Critical Care Obstetrics and Gynecology

Interview

Question 1

Why am I not having a Pap smear done this year? Do I still need to have a yearly GYN exam?

Answer: Pap smear frequency is no longer yearly as recommended in the past for low-risk patients. A yearly GYN exam is still advised even in the absence of a Pap smear being performed.

In 2012, the American Society for Colposcopy and Cervical Pathology (ASCCP), the American Society for Clinical Pathology (ASCP), and the American Cancer Society (ACS) teamed up to produce new Pap screening guidelines based on similar conclusions reached after reviewing scientific literature. They essentially concluded that frequent Pap screening (yearly) did not find more cases of cancer in low-risk patients. Patients are considered low-risk if they have normal Pap smears and screen negative for Human Papilloma Virus (HPV.) They did not change the screening recommendations for high risk patients. The American College of Obstetrics and Gynecology (ACOG) adopted these guidelines.

A Pap smear is intended to screen for cervical abnormalities – precancerous and cancerous findings. Occasionally, the test may pick up a uterine abnormality. It is not intended to be a screening tool for uterine cancer, ovarian cancer or other sexually transmitted infections (STIs) excluding HPV.

The current Pap guidelines for LOW-RISK patients is mentioned in Table 1.

Table 1: The current Pap guidelines for LOW-RISK patients.

If you have had a hysterectomy and your cervix remains, you should follow the above guidelines for Pap screening. If you have had a hysterectomy including removal of your cervix for benign indications, you no longer need a Pap smear. Hysterectomy or not, an annual exam with your OBGYN or primary care provider is still recommended to include a thorough breast and genital exam, evaluate your ovaries/cervix/uterus if still present, and screen for any other vaginal or urinary tract infections. Sometimes an OBGYN is the only provider a woman sees annually, so something as simple as monitoring her blood pressure in the exam is key to great healthcare.

Question 2

My daughter is starting college in the fall. Should I schedule a GYN exam for her before she leaves?

Answer: A GYN exam for a female under the age of 21 should be scheduled if she is sexually active, is considering become sexually active in the near future, or if she is having menstrual irregularities for which she would like to seek treatment. Otherwise, she can wait until age 21 at which time her first Pap smear will be due.

It is not uncommon for sexually active females under the age of 21 to be exposed to the Human Papilloma Virus (HPV) which can lead to precancerous genital lesions. When providers find abnormalities on Pap tests, we want to treat them. However, studies have shown that the majority of these lesions in patients under the age 21 will regress on their own without any residual effects. Treating those lesions as soon as they are discovered can result in surgical procedures at a very young reproductive age that could potentially weaken the cervix for future pregnancies. Hence, the recommended age of 21 for initial Pap smears.

If your daughter is sexually active prior to the age of 21, she should have a GYN exam to be screened for sexually transmitted infections, to have a discussion on safe sex and for contraception options if not planning immediate pregnancy. Treatments for painful or heavy menses may also be reviewed. The exam itself may be performed by her pediatrician or in an OBGYN office. Your daughter should be current with her Gardasil vaccinations (HPV vaccine) prior to leaving for college as well.

Question 3

I think I’m menopausal. What can I do for the hot flashes, vaginal dryness, and decreased libido?

Answer: Over the counter herbal remedies and holistic modalities should be used as a first-line treatment. Surgical procedures and prescription medications can also provide relief.

Hot flashes can be life-altering. Frequent night sweats and flashes may interrupt sleep. The full blown hot flash with beads of sweat on the forehead and damp armpits in the middle of giving that important presentation at work can be embarrassing. Sometimes herbal remedies such as Black Cohosh and soy supplementation may help hot flashes. If the symptoms are severe, Hormone Replacement Therapy (HRT) may be prescribed by your OBGYN. Types of HRT recommended are based on the presence or absence of a uterus, and the frequency or mode of administration desired. HRT may be administered as an oral pill, vaginal pill, transdermal patch, topical cream or gel form.

Vaginal dryness in menopause occurs due to decreased estrogen previously present to help with lubrication and elasticity for the vagina. This can be addressed with over the counter water based lubricants. If these are unsuccessful, vaginal estrogen supplementation may be used if you do not have any medical contraindications. Patients who are not candidates for hormonal treatment may consider laser vaginal rejuvenation offered in some OBGYN offices.

Decreased libido is another common problem for menopausal women. Unfortunately, there are few true cures for this issue. Occasionally, testosterone supplementation has been used. One prescription pill has been released to improve female libido, however, the patient cannot indulge in any alcohol intake while on the medication. Its reception by the general public has not been extremely popular due to its potential severe side effects.

Question 4

I’m almost 50 years old. Do I still need contraception?

Answer: If you are still having menses no matter how irregular they might be, you can get pregnant. If having a baby is not on your wish list, you need contraception.

Life has chapters. For many women as they approach age 50, they have completed childbearing. Some are divorced or widowed and re-entering the dating scene. Others are married or single but are not interested in any(more) children. They may begin to think that they are too old get pregnant, or perhaps skipping a few periods makes them think they are menopausal. You are not considered to be menopausal until you have skipped 12 consecutive months of menses-that’s one full year uninterrupted. If you don’t fall into this category, even with a history of infertility, you can get pregnant. It happens. The “perimenopausal” pregnancy while having almost grown children occurs more often than you think.

Permanent contraception options include vasectomy by the male done in an office under local anesthesia. Female surgical options done in a hospital under general anesthesia are laparoscopic tubal sterilization performed abdominally and the procedure called Essure, which is done vaginally. The latter may alternatively be performed in an office setting with local anesthesia. All of these are viewed as non-reversible.

Reversible forms of contraception include condoms, a daily option of birth control pills, weekly use of a patch, monthly use of a vaginal ring, and an every 3 month injection. Long Acting Reversible Contraception (LARCs) include an implant in the arm that lasts up to 3 years, and a variety of intrauterine devices that last up to 3 years, 5 years or 10 years. Contraception recommendations are made based on medical history, smoking history, number of sexual partners, menstrual history and the ability for the patient to be compliant with medication. Age alone does not exclude a patient from any of these modalities.

Question 5

Now that I’m getting older, my periods are horrendous. They are extremely heavy, more frequent, and inconveniencing my ability to work effectively because of the necessary bathroom breaks. What are my treatment options?

Answer: Perimenopausal bleeding irregularities are not uncommon. Hormonal and surgical treatments may allow you to keep your uterus.

The transition into menopause for women may vary. For many, menses become very irregular. They may be closer together or skip months with a much heavier flow. Any female over the age of 35 who notices a change in her menstrual flow with it being heavier and/or more frequent, needs have an assessment of the uterine lining with an endometrial biopsy before starting any treatment. She should also have a pelvic sonogram to assess the character of the uterus itself and rule out masses such as fibroids.

Heavy bleeding in a patient who still needs contraception can be treated with oral hormones such as birth control pills for nonsmokers, or perhaps an IUD may be her choice to eliminate the requirement for daily compliance with pills. If she has completed childbearing, she may also consider an outpatient surgical procedure called an “ablation.” This procedure is performed vaginally through the cervix and allows the lining of the uterus to be cauterized with an electrical current or water. Afterwards, the uterine lining bleeds very little if at all. Studies have shown that at least 85% of patients may no longer have menses after the procedure. However, this is not a form of contraception. The treatment of last resort for heavy menses is a hysterectomy if all other options have been exhausted.

In summary, Pap smear frequency is determined by a variety of factors including your age and risk. The recommended age for the initial Pap smear is age 21, however females under that age should have a GYN exam or consultation if they have any other GYN concerns. If pregnancy is undesired, some form of contraception is recommended if a female still has menses. Significant perimenopausal symptoms including bleeding changes have treatment options that don’t require major surgery. Discuss your options with your provider. Open dialogue from you as a patient with full disclosure of symptoms and medical history allows providers to personalize medical recommendations, partnering with you to provide the safest treatments possible.