How to keep the annual visit annual
Pap test or no Pap test, every woman needs a yearly exam, for reasons vital to her health—and to ObGyn practice.
OSTEOPOROSIS
Low weight, no current use of estrogen, and age are incorporated into the 3-item Osteoporosis Risk Assessment Instrument (ORAI), which helps identify women younger than 65 who should be screened (www.osteoed.org/faq/screening/orai.html).
Bisphosphonates, such as alendronate and risedronate; selective estrogen-receptor modulators (SERMs), such as raloxifene; calcitonin; and estrogen can improve bone density and reduce risk for fractures.
DEPRESSION
All patients should be screened for depression—if there are systems in place to assure accurate diagnosis, effective treatment, and careful follow-up.
Asking these 2 questions may be as effective as using longer screening instruments:
- Over the past 2 weeks, have you ever felt down, depressed, or hopeless? (I may add, "…any more than is usual these days?")
- Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Patient outcomes improve significantly when depression recognition and management are integrated into usual care in primary care practices.
THYROID DISEASE
We do not test routinely, but if there are menstrual irregularities or amenorrhea, or if a patient is gaining weight and feeling tired, it may be enough to trigger a check.
Consider testing if there are symptoms of hypothyroidism (unusual tiredness, weight gain, feeling cold, constipation, changes in hair or skin) or hyperthyroidism (rapid heartbeat, feeling hot, anxiety, muscle weakness, or trouble sleeping).
BLADDER HEALTH
I've learned from my patients how to conduct a good review of systems, when I'm taking a patient in. If you ask, "Are you having any problem with your bladder?" they all say "No." If you ask, "Do you have any leakage when you cough or sneeze?" they all say "Yes!" So, asking the right questions helps us to at least find who needs further screening and evaluation—and a great many women can be helped if we find the problem in the first place.
Ask specific questions in everyday, nontechnical language.
Even though incontinence can be improved in 8 out of 10 cases, fewer than half of those with bladder problems tell their doctor, and hence go untreated.
De-stigmatizing HPV testing in 90 seconds or less
Michael D. Randell, MD
Department of Obstetrics and Gynecology, Northside Hospital, Atlanta, www.obgynatlanta.com
The message is clearer than ever: screening for cervical disease involves being prepared to offer HPVDNA testing.
- This year, for the first time, the federal government put HPV on its annual list of known human carcinogens.1
- Screening strategies in the April 2005 American College of Obstetricians and Gynecologists' Practice Bulletin include: 1) triage of all women with ASC-US cytology using reflex HPV DNA testing for high-risk HPV types; 2) in women over 30, primary testing using a combination of cervical cytology and HPV DNA screening.2
A sensitive issue. Unlike the "neutral" terms (ie, dysplasia or CIN) we used to explain the Pap smear for cervical disease, discussing HPV testing requires using the phrase "sexually transmitted infection." Public awareness of HPV is just beginning.
Few women understand why their ObGyn would advise a test for a sexually transmitted infection "out of the blue"—not realizing that the Pap test has always been a test for the manifestation of HPV infection. We want to avert undue anxiety or offense in our patients, yet provide up-to-date care.
Simple but sensitive
Many patients probably are uninformed or misinformed. The news media is no longer the universal "second opinion" on medicine—we are. Media messages reach patients first, and information on HPV is not always accurate.3
When a patient comes in for an office visit, it may be her best opportunity—and ours—to discuss the facts.
The ACOG Practice Bulletin includes a detailed, comprehensive discussion on what to counsel patients.
I've developed a way to cover just the basics. I believe that this proactive approach strengthens patient relationships and improves compliance with follow-ups.
The time-tested "5 Ws" formula is failsafe—you can't easily leave out any critical information when offering HPVDNA testing.
WHO "Most women are positive for HPV at some time, and most clear their infection. It is easily transmitted; condoms are not complete protection."
- This points out how common HPV infection is.
WHAT "HPV is the cause of cervical cancer. Testing lets a woman know whether she is at risk for having or developing cervical cancer or a high-grade precursor lesion over the next 3 years."
- This explains that HPV is linked to high-grade lesions and cervical cancer.
WHEN "HPV DNA testing is appropriate in women aged 30 or older, in addition to the Pap."
- This statement explains the timing of when to begin primary HPV DNA testing.
WHERE "If your test result is positive, you should not blame your partner, because there is no way to tell where or when you were exposed to the virus. Exposure could have been many years ago."
- This point should be explained in advance of results. Monogamous patients want to know where they got the infection.
WHY "If both the Pap and HPV tests are negative, you'll have peace of mind knowing that you do not have a high-grade cervical lesion or cervical cancer."
- This statement refers to the 99% to 100% negative predictive value for CIN 2 and 3, using concurrent cervical cytology and HPV DNA testing.2
- In addition, because HPV DNA testing is more sensitive than cervical cytology for detecting CIN 2 and 3, women with negative concurrent test results can be reassured that their risk of unidentified CIN 2 and 3 or cervical cancer is approximately 1 in 1,000.2
If the HPV test is positive, further counseling can involve a similar, straightforward approach, and patients can be managed according to published guidelines.
Skip "low-risk" patients?
Is it reasonable to presume that some patients are not at risk for HPV infection? (If we truly believe that some patients have no risk, why even do a Pap?) Any woman who has ever had sexual intercourse is at some risk, given the natural epidemiology of HPV.
Whereas Pap test results involve subjectivity, HPV test results are objective. If there are no cytological findings in the presence of a positive HPV test, then both tests should be repeated in 6 to 12 months. Women with persistent infections should undergo colposcopy regardless of Pap test results.
Many sexually active women will have an HPV infection at some time in their lives, we can assume. Essentially, testing at age 30 or older tries to ascertain whether the infection has cleared. Women over 30 are the target population for cervical cytology screening with HPV DNA testing.2 In women younger than 30, HPV is very prevalent, and cervical cancer prevalence is relatively low. But after 30, HPV prevalence is low, and cervical cancer increases. Thus, primary testing is more practical for the older group.
1. National Toxicology Program, Department of Health and Human Services. 11th Report on Carcinogens. Fact Sheet. January 31, 2005. Available at: https://ntp.niehs.nih.gov. Accessed August 15, 2005.
2. American College of Obstetricians and Gynecologists. Human papillomavirus. Practice Bulletin No. 61. April 2005.
3. Anhang R, Stryker JE, Wright TC, Jr, Goldie SJ. News media coverage of human papillomavirus. Cancer. 2004;100:308-314.
The author is on the speakers bureaus for 3M Pharmaceuticals, Cytyc Corp, Digene Corp, and Quest Diagnostics.
