Real Medicine

Demystifying Women’s Health

If you want to rile me up, you should talk about women’s health. Even the word, Women’s Health, annoys me. Why should only issues relating to my genitalia and my baby-making organs and my female hormones be referred to as Women’s Health, but the rest of me is… what? Men’s Health? And for that matter, why should cervical cancer or endometriosis or ovarian failure be the concern of women only? Just because men don’t get the disease does not mean that it does not affect them.

womenhealth

The thing that started me off on this train of thought (or flight of ideas, depending on how you want to look at it), was this poster for self-administered HPV Tests which I saw at the airport a few weeks ago. The poster claims that the test is more accurate, easier, and only needs to be done every two years.

selftest - Copy

The poster stinks of anti-medical facility attitudes that are more prevalent these days, and I was immediately suspicious. A little too suspicious, it turns out, but I’ll come back to this.

The marketing of these tests claims that HPV tests usually need to be done every year, and therefore their test is superior as it needs to be done every two years. As it turns out, the official guidelines are to have a Pap smear done every three to five years after a negative smear. The one area where this varies is in immune-compromised women, especially those with HIV. In these cases, smears should ideally be done annually.

The reason just thinking about this annoys me is because South Africa has decided to recommend one pap smear per decade and one every three years for HIV positive women. AND women are only entitled to three free smears in their lifetime. This illustrates incredibly poor knowledge of the disease progression and tells me that probably someone with little to no clinical experience is making these decisions.

The assumptions made here are pretty flagrant (and all false):

1. that cervical neoplasia is slow-growing enough to justify ten-yearly screenings

2. that women will somehow find the money to pay for more than three smears in their lifetimes if they should want more than three

3. that women over 55 are no longer at risk of Cervical Cancer.

Getting back to the self-tests: It seems there is some literature supporting the efficacy of this test (I still have my doubts). China, apparently, is investigating using self-testing as a means to address their very poor screening rates.

I am still not happy with the tone of the advert, and here’s why: the whole thing spouts, “don’t go to your Gynae, it’s so uncomfortable and dehumanising.” Frankly, half of the dehumanising aspect of gynaecological exams is what women are unintentionally brainwashed to believe as they grow up (and yes, speculae do look a little like instruments of torture).

Really? REALLY?

I am not denying that there are OBGYNs out there who make their patients feel extremely uncomfortable, but having worked with a bunch of them I know that so many do their best to make it a quick and painless examination.

Why do we perpetuate this idea of horrible gynaecological exams as though it is a painful rite of passage? Are we all secretly masochists? We are not making people suffer in a spirit of sisterhood, we’re simply scaring so many away from potentially life-saving investigations.

I do not want my patients – the majority of them living in some degree of financial struggle – to think that they have to fish out R700 (about 70USD)  for a self-test when they are entitled to a free test. I don’t want them to have to worry about whether they are doing it right. There are so many patients who can barely figure out whether they have to take their tablets in the morning or at night.

While cervical cancer might be one of our main concerns right now, that is certainly not the only thing addressed at a Gynae visit. I do not think it is justifiable for a woman never to have a thorough Gynae exam, even if we can accurately screen for HPV with these tests, because there is so much more that a pelvic exam and the appearance of the cervix can tell us. Certainly, when I rotated through Gynaecology, there were a lot non-HPV matters we addressed with our patients, from other STIs to matters of intimacy.

Most of all, I don’t want my patients to have a nameless, faceless individual tell them they have suspicious cytology. With our already-high rate of defaulting, we need to be able to do face-to-face consultations, to tell someone the facts while still giving them hope. You can say what you want, but there are some things a telephonic consultation just cannot beat. Who is going to take medical ethical responsibility for what happens to this patient?

I am not going to try to deny that these self-administered tests could fill a gap. I just don’t think that it fits the gap we have in South Africa very well. Unless  this can be rolled out to clinics that have a lack of personnel and equipment, the most it is ever going to accomplish is make a few bucks from the privileged few in our country.

Interesting reading material:

1. Comprehensive Cervical Cancer Control: A Guide to Essential Practice (PDF), World Health Organisation

2. Screening for Cervical Cancer in HIV Infected Women, UpToDate

3. National Guideline for Cervical Cancer Screening Programme, KZN Health

4. A South African study is in progress to establish the feasibility of this testing method in a community-based setup. I’ll be watching this with interest.

P.S: I’m not change-averse/a Luddite/etc. Just a little skeptic – and admit it, the world does need a few skeptics.

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17 thoughts on “Demystifying Women’s Health”

  1. Wow you are so right. The medical community is still full of attitudes about women, particularly that women are irrational. Because of that perception, many doctors listen but they do not hear women.

    Second, take the topic of episiotomies f0r instance. Many doctors at least, used to believe that first time perspective moms almost invariably need these done. However that is not necessarily the case and in fact, between the cut and the sutures, many nurses, midwives and doulas feel this procedure is largely thrust upon women

    The University of Michigan used to do exams on sedated women. This was done part of the ob/gyn rotation. Due to a backlash, this practice has since stopped. Involuntary ones anyway. Doctors were saying that is no big deal since a lot of these women had gynecological issues to begin with.

    Cervical Dysplasia can come on really fast and in fact, my girlfriend went from Cin1 to Cin2 so fast that he was alarmed. So 3-10 year intervals are almost suicidal for women.

    As I understand, foreceps were invented by a man and he was kind of like a closer in baseball. He would do the episiotomy and deliver the baby and then leave again.

    Some doctors have a disdain for Midwives, citing rare examples of emergencies. Now, many hospitals have rooms that appear more women-friendly. And many encourage the man to be around.

    Tina and I were very fortunate to have one of the top Ob/Gyn practices in America (he and his wife) and they work at a free clinic. I saw him throw out a sales person for not offering help to the indigent. Nice man and great doctor.

    We also had a pretty good doctor for Lily’s colposcopy and to his amazement, a good diet and healthy living attributed to the dysplasia being totally gone. Who knows what happened but he was gracious as was the Nurse Practitioner. When they wanted to do an amniocentesis on her my girlfriend was startled and uncooperative. I talked to her and they were amazed at how calm she was..

    We had classes for parents at USF Women’s Hospital in Tampa and when my girlfriend saw the size of the foreceps she dropped the books she had in her hand from sheer terror.

    I encourage you to be as proactive as you can in stanching the tide of abuse, whether if that abuse is global or parochial.

  2. Not completely on-topic, but this self-test thing sounds very much like the campaign to prevent transmission of HIV and other STIs by having men undergo circumcision. I understand the procedure does have some success in decreasing the risk of transmission for men, though no more than good hygiene habits (I think I just figured out who came up with this idea) and it’s hardly a cure-all. But I wonder how many men out there now believe they’re immune to HIV because they’ve been circumcised.

    I think it’s good to be sceptical about stuff like this. And I agree with you that that personal contact is necessary. I’m a guy, so I can’t comment on the experience of an OBGYN exam, but have had a prostate exam and am sure I would prefer to do it myself at home. On the other hand, if there’s something wrong, I’d prefer a person telling me, who can answer my questions and refer me for counselling if needed, etc. There’s a reason we don’t have self-test kits for HIV either (though I’m sure someone in our government would think it a great idea should it become available).

    1. Thanks for the thoughts. I actually posted a bit about the circumcision about it a while ago. Definitely a lot of controversy around it and it seems that the literature supporting it might actually be mistaken.

      I think prostate exams are pretty uncomfortable too – they’re just a lot quicker than the OBGYN. I think it’s valid to suggest that one would rather perform the test yourself, but the counseling part is the one of biggest concern. That’s the same reason I’d be skeptical about home-testing for HIV: because the result is a game-changer regardless of whether it is positive or negative, and people need to be counseled. I was tested without decent counseling because people just assumed I didn’t need it being in the medical field anyways, and I still feel a little resentful for the unnecessary stress I went through while waiting for the result.

  3. I guess it’s a balancing act between trusting women (to make autonomous decisions based on informed opinions) versus having enough safety nets in place for those who fall through the cracks.

    We have a patriarchal medical system with very limited resources and the Pap smear recommendations are inadequate but at least it’s something. This test appeals to a segment of the population who prefer to take their health into their own hands – luckily most of them have enough resources to get to a medical professional should the need arise.

    My worry (and I think you allude to this) is the damage that can be done when people with limited resources eschew their local clinics and hospitals in favour of D.I.Y. healthcare, without having access to accurate information, or money/time in case things go wrong. There is also a very real risk of false security, or false panic, which often happens with “Google patients.”

    1. Thanks, Doc! You hit the nail on the head, and that is exactly what I worry about. I all for people taking their health into their own hands when they have the resources to do so, but I worry about those who do not have those resources. I definitely do not want to deny anyone their right to making autonomous decisions. It is a fine line to tread indeed.

  4. Oh preach it sister! STDs combat ignorance within and outside medical spheres (hence my lil series on HIV!) I’ve heard of stories of health care personnel mistreating or talking down to people with STDs. For shame!

    It would seem that papsmears aren’t just for HPV cervical cancer screenings are they? Can’t we catch very treatable and transmissible diseases to better the general population, let alone the babies of pregnant women with STDs which can cause congenial infections?

    1. Thanks! There are healthcare workers who do treat women with STDs poorly. I can understand why they get a little annoyed but there is no excuse for treating a patient as sub-human.

      I think the most important part of the pap smear itself is still screening for neoplasia, but the whole exam leading up to the smear tests for a lot more, including taking a smear of any suspicious discharge, is also important. And the congenital aspect is of course very important. Depending, of course, on the context of the community you’re working in. I think we all need to learn to tailor our examinations to the needs of our service population. If HPV incidence is very rare in a community, then less frequent Pap smears can probably be justified, depending on the relevant literature.

      Loved your HIV series, actually!

      1. All good points. I think over here the new recommendation is for less papsmears for young women with negative results for HPV. Tailoring treatment to your patient population has been a phrase I’ve been hearing as second year progresses. Whether meeting mental or spiritual or physical needs, treatment also should consider patients’ thoughts and wishes out of a doctor visit! Keep making people think, thanks for the compliment, and love reading your stuff!

  5. Actually the evidence is the thing I follow and what’s best for me, which means routine bimanual pelvic exams are out, fortunately, they’re no longer recommended here in Australia. (and haven’t been for many years)
    The evidence for routine pelvic exams is not good, they are of poor clinical value and expose women to serious risk, even unnecessary surgery. The American obsession with this exam has resulted in poorer health outcomes for women. 1 in 3 US women will have a hysterectomy by age 60 (very high) and they have more than double the number of oophectomies than countries that don’t recommend routine pelvic exams. The RPE is not a screening test for ovarian cancer. Dr Carolyn Westhoff, an American ob-gyn, is trying to get the message out to women. Sadly, some American women avoid medical care because of the obsession with the pelvic exam.
    Routine breast exams are not recommended here either, they are of no proven benefit, but lead to excess biopsies. I’ve also, rejected mammograms due to concerns about over-diagnosis and uncertainty of benefit. The Nordic Cochrane Institute, an independent medical research group, has an excellent summary of all of the evidence at their website.

    As for pap testing, a small number of women do benefit, but most programs around the world have not followed the evidence leading to widespread harm and distress. The Dutch and the Finns have followed the evidence. Sth Africa is different, but in the States, UK and Australia cervix cancer (cc) was always rare and in natural decline before testing even started, so very few women can benefit from pap testing.

    The Finns have since the 1960s offered 7 pap tests, 5 yearly from 30 to 60 and they have the lowest rates of cc in the world and refer far fewer women for colposcopy/biopsies/over-
    treatment. (fewer false positives) Damage to the cervix can lead to infertility, miscarriages, premature babies, c-sections etc. The Dutch had the same program as the Finns, but will shortly scrap population pap testing and offer instead 5 hrHPV primary tests (or women can self-test using the Delphi Screener) at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV+ and at risk will be offered a 5 yearly pap test. (until they clear the virus)
    This will save more lives and take most women out of pap testing and harms way.

    I rejected our program more than 30 years ago, I was content with my near zero risk of cc rather than a 77% lifetime risk of colposcopy/biopsy. The lifetime risk of cc is 0.65% here…(I now understand I’m HPV-)

    Australian women are given bad medical advice and urged/pressured to have 26 or even more pap tests, serious over-screening which does nothing more than fill up day procedure with women having unnecessary biopsies and “treatments”.
    In my opinion, the huge profits generated by over-screening and over-treatment has been the motivation to leave our outdated and excessive program in place, with most women in the dark and without access to real and balanced information, it was easy to stay with excess.
    Women who want to check for STIs can request a self-swab, blood or urine test here, there is no need for a pelvic exam.

    Personally, I hate the medicalization of the asymptomatic female body and the lack of respect for our bodily privacy, autonomy, health and well-being. Screening should always follow the evidence and respect informed consent, we have a right to the evidence and to accept or decline as we see fit. Some women find these exams difficult and even painful (especially after menopause) – self-testing should be offered to all women.

    I understand the situation in Africa is very different and cervical cancer is a bigger threat, but population pap testing is now outdated and if it’s all that’s available, those who wish to test should ensure they’re not being over-screened, the Finns have shown less screening produces better health outcomes.
    The Americans are doing HPV AND pap testing on all women, this provides no additional benefit, but creates the most over-investigation, great for medical profits, but a lousy deal for women. Women in that country are routinely coerced into elective cancer screening and excess (RPE, RBE) which means there is no consent at all…many women are denied the Pill unless they agree to excess and cancer screening. (often excessive or inappropriate cancer screening)
    Women need to be very careful negotiating the medical world…we only have one precious body. Make sure what’s being offered is actually in YOUR best interests.

    Loved South Africa when I visited about 10 years ago…and I enjoyed reading your article.

    1. Hi Elizabeth, thanks for commenting. If you have any links to the info you mention I would be very interested in reading it. In South Africa we are pretty strict about who gets hysterectomies, in fact at the hospital where I train the registrars worry that they won’t learn how to perform a hysterectomy because so few of them are performed. I would wager a guess that it is more an over-eagerness to operate than the emphasis on bimanual exams that is the root cause of the high rates of hysterectomies (and I agree, 1/3 is waaaay too much).

      I found your info very interesting. Certainly things are quite different in Australia, Europe and North America. In South Africa and Asia lifetime risks for cervical cancer are quite high, and I would think that the benefits of pap smears and examinations are probably still pretty high. At least, that is what we are taught… given your information I will see whether I can find any South African specific studies on the matter too. We have had some patients who progressed so rapidly from LSIL to HSIL, especially immune-compromised ladies… and it’s terrible for them.

      26 Pap tests a year is intense. Agree that it seems profit driven and some attention should be given to lowering that. I’ve never witnessed someone being denied the pill unless consenting to extensive Pap testing, certainly that should not be allowed. I agree that profiteering from over-testing is a huge problem. Will definitely look into the applicability of what you mentioned to the African context.

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