :-)
I think it is also important to note that, unlike the mammogram guidelines, these were not issued by a government committee.
Instead of saying that the pap smear is causing harm, you should be more precise and saying that the way they remove pre-cancerous cells is causing the harm.
I challenge that the proper response would be to encourage pap smears and change the policy related to when they remove pre-cancerous cells, rather than simply have women live in ignorance.
With respect and sympathy for your friend's story, I have to disagree with you when you say that "there is absolutely NO argument for having less frequent pap smears."
For some of us, pap smears are physically painful. For some survivors of assault and abuse, they can be emotionally fraught as well. Plus you say that they only hurt "insurance companies' wallets." The problem is that somebody has to pay for annual pap smears. If it's the insurance companies paying, it means that their customers are eventually paying as well, though higher premiums. If it's the government paying through a public plan or subsidies, then it's ultimately the tax payers' dollars. In other words, even if I don't actually pay directly for my pap smear, more frequent pap smears do cost me more money.
There are definitely lots of women like your friend for whom an annual smear saved her life. But how many more lives would be saved by a twice-annual pap smear? By a monthly pap smear? Could we save women pain and trauma and money by having pap smears a little less frequently, without putting us at significantly higher risk? These are tricky questions with no easy answers.
I'm not sure how it works for the american health system, but my doctor here (Canada) told me that you can still *request* to get one done once a year, or more (especially if you have reason to believe you need more; I have a high rate of cancer in my family, so I'm get checked up twice a year). It's just not mandatory; it's too bad more doctors don't say what mine did.
i disagree that the mammogram guidelines were met with serious criticism. they were only met with serious confusion from women, and criticism by some doctors on an emotional basis, not a scientific one. yes, at first it seems like fewer mammograms would mean breast cancers are not detected and a woman would die, but that's not how it's going to work. mammograms are very invasive screenings. decreasing mammograms doesn't mean decreasing breast exams. also, yearly mammograms help detect tumors earlier but they don't really improve survival rates. what they do is increase unnecessary biopsies and hoop-la. you could also look at the mammogram guidelines for other countries.
removing yearly requirement/recommendation for Pap smears also make sense given the nature of HPV. of course the more sexually active a woman is, with men or women, the more screenings she'd need. i think we do need to raise awareness about that. what we need more education and access for is condoms, birth control devices, etc.
coverage of this issue on feministing has been pretty unbalanced. yes, there are doctors, particularly oncologists and surgeons who are alarmed about reduced screenings. but for many doctors and scientists the new guidelines make a lot of sense.
read another blogger's coverage here:
http://momstinfoilhat.wordpress.com/2009/12/08/mammograms-and-the-uspstf-its-the-denominator-stupid/
I disagree that the reaction of the doctors and patients was emotional and not scientific. The task force itself said that the reason they changed the guidelines was to save women stress, not because there was any scientific benefit or that yearly mammograms could do any physical harm (unlike yearly pap smears, which, as I said earlier can affect fertility). In fact, the task force itself conceded that yearly mammograms do save a small number of lives, but they felt that that benefit was outweighed by the larger number of women having a stressful test.
I'm sorry, but saving women from emotional turmoil makes me think of the Victorian era, and not in a good way. I want my doctors to make the best recommendations based on saving my life, not on what might make be worried. Let me decide what amount of stress I can and cannot handle.
i have to disagree with miriam on the premise of this post.
it's true that our healthcare system is dysfunctional and we don't value primary care in america. our healthcare system is insane, plain and simple. but that does not mean we need to put pressure on all women to get screenings that are not evidence based. that's just putting a band-aid on a broken system without curing anything. what's worse, such pressures to follow non-evidence based guidelines are put more on women because socially we're easier to control.
amen to Lily A, who points out that we could be doing screenings every month, every day to catch diseases early. but at some point, the risks outweigh the benefits, especially when it comes to an invasive screening like mammograms. the cost-benefit analysis is important too. money is not unlimited and we have to evaluate how to distribute cost with the least harm. i can't say enough times that there are many people in the medical and scientific community who for good reasons support lesser mammograms for low risk women. in rare cases mammograms can induce cancer, so all those risks has to be balanced with the benefits.
pap smears are less invasive, so i'm just a little on the fence about this one. but again, screening often depends on your risk. you can go to your doctor to talk about sexual and other health matters without having to do a pap smear. pap smears might force you to go, but it's not like you get a lot of quality time with your doctor because of it. focusing on health education and increasing primary care is not the same thing as pressuring women to get non-evidence based screenings.
i think more awareness and acceptance of the HPV vaccine makes reduced pap smears for low risk women acceptable. now let's raise awareness about the vaccine, for both girls and boys.
I'm confused. I've never gotten a mammogram so I wouldn't know, but how is a mammogram MORE invasive than a pap? Are you referring to the use of radiation?
I am a survivor of sexual trauma, and so PAPs are already physically painful and emotionally draining. I sometimes get worked up weeks before the appointment, have panic attacks and contractions while the speculum is in, and I always cry. It would be good to not be forced to undergo this on some arbitrary basis.
That being said, I have a rather advanced form of one of the bad strains of HPV called low-grade squamous intraepithelial lesions (LSIL), that was detected by a PAP. My doctor said there's like a 10 or 20% chance it will become cancerous. However, I was only getting PAPs at like 2 or 3 year intervals, and my condition was caught early. We caught it right as it became ASCUS, or the first stage of abnormal, and now, since we know it's progressing, I can choose to get the exams more frequently as needed. And that's the most important thing to me--being able to do a PAP or refuse as I see fit.
When my health is concerned I can handle it, but not when I just have to go in and let someone touch me and look at me because "the experts" say I'm supposed to on an annual basis. I guess that's the hardest part for me: balancing the importance of detecting health problems early and the stress of being retraumatized.
I know a lot of women who insist that they have yearly screenings, and I know many who are just as happy having them only every few years. I think we should make that choice for ourselves, and that's why I cringe every time new "guidelines" come up. They end up being just another way to infringe on our bodily autonomy.
I don't think guidelines based on science and intended to give us the best tools for a healthy life interfere with bodily autonomy. If they were requirements, that would be another story. Of course we should make the choices for ourselves, but isn't it the responsibility of health care professionals to give us the best advice they can?
I think that being forced to have a PAP just so I can get birth control is definitely an infringement on my bodily autonomy.
The right is already having a conniption over the Mammogram recommendations because they believe it's proof of upcoming "rationing" of healthcare should public option pass. And while there's a huge argument to be made for cutting healthcare costs by reducing the number of unnecessary tests (of which having mammograms starting at 40 when you have no risk factors is one), I don't believe that non-yearly pap smears are one of them.
The risk factors for breast cancer are fairly static: genetics don't change and environmental/lifestyle choices rarely change between 40 and 50. You also have a precursor self-exam that can give you a heads' up if your boobs tend to be on the lumpy side.
But cervical/uterine health is not based on static risk factors: The percentage of women who are both a) not sexually active and b) have zero genetic precursors is much too small a minority to base public policy on. Even monogamous, birth-control-all-set-tyvm sex should have frequent checkups because by the time you get symptoms of something being wrong, it may be too late to treat. Not to mention shit like endometriosis -- something that is not really related to sexual activity but should be caught and treated before it goes apeshit on your reproductive system. If the infertility doesn't bother you, the pain likely will.
I can't agree with this recommendation. I understand that pap smears suck, and can be traumatic, but they really are quite necessary for women's health.
I'm all for reducing the number of "unnecessary" tests and screenings. But I'm starting to get suspicious that so far we're 2 for 2 in that it's only women's health procedures that are falling under the banner of "unnecessary."
How are you suggesting asymptomatic women get routinely screened for endometriosis?
And please show me the data on annual paps over two-yearly, if you're going to assert baldly that they're "necessary". Not hand-waving; data.
btw, i am concerned about the mammogram guidelines as it relates to black women, because black women are at higher risk than white women, even though we might ignore that when we say "women." so the new guidelines definitely needs caveats.
i think the pap smear guidelines too should contain extra caution about safe sex practices, etc.
i wanted to post a related article for consideration:
http://www.sciencebasedmedicine.org/?p=3082
I would like to mention one of the related issues that has not been brought up here: the reproductive health of low-income women. I live in Louisiana, and I cannot afford birth control or to go to a private gyno for health care becasue I don't have health insurance. I make too much to qualify for Medicaid, so I am in a crappy in between place. In Louisiana, each parish (county) has a health unit which gives free contraception (birth control, mirena, condoms, whatever you want) to women of reproductive age. The system works this way: a woman comes in, gets a pap smear, an HIV test, full STD screening, blood pressure taken, tetanus (if needed) and a PAP and exam. Once you go through this drill, you get counseled on different options of birth control, then you are given 12 months worth of birth control and a bag of condoms and spermicide for back-up. You cannot get birth control without an exam.
Your records are kept, and each year you return you get an HIV test and PAP smear and exam, and STD screening. This system works because women who come in for birth control get EVERYTHING -- ensuring they know their HIV and STD status, get proper counseling, and get screened for HPV, cysts, etc. Many low-income women could not afford these services and/or may not be able to get them when needed if the state did not provide it all at once. I don't think having a PAP is a waste of time -- it's great screening for HPV, or, if like me, you had cysts and didn't know it... medical problems happen. Our system is already so focused on "fixing" the problem after diagnosis instead of prevention that the idea of throwing out preventative menthods seems counterproductive. We already have plenty of women who do not get the healthcare they need or who cannot make regular gyno visits (due to money, taking off work, travel costs, lack of childcare, and many other reasons). Why cut preventative care? States like mine will be the first to jump on these suggestions because they cost less -- not because they are better for women. I would hate to see poor women lose out because they are often more susceptible to health problems. Plus, in Louisiana, cancer rates are tremendously higher -- and so are reproductive health problems -- than many other parts of the country. This is probably due to environmental factors; Louisiana has more factories and looser pollution restrictions than most any other state... which is why we have "Cancer Alley," a factory and oil refinery-congested area between Baton Rouge and New Orleans with a tremendously high cancer rate.
Why cut preventative care?
Its not simply the cost of the test, but also the problems if a false positive results in a unnecessary biopsy. Those biopsies contain risks to the patient. How many healthy people should be put at risk of future health complications in order to detect a real threat?
What the science suggests is that we are not finding more cancers, we are by and large only increasing the number of false positives we have.
For example, they no longer recommend anyone below the age of 21 receive a pap smear, largely because for the 15-19 cohort there were approximately 14 annual cases of cervical cancer. If you have a test which is say 98% accurate and you require two irregular tests in a row before you perform a biopsy you are still looking at 4000 unnecessary biopsies. In preventing future health problems we have too look at the problems caused to those 4,000 people who were otherwise healthy.
It's the same reason we no longer vaccinate children against small pox, because the risk of them suffering from complications from the vaccine are much larger then the risk of them actually contracting the disease. Even though the vaccine itself is very safe.
I grew up in Ireland where the norm is to only have one every two years (I had one 6 months after starting the pill aged 19, then a year later, then every two years after that).
I now live in London and over here you only have one every 3 years.
I was surprised to read that you have them every year in the US.
I remember reading a few years ago that if you get a normal pap test you really didn't need another for a good 2-3 years. I always felt the yearly thing was just another hoop for "sluts" to jump through in order to get birth control pills. Which was even more annoying because unless my cervix was going rogue, I had no reason to get a pap test year after year after year.
Look. I don't want to have sex. I just want to stop my periods. That's all. Stop holding them hostage. And if you're going to force me onto the table to get them, you only get access to one set of bits. Not two.
What on earth is with the finger up the butt? Last time I went for a pap my gyn wanted to stick a finger up my butt and I firmly said, "NO." Due to my medical condition I get fissures easily and I had them at that moment. She didn't stick anything in, but she did poke the fissure and nearly get kicked in the head. The first gyn I ever went to never went near my butt (so to speak). So I dunno why this one did. Nice lady, but do not stick nuthin' in my butt. It is a ONE WAY ZONE.
I only wish men had to be annually prodded half as much.
I definitely agree with you. On my first PAP, my doctor didn't tell me I could refuse the breast exam and the bimanual and still have it "count" as a PAP and get my damn pills. Now, I make it clear before I'm even on the table that speculum in, speculum out, that's it. No fingers, no breast exam, no rectal.
Also, someone upthread said that these exams were "quite necessary." Let me make that decision, huh? You're right they can be traumatic and painful, and therefore I will decide when and whether to have them. I think the most important thing is to educate women so we know how to decide for ourselves what level of care we need. There should not be a "one-size-fits-all" attitude to this.
Here's my issue with it, and it's from personal experiences so it doesn't necessarily mean that this should be the end-all be-all, just another perspective no one has brought up:
I have had 3 biopsies now over the last 5 years which resulted in pre-cancerous cervical dysplasia anywhere from stage 2 to stage 4. I have had 2 surgeries now to remove the dysplasic cells. I just had another abnormal pap after 3 normal paps (all 4 this year, i have to go 4 times a year for paps because of my history). Because insurance agencies follow these guidelines, my insurance only pays for 1 pap smear per year; I have to pay for the rest. So if they change this guideline to once every two years, that's yet another pap smear that I will probably have to pay for out of my own pocket.
Also given my history, in all seriousness, there's no doubt in my mind I would have cervical cancer right now if I only went once every two years. when I had a abnormal pap last year in September, they did a biopsy in October which came back stage 3 pre-cancerous dysplasia. By the time I had surgery in November, the results came back stage 4 pre-cancerous dysplasia (the next is stage is stage 1 cancer). In one month it moved that fast; if I had not had a pap smear that year (i had 4 normal paps in a row the year before after my last surgery, so was back on a normal pap routine) and waited two years instead of one, I am certain I would have at least stage 1 cervical cancer.
So from my perspective, an annual pap smear exam saved me from cancer. end of story.
I get the sexual abuse trauma some have discussed, but I think that is a personal decision and should not be a weight on the new guidelines suggestion because the purpose of the pap smear is to test for cervical cancer in an effort to prevent it; sexual abuse trauma or not, a person can still be at risk for cervical cancer and if they want to prevent it or detect it early, this is the procedure they need to have to do that.
I just wanted to add this to the discussion because no one has talked about the results of these new guidelines on the insurance you will receive. I need multiple pap smears a year until I am normal, and then I need them every single year. This hurts me financially because, as I mentioned before, the insurance company will only pay for one pap smear a year due to the guidelines they currently have under the status quo; increasing to every 2 years will just make it that much hard on me.
There is a massive amount of privilege tied up in lecturing us that we'd all benefit from discussing their sex life and "lifestyle" with a doctor regularly. Massive.