Commentary

Reinventing the role of the gynecologist


 

The time is now to change office gynecologic care.

Scientific advances in cervical surveillance enable women to be screened later in life, less frequently, and more efficiently than ever before. The American Congress of Obstetricians and Gynecologists recommends that screening start at age 21, then continue at 3-year intervals until age 30, if the results are normal. At age 30, cotesting for human papillomavirus enables the screening interval to be extended to 5 years, if the results are normal. Screening endpoints may be reached upon removal of the cervix (if there is no history of cervical intraepithelial neoplasia [CIN] II or greater) or by age 65 (if there is adequate negative screening and no history of CIN II or greater in the past 20 years).

Dr. David M. Jaspan

In November 2009, the U.S. Preventive Services Task Force (USPSTF) released the statement that the current evidence is insufficient to assess the additional benefits and harms of the clinical breast exam beyond those of the screening mammogram.

The ACOG Committee Opinion #534, entitled "The Well-Women Visit," was published in August 2012. This document states: "An annual pelvic examination seems logical, but also lacks data to support a specific time frame of frequency of such examinations. The decision whether or not to perform a complete pelvic examination at the time of the periodic health examination for the asymptomatic patient should be a shared decision after a discussion between the patient and her health care provider."

The recent recommendation for dual-energy x-ray absorptiometry scans state that with a normal result, the testing interval may be extended to 15 years.

The traditional "annual exam" must change or office gynecology may run the risk of becoming obsolete.

Epidemiologic data from the Centers for Disease Control & Prevention show that the most common cause of death in women is cardiovascular disease (23.5%), followed by cancer (22.6%). Obesity continues to plague the United States, and is more common in women than in men, and most common in African American women.

In the past, gynecologists have significantly impacted public health through our vigilant use of the Pap smear. Today, we have the opportunity to lead the charge in cardiovascular disease prevention, genetics screenings for cancer risk, lifestyle intervention to begin the fight against obesity, and fulfillment of the mandate to educate reproductive age women about the benefits of long-acting reversible contraception.

Certainly ob.gyns. are adept in the art of obtaining a family history. With the ever-changing opportunities in the expanding world of genetic testing, it is incumbent upon ob.gyns. to guide our at-risk patients to a genetic counselor. Positive outcomes will lead to more vigilant testing, and at best cancer prevention, or at the least, a diagnosis prior to advanced stages. Negative results will limit unnecessary testing and relieve patient anxiety.

We must find novel and effective tools to help our patients begin to wage war on obesity. We may start by listing the body mass index for every patient in every chart, and discussing weight as a health concern, which is no different from how we address hypertension.

Recent data reveal that prematurity, preeclampsia, placental abruption, and gestational diabetes are harbingers of cardiovascular risk. In addition, the Dallas Heart Study found that "women who have two to three live births have a lower rate of subclinical atherosclerosis when compared to women that have either never delivered a live baby or those that have delivered four or more children." These obstetrically derived data place the ob.gyn. in a unique position to identify possible cardiovascular risk potentially years before there is clinical disease. Our patients also should be queried about familial cardiac risk factors such as stroke, myocardial infarction, and early cardiac death (defined as cardiac death in a first-degree male relative younger than 55 years of age or in a first-degree female relative younger than 65 years of age).

We propose that ob.gyns. adopt a hybrid ob.gyn. approach to the algorithm accepted by the American College of Cardiology/American Heart Association Global Cardiovascular Risk Calculator (which can be found in the Apple app store). The calculation is based on race, age, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, diabetes, smoking, and current use of blood pressure medication. If your patient is 40 years of age or older and her global score is 7.5% or greater for a cardiovascular event in 10 years, your patient should be considered for aggressive risk factor modification. If the score is less than 7.5% with a family history of cardiovascular disease in the same patient, additional testing should be considered to further risk stratify the patient.

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