Annual Order: Talk to Your Doc

The focus of your gynecologic exam will evolve as you age.

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Talking openly with your OB/GYN during your annual visit will ensure that you get what you need at your stage of life.

By Diana Price

Do you see your gynecologist each year for an annual exam? For many women various guidelines released by medical organizations over the past several years—which have included differing opinions about the value of annual pelvic exams,1 conflicting statements related to the recommended frequency of mammograms,2,3 and updated Pap test schedules4—have caused some confusion about whether an annual exam is necessary and what should be included in the visit.

The recommendation against regular pelvic exams, issued by the American College of Physicians in 2014, and the mammography schedule released by the US Preventive Services Task Force,5 which pushed the start to annual mammogram screening to age 50 (from 40), were both based on evidence that the risks associated with these preventive screenings may outweigh the benefits for healthy, low-risk populations.

Lauren Streicher, MD, associate clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine and author of The Essential Guide to Hysterectomy: Advice from a Gynecologist on Your Choices before, during, and after Surgery (M. Evans, 2013; $22.95) and Sex Rx: Hormones, Health, and Your Best Sex Ever (Dey Street Books, 2015; $15.99), says that when evaluating these recommendations and planning medical care, women should remember that “these are not rules; they are recommendations from various organizations” and that each woman should consider her own needs and her and her family’s medical history to determine when and with what frequency to see her gynecologist.

As part of that decision-making process, Dr. Streicher says, women should be aware of the many benefits of an annual exam with an obstetrician/gynecologist (OB/ GYN)—and the risks of avoiding the visit. “Conflicting guidelines can be confusing, but putting off an appointment until you experience symptoms of some kind is not a good idea.”

This is because, according to Dr. Streicher, a thorough gynecologic exam includes a lot more than a Pap test. “A lot of women aren’t aware of all the components of an exam: I’m looking at the vulva [the external opening of the vagina] to screen for precancers and lesions; I’m examining the cervix and also the walls of the vagina and the tissue integrity; I’m looking for abnormal discharge; and I’m conducting a bimanual exam to check for any pelvic masses.”

The American Congress of Obstetricians and Gynecologists (ACOG) recommends that women begin seeing a gynecologist in their teens (age 13 to 15) and continue annually. ACOG guidelines6 for this annual visit include a general exam (height, weight, and body mass index, or BMI); a breast exam; a pelvic exam (with or without a Pap test); blood, urine, and screening for sexually transmitted diseases (STDs); bone mineral testing; colorectal cancer screening; and appropriate diabetes and heart health tests as necessary.

If you haven’t had an annual exam recently, or if you are planning for your next regular visit, Dr. Streicher offers the following discussion topics to address, in addition to those recommended by the ACOG, based on your age and stage in life.

Twenties

Though this decade can be a time of transition for many women, establishing and maintaining regular visits with a gynecologist in your twenties can help you make good choices for long-term gynecologic health. Dr. Streicher recommends the following priorities for care.

Establish a relationship with a gynecologist. Streicher notes that it’s important to seek out a specialist who is an expert in the issues that are of greatest concern to you: “A lot of women assume that all OB/GYNs have the same training and area of expertise, but there are not only subspecialties in the field, there are also specific areas of interest. Ask yourself what your needs are and find a doctor who shares your care priorities.”
Compile family history and identify cancer risk. “The most important thing for a woman in her twenties is to do a careful family history,” Dr. Streicher says. “This is the time you sit down with your mother and father and get as specific as possible about any family cancer history.” Having put together a very careful history, discuss it with your gynecologist to create a screening schedule that reflects your history.
Address your sexual health. Be sure to discuss both STD screening and prevention, as well as any questions you have about sexual pleasure. “We talk a lot about safe sex but not about good sex,” Dr. Streicher says. “Your gynecologist should be able to help you navigate having a pleasurable sexual experience, if that’s an issue for you, so bring this up at your appointment.”
Discuss fertility. Whether you’re seeking contraception or are considering starting a family, discussions with your gynecologist in your twenties will likely include fertility. “Make sure you have a method of contraception that is appropriate and the safest for you,” Dr. Streicher says, “and be proactive about discussing fertility preservation.”
If you haven’t already, get your HPV vaccine. “We know that the human papillomavirus (HPV) is not only responsible for cervical cancers but can also lead to vulvar, vaginal, anal, and some head and neck cancers,” says Dr. Streicher. “Get your vaccine in your twenties because that’s when insurance will cover it.” And, she notes, if you’re worried that it’s too late to be vaccinated because you may already have been exposed, be aware that the vaccine offers protection against nine types of HPV; even if you’ve been exposed to one or two HPV types, you’ll still get protection from the others.”

Thirties

For many women gynecologic visits in this decade revolve around fertility—contraception, pregnancy, and fertility preservation. “During your thirties we focus on timing— what we can do to get ready to be pregnant or, if you’re not ready to get pregnant, fertility preservation,” Dr. Streicher says.

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Contraception. As in your twenties, engage in an open dialogue with your gynecologist about what birth control options are best for you, understanding that they may change over time.
Sexual health. Again, Dr. Streicher encourages women to be advocates not only for STD prevention but also for their own sexual experience: “Only about 3 percent of physicians will bring up sexual pleasure, and if they do, it’s along the lines of ‘Do you have any sexual problems?’ rather than ‘Are you able to have an orgasm?’” Talk openly with your gynecologist; and, if that physician isn’t comfortable with the topic, consider seeking a gynecologist with expertise in sexual health.
Pregnancy. If you are trying to get pregnant in your thirties, be open and proactive with your gynecologist. “There’s this myth out there that you should try for a year to get pregnant before looking into why you’re not getting pregnant, but that’s crazy,” Dr. Streicher says. “If you’re having a problem, let’s identify it right away and jump on that.”
Fertility preservation. If you’re not ready to have a baby now but you want to have the option later, begin conversations early with your gynecologist. “This is the time to talk about egg freezing and other options so that someone has a sense of what the timeline is and we can address things proactively to ensure a woman has as many options as possible.”

Forties

For some women the forties may be a time when the annual visit takes a backseat to the demands of family and professional responsibilities, or the visit is postponed because of the perception that if annual Pap tests aren’t recommended, the visit isn’t as necessary. But Dr. Streicher cautions again that women should be aware of the additional areas an exam covers: “If a woman hasn’t seen a gynecologist in three years because she hasn’t needed a Pap test, she won’t have had STD screening, she may have fibroids or other issues that haven’t been examined, and we won’t see her until she has symptoms of some kind that could have been detected earlier through an annual exam.”

Here are the topics to be sure to cover in conversations with your gynecologist in your forties.

Hormonal changes. “Women are likely starting to experience hormonal changes; if so, be sure that your gynecologist is prepared to discuss symptoms and management and that they have the expertise to treat these issues,” Dr. Streicher says.
Cancer screening. In addition to screening for cervical cancer with a Pap test, Dr. Streicher notes, your gynecologist can be on the lookout for signs and symptoms of other gynecologic cancers, including cancers of the vulva, ovarian cancer, and uterine cancer. “Uterine cancer is the most common gynecologic cancer,” she says, “and it often manifests with irregular or heavy bleeding, which can be tricky. Don’t assume that irregular bleeding is related to menopause.” Depending on your personal screening timetable, you may also begin having regular mammograms at 40.

Fifties

Menopause is the central gynecologic health concern for most women in their fifties, according to Dr. Streicher.

Menopause symptom management. If you feel that your concerns about symptom management are not being addressed, Dr. Streicher recommends seeking an expert through the listing offered by the North American Menopause Society (menopause.org): “Women should know that just because their current gynecologist hasn’t been able to help, there are solutions available for issues like hot flashes and vaginal dryness.”
Cancer screening. This remains an important issue for women in their fifties. In addition to scheduling an annual mammogram, women should be aware that the risk of vulvar and vaginal cancers also increases with age and should be monitored by a gynecologist.
Sexual health. Streicher notes that the fifties can be a transitional time for women, a period that often includes life changes around children leaving home, divorce or separation, and career changes. For women with new sexual partners at this time in life, review of STD prevention and screening and other topics related to sexual health is essential.

Sixties and Beyond

As women’s lives remain increasingly full through later years, careful care for sexual health and lingering menopausal symptoms is important. “The idea that menopause issues are over by this time is just wrong,” says Dr. Streicher. “Vaginal dryness persists and gets progressively worse, hot flashes remain an issue, and we start to deal with incontinences, urinary prolapse, and vulvar issues through the sixties, seventies, and eighties.”

Keep the conversation going. Streicher urges women to continue an open dialogue with their gynecologist as they age and to bring up the issues that matter to them to live their best life during these years. “Women are always so relieved when I bring up topics like vaginal dryness that I might notice during an exam,” Dr. Streicher says, “because often they’re embarrassed to broach the topic themselves.”
Incontinence. It’s especially important to let your gynecologist know about incontinence issues, Dr. Streicher says. “Thirty percent of women at some point in their life have an involuntary loss of urine or stool, but they generally won’t bring it up because they assume it’s just part of aging and that there isn’t a solution.” But, she adds, “just because it’s a common problem doesn’t mean you have to accept it or that there aren’t solutions.”

Prepare for Your Appointment—and for the Possibility That You May Need to Book Another

There’s no doubt that, if comprehensive, an annual exam covers a lot of territory. Not only is your physician performing a thorough gynecologic exam, she or he is also talking to you about your overall health and related emotional well-being.

Prepare for the exam in advance by writing down any specific questions you have, with as much detail as possible, and passing that directly to the physician. But, Dr. Streicher notes, be aware that if you have specific concerns that warrant further discussion or examination, you will likely need to book a follow-up appointment.

“Generally, you have about 15 minutes allotted for the annual exam. That’s just not enough time to go into much depth about any one issue,” Dr. Streicher says. “Do yourself a favor and book a separate appointment so that you can get the care you need.”

References:

Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD, for the Clinical Guidelines Committee of the American College of Physicians. Screening pelvic examination in adult women: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2014;161(1):67-72. doi: 10.7326/M14-0701 http://annals. org/article.aspx?articleid=1884537.
Breast Cancer: Screening. US Preventive Services Task Force website. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/ breast-cancer-screening1. Accessed August 1, 2016.
Oeffinger KC, Fontham ET, Etzioni R, et al. Breast cancer screening for women at average risk: 2015 Guideline update from the American Cancer Society. Journal of the American Medical Association. 2015;314(15):1599-614. doi: 10.1001/ jama.2015.12783.
Cervical Cancer: Screening US Preventive Services Task Force website. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/ cervical-cancer-screening. Accessed August 1, 2016.
Statement on ACOG’s Consensus Conference. Screening US Preventive Services Task Force website. Available at: http://screeningforbreastcancer.org. Accessed August 1, 2016.
Your Annual Healthcare Visit. American Congress of Obstetricians and Gynecologists website. Available at: http://www.acog.org/About-ACOG/ACOG-Departments/ Annual-Womens-Health-Care/Your-Annual-Health-Care- Visit. Accessed August 1, 2016.